Lacey and Street BioPsychoSocial Medicine (2017) 11:30

DOI 10.1186/s13030-017-0115-7

RESEARCH Open Access

Measuring healthy behaviours using the

stages of change model: an investigation
into the physical activity and nutrition
behaviours of Australian miners
Sarah J. Lacey* and Tamara D. Street

Abstract
Background: Obesity is one of the fastest growing modern day epidemics affecting preventable disease and
premature deaths. Healthy lifestyle behaviours, such as physical activity and nutritional consumption, have been
shown to reduce the likelihood of obesity and obesity related health risks. Originally designed for measurement of
unhealthy behaviours, the Stages of Change model, describes ‘precontemplators’ as individuals who engage in the
unhealthy behaviour, are unaware that their behaviour is problematic, and are resistant to change. The aim of this
study was to refine and assess the measures of the Stages of Change model in order to achieve a concise and
reliable classification of precontemplators, in the context of healthy behaviours.
Methods: Eight hundred and ninety-seven employees participated in a health survey measuring current health
behaviours and stage of change. This study compared a traditional precontemplation measure to a modified
version in the assessment of two healthy behaviours: physical activity and fruit and vegetable consumption.
Results: The modified measure was more accurate and captured fewer individuals currently meeting the guideline
for both physical activity and nutrition, compared to the traditional measure of stages of change. However, across
all stages of change, the measure incorrectly classified some employees with regards to meeting health guidelines.
Conclusions: When applied to healthy behaviours, the stages of change measure for precontemplation should be
further refined to reflect knowledge that the behaviour is unhealthy, and apathy to change. Additionally, measures
should define health guidelines to increase reliable classification across all stages of change. The findings can be
applied to inform the design and implementation of health promotion strategies targeting obesity related lifestyle
behaviours in the general population.
Keywords: Behaviour change, Intervention design, Nutrition, Obesity, Physical activity, Stages of change

Background diet [2]. Often, the scientific community has focused on

Obesity, as defined by abnormal or excessive fat accumu- treatment of obesity related disorders, most often in clin-
lation, has been associated with increased risk of chronic ical samples [3]. More preventative work is needed in the
diseases; including cardiovascular disease, type 2 diabetes, area of behaviour change research applying obesity pre-
musculoskeletal disorders, and some cancers [1]. The vention strategies targeting lifestyle behaviours pertinent
World Health Organization (WHO) refers to obesity as an to the general population.
‘epidemic disorder’ [1]. Encouragingly, research has shown Obesity prevention strategies usually focus on communi-
that the risk of obesity and related health disorders can be cating the benefits of a healthy lifestyle (e.g. The ‘Swap It,
significantly reduced through healthy lifestyle behaviours, Don’t Stop It’ campaign’; [4]). Despite the benefits of a
such as being physically active and maintaining a healthy healthy lifestyle being largely well-known in western coun-
tries, the prevalence of obesity continues to rise. This
* Correspondence: [email protected] trend suggests that the current mass education approach
Wesley Medical Research, PO Box 499, Toowong, QLD 4066, Australia

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Lacey and Street BioPsychoSocial Medicine (2017) 11:30 Page 2 of 8

