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The Role of Questionnaires in Health Promotion Programs That Emphasize Regular Physical Activity or Fitness

Posted on: Friday, 25 March 2005, 03:00 CST

ABSTRACT

Health promotion programs are multifaceted efforts directed toward the improvement of an individual or population's overall well- being. An increased physical activity level is an important goal for program participants because research indicates healthful effects from exercise as well as a reduction in the risk of illness and death from a variety of causes. Safe development and implementation of a new activity or exercise regimen requires an appraisal of an individual's: (1) risk for cardiovascular events, (2) current functional status, as well as, (3) a method for measuring outcomes from the participant's perspective. This article discusses the general purpose, composition, and performance of survey instruments used to address these 3 important issues. A variety of questionnaires are available for use to appraise current health, screen for risk, assess functional status, and measure outcomes of health promotion programs. Outcome tools are appropriately multidimensional reflecting holistic concepts of wellness and quality of life. Measurement properties of the majority of instruments are modest with the exception of the SF-36 and the SF- 12, both of which have demonstrated consistent reliability and validity in healthy and clinical populations. Selection of questionnaires depends upon characteristics of the population served as well as the purpose and design of the health promotion program. Instruments with established measurement properties are preferable when available.

INTRODUCTION

Health promotion programs are multifaceted efforts directed toward the improvement of an individual or population's overall well- being.1 These programs may stand alone or may work in combination with disease prevention activities by screening for and attempting to minimize disease consequences. Programs often focus on physical activity levels, nutrition and diet management, stress management, and modification of risky lifestyle behaviors.2 An increased physical activity level is an important goal for participants in these programs because research indicates both a healthful effect from exercise3,4 as well as a reduction in the risk of illness and death from a variety of causes.5 In response to this evidence, the federal government,1,3 disease advocacy groups,6,7 and professional organizations8-10 have issued statements identifying regular physical activity as an integral component of improved health.

Efforts to increase one's physical activity levels include vigorous formal exercise programs intended to improve aerobic and muscular fitness as well as informal routines built around activities of daily living such as regular walks and climbing stairs.3 Programs for members of the general population may be self- directed or may be implemented in fitness centers while programs for patient populations often occur in clinical facilities. Regardless of the modality, goal, or setting, an individual starting a new activity regimen should consider the following questions: (1) "Am I healthy enough to increase my activity levels now?" (2) "How much activity should I start with?" and (3) "How will I know if I have improved?" Answers to these questions allow the participant and those who may direct him to address safety concerns, determine appropriate exercise levels, and assess program effectiveness.

Results of graded treadmill or cycle ergometry tests as well as strength tests such as the one-repetition maximum lift often are used to help answer questions pertaining to exercise safety, prescription, and outcome. Such measures are objective, standardized, and quantifiable but may not be available or practical in all situations. Even when used, these tests provide an incomplete picture of an individual's status because, by definition, they focus on performance at one point in time in a controlled setting. Participant-completed questionnaires commonly are used to supplement, or substitute for, information obtained from exercise tests. Depending on their design and intent, questionnaires offer insight into an individual's perceptions about his health and well- being or the impact of illness or disability.11 Questionnaires also may assess a person's knowledge, beliefs, and attitudes regarding health promotion activities or risks of disease development.12

Although the information collected from questionnaires is subjective, a well-designed instrument will demonstrate certain properties consistent with its purpose. For example, a questionnaire designed to screen individuals at risk for disease should be sufficiently sensitive to classify correctly true positives (people with disease) or sufficiently specific to classify correctly true negatives (people without disease), or both.13 An instrument designed to measure outcome after an exercise program must be responsive to change in the individual(s) surveyed.14 Internal consistency (eg, items addressing similar concepts grouped together), parsimony (eg, lack of redundancy), and generalizability (eg, usability with a variety of individuals or groups) are additional features of well-designed questionnaires.14,15 Finally, a survey instrument should be reliable and valid; in other words, scores must be repeatable and the instrument must measure what it claims to measure.14,15 Confirmation of these features is achieved through research in a variety of settings and populations.

