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University of Chichester
Department of Psychology and Counselling
PSY301: Independent Project
2016-17
Project Supervisor: Dr. Esther Burkitt
Word Count: 7350
1
Perceptions of Health and Source Credibility in
relation to weight differentials in Health
Professionals
1407303
Declaration of Authenticity
I hereby certify that this material which I now submit for assessment on the programme of study leading to the award of BSc (Hons) Psychology is entirely my work and has not been taken from the work of others save to the extent that such work has been cited and acknowledged within the text of my own work. Furthermore, I certify that all data obtained during the course of this research work and included in this text is genuine and authentic.
Signed: H A McDowall
Student Number:1407303
Date: 10-04-2017
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Contents
Abstract 5
Introduction 7
Method 15
Participant Demographics 16
Materials and procedure 18
Results 20
Weight Gain within subjects 21
Weight Loss within subjects 24
Between subjects reported weight status 27
Negative health behaviours 27
Source credibility 27
Sense of control 28
PC:PM ratios and health behaviours 30
Discussion 31
References 37
Appendix A Ethics application 43
Appendix B Recruitment email 69
Appendix C Welcome message – Information sheet 70
Appendix D Consent 73
Appendix E Demographic questions 74
Appendix F Paragraph on Healthy Eating 75
Appendix G Paragraph on Smoking Cessation 76
Appendix H Newspaper Credibility Index 77
Appendix J Source Credibility Scale 78
Appendix K Sense of Control Scale 79
Appendix L1 Scale reliability WG 80
Appendix L2 Scale reliability WL 81
Appendix M1 Normality of scales WG 823
Appendix M2 Normality of scales WL 83
Appendix N1 Flow of silhouette generation 84
Appendix N2 Healthy and Unhealthy silhouette generation 85
Appendix O Validity of the Healthy weight silhouette 86
Appendix P Validity of the Unhealthy weight silhouette 87
Appendix Q Professional profiles 88
Appendix R Debrief 89
Appendix S1 Time 2 correlations PM/WG 93
Appendix S2 Time 2 correlations PC/WG 94
Appendix S3 Time 2 correlations PM/WL 95
Appendix S4 Time 2 correlations PC/WL 96
Appendix T SPSS Scatterplot Time 2 PM/SC and T2, PC/SC 97
Appendix U Procrastination PM: PC Control model 98
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Abstract
This study investigated relationships between Health Practitioner (HP)
modelling of weight gain (WG) or weight loss (WL) on source credibility (SC) and
relationships between SC, perceived sense of control and procrastinatory tendency
towards adopting Healthy Eating (HE) or Smoking Cessation (SMKC) advice.
Ninety-eight participants were recruited to one of two survey conditions, a WG
condition (n = 46) in which participants were shown a healthy-weight HP silhouette
accompanied by two paragraphs on HE and SMKC advice at Time 1 (T1) and a
narrative about the HP gaining weight at Time 2 (T2) and a WL condition, (n = 52) in
which participants were shown an overweight HP silhouette accompanied by identical
advice and narrative about the HP losing weight. Conditions were administered as
online questionnaires. Measures of Believability, Authoritativeness and Character
were completed before and after WG or WL manipulation. Participants answered
questions about HP negative health behaviours, their own weight and smoking status.
Participants were measured post manipulation on perceived sense of control
subscales, Personal Mastery (PM) and Perceived Constraints (PC). Based upon
previous research, a median split was performed to create High, Medium and Low
levels of PM and PC creating new variables based on PM: PC ratio representing ‘at
risk’ groups for health procrastination, each possessing unique behavioural expression
- High Conflict (HC), Low Motivation (LM) and High Powerlessness (HPW)
procrastination.
Four hypotheses were proposed. 1) HP modelling of unhealthy-weight or healthy
weight appearance is over and above written advice a primary determinant of SC.
2) Modelling WG or WL will have a greater effect on SC ratings for Healthy Eating
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(HE) advice, than on SC ratings for Smoking Cessation (SMKC) advice.
3) Modelling successful WL will predict higher SC ratings. Modelling WG will
predict lower SC ratings. 4) Predictive relationships exist between Personal Mastery
(PM) and Perceived Constraint (PC) ratios, actual behaviour, participant-reported
weight status and SC ratings.
SC of written advice on HE and SMKC measured as ‘Believability’ and SC of the HP
measured as ‘Authoritativeness’ and ‘Character’ were significantly lower within the
WG condition at T2 post weight gain manipulation and higher at T2 within the WL
condition post weight loss manipulation. SC was significantly lower between the WG
condition at T2 than the WL condition at T2. Participants in the WG condition were
significantly more judgemental about negative health behaviours exhibited by HPs,
which was not reflected in judgements about their own weight status. PM: PC ratios
were more predictive of actual behaviour and reported weight status in the WL
condition than the WG condition. All Hypotheses were supported.
Study aims were to make recommendations for cost-effective triage, intervention
planning and organisational change and to apply findings to the theory of planned
behaviour (TPB) Ajzen, (2011), to reduce the ‘intention behaviour gap’, (Marks,
Murray, Evans, & Estacio, 2015).
It is recommended that; HPs make health behaviour changes consistent with personal
and organisational ethos; the theory of planned behaviour (TPB) proposed by Ajzen,
(2011) be extended to include a greater role for environmental constraints imposed
upon all help seekers (HSKs) and that a PM: PC assessment tool be used at triage to
target those most at risk of Health Procrastination (McDowall, 2015).
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Perceptions of Health and Source Credibility in relation to weight differentials in
Health Professionals
This study explores whether being visibly overweight as a Health Professional
(HP) influences levels of perceived source credibility (SC) on the part of helpseekers
(HSKs) and if so, whether this effect persists past the transactional stage of the HP:
HSK relationship when the HP can be seen to have gained or lost weight. This study
aims to discover if this effect applies equally to lifestyle advice given for weight
related advice on Healthy Eating (HE) and non-weight-related advice on Smoking
Cessation (SMKC), and whether demonstrating successful WL overcomes this effect.
This study also proposes how efficacy-beliefs about self and others, measured as SC
and perceived sense of control on the part of HSKs might influence procrastinatory
tendency towards adopting HE or SMKC advice. Recommendations are made for
cost-effective triage pre-intervention- planning, organisational change and extension
of the theory of planned behaviour (TPB), (Ajzen, 2011).
HPs are front-line staff responsible for healthy lifestyle promotion, delivery
and referral for a range of lifestyle behaviours, often as a function of a primary care
multi-disciplinary team. The prevalence of obesity and associated health risks are of
international, contempory and future concern for health care providers whose limited
resources must be justifiably allocated based on optimal cost: benefit ratio for both
provider and patient (Dugdill, Crone, & Murphy, 2009). Meanwhile, health care
providers such as the National Health Service (NHS) employ staff across all sectors
who visibly suffer difficulties in controlling their own weight, wellness and fitness
behaviours. More than 700,000 NHS staff are overweight or obese, the rate of
sickness-related absence in the NHS (4∙1%) is 27% higher than the UK public sector
7
average and three quarters of hospitals do not offer healthy food to staff who work
night shifts. The annual cost of sickness-related absences in the NHS alone exceeds
£2∙4 billion. Additionally, some NHS Trusts place calorific food and drink vending
machines in hospital department waiting areas for patients and staff whilst failing to
provide adequate meal, rest, hygiene and exercise facilities for staff working
unconventional shift patterns in demanding work environments associated with high
levels of stress (Maruthappu, 2016).
This study argues that the human and environmental costs of failing to address
the problem of HP obesity through a misplaced sense of propriety is no longer
affordable and that organisational employment policy should reflect this concern. The
NHS requires a parsimonious and cost-effective method of implementing weight
management and fitness interventions for staff as well as patients (NHS England,
2016).
Self-efficacy beliefs concerned with perceived ability to influence life events
are core to the foundation of human motivation, performance accomplishments and
emotional well-being (Bandura, 1997, 2006). This study proposes that modelling
obesity in a health care setting acts as an indicator of poor self-control over negative
health behaviours on the part of the HP and that obesity over and above other negative
behaviours such as smoking, largely banned from the workplace, not only raises
unique challenges for organisational reform, but has a detrimental effect on SC and
subsequent uptake of behaviour change (BC) or lifestyle advice by HSKs.
Obesity is an overt indicator of poor health self-efficacy, whereas other
negative health behaviours such as alcoholism, substance abuse, smoking, and mental
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illness may remain hidden or deliberately concealed from help-seekers (HSKs).
Overweight appearance continually cues automatic, unconscious prejudice about the
perceived competency of the HP by the HSK. Automatic judgements, assumptions,
attributions and prejudices about obese people tend to be uniformly negative in
Western cultures e.g. “fat people are lazy, greedy and could change their behaviour if
they wanted to” (Nelson, 2002). Other negative behaviours like smoking or
alcoholism tend to be regarded as ‘illness’ rather than a 'lifestyle choice' and as such
are more empathetically processed, causation for non-obesity negative health
behaviours being most usually associated with ‘coping with stress’ for both HPs and
HSKs alike (Nelson,2002). This study will explore the effects of priming participants
with a WG or WL condition on perceptions of HP health, HP credibility and
subsequent likelihood of BC under experimental conditions where empathy is not a
factor.
First impressions based upon appearance about another’s efficacy or
competence assume that individual qualities and personality are coherent and stable
(Asch, 1946). Judgement about another’s self- efficacy is an effortless, unconscious,
‘system one’ process as proposed by Kahneman, (2011), the heuristic used when
HSKs assess HP SC in the first instance (Neall, Atherton, & Kyle, 2016). In his
model of persuasive behavior and motivation, Fogg (2009) agrees that SC as derived
from “initial judgments based on surface traits such as a person’s looks, his or her
dress, or hairstyle” are subcomponents of motivation and perceived ability.
McCroskey (1966), concluded that of five dimensions of credibility; competence,
character and sociability were the most important in establishing and maintaining
transactional credibility, the transactional phase being the interaction of the HSK with
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the HP as influenced by their assumed relational roles. Collins, Hahn, von Gerber, &
Olsson, (2015) propose that when we form, or change our beliefs about the world, we
draw in large part on other people’s claims. Collins et al., proposed a bi-directional
relationship existing between source characteristics and message content that has
implications for the development of health efficacy beliefs i.e. beliefs about the
intervention and about the person delivering the intervention that predict the
likelihood that BC is achievable. Their study drew upon models of belief change by
Bovens and Hartmann, (2004) and Olsson and Angere (2013) who argue that our
beliefs 'shape' or 'offer a framework' for every aspect of our lives, determinants of our
behaviour. People influential in shaping our personal and social norms, values and
behaviours are those with whom we come into contact regularly. They may include a
nurse you happen to pass in the hospital corridor or an HP who has been assigned to
impart lifestyle advice.
In the absence of a widely endorsed single index of SC, this study utilises the
‘Believability’ aspect of McCroskey’s scale to measure he SC of written advice on
HE and SMKC at Control, against which ‘Character’ and ‘Authority’ of the HP are
compared. It is argued that initial impressions undergo further processing based upon
transactions that take place between the source and the receiver. This study argues
that because the initial prejudicial impression is continually being ‘cued’ or reinforced
throughout the HP: HSK interaction, the negative effect on SC and perceived
competence persists, confusion arising from the lack of congruence and consistency in
the messages being communicated, described as cognitive dissonance, (Festinger,
1977). The HSK uses this information consciously and arguably unconsciously, to
10
evaluate the competence of the HP and importantly, to evaluate how achievable the
BC being asked of them, is.
Research into related fields of attraction, persuasion, message framing and
obesity stigmatisation suggest that evaluating SC is a dynamic cognitive process
inseparable from the situational context in which it occurs. A recent study examining
the effects of viewing the ‘The Weight of the Nation’ documentary aired in the US on
viewers’ attitudes about obesity, concluded that although participants’ negative
judgments of people with obesity, desire for social distance and support for equal
rights for people with obesity improved after watching the video, the perceived
attractiveness of people with obesity did not change relative to the control condition
(Burmeister, et al. ,2016). Khan, Tarrant, Weston, Shah, and Farrow, (2017), found
that the presentation of a psychological cause for obesity elicited less prejudice
compared to behavioral causes but greater prejudice compared to genetic causes.
Observed differences were found to be a function of the ‘agency’ ascribed to the
target’s obesity and ‘empathy’ expressed for the target. Findings highlight the impact
that communicating obesity in terms of psychological causes can have for the
expression of obesity prejudice. However, it is important to note that most studies in
the field of BC use self-reports to assess reported prejudice, subject to social
desirability biases. This study, alternatively, will assess obesity prejudice and
stigmatisation using an implicit measure (Nelson, 2002).
Communications research in primary care has concentrated on General
Practitioner: Patient interactions and Nurse: Patient ‘therapeutic relationships’,
focusing specifically on explicit verbal communication styles, easily recorded and
analysed, rather than on implicit non-verbal communication requiring more subjective
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analysis and interpretation. Unlike the internet health advice domain which is well
researched in terms of persuasion, message framing and implicit messaging, the
‘implicit message’ element of assessing SC at face to face and organisational level
remains experimentally under-researched, most studies utilising self-report measures
of intention and attitude change (Dugdill, Graham, & McNair, 2005).
Communication may be intentionally or unintentionally, transmitted and received in
appearance, eye contact, tone of voice and proximity when forming trusting
therapeutic relationships (Pellegrini, 2016). Trust in the HP is associated with high
levels of patient satisfaction, self-management and health outcomes (Matusitz &
Spear, 2014). It would be logical to assume therefore, that HPs operating within a
health care setting should promote trust not only in their personal self-efficacy but in
the organisation, they represent. The organisation should facilitate, but may
compromise BC, organisational behaviour frequently being at odds with empirical
evidence and explicit policy. The importance of consistent, coherent signals and
avoidance of organisational hypocrisy is vital with respect to behaviour change
programs (Hoogervorst, van der Flier, & Koopman, 2004).