may, by itself, be ineffective in prompting behaviour change and colleagues’ Stages of Change model [5, 17, 18] (which
in the general population. Adults who continue to engage forms part of the broader Transtheoretical Model of Behav-
in unhealthy lifestyle behaviours considerably increase their iour Change) assesses an individual’s readiness to change a
risk of obesity, obesity related health risks, and premature health behaviour. Although there has been debate regarding
death [5]. It is therefore imperative for health professionals the validity of the Stages of Change Model as a stand-alone
to understand behaviour change models that explain vari- theory outside of the context of the Transtheoretical Model
ation in lifestyle behaviours in order to design effective (e.g. [19]), the majority of studies to date apply the model
obesity prevention behaviour change interventions. in this way [20]. The model is comprised of five stages
that represent incremental increases in preparedness to
Behaviour change change: (i) precontemplation – the individual is unaware of
Achieving and maintaining lifestyle behaviour changes are a the consequences of their behaviour and resistant to
multifaceted process encompassing an individual’s motiv- change; (ii) contemplation – the individual is aware of the
ation for, and preparedness to, change. Health behaviour consequences of their behaviour and open to change; (iii)
change typically requires a significant life event, such as the preparation – the individual shows anticipation and willing-
illness or death of a loved one and a newfound understand- ness to change within the next six months; (iv) action – the
ing of the consequences of the problematic behaviour, to individual is in the process of changing their behaviour and
prompt the change [6]. Hence, achieving lifestyle behaviour shows enthusiasm and momentum; and (v) maintenance –
change is particularly difficult for ‘non-clinical’ individuals the individual has sustained the new behaviour for more
that have not been diagnosed with a specific illness or expe- than six months and shows perseverance in maintaining
rienced a motivating life event. Arguably, it is this group of the change.. In some versions of the model a sixth stage,
‘precontemplators’ who lack the understanding of the con- ‘termination’ – which refers to the cessation of an un-
sequences of their behaviours, self-efficacy, or motivation to healthy behaviour with no temptation to relapse – is in-
change that would be the least likely to volunteer to partici- cluded following the ‘maintenance’ stage.
pate in an obesity prevention intervention. To facilitate Fundamentally, the model assesses change as a tem-
health practitioners in assisting precontemplators, a reliable poral dimension occurring over time rather than a sin-
measure to identify individuals who are not meeting health gular event. The typical example of such a temporal
guidelines and not contemplating improving their health change is an individual’s transition between smoking and
behaviours is needed. non-smoking behaviours. That is, in assessing behaviour
it is important to consider the process of preparing to
The importance of theory change over time as well as the behaviour itself [21]. Al-
Scientific research has shown that health behaviour though the time it takes an individual to progress from
change programs are most effective when they are guided one stage to the next is variable, the processes required
by a theoretical construct [7–10]. Surprisingly, behavioural to advance, including decisional balance and self-
change interventions have seldom referred to theory in efficacy, are not. It is estimated that only a minority
the design phase of practical interventions, rather than (usually less than 20%) of a population is prepared to
simply applying theoretical constructs as an outcome take action to change a specific health behaviour at any
measure [11]. Hence, the ability to dissect and evaluate given time [16].
such behavioural change interventions is limited, and rep- The strength of the Stages of Change model lies in its
lication of successful results becomes less likely [12]. capacity to match the stage of each individual with specific
One of the most commonly applied models of behaviour intervention strategies [22]. Recently, the Stages of Change
change is Prochaska and DiClemente’s Stages of Change model has been successfully applied in the development of
model. This model has been well validated in the literature effective semi-tailored health interventions including smok-
[9, 13]. A major benefit of the Stages of Change model is ing cessation [23], condom use [24], and fruit and vegetable
its potential concision of assessment. This makes it at- consumption [25]. Moreover, interventions based on the
tractive to health practitioners compared with other Stages of Change model have been associated with greater
models of behaviour change, such as the Health Belief participation when compared with other theory based inter-
Model [14] and Theory of Planned Behaviours [15], that ventions. This may be a result of the semi-tailored nature
typically require assessment of a multitude of variables for of the approach being perceived as a personalised program
the purpose of categorisation. and appealing to the wider population [12].