On the other hand, even the best questionnaire may suffer from response bias in that individuals may inaccurately recall the information requested, omit answers to some questions, or provide socially desirable responses to items that over- or underestimate actual performance or status.16 Additional challenges to accurate survey completion include diminished cognitive status, lack of literacy, and language translation problems.16 Despite these limitations, questionnaires are popular instruments for gathering information about a person's, or population's, perceived health status and activity profile.

A variety of questionnaires that address the different components of health promotion are available.10,17 This article will discuss the general purpose, composition, and performance of survey instruments relevant to the questions surrounding physical activity and exercise within health promotion programs. Selected questionnaires in each category will be reviewed in more detail in order to illustrate key points.

HEALTH APPRAISAL AND RISK SCREENING QUESTIONNAIRES

Health appraisal questionnaires are used to gather information about a person's: (1) current health problems, (2) risk for future health problems, and (3) signs and symptoms of potentially undiagnosed health problems.18 Additional questions may survey participants' attitudes and beliefs about health or physical activity or their goals and intentions for an exercise program.19,20 Answers to questions pertaining to the first 3 content areas are used to determine whether medical clearance is indicated prior to the start of a new exercise program. Medical clearance usually refers to an examination by a physician. A supervised maximal exercise test also may be required to determine the safe boundaries for a new exercise prescription or physical activity program.

Of particular concern is the potential for a participant to suffer a catastrophic cardiac event during exercise. The American College of Sports Medicine (ACSM) and the American Association of Cardiovascular and Pulmonary Rehabilitation (AACVPR) have published risk stratification guidelines for use with health appraisal results obtained prior to a new exercise program.10,21 Application of these criteria in conjunction with a health appraisal questionnaire is recommended to guide decision-making regarding medical clearance as well as exercise prescription and need for supervision and monitoring during activity.

General health appraisal questionnaires are similar in content but to date have not been standardized to a specific format.18-20 These instruments usually are administered at participant enrollment at health and fitness facilities and may require a reasonable length of time to complete. Their intent is to solicit sufficient information for a medical history and risk analysis. Some authors recommend coding the instrument to further delineate participant risk or need for additional assessment prior to initiating the exercise program.19 The analogous appraisal in a clinical setting is the routine history collected during patient intake and interview.

An alternative (or supplement) to obtaining a written medical history is a brief screening instrument to assess exercise risk. The Canadian developed Physical Activity Readiness Questionnaire (PAR- Q) is a commonly used screening tool.22 Only 7 questions in length, the PAR-Q was developed tor use with apparently healthy individuals aged 15-69 (Figure 1). A 'yes' answer to any one of the questions is an indication to consult a physician prior to initiating a new exercise program. Those over 69 years old are advised to consult with a physician rather than complete the questionnaire.

The original version of the questionnaire was hypothesized to be 100% sensitive but apparently demonstrated more limited specificity.2 In other words, some individuals were redirected to a physician despite a low risk associated with the start of a new exercise program. Cardinal \et al23 evaluated a revised version of the PAR-Q in a sample of 197 adults between the ages of 60 and 69. Seventy-three percent of the sample was African-American, and 70% indicated a low socioeconomic status. These sociodemographic characteristics reflected individuals at greater risk for cardiovascular events during exercise. The authors reported a 9.4% reduction in exclusions from physical activity with the revised PAR- Q as compared to the original version. Unfortunately, neither sensitivity nor specificity of the instrument was evaluated against a gold standard, such as angioplasty, to confirm the presence or absence of cardiovascular disease in the sample used.

