## Abstract

In a pilot health promotion program for couples, we aimed to build on re-evaluation of attitudes to health occurring early in marriage, and social support provided by partners, to address the weight gain and physical inactivity which may follow marriage. A randomized controlled trial lasting 16 weeks used six modules focusing on nutrition and physical activity but including information about alcohol and smoking. Thirty-four of 39 couples enrolled completed the study. Self-efficacy for diet and physical activity increased significantly in the program group while ranking of barriers to healthy behaviours decreased and ranking of beliefs about the benefits of health behaviours increased relative to controls. Intake of fat, take-away foods and alcohol decreased, and consumption of fruit, vegetables and reduced-fat foods increased significantly in the program group. Physical activity in the program group increased by the equivalent of 50 min of brisk walking weekly but did not differ significantly from controls. Cholesterol fell significantly by 6% more in the program group than controls. In focus groups, participants unanimously found the program valuable. Health promotion programs designed for couples can achieve short-term changes in behaviour and risk factors. Larger trials with longer-term monitoring, incorporating feedback from focus groups and cost–benefit analysis, are in progress.

## Introduction

Couples beginning their life together embark on a period of adjustment in which changes in lifestyle are likely to have substantial influences on their health and that of their future children. Several reports suggest that this period of changing lifestyle is associated with worsening of modifiable risk factors for lifestyle diseases, particularly weight gain and physical inactivity (Craig and Truswell, 1988; Kahn and Williamson, 1990, 1991; Kahn et al., 1991). Cross-sectional studies examining weight in relation to marital status have produced various results (Kittel et al., 1978; Noppa and Bengtsson, 1980; Ross and Mirowsky, 1983; Sobal et al., 1992) while interpretation of some reported studies is limited by lack of control groups (Craig and Truswell, 1990), and failure to adjust for age and socio-economic variables (Sobal et al., 1992).

More consistent results come from longitudinal studies reporting weight gain early in marriage (Craig and Truswell, 1988; Kahn and Williamson, 1990, 1991; Kahn et al., 1991; Rissanen et al., 1991; French et al., 1993). In a study of Australian couples followed for 2–3 years after marriage, husbands, but not wives, gained weight (Craig and Truswell, 1988a,b, 1990), in agreement with the reported perception among men that weight gain is associated with becoming married (Egger and Mowbray, 1993). Weight gain associated with marriage in men has been confirmed in longer-term studies (Kahn and Williamson, 1990). However, in a study documenting weight change over the first year of marriage in couples in the US, women, but not men, were reported to have gained weight (Rauschenbach et al., 1995). In the longer term, as for men, marriage was associated with weight gain in women (Kahn and Williamson, 1991).

Few studies have examined reasons why weight gain may follow marriage. Craig and Truswell (Craig and Truswell, 1988) documented a decrease in sporting activities following marriage in both men and women, and, in men, weight gain correlated with decreased exercise but quantitative dietary data were not collected in that study.

There is, then, evidence suggesting that weight gain and decreased physical activity emerge as problems early in the period of adjustment for couples beginning their lives together. Social scientists recognize the concept of lifecourse' (Backett and Davison, 1995) in which stages of life and their associated lifestyles and attitudes to health have been identified. Early in marriage is a time of re-evaluating lifestyle and accepting that behaviours will change. It is therefore likely to be a period of increased receptivity to health promotion messages, as well as providing the opportunity to use the social support (Thoits, 1986) provided by targeting couples.

However, no reported health promotion strategies have focused specifically on this group. We therefore undertook a pilot study to determine the acceptability of, compliance with and responses to a health promotion program for couples. The study was designed as a randomized controlled trial, and targeted nutrition and physical activity in couples who had been cohabiting for not more than 2 years. Both married or unmarried couples were included, given the current prevalence of cohabition without marriage.

## Subjects and methods

Couples were recruited by advertisement in the press, and through publicity on radio and television programs. Inclusion was restricted to Perth couples cohabiting for the first time, not living together for more than 2 years, intending to reside in Perth for the length of the study and not planning a pregnancy during the time of the intervention. Additionally, participants were required to be without serious illness such as heart disease, diabetes or severe asthma. Couples were randomly assigned to the intervention or control groups and continued the study for 4 months. Those allotted to the control group were offered the program at the completion of the study, which was approved by the University of Western Australia's Committee for Human Rights. All subjects provided informed written consent.

Sample size calculations were based on data from previous studies in this department and used an α level of 0.05 with a power of 80% as a minimum. According to these calculations 16 couples per group would allow recognition of a difference from controls of 2% in total fat intake, energy expenditure equivalent to brisk walking for 45 min/week and 5 units in self-efficacy for diet or physical activity behaviours.

### Health promotion program

The program continued for 16 weeks and consisted of a series of six modules which addressed nutrition and physical activity and the benefits of a healthy lifestyle. The physical activity program aimed to encourage participants to accumulate at least 30 min of moderate activity on most days as recommended by the American College of Sports Medicine (Pate et al., 1995). The nutrition program aimed to apply the Australian national dietary guidelines (NHMRC, 1992) to encourage the consumption of a variety of foods low in fat, high in fibre and low in salt. Specifically, the program encouraged the adoption of permanent dietary habits in which no more than 30% of energy was derived from fat along with a daily consumption of 30 g of fibre from grains, fruits and vegetables as recommended by the Health Targets and Implementations (Health for All) Committee (1988).

At an initial visit, the purpose of the study was explained in detail to each couple, baseline measurements were recorded and questionnaires completed. Couples received the modules at intervals of 2–3 weeks, alternating mail-outs with contact sessions at which the nutrition and physical activity facilitators explained the aim of the modules, demonstrated exercise technique, answered questions and reviewed progress.

The modules were developed to move participants gradually toward the long-term aims of the program with each module building on the previous ones. The program was self-directed and avoided being prescriptive. Topics presented included the benefits of exercise and good nutrition, how to start an exercise program, injury prevention, recognizing signs of overexertion, back care, cultivating exercise partners, the Healthy Diet Pyramid, types and sources of dietary fat, healthy eating on a budget, specific nutrient needs, and choosing healthy meals in restaurants. As the program was directed towards couples, the final module provided information about exercise and diet before, during and after pregnancy.