The stages of change model Measures of stages of change variables

Studies of behaviour change have shown that modifying be- Applying the Stages of Change model in an obesity pre-
haviour typically requires an individual to move through a vention intervention requires a reliable and valid meas-
series of stages of preparedness to change [16]. Prochaska ure [13]. The most prominent measure within the
Lacey and Street BioPsychoSocial Medicine (2017) 11:30 Page 3 of 8

literature is the University of Rhode Island Change operating in rural Australia. Participants were predomin-
Assessment Scale (URICA) [26]. The URICA includes antly male (73.60%, n = 658), married or partnered
32-items measured on a 5-point likert scale. While some (64.7%, n = 559), and predominantly aged between 25
studies have condensed the stages of change assessment and 44 years (58.9%, n = 474).
to a single item measure [20], little reporting has been
done on the validity of such measures. Nevertheless, Materials
concision in assessment is preferred in applied settings Health survey
where time constraints commonly exist (e.g. workplace A self-report health survey was administered onsite to
settings [27]). measure physical activity and nutrition health behav-
Since the Stages of Change model was developed for iours, and theoretical stage of change. The health related
understanding unhealthy behaviours, this influences the survey items replicated previously validated items in the
wording of its associated measures. As such, adjustments Australian Bureau of Statistics Australian Health Survey
may be required in order to apply both the model and [28]. Physical activity was measured as the total amount
associated measures for the assessment of healthy be- of minutes an individual engaged in moderate physical
haviours. For example, the first URICA item for precon- activity over a period of seven days. Nutrition was mea-
templation states, “As far as I’m concerned, I don’t have sured as the average quantity of daily serves of vegeta-
any problems that need changing”. When applied to the bles and fruit. Consistent with the WHO guideline [2],
context of unhealthy behaviours it is clear that a positive participants were classified as meeting the physical activ-
response to the item would indicate a lack of awareness ity guideline if they reported engaging in at least 150
of the problem behaviour. However, when applied to a min of moderate exercise over a period of seven days.
healthy behaviour such as physical activity, an individual Participants were classified as meeting the nutrition
who has sustained the healthy behaviour over a six guideline if they reported consuming an average mini-
month period, (representing the ‘maintenance’ phase of mum quantity of five serves of vegetables and two serves
the model), may respond positively to this item. There- of fruit daily. The measure of theoretical stage of change
fore, in order to successfully apply the Stages of Change based on the model by Prochaska and DiClemente [6]
model to healthy behaviours for the purpose of obesity was modified to incorporate an additional ‘precontem-
risk management interventions, it is imperative that the plation’ stage response that read, “I know I should im-
model be adjusted to accurately assess the stage con- prove my [exercise / eating] habits but I don’t intend to”.
structs in the context of healthy behaviour changes. Response options for all stages are presented in Table 1.

Project aim Procedure

According to the Stages of Change model, ‘precontempla- Health survey
tors’ both engage in the unhealthy behaviour, and are un- During visits by the research team to the mining com-
aware that their current behaviour is problematic. pany, employees operating in selected representative
Therefore, a measure of those within the ‘precontempla- work units were invited by their supervisor to participate
tion’ phase of the Stages of Change model should capture in the health survey. Supervisors were not made aware
individuals that do not engage in the healthy behaviour of whether employees accepted the invitation to volun-
(such as adequate physical activity and fruit and vegetable tarily participate.
consumption). The aim of this study was to compare two
concise survey measures of Prochaska and DiClemente’s Data analysis
[6] ‘precontemplation’ phase of stages of change in the as- All analyses were conducted using IBM SPSS version 21.
sessment of healthy behaviours in a general population Analysis of results involved chi square testing with post-
(i.e. non-clinical) workplace sample. The authors hypothe- hoc Cramer’s V analyses and cross tabulation analyses to
sised that the modified measure of precontemplation, compare the proportion of participants who met the
which expressed knowledge of a need to change the health guidelines for physical activity and nutrition in each
behaviour but apathy to do so, would more accurately stage of change.
capture precontemplators’, who did not meet the WHO
guideline for physical activity or nutrition [2], compared Results
with the traditional measure of precontemplation. The raw data was reviewed for accuracy of data entry,
quantity and patterns of missing values. Of the 897 sur-
Method vey responses received, two participants were excluded
Participants from analysis; one participant was found to have com-
A cluster sample of 897 employees was recruited from pleted only the demographic items of the survey whilst
selected work units within a large mining company another participant failed to complete the theoretical
Lacey and Street BioPsychoSocial Medicine (2017) 11:30 Page 4 of 8