The authors also noted concurrent validity between the 2 questionnaires (phi coefficient = 0.43-0.71, P< 0.0001); however, the relationship between the PAR-Q (in either form) and self- reported current physical activity levels was low (contingency coefficient = 0.22, P < 0.05). Further validation and assessment of the questionnaire's measurement properties has not been reported; however, the Canadian Society for Exercise Physiology has revised the questionnaire again in an effort to improve its useful ness.22 In addition, the Society developed the Physical Activity Readiness Medical Examination Questionnaire (PARmed-X) for physician use when screening individuals referred for medical clearance as a result of the PAR-Q.24 In spite of its potentially limited measurement properties, individuals and health promotion programs likely will continue to use the PAR-Q because the instrument emphasizes patient/ client safety.

In summary, health appraisal and risk screening questionnaires are available for adoption and use in health promotion programs that include physical activity. The measurement properties of some of these instruments have not been reported in the literature or have demonstrated limitations; therefore, selection of a tool should be based upon the individuals served as well as the program's purpose.

Figure 1. Source: Physical Activity Readiness Questionnaire (PAR- Q) 2002. Reprinted with permission from the Canadian Society of Exercise Physiology. http://www.csep.calforms.asp.

Figure 1. Source: Physical Activity Readiness Questionnaire (PAR- Q) 2002. Reprinted with permission from the Canadian Society of Exercise Physiology. http://www.csep.calforms.asp.

PHYSICAL ACTIVITY ASSESSMENT QUESTIONNAIRES

Initiation of a new activity or exercise program requires a starting point that is consistent with an individual's current functional capacity. A graded treadmill or cycle ergometry test is a commonly used objective method for obtaining this information. Measures acquired during the test, such as heart rate and rhythm, blood pressure, respiratory rate, and assessment of expired gas provide physiologic evidence of a person's relative ability to exercise. Formal testing is indicated for individuals at moderate to high risk for cardiovascular disease as well as for individuals with documented disease or disability.21 Many individuals starting a new activity program at home or through a fitness center, however, may not have access to or require a graded exercise test. Physical activity questionnaires may provide general estimates of exercise capacity in situations where testing is not feasible or available.

The most simplistic approach to estimating functional capacity is to survey routinely performed activities and then estimate their energy cost in metabolic equivalents (METs) from a published compendium.25 Total calories expended per time period may be calculated; however, this method does not account for factors such as personal characteristics (ie, weight) and performance details (ie, duration, intensity, technique). In addition, most compendia are developed based on young adult male populations. As a result, functional capacity may be overestimated significantly for older individuals and women using this method."16

A variety of physical activity questionnaires have been developed in order to improve upon the limitations of a general appraisal of daily METs. The majority of these instruments, a collection of which was published in 1997 in Medicine and Science in Sport and Exercise,26 are used in population level studies of activity levels. All of the questionnaires rely on subject recall over a defined period of time (ie, 1 week, 1 month, 1 year). Some of the questionnaires are targeted toward specific age groups (ie, Modifiable Activity Questionnaire for Adolescents; Physical Activity Questionnaire for the Elderly) while others are intended for use in the general population (Modifiable Activity Questionnaire). Commonly surveyed items include leisure activities, occupational demands, and household or caregiving requirements. Frequency, duration, and intensity of activities are queried in longer surveys in an effort to improve estimates of energy expenditure. Finally, instruments may be self-administered or are specifically designed for use with an interviewer.

Kriska and Caspersen provided information regarding the reliability and validity of the questionnaires included in their 1997 article.26 Reliability, assessed through repeat administrations of the survey, generally declined the greater the time interval between assessments. For example, the correlation coefficient for test-retest performance of the Modified Activity Questionnaire for Adolescents' measure of hours per week of activity was 0.78 (P < 0.05) for the 1-month retest interval and 0.54 (P < 0.05) for the 1- year retest interval for male subjects. By comparison, the coefficient for test-retest performance of the Physical Activity Scale for the Elderly was 0.75 (P < 0.05) for a retest interval of 3 to 7 weeks. This variability in scores is understandable given the limits of human recall. Validity studies of these instruments demonstrated a similar range of performance with the highest correlation coefficients (0.60 - 0.80) resulting when comparisons were made to other estimates of functional capacity such as categorical descriptions of activity level (ie, vigorous or moderate) and accelerometer counts. Coefficients were significantly lower when survey results were compared to physiologic measures such as heart rate (0.13; P < 0.05) and leg strength (0.25; P< 0.05). A similar result was noted for one questionnaire with respect to a comparison against estimated maximal oxygen consumption (0.20; P < 0.05).