Information about behavioural modification was also included in each module and covered such topics as barriers to behaviour change, costs and benefits of a healthy lifestyle, goal setting, time management, and stress management. Although reducing alcohol consumption and cigarette smoking were not the main focus of the program, information on these topics was included consistent with the objective of achieving a healthy lifestyle.

### Physiological measurements

All measurements were made at the beginning and end of the 16-week program. Systolic and diastolic blood pressure and heart rate were measured using a Dinamap 1846 SX/P (Critikon, USA). Subjects were seated, given a familiarization measurement and then asked to sit quietly for 5 min. Three readings were then taken at 1-min intervals and the mean used in subsequent analyses. Anthropometry included height, weight, hip and waist circumferences. A non-fasting blood sample was taken for determination of total cholesterol and high-density lipoprotein (HDL)-cholesterol in all subjects and analysed using standard methods by the Department of Biochemistry, Royal Perth Hospital.

### Lifestyle behaviours

Instruments specific for exercise, diet, alcohol and smoking behaviours were used. A five-item algorithm based on the model developed by Prochaska and DiClemente (Prochaska and DiClemente, 1983) assessed stage of change for each of the health behaviours, and was used in modifying individual goals and strategies. With the small number of couples included in the study no group comparisons were carried out for stages of change. Barriers to desirable behaviours (i.e. regular exercise, healthy diet) were assessed using items developed for previous studies in this department (Gracey et al., 1996) using a six-point scale with a maximum possible score of 72. The Low Fat Diet scales developed by Plotnikoff and Higginbotham (Plotnikoff and Higginbotham, 1995) which measure self-efficacy, response efficacy and intentions were modified for use with each of the health behaviours. Beliefs about the benefits of health behaviours were elicited using a six-point scale. Separate questionnaires for diet, physical activity, alcohol drinking and smoking used items addressing beliefs about associations between each behaviour and lower blood pressure, lower cholesterol, decreased risk of heart disease, increased longevity, improved general health and control of weight gain. For each item, a higher score indicated a stronger belief in the benefits of the behaviour.

Dietary intake was assessed at pre- and post-intervention using 24-h diet records completed on three specified days which included 2 weekdays and one weekend day. Participants were given detailed instructions on how to complete these diet records and measure foods using cups and spoons. Daily nutrient intake was calculated using the Xyris Diet/1 Software (Brisbane, Queensland, Australia) based on the current Commonwealth of Australia Department of Health NUTTAB 1995 database updated from Lewis and Holt (Lewis and Holt, 1991). A modified version of the short fat questionnaire' developed by Dobson et al. (Dobson et al., 1993) was also used before and after the program and in the eighth week of the program. This questionnaire includes items relating to intake of fat, fruit, vegetables and fibre. Questions concerning consumption of salt, reduced fat products, and variety of fruit and vegetables were added to this basic questionnaire.

Both a 7-day recall questionnaire (Sallis et al., 1985) and a 14-day activity recall (Department of the Arts, Sport, the Environment and Territories, 1992) were used to assess the level of habitual physical activity, and allowed checking of consistency of responses with the 7-day recall overlapping the 14-day recall. The 7-day recall method was originally used in the Stanford Five-City Project (Sallis et al., 1985), and is an interviewer-administered recall of both leisure-time and occupational activity. The 14-day recall was modified from the questionnaire used by the Australian Department of the Environment, Sport and Territories (Department of the Arts, Sport, the Environment and Territories, 1992) during 1990–91 in the Pilot Survey of the Fitness of Australians'. Slight modification of the original questionnaire, which was an interviewer-administered recall of leisuretime physical activity, allowed the use of a self-administered format. A similar format was used in designing Activity Diaries given to couples assigned to the program group. Individuals were asked to record the amount, type and intensity, on a four-point rating scale, of all leisure-time activity. Diaries were returned by mail every 2 weeks to allow monitoring of individual progress and provide a basis for feedback to the couples during their subsequent contact session with the facilitators. Results relate to the 14-day records.

Alcohol intake was measured using 7-day retrospective diaries and amounts were converted to their equivalent in g/day of ethanol. Usual patterns of alcohol consumption were elicited by questionnaire allowing categorization of volunteers as non-drinkers, safe' drinkers whose alcohol intake conformed to Australian national guidelines (NHMRC, 1991), which recommend that women should not exceed two standard drinks per day and men should not exceed four standard drinks per day, or unsafe' drinkers whose alcohol intake regularly exceeded these limits. Questionnaires also elicited the pattern of drinking in relation to regular weekday habits and weekend binge' drinking. Smoking habits, including amount, duration and interval since commencing smoking or giving up smoking were established by questionnaire.

### Focus groups

The focus group approach (Basch, 1987) was based on the premise that in opening up investigation of a hitherto neglected area it is vital to listen first to the participants, and that the information obtained would provide a guide to future development of the program in terms of choice of vocabulary and other aspects of instrumentation.

Focus groups, each including six couples who participated in the program, were conducted at the end of the intervention by a trained moderator. The format comprised nine main questions which sought information on the participant's attitudes to the program overall and its structure; difficulties experienced in compliance with the program's goals; knowledge and awareness of a healthy lifestyle; and possible improvements to the program. Within each question there were a number of other questions which allowed the interviewer to probe for additional data. The focus group lasted for approximately 60 min. Prior to the commencement of the session it was explained by the interviewer that confidentiality was assured, as was the right of participants to remove themselves from the focus group at any time without prejudice. The session was videotaped using a Panasonic AD450 videocamera set approximately 3 m from the subjects at an angle which ensured that all subjects were in full view of the camera during the entire focus group session. The videocamera was operating prior to participants entering the room. An opportunity was given for clarification of each question before the participants responded to it.

Qualitative techniques were used to analyse the data (Zemke and Kramlinger, 1985). This consisted of generating a list of key ideas, words, phrases and verbatim quotes; using ideas to formulate categories and placing ideas and quotes in appropriate categories; examining the contents of each category for subtopics; and selecting the most frequent and most useful illustrations for the various categories.