Table 1 Health Survey Stages of Change Survey Measures

Stages of Change Survey Measure
Maintenance I took action more than 6 months ago to change my [exercise /
eating] habits and I’m working hard to maintain this change
Action I am doing something to improve my [exercise / eating] habits
Preparation I have definite plans to improve my [exercise / eating] habits in the next month
Contemplation I’m seriously intending to improve my [exercise / eating] habits in the next 6 months
Precontemplation Traditional Measure As far as I’m concerned my [exercise / Modified Measure I know I should improve my [exercise /
eating] habits don’t need changing eating] habits but I don’t intend to

stages of change questions. From the remaining 895 par- (16) = 590.50, p < .001. No other significant differences
ticipants, a Little’s MCAR analysis confirmed that miss- were observed.
ing data occurred at random, χ2(20) = 17.43, p = .625. A preliminary analysis of the association between the-
Survey responses that included missing data were ex- oretical stages of change and WHO health guidelines re-
cluded based on a pairwise deletion. No further data im- vealed overall significant differences in the percentage of
putation occurred. participants who met the guidelines for physical activity
The demographic characteristics of survey participants (χ2 (5) = 101.89, p < .001, Cramer’s V = .35) and nutri-
has been summarised in Table 2. The worksite was split tion, χ2 (5) = 19.83, p < .001, Cramer’s V = .150. A fur-
across a large mine site and a smaller mine site that was ther cross-tabulation of the percentage of sampled
located out of the township but in the same region. The employees satisfying the WHO guideline was conducted
living arrangements of employees differed significantly (refer Table 3). Results of the cross-tabulation showed
between the two sites, with the majority of participants that the variance of participants who met the guideline
at the smaller site being fly-in fly-out workers was greater across the physical activity stages of change
(91.2%, n = 145), compared with the township site where (range = 21.9% to 70.2%) when compared to nutrition
the rate of fly-in fly-out was 21.3% (n = 186), χ2 (range = 2.9% to 14.3%). The percentage of participants
who met the WHO guideline for either physical activity
or nutrition, when compared to those who did not, was
Table 2 Participant Characteristics
greater only in the group that identified with the trad-
Characteristic Frequency Percent
itional ‘precontemplation’ stage for physical activity. A
Gender (n = 894)
Male 658 73.6
Table 3 Employees Meeting WHO Health Guidelines across
Female 236 26.4 Theoretical Stages of Change
Age (n = 805) Health Behaviour & Stages of Meet Guidelines
< 18 years 9 1.1 Change
No Yes
18–24 years 99 12.3 n % n %
25–34 years 288 35.8 Physical Activity (n = 828)
35–44 years 186 23.1 Precontemplation (traditional) 74 29.8 174 70.2
45–54 years 164 20.4 Precontemplation (new) 48 59.3 33 40.7
55–64 years 52 6.5 Contemplation 130 66.0 67 34.0
65–74 years 7 0.9 Preparation 100 78.1 28 21.9
Marital status (n = 864) Action 60 50.4 59 49.6
Partner 559 64.7 Maintenance 33 60.0 22 40.0
No partner 305 35.3 Nutrition (n = 880)
Employment status (n = 886) Precontemplation (traditional) 308 88.0 42 12.0
Employee 775 87.5 Precontemplation (new) 89 93.7 6 6.3
Contractor 111 12.5 Contemplation 137 95.1 7 4.9
Living arrangements (n = 888) Preparation 74 96.1 3 3.9
Resident living in local to the mine site 702 79.1 Action 133 97.1 4 2.9
Fly-in fly-out 186 20.9 Maintenance 66 85.7 11 14.3
Note. Values represent valid responses only Note. Values represent valid responses only
Lacey and Street BioPsychoSocial Medicine (2017) 11:30 Page 5 of 8

