- Email: [email protected]
College Students' Barriers and Enablers for Healthful Weight Management: A Qualitative Study
Research Brief College Students’ Barriers and Enablers for Healthful Weight Management: A Qualitative Study Mary L. Greaney, PhD1; Faith D. Less, MS2; Adrienne A. White, PhD, RD3; Sarah F. Dayton, MS4; Deborah Riebe, PhD5; Bryan Blissmer, PhD5; Suzanne Shoff, PhD6; Jennifer R. Walsh, MS, RD3; Geoffrey W. Greene, PhD, RD, LDN7 ABSTRACT Objective: To identify barriers and enablers for healthful weight management among college students. Design: Sixteen on-line focus groups, homogeneous by sex and university. Setting: Eight universities in 8 states. Participants: College students (N ¼ 115; 55% female; mean age 19.7 1.6). Analysis: Qualitative software, Nvivo version 2 (QSR International, Victoria, Australia, 2002), was used; similar codes were grouped together and categorized using an ecological model. Results: Males and females cited the same barriers to weight management: intrapersonal (eg, temptation and lack of discipline); interpersonal (social situations); and environmental (eg, time constraints, ready access to unhealthful food). Similar enablers were identified by sex: intrapersonal (eg, regulating food intake, being physically active); interpersonal (social support); and environmental (eg, university’s environment supports physical activity). More barriers than enablers were given, indicating that these college students were more sensitive to barriers than the enablers for weight management. Factors viewed by some students as barriers to weight management were viewed as enablers by others. Conclusions and Implications: When designing weight management interventions for college students, sex specificity may not be as important as considering that a barrier for one student may be an enabler for another. From an ecological perspective, individually focused interventions must be implemented in conjunction with environmental-level interventions to facilitate behavior change. Key Words: college students, weight management, focus groups (J Nutr Educ Behav. 2009;41:281-286.)
INTRODUCTION Entering college is a key transitional period for young adults.1 They face challenges adjusting to new surroundings and workloads, and many will have greater lifestyle freedom than ever before. Often these changes are associated with excessive weight gain.2 Low intake of fruits and vegeta-
bles, excess caloric intake, and lack of physical activity are frequently cited as reasons for weight problems in adults.3 Many college students have low intakes of fruits and vegetables and high intakes of food with excess calories, saturated fats, alcohol, and added sugars.4,5 Based on national surveys of college students, only 5.7% report eating 5 or more daily
1
Public Health Nutrition, Department of Nutrition, Harvard School of Public Health, Boston, MA 2 Program in Gerontology, University of Rhode Island, Kingston, RI 3 Department of Food Science and Human Nutrition, University of Maine, Orono, ME 4 Cornell Cooperative Extension, Cornell University, Ithaca, NY 5 Department of Kinesiology, University of Rhode Island, Kingston, RI 6 Department of Nutritional Sciences, University of Wisconsin–Madison, Madison, WI 7 Department of Nutrition and Food Sciences, University of Rhode Island, Kingston, RI The study was supported by the National Research Initiative of the United States Department of Agriculture Cooperative State Research, Education and Extension Service, grant number #2005-35215-15412. Address for correspondence: Mary L. Greaney, PhD, Public Health Nutrition, Department of Nutrition, Harvard School of Public Health, Boston, MA 02115; Phone: (617) 432-3726; Fax: (617) 432-3755; E-mail: [email protected] Ó2009 SOCIETY FOR NUTRITION EDUCATION doi:10.1016/j.jneb.2008.04.354
Journal of Nutrition Education and Behavior Volume 41, Number 4, 2009
servings of fruits and vegetables,6 62% report only 1-2 daily servings of fruits and vegetables,6 and 21.8% report eating 3 or more high-fat food items a day.7 Furthermore, college students as a population are physically inactive,8,9 with only 20% reporting participation in moderate physical activity and 30% in vigorous physical activity on a regular basis.6,10 The most rapid weight gain for adults is during their twenties,11 which may result in gains in weight and body fat above normal maturation.2,12,13 According to results of the 2006 American College Health Assessment, 4.5% of college students are underweight, 64.1% are a healthful weight, 21.9% are overweight, and 9.5% are obese, with rates of overweight and obesity higher among males than females.14 Excess weight gain during early adulthood may lead to increases in overweight and obesity later in life, with associated health consequences.15,16 To prevent obesity, consuming a healthful diet and being physically active are important.17
281
282 Greaney et al Educators in nutrition and exercise science are key in developing effective interventions to prevent obesity. To address topics such as body weight that may be considered sensitive, on-line focus groups provide a forum for preserving anonymity and increasing frank discussions.18 Online focus groups may be especially suited to college students because of their familiarity with computers. Although paralinguistic cues and body language are not apparent during online focus groups, respondents easily communicate attitudes and personality through writing.19,20 A series of on-line focus groups was conducted as part of a collaboration of 8 universities from 8 states (Michigan State University, Pennsylvania State University, South Dakota State University, Syracuse University, Tuskegee University, University of Maine, University of Rhode Island, and University of Wisconsin–Madison) to identify factors college students consider to be barriers and enablers to healthful weight management. Findings will be used to develop a Web-based weight management curriculum for college students using the Health at Every Size (HAES), nondiet approach that encourages internally regulated eating, enjoyment of eating and physical activity, and size acceptance.21
DESCRIPTION OF FOCUS GROUPS AND ON-LINE ASSESSMENTS Sixteen on-line focus groups were conducted synchronously22 using WebCT, a computer conferencing program, which allowed for the moderator and the focus group participants to interact in a chat-like format. A researcher trained in qualitative methods moderated all focus groups (8 with males and 8 with females) using a pilot-tested discussion guide. To set the foundation for subsequent curriculum design, Keller’s ARCS model (attention, relevance, confidence, satisfaction) was used to guide development of the focus group discussion guide.23 The ARCS model was selected for its orientation toward development of instructional materials that are inherently motivating to the target group. The attention and relevance aspects of the ARCS model