### Statistical methods

One-way analysis of variance was used to compare groups at baseline. The effects of the program were assessed using the SAS Mixed' procedure (Murray and Wolfinger, 1994) which allows analysis according to the unit of randomization (couples) and accounts for correlation between variables within couples. The models used were based on the analysis of covariance approach, with adjustment for baseline values, as described by Murray and Wolfinger (Murray and Wolfinger, 1994). Data are shown as means and 95% confidence limits. P < 0.05 was considered significant.

## Results

Thirty-nine of eighty-four couples who expressed an interest in participating met the entry criteria. Thirty-four couples, 17 per group, completed the study. Five couples withdrew, one because of marital problems, one through lack of time, one because of major surgery and two couples gave no reason. The mean age for men was 29.1 (SD 6.2) years and for women was 26.7 (SD 4.6) years. Baseline characteristics of the couples are shown in Tables I–III.

### Barriers to positive health-related behaviours

At baseline the total score for ranking of the importance of barriers to healthy eating was statistically significantly higher in those randomized to the control group (mean 50 ± 2) than in the intervention group (mean 44 ± 2).

At the end of intervention, after adjustment for baseline values, the total score for barriers to healthy eating had decreased statistically significantly in the intervention group (mean 38 ± 2) and increased in the controls (mean 57 ± 2). Thus, even with adjustment for differences at baseline, couples receiving the program perceived barriers to healthy eating as being less important than did controls. The intervention group ranked knowing how much to eat (P = 0.0434), knowing which foods are low in fat and sugar (P = 0.0006), knowing which foods are high in fibre (P = 0.0003), having trouble in sticking to a healthy diet (P = 0.0044), knowing the fat content of foods (P = 0.0083) and knowing the total amount of fat to eat daily (P = 0.0383) as significantly less important barriers to healthy eating than did the controls.

At the end of intervention, the total score for barriers to physical activity was statistically significantly lower in the intervention group, after adjustment for baseline values with a mean of 26 (±1) in the program group and 32 (±1) in the controls. The ranking was significantly lower in the program group than in controls for the following barriers: inactive friends (P = 0.0046), lack of family support (P = 0.0300), not knowing which activities to do (P = 0.0334), lack of willpower (P = 0.0026), apparent lack of benefits from physical activity (P = 0.0004), lack of companions for physical activity (P = 0.0010), trouble in sticking to a routine (P = 0.0114), interference with social life (P = 0.0070) and expense (P = 0.0312).

### Health beliefs

There were no statistically significant differences between treatment groups at baseline in the total score for health beliefs relating to diet with a mean of 33 (±1) in both the program and control groups. Similarly, there were no statistically significant differences at baseline in total score for beliefs about physical activity with respective means of 30 (±1) and 31 (±1), alcohol intake (mean 31 ± 1 versus mean 28 ± 1, respectively) or smoking (mean 32 ± 1 versus mean 33 ± 1, respectively).

At the end of the program, health belief score for diet had increased in the program group with a mean of 35 (±1) which differed significantly (P = 0.0003) from that of 33 (±1) in controls. Volunteers in the program group ranked beliefs about diet and blood pressure (P < 0.0001), diet and heart disease (P = 0.0032), diet and longevity (P = 0.0068), diet and general health (P = 0.0130), and preventing weight gain (P = 0.0415) significantly more highly than those in the control group.

Total score for health beliefs relating to physical activity was also significantly greater in the program group at the end of intervention (P = 0.0014) with a mean of 34 (±1) compared with a mean of 32 (±1) in controls. Post-intervention, ranking for beliefs about physical activity and cholesterol (P = 0.0111), heart disease (P = 0.0073), longevity (P = 0.0156), general health (P = 0.0102) and weight control (P = 0.0323) was significantly greater in the program group.

At the end of the program, ranking of health beliefs related to alcohol intake was also significantly greater (P = 0.0009) in the program group with a mean of 33 (±1) compared to 29 (±1) in controls. The program group ranked their beliefs about alcohol and blood pressure (P = 0.0001), cholesterol (P = 0.0154), heart disease (P = 0.0124), longevity (P = 0.0389) and weight control (P = 0.0341) significantly more highly than the control group.

There were no statistically significant differences between program and control groups in total score or in individual items for beliefs about smoking and health.

### Self-efficacy

At baseline, self-efficacy for diet was significantly higher (P = 0.0030) in the program group (mean 44 ± 1) than in the controls (mean 38 ± 2). Differences between the treatment groups increased after the intervention with a mean of 51 (±2) in the program group and 38 (±2) in the controls (P = 0.0001).

For physical activity, scores for self-efficacy did not differ statistically significantly between groups at baseline with means of 40 (±1) in the intervention group and 38 (±1) in the controls. By the end of intervention the self-efficacy score for physical activity differed significantly in the treatment groups (P = 0.0123) and had increased to 44 (±1) in the program group compared to 37 (±1) in the controls.

Self-efficacy for alcohol intake did not differ between groups at baseline with a mean of 31 (±1) in the program group and 31 (±1) in the controls. At the end of intervention the score had increased to 32 (±1) in the intervention group and was 30 (±1) in the controls but this difference was not statistically significant. Self-efficacy for smoking did not show statistically significant differences between groups at baseline (mean 35 ± 2 in the program group; mean 34 ± 2 in the controls) or at the end of intervention when the respective means were 35 (±3) and 36 (±3).

### Measures of health-related behaviours

#### Diet

Nutrient intake determined from diet records (Table I) showed a significantly greater fall in energy intake in the program group, after adjustment for differences at baseline (P = 0.0183). Decreases in intake of total fat (P = 0.0352) and saturated fat (P = 0.0142) were also significantly greater in the program group. Groups did not differ statistically significantly in the intake of polyunsaturated or monounsaturated fats or in fibre consumption.