visual inspection of the percentage of participants meet- the scale. For instance, according to the Stages of Change
ing the guidelines with 95% confidence intervals (shown theory model, ‘precontemplators’ engage in the unhealthy
in Fig. 1) revealed that the percentage of participants behaviour and are unaware of that their current behaviour
who met the physical activity guidelines was noticeably is problematic. Thus, the measure of ‘precontemplation’
higher for those identified as being in the traditional should capture individuals that are not currently meeting
‘precontemplation’ stage of change for physical activity the guidelines for healthy behaviours (such as physical ac-
(“As far as I’m concerned my exercise habits don’t need tivity and nutrition). The results demonstrated that the
changing”) than for individuals identified as being in any modified ‘precontemplation’ stage of change survey mea-
other stage of change for physical activity. Also evident sures (“I know I should change my [exercise / eating]
in Fig. 1, the percentage of participants who met the nu- habits but I don’t intend to”) were associated with a re-
trition guidelines was noticeably higher for those identi- duced likelihood of capturing individuals who met the
fied as being in the traditional ‘precontemplation’ stage WHO guideline [2] for a healthy behaviour (as applied to
for nutrition (“As far as I’m concerned my eating habits physical activity and fruit and vegetable consumption)
don’t need changing”) or the ‘maintenance’ stage for nu- when compared to the traditional measure of “As far as
trition (“I took action more than 6 months ago to change I’m concerned my [exercise / eating] habits don’t need
my eating habits and I’m working hard to maintain that changing”. Therefore, it is considered likely that the modi-
change”) than for individuals identified as being in any fied ‘precontemplation’ measure was a more accurate as-
other stage of change for nutrition. sessment of individuals in the ‘precontemplation’ stage of
change for a healthy behaviour.
Discussion Based on these findings, we know that participants
This study compared a traditional and modified measure who identified with the traditional ‘precontemplation’
of the Stages of Change model with the health behav- stage for physical activity and / or nutrition (“As far as
iours of physical activity and nutrition in a non-clinical I’m concerned my exercise / eating habits don’t need
workforce sample. As predicted, the modified survey changing”) were likely to meet the WHO guideline. For
measure of ‘precontemplation’ was more reliable at cap- example, the results showed that as the stage of change
turing participants who reported not engaging in the increased, representing a theoretical increase in pre-
healthy behaviours of physical activity and nutrition, as paredness to change a health behaviour, the incidence of
assessed by the WHO guidelines [2]. This outcome sup- meeting the guideline for physical activity decreased,
ports the proposition that there is a strong need for val- until the point of action. A similar trend was identified
idation of concise Stages of Change model measures for in the nutrition behaviour however the incidents of
the assessment of healthy behaviour changes. meeting the WHO guideline [2] did not increase until
The Stages of Change model has traditionally been ap- the measured maintenance stage. This suggests that ei-
plied to unhealthy behaviours (e.g. smoking cessation) ther the survey measure lacks validity in the context of
and the traditional survey measure reflects engaging in preparedness to change healthy behaviours or that the
unhealthy behaviours, particularly at the lower end of survey question was poorly understood by participants.

a 80 b 20

70 18
Percent meeting WHO guidelines
Percent meeting WHO guidelines

16
60
(shown with 95% CI)
(shown with 95% CI)

14
50 12
40 10

30 8
6
20
4
10
2
0 0
Preparation

Action

Maintenance
Contemplation
Precontemplation

Precontemplation

Contemplation

Preparation

Maintenance
Action
Precontemplation

Precontemplation
(traditional)

(traditional)
(new)

(new)

Physical Activity Stage of Change Nutrition Stage of Change

Fig. 1 Percentage of employees meeting the World Health Organisation guideline for (a) physical activity and (b) nutrition by theoretical stage of
change. Error bars represent 95% confidence intervals
Lacey and Street BioPsychoSocial Medicine (2017) 11:30 Page 6 of 8