Journal of Nutrition Education and Behavior Volume 41, Number 4, 2009 were used to cultivate questions designed to elicit general issues of interest and specific health concerns important to college students. Resulting discussion questions addressed semester goals, factors making it difficult to maintain a healthful weight, triggers to eating, regulating intake of food and nonalcoholic beverages, and concerns about body shape and size. Full-time students, 18-24 years old, who were not majoring in nutrition or exercise science, were recruited through e-mail, posted flyers, or inperson contact. Before participating in a focus group, participants completed an on-line consent form, provided demographic information, answered questions about frequency of computer use, and completed assessments of fruit and vegetable intakes and physical activity. Participants also reported their height and weight, which were used to calculate body mass index (BMI). The 2-item Fruit and Vegetable Screener measured self-reported ‘‘cups’’ of fruits and vegetables (assessed separately) ‘‘usually’’ eaten per day.24 Physical activity level was assessed using the International Physical Activity Questionnaire (IPAQ) short form25 to assess participation in walking and in moderate and vigorous activity based on metabolic equivalent (MET). One MET is the amount of energy a person expends while sitting quietly. Moderate activities burn 3 to 6 METs, whereas vigorous activity burns 6 or more METS. The IPAQ was used to determine the percentage of participants who engaged in 30 minutes or more a day of moderate-intensity activity 5 days per week and the percentage who engaged in 20 minutes or more of vigorous-intensity activity on 3 or more days per week. This assessment was conducted to complement the qualitative data. Participants received a $10 incentive for being in the focus groups and completing the on-line assessment. This study was approved by the Institutional Review Boards at all participating universities. Two researchers trained in qualitative methods independently coded all transcripts using NVivo software, and any inconsistencies in coding were reviewed until consensus was reached. Similar codes were grouped together and categorized. As barriers and enablers to weight management
emerged, they were organized into intrapersonal, interpersonal, and environmental categories using an ecological model as the framework.26 Similarities and differences by sex were examined. The quantitative data collected via the on-line assessment were analyzed using SPSS software (version 15.0, SPSS Inc., Chicago, Ill., 2006). Means, standard deviations, and frequencies for demographic characteristics, physical activity, and fruit and vegetable consumption were calculated. Chi-square statistics and analysis of variance (ANOVA) were used to determine if sex differences existed, and significance was set a priori at P < .05.
LESSONS LEARNED In total, 115 (66%) of the 174 recruited students participated in the focus groups. More than half (54.8%) were female, and the majority was white (n ¼ 94, 82.5%). Based on BMI, most participants were of normal weight (n ¼ 83; 72.2%): however, 25.2% (n ¼ 29) were overweight or obese. Almost all participants (n ¼ 104, 90.3%) reported being comfortable or very comfortable using computers. There was no difference by sex in BMI status or comfort level with computer use (P > .05). Table 1 presents participants’ reported physical activity and consumption of fruits and vegetables. Although there were no significant differences by sex in mean cups of fruits or mean servings of vegetables consumed (P < .05), participants’ fruit and vegetable intakes were higher than those usually found in college students.6,27 The estimates of cups of fruits and vegetables usually eaten approached 2005 Dietary Guidelines recommendations,28 which was likely an artifact of the unit of measurement as ‘‘cups’’ rather than ‘‘servings.’’ College students appear to consider the units as interchangeable,29 despite the definition of a cup as approximately 2 servings.28 There was no difference by sex in the reported MET minutes of walking per week or moderate activity, but males reported significantly more vigorous activity per week than females.
Semester Goals All participants identified goals for the semester, with the most frequently
Journal of Nutrition Education and Behavior Volume 41, Number 4, 2009 Table 1. Self-reported Physical Activity and Fruit and Vegetable Consumption of College Students Who Participated in On-line Focus Groups (n = 115) Mean Standard Deviation Fruit and vegetable consumption Cups of fruit usually eaten/day Cups of vegetables usually eaten/day Physical activitya METb minutes walking/week MET minutes moderate activity/week MET minutes vigorous activity/weekc
4.2 3.6
2.4 2.1
1640.1 924.0 1780.6 N 30þ minutes of moderate activity on 5þ days/week 34 20þ minutes of vigorous activity on 3þ days/week 53
1372.3 1231.0 1393.8 % 29.6 46.1
a
Based on the 7-item International Physical Activity Questionnaire25; bBased ¼ metabolic equivalent; cSignificant difference by sex.
cited being (1) improving and/or maintaining academic standing; (2) being healthy, including increasing physical activity and/or improving diet; (3) maintaining or developing an active social life; and (4) gaining, losing, or maintaining weight. Almost all participants had goals related to getting more exercise and/or improving their diet. Exercise goals included going to the gym more often and exercising regularly; dietary goals included eating better, increasing consumption of fruits and vegetables, and reducing intake of unhealthful food. Male participants were more likely to want to ‘‘bulk up,’’ whereas the females wanted to become ‘‘toned.’’ Weightrelated goals included wanting to lose, gain, or maintain current weight. Although several females stated that their goal was to maintain their current weight, females were more likely than males to mention losing weight, typically 5 to 20 pounds, as a goal. Losing weight was mentioned as a goal in less than one-third of the male focus groups, and they were more likely than females to be specific about wanting to lose fat but gain muscle mass.
Barriers and Enablers to Healthful Weight Management When asked what makes it difficult and what makes it easy to be at a healthful weight, the following barriers and enablers (underlined in the text below) to weight management emerged during analysis (Table 2).