Literature exploring Practitioner relationships in a variety of contexts
demonstrated a lack of discrepancy between obesity and other negative health
behaviours when assessing intervention outcomes. Some studies found that matching
obese HPs to obese HSKs was positive, equalising the balance of status, prompting
mutual empathy and sharing of coping-strategies over time that overcame initial poor
SC inherent in the overt “I’m not coping either” message. However, reported patient
satisfaction did not translate into BC. Personal experience of the ‘presenting problem’
on the part of HPs was valued by HSKs but only when the practitioner had been able
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to illustrate his/her own success in making that change (Hutson, 2013). Other studies
found that matching obese HPs to HSKs transmitting an “I’m not coping, you’re not
coping either” message was utilised by the HSK to make negative attributions of poor
self-efficacy and low levels of competence on the part of the HP that were internalised
when making negative decisions about how achievable behaviour change was for the
HSK, an illustration perhaps of the fundamental attribution error (Ross, Amabile, &
Steinmetz, 1977) and self -fulfilling prophesy respectively (Merton, 1948).
Conversely, demonstrating or modelling successful BC as represented by healthy
physical appearance has been shown to produce positive effects for both the
relationship and intervention outcome (Bandura,1973,1999). Research further
suggests that normative beliefs (evaluations of what is socially desirable or
appropriate) are a theoretically relevant precondition underlying the manifestation of
the self-prophecy effect (Merton, 1948). Research by Sprott, Spangenberg, and
Fisher, (2003) indicated that for different behaviors, the act of making a prediction
about behaviour is most effective when normative beliefs are strong. This study
argues that self-prophecy inherent in the perceived ability of the overweight HP to
promote socially desirable behaviors may have a catastrophic effect, unintentionally
promoting the ‘normality’ of undesirable behaviours, the level of threat posed and
normative beliefs being blatantly contradictory. The obesity paradox for example, a
term for a medical hypothesis which holds that obesity (and high cholesterol) may,
counterintuitively, be protective and associated with greater survival in certain groups
of people, since discredited as applying to all obese individuals, nevertheless, endures
as a norm among groups of obese individuals, thought to be the result of ‘behavioural
contagion’ (Wheeler, 1966).
13
Neither motivational communication models nor health BC models to date
have explored the potential negative impact of messages implicit in overweight
physical appearance as being decisive for patient perceptions of SC, nor the
implication this has for efficacy beliefs, perceived sense of control, intention
formation and likelihood of subsequent BC that are components of such models
(Smith, 2016; Steptoe & Appels, 1989). This study proposes that perceived constraint
beliefs (PC), whether constraints be real or imagined, constitute barriers to behaviour
change when a person’s personal mastery beliefs (PM) about self- control, and similar
concepts of self -efficacy, autonomy, self-determination or competence, are relatively
lower than PCs or, as in perfectionists, unrealistically high (Lachman & Weaver,
1998). Previous research by the author about perceived levels of control indicates that
successful BC is predicted when level of PM, analogous to self-efficacy, exceed
levels of PC. This study aims to demonstrate relationships between three distinct
types of procrastination, accompanied by distinct behavioural expression - High
Conflict Reactance, Low Motivation and High Powerlessness procrastination, actual
behavior, reported weight status and SC (McDowall, 2015).
Cross-cultural researchers Riemer, Shavitt, Koo, and Markus, (2014), in
proposing a normative-contextual model of attitude change argue for a less person-
centric approach employed in traditional Western psychology, reflected in its
obsession with individual-level solutions to social-level problems. This study argues
that environmental PCs are more predictive of BC than PM, that BC is unlikely if PCs
overwhelm PM and that models of BC such as the TPB Ajzen (2011) should include
PM: PC ratios in pursuance of closing the intention-behaviour gap.
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Four hypotheses are proposed. 1) HP modelling of overweight appearance is
over and above written advice content, a primary determinant of SC. 2) Modelling
WG or WL will have a greater effect on SC ratings (Believability, Authoritativeness,
Character) for HE advice, than for SMKC advice. 3) Modelling successful WL will
predict higher SC ratings, modelling WG will predict lower SC ratings.
4) Predictive relationships exist between High, Medium and Low levels of PM and
PCs, actual behaviour, reported weight status and SC.
Method
This study employs an experimental, within subjects, repeated measures and
between subjects’ design. Between-subject’s independent variables are the two
conditions WG and WL, the dependent variable being SC at Time 2. Within subjects
SC was measured at Control, Time One (T1) pre-manipulation and Time Two (T2)
post manipulation to detect differences in SC. Believability of the written advice
about HE and SMKC was measured at Control, T1 and T2 to isolate the effect of the
written material from the weight differential manipulation. Authoritativeness and
Character of the HP was measured at T1 and T2 for HE and SMKC advice within the
WG and WL conditions. This study is an extension of previous research on SC
beliefs, procrastination and the likelihood of behaviour change. A median split was
performed to create High, Medium and Low levels of PM and PC to create new
variables based on PM: PC ratio reflecting those ‘at risk’ of Health Procrastination -
High Conflict (HC) Low Motivation (LM) and High Powerlessness (HPW)
procrastination. Relationships between smokers, night shift work and those who
reported themselves as overweight or underweight and PM: PC ratio were explored.
15
Participants
Ethical approval was obtained (Appendix A). Two surveys were created using
Qualtrics software (2017). Two survey links to survey conditions WL and WG were
posted within a recruitment email (Appendix B). Participants with surnames A-M
completed the WG condition questionnaire (n = 46), surnames N-Z completed the WL
condition questionnaire (n = 52). Participants were recruited by personal email and
snowball sampling, followed by a second-wave recruitment comprising first and
second-year participant-pool psychology undergraduates completing in exchange for
30 minutes’ course credits and third-year students recruited via student Facebook
pages. Consent was obtained from participants. ‘Skip logic’ prevented anyone under
the age of eighteen or anyone who did not consent to complete the survey, from doing
so (Appendices C and D). Participants were asked to generate a unique identification
code comprising place of birth, the first letter of their surname and year of birth, for
example, ‘LondonM66’ or to gain course credits, give their student ID. These linked
responses with data to enable data withdrawal. Participants were asked for
demographic information (Appendix E) displayed in Table 1.
16
Table 1. Participant demographics
Materials and Procedure
Two short paragraphs (Appendices F and G) on HE and SMKC were sourced
from the NHS Choices website (2016), These were presented at Control (before
17
Demographic WG condition Percentage WL condition Percentage
Number 46 100 52 100
Males 11 23.9 14 26.9
Females 35 76.1 38 73.1
Mean age 43 41
Max age 85 79
Min age 18 19
White British 41 87.5 47 87
White Irish 2 4.3 1 1.9
Other white 4 6.5 3 5.6
Other black 1 2.2
Retired 10 21.7 15 28.9
Homemaker 1 2.2 1 1.9
Students 21 45.7 26 50
Employed full time 9 21.7 7 13.5
Employed part time 3 8.7 2 3.9
Nightshift 2 4.3 2 3.8
Smokers 5 11.6 7 14.9
manipulation) to measure ‘Believability’ of the written advice using the Newspaper
Credibility Index (Meyer,1988), (Appendix H). The dimension of ‘Belief’ about SC
was measured on a 5 item Likert Scale. Use of this index was based upon previous
research by Collins, Hahn, von Gerber, & Olsson, (2015), when evaluating the
existence of bi-directional interactions between the ‘believability’ of the message and
credibility of the source. In this study, the ‘source’ is the HP and the message is the
written advice on HE and SMKC. McComas and Trumbo (2001) used Meyer's
(1988) scale in five environmental health-risk communication case studies. The scale
performed well both within and across the three source types, with an alpha of .83
across the five newspaper measurements, .86 across five industry measurements,
and .83 across the five-state public health department measurements.
The Source Credibility Scale (McCroskey, 1966), (Appendix J), measured the
‘Authoritativeness’ and ‘Character’ of the source, an HP named ‘Charlie’ on six
question, seven item Likert Scales. These concepts measuring the personal credibility
of the HP were thus isolated from the credibility of the written advice (Collins et al.,
2015). In testing construct validity, Carbone (1975) found that ratings of high- and
low-credibility sources were significantly different and in the expected direction
across the two dimensions.
The Sense of Control Scale (Appendix K), Lachman & Weaver (1998)
comprised sub-scale measures of Control - PM and PCs on a seven point Likert scale.
Previous research by the researcher found significant predictive ratio effects between
High and Low levels of PM: PC and Procrastination that were absent when subscales
were summed to create an overall measurement of perceived control, as in the original
scale usage.
18
All scales used achieved internal consistency ranging from Cronbach’s = .80
to = .95. The two short scales PM and Believability with inter item consistency
ranging from = .50 to = .64, were within the optimal range for scales with fewer
than 10 items (Briggs & Cheek, 1986). Internal consistency values for all measures
appear in Appendix L, Table 1 and Table 2. None of the scales achieved normality
(Appendix table M1 and M2).
Two images were generated as illustrated in figure 1. and figure 2. depicting a
healthy-weight HP and an unhealthy weight HP.
Figure 1. Figure 2.
Healthy-weight HP silhouette Unhealthy weight HP silhouette
Silhouette generation is described in Appendix N and N2. To check silhouette
validity, participants were asked to rate the health status of each on a five point likert
scale ranging from ‘healthy’ to ‘unhealthy’ (Appendices O and P). Silhouettes were
presented at the end of the questionnaire rather than at the beginning, so as not to
prime experiment responses. Validity was established with 61.70 % and 70%
agreement on the healthy weight and 81.39 % and 89.36 % agreement on the
unhealthy weight silhouette status.
19
A professional profile was constructed and placed within a narrative about the
HP, named Charlie, depicting her losing weight over a three-year period in the WL
condition or gaining weight in the WG condition (Appendix Q). The name ‘Charlie’
was chosen because it was a gender-neutral name. It proved impossible to remove all
hints of gender, but since females are over-represented in the NHS, in caring roles
generally and more likely to be obese (Keogh, 2014), this was ecologically valid.
Uniform and outline were depicted in black silhouette to reduce any ethnicity or
uniform colour/rank effect on Authoritativeness. Each narrative-silhouette
manipulation was followed by measures of SC comprising measures of ‘Believability’
of the written advice and ‘Authoritativeness’ and ‘Character’ of the HP.
Participants rated on a five point Likert scale perceptions of their own weight
status, ranging from ‘underweight’ to ‘overweight’. Participants were asked to rank
HP obesity, smoking, alcohol abuse, poor hygiene and substance abuse in order of
importance for credibility. The question ‘Do you currently work night shifts?’ was
asked as research shows that shift workers find it particularly difficult to control their
weight. The question ‘Do you currently smoke at all?’ was asked of participants
because smoking may sometimes be used to regulate food intake as an appetite
suppressant, smokers often complaining they put on weight when they quit the habit.
Smokers may also show procrastination towards behaviour change. This was an
objective, categorical measure of actual behaviour used in final analyses.
Survey conditions took no longer than 30 minutes to complete. Participants were
debriefed as to the purpose of the study (Appendix R). Data was collated and analysed
using IBM Statistical Package for the Social Sciences (SPSS).
20
Results
Weight Gain Within Subjects analyses
Removing outlier 7 and 8 data from analyses did not induce normality for T1
and PM scales affected. Nonparametric tests were adopted for all analyses. Since all
scale measures were measuring different components of SC, analyses were conducted
separately for each variable. Pairwise comparisons were performed (SPSS, 2017)
with a Bonferroni correction for multiple comparisons for significant results only.
Believability of HE written advice. A Friedman’s test was run to determine
if there were differences in Believability of the HE written advice at Control,
T1 and T2. Believability of HE written advice was significantly different at
the different time points, 2 (2) = 18.5, p <.000. Post hoc analysis revealed
statistically significant differences in Believability of HE written advice from
Control (Mdn = 16, range:11-21) to Believability of written HE advice given
at T1 (Mdn = 19, range: 5-25, p = .006) and Believability of written HE advice
at T2 (Mdn = 14.50, range:5-23, p =.000), revealing a significant decline in
Belief in HE written advice post WG, supporting Hypotheses 3. There was no
significant difference between Believability of the HE written advice at
Control and T2 indicating either that there is no relationship between written
advice and source, or possibly that sample size was too small for a significant
effect to be observed, n = 46.
Believability of SMKC written advice. A Friedman’s test was run to
determine if there were differences in Believability of SMKC written advice at
Control, T1 and T2. Believability of written advice on SMKC was not
21
significantly different at different time points, 2 (2) = 2.67, p = .27.
Believability of written advice about SMKC was unaffected by WG.
Believability of written advice on HE and SMKC comparisons.
A Friedman’s test was run to determine if there were differences in
Believability of HE written advice and Believability of SMKC advice at T1
and T2. Believability of written advice on HE at T1 was significantly
different at T2 2 (3) =19.30, p <.000. Post hoc analysis revealed that
Believability of written advice about HE and SMKC was not significantly
different at T1. However, after the HP had gained weight at T2, significant
differences between HE written advice (Mdn = 14.5, range5-23) and SMKC
written advice (Mdn = 17.5, range: 5-25, p = .03) were apparent. HE written
advice was significantly less Believable after WG at T2 (Mdn = 14.5, range:
5-23) than SMKC written advice at T2 (Mdn = 17.5, range: 5-25, p = .002),
indicating that modelling WG is more detrimental for advice on HE than for
advice on SMKC, supporting Hypothesis 2.
Authoritativeness of the HP at time 1 and time 2 for HE and SMKC
advice. A Friedman’s test was run to determine if there were differences in
Authoritativeness of the HP giving advice on HE and SMKC at T1 and T2.
Authoritativeness of the HP at T1 was significantly different at T2 2 (3)
=25.66, p <.000. Post hoc analysis revealed that Authoritativeness of the HP
advice given about HE at T2 (Mdn = 24.5, range: 8-42) after WG, was rated
significantly less Authoritative than HE advice given at T1 (Mdn = 34.5,
range:6-42, p = .005) and Authoritativeness of the SMKC advice given at T1
(Mdn = 36.00, range: 6-42, p < .000). Authoritativeness of the HP giving
22
advice about HE at T2 (Mdn = 24.5, range:8-42), after WG, was significantly
less Authoritative than SMKC advice given at T2 (Mdn = 30.00, range:10-42,
p =.003), supporting Hypotheses 2 and 3.
Character of the HP at T1 and T2 for HE and SMKC advice.
A Friedman’s test was run to determine if there were differences in Character
of the HP giving advice on HE and SMKC at T1 and T2. Character of the HP
was judged to be significantly different between T1 and T2, 2 (3) =19.78,
p <.000. Post hoc analysis revealed that Character of the HP giving advice
about HE at T2 after WG (Mdn = 28.00, range:10-41), was rated as
significantly less credible than the Character of the HP giving the same advice
on HE at T1 (Mdn = 32.5, range: 7-42, p = .004). Character of the HP giving
advice about HE at T2 (Mdn =28.00 range: 10-41), was rated as significantly
less credible than when giving advice on SMKC at T1 (Mdn = 33.00, range:
6-42, p =.001). There were no significant Character differences between the
two types of advice given (SMKC and HE) at either T1 or T2. Hypothesis 3
was supported, but Hypothesis 2 was not.