A recent review by Shepard"' noted similar reliability and validity findings for physical activity questionnaires as well as several other limitations including: (1) floor effects for individuals with low baseline functional capacity, (2) ceiling effects for individuals with high baseline functional capacity, (3) reliance on absolute rather than relative energy expenditures, and (4) small effect sizes. He also noted that questionnaires often include activities that may be inappropriate or irrelevant for the target population studied, a concern similar to that identified with the compendia of physical activity energy costs. In light of these concerns as well as the variance in measurement properties, the usefulness of general physical activity questionnaires for exercise design in health promotion programs is limited. As the instruments reviewed were not designed for use with patient populations, they are not recommended for use in clinical health promotion activities.

Several clinical researchers have developed and tested physical activity appraisal questionnaires for use in patient populations.27,28 One example of such an instrument is the Duke Activity Status Index (DASI). The DASI surveys respondents regarding personal care, household duties, ambulation, sexual function, and recreational activities (Figure 2). Hlatky et al27 initially developed this 12-item instrument by comparing survey scores with measured peak oxygen uptake (VO^sub 2peak^) in 50 subjects performing a graded cycle ergometry test due to cardiac disease. The instrument was validated on a second group of 50 subjects also undergoing exercise testing. The authors reported overall Spearman correlation coefficients of 0.80 (P < 0.0001) in the development group and 0.58 (P < 0.0001) in the validation group. In addition, results of a linear regression model indicated that 64% of the variance in VO^sub 2peak^ was explained by the DASI score. An important limitation of the instrument was noted, however, in that correlations were weakest for patients with low measured functional capacity (< 5 METs).

Figure 2. The Duke Activity Status Index. Hlatky MA, Boineau RE, Higginbotham MB, et al. A brief self-administered questionnaire to determine functional capacity (the Duke Activity Status Index). Am J Cardiol. 1989;64:651-654. Reprinted with permission from Excerpta Medica, Inc.

Subsequent authors have tested the DASI in patients with other diagnoses. Alonso et al29 utilized an 8-item version of the DASI and reported a high internal consistency (Cronbach's α = 0.81 - 0.89) as well as an effect size of 0.75 (P < 0.001) when used with 46 patients following angioplasty. The correlation between questionnaire score and exercise test duration, however, was modest at 0.45 (P < 0.01). Arena et al29 reported that the DASI was highly reproducible when used with a group of patients with congestive heart failure but the ability of the survey score to predict VO^sub 2peak^ was more limited (r^sup 2^ = 0.41; P < 0.001) as compared to Hlatky et al's findings. Finally, Carter et al29 studied the concurrent criterion validity of the DASI physiologic indicators in 119 patients with chronic obstructive pulmonary disease. Correlation was highest with 6-minute walk distance (r = 0.53; P < 0.01) followed by oxygen uptake (r = 0.38; P < 0.001) and minute ventilation (r = 0.27; P < 0.004). All of these studies are limited by the relatively small sample sizes utilized. Nevertheless, taken together along with Hl\taky et al's original work, these findings suggest that the DASI provides useful information regarding many patients' functional capacity. The DASI would not be an appropriate substitute, however, for an exercise test, especially for those at greatest risk of cardiac events.