Intrapersonal-level barriers. Across all focus groups, participants spoke of not exercising making it difficult to maintain a healthful weight. Males viewed a lack of exercising—specifically not lifting weights—as being negatively associated with weight loss, whereas females viewed a lack of exercise as promoting weight gain. Both males and females spoke of not being motivated to exercise. Both males and females mentioned that not eating healthful food makes it difficult to maintain a healthful weight; reasons given were limited time, reliance on precooked meals and unhealthful food, and/or limited knowledge to shop and/or prepare healthful food. Other intrapersonal barriers for both males and females included temptation and lack of discipline and being bored. Only females mentioned stress as being associated with overeating. barrier. Participants noted that the behavior of others often influences what and when they eat and that social situations, like going out to dinner, were associated with overeating and eating unhealthful food. Both males and females spoke about external social pressures to eat, but females were more likely than males to state that social situations made it difficult to maintain a healthful weight. Although there were participants— both male and female—who did not drink alcohol, many noted that alcohol played an important part in their
Greaney et al 283 social lives. Males and females spoke of calories in alcohol and in ‘‘drunk eating,’’ a term used for eating fattening food in excess when intoxicated as contributing to weight gain.
Environmental-level barriers. Students reported that time constraints associated with being a student, make it difficult to obtain or prepare healthful meals and to exercise. Participants also felt that unhealthful food served at university cafeterias contributed to overeating and made it difficult to eat healthfully and maintain a healthful weight. More females than males stated that they had difficulty controlling intake of unhealthful food, especially if they were on a college meal plan that allowed unlimited access to food. Additionally, ready access to unhealthful food, including fast-food restaurants was seen as making it difficult to maintain a healthful weight. Conversely, lack of access to healthful food, including a lack of grocery stores and transportation to get to them, served as barriers for weight management for some. Students also spoke of a high monetary costs associated with healthful behaviors, specifically that a lack of money and limited budgets make it difficult to join an off-campus fitness center and/or pay the fees associated with on-campus facilities. Having a limited disposable income was seen as making it difficult to eat well as healthful food items were perceived as being more expensive than unhealthful food. More males than females mentioned the expense of eating healthfully and suggested that it is much cheaper and easier to eat unhealthful options.
Interpersonal-level
Intrapersonal-level enablers. Overall, participants said it was important to be ‘‘aware of what to eat and what not to eat.’’ In the majority of the focus groups, regardless of sex, participants stated that regulating food intake, which was done by ‘‘eating in moderation,’’ ‘‘watching portion size,’’ and not exceeding a ‘‘daily calorie limit,’’ enabled them to maintain a healthful weight. These participants said it was important to drink water and eat healthful food; eat around the same time daily; limit snacks; and eat only when hungry. Across all groups, participants
284 Greaney et al
Journal of Nutrition Education and Behavior Volume 41, Number 4, 2009
Table 2. Identified Barriers and Enablers to a Healthful Weight among College Students Who Participated in On-line Focus Groups (n = 115) BARRIERS Intrapersonal-level Not exercising Not eating healthful food Temptation and lack of discipline Boredom Stress Interpersonal-level Social situations Environmental-level Time constraints associated with being a student Food served at university’s cafeteria Ready access to unhealthful food, including fast-food restaurants Lack of access to healthful food High monetary costs associated with healthful behaviors ENABLERS Intrapersonal Regulating food intake Being physically active Having a high metabolism Interpersonal-level Social support Environmental-level University’s dining services make it possible to eat healthfully University’s environment supports physical activity
said that being physically active made it easy to maintain a healthful weight even though they did not all exercise. Participants spoke of exercising countering overindulging in food and/or alcohol. The majority of participants stated or implied that they balanced their caloric intake with their energy expenditure. In all of the male focus groups but in only 2 of the female focus groups, there were several participants who stated that having a high metabolism enabled them to maintain their weight.
Interpersonal-level enabler. Females were more likely than males to state that their friends provided social support to eat healthfully. Social support was seen, also, as making it easier to be physically active. Both males and females mentioned that they were more likely to go to the gym if they went with a friend.
Environmental-level
enablers. In contrast to the theme food served at university cafeterias, identified earlier as a barrier to healthful eating, a similar theme, university dining services
make it possible to eat healthfully emerged as supportive of healthful weight management. Additionally, participants felt that the university’s environment supports physical activity by having access to gyms making it easier to maintain weight. Male students spoke of enjoying intramural sports and that their participation resulted in them being physically active. There were 4 participants who were members of their university’s athletic teams who stated that this commitment resulted in them being physically active. In approximately half of the focus groups, participants said the geographic layout of their campus made it easy to maintain a healthful weight and that parking shortages forced them to walk/bike from their home/dorms to class.
What Is Needed to Become More Physically Active? When asked what would enable them to become more active, the vast majority of participants stated that they would need more time, as academic and work obligations made it difficult
to be physically active. They noted that getting into a routine might be beneficial. Some students said that their university needs better fitness facilities because of overcrowded and/or inadequate facilities. Participants also mentioned that additional resources such as having a personal trainer, free membership to a gym, or a fitness center in the residence hall would enable activity. Many females felt that they would be more physically active if they knew what classes (eg, Pilates) were available on campus and if they knew how to use the available equipment. Participants stated that additional opportunities (eg, intramural sports and group events) and increased social support would help them become more physically active.