#### Physical activity

Weekly leisure-time energy expenditure as assessed by the 14-day recall increased by 473.2 (±243.1) kcal/week in the program group and by 123.8 (±340.5) kcal/week in the controls. A variety of physical activities was used and the difference between the groups is equivalent to about 50 min of brisk walking per week. However, these differences were not significant (P = 0.2120). Both focus groups (see below) and interaction with facilitators indicated that the program group was more aware of the importance of incidental exercise, such as using stairs instead of lifts, and had changed their behaviours to incorporate these activities.

#### Smoking

In the program group, at entry to the study, there were seven men (32%) and three women (14%) who were current smokers; two men (13%) and two women (12%) among the control group were smokers. At the end of the program four men and two women in the intervention group as well as two women and one man in the control group had given up smoking.

#### Alcohol drinking

There were two men (both in the intervention group) and three women (two controls and one in the intervention group) who never drank alcohol. Four men (three controls and one in the program group) and seven women (three controls and four in the program group) drank alcohol only on special occasions. Twenty-five men (14 program and 11 control) were classified as unsafe' drinkers as were 20 women (12 program and eight control). All unsafe' drinkers exceeded the recommended limits at weekends and not on weekdays. Mean daily ethanol intake at baseline was 17.6 (±4.9) g in men in the program group and 5.0 (±1.5) g in the controls (P = 0.0326). For women, the respective means were 12.7 (±2.5) and 6.8 (±3.1) g, and these did not differ statistically significantly.

At the end of intervention, two men and three women from the program group had changed from an unsafe' drinking to a safe' drinking pattern, while three men from the control group had moved from safe' to unsafe' drinking habits. Mean daily ethanol intake decreased by 8.3 (±5.6) g/day in men in the program group and increased by 8.7 (±5.8) g/day in the controls with a significant difference between groups (P = 0.0437). For women, alcohol intake fell by 6.7 g/day in the program group and by 0.8 g/day in the controls; this change was not statistically significant.

#### Changes in risk factors

Total cholesterol fell by 4% in the program group (Table II) and increased by 2% in the controls leading to a significant difference between groups (P = 0.0359). There were no statistically significant differences in blood pressure or in anthropometry between the program and control groups.

## Focus groups

All those who attended the focus groups enjoyed the program very much. The program was unanimously considered to be valuable, particularly the material presented on exercise and nutrition and the process of keeping diet records. Central to all responses was that the program made them aware of their inappropriate lifestyle prior to participating. Comments included:

I could see how to put things into practice as a result of doing the program. (Male)

The program made us aware of the ugly things we once were—first time I did it (record food) all that I saw on my record list was chocolate biscuits, chocolate, ice cream and junk food. I didn't know I ate all that! (Female)

All participants regarded the contact sessions as very important, providing the opportunity to clarify the written materials, to ask questions and to speak with other people in the program and with the experts'. Some of the comments were:

The people running the program told us about the principles behind what we were doing and the reasons why we were doing it. (Male)

The contact sessions allowed us to get good ideas from other people and to share experiences. (Female)

The contact sessions really motivated us to read the material and this increased our knowledge. We used to ask each other questions about the material. (Female)

The modules were highly rated by the participants who cited their presentation/format, amount of information provided, their length and language as excellent. In addition, the individuality of the units, yet how they linked to each other sequentially, was seen as an excellent characteristic. There was complete agreement that all participants would recommend the program to others.

The only problem in complying with the program related to the time needed for exercise. Since all of the participants worked during the day, they often found it difficult when they came home in the evening to undertake exercise. On the positive side, this problem raised individual's awareness of their current lack of exercise. Some of the comments included:

We set one night on one side to go to the pool—we made sure of that. (Female)

I now put time aside to exercise. (Male)

Instead of driving to the video shop we now walk—its only 10 minutes but it makes you feel good. (Male)

The writing down of exercises at the start was excellent—it set the way. (Male)

Eating out in restaurants or at friends' was discussed as being a potential problem. One participant stated:

Integrating social life—for example, when at restaurants with other people can be difficult! At least I knew what to choose to eat though. (Female)

Overall, participants were in total agreement that the program had assisted them to identify and refine strategies which enhanced their uptake and maintenance of the recommended exercise and nutrition activities.

All participants stressed the importance of partners in helping to exercise regularly and/or improve eating patterns and regarded the couples-based' structure of the program as a major advantage. Partners influenced behaviours in some cases by engendering feelings of guilt for not complying, or by positive reinforcement looking good/taking exercise, etc.'.

All of the participants recognized the importance of adopting a healthy lifestyle prior to beginning the program. None of them, however, followed such a lifestyle. One comment which typified the consensus was:

You knew that you should eat properly, exercise, etc....but didn't. (Female)

There was total agreement that if this program was not available there would not be an accessible source of information necessary to adopt a healthier lifestyle. Some individuals cited:

Choice magazine/Women's Weekly—other snippets. These do not say why you should do this or eat that. (Female)

This program helped me to see the broad benefits. (Male)

Even if I eat a piece of cheese I know what I'm eating and I think about what I'm eating. (Male)

I now know that fat isn't bad, it's OK—its the amount. (Female)

The whole group stressed that since beginning the program they had become a lot more careful in their selection of foods. Comments included:

We take more note now about what we buy off the shelf—always read the information provided. (Female)

When we shop we always now look at the information on the packaging. We even look to see if the Heart Foundation tick is there. (Male)

According to all of the participants there had been no negative financial or social costs. Comments in support of this included:

Before starting the program we spent easily $110 a week on food—we don't know how—but we bought all the usual things like chocolate, biscuits, pies, soft drink. Now we spend no more than$70 week—in fact we spent $67 this week. (Female) We check the fridge before we go shopping each week and buy what we need and this saves us money. (Female) If we are going out to someone's for a meal or we are going for a big night out we can plan for it as a result of the program. (Male) ## Discussion This pilot study has shown the potential to achieve change in health-related behaviours in couples who are in the process of adopting a shared lifestyle. The program takes advantage of the reassessment of attitudes to health occurring at this point in the lifecourse and builds on the support arising from targeting couples rather than individuals. Responses from participants were uniformly positive, with particular emphasis on the difficulty of obtaining from other sources the information included in the program. Although the study was carried out as a pilot program to assess the suitability of the material for this group, monitor compliance and obtain feedback from participants, and was not designed to provide sufficient power to recognize changes in all behavioural variables, several statistically significant improvements in health behaviours were demonstrated. These included increased consumption of reduced-fat foods and fruit and vegetables, and decreased consumption of take-away foods. Improvements in diet were confirmed by a statistically significant decrease in fat consumption measured by a short fat questionnaire', and by a decreased intake of total energy, total fat and saturated fat in nutrient analysis from 3-day diet records. Weekly physical activity increased by the equivalent of 50 min of brisk walking relative to the control group but this difference was not statistically significant. In addition, the program group had become aware of the importance of incidental exercise, and had moved to incorporating walking and stair-climbing as part of their daily activities. Behaviour modification was a major component of the program. Some couples knew that they should improve their lifestyle but were uncertain about how to achieve behaviour change. Participants found it particularly helpful to have a program which provided knowledge but also the skills to put this knowledge into practice. Although diet and physical activity were the main focus of the program, information about alcohol and smoking was included in the modules, along with general strategies for achieving behavioural change. Alcohol intake decreased statistically significantly in the program group with a move from unsafe' to safe' drinking practices while some of the control group changed from safe' to unsafe' drinking. Although more smokers in the program group quit by the end of intervention, numbers were too small to allow valid comparisons of quitting rates between groups. These changes in health behaviours were accompanied by a reassessment of perceived barriers to behaviour change. Participants in the program group showed a decrease overall in the ranking of the importance of barriers to changing behaviours related to diet and physical activity. Specifically, barriers to change addressed in the program, such as the fat content of foods, were ranked statistically significantly less highly at the end of intervention in the program group. The score for health beliefs related to each health behaviour, indicating a stronger belief in the benefits of healthy behaviours, increased statistically significantly in the program group in relation to diet, physical activity and alcohol, although modifying alcohol intake was not a primary focus of the program. These changes were accompanied by a statistically significant increase in self-efficacy for diet and physical activity behaviours. Unlike our earlier findings in 15- (Gracey et al., 1996) and 18-year-olds in Perth (Milligan et al., 1997), lack of healthy foods at home and lack of control over foods available at home were not perceived as barriers to healthy eating. This probably reflects the domestic independence of the couples in the present study. In younger subjects (Gracey et al., 1996; Milligan et al., 1997), lack of knowledge about the nutrient content of foods was a major barrier to healthy eating. In those subjects, the reality of this perception was confirmed by responses to questions relating to knowledge about foods (Gracey et al., 1996). In contrast, most of the couples in the present study did not rank ignorance about nutrient content of foods as being highly important but they were concerned about not knowing how much fat they should be eating. These differences could be interpreted as indicating that the couples who have assumed responsibility for catering for themselves have at the same time acquired some knowledge about foods and nutrients. However, it appears that they perceive the need for more information about the amount of fat in foods. Furthermore, the decrease in perceived importance of knowledge about nutrient content by the end of intervention suggests that the program addressed difficulties of which the participants were unaware initially. The high ranking of problems in buying suitable foods for lunch is similar to our earlier studies in 15- and 18 year-olds, and suggests that lack of healthy choices for lunchtime foods is a problem extending beyond the well-recognized difficulties of food choices available at school canteens. The expense of healthy foods which was perceived as an important barrier by a few participants initially proved to be unrealistic and, as indicated by comments in focus groups, participants in the program actually saved money on their food bills. Among men and women in the UK (Lloyd et al., 1995), lack of knowledge about the fat content of foods, expense and problems in shopping for these foods were perceived as barriers to eating a reduced-fat diet but the unattractive taste of reduced-fat foods was considered the most important barrier in that study. Actual barriers to change influencing attempts to eat a diet low in fat were similar