Weight Loss condition within subjects’ analyses WL
Removing outlier data from analyses did not induce normality in distribution
of the T2 scales affected. Nonparametric tests were adopted for all analyses.
Since all scale measures were measuring different components of SC, analyses were
conducted separately for each variable. Pairwise comparisons were performed (SPSS,
23
2017) with a Bonferroni correction for multiple comparisons for significant results
only.
Believability of HE written advice. A Friedman’s test was run to determine
if there were differences in Believability of HE written advice at Control, T1
and T2. Believability of written advice on HE was significantly different at
the different time points, 2 (2) = 27.21, p <.000. Post hoc analysis revealed
that Believability of written advice on HE at Control (Mdn = 18, range:11-25)
was significantly higher at T2 when the HP had lost weight (Mdn = 20,
range:13-25, p <.000) and Believability of the HE advice at T1 (Mdn = 18
range: 6-25) was significantly higher at T2 (Mdn = 20, range 13-25, p <.000).
These results support Hypothesis 1.
Believability of SMKC written advice. A Friedman’s test was run to
determine if there were differences in Believability of SMKC written advice at
Control, T1 and T2. Believability of written advice on SMKC was
significantly different at the different time points, 2 (2) = 16.15, p <.000.
Post hoc analysis revealed significant differences between Believability of the
SMKC written advice Control (Mdn = 18, range: 10-25), and Believability of
the same advice at T1 (Mdn = 19, range: 9-25, p = .043), at Control (Mdn =
18, range:10-25) and T2 (Mdn = 19, range 15-25, p = .002). Believability of
SMKC advice however, did not change significantly between T1 and T2,
indicating that the WL manipulation did not affect SMKC advice credibility as
much as for HE advice. This finding supports Hypothesis 2.
24
Believability of written advice on HE and Believability of written advice
on SMKC comparisons. A Friedman’s test was run to determine if there
were differences in Believability of the HE written advice and the
Believability of SMKC advice at T1 and T2. Believability of written advice
on HE and SMKC was significantly different at the different time points
2 (5) = 46.08, p <.000. Post hoc analysis revealed that Believability of
SMKC written advice at Control (Mdn = 18, range 10-25), was significantly
lower than Believability at T2, (Mdn = 19, range: 15-25, p < .007), signifying
that modelling WL significantly enhanced credibility of written SMKC advice.
Similarly, Believability of HE advice at Control (Mdn = 18, range: 11-25) was
significantly higher at T2 (Mdn = 20, range: 13-25, p = .000). Results
isolating the effect of written advice Controls from the WL manipulation
support Hypothesis 1. There were no significant differences between the two
types of advice (HE and SMKC) at T2, indicating that both pieces of advice
were judged to be equally believable at T2.
Authoritativeness of the HP at T1 and T2 for HE and SMKC.
A Friedman’s test was run to determine if there were differences between
Authoritativeness of the HP when giving advice on HE and SMKC at T1 and
T2. Authoritativeness of the HP at T1 was significantly different at T2
2 (3) =39.81, p <.000. Post hoc analysis revealed that Authoritativeness of
the HP giving advice on HE at T1 (Mdn = 32, range:14-42) was significantly
enhanced at T2 when the HP had lost weight (Mdn = 36, range: 19-42,
p<.000), supporting Hypothesis 3. Authoritativeness of HE advice was
significantly lower at T1 (Mdn = 32, range:14-42) than SMKC advice at T2
25
(Mdn = 36, range: 24-42, p<.000), reflecting SC Authoritativeness differences
between the two types of advice, supporting Hypothesis 2. There were
significant differences between Authoritativeness of the HP giving advice
about SMKC at T1 (Mdn = 35 range:21-42) and HE advice at T2 (Mdn = 36,
range:19-42, p =.02), further supporting Hypothesis 3.
Character of the HP at T1 and T2 for HE and SMKC advice.
A Friedman’s test was run to determine if there were differences in Character
of the HP giving advice on HE and SMKC advice at T1 and T2. Character of
the HP was judged significantly different between T1 and T2, 2 (3) = 43.41,
p <.000. Post hoc analysis revealed that Character of the HP when giving HE
advice at T1, before weight Loss, (Mdn = 33, range: 18-42), was significantly
lower than for SMK advice given at T2 after the HP lost weight (Mdn = 36,
range:24-42, p =.001), supporting Hypothesis 2 and 3. Character ratings for
the HP giving HE advice at T1 (Mdn =33, range: 18-42) were deemed to be
significantly higher for the same advice at T2 (Mdn =36, range:24-42,
p <.000). This effect was also seen between Character ratings for the HP
when giving SMKC advice at T1 (Mdn = 33, range:16-42) and T2 (Mdn = 36,
range:24-42, p = .03), further supporting Hypothesis 3.
Between Subjects Analyses
Table 2.1. Participant self- reported weight status Weight Gain condition n = 46
Weight status Frequency Percent
Underweight 1 2.2
26
Slightly underweight 4 8.7
Average weight 21 45.7
Slightly overweight 16 34.8
Overweight 4 8.7
Table 2.2 Participant reported weight status Weight Loss condition n = 52
Weight status Frequency Percent
Underweight 0 0
Slightly underweight 6 12.8
Average weight 26 55.3
Slightly overweight 7 14.9
Overweight 8 17.0
Results of a Mann -Whitney test showed no significant difference in perceived
participant weight status between the WG condition (Mdn = 3.00, range: slightly
underweight -slightly overweight, n = 46) and WL condition (Mdn = 3.00, range:
slightly underweight -slightly overweight, n = 52), U = 1086.00, z = - .858, p = .391,
r = - 0.87, a small effect (Cohen, 1988).
Negative Behaviours exhibited by HPs and SC
Results of a Mann-Whitney test showed significant difference in ratings of
negative health behaviours between the WG condition (Mdn = 402.00) and WL
27
condition (Mdn = 352, p = .40). Participants in the WG condition were harsher in
their judgement about negative behaviours than participants in the WL condition
U = 880.00, z = - 2.117, r = - 0.21, a small effect (Cohen, 1988), but not about their
own weight as compared to self-reported weight status.
SC of the HP between conditions
Results of a Mann-Whitney test showed significant difference in
Authoritativeness (Mdn =56) and Character (Mdn = 57) at T2 in the WG condition
and, significant differences in Authoritativeness (Mdn = 73) and Character (Mdn =
72) at T2 in the WL condition U = 2013.00, z = 5.824, p <.000, r = 0.59, a large effect
size (Cohen, 1988), supporting Hypothesis 3.
SC of written advice between conditions
Results of a Mann-Whitney test showed significant difference in Believability
of written advice about HE at T2 in the WG condition (Mdn = 14.50) and
Believability of written advice on HE at T2 in the WL condition (Mdn = 17.50),
U = 1971.50, z = 5.54, p <.000, r = 0.56, a large effect size (Cohen, 1988). There
were significant differences in ratings of Believability at T2 for HE written advice
(Mdn = 20.00) and Believability of SMKC advice at T2 (Mdn = 19.00) in the WL
condition U = 1574.00, z = 2.70, p = .007, r = 0.27, representing a small – medium
effect size (Cohen, 1988).
28
Sense of Control Analyses
Relationships between PM, PC and SC were investigated using Spearman’s
product- moment correlation co-efficient. Correlation tables in Appendix S tables S1-
S4 show relationships between PM, PC and six measures of credibility at T2 in each
condition. SC, PM and PC scores were summed. T2 WL correlations between PM
and SC were positive, r = .382**, n = 52, p = .005 and T2 correlations between PC
and SC negative r = -.362**, n = 52, p = .008 (** p < .001 2 tailed), a medium effect
size (Cohen ,1988), supporting Hypothesis 3 (Appendix T).
Negative correlation between T2 PM and SC appear in Figure 3.1 and starkly opposite
positive relationships between T2 PC and SC appear in Figure 3.2.
1 20
10002000300040005000600070008000
Total T2 SC scores
Tot
all T
2 P
M S
core
s
1 20
10002000300040005000600070008000
Total T2 SC scores
Tota
l T2
PC S
core
s
Figure 3.1. Figure 3.2
29
Tables 4.1 and 4.2 depict smoking, reported weight and reported PM: PC ratios.
Table 4.1 Smoking, reported weight and reported sense of control PM: PC
WG condition
PM: PC Smokers Under Slightly Under Average Slightly Over OverLow: Low 2Low: Med 3 3 1Low: High 2 1 1 2 1 2Med: Low 1 1 4 **1 2Med: Med 1 1 3 1Med: High 1 3High: Low 2 4 1High: Med 2High: High 1 **1
Notes. Participants at risk
** Night shift
Table. 4.2 Smoking, reported weight and reported sense of control PM: PC
WL condition
PM: PC Smokers Under Slightly Under Average Slightly Over OverLow: Low 4 **1Low: Med 1 1Low: High 2*1 1 7 ** 4 *2 2*1Med: Low 1 3 2
30
Med: Med 5 2 2 3 3Med: High 1 1High: Low 7High: Med 2 1High: High 1 2
Notes. Participants at risk
*Participants who reported as being overweight and smokers
**Night shift.
Discussion
Modelling WG or WL was over and above written advice a primary
determinant of SC, supporting Hypothesis 1 and the work of, Meyer (1988) on SC.
However, findings only support the bi-directional belief relationship between the
message and source found by Collins et al., (2015), in the WL condition. This is
explained by a priming effect inherent in the experimental design, being more
powerful in the WL condition. Bovens and Hartmann (2004) and Olsson and Angere
(2013) explain this as due to the situational context present in the WL narrative.
Because information presented in the WL condition was regarded as more ‘congruent’
and believable than the WG condition, higher levels of SC were found in that
condition, congruence being a property of an ‘information set’ that boosts confidence
that its content is true. Increased congruence or similarly, absence of cognitive
dissonance (confusion) as proposed by Festinger, (1962), would explain why
modelling WG, produced an insignificant spillover effect from HE to SMKC advice
in the WG condition but had a significant spillover effect in the WL condition.
Spillover is the likelihood that SC of the HP on HE advice will affect SC of the HP on 31
SMKC. Results starkly illustrate that when SC is high all pieces of advice are
positively affected but when SC is low, as in the WG condition, HE advice was
affected more.
Modelling WG predicted lower SC ratings, modelling WL predicted higher
SC ratings for all measures within and between subjects as hypothesised. Findings
are explained by self-discrepancy theory (Higgins,1987), whereby discrepancies
between the actual/own self-state and ‘ought’ self-states (i.e., representations of an
individual's beliefs about his or her own or a significant other's beliefs about the
individual's duties, responsibilities, or obligations) signify the presence of negative
outcomes. Clearly there is a strong link between SC and efficacy beliefs about self
and others. This is further explored in self-determination theory proposed by Deci and
Ryan (2010) which addresses the social conditions that enhance or diminish
motivation, depending on the degree to which basic psychological needs for
autonomy, competence, and relatedness are supported or thwarted, low HP SC
representing a lack of support for BC.
Overall sense of control was not associated with low SC in the WG condition
but was significantly correlated with higher SC in the WL condition. The sense of
control scale created by Lachman and Weaver (1998) only predicted significant
relationships between overall sense of control and SC in the WL condition where, as
discussed previously, congruency, consistency and SC were higher.
A median split was performed on sense of control subscales PM and PC to
create three new variables based on extreme high and low values. Powerlessness
Procrastination (Low PM: High PC), Low Motivation Procrastination (Low PM: Low
32
PC) and High Conflict Reactionary Procrastination (High PM: High PC). An
illustration of this procrastination model appears in Appendix U.
Powerlessness procrastination may be overcome by exhibiting procrastinatory
behaviour. The act of choosing 'not to act' is a way of exerting control in a situation
where perceived lack of PM control is overwhelming or PCs cannot be realistically
overcome (Steptoe & Appels,1989). This is a similar concept to ‘learned
helplessness’ (Maier & Seligman, 1976). For smokers and overweight individuals
who feel that high levels of PCs coexist for them alongside low levels of PM, exerting
control by refusing to accept the credibility of either the message, the message source
or the intervention proposed to help them quit or change their behaviour is known as
‘reactance’ (Brehm, 1966).
Low Motivation procrastination results from indecisiveness. Low PM
accompanied by similarly low levels of PC means that the number of behavioural
choices available are many. HSKs become overwhelmed by having to decide.
Decision making is effortful (Kahneman, 2011). It is easier to delay decision-making
than to risk making the wrong decision. People rationalise the delay in decision
making as ‘considered’ decision-making. It tends not to upset the individual, though
it may elicit a frustrated or infuriated response from others who view the individual as
being weak-willed (Nelson,2002).
High Conflict Reactionary Procrastination is an extreme, often angry reaction
associated with strong emotional responses. For perfectionist or highly conscientious
individuals these are the conditions that may elicit extreme withdrawal from ‘reality’
as a way of enforcing control over others and self. e.g. workplace sabotage,
33
vandalism, suicide, self-harm, anorexia, retreat into psychoticism, substance abuse or
suicide bombing/terrorism. It may take the form of extreme prejudice against the
message source to the degree that, however logical, reasonable and well-meant the
advice, the HSK rejects the message totally, refusing to even consider it. Negotiating
with such irrational delusional beliefs often proves fruitless.
Categorising procrastinatory responses into these sub-categories explains why
some individuals often fail to change their behaviour despite remaining fully aware of
the negative health consequences of not doing so. It is recommended, therefore, that a
modified sense of control measure be used at triage to predict likelihood of health
procrastination and to identify areas of PM and PCs in the individual’s daily life that
would benefit from intervention. This is in accordance with Parker, Manstead, &
Stradling, (1995) who in extending the TPB (Ajzen, 2011) called for the development
of a belief-based measure of perceived behavioural control.