DISCUSSION An ecological model was used to interpret data from on-line focus groups in college students conducted separately by sex. An important finding from this study was that despite males and females having different weight goals, few sex differences were identified when considering barriers and enablers to weight management. Both males and females cited the same intrapersonal barriers (eg, not eating healthful food; not exercising), interpersonal barrier (social situations), and the environmental barriers of time constraints and ready access to unhealthful food. When identifying enablers to maintaining a healthful weight, both males and females identified similar intrapersonal enablers (eg, regulating food intake, being physically active) and environmental enablers (eg, university dining services make it possible to eat healthfully and university environment supports physical activity). A lack of time to cook and cost of healthful food emerged more often among males than females, whereas stress contributing to overeating was identified only in focus groups with females. Females spoke of social support (ie, friends) as being both an enabler and a barrier to eating healthfully and being physically active, whereas males spoke of friends in terms of providing support to be physically active. Overall, participants identified more barriers than enablers. This finding is of concern, as students who perceive more barriers than
Journal of Nutrition Education and Behavior Volume 41, Number 4, 2009 enablers to physical activity tend to be less active.30 It is important to note that what may be a barrier for one young adult may be perceived as an enabler by another. For example, the environmental factor of dining halls was seen as a barrier to healthful eating for many students, but for some was seen as an enabler owing to the availability of healthful food options. Participants in these focus groups reported consuming more fruits and vegetables6,27 and being more physically active than other college samples.31 Although there were no differences in fruit and vegetable intakes by sex, males reported more vigorous activity than females. In addition, 72% of participants were within the normal weight range, which is slightly higher than rates found in larger samples.14,32 It is likely the self-selection recruitment process resulted in students interested in health participating in the groups. In support of this statement is the fact that 2 of the 4 most frequently mentioned semester goals were health related. Though findings were generated from participants at 8 universities in 8 states, the generalizability may be limited because of the use of convenience sampling and because 50% of the universities were located in the northeastern United States. Other study limitations include the use of self-report to measure physical activity participation and fruit and vegetable consumption.24,25 In addition, 4 of the 115 participants spoke of being members of college athletic teams. It would have been best to exclude student athletes. On-line focus groups are novel and may have a potential for abbreviated responses, misinterpretation of response context, and less discussion than might occur in an in-person focus group.33 For this study, the strengths of the on-line format were apparent. Most participants were comfortable using computers and had ready computer access. They retained their anonymity, which may have facilitated a greater sharing of thoughts than if the discussion had taken place in-person.
trapersonal, interpersonal, and environmental levels, intervention efforts should focus at both the individual and environmental levels simultaneously to facilitate behavior change. Weight management interventions for college students should be designed to emphasize the proximal benefits of consuming a healthful diet and being physically active that are salient for this population in conjunction with environmental interventions. Students, faculty, staff, and administrators can work together to make meaningful changes within the university environment. Nutrition educators can partner with dining service personnel to provide guidance for students when making food choices. They can also write articles for campus newspapers addressing barriers and enablers to healthful weight management, including quick recipes and innovative ways to be physically active on tight schedules. Advocating for students to have increased access to fitness facilities and increasing their awareness of scheduled exercise classes and fitness center hours is needed. Educators with expertise in nutrition and/or physical activity can partner to develop service learning projects for students to share with their peers on ways to overcome barriers and facilitate enablers to healthful weight management. Researchers may want to explore the differences in barriers and enablers for maintaining a healthful weight based on whether students subscribed to meal plans or lived on or off campus.
IMPLICATIONS FOR RESEARCH AND PRACTICE
REFERENCES
As barriers and enablers to weight management were identified at the in-
ACKNOWLEDGMENTS The study was supported by the National Research Initiative of the USDA Cooperative State Research, Education and Extension Service, grant number #2005-35215-15412. We appreciate the assistance of Breanna Lynch and Seung-Yeon Lee, and thank all of the students who participated in this study.
1. Arnett JJ. Emerging adulthood, a theory of development from the late teens through the twenties. Am Psych. 2000;55:469-480.
Greaney et al 285 2. Racette SB, Deusinger SS, Strube MJ, Highstein GR, Deusinger RH. Weight changes, exercise, and dietary patterns during freshman and sophomore years of college. J Am Coll Health. 2005; 53:245-251. 3. Mokdad AH, Bowman BA, Ford ES, Vinicor F, Marks JS, Koplan JP. The continuing epidemics of obesity and diabetes in the United States. JAMA. 2001;286:1195-1200. 4. Betts NM, Amos RJ, Keim K, Peters P, Stewart B. Ways young adults view foods. J Nutr Educ Behav. 1997;29:73-79. 5. Horacek TM, Betts NM. College students’ dietary intake and quality according to their Myers Briggs type indicator personality preferences. J Nutr Educ. 1988;30:387-395. 6. American College Health Association. American College Health Association– National College Health Assessment (ACHA-NCHA) Web Summary. Updated August 2007. Available at: http:// www.acha-ncha.org/data_highlights. html. Accessed March 12, 2008. 7. Centers for Disease Control and Prevention. Youth Risk Behavior Surveillance: National College Health Risk Behavior Survey—United States, 1995. Morb Mortal Wkly Rep. 1997; 46:1-54. 8. Centers for Disease Control and Prevention. Prevalence of physical activity, including lifestyle activities among adults—United States, 2000-2001. Morb Mortal Wkly Rep. 2003;52:764769. 9. Centers for Disease Control and Prevention. Physical activity and health: a report of the surgeon general. Available at: http://www.cdc.gov/nccdphp/ sgr/summary.htm. Accessed March 2008. 10. Douglas KA, Collins JL, Warren C, et al. Results from the 1995 National College Health Risk Behavior Survey. J Am Coll Health. 1997;46:55-66. 11. Lewis CE, Jacobs DR Jr, McCreath H, et al. Weight gain continues in the 1990s: 10-year trends in weight and overweight from the CARDIA study. Am J Epidemiol. 2000;151:1172-1181. 12. Hoffman DJ, Policastro P, Quick V, Lee SK. Changes in body weight and fat mass of men and women in the first year of college: a study of the ‘‘freshman 15.’’ J Am Coll Health. 2006;55:41-45. 13. Levitsky DA, Halbmaier CA, Mrdjenovic G. The freshman weight gain: a model for the study of the
Journal of Nutrition Education and Behavior Volume 41, Number 4, 2009
286 Greaney et al
14.
15.
16.
17.
18.
19.
20.
epidemic of obesity. Int J Obes Relat Metab Disord. 2004;28:1435-1442. American College Health Association National College Health Assessment Spring 2006 Reference Group Data Report (abridged). J Am Coll Health. 2007;55:195-206. Must A, Spadano J, Coakley EH, Field AE, Colditz G, Dietz WH. The disease burden associated with overweight and obesity. JAMA. 1999; 282:1523-1529. Must A, Strauss RS. Risks and consequences of childhood and adolescent obesity. Int J Obes Relat Metab Disord. 1999;23:S2-S11. United States Department of Health and Human Services. The Surgeon General’s Call to Action to Prevent and Decrease Overweight and Obesity 2001. Available at: http://www.surgeongeneral. gov/topics/obesity/. Accessed July 31, 2007. Campbell MK, Meier A, Carr C, et al. Health behavior change after colon cancer: a comparison of findings from faceto-face and online focus groups. Fam Community Health. 2001;24:88-103. Kenny AJ. Interaction in cyberspace: an online focus group. J Adv Nurs. 2005;49:414-422. Fox FE, Morris M, Rumsey N. Doing synchronous online focus groups with young people: methodological reflec-
21.