to perceived barriers although the cost of low-fat foods was seen to be not a real problem. However, lack of family support emerged as an unanticipated difficulty (Lloyd et al., 1995) while ignorance about the fat content of foods, particularly when eating out, was a barrier to maintenance of a diet low in fat. In the present study, participants found that they actually saved money in changing to a healthy pattern of eating and that the social support arising from involvement of both partners was a strength of the program. The taste of low-fat foods appeared to be a less important barrier in the present study, consistent with reports from other Australian groups (Crawford and Baghurst, 1990), and may relate to the ready availability of low-fat foods in Australia combined with local and national health promotion campaigns encouraging their use. Barriers to physical activity were similar to those found in our previous study of 18-year-olds in Perth (Milligan et al., 1997). These were lacking willpower, being too tired, sticking to a routine and lack of planning time, and, for women, lack of companions with whom to exercise. At the end of the intervention, participants in the program group ranked barriers to physical activity as statistically significantly less important. The health belief model has been used to assess beliefs likely to influence health-related behaviours (Contento and Murphy, 1990), based on associations between these behaviours and an individual's perception of risk (Thomas, 1994). Participants in the program showed statistically significant increases in health belief scores for dietary behaviours and physical activity, which were the focus of the program, and also alcohol drinking behaviour which was not targeted specifically. These changes may have been influenced by improved knowledge from materials provided in the program modules. Although knowledge and behaviours may not be strongly correlated (Carmody, 1987), knowledge about health behaviours is a predisposing factor for behaviours such as healthy dietary choices (Thomas, 1994). Perceived self-efficacy, the belief that an individual can carry out a behaviour (Bandura 1977), is suggested to be an important determinant of health behaviours including diet and physical activity (Sallis et al., 1988), smoking (Condiotte and Lichtenstein, 1981) and alcohol drinking (Evans and Dunn, 1995). Improved behaviours following programs to increase self-efficacy are recognized (Strecher et al., 1986), and our study confirms that behavioural change towards better eating habits and greater physical activity is accompanied by greater self-efficacy for both these behaviours. Changes in psychological measures were paralleled by improvements in several indicators of dietary behaviour. These changes were consistent with the themes presented in the program modules, i.e. to eat less fat and more fruit and vegetables. Although there was a large increase in the mean weekly physical activity, equivalent to 50 min of brisk walking per week, in the program group the wide spread of values led to there being no statistically significant difference between the treatment groups. However, this pilot study was not designed with adequate power to detect such differences, as the variability was greater than anticipated, and this will be addressed in a larger study using this program. Feedback from the sessions with facilitators and the focus groups indicated that participants were more aware of the value of incidental exercise in activities such as taking the stairs or walking to the shops instead of driving. Such activities adopted as regular behaviours have an important role in reducing the risk of lifestyle diseases (Gordon et al., 1993; Pate et al., 1995). Improved behaviours in relation to alcohol consumption also occurred with a decrease in mean daily ethanol intake equivalent to almost one drink per day in men and about one drink in 2 days in women in the program group. There was also a change from unsafe' to safe' drinking in five participants in the program while, in the control group, three men changed from safe' to unsafe' drinking patterns. These changes occurred although alcohol drinking was not the primary target of the program. Six smokers in the program group and three in the control group had given up smoking at the end of the program. Because of the small numbers and differences in the rate of smoking between the program and control groups at baseline, it was not possible to compare changes in smoking rates between treatment groups. However, these results are encouraging and suggest that the incorporation of information about smoking is likely to be a useful part of the program. These changes in a range of health behaviours are consistent with the re-evaluation of health attitudes expected at this stage of an individual's lifecourse (Backett and Davidson, 1995) and reinforce the rationale for targeting couples at this point. Changes in dietary behaviours, with decrease in consumption of total and saturated fat of about 2%, were associated with a statistically significant decrease in blood cholesterol. Although this difference in mean fat consumption appears small, Oster and Thompson (Oster and Thompson, 1996) estimate that, based on US data, a 3% reduction in saturated fat consumption would decrease incidence of coronary artery disease in adults by almost 100 000 over a 10 year period. No other statistically significant changes in cardiovascular risk factors were seen but, as pointed out above, the pilot study was not designed with sufficient power to recognize small differences in blood pressure or measures of obesity. Results of this study depend on self-reports and are potentially open to bias, with the possibility of participants coming to know which responses are considered favourable and reporting these. In the present study, assessment of responses depended on completion of detailed physical activity diaries and measured 3-day diet records, all of which were examined for inconsistencies. The use of overlapping 7- and 14-day activity records provided further validation. Contact sessions with the facilitators also provided