In this study of the 5 smokers in the WG condition, 2 of 4 participants
reporting as overweight and one underweight, were predicted by their sense of
PM: PC ratio as being at risk of health procrastination. In the WL condition, only 2 of
the 7 smokers, and 2 of the 8 participants reporting as overweight, were predicted by
their sense of control ratio to behave in a procrastinatory way towards health advice
and this tendency was shown to be associated with low levels of SC3. Whilst
reported weight status may have suffered from a priming effect of the WL condition,
where significant correlations between SC and sense of control were apparent (absent
in the WG condition), significance values may have been affected by the relatively
small sample size. None of the night shift workers smoked or reported themselves as
overweight.
34
Participants in the WG condition were significantly more judgmental about
negative health behaviours exhibited by HPs, which was not reflected in judgements
about their own weight status. This may be due to study design priming implicit
prejudice or stereotypical attitudes. However, fundamental attribution error would
equally explain the dispositional judgements made about the behaviour of others and
the more favourable judgements made about participants’ own weight status (Ross,
Amabile, & Steinmetz, 1977).
In the theory of planned behaviour (TPB), Ajzen, (1991), behaviour is
proposed as being a function of the willingness to perform a behaviour (intention) and
the degree of control the individual has over the behaviour. Intention is proposed as
being a function of control and perceived behavioural norms. The more social
pressure the individual perceives that they should comply with BC, coupled with a
high sense of PM over behaviour, the stronger intentions and behaviour should be.
Results indicate relationships between SC, PM: PC ratios that are consistent with this
model of BC. The TPB has been criticised for modelling behaviour on rationality in
weighing up the costs and benefits of an action (Manstead, 2011). This study, in
measuring implicit prejudice has attempted to overcome that criticism. Recently there
has been renewed interest in utilising moral norms in behaviour change models
(Brandt & Rozin, 2013). However, prejudice being overwhelmingly viewed as
negative, has meant that the subject of obesity, rather than being dealt with in terms of
‘real threat’, is often not dealt with at all, even by the very organisations that should
be promoting healthy lifestyle advice (Nelson, 2002).
The government has called for an active health care system in which HPs offer
advice on a range of healthy lifestyle behaviours (Dugdill, Graham, & McNair, 2005).
35
This study based upon existent research suggests that inconsistency and incongruence
inherent in an overweight HP giving such advice is sufficient to induce reactance
(Brehm, 1966). Organisational hypocrisy is apparent in the continued employment of
overweight staff in the absence of sustainable and effective policies and practices
aimed at addressing the problem in the workplace, such as continuing to use vending
machines in waiting rooms as alternatives to out- of- hours meal provision, lack of
staff rest and food preparation areas and lack of onsite staff physical exercise
facilities.
Limitations of this study are that it is experimental and thus lacks ecological
validity. Further research using weight differentials of HPs and performance data is
recommended, with a focus on longitudinal effects, as it is currently unknown
whether the effects persist in long-term HSK: HP relationships in the real world or to
what extent they are moderated or mediated by prevalent social norms. Behavior is
extremely complex and unpredictable across situational contexts and time, social
norms evolve constantly, personal attributes and abilities fluctuate.
Patterns of results across a range of studies on behaviour change suggest that
social relationships, social networks and social support have causal effects on health,
exposure to stress and health that would be supported by the PM: PCs aspect of this
study (House,1987). Much cross-cultural research exists to support the idea that
psychosocial variables underlie the relationship between socio economic status,
income equality and health (Chen,2004, Marmot,2004, Wilkinson & Pickett, 2009)
which would also be in accord with the PM: PC control ratio effects found in this
study. It is however, reassuring that for most people, achieving a balance between
PM and PCs is achievable given a supportive environment.
36
In conclusion, it is recommended that in addition to policy changes already
proposed, BC interventions should be easier to do than not do, be realistically
achievable by the individual given their PM: PC ratio at triage, be bolstered by social
norms and occur in a facilitative rather than an obesogenic environment.
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42
Appendix A
Section A: Basic information
A1: Title of study: “Do as I say, not as I do”: Perceptions of health and source credibility in relation to weight differentials in health professionals.
A2: Name of Applicant: (in collaborative projects, just name the lead applicant)
Mrs Helen McDowall
A3: Position of Applicant (e.g. UG/Masters/PGR student, academic)
Psychology undergraduate
A4: Programme of study: (for UG or taught Masters students only)
Psychology Bachelor of Science
A5: Department of Applicant: Psychology and Counselling
A6: Checklist to ensure application is complete. Have you prepared the following documents to accompany your application for ethical approval, please tick the appropriate column for each of the following?Document Yes No N/A
Confirmation of Ethical Approval of any other organisation
(e.g. NHS, MoD, National Offender Management Service)
Recruitment information / advertisement (e.g. draft text for email/ poster/social media/letter)
Information sheet for participants
Information sheet for carers/guardians
Information sheet/letter for gatekeepers e.g. Head teacher, teacher, coach
Consent form for participants
Assent form for younger children
Documentation relating to the permission of third parties other than the participant, guardian, carer or gatekeeper
43
(e.g. external body whose permission is required)Medical questionnaire / Health screening questionnaire
Secondary information sheet for projects involving intentional deceit/withholding information
Secondary consent form for projects involving intentional deceit/withholding information
Debrief sheet to give to participants after they have participated
Statements about completeness of the application Yes No N/AFor research involving under 18s or vulnerable groups, where necessary, a statement has been included on all
information sheets that the investigators have passed appropriate Disclosure and Barring Service1 checks
I can confirm that the relevant documents listed above make use of document references including date and
version number
I can confirm that I have proof read my application for ethical approval and associated documents to minimise
typographical and grammatical errors
Declaration of the applicant:
I confirm my responsibility to deliver the research project in accordance with the University of Chichester’s policies and procedures, which include the University’s ‘Financial Regulations’, ‘Research Ethics Policy’, ‘Data Systems and Security Policy’ and ‘Data Protection Policy’ and, where externally funded, with the terms and conditions of the research funder.
In signing this research ethics application form, I am also confirming that:
The research study must not begin until ethical approval has been granted. The form is accurate to the best of my knowledge and belief. There is no potential material interest that may, or may appear to, impair the independence and
objectivity of researchers conducting this project. Subject to the research being approved, I undertake to adhere to the project protocol without
deviation (unless by specific and prior agreement) and to comply with any conditions set out in the letter from the University ethics reviewers notifying me of this.
I undertake to inform the ethics reviewers of significant changes to the protocol (by contacting the clerk to the Research Ethics Committee ([email protected]) in the first instance).
I understand that the project, including research records and data, may be subject to inspection for audit purposes, if required in future, in keeping with the University’s Data Protection Policy.
I understand that personal data about me as a researcher in this form will be held by those involved in the ethics review procedure (e.g. the Research Ethics Committee and its officers and/or ethics reviewers) for five years after approval and that this will be managed according to Data Protection Act principles.
I understand that all conditions apply to any co-applicants and researchers involved in the study, and that it is my responsibility to ensure that they abide by them.
For the Student Investigator: I understand my responsibilities to work within a set of safety, ethical and other guidelines as agreed in advance with my supervisor and understand that I must comply with the University’s regulations and any other applicable code of ethics at all times.
1 Working with under 18’s or other vulnerable groups may require a Disclosure and Barring Service Check. Contact [email protected] if you are not sure whether you have an up to date and relevant DBS check or if you require more information. D1o note that a DBS check may take several weeks to obtain.
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Signature of Applicant: H A McDowall Date: 04/11/2016
Section B: Authoriser assessment and approval
B1: Name of Authoriser: Esther Burkitt
B2: Position of Authoriser:(e.g. supervisor, line manager)
Supervisor
AUTHORISER:Please categorise the application (A, A+ or B) ensure that the application form and all of the required documentation are complete before signing this application.Authoriser assessment: (tick as appropriate – see Section 10 of the Research Ethics Policy)
Category A: Proceed with the research project.
Undergraduate applications: Form and documentation retained at Department level, details A1 to A4 forwarded by the supervisor to the Research Office. Masters, PhD and staff applications: Form and documentation forwarded to the Research Office [email protected]
X
Category A+: (for placebo controlled studies or similar see Appendix 12)
Proceed with the research project.
Undergraduate applications: Form and documentation retained at Department level, details A1 to A4 forwarded by the supervisor to the Research Office. Masters, PhD and staff applications: Form and documentation forwarded to the Research Office [email protected]
Category B: Submit to the Ethical Approval Sub-group for consideration.
Proceed only when approval granted by the Chair of the Research Ethics CommitteeAuthoriser, please provide a comment on your assessment of the research project and for those projects involving vulnerable groups that you are authorising as Category A please justify this classification in the box below. As a further point, do make appropriate reference to any other codes of practice in your discipline particularly if you think that the proposed research may be in tension with those codes.Comment:
Authoriser’s declaration: I have read the Research Ethics Policy and this has informed my judgement as to the category
of assessment of this application.
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I understand that the applicant has taken account of the Research Ethics Policy and other relevant University policies in preparing this application.
For Supervisors: I understand my responsibilities as supervisor, and will ensure, to the best of my abilities, that the student investigator abides by the University’s Research Ethics Policy at all times.
Authoriser, please complete this table making it clear which version of the application form you are approving:
Version of the form (e.g. original version/ amended version following REC sub-group comments)
Signature of authoriser Date
V2 4.11.16V3 EBurkitt 4.11.16
Section C: Ethical Review Questions begin:
C1. Does the study involve human participants?
Participants in research are taken to include all those involved in the research activity either directly or indirectly and either passively, such as when being observed part of an educational context, or actively, such as when taking part in an interview procedure.
NB: The University does not conduct research on animals. If your proposed project involves animals in any way, please seek advice from the Research Office before proceeding.
Yes
If answer to C1 is ‘No’ then you do not need to complete this form and you do not need to seek formal ethical approval. Nevertheless, you are required to conduct your research in accordance with the Research Ethics Policy (REP) and Researcher Code of Conduct.
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C2. Why should this research study be undertaken? Brief description of purpose of study/rationale
Nurse Practitioners are front- line staff in Health Promotion Delivery and Referral, increasingly so in a Primary Multi - Disciplinary Team (MDT) setting. ‘Styles of communication’ research in Primary Care have concentrated on GP: Patient interactions and on explicit verbal communication.
Neither Motivational Communication Models nor Behaviour Change Models to date have explored the negative impact of messages implicit in overweight - nurse – physical - appearance as being the primary decisive factor in patient perceptions of Source Credibility, nor the implication this has for intention formation and subsequent behaviour change that are components of all major theoretical behaviour - change models.
Obesity is of current interest in the media and for health care providers, especially the National Health Service (NHS) and for Government Policy aimed at promoting healthy lifestyle. Obesity, as an indicator of negative health behaviour, over and above other negative behaviours such as smoking (which has largely been banned from the workplace) presents challenges for researchers in several ways: Firstly, it is an overt indicator of poor health NCD Risk Factor Collaboration. (2016). Trends in adult body-mass index in 200 countries from 1975 to 2014: a pooled analysis of 1698 population-based measurement studies with 19· 2 million participants. The Lancet, 387(10026), 1377-1396. whereas, other less obvious behaviours - ‘addictions’ for example, that have received attention in contempory literature, such as alcoholism, substance abuse, smoking and mental illness; largely remain hidden from the Patient and are not therefore used in patient decision - making. At least, not in the first instance. Further longitudinal research should therefore follow from this study to track changes in attitude over time.
Literature exploring Practitioner relationships in a variety of contexts demonstrated a lack of discrepancy between obesity and other negative health behaviours when assessing intervention outcomes. In consequence, some studies found that behaviour - matching between practitioners and patients was positive for both the relationship, and for the subsequent likelihood of behaviour change. Personal experience of the ‘presenting problem’ on the part of practitioners was valued by help- seekers or patients, but only when the practitioner had been able to illustrate his/her own success in making that change e.g. successful ‘weight- watcher’ or ‘slimming world’ models are used to encouraged weight- loss in others’.
Studies, which failed to isolate obesity from other negative health behaviours such as smoking, found that matching of overweight / obese Practitioners to patients/ help- seekers presenting a wide range of negative health problems, was negative for both the relationship and outcome. In summary, demonstrating or modelling effective, successful behaviour change as reflected in healthy physical appearance, had secondary positive effects for both the relationship and intervention outcome (Bandura,1973,1999) These results appear to have an association with levels of Control. Namely, Perceived Constraint Beliefs, (real or otherwise, that constitute barriers to behaviour change) and Personal Mastery (Beliefs about self- control, self -efficacy, autonomy, self-determination, competence) as used in Models of Behaviour change.
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Another issue that emerged from the literature search was of ‘Automatic’ or ‘System -1 thinking’, Kahneman, D. (2011). Thinking, fast and slow. New York, NY: Farrar, Straus & Giroux, which appears to be the heuristic used when help - seekers assess Nurse Practitioner source credibility. Neall, R. A., Atherton, I. M., & Kyle, R. G. (2016). Nurses' health‐related behaviours: protocol for a quantitative systematic review of prevalence of tobacco smoking, physical activity, alcohol consumption and dietary habits. Journal of advanced nursing, 72(1), 197-204. Automatic judgements, assumptions, attributions and prejudices made about obese people tend to be uniformly negative e.g. “fat people are lazy, greedy and could change their behaviour if they wanted to”. Other negative behaviours like smoking or alcoholism tended to be regarded as “illness” rather than a 'lifestyle choice' and as such were more sympathetically and empathetically processed by Patients / help seekers. Attributed causation was most usually associated with “coping with the stress of the job” for both Nurse Practitioners AND patients/ help seekers alike. For this reason, I wanted to test if weight differential predicted source credibility regardless of the type of health advice given. Dietary advice being logically paired with overweight appearance of the HP, but unrelated to Smoking cessation advice.
Research into Source Credibility and Health Promotion has almost exclusively focussed on the importance of the ‘message’. Thousands of studies have explored written or visual sources of information e.g. pamphlets, advertisements or internet sources of advice. Some are beginning to look at visual presentations, tutorials and lectures, but very few if any have looked in detail at practitioner: patient face – to - face interaction beyond verbal exchanges.