22.
23.
24.
25.
26.
27.
tions. Qual Health Res. 2007;17:539547. Foster GD, McGuckin BG. Nondieting approaches: principles, practices, and evidence. In: Wadden TA, Stunkard AJ, eds. Handbook of Obesity Treatment. New York: Guilford Press; 2002;494508. Cameron KA, Salazar LF, Bernhardt JM, Burgess-Whitman N, Wingood GM, DiClemente RJ. Adolescents’ experience with sex on the web: Results from online focus groups. J Adolesc. 2005;2:535-540. Keller J. The systematic process of motivational design. Performance and Instruction J. 1987;9/10:1-8. Greene G, Horacek T, White A, Ma J. Use of a diet interview method to define stages of change in young adults for fruit, vegetable and grain intake. Top Clin Nutr. 2003;18:32-41. Craig CL, Marshall AL, Sjostrom M, et al. International physical activity questionnaire: 12-country reliability and validity. Med Sci Sports Exerc. 2003;35:1381-1395. McLeroy KR, Bibeau D, Steckler A, Glanz K. An ecological perspective on health promotion programs. Health Educ Q. 1988;15:351-377. Horacek T, White A, Betts NM, et al. Decisional balance, self-efficacy and weight satisfaction discriminate stages
28.
29.
30.
31.
32.
33.
of change for fruit and vegetable intakes among young men and women. J Am Diet Assoc. 2002;102:1466-1470. US Department of Health and Human Services, US Department of Agriculture. Dietary Guidelines for Americans. 6th ed. Washington, DC: US Government Printing Office; 2005. Buckla C, Greene G. Assessment of fruit and vegetable intake and physical activity levels of young adults. Paper presented at: 5th Annual Conference of the International Society of Behavioral Nutrition and Physical Activity, Boston, MA; 2006. Grubbs L, Carter J. The relationship of perceived benefits and barriers to reported exercise behaviors in college undergraduates. Fam Community Health. 2002;25:76-84. Buckworth J, Nigg C. Physical activity, exercise, and sedentary behavior in college students. J Am Coll Health. 2004;53:28-34. Seo DC, Nehl E, Agley J, Ma SM. Relations between physical activity and behavioral and perceptual correlates among Midwestern college students. J Am Coll Health. 2007;56:187-197. Schneider S, Kerwin J, Frechtling J, Vivari B. Characteristics of the discussion in online and face-to-face focus groups. Soc Sci Comput Rev. 2002;20: 31-42.
INTRODUCTION Entering college is a key transitional period for young adults.1 They face challenges adjusting to new surroundings and workloads, and many will have greater lifestyle freedom than ever before. Often these changes are associated with excessive weight gain.2 Low intake of fruits and vegeta-
bles, excess caloric intake, and lack of physical activity are frequently cited as reasons for weight problems in adults.3 Many college students have low intakes of fruits and vegetables and high intakes of food with excess calories, saturated fats, alcohol, and added sugars.4,5 Based on national surveys of college students, only 5.7% report eating 5 or more daily
1
Public Health Nutrition, Department of Nutrition, Harvard School of Public Health, Boston, MA 2 Program in Gerontology, University of Rhode Island, Kingston, RI 3 Department of Food Science and Human Nutrition, University of Maine, Orono, ME 4 Cornell Cooperative Extension, Cornell University, Ithaca, NY 5 Department of Kinesiology, University of Rhode Island, Kingston, RI 6 Department of Nutritional Sciences, University of Wisconsin–Madison, Madison, WI 7 Department of Nutrition and Food Sciences, University of Rhode Island, Kingston, RI The study was supported by the National Research Initiative of the United States Department of Agriculture Cooperative State Research, Education and Extension Service, grant number #2005-35215-15412. Address for correspondence: Mary L. Greaney, PhD, Public Health Nutrition, Department of Nutrition, Harvard School of Public Health, Boston, MA 02115; Phone: (617) 432-3726; Fax: (617) 432-3755; E-mail: [email protected] Ó2009 SOCIETY FOR NUTRITION EDUCATION doi:10.1016/j.jneb.2008.04.354
Journal of Nutrition Education and Behavior Volume 41, Number 4, 2009
servings of fruits and vegetables,6 62% report only 1-2 daily servings of fruits and vegetables,6 and 21.8% report eating 3 or more high-fat food items a day.7 Furthermore, college students as a population are physically inactive,8,9 with only 20% reporting participation in moderate physical activity and 30% in vigorous physical activity on a regular basis.6,10 The most rapid weight gain for adults is during their twenties,11 which may result in gains in weight and body fat above normal maturation.2,12,13 According to results of the 2006 American College Health Assessment, 4.5% of college students are underweight, 64.1% are a healthful weight, 21.9% are overweight, and 9.5% are obese, with rates of overweight and obesity higher among males than females.14 Excess weight gain during early adulthood may lead to increases in overweight and obesity later in life, with associated health consequences.15,16 To prevent obesity, consuming a healthful diet and being physically active are important.17
281
282 Greaney et al Educators in nutrition and exercise science are key in developing effective interventions to prevent obesity. To address topics such as body weight that may be considered sensitive, on-line focus groups provide a forum for preserving anonymity and increasing frank discussions.18 Online focus groups may be especially suited to college students because of their familiarity with computers. Although paralinguistic cues and body language are not apparent during online focus groups, respondents easily communicate attitudes and personality through writing.19,20 A series of on-line focus groups was conducted as part of a collaboration of 8 universities from 8 states (Michigan State University, Pennsylvania State University, South Dakota State University, Syracuse University, Tuskegee University, University of Maine, University of Rhode Island, and University of Wisconsin–Madison) to identify factors college students consider to be barriers and enablers to healthful weight management. Findings will be used to develop a Web-based weight management curriculum for college students using the Health at Every Size (HAES), nondiet approach that encourages internally regulated eating, enjoyment of eating and physical activity, and size acceptance.21