opportunities for recognizing that behaviours did not agree with written reports. We found no evidence of reporting biased to produce favourable responses, but acknowledge that this is a possible source of error which would exaggerate differences between the intervention and control groups. On the other hand, measurements in the control group may have been influenced by changes in behaviour arising from inclusion in the study without receiving the program, the so-called Hawthorne effect (Murray et al., 1988), thus diluting the difference in response between control and program groups. Longitudinal studies support the association between weight gain and becoming married. Craig and Truswell (Craig and Truswell, 1990) compared weight gain in the couples included in their study with cross-sectional data from the Australian National Heart Foundation Risk Factor Prevalence Study (1983) which included both married and unmarried men and women of comparable age. The mean increase in body mass index (BMI) seen in their study was greater than that seen in the cross-sectional data. In analyses adjusting for age, Rauschenbach et al. (Rauschenbach et al., 1995) found that weight gain over 1 year was greater in women who became married compared to already married women who remained married. Although weight gain was greater in older women, regardless of marital status, Rauschenbach et al. (Rauschenbach et al., 1990) demonstrated a significant effect of becoming married on weight gain over 12 months independent of age and several demographic variables. In the present study, although mean weight decreased in both men and women in the program group, and in men in the control group, while there was an increase in mean weight in women in the control group, between-group differences were not statistically significant. Increased weight and decreased physical activity in couples beginning to live together (Craig and Truswell, 1988; Kahn and Williamson, 1990, 1991; Kahn et al., 1991) appear to be inconsistent with reports of lower mortality among married people, particularly men (Gove et al., 1983; House et al., 1988; Trovato and Lauris, 1989; Ebrahim et al., 1995). Sobal et al. (Sobal et al., 1992) suggest that protective effects of marriage on other behaviours, particularly risk behaviours (Umberson, 1987), and the importance of social support (Turner and Marino, 1994) may attenuate the effects of obesity and physical inactivity on risk for lifestyle diseases. However, as obesity and physical inactivity are well-recognized risk factors for cardiovascular and other lifestyle diseases, control of these factors is desirable for adults embarking on a shared lifestyle, and, in the longer term, is likely to improve lifestyle and reduce risks in their children. Focus groups were used in the present study to obtain an overview of issues, themes and attitudes in nutrition and physical activity programs, to generate information helpful in the construction of quantitative instruments, to provide overall background information in the area, and to generate hypotheses that can be further tested in later research. In addition, it was aimed to obtain as full an account as possible of couple's perspectives in their own terms and to elicit any relevant views, concerns or misunderstandings. This qualitative information proved helpful in emphasizing the need for and acceptability of health promotion programs for couples and supported the rationale for targeting this group, with particular reference to the social support from involving partners. Several suggestions were made about minor changes likely to improve the modules and their presentation; these have been incorporated into materials for larger studies now in progress. Our findings confirm that focus groups are an important resource in the design and implementation of health promotion programs (Basch, 1987). This pilot study has shown that couples beginning to cohabit are receptive to health promotion and perceive this information as not being readily available without a program of the type implemented in the present study. Good compliance and positive feedback from participants, improved health behaviours and lower blood cholesterol indicate the potential value of such a program which builds on the social support engendered by targeting couples. However, generalization of the findings to the wider community is limited by the healthy volunteer' effect, a phenomenon in which volunteers, such as the couples in the present study recruited by advertisement, tend to have more favourable lifestyles and health outcomes (Lindsted et al., 1996). Further studies are in progress of a size adequate to examine other endpoints, to assess maintenance of behaviours in the longer term and to estimate the cost–benefits of programs of different levels of intensity. Table I. Intakes of nutrients targeted in the program before and after intervention in men and women (values are means and 95% confidence limits) Variable Control Program Men (n = 17) Women (n = 17) Men (n = 17) Women (n = 17) Energy (MJ) baseline 9.5 (7.8, 11.1) 7.1 (6.1, 8.1) 11.2 (9.5, 12.9) 9.1 (7.4, 10.7) end 9.2 (8.0, 10.5) 6.8 (6.1, 7.5) 8.9 (7.8, 10.0) 7.7 (6.8, 8.5) Total fat (% energy) baseline 32.0 (28.3, 35.7) 31.6 (27.6, 35.7) 32.3 (29.1, 35.6) 31.8 (29.0, 34.6) end 32.2 (28.5, 35.8) 32.6 (28.5, 36.7) 30.8 (26.8, 34.7) 31.3 (27.3, 35.1) Saturated fat (% energy) baseline 14.3 (12.7, 15.8) 13.3 (11.0, 15.3) 13.6 (11.6, 15.5) 14.2 (12.4, 16.0) end 13.9 (12.0, 15.8) 13.8 (12.2, 15.4) 11.9 (9.4, 14.4) 13.0 (10.6, 15.3) Polyunsaturated fat (% energy) baseline 4.2 (3.6, 4.8) 4.1 (3.5, 4.7) 4.3 (3.7, 5.0) 4.1 (3.3, 4.7) end 4.5 (4.0, 5.1) 4.3 (3.6, 4.9) 4.6 (3.9, 5.4) 4.4 (3.5, 5,2) Monounsaturated fat (% energy) baseline 12.5 (11.2, 13.9) 11.2 (9.7, 12.8) 11.2 (9.6, 12.7) 10.4 (9.2, 11.6) end 11.2 (9.6, 12.7) 11.6 (9.3, 13.8) 10.9 (9.3, 12.6) 11.0 (9.5, 12.5) Fibre (g/day) baseline 22.0 (17.5, 26.4) 21.0 (16.3, 25.6) 26.7 (23.4, 30.1) 22.5 (19.0, 26.1) end 22.0 (18.0, 26.1) 20.0 (17.0, 22.9) 27.0 (24.6, 29.5) 24.2 (20.7, 27.7) Sodium (g/day) baseline 3.1 (2.5, 3.8) 2.4 (2.0, 2.8) 3.3 (2.7, 4.0) 3.1 (2.4, 3.9) end 3.3 (2.8, 