In a recent article (2015) that deals with the bi - directional relationship between source characteristics and message content that shapes our beliefs about the intervention, the person delivering the intervention and the likelihood that it is achievable. This keynote paper calls for ‘further research in real- world contexts’. “When we form, or change our beliefs about the world, we draw in large part on other people’s claims”: Collins, P. J., Hahn, U., von Gerber, Y., & Olsson, E. J. (2015). The Bi-directional Relationship Between Source Characteristics and Message Content. In Proceedings of the annual meeting of the cognitive science society (CogSci 2015). This study draws upon models of Belief Change by Bovens & Hartmann, (2004) and Olsson and Angere (2013). Our beliefs 'shape' or 'offer a framework' for every other aspect of our lives. They are determinants of our behaviour. This is a key paper for the rationale behind this study. The people who are influential in shaping our personal norms, values and behaviours are those with whom we come into daily contact. This may be on several levels. ‘Daily contacts’ may Include Facebook friends, TV personalities, news readers, radio programme presenters, talk- show hosts as well as work and leisure contacts, family and friends. Anyone in short, with whom we come into daily regular contact, with whom we feel affinity. Even those who are not regular contacts, but whose opinion we care about or to whom we aspire to be like. e.g. a celebrity, guru, saint, religious idol or parent. Acquaintances, for example, a nurse you happen to pass in the hospital corridor or a nurse whom you have never met, but who has been assigned to impart some kind of lifestyle advice, will fall outside of this category at least on initial meeting when automatic thought processes aid ‘first impressions’. This important distinction is made because it is the first impression that determines whether the relationship continues.
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This study is relevant therefore to closing the intention: behaviour gap that is the focus of so much psychology health research This is discussed in a book recently published - Cognitive Mechanisms of Belief Change (2016) by Aaron Smith. And builds on the book: Hood, B. (2009). Supersense: from superstition to religion-the brain science of belief. Hachette UK.
NHS England’s March 2016 Delivering Triple Prevention Strategy document deals with organisational change to fight obesity. The NHS will need a parsimonious and cost- effective way of implementing weight management and fitness changes for staff as well as patients. This research aims to add insight as to how this might most effectively be achieved.
C3a. What are you planning to do?
Provide a description of the methodology for the proposed research, including proposed method and duration of data collection, tasks assigned to participants of the research and the proposed method and duration of data analysis. If the proposed research makes use of pre-established and generally accepted techniques, e.g. established laboratory protocols, validated questionnaires, please refer to this in your answer to this question. (Do not exceed 500 words). If it is helpful for the panel to receive further documentation describing the methodology, then please append this to your application and make specific reference to it in box 3a below.
Data collection will begin as soon as ethical permission has been awarded. A survey will be administered online using Qualtrics software to the participant pool comprising second and first year psychology students in this University and on the psychology student third year Facebook page. Survey participation by 90 undergraduates will be rewarded with 30 minutes’ course credit for participant participation as part of the course requirement. The sample will be alternately assigned to two versions of the questionnaire, version 1 and version 2 to determine if the order of weight gain and weight loss influences credibility of the health message. Existing literature predicts that the effects of this manipulation will influence Source Credibility. Questionnaire 1 will show the overweight image first accompanied by a narrative about the person losing weight and questionnaire 2 will show the healthy weight image first accompanied by a narrative about how the person has gained weight. Both scenarios will be followed by measures of source credibility to assess if there is a difference. To check that the health status of the images is perceived accurately and uniformly by all participants both images will be presented at the end of the questionnaire. A 5 point likert scale will assess how ‘healthy’ the participants think each image is by asking them to rate the images from unhealthy, slightly unhealthy, neither unhealthy nor healthy, slightly healthy and healthy.
Each questionnaire should take no longer than 30 minutes to complete.
The duration of data collection, depending on response will be two weeks to allow students to complete other work alongside survey completion. Once the number of participants begins to slow and the minimum number required for statistical power have responded, the
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survey will end.
Participants will be asked to complete consent, demographic information and survey questionnaires online using Qualtrics software. Demographics will include Age, Gender, socio- economic background, ethnicity, and occupation. Participants will be asked whether they consider themselves to be underweight, slightly underweight, average weight for my
height, slightly overweight, overweight. This question will appear at the end of the survey to prevent it priming their answers. This is needed because self-identity biases influence responses Sherman, D. K., & Cohen, G. L. (2006). The psychology of self-defence: Self‐affirmation theory. Advances in experimental social psychology, 38, 183-242.
Questionnaires are valid and reliable and have been used in many previous peer - reviewed studies. They are included as Appendices. They are the Sense of Control Scale;
The Newspaper Credibility Index which measures ‘believability’ and the Source Credibility Scale which measures ‘Authority’ and ‘Character’. The stimuli image will be followed by a reminder of the health message, the Source Credibility scale and Newspaper Credibility index, twice, once for the dietary advice and once for smoking cessation. The Sense of Control scale will be administered once to measure Participant levels of Personal Mastery and Perceived Constraints. That the overall sense of control a person calculates they have over their life has a main effect on health behaviour is well documented.
IVs: Photographs will be presented - 2 photographs, 1 for each level of message – dietary advice and smoking cessation advice, will be presented and then participants will be asked to complete a combined scale measuring Overall Source Credibility. Measures of Authority, Character and Believability will be completed for a Healthy weight nurse who has gained weight in Questionnaire 1 and an Overweight nurse who loses weight in questionnaire 2 and a no-nurse (standalone message) which is presented in both questionnaire versions. The images will be accompanied by a narrative explaining they have either gained, or lost weight. Images will be a full-body outline of a health professional in uniform on a neutral background. The images will be black and white (to remove influence of colour and minimise effects of skin colour or ethnicity). A female image has been chosen since this reflects the gender bias in real-life healthcare. At the beginning of the questionnaire participants will be asked to rate each photographic image on a five point likert scale to check that the images have a uniform health perception for participants. Anonymised photographs, sourced from the public domain on Google Images will be of one person. The image will be digitally enhanced to reflect reality and main effect of relative body size. The photographs appear in the appendices. They will be presented with a simultaneous valid health message, one about healthy diet and the other, smoking cessation. Message content will be extracted from the latest NHS Advice available on the HNS Choices website which is constantly reviewed. and last updated March 2016. Both images are in identical uniform tunics and trousers to confer equal status. To control for gender effects and status effects photographs will of the same nurse before and after weight loss. To isolate the effect of ‘overweight appearance’, a Control Condition: 'No Nurse' (NN) will be presented with no photograph, just the stand - alone message for the two conditions – smoking cessation and snacking avoidance.
Everyone completes the Sense of Control sub scale measures of Personal Mastery and Perceived Constraints. This is so I can calculate 'likely' and 'unlikely procrastinators' (which
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in turn, predicts likelihood of behaviour change). Then I can see if Appearance moderates the known effect of Source Credibility on likelihood of behaviour change (procrastination) and if so, which one, the perceived Sense of control or perceived Source Credibility) predicts most of the % variation in likelihood of procrastination (behaviour change). It is hypothesised that sense of control and source credibility will be strongly, positively correlated
Counterbalancing:
Questionnaire 1: Overweight nurse ‘Charlie’ is introduced as being Overweight first and then a narrative explains that Charlie has lost some weight in the next image to see if it makes any difference to source credibility as detailed below: I predict that weight loss will predict increased source credibility scores as a function of the nurses' perceived coping/ competency skills.
Questionnaire 2:Healthy weight Charlie is introduced first and gains weight as below. I predict that weight gain will create decreased credibility scores as a function of the nurses perceived coping/competency skills
DVs: Will be measured using sub-scales of the Sense of Control Scale Lachman, M. E., & Weaver, S. L. (1998a). Low procrastination (High Personal +Low Perceived constraints) Mastery and Source Credibility) and Source Credibility (mean Authoritativeness + Character (Mc Croskey,1966) and Believability), Meyer, P. (1988). & McCroskey, J. C. (1966). 51
Healthy Weight
ImageOverweight
ImageControl
Message only
Smoking 15 15 15Snacking 15 15 15
Overweight
Image Healthy
Weight ImageControl
Message onlySmoking 15 15 15Snacking 15 15 15
C3b. When are, you planning to do it?
Please enter the anticipated start and end dates of your study (Consider at which point you will be involving human participants, this would typically be in the data collection/information gathering phase of the project but may be earlier):
9/01/2016 – 30/02/2017. Depending on ethical approval and response rate, data collection may end sooner than this. Also, I should bear in mind Christmas and New Year Break disruption. The student participation scheme will not be available until the beginning of next semester.
C4. Where will the research be undertaken?
Briefly describe the location of the study, provide details of any special facilities to be used and any factors relating to the study site/location that might give rise to additional risk of harm or distress to participants or members of the research team together with measures taken to minimise and manage such risks:
Data collection will be online using Qualtrics software. Participants will complete in their own time and will be instructed to complete the questionnaire individually.
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C5. Who are the participants?
Please indicate the number of participants in each of the groups in the table below.
If the precise number of participants is not known, then please make an estimate.
Please enter ‘0’ in the ‘Numbers in study’ column for those groups that are not included in your study.
Please note that the examples provided of different sorts of vulnerability are not an exhaustive list.
Participant No
Adults with no known2 health or social problems i.e. not in a vulnerable group: 90
Children aged 16-173 with no known3 health or social problems: 0
Children under 16 years of age with no known3 health or social problems: 0
Adults who would be considered as vulnerable e.g. those in care, with learning difficulties, a disability, homeless, English as a second language, service users
of mental health services, with reduced mental capacity4
Identify reason for being classed as vulnerable group and indicate ‘numbers in study’ in next column adjacent to each reason (expand the form as necessary):
………………………………………………..………………………………………………..
0
Children (aged <18) who would be considered as particularly vulnerable e.g. those in care, with learning difficulties, disability, English as a second languageIdentify reason for being classed as vulnerable group and indicate ‘numbers in study’
in next column adjacent to each reason (expand the form as necessary):
………………………………………………..
………………………………………………..
0
Other participants not covered by the categories listed above (please list): List other categories here: …………………………………………….
0
C6a. Is there something about the context and/or setting which means that the potential risk of harm/distress to participants or research is lower than might be expected?
Answer: Yes
2 Known to the researcher3 A summary of UK definition of ‘Child’ :
http://www.nspcc.org.uk/Inform/research/briefings/definition_of_a_child_wda59396.html 4https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/224660/
Mental_Capacity_Act_code_of_practice.pdf53
Consider if the study is part of routine activity which involves persons with whom you normally work in a typical work context e.g. Teachers working with children in a classroom setting, researchers in the performing arts working with performers, sports coaches working with athletes/players or research involving students in an academic setting.
Optional: Further information to justify answer to 6a
Answers to the Demographics section of the questionnaire will be coded and anonymous. Demographic information will not be sufficiently detailed to allow any link to be made between participant and their response. Student numbers are requested to attain accreditation for participant participation. Data may be withdrawn up until 1 week after participation, if the participant requests it.
C6b. Are there any conflicts of interests which need to be considered and addressed? (For example, does the research involve students whom you teach, colleagues, fellow students, family members? Do any of the researchers or participants have any vested interest in achieving a particular outcome? See section 9 of the Research Ethics Policy (REP))
Answer: Yes
If conflicts of interest are envisaged, indicate how they have been addressed: See below.
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Colleagues conducting research may feel some desirability - bias towards completing a fellow student’s research, seeking goodwill, truthful and considered answers and co-operation for their own projects (which may extend to the second - year group who will be conducting Independent projects in 2017-2018.
Fellow students needing course credits may see this opportunity as a ‘means to an end’ for themselves rather than a professional study intended to advance knowledge and either fail to complete the questionnaire correctly, or, not at all.
Non - Psychologists may have pre-existing prejudices against Psychology or Psychologists or resent the questionnaire invitation as an additional intrusion or onerous task in their lives.
This will be overcome by stressing that participation is voluntary. Also by stressing that the data generated by participation will be anonymous, so even I will not know who has completed the questionnaire. This is of relevance to any questionnaires completed by relatives, friends or acquaintances. Participants will either be asked to enter their student number to gain course credit, or they will be assigned a code based on the place they were born, the first letter of their surname and year. An example of this will be given on the Qualtrics consent form for them to follow.
If any of the participants learns the purpose of the study, they may deliberately or subconsciously answer the questions according to social desirability bias.
It is vital that the purpose of the study remains unknown. To disguise the real purpose of the research, the words ‘Source credibility’, ‘credibility’, ‘control’, ‘procrastination’ ‘Nurse, ‘Health - Professional’, ‘behaviour change’ or ‘obesity’ as being the issues related to that being investigated will not be mentioned. Participants will be asked to complete the questionnaire quickly and to not think about each question too deeply because I am more interested in their automatic response, rather than their considered one. The statement will read “This study is interested in message - framing effects in health advertising. You will be asked to view a series of photographs accompanied by a message (or a message on its own) and we would like you to indicate how much or how little you agree or disagree with the following statements”. By being very non - specific, no deception is explicitly implied.
Participants who are also heath workers themselves, or who are related to health professionals who may be overweight, may feel they are being disloyal, or that their professionalism is being questioned, should they suspect the purpose of the study. They may go on to indicate that source credibility is not damaged by appearance, even though their initial response was that it is. i.e. they lie out of misplaced loyalty which skews the results of the study. In addition, participants may fail to acknowledge their own prejudices and fail to report any influence of the nurse’s appearance on credibility when in fact there was one - social desirability bias. Health service providers have vested interest because the results of the study could potentially help determine strategy and policy decisions I the future.
It will be necessary therefore, to disguise the real purpose of the research, by not mentioning the words ‘Source credibility’, ‘credibility’, ‘control’, ‘procrastination’ ‘Nurse, ‘Health - Professional’, ‘behaviour change’ or ‘obesity’ as being the issues related to that being investigated. Participants will be asked to complete the questionnaire quickly and to not think about each question too deeply. The statement will read “This study is interested in message - framing effects in health advertising. You will be asked
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C7. How will potential participants in the study be identified, approached and recruited?
Please include details of:
Basis for selection of participants in the study: e.g. participants must be clinically obese adults; participants must be social workers over the age of 50; participants must have achieved Grade 5 in an appropriate musical instrument
Any criteria for exclusions (e.g. participants declaring a heart problem will be excluded)
How the selection criteria will be applied e.g. Health questionnaire completed prior to joining the study?
The means by which the participants will be recruited (e.g. through an advert, through a school, through a sports club), please be specific about the medium of the advertisement/recruitment information (e.g. poster, email, website, social media, word of mouth) and mention any third parties who may be involved in supporting the recruitment.
Please see recruitment email in Appendix.
I am aiming for a random sample, recruited either online via Psychology student Facebook pages for year 1 and year 2 or by posting on Moodle. Non-student contacts will be emailed individually and asked to recruit people they think might be interested in completing this research by sharing the recruitment link.