DESCRIPTION OF FOCUS GROUPS AND ON-LINE ASSESSMENTS Sixteen on-line focus groups were conducted synchronously22 using WebCT, a computer conferencing program, which allowed for the moderator and the focus group participants to interact in a chat-like format. A researcher trained in qualitative methods moderated all focus groups (8 with males and 8 with females) using a pilot-tested discussion guide. To set the foundation for subsequent curriculum design, Keller’s ARCS model (attention, relevance, confidence, satisfaction) was used to guide development of the focus group discussion guide.23 The ARCS model was selected for its orientation toward development of instructional materials that are inherently motivating to the target group. The attention and relevance aspects of the ARCS model
Journal of Nutrition Education and Behavior Volume 41, Number 4, 2009 were used to cultivate questions designed to elicit general issues of interest and specific health concerns important to college students. Resulting discussion questions addressed semester goals, factors making it difficult to maintain a healthful weight, triggers to eating, regulating intake of food and nonalcoholic beverages, and concerns about body shape and size. Full-time students, 18-24 years old, who were not majoring in nutrition or exercise science, were recruited through e-mail, posted flyers, or inperson contact. Before participating in a focus group, participants completed an on-line consent form, provided demographic information, answered questions about frequency of computer use, and completed assessments of fruit and vegetable intakes and physical activity. Participants also reported their height and weight, which were used to calculate body mass index (BMI). The 2-item Fruit and Vegetable Screener measured self-reported ‘‘cups’’ of fruits and vegetables (assessed separately) ‘‘usually’’ eaten per day.24 Physical activity level was assessed using the International Physical Activity Questionnaire (IPAQ) short form25 to assess participation in walking and in moderate and vigorous activity based on metabolic equivalent (MET). One MET is the amount of energy a person expends while sitting quietly. Moderate activities burn 3 to 6 METs, whereas vigorous activity burns 6 or more METS. The IPAQ was used to determine the percentage of participants who engaged in 30 minutes or more a day of moderate-intensity activity 5 days per week and the percentage who engaged in 20 minutes or more of vigorous-intensity activity on 3 or more days per week. This assessment was conducted to complement the qualitative data. Participants received a $10 incentive for being in the focus groups and completing the on-line assessment. This study was approved by the Institutional Review Boards at all participating universities. Two researchers trained in qualitative methods independently coded all transcripts using NVivo software, and any inconsistencies in coding were reviewed until consensus was reached. Similar codes were grouped together and categorized. As barriers and enablers to weight management
emerged, they were organized into intrapersonal, interpersonal, and environmental categories using an ecological model as the framework.26 Similarities and differences by sex were examined. The quantitative data collected via the on-line assessment were analyzed using SPSS software (version 15.0, SPSS Inc., Chicago, Ill., 2006). Means, standard deviations, and frequencies for demographic characteristics, physical activity, and fruit and vegetable consumption were calculated. Chi-square statistics and analysis of variance (ANOVA) were used to determine if sex differences existed, and significance was set a priori at P < .05.
LESSONS LEARNED In total, 115 (66%) of the 174 recruited students participated in the focus groups. More than half (54.8%) were female, and the majority was white (n ¼ 94, 82.5%). Based on BMI, most participants were of normal weight (n ¼ 83; 72.2%): however, 25.2% (n ¼ 29) were overweight or obese. Almost all participants (n ¼ 104, 90.3%) reported being comfortable or very comfortable using computers. There was no difference by sex in BMI status or comfort level with computer use (P > .05). Table 1 presents participants’ reported physical activity and consumption of fruits and vegetables. Although there were no significant differences by sex in mean cups of fruits or mean servings of vegetables consumed (P < .05), participants’ fruit and vegetable intakes were higher than those usually found in college students.6,27 The estimates of cups of fruits and vegetables usually eaten approached 2005 Dietary Guidelines recommendations,28 which was likely an artifact of the unit of measurement as ‘‘cups’’ rather than ‘‘servings.’’ College students appear to consider the units as interchangeable,29 despite the definition of a cup as approximately 2 servings.28 There was no difference by sex in the reported MET minutes of walking per week or moderate activity, but males reported significantly more vigorous activity per week than females.
Semester Goals All participants identified goals for the semester, with the most frequently
Journal of Nutrition Education and Behavior Volume 41, Number 4, 2009 Table 1. Self-reported Physical Activity and Fruit and Vegetable Consumption of College Students Who Participated in On-line Focus Groups (n = 115) Mean Standard Deviation Fruit and vegetable consumption Cups of fruit usually eaten/day Cups of vegetables usually eaten/day Physical activitya METb minutes walking/week MET minutes moderate activity/week MET minutes vigorous activity/weekc
4.2 3.6
2.4 2.1
1640.1 924.0 1780.6 N 30þ minutes of moderate activity on 5þ days/week 34 20þ minutes of vigorous activity on 3þ days/week 53
1372.3 1231.0 1393.8 % 29.6 46.1
a
Based on the 7-item International Physical Activity Questionnaire25; bBased ¼ metabolic equivalent; cSignificant difference by sex.
cited being (1) improving and/or maintaining academic standing; (2) being healthy, including increasing physical activity and/or improving diet; (3) maintaining or developing an active social life; and (4) gaining, losing, or maintaining weight. Almost all participants had goals related to getting more exercise and/or improving their diet. Exercise goals included going to the gym more often and exercising regularly; dietary goals included eating better, increasing consumption of fruits and vegetables, and reducing intake of unhealthful food. Male participants were more likely to want to ‘‘bulk up,’’ whereas the females wanted to become ‘‘toned.’’ Weightrelated goals included wanting to lose, gain, or maintain current weight. Although several females stated that their goal was to maintain their current weight, females were more likely than males to mention losing weight, typically 5 to 20 pounds, as a goal. Losing weight was mentioned as a goal in less than one-third of the male focus groups, and they were more likely than females to be specific about wanting to lose fat but gain muscle mass.