In summary, a wide variety of physical activity appraisal questionnaires are available for use with apparently healthy and patient populations. Reported measurement properties are highly variable and modest at best. In addition, the potential for over- estimation of performance by survey respondents is an important limitation, suggesting that these instruments are most useful when implemented in conjunction with physiologic measures of functional capacity. The nonclinical tools provide reasonable estimates for population level surveys of health status and may be appropriate for individuals interested in a rough approximation of their current exercise tolerance. Clinical tools may assist with exercise test and prescription design as well as with office-based follow-up of functional capacity.

OUTCOMES SURVEY INSTRUMENTS

The positive outcomes of health promotion efforts such as increased physical activity have been demonstrated repeatedly with respect to physiologic measures of function and disease.3,4 The effect that such efforts have on perceived well-being and quality of life is of particular interest as this information provides insight into the relevance and meaningfulness these activities have for program participants. Outcomes research evaluating the impact of physical activity programs on healthy subjects' overall perceived well-being, however, appears limited. A literature search resulted in several studies that examined the measurement properties of various comprehensive wellness inventories designed for use primarily in specific wellness programs.29-32 Additional research examined the effect of physical activity on health-related quality of life (HRQOL) using instruments routinely used in clinical studies.33,34 A third group of articles evaluated the impact of physical activity on well-being and quality of life in older adults using questionnaires that assessed only psychological and emotional domains.4,35,36 The remainder of this article will compare and contrast selected wellness inventories with HRQOL questionnaires that include a physical functioning domain.

Wellness inventories generally are designed to capture a holistic picture of an individual's lifestyle including behaviors and beliefs that support or inhibit one's ability to lead a productive and satisfying life.32 Comparable to well-established HRQOL instruments, these questionnaires are multidimensional and commonly survey participants regarding: physical health including fitness, nutrition, and controlled substance use; emotional status including stress management and coping; spiritual status; intellectual functioning and work; social support; and risk taking behaviors.29- 32 An important difference is that wellness inventories may serve simultaneously as instructional tools that educate regarding, and reinforce, wellness promoting behaviors.32 Inventories designed for this purpose potentially are less useful program outcomes tools as they may encourage socially desirable or expected responses from participants.

Several wellness inventories have been assessed for their measurement properties. Palombi11 evaluated the reliability and validity of 3 instruments-The Wellness Inventory, The Lifestyle Assessment Questionnaire, and the Lifestyle Coping Inventory-when applied to 110 university students. Survey length was 120, 100, and 142 items respectively. Results of her analysis indicated reasonable internal consistency for all 3 questionnaires (Cronbach's alpha = 0.93); however, her single administration design precluded her ability to test for stability over repeated measures. Content and construct validity analyses conducted by examining correlations among the 3 tools suggested that all of them measured the phenomenon 'wellness.' Adams et al34 reported similar results for the Perceived Wellness Survey, an instrument the authors developed and tested using a sample of 558 employees and university students in Texas and Pennsylvania. The larger sample size in this study, as well as its greater diversity, suggest greater credibility and usefulness for this survey as compared to the instruments in Palombi's work.

The psychometric properties of 2 additional wellness inventories designed for use in specific programs also were described. Renger et al33 developed the Optimal Living Profile (135 items) for use at a commercial wellness center and evaluated its performance on 102 potential program participants. Results indicated adequate reliability with test-retest coefficients for subscale scores of 0.53-0.86 and internal consistency coefficients of 0.78-0.95. Validity of the instrument, on the other hand, was weakly supported. Comparison of scores with expert assessments produced coefficients ranging from 0.04-0.78. In addition, domains within the survey were moderately related (0.33-0.75) suggesting that they were inadequately defined. Squire et al32 described a national validation process for the LaCrosse Wellness Inventory, a 178-item questionnaire used in the LaCrosse Wellness Project. Interpretation and application is restricted, however, because the authors did not provide actual statistical results.