In Australia, where the study took place, the benefits behaviour change findings in which the theory has been
of a healthy lifestyle are widely advertised through a var- applied to risky behaviours may not be generalised to
iety of government campaigns and educational institu- healthy behaviours.
tions. Accordingly, the modified wording indicated that In addition, this paper makes a valuable contribution
the theoretical construct of ‘precontemplation’ for to public health research and practice. Specifically, the
healthy behaviours within the Australian culture could rising prevalence of obesity rates suggest that current
better be represented as ‘individuals know that their be- mass education campaigns are, by themselves, ineffective
haviour is unhealthy but are apathetic to change’. Al- as a public health prevention strategy. Understanding
though the measure of ‘precontemplation’ was improved the differences in cognitive appraisals of healthy lifestyle
by the authors’ modification, it should be noted that behaviours and how to assess them, as highlighted in
both the traditional and modified survey question cap- this study, may be used to inform the development of
tured individuals currently satisfying the WHO guide- semi-tailored obesity prevention strategies targeting in-
lines [2] for healthy behaviours. This finding may reflect dividuals who are most at need of such interventions,
similar translation issues from unhealthy to healthy be- namely ‘precontemplators’. Thus, it is anticipated that
haviours in the wording of the traditional survey meas- improving the scientific validity of measuring behaviour
ure of those within the ‘maintenance’ phase. Specifically, change intentions and development of workplace and
the traditional reference to changing a behaviour “more public health campaigns as outlined herein will result in
than 6 months ago” is not appropriate for persons who more effective preventative health promotion strategies
have never engaged in the unhealthy behaviour. It is that target healthy lifestyle behaviours and obesity.
likely that adjusting the ‘maintenance’ measure to in-
clude people that have sustained the healthy behaviour Limitations
for an extended period of time may reduce the indices Limitations of the current study included the reliance on
of healthy individuals identifying with lower stages of self-report measures for existing health behaviours, po-
change for healthy behaviours. tentially insufficient literacy skills of some participants,
Overall, participants in the ‘precontemplation’ stage of cluster volunteer sampling methodology, and possible
the model were more likely than those in the higher gender influence on participants’ healthy lifestyle
stages to meet the WHO guideline [2] for both physical behaviours.
activity and balanced dietary behaviours. This finding Ideally, complex health behaviours such as physical
may represent a misunderstanding of the question by activity and nutrition require more objective measures
participants, but given the significant result it was con- (e.g. through the use of an activity tracker device). Re-
sidered more likely to indicate the need for refinement grettably, organisational constraints and the large work-
of the Stages of Change model survey measures for the force sample meant that objective measures were not
assessment of healthy behaviours. considered feasible by the organisation in this instance.
Whilst conducting the health survey the researchers
Implications were informed by Managers that a small number of partic-
This study provides practical contributions to both be- ipants did not have the literacy skills to complete the sur-
haviour change theory and applied health promotion. vey. When informed of these instances, the researchers
Theoretically, employees who are classified as ‘precon- assisted by reading the questions aloud to the participant
templative’, ‘contemplative’ or ‘in preparation’ should not and transcribed their responses in order to overcome this
be meeting the health guidelines. However, this study barrier. However, it is possible that some additional indi-
identified that the current stages of change measure incor- viduals with poor literacy skills did not inform the re-
rectly classified some employees who met the guidelines searchers and may have completed the survey without
as ‘precontemplative’, ‘contemplative’ or ‘in preparation’. fully understanding the questions. Furthermore, for those
Similarly, some employees who did not meet the guide- who had the questions read aloud, this action may have
lines were incorrectly classified as being in the ‘action’ or resulted in a bias or Hawthorne effect whereby the partici-
‘maintenance’ stage. This finding implies that further re- pant responded with the answer they assumed the re-
finement is required to achieve concise measures of theor- searcher expected to hear.
etical stages of change that can be applied to healthy In order to minimise disruption to the operational pro-
behaviours. The development and validation of concise cesses of the organisation, cluster volunteer sampling was
measures that reliably classify employee readiness for en- employed whereby employees of selected work units were
gaging in behaviours that meet physical activity and nutri- invited to participate. Although consideration was given
tion guidelines is essential to facilitate the appropriate to selecting a variety of work units that represented a
matching of semi-tailored obesity risk management strat- broad spectrum of employees, it is not possible to ascer-
egies with an individual’s readiness. Furthermore, previous tain whether differences in demographic characteristics,
Lacey and Street BioPsychoSocial Medicine (2017) 11:30 Page 7 of 8