Barriers and Enablers to Healthful Weight Management When asked what makes it difficult and what makes it easy to be at a healthful weight, the following barriers and enablers (underlined in the text below) to weight management emerged during analysis (Table 2).
Intrapersonal-level barriers. Across all focus groups, participants spoke of not exercising making it difficult to maintain a healthful weight. Males viewed a lack of exercising—specifically not lifting weights—as being negatively associated with weight loss, whereas females viewed a lack of exercise as promoting weight gain. Both males and females spoke of not being motivated to exercise. Both males and females mentioned that not eating healthful food makes it difficult to maintain a healthful weight; reasons given were limited time, reliance on precooked meals and unhealthful food, and/or limited knowledge to shop and/or prepare healthful food. Other intrapersonal barriers for both males and females included temptation and lack of discipline and being bored. Only females mentioned stress as being associated with overeating. barrier. Participants noted that the behavior of others often influences what and when they eat and that social situations, like going out to dinner, were associated with overeating and eating unhealthful food. Both males and females spoke about external social pressures to eat, but females were more likely than males to state that social situations made it difficult to maintain a healthful weight. Although there were participants— both male and female—who did not drink alcohol, many noted that alcohol played an important part in their
Greaney et al 283 social lives. Males and females spoke of calories in alcohol and in ‘‘drunk eating,’’ a term used for eating fattening food in excess when intoxicated as contributing to weight gain.
Environmental-level barriers. Students reported that time constraints associated with being a student, make it difficult to obtain or prepare healthful meals and to exercise. Participants also felt that unhealthful food served at university cafeterias contributed to overeating and made it difficult to eat healthfully and maintain a healthful weight. More females than males stated that they had difficulty controlling intake of unhealthful food, especially if they were on a college meal plan that allowed unlimited access to food. Additionally, ready access to unhealthful food, including fast-food restaurants was seen as making it difficult to maintain a healthful weight. Conversely, lack of access to healthful food, including a lack of grocery stores and transportation to get to them, served as barriers for weight management for some. Students also spoke of a high monetary costs associated with healthful behaviors, specifically that a lack of money and limited budgets make it difficult to join an off-campus fitness center and/or pay the fees associated with on-campus facilities. Having a limited disposable income was seen as making it difficult to eat well as healthful food items were perceived as being more expensive than unhealthful food. More males than females mentioned the expense of eating healthfully and suggested that it is much cheaper and easier to eat unhealthful options.
Interpersonal-level
Intrapersonal-level enablers. Overall, participants said it was important to be ‘‘aware of what to eat and what not to eat.’’ In the majority of the focus groups, regardless of sex, participants stated that regulating food intake, which was done by ‘‘eating in moderation,’’ ‘‘watching portion size,’’ and not exceeding a ‘‘daily calorie limit,’’ enabled them to maintain a healthful weight. These participants said it was important to drink water and eat healthful food; eat around the same time daily; limit snacks; and eat only when hungry. Across all groups, participants
284 Greaney et al
Journal of Nutrition Education and Behavior Volume 41, Number 4, 2009
Table 2. Identified Barriers and Enablers to a Healthful Weight among College Students Who Participated in On-line Focus Groups (n = 115) BARRIERS Intrapersonal-level Not exercising Not eating healthful food Temptation and lack of discipline Boredom Stress Interpersonal-level Social situations Environmental-level Time constraints associated with being a student Food served at university’s cafeteria Ready access to unhealthful food, including fast-food restaurants Lack of access to healthful food High monetary costs associated with healthful behaviors ENABLERS Intrapersonal Regulating food intake Being physically active Having a high metabolism Interpersonal-level Social support Environmental-level University’s dining services make it possible to eat healthfully University’s environment supports physical activity
said that being physically active made it easy to maintain a healthful weight even though they did not all exercise. Participants spoke of exercising countering overindulging in food and/or alcohol. The majority of participants stated or implied that they balanced their caloric intake with their energy expenditure. In all of the male focus groups but in only 2 of the female focus groups, there were several participants who stated that having a high metabolism enabled them to maintain their weight.
Interpersonal-level enabler. Females were more likely than males to state that their friends provided social support to eat healthfully. Social support was seen, also, as making it easier to be physically active. Both males and females mentioned that they were more likely to go to the gym if they went with a friend.
Environmental-level
enablers. In contrast to the theme food served at university cafeterias, identified earlier as a barrier to healthful eating, a similar theme, university dining services
make it possible to eat healthfully emerged as supportive of healthful weight management. Additionally, participants felt that the university’s environment supports physical activity by having access to gyms making it easier to maintain weight. Male students spoke of enjoying intramural sports and that their participation resulted in them being physically active. There were 4 participants who were members of their university’s athletic teams who stated that this commitment resulted in them being physically active. In approximately half of the focus groups, participants said the geographic layout of their campus made it easy to maintain a healthful weight and that parking shortages forced them to walk/bike from their home/dorms to class.
What Is Needed to Become More Physically Active? When asked what would enable them to become more active, the vast majority of participants stated that they would need more time, as academic and work obligations made it difficult
to be physically active. They noted that getting into a routine might be beneficial. Some students said that their university needs better fitness facilities because of overcrowded and/or inadequate facilities. Participants also mentioned that additional resources such as having a personal trainer, free membership to a gym, or a fitness center in the residence hall would enable activity. Many females felt that they would be more physically active if they knew what classes (eg, Pilates) were available on campus and if they knew how to use the available equipment. Participants stated that additional opportunities (eg, intramural sports and group events) and increased social support would help them become more physically active.