3.8) 2.7 (2.1, 3.3) 3.3 (2.8, 3.8) 2.8 (2.4, 3.3) Variable Control Program Men (n = 17) Women (n = 17) Men (n = 17) Women (n = 17) Energy (MJ) baseline 9.5 (7.8, 11.1) 7.1 (6.1, 8.1) 11.2 (9.5, 12.9) 9.1 (7.4, 10.7) end 9.2 (8.0, 10.5) 6.8 (6.1, 7.5) 8.9 (7.8, 10.0) 7.7 (6.8, 8.5) Total fat (% energy) baseline 32.0 (28.3, 35.7) 31.6 (27.6, 35.7) 32.3 (29.1, 35.6) 31.8 (29.0, 34.6) end 32.2 (28.5, 35.8) 32.6 (28.5, 36.7) 30.8 (26.8, 34.7) 31.3 (27.3, 35.1) Saturated fat (% energy) baseline 14.3 (12.7, 15.8) 13.3 (11.0, 15.3) 13.6 (11.6, 15.5) 14.2 (12.4, 16.0) end 13.9 (12.0, 15.8) 13.8 (12.2, 15.4) 11.9 (9.4, 14.4) 13.0 (10.6, 15.3) Polyunsaturated fat (% energy) baseline 4.2 (3.6, 4.8) 4.1 (3.5, 4.7) 4.3 (3.7, 5.0) 4.1 (3.3, 4.7) end 4.5 (4.0, 5.1) 4.3 (3.6, 4.9) 4.6 (3.9, 5.4) 4.4 (3.5, 5,2) Monounsaturated fat (% energy) baseline 12.5 (11.2, 13.9) 11.2 (9.7, 12.8) 11.2 (9.6, 12.7) 10.4 (9.2, 11.6) end 11.2 (9.6, 12.7) 11.6 (9.3, 13.8) 10.9 (9.3, 12.6) 11.0 (9.5, 12.5) Fibre (g/day) baseline 22.0 (17.5, 26.4) 21.0 (16.3, 25.6) 26.7 (23.4, 30.1) 22.5 (19.0, 26.1) end 22.0 (18.0, 26.1) 20.0 (17.0, 22.9) 27.0 (24.6, 29.5) 24.2 (20.7, 27.7) Sodium (g/day) baseline 3.1 (2.5, 3.8) 2.4 (2.0, 2.8) 3.3 (2.7, 4.0) 3.1 (2.4, 3.9) end 3.3 (2.8, 3.8) 2.7 (2.1, 3.3) 3.3 (2.8, 3.8) 2.8 (2.4, 3.3) Table II. Occupation of participants Group Managers Professionals Para-professionalsa Trades Clerks Sales Plant operators/drivers Studentsb aPara-professionals include such occupations as research assistants and X-ray assistants. bAll were tertiary or technical college students. Program women men Control women men Group Managers Professionals Para-professionalsa Trades Clerks Sales Plant operators/drivers Studentsb aPara-professionals include such occupations as research assistants and X-ray assistants. bAll were tertiary or technical college students. Program women men Control women men Table III. Physical measurements at baseline and at the end of the program in men and women according to program group (values are mean and 95% confidence limits) Variable Control Program Men (n = 17) Women (n = 17) Men (n = 17) Women (n = 17) Age (years) 27.1 (24.0, 30.1) 26.6 (25.0, 29.1) 30.6 (27.9, 33.3) 27.1 (25.0, 29.1) BMI (kg/m2 baseline 25.1 (23.9, 26.2) 24.0 (21.4, 26.5) 26.3 (24.8, 27.8) 24.5 (22.9, 26.2) end 25.1 (23.8, 26.5) 24.3 (21.4, 27.1) 25.1 (23.7, 26.5) 24.4 (22.5, 26.3) Weight (kg) baseline 80.6 (76.4, 84.4) 66.5 (58.7, 74.3) 80.6 (76.6, 84.5) 67.2 (61.9, 72.4) end 80.3 (75.5, 85.1) 67.1 (58.5, 75.7) 78.4 (73.7, 83.1) 66.9 (60.3, 73.5) Waist:hip ratio baseline 0.85 (0.83, 0.87) 0.74 (0.72, 0.75) 0.86 (0.84, 0.88) 0.73 (0.70, 0.74) end 0.85 (0.83, 0.87) 0.74 (0.72, 0.76) 0.86 (0.83, 0.88) 0.76 (0.68, 0.84) Recreational energy expenditure (MJ/week) baseline 6.1 (2.7, 9.4) 5.8 (1.6, 9.9) 6.6 (3.9, 9.4) 5.1 (3.5, 6.8) end 6.9 (3.8, 10.0) 5.8 (2.5, 9.1) 8.4 (4.6, 12.1) 5.7 (3.7, 7.6) Fitness (kgm/kg/min) baseline 13.8 (12.7, 15.0) 12.1 (10.5, 13.7) 14.8 (13.3, 16.2) 12.3 (10.5, 13.7) end 14.3 (12.4, 16.2) 11.9 (0.6, 14.2) 15.6 (13.8, 17.3) 13.1 (11.5, 14.7) SBP (mm Hg) baseline 123 (118, 129) 111 (103, 119) 118 (112, 123) 113 (108, 118) end 119 (113, 125) 110 (104, 116) 115 (107, 121) 113 (106, 121) DBP (mm Hg) baseline 69 (66, 72) 68 (64, 72) 69 (67, 72) 67 (64, 71) end 66 (63, 69) 67 (62, 71) 67 (65, 70) 68 (64, 73) Cholesterol (mmol/l) baseline 4.9 (4.5, 5.3) 4.8 (4.3, 5.2) 5.4 (5.1, 5.8) 5.0 (4.7, 5.3) end 4.9 (4.4, 5.4) 5.2 (4.7, 5.6) 5.0 (4.6, 5.3) 4.9 (4.5, 5.3) HDL (mmol/l) baseline 1.1 (1.0, 1.3) 1.5 (1.4, 1.7) 1.2 (1.1, 1.3) 1.6 (1.5, 1.8) end 1.2 (1.1, 1.3) 1.6 (1.4, 1.8) 1.1 (1.0, 1.2) 1.6 (1.4, 1.8) Variable Control Program Men (n = 17) Women (n = 17) Men (n = 17) Women (n = 17) Age (years) 27.1 (24.0, 30.1) 26.6 (25.0, 29.1) 30.6 (27.9, 33.3) 27.1 (25.0, 29.1) BMI (kg/m2 baseline 25.1 (23.9, 26.2) 24.0 (21.4, 26.5) 26.3 (24.8, 27.8) 24.5 (22.9, 26.2) end 25.1 (23.8, 26.5) 24.3 (21.4, 27.1) 25.1 (23.7, 26.5) 24.4 (22.5, 26.3) Weight (kg) baseline 80.6 (76.4, 84.4) 66.5 (58.7, 74.3) 80.6 (76.6, 84.5) 67.2 (61.9, 72.4) end 80.3 (75.5, 85.1) 67.1 (58.5, 75.7) 78.4 (73.7, 83.1) 66.9 (60.3, 73.5) Waist:hip ratio baseline 0.85 (0.83, 0.87) 0.74 (0.72, 0.75) 0.86 (0.84, 0.88) 0.73 (0.70, 0.74) end 0.85 (0.83, 0.87) 0.74 (0.72, 0.76) 0.86 (0.83, 0.88) 0.76 (0.68, 0.84) Recreational energy expenditure (MJ/week) baseline 6.1 (2.7, 9.4) 5.8 (1.6, 9.9) 6.6 (3.9, 9.4) 5.1 (3.5, 6.8) end 6.9 (3.8, 10.0) 5.8 (2.5, 9.1) 8.4 (4.6, 12.1) 5.7 (3.7, 7.6) Fitness (kgm/kg/min) baseline 13.8 (12.7, 15.0) 12.1 (10.5, 13.7) 14.8 (13.3, 16.2) 12.3 (10.5, 13.7) end 14.3 (12.4, 16.2) 11.9 (0.6, 14.2) 15.6 (13.8, 17.3) 13.1 (11.5, 14.7) SBP (mm Hg) baseline 123 (118, 129) 111 (103, 119) 118 (112, 123) 113 (108, 118) end 119 (113, 125) 110 (104, 116) 115 (107, 121) 113 (106, 121) DBP (mm Hg) baseline 69 (66, 72) 68 (64, 72) 69 (67, 72) 67 (64, 71) end 66 (63, 69) 67 (62, 71) 67 (65, 70) 68 (64, 73) Cholesterol (mmol/l) baseline 4.9 (4.5, 5.3) 4.8 (4.3, 5.2) 5.4 (5.1, 5.8) 5.0 (4.7, 5.3) end 4.9 (4.4, 5.4) 5.2 (4.7, 5.6) 5.0 (4.6, 5.3) 4.9 (4.5, 5.3) HDL (mmol/l) baseline 1.1 (1.0, 1.3) 1.5 (1.4, 1.7) 1.2 (1.1, 1.3) 1.6 (1.5, 1.8) end 1.2 (1.1, 1.3) 1.6 (1.4, 1.8) 1.1 (1.0, 1.2) 1.6 (1.4, 1.8) Fig. 1. Percentage of men (black columns) and women (white columns) ranking barriers to dietary behaviours in the two most important categories. Fig. 1. Percentage of men (black columns) and women (white columns) ranking barriers to dietary behaviours in the two most important categories. Fig. 2. Percentage of men (black columns) and women (white columns) ranking barriers to physical activity in the two most important categories. Fig. 2. Percentage of men (black columns) and women (white columns) ranking barriers to physical activity in the two most important categories. Fig. 3. Percentage of men (black columns) and women (white columns) ranking barriers to moderate alcohol drinking in the two most important categories. Fig. 3. Percentage of men (black columns) and women (white columns) ranking barriers to moderate alcohol drinking in the two most important categories. Fig. 4. 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