Because a large proportion of participants are likely to be fellow students, one might expect this to be an issue, they being too homogenous a sample, containing a high proportion of psychology undergraduates.
However, for this research, all participants will have had an equal chance of either meeting a health professional at some point on their lives, know someone who has, or will do so in the future. i.e. the chances are, that all of them will have encountered some sort of heath advice before, either in a hospital or care setting, via internet source, via Television advertising, via newspaper or other written media, in a leisure or sporting context, at school, or by visiting their GP or Dentist. That is, they are equally experienced and able to respond accurately to the questionnaire. No special conditions, knowledge or conditions apply.
I will include ‘occupation’ in the demographics to identify potentially ‘interested’ parties. I will ask the participant to indicate on a five point likert scale whether they consider themselves to be overweight – I consider myself underweight, slightly underweight, average weight, slightly overweight, overweight. This will be asked at the end of the questionnaire so as not to prime their answers.
C8. Will any payment, gifts, rewards or inducements be offered to participants to take part in the study? See section 11 of the REP.
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Answer: Yes
Please provide brief details and a justification:
Participation credits 30 minutes, ‘half an hour’, in exchange for participation as a course requirement for those in the participant pool. A Thank you message at the end of the survey and on debrief.
C9a. Is the process of the study and/or its results likely to produce distress, anxiety or harm in the participants even if this would be what they would normally experience in your work with them? See section 5 of the REP.
Answer: No
If you answered Yes to 9a, please answer 9b below:
C9b. Is the process of the study and/or its results likely to produce distress or anxiety in the participants beyond what they would normally experience in your work with them?
Answer: No
If yes, this Application must be categorised as ‘B’
Please provide details:
C9c. What steps will you take to deal with any distress or anxiety produced?
E.g. have a relevant professional on-hand to support distressed/anxious participants. Careful signposting to counselling or other relevant professional services. Other follow-up support.
No distress or anxiety arising from participating in this study is anticipated. However, should participants feel the need to discuss any issues raised by participating in this study and are a student at Chichester University, they should speak to a member of the SIZ desk to arrange a counselling triage consultation. Counselling services can be accessed by calling the SIZ desk on 01243 81(6222), by Email: [email protected], Online Support Me - Self Service Portal accessed from the Moodle or In Person at the SIZ counter in University Learning Resource Centres. Others are advised to seek counselling support from their GP.
The above contact information will appear in the Information and Debrief parts of the questionnaire. The online information will restate participants’ right to withdraw at any point if they feel uncomfortable responding to the questions.
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C9d. What is the potential for benefit to research participants, if any?E.g. Participants may gain an increased awareness of some issue or some aspect of themselves.Participants may gain experience resulting from participation which will help them design better research studies themselves later-on and help them in critical analyses of previous research and methods used in the field i.e. participation is a ‘learning experience’.
Course credits are relatively easily achieved in a short space of time which allows students to get on with their own module assignments. This is an incentive to participate.
Some will be interested in the outcome of the research, since it may be of potential relevance to health care promotion strategy, to NHS policy, to adapting models of behaviour change and to adding to previous research in the fields of health and behaviour- change generally.
Self - awareness may be raised as participants must confront their own, arguably innate prejudice about ‘overweight’ people and the associated discomfort (dissonance) that accompanies that thought process.
C10a. Will the study involve withholding information or misleading participants as part of its methodology? (Please refer to sections 6.11 and 10 of the REP for further guidance)
Answer: No
Please provide details if this has not already been explained in section 3a:
C10b. Do you envisage that withholding information or misleading participants in this way will lead to any anxiety, distress or harm?
Answer: No
Please justify your answer to 10b.:
If the study purpose is suspected, that will potentially distort the responses through the mechanism of social desirability bias. The whole study could be invalidated.
It is the University Research Ethics Policy that all projects with the exception of double blind placebo trials (or similar) will be categorise as Category B. Double blind placebo trails (or similar) may be categorised as Category A+
C11a. Does your proposal raise other ethical issues apart from the potential for distress, anxiety, or harm?
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Answer: Yes
C11b. If your answer to C11a. was ‘yes’, please briefly describe those ethical issues and how you intend to mitigate them and/or manage them in the proposed study, otherwise jump to C11c.
People often do not change their behaviour even though they do know/ believe that their behaviour is, or will likely cause illness in the future i.e. their choice to continue doing something that harms, is, on the face of it, irrational. Does cognitive dissonance resulting from the mixed messages given when overweight health professionals give health advice, reinforce this effect? This effect being called ‘Health Procrastination’ (McDowall, 2016). Procrastination being defined as “The action of delaying or postponing something” (sometimes indefinitely).
If the conclusion of this study is in the affirmative, then potentially, questions will be asked about whether overweight staff should be involved at all in health promotion. This could have wide - ranging consequences for health service/ NHS/Government policy and for the urgent prioritisation of occupational health services for health care workers. It may also help to prioritise the reduction in obesity, facilitate necessary changes and increase physical activity opportunities not only at organisational level, but for everyone. NHS England launched its ‘triple solution’ in March of this year (2016) to try to address the problem of poor source credibility in the NHS.I believe this study could give further insight into which interventions are likely to be most effective.
It is not the intention of myself in conducting this study to heighten prejudice against overweight individuals. I do believe that ignoring a problem by pandering to ‘political correctness’ when a problem plainly does exist, is not ethical. Failing to deal with the problem of overweight staff in the NHS or Health Care generally, (neglect), is just as unethical as failing to acknowledge the issue at all.
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C11c Does your proposed study give rise to any potential risk of harm or distress to yourself or other members of the research team? OR is there any risk that you could find yourself in a vulnerable position as you carry out your study.
Discussing overweight/ obesity can be highly emotive.
Bringing about cognitive dissonance by getting participants to confront their own prejudice may make them feel that I or others, might judge them unfavourably. If, I find that being overweight as a health - care worker does compromise professional and/ or organisational effectiveness, I could rapidly become very unpopular. There may even be attempts to discredit me.
I know it seems far- fetched to allude to this, but I have been a ‘whistle – blower’ in the past and struggled not only to be heard at all, but then to be believed. I had to compile my own evidence and even then, the authorities didn’t want to know about either the extent to which, or for how long inspectors had been deceived.
I Hereby claim the term ‘Health Procrastination’ and the four - level interaction between Personal Mastery and Perceived Constraints in the prediction of four distinct types of Procrastination, with their associated descriptives as my intellectual property.
Powerlessness Procrastination (Low PM + High PC) Powerlessness may be overcome by exhibiting procrastinatory behaviour. The very act of choosing 'not to act' is a way of exerting control in a situation where perceived lack of any control is overwhelming or cannot be realistically overcome e.g. palliative care patients can become very obstinate or stubborn over what they will or will not eat. For smokers who feel that their situation is too stressful to “give up at this time” they will exert control by refusing to accept the credibility of either the message, the message source or the intervention proposed to help them quit. This is known as reactance.
Poor Decision - Making Procrastination (Low PM + Low PC) results from cognitive dissonance. Accompanied by low sense of control, feeling overwhelmed by having to decide. Everything is effortful. It is easier to delay making a decision than to risk making the wrong one. The kind of procrastination people are quite happy to rationalise as ‘considered’ decision – making. It tends not to upset the individual, though it may elicit a frustrated or infuriated response from others who view the individual as being weak- willed.
High Conflict Reactionary Procrastination (High PM+ High PC) is an extreme, often angry reaction associated with strong emotional responses. These are the conditions that may elicit extreme withdrawal from ‘harsh reality’ as a way of enforcing control (manipulation) on others e.g. suicide, retreat into psychoticism, drug taking or even suicide bombing/ terrorism. It may take the form of extreme prejudice against the Message Source to the degree that, however logical, reasonable and well-meant the advice, the help-seeker rejects the message totally, refusing to even consider it. Negotiating with such irrational delusional beliefs is fruitless.
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C12. Will informed consent of the participants be obtained and if so, how?
NB: Please see Recruitment Email in Appendix.
A recruitment email, written in an accessible style providing a brief description of what the study is about followed by the survey requirements. Participants will be asked to indicate by clicking on the response they wish to give or answering a YES/NO question.
Freedom to withdraw without giving a reason, plus any time restrictions to withdraw data that apply will be clearly stated.
An anonymity statement will be followed by how this will be operationalised, at the commencement, during and after the research has ended.
A statement about risks and/or benefits will be included.
This will be followed by the question “Do you consent to participating in this study?” YES /NO?
The questionnaire will skip to the end of the survey if ‘NO’ is selected.
Contact Details of the researcher will be included and length of time this will remain in place.
An invitation to ask questions, information about how research data will be stored and used (now & in future) plus information about when it would be impractical to withdraw data, which in this study would be at commencement of analysis using SPSS.
Debriefing: Will inform participants of the procedure, true full nature of the research, the outcome of the research, its implications and to provide assurances of continued confidentiality, anonymity and retention of data. To identify unforeseen harm, discomfort or misconceptions to arrange any assistance required.it will also include a post - hoc consent option. Support contact details are also supplied.
Please see Debrief in appendix.
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C13. Is there anyone whose permission should be sought in order to conduct your study? E.g. Head teacher of a school, parents/guardians of child participants.
Answer: No
When and how will informed-consent be obtained and from whom? Will it be written or oral consent bearing mind that oral consent will not be considered adequate other than in exceptional circumstances and must be appropriately justified in your application? If you are seeking to gain ‘loco parentis’ consent from a school rather than seeking individual parental consent, please describe your reasoning.
C14. Do you need to seek the permission of any other organisations, individuals or groups other than outlined in section 13? E.g. the Research Ethics Committee of partner or participating organisations. Organisations like the NHS and the Prison Service have specific systems for granting ethical approval for research.
Answer: No
Please note that all applications must go through the University of Chichester Application for Ethical Approval process and that they must meet the Research Ethics Policy (REP) requirements. Other prior approval will be taken into account but will not in itself be sufficient to gain University Research Ethics Approval. Each application must normally be accompanied by evidence (e.g. formal statement from the appropriate Ethics Committee) confirming approval by the external body (and any concerns/issues identified). In cases where an external body requires prior approval from the University Research Ethics Policy (such as some NHS work) the Research Ethics Committee (REC) may grant in principle approval pending written confirmation of ethical approval by the external body.
Please describe the permission that is required and how you will be seeking that permission: Please attach any relevant documentation e.g. letter, that relates to the seeking of the relevant permissions.
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C15. It is normally required that a participant’s data is treated confidentiality at the outset of, during and after the research study. Will this be the case?
Answer: Yes
If the answer is ‘yes’ please describe how you will be maintaining the confidentiality of participants’ data. If the answer is ‘no’ please justify the exceptional circumstances that mean that confidentiality will not be guaranteed. See section 7 of the REP.
Please make reference to measures you are taking to ensure security of data from the point of data collection, transfer from notebooks/voice recorders etc., onto secure devices, to the point of analysis, sharing and final storage. Actions should be in accordance with the University’s Data Systems and Security Policy and Data Protection Policy (in particular see Appendix 4 of the Data Protection Policy for guidance for University staff).
Please provide details:
Outset:
Participants will be asked their name on the consent form which will be separated from response data and only unified by the researcher who will know which name applies to which code. Participants will be asked to create an identification code comprising their place of birth, the first letter of their surname and their year of birth. Example: ‘LondonM66’ plus their ‘student number’ for university participation credit. Student numbers will be asked for at the end of the “your response has been recorded” page to avoid non- participants getting credit where none is deserved! (Because all participants need to be over 18 years of age, there will be no need to include the 19 or 20 prefix to the year of birth). I will not be asking for any uniquely identifiable ID information that can be confidently linked to participant responses. Email addresses will be kept so a check can be made of which participants deserve participant credits.
During:
Once data has been imported via Qualtrics to SPSS, data withdrawal and data destruction will be impossible as will modification of their consent. These options will only apply to the data - gathering stage.
Future:
Data sets only will be retained and stored on a secure memory device for the period of one year following the dissemination of results and conclusions or for five years following publication. This is for the purposes of transparency, replication or checking of results and analysis involved in peer - review that might occur prior to publication. However, at no point will data when reported be traceable to individual participants.
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C16. It is normally required that the anonymity of participants is maintained and/or that an individual’s responses are not linked with their identity. Will this be the case?
Answer: Yes
If the answer is ‘yes’ please describe how you will be maintaining the anonymity of participants. If the answer is ‘no’ please justify the circumstances that mean that anonymity will not be guaranteed. See section 7 of the REP. NB: in group studies, it is likely that each individual in the group will be aware that others in the group are participating in the study – they are therefore not anonymous to each other. However, their identity should not normally be associated with their individual responses. In some studies, individual participants may not want their identify known to other participants and the study must be designed and undertaken accordingly.
Please provide details:
Participants will be asked to create an identification code comprising their place of birth, the first letter of their surname and their year of birth. Example: ‘LondonM66’ plus their ‘student number’ for university participation credit. Student numbers will be asked for at the end of the “your response has been recorded” page to avoid non- participants getting credit where none is deserved! (Because all participants need to be over 18 years of age, there will be no need to include the 19 or 20 prefix to the year of birth). I will not be asking for any uniquely identifiable ID information that can be confidently linked to participant responses.
For any family, friend acquaintance responses, it will be made clear that data will be collected via my university email address, not my personal address and responses will be filtered by the Qualtrics programme, not processed directly by me, nor inputted into SPSS by me. This is to avoid researcher bias and to avoid social desirability bias, neither of which is conducive to the accuracy of this study.
To maintain the individuality of participant identity, no group emails will be sent, so individual email addresses and names will not appear in the address/ contact bar of any communication. Participation will be by voluntary invitation only. Should further contact be needed, for dissemination of results or debriefing, it will be conducted by asking, participants to purposefully request further information, placing responsibility for contact with them.
C17. Will participants have a right to comment or veto material you produce about them?
Answer: No
Please give details and if your answer is ‘no’ then please provide a justification.
Reports will be on cohort averages rather than individual data sets.
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C18. Does the project involve the use of or generation/creation of audio, audio visual or electronic material (e.g. Dictaphone recording, video recording) directly relating to the participants?
Answer: No
If yes, please describe how the collection and storage of this will be managed bearing in mind data protection and anonymity issues (see section 7 of the REP).
C19. How will the participants be debriefed?