health behaviours, or stage of change would have been ob- stage for nutrition behaviours. Accordingly, the results
served for employees in work units that were not of this study have important theoretical implications for
included. advancing the measurement of psychological prepared-
Finally, it should be acknowledged that the sample in- ness for healthy behaviour changes. The findings also
cluded a high proportion of males (73.6%) and that the have practical contributions and can be applied to in-
potential influence of gender on health behaviours and form the design and implementation of behaviour
preparedness to change was not investigated in this change strategies to proactively reduce obesity related
study. Therefore, it is unclear whether the results pre- preventable disease and premature deaths.
sented herein are generalisable to a population sample
Abbreviations
where the gender proportions are more balanced. URICA: University of Rhode Island Change Assessment Scale; WHO: World
Health Organization
Future research
Despite the aforementioned design limitations of the Acknowledgements
The authors acknowledge the corporate and community supporters who
current study, including the potential for gender effects donated to Wesley Medical Research to advance health and medical
on lifestyle behaviours and preparedness to change, the research.
findings highlight the ineffectiveness of current measures
Funding
and should be used as a baseline study to inform future This project was funded by an anonymous corporate donation to Wesley
research into behaviour change measurement for healthy Medical Research.
behaviours and public health campaigns targeting obes-
ity. More specifically, future research should work to re- Availability of data and materials
Due to the conditions outlined in the ethics approval and identifiable
fine the measurement of the Stages of Change model for information included in the data file and survey materials, these items have
application to healthy behaviours in a general popula- not been made available for review.
tion. It is recommended that researchers refine the con-
Authors’ contributions
cise measures of stages of change to include definitions SJL and TDS contributed equally to the project design, data collection, data
of physical activity and nutrition guidelines in the ques- analysis, and manuscript preparation. All authors read and approved the final
tion and response options that specify yes and no with manuscript.
regards to meeting the guidelines in addition to readi-
Ethics approval and consent to participate
ness for change options. For example, the concise nutri- This study was conducted as part of a larger study by Wesley Medical
tion stages of change measure could ask “On average do Research and received ethical clearance from the UnitingCare Health Human
you eat at least five serves of vegetables and two serves of Research Ethics Committee (#2013.03.74). A participant information
statement and consent form were provided and verbally explained to each
fruit daily?” An example response option for the modi- participant. Participation was voluntary and participants were allowed time
fied ‘precontemplation’ stage that incorporates reference to read the forms prior to the commencement of the survey. Participation in
to not meeting the guideline could be “No, I know I the survey was anonymous and did not affect an employees’ relationship
with the employer.
should improve my eating habits but I don’t intend to”.
Future health behaviour change studies should not only Consent for publication
consider, but also evaluate the role of behaviour change Not applicable.
theory in the program development process.
Competing interests
The authors declare that they have no competing interests.
Conclusions
This study further extended the Stages of Change model Publisher’s Note
by including an additional measure of ‘precontempla- Springer Nature remains neutral with regard to jurisdictional claims in
tion’. A self-report health survey incorporating a modi- published maps and institutional affiliations.
fied stages of change measure of ‘precontemplation’ was Received: 21 August 2017 Accepted: 11 October 2017
developed as part of this project. The survey was admin-
istered onsite to 897 shift workers in rural Australia. Re-
sults of the analyses revealed that the modified measure References
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