An important feature of each of these studies is the use of apparently healthy members of the available population in order to test reliability and validity of each instrument. As a result these questionnaires may be more applicable for participants in general health promotion programs conducted at fitness centers or other nonmedical facilities. Their considerable length, as well as their variable measurement properties are additional features to consider prior to selection. Health promotion programs for patient populations or those with chronic diseases, on the other hand, may find HRQOL surveys more suitable for measuring the impact of physical activity on outcomes. A number of HRQOL surveys are generic in nature in that they are intended for use with any patient population (ie, the Functional Status Questionnaire), while others have been developed specifically to address individuals with specific diseases or disorders (ie, the St. George's Respiratory Questionnaire).37 Among the many generic health status instruments available, the Medical Outcomes Study ShortForm 36 (SF-36) and Short- Form 12 (SF-12) are two HRQOL instruments that tit this purpose for several reasons. First, both instruments have been extensively tested and validated with large numbers of individuals with a wide range of diagnoses.)38,39 Second, both are norm referenced thereby allowing comparisons to the general population.40,41 Third, both instruments assess physical and mental components of health, with higher scores indicating better quality of life, but are comparatively brief (36 and 12 items, respectively). Finally, researchers have started using the SF-36 for the purpose of assessing physical activity's relationship to, and impact upon, HRQOL in both healthy subjects and patients.42-44

Stewart et al45 examined the association between aerobic fitness, strength, physical activity, body composition, and HRQOL and mood in 82 apparently healthy men and women ages 55 to 75. Fitness, strength, and body composition were measured physiologically while physical activity levels and mood were obtained through questionnaire. The HRQOL was measured by the SF-36. These authors reported that increased levels of aerobic fitness were associated with higher SF-36 scores for physical functioning, bodily pain, and vitality as well as for the physical component subscale score. Strength was not associated with HRQOL scores in any domain. In an apparent contradiction, greater degrees of physical activity were associated with lower (worse) bodily pain scores. This result may reflect inadequacies of the physical activity inventory as compared to more precise measures of fitness such as VO^sub 2^ peak. An important limitation for this study is the use of subjects who were preparing to enter an exercise training trial. The use of this group, along with the cross-sectional design, make it impossible to determine whether greater fitness causes better HRQOL or higher general well-being results in greater motivation to be active.

Laforge et al46 used the SF-36 to evaluate the relationship between HRQOL and readiness for exercise as classified by the Transtheoretical Model of Behavioral Change. This model identifies 5 stages-precontemplation, contemplation, preparation, action, and maintenance-through which an individual may progress in order to achieve a lifestyle change. Results from structured telephone interviews of 1,387 randomly selected adults indicated a linear relationship between exercise stage and physical health domains. In other words, subjects who were starting new activities or had established routines had higher physical health scores than subjects who were considering, but had not yet implemented, an exercise program. By comparison, the mental health scores either demonstrated nonlinear relationships or did not discriminate among the various exercise stages. The authors noted that previous research indicates an inconsistent relationship between physical activity and mental health, with benefits accruing primarily to those with the highest activity levels. Inclusion of independently verified exercise levels may have resulted in clearer relationships between physical activity and mental health scores in this study.

A recent randomized clinical trial examined the impact of wellness interventions on HRQOL in women (n=113) with multiple sclerosis.44 Subjects in the experimental group participated in 8 sessions designed to educate them regarding health promoting behaviors and to provi\de them with the skills and abilities necessary to assess their current situation and implement change. Members of the control group were assigned to a waiting list for the wellness sessions scheduled after the data collection concluded. All subjects were surveyed about their use of health promoting behaviors, including physical activity. The HRQOL was measured using the SF-36. Results indicated that subjects in the intervention group reported higher levels of health promoting behaviors than did subjects in the control group. Intervention group participants also scored higher on the bodily pain and mental health subscales of the SF-36. The lack of impact on physical functioning scales likely was a reflection of disease effects as severity of impairment was strongly correlated with baseline functional scores. Because physical activity was one of several health promotion strategies encouraged in the intervention group, it is difficult to isolate its independent effects. Nevertheless, this study suggests that health promotion activities including exercise may improve emotional and psychological outlook irrespective of differences in physical performance in individuals with chronic disease.