It is expected that wherever possible all participants will receive some form of debriefing. This might be a verbal debriefing or a written debriefing depending on the context of the study. Debriefing provides an opportunity to remind participants of the procedures and outcomes of the research, and to provide further assurances on areas such as confidentiality, anonymity, and retention of data. Projects that intentionally withhold information or deceive as part of their methodology must include a written debrief sheet. (Please refer to sections 6.1 and 6.2 of the REP for further guidance)
A written debrief opportunity will be made available for participants at the end of the test items on Qualtrics for all participants. Please see attached written debrief sheet in appendices.
The purposes of the Debrief will be:
Informing participants of the procedure, the true full nature of the research, the outcome of the research, its implications and to provide assurances of continued confidentiality, anonymity and information about retention of data for a period of one year following the end of the study.
To identify unforeseen harm, discomfort or misconceptions, to arrange any assistance required.
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C20a. Might the research entail a higher than normal risk of damage to the reputation of the University, since it will be undertaken under its auspices? (e.g. research with a country with questionable human rights, research with a tobacco company. See section 9.3 of the REP).
Answer: No
C20b. If your answer to 20a was yes, please describe the potential risk to the University’s reputation and how this risk will be mitigated. If no, please jump to C20c.
C20c. Does the research concern groups or materials that might be construed as extremist, security sensitive or terrorist?
If so please describe how you will manage the research so that it is not in breach of the Terrorism Act (2006) which outlaws the dissemination of records, statements and other documents that can be interpreted as promoting or endorsing terrorist acts. For example, relevant documents, records, information and data pertaining to the research can be stored on a secure University server. Contact the Director of Research in the first instance if you are unsure as to how to proceed.
No
C21a. Will your results be available in the public arena? (e.g. publication in journals, books, shown or performed in a public space, presented at a conference, internet publication and placing a dissertation in the library) see section 8 of the REP.
Answer: Yes
If yes, please provide brief details:
NB: Have you considered the date by which it would be impractical for participants to withdraw their data from your study? Once you have begun to analyse the data or prepare it for publication it is reasonable for you to state that it will not be possible for a participant to request that their data is removed from the study. You need to make this clear on the information sheet.
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I hope to have this and my past paper on Procrastination published. I aim to write a book post – graduation in which this study may appear. Depending on impact, this research paper (but not actual data) could enter the public domain. For this reason, data must be kept for a period of five years after publication. Dissemination will include a poster presentation on Chichester campus as part of the module assessment on Tuesday 25th April 2017.
C21b. Will your research data be made available in the public arena?Certain research funding bodies require that research data is made Open Access i.e. freely available to the public. The University has a Research Data Policy that outlines the expectations and requirements for researchers at the University. Contact the Director of Research in the first instance if you are unsure as to how to proceed.
Answer: No
If yes, please provide brief details as to how the data will be prepared for public access including an overview of the meta-data that will accompany published data sets. Please also confirm that your intentions with respect to making data open access are clearly communicated to participants so that they can provide informed consent:
C22. Are there any additional comments or information you consider relevant, or any additional information that you require from the Committee?
No
[end of form]
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Appendix B
Recruitment email
You are warmly invited to participate in a study about how messages are framed in
health promotion.
You will complete an online survey gathering demographic information followed by a
series of questions about pictures accompanied by a narrative, followed by questions
about perceived sense of control.
The survey should take about 20 minutes
No distress or anxiety arising from participation is anticipated
There are no right or wrong answers to any of the questions. I am interested only in
finding out about your thoughts and feelings.
Participation is voluntary and you are free to withdraw at any time.
Any further questions, please contact the researcher Helen McDowall Email:
If you would like to access the survey, please follow one of the links below:
For those whose surname begins with a letter A-M click survey WG. For those with a
surname beginning with a letter N-Z please use survey WL. Thankyou.
(A-M) Survey WG https://chichpscyh.eu.qualtrics.com/SE/?
SID=SV_beGSRAFbFtq5SS1
(N-Z) Survey WL
https://chichpscyh.eu.qualtrics.com/SE/?SID=SV_1WTLrIJy8vH01rD
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Appendix C
Welcome Message
Thank you for agreeing to take part in this study about how messages are framed in
health advertising.
What is the purpose of the research and how will it be carried out?
Message framing is about how individuals, groups, and societies, organise, perceive,
and communicate about reality. The purpose of the research is to understand how we
make decisions about who to believe when seeking advice about how to improve our
health.
What will you be asked to do?
You will be asked basic demographic information e.g. Age, Gender. You will then
be asked to view photographs accompanied by a message, or a message on its own.
You will be asked to indicate how much you agree or disagree with the statements
that accompany them. A final survey measures the sense of control you experience
over your life and measures whether all participants perceived the photographs in the
same way.
The survey should take no more than 30 minutes. Year One and Year Two
Department of Psychology Students will earn 30 minutes’ participant participation
credits on supplying their student number at the end of the survey.
What are the anticipated benefits of participating in the survey?
It is hoped that information resulting from this research will add impetus to and
practical advice about how best to implement effective health improvement
interventions for everyone.
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Are there any risks associated with participating in the research?
There are no risks attached to participating in this study. Data will not be analysed
individually. I will be looking at trends and group means, and in the reporting of the
project, no information will be released which will enable the reader to identify you.
You will be asked to generate a unique code consisting of your pace of birth, the first
letter of your surname and the last two digits of the year you were born e.g.
LondonM66. Email addresses will be deleted from the data set once responses have
been recorded.
Do I have to take part?
No. Participation is entirely voluntary.
What happens if you change your mind and want to withdraw?
You have the right to withdraw at any time without giving any reason for doing so.
What will happen to the information collected as part of the study?
You may apply for data withdrawal up to one week after participation by contacting
the researcher. If you would like to access the results of the research, there will be
opportunity to ask for this at the end of the survey.
Data collected will be kept completely confidential, used only for statistical analysis
and stored and disposed in accordance with the Data Protection Act and the
University Data and Systems Security Policy.
Who can you contact if you have any questions about the project?
If you have any questions regarding the study, please contact Helen McDowall:
Email [email protected] or my supervisor, senior lecturer Esther Burkitt:
Email: [email protected]
70
Should you have any complaint about the project please contact: Dr Andy Dixon -
Director of Research, Department of Psychology and Counselling, University of
Chichester, College Lane, Chichester, West Sussex, PO19 6PE.
Email: [email protected]; Phone: 01243 812125 or the researcher
Email: [email protected].
This project has been approved in accordance with the University of Chichester
Ethical Policy Framework
There are no right or wrong answers to any of the questions. I am interested only in
finding out about your thoughts and feelings. Please answer all the questions quickly,
honestly and accurately. Do not spend too long on each response!
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Appendix D
Consent I am over the age of 18
I have read and understand the information provided for this research project.
I understand that my participation in the activity is voluntary and that I am free to withdraw my involvement without giving a reason.
I am aware of the timescales in which I can withdraw my data (as indicated on the Information Sheet) and I agree that all research gathered for the study may be published provided I cannot be identified individually.
I understand that all information will be anonymised and that my personal information will not be released to any third parties.
Contact information has been provided should I wish to seek further clarification about the study or am interested to discovering the overall findings at a later stage
I agree to participate in this research. Yes/No
By clicking ‘continue’, you are agreeing to participate in this study, and agree that you have read and understood the terms outlined above.
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Appendix E
Demographic questions
Using the slider, please indicate your age in years
Please indicate your gender M/F/Other
Ethnicity (please tick).
Asian/Asian British – Bangladeshi Black/Black British – African
Asian/Asian British – Pakistani Black/Black British – Caribbean
Asian/Asian British – Indian Other Black Background
Chinese White – British
Other Asian Background White Irish
Mixed – White & Black Caribbean Other White Background
Mixed – White & Black African Other Mixed Background
Mixed – White & Black Asian Other Ethnic Background
Nationality _____________________________________________
(e.g., British, Irish)
Please Indicate your main occupation?
Retired home- maker student, employed full time employed part time, unemployed.
Do you work night shifts? Yes/ No
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Appendix F
Paragraph wording for Healthy Eating advice (NHS Choices website, 2016)
A short paragraph has been written based on the latest information available about the
best way to eat healthily. Before publication, we would like to ask your opinion about
it. Please read the information and respond to the questions that follow.
These eight practical tips cover the basics of healthy eating, and can help you make
healthier choices.
Base your meals on starchy carbohydrates
Eat lots of fruit and veg
Eat more fish – including a portion of oily fish
Cut down on saturated fat and sugar
Eat less salt – no more than 6g a day for adults
Get active and be a healthy weight
Don't get thirsty
Don't skip breakfast
The key to a healthy diet is to eat the right number of calories for how active you
are, so that you balance the energy you consume with the energy you use. If you
eat or drink too much, you'll put on weight. If you eat and drink too little, you'll
lose weight. Eat a wide range of foods to ensure that you're getting a balanced diet
and that your body is receiving all the nutrients it needs.
Please rate on a scale of 1-5, how much you believe the information...
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Appendix G
Paragraph Wording for Smoking Cessation Advice (NHS Choices website, 2016)
Another short paragraph has been written reflecting latest research about the best way
to quit smoking. Before publication, we would like to ask your opinion about it.
Please read the information and respond to the questions that follow.
If you want to stop smoking, several different treatments are available from shops,
pharmacies and on prescription to help you beat your addiction and reduce withdrawal
symptoms. The main options are:
Nicotine replacement therapy (NRT)
Varenicline (Champix)
Bupropion (Zyban)
E-cigarettes
The best treatment for you will depend on your personal preference, your age,
whether you're pregnant or breastfeeding and any medical conditions you have. Speak
to your GP or an NHS stop smoking adviser for advice. Research has shown that all
these methods can be effective. Importantly, evidence shows that they are most
effective if used alongside support from an NHS stop smoking service.
Please rate on a scale of 1-5, how much you believe the information…
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Appendix H
Newspaper Credibility Index measuring believability of the message (Meyer, 1988)
The question asked was: “Please rate on a scale of 1-5, how much you believe the
information ‘Can’t' be trusted-Can be trusted’, ‘Is inaccurate-is accurate’, ‘Is unfair-is
Fair’, ‘Doesn't tell whole story-tells the whole story’, ‘Is biased-is unbiased’.”
Can’t' be trusted 1 2 3 4 5 Can be trusted
Is inaccurate 1 2 3 4 5 Is accurate
Is unfair 1 2 3 4 5 Fair
Doesn't tell whole story 1 2 3 4 5 Tells the whole story
Is biased 1 2 3 4 5 Is unbiased
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Appendix J
The source credibility scale (McCroskey, 1966), consisted of two subscales
measuring the ‘Authoritativeness’ of the source’ and ‘Character’ of the source.
The questions asked were; “Please rate on a scale of 1-7 how credible you now think
Charlie’s information about healthy eating is now “…: Reliable-Unreliable (reverse
code), Uninformed-Informed, Unqualified-Qualified, Intelligent-Unintelligent
(reverse code), Valuable-Worthless (reverse code) and Inexpert-Expert. Items were
summed to create the variable ‘Authoritativeness’.
Reliable 1 2 3 4 5 6 7 Unreliable (rc)
Uninformed 1 2 3 4 5 6 7 Informed
Unqualified 1 2 3 4 5 6 7 Qualified
Intelligent 1 2 3 4 5 6 7 Unintelligent (rc)
Valuable 1 2 3 4 5 6 7 Worthless (rc)
Authoritativeness
Character
The question asked was: “Please rate on a scale of 1-7 how credible you now think
Charlie’s information about healthy eating is now…: Honest-Dishonest (reverse
code), Unfriendly-Friendly, Pleasant-Unpleasant (reverse code), Selfish-Unselfish,
Awful-Nice and Virtuous-Sinful (reverse code). Items were summed to create the
variable Character’.
Honest 1 2 3 4 5 6 7 Dishonest (rc)
Unfriendly 1 2 3 4 5 6 7 Friendly
Pleasant 1 2 3 4 5 6 7 Unpleasant (rc)
Selfish 1 2 3 4 5 6 7 Unselfish
Awful 1 2 3 4 5 6 7 Nice
Reverse coded items are annotated (rc).
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Appendix K
The Sense of Control Scale comprised 12 items on a 7 point likert scale (Lachman & Weaver, 1998). The ‘don’t know’ column was excluded from analysis.
Participants were asked “Please could you indicate how much you agree or disagree on a sale of 1-7 (Strongly disagree, somewhat disagree, disagree a little, don’t know, agree a lot, somewhat agree and strongly agree) with the following statements…
1. There is little I can do to change many of the important things in my life.
2. I often feel helpless in dealing with the problems of life.
3. I can do just about anything I really set my mind to do.
4. Other people determine most of what I can and cannot do.
5. What happens in my life is often beyond my control.
6. When I really want to do something, I usually find a way to succeed at it.
7. There are many things that interfere with what I want to do.
8. Whether or not I am able to get what I want is in my own hands.
9. I have little control over the things that happen to me.
10. There is really no way I can solve some of the problems I have.
11. Sometimes I feel that I am being pushed around in life.
12. What happens to me in the future mostly depends on me.
Sense of control subscales
The perceived constraints (PC) subscale comprised questions 1, 2, 4, 5, 7, 9, 10, & 11 (summed) (Cronbach’s α = 0.86)
The personal mastery (PM) subscale comprised questions 3, 6, 8, & 12 (summed) (Cronbach’s α = 0.70)
Subscales were treated as independent variables and remained unsummed for the purposes of this study.
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Appendix L1
Table L1. Scale reliability WG condition
Scale Title Items Cronbach
Believability written advice HE Control 5 .64*
Believability written advice SMKC Control 5 .77
Authoritativeness of HP Healthy Eating T1 6 .92
Character of HP Healthy Eating T1 6 .91
Believability Healthy Eating Advice T1 5 .89
Authoritativeness of HP Smoking Cessation T1 6 .94
Character of HP Smoking Cessation T1 6 .95
Believability of smoking cessation advice T1 5 .91
Authoritativeness of HP Healthy Eating T2 6 .93
Character of HP Healthy Eating T2 6 .85
Believability Healthy Eating advice T2 5 .92
Authoritativeness of HP Smoking Cessation T2 6 .95
Character of HP Smoking Cessation T2 6 .88
Believability of smoking cessation advice T2 5 .91
Personal Mastery 4 .66**
Perceived Constraints 8 .91
Table L 1. Reliability of scales Weight Gain condition
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Notes * and ** scale reliability within optimal range for scales with fewer than 10 items (Briggs & Cheek, 1986).