In summary, outcome questionnaires available for use in health promotion programs emphasizing physical activity are multidimensional instruments that attempt to capture wellness or health-related quality of life. Wellness inventories have not been tested extensively and, therefore, exhibit variable measurement properties. The HRQOL instruments such as the SF-36 and SF-12 have demonstrated consistent reliability and validity in both general and patient populations; therefore, these questionnaires may be preferable for evaluating the outcomes of a physical activity program.

CONCLUSION

A variety of questionnaires are available for use by health promotion programs to appraise participants' current health, screen for risk, assess functional status, and measure outcomes (Table 1). Outcome tools are appropriately multidimensional reflecting holistic concepts of wellness and quality of life. Measurement properties of the majority of instruments are modest with the exception of the SF- 36 and the SF-12, both of which have demonstrated consistent reliability and validity in healthy and clinical populations. Selection of questionnaires depends upon characteristics of the population served as well as the purpose and design of the health promotion program. Instruments with established measurement properties are preferable when available.

Table 1. Characteristics of Selected Questionnaires

REFERENCES

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24. Canadian Society for Exercise Physiology. PARmed-RX (Physical Activity Readiness Medical Examination - revised 2002). Available at: http://www.csep.ca/pdfs/ parmedx.pdf. Accessed December 15, 2004.

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27. Hlatky MA, Boineau RE, Higginbotham MB, et al. A brief self- administered questionnaire to determine functional capacity (the Duke Activity Status Index). Am J Cardiol. 1989;64:651-654.

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36. Stathi A, Fox KR, McKenna J. Physical activity and dimensions of subjective well-being in older adults. J Aging Phys Activity. 2002;10:76-92.

37. QOLID: The Quality of Life Instruments Database. Available at: http://www.qolid.org. Accessed December 15, 2004.

38. McHorney CA, Ware JE, Raczek A. The MOS 36-item Short-Form Health Survey (SF-36): psychometric and clinical tests of validity in measuring physical and mental health constructs. Med Care. 1993;31:247-263.

39. Ware JE, Kosinski M, Keller SD. A 12-item Short-Form Health Survey: construction of scales and preliminary tests of reliability and validity. Med Care. 1996;34:220-233.

40. Ware JE. SF-36 Health Survey: Manual & Interpretation Guide. Boston, Mass: Medical Outcomes Trust; 1993.

41. Ware JE, Kosinski M, Turner-Bowker DM, Gandek B. SF-12 v.2: How to Score Version 2 of the SF-12 Health Survey. Lincoln, RI: QualityMetric Incorporated; 2002.

42. Stewart KJ, Turner KL, Bacher AC, et al. Are fitness, activity and fatness associated with health-related quality of life and mood in older persons? J Cardiopulm Rehabil. 2003;23:115-121.

43. Laforge RG, Rossi JS, Prochaska JO, et al. Stage of regular exercise and health-related quality of life. Prev Med. 1999;28:349- 360.

44. Stuifbergen AK, Becker H, Blozis S, Timmerman G, Kullberg V. A randomized clinical trial of wellness intervention for women with multiple sclerosis. Arch Phys Med Rehabil. 2003;84:467-76.

Dianne V. Jewell, PJ, PhD, CCS, FAACVPR

Virginia Commonwealth University, Department of Physical Therapy, Richmond, VA

Address correspondence to: Dianne V. Jewell, PT, PhD, CCS, FAACVPR, Virginia Commonwealth University, Department of Physical Therapy, PO Box 980224, Richmond, VA 23298-0224 Ph: 804-828-0234, Fax: 804-828-8111 (dvjewell@vcu.edu).

Copyright Cardiopulmonary Physical Therapy Journal Mar 2005

Source: Cardiopulmonary Physical Therapy Journal

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