Appendix L2
Table L2. Scale reliability WL condition
Scale Title Items Cronbach
Believability written advice HE Control 5 .61*
Believability of written advice SMKC Control 5 .84
Authoritativeness of HP Healthy Eating T1 6 .90
Character of HP Healthy Eating T1 6 .86
Believability Healthy Eating Advice T1 5 .88
Authoritativeness of HP Smoking Cessation T1 6 .91
Character of HP Smoking Cessation T1 6 .89
Believability of smoking cessation advice T1 5 .86
Authoritativeness of HP Healthy Eating T2 6 .94
Character of HP Healthy Eating T2 6 .86
Believability of Healthy Eating advice T2 5 .86
Authoritativeness of HP Smoking Cessation T2 6 .93
Character of HP Smoking Cessation T2 6 .91
Believability of Smoking Cessation advice T2 5 .85
Personal Mastery 4 .50**
Perceived Constraints 8 .80
Table L2. Reliability of scales Weight Loss condition
80
Note * scale reliability within optimal range for scales with fewer than 10 items (Briggs &
Cheek, 1986
Appendix M1
Kolmogorov-Smirnova Shapiro-Wilk
Statistic df Sig. Statistic df Sig.
Believability HE Msg control .140 36 .074 .961 36 .237
Believability Smk Msg Control .123 36 .182 .957 36 .168
AuthoritativenessHET1 .182 36 .004 .805 36 .000
CharacterHET1 .160 36 .021 .821 36 .000
BelievabilityHET1 .164 36 .015 .873 36 .001
AuthoritativenesssmkT1 .180 36 .005 .765 36 .000
CharactersmkT1 .165 36 .015 .813 36 .000
BelievabilitysmkT1 .131 36 .121 .858 36 .000
AuthoritativenessHET2 .109 36 .200* .952 36 .123
CharacterHET2 .127 36 .150 .963 36 .260
BelievabilityHET2 .086 36 .200* .960 36 .217
AuthoritativenesssmkT2 .195 36 .001 .882 36 .001
CharactersmkT2 .094 36 .200* .971 36 .450
BelievabilitysmkT2 .147 36 .047 .895 36 .002
Personal Mastery .134 36 .101 .924 36 .017
Perceived Constraints .196 36 .001 .917 36 .010
Table M 1. Normality of scales Weight Gain condition
*. This is a lower bound of the true significance.
a. Lilliefors Significance Correction
81
Table M 1. Normality of scales WG condition
82
83
Appendix M2
Table M2. Normality of scales WL condition
Kolmogorov-Smirnova Shapiro-Wilk
Statistic df Sig. Statistic df Sig.
Believability H E Msg Control WL .095 49 .200* .979 49 .530
Believability Smk Msg Control WL .123 49 .063 .958 49 .081
AuthoritativenessHET1WL .110 49 .187 .945 49 .023
CharacterHET1WL .070 49 .200* .971 49 .267
BelievabilityHET1WL .101 49 .200* .962 49 .112
AuthoritativenesssmkT1WL .127 49 .045 .921 49 .003
CharactersmkT1WL .131 49 .034 .963 49 .122
BelievabilitysmkT1WL .130 49 .039 .956 49 .066
AuthoritativenessHET2WL .191 49 .000 .872 49 .000
CharacterHET2WL .160 49 .003 .914 49 .002
BelievabilityHET2WL .170 49 .001 .927 49 .005
AuthoritativenesssmkT2WL .171 49 .001 .891 49 .000
CharactersmkT2WL .134 49 .027 .927 49 .005
BelievabilitysmkT2WL .155 49 .005 .906 49 .001
Personal Mastery .174 49 .001 .939 49 .013
Perceived Constraints .156 49 .004 .943 49 .020
Table M 2. Normality of scales Weight Loss condition
*. This is a lower bound of the true significance.
a. Lilliefors Significance Correction
Appendix N1
Flow of Silhouette Generation
Silhouette generation: original photographs to final images of slim and overweight
silhouette http://s15.postimg.org/6hes7gcm3/before after.jpg ) 84
Appendix N2
The ‘unhealthy’ weight image was created by superimposing an unhealthy weight
image over the ‘healthy’ weight image by using scissors, paper glue and a scanner to
produce the final silhouettes, so the only manipulation between the images was weight
differential appearance. The unhealthy silhouette depicted the same HP wearing an
‘empathy suit’ to simulate WG worn by health care professionals to mimic obesity to
foster appreciation of how obese patients cope with challenging healthcare
environments.
85
Appendix O
Figure1. Establishing Validity of the Healthy Weight silhouette on a scale 1-5 Healthy to Unhealthy
86
Appendix P
Figure 2. Establishing Validity of the Unhealthy Weight silhouette on a scale 1-5 Healthy to Unhealthy
87
Appendix Q
The HP Professional Profile at Time 1.
Let me introduce you to Charlie. Charlie is a highly-respected Nurse Practitioner with
special responsibility for giving health advice on behalf of the primary care
multi-disciplinary team. Charlie has been a health professional for 10 years and has
developed expertise and knowledge in two specialist fields; healthy eating and
quitting smoking. Charlie is responsible for producing the information you read in the
previous section.
This is Charlie at the time of writing the draft version information about eating
healthily or quitting smoking. (Here the first silhouette was presented. In the weight
gain condition, the healthy silhouette was presented first. In the weight loss condition
the unhealthy silhouette was presented first).
Here is a reminder of the information about eating healthily or quitting smoking.
Please rate on a scale of 1-7 how credible you think Charlie’s information on eating
healthily/quitting smoking is now....
The HP Profile Manipulation at Time 2
Now jump forward in time three years. Charlie is still a respected Nurse Practitioner
with special responsibility for giving health advice on behalf of the primary care
multi-disciplinary team. Charlie has now been a health professional for 13 years and
has maintained expertise and knowledge in two specialist fields. Charlie remains
responsible for producing the information on healthy eating and quitting smoking
which remains unchanged after several reviews. However, Charlie now looks like
this. (Here the second silhouette was shown. In the weight loss condition the healthy
weight silhouette and in the weight gain condition, the unhealthy silhouette).
Charlie has lost/gained a lot of weight! Here is a reminder of the information about
healthy eating/quitting smoking. Please rate on a scale of 1-7 how credible Charlie’s
information about healthy eating is now….
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Appendix R
Debrief
Department of Psychology and Counselling
University House
University of Chichester
College Lane
Chichester
West Sussex
PO19 6PE
Telephone +44 1243 816000
Email [email protected]
Thank you for participating in this study.
This study was about source Credibility and Procrastination Interactions in Health
Promotion.
Source Credibility is “the degree to which people believe and trust what
other people and organisations tell them about a particular product or service”
Source credibility theory states that people are more likely to be persuaded when
the source presents itself as credible.
To procrastinate means “to put off doing something until a future time, sometimes
indefinitely”
Previous research has indicated that perceptions of source credibility are the result of
a bi - directional interaction between the message itself and the source of the message,
in this case between a Nurse Practitioner and information presented about avoiding
snacking and quitting smoking.
Also, previous research has shown a strong correlation between the amount of
perceived control a person has over their behaviour and the chances they will ‘action’
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that behaviour in the presence of an intention to do so. This belief about control forms
a basis for all Health behaviour - change models.
However, none of the behaviour change models to date make the following distinction
between the sub - types of control interactions and sub- types of procrastination
behaviours resulting from them.
Previous research into procrastination showed me that for every interaction between
sub - scales of Control called ‘Personal Mastery’ and ‘Perceived Constraints’, the
likelihood of ‘non – procrastination’ or “getting on with it,” is only present when
Personal Mastery is perceived as being High and when Perceived Constraints or
perceived barriers (whether they be real or imagined), to that behaviour occurring, are
simultaneously Low. For all other interactions, the chance that procrastination will be
triggered is raised.
In this study, I was interested in the effect that perceived Source Credibility,
dependent upon whether the Nurse had visibly lost or gained weight had on the
chances that a healthy or desirable behaviour change will occur. This relevant because
of the 1.3 million NHS workers in Britain in 2016, it is estimated, half are overweight
or obese. These are the very people that are charged with the job of imparting health
advice across a wide range of health – related behaviours at an individual and
organisational level.
Current study
In phase one, a stand-alone message control was presented and you were asked to rate
the credibility or believability of two paragraphs. One was about avoiding snacking
and another about quitting smoking.
In phase two, you were all presented with A matched – condition: ‘Overweight
Nurse’ and Avoiding Snacking and an unmatched condition: Overweight and
Smoking Cessation.
Half of you completed version 1 of the questionnaire, whereby the nurse was seen to
successfully lose weight and the other half completed version 2 whereby, the nurse
was seen to unsuccessfully gain weight over time. You completed measurements of
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Source Credibility for each condition to ascertain if appearance does indeed affect
Source Credibility. Neutral photographic representations of a nurse called Charlie (a
name applicable to both men and women), in two forms Overweight and healthy
weight, were presented to control for potential gender, ethnicity and status confounds.
A short profile about ‘Charlie’ established his/ her professional authority and acted as
an additional control for status.
In phase three, all of you completed a measurement of how much control you feel you
have in your own life which was used to discover how likely you are to exhibit
procrastinatory behaviour, in this case, in relation to doing something positive about
your health. This enabled me to see if there was any link between the two concepts
source credibility and procrastination, and in doing so establish a link to the likelihood
of behaviour change in the real world. That is, if overweight nurses are less likely to
get results across a range of health interventions or just those to which they and their
patients are matched.
The final question was about whether you considered yourself to be overweight. This
was important, because previous research indicates that we judge the likelihood we
can achieve a desirable behaviour e.g. losing weight, on how successful others around
us are in exhibiting their own success. In the case of obesity, the attributions about the
person who is overweight are uniformly negative. In other words, Obesity is not
considered socially desirable. Previous studies that had not made the distinction
between advice given by overweight staff and advice given by healthy- weight staff
also failed to distinguish between the type of advice being given i.e. whether the
‘problem’ presented by the patient is matched or unmatched to that of the health care
professional. I wanted to see if self-identity biases influenced responses.
Participants’ had the right to withdraw data for a period of one week following
completion of the survey.
If you experienced discomfort responding to the questions when participating in this
study and are a student at Chichester University, please speak to a member of the SIZ
desk to arrange a counselling triage consultation. Counselling services can be
accessed by calling the SIZ desk on 01243 81(6222), by Email: [email protected],
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Online Support Me - Self Service Portal accessed from the Moodle or In Person at the
SIZ counter in University Learning Resource Centres. Others are advised to seek
counselling support from their GP.
Please do not hesitate to contact me in the future to discover the overall findings once
the study is completed. Email: [email protected].
If you have any complaints about participation, please do not hesitate to contact the
supervising lecturer Esther Burkitt at [email protected]
Thank you for your time, it is very much appreciated.
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Appendix S1
PM
Spearman's
rho
BelievabilityHET2 Correlation Coefficient .034
Sig. (2-tailed) .821
N 46
AuthoritativenesssmkT2 Correlation Coefficient .075
Sig. (2-tailed) .618
N 46
CharacterHET2 Correlation Coefficient -.167
Sig. (2-tailed) .267
N 46
AuthoritativenessHET2 Correlation Coefficient -.005
Sig. (2-tailed) .971
N 46
BelievabilitysmkT2 Correlation Coefficient .068
Sig. (2-tailed) .655
N 46
CharactersmkT2 Correlation Coefficient -.087
Sig. (2-tailed) .564
N 46
Table S1. Time 2 correlations Personal Mastery WG condition
Table S 1. T2 SC correlations Personal Mastery WG condition
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Appendix S2
Table S2. Time 2 correlations Perceived Constraints WG condition
PCSpearman's rho BelievabilityHET2 Correlation Coefficient -.205
Sig. (2-tailed) .172
N 46
AuthoritativenesssmkT2 Correlation Coefficient -.173
Sig. (2-tailed) .251
N 46
CharacterHET2 Correlation Coefficient .054
Sig. (2-tailed) .722
N 46
AuthoritativenessHET2 Correlation Coefficient -.196
Sig. (2-tailed) .192
N 46
BelievabilitysmkT2 Correlation Coefficient -.166
Sig. (2-tailed) .269
N 46
CharactersmkT2 Correlation Coefficient -.129
Sig. (2-tailed) .392
N 46
Table S 2. T2 SC correlations Perceived Constraints WG condition
94
Table S 3. T2 SC correlations Personal Mastery WL condition
95
Appendix S3
Table S3. Time 2 correlations Personal Mastery WL condition
PM
Spearman's rho BelievabilityHET2WL Correlation Coefficient .258
Sig. (2-tailed) .065
N 52
BelievabilitysmkT2WL Correlation Coefficient .281*
Sig. (2-tailed) .044
N 52
AuthoritativenessHET2W L Correlation Coefficient .278*
Sig. (2-tailed) .046
N 52
AuthoritativenesssmkT2WL Correlation Coefficient .265
Sig. (2-tailed) .058
N 52
CharacterHET2WL Correlation Coefficient .336*
Sig. (2-tailed) .015
N 52
CharactersmkT2WL Correlation Coefficient .432**
Sig. (2-tailed) .001
N 52
*. Correlation is significant at the 0.05 level (2-tailed)
**. Correlation is significant at the 0.001 level (2 tailed)
Appendix S4
Table S4. Time 2 correlations Perceived Constraints WL condition
PC
Spearman's rho BelievabilityHET2WL Correlation Coefficient -.266
Sig. (2-tailed) .057
N 52
BelievabilitysmkT2WL Correlation Coefficient -.273
Sig. (2-tailed) .050
N 52
AuthoritativenessHET2WL Correlation Coefficient -.212
Sig. (2-tailed) .131
N 52
AuthoritativenesssmkT2WL Correlation Coefficient -.300*
Sig. (2-tailed) .031
N 52
CharacterHET2WL Correlation Coefficient -.291*
Sig. (2-tailed) .036
N 52
CharactersmkT2WL Correlation Coefficient -.256
Sig. (2-tailed) .067
N 52
*. Correlation is significant at the 0.05 level (2-tailed).
Table 4. T2 SC correlations Perceived Constraints WL condition
96
Appendix T
Table T1. Scatterplot showing correlation between PM and SC at T2 WL condition
Table T2. Scatterplot showing correlation between PC and SC at T2 WL condition.
97
Appendix U
Procrastination PM: PC Control model
98
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