DISCUSSION An ecological model was used to interpret data from on-line focus groups in college students conducted separately by sex. An important finding from this study was that despite males and females having different weight goals, few sex differences were identified when considering barriers and enablers to weight management. Both males and females cited the same intrapersonal barriers (eg, not eating healthful food; not exercising), interpersonal barrier (social situations), and the environmental barriers of time constraints and ready access to unhealthful food. When identifying enablers to maintaining a healthful weight, both males and females identified similar intrapersonal enablers (eg, regulating food intake, being physically active) and environmental enablers (eg, university dining services make it possible to eat healthfully and university environment supports physical activity). A lack of time to cook and cost of healthful food emerged more often among males than females, whereas stress contributing to overeating was identified only in focus groups with females. Females spoke of social support (ie, friends) as being both an enabler and a barrier to eating healthfully and being physically active, whereas males spoke of friends in terms of providing support to be physically active. Overall, participants identified more barriers than enablers. This finding is of concern, as students who perceive more barriers than
Journal of Nutrition Education and Behavior Volume 41, Number 4, 2009 enablers to physical activity tend to be less active.30 It is important to note that what may be a barrier for one young adult may be perceived as an enabler by another. For example, the environmental factor of dining halls was seen as a barrier to healthful eating for many students, but for some was seen as an enabler owing to the availability of healthful food options. Participants in these focus groups reported consuming more fruits and vegetables6,27 and being more physically active than other college samples.31 Although there were no differences in fruit and vegetable intakes by sex, males reported more vigorous activity than females. In addition, 72% of participants were within the normal weight range, which is slightly higher than rates found in larger samples.14,32 It is likely the self-selection recruitment process resulted in students interested in health participating in the groups. In support of this statement is the fact that 2 of the 4 most frequently mentioned semester goals were health related. Though findings were generated from participants at 8 universities in 8 states, the generalizability may be limited because of the use of convenience sampling and because 50% of the universities were located in the northeastern United States. Other study limitations include the use of self-report to measure physical activity participation and fruit and vegetable consumption.24,25 In addition, 4 of the 115 participants spoke of being members of college athletic teams. It would have been best to exclude student athletes. On-line focus groups are novel and may have a potential for abbreviated responses, misinterpretation of response context, and less discussion than might occur in an in-person focus group.33 For this study, the strengths of the on-line format were apparent. Most participants were comfortable using computers and had ready computer access. They retained their anonymity, which may have facilitated a greater sharing of thoughts than if the discussion had taken place in-person.
trapersonal, interpersonal, and environmental levels, intervention efforts should focus at both the individual and environmental levels simultaneously to facilitate behavior change. Weight management interventions for college students should be designed to emphasize the proximal benefits of consuming a healthful diet and being physically active that are salient for this population in conjunction with environmental interventions. Students, faculty, staff, and administrators can work together to make meaningful changes within the university environment. Nutrition educators can partner with dining service personnel to provide guidance for students when making food choices. They can also write articles for campus newspapers addressing barriers and enablers to healthful weight management, including quick recipes and innovative ways to be physically active on tight schedules. Advocating for students to have increased access to fitness facilities and increasing their awareness of scheduled exercise classes and fitness center hours is needed. Educators with expertise in nutrition and/or physical activity can partner to develop service learning projects for students to share with their peers on ways to overcome barriers and facilitate enablers to healthful weight management. Researchers may want to explore the differences in barriers and enablers for maintaining a healthful weight based on whether students subscribed to meal plans or lived on or off campus.
IMPLICATIONS FOR RESEARCH AND PRACTICE
REFERENCES
As barriers and enablers to weight management were identified at the in-
ACKNOWLEDGMENTS The study was supported by the National Research Initiative of the USDA Cooperative State Research, Education and Extension Service, grant number #2005-35215-15412. We appreciate the assistance of Breanna Lynch and Seung-Yeon Lee, and thank all of the students who participated in this study.
1. Arnett JJ. Emerging adulthood, a theory of development from the late teens through the twenties. Am Psych. 2000;55:469-480.
Greaney et al 285 2. Racette SB, Deusinger SS, Strube MJ, Highstein GR, Deusinger RH. Weight changes, exercise, and dietary patterns during freshman and sophomore years of college. J Am Coll Health. 2005; 53:245-251. 3. Mokdad AH, Bowman BA, Ford ES, Vinicor F, Marks JS, Koplan JP. The continuing epidemics of obesity and diabetes in the United States. JAMA. 2001;286:1195-1200. 4. Betts NM, Amos RJ, Keim K, Peters P, Stewart B. Ways young adults view foods. J Nutr Educ Behav. 1997;29:73-79. 5. Horacek TM, Betts NM. College students’ dietary intake and quality according to their Myers Briggs type indicator personality preferences. J Nutr Educ. 1988;30:387-395. 6. American College Health Association. American College Health Association– National College Health Assessment (ACHA-NCHA) Web Summary. Updated August 2007. Available at: http:// www.acha-ncha.org/data_highlights. html. Accessed March 12, 2008. 7. Centers for Disease Control and Prevention. Youth Risk Behavior Surveillance: National College Health Risk Behavior Survey—United States, 1995. Morb Mortal Wkly Rep. 1997; 46:1-54. 8. Centers for Disease Control and Prevention. Prevalence of physical activity, including lifestyle activities among adults—United States, 2000-2001. Morb Mortal Wkly Rep. 2003;52:764769. 9. Centers for Disease Control and Prevention. Physical activity and health: a report of the surgeon general. Available at: http://www.cdc.gov/nccdphp/ sgr/summary.htm. Accessed March 2008. 10. Douglas KA, Collins JL, Warren C, et al. Results from the 1995 National College Health Risk Behavior Survey. J Am Coll Health. 1997;46:55-66. 11. Lewis CE, Jacobs DR Jr, McCreath H, et al. Weight gain continues in the 1990s: 10-year trends in weight and overweight from the CARDIA study. Am J Epidemiol. 2000;151:1172-1181. 12. Hoffman DJ, Policastro P, Quick V, Lee SK. Changes in body weight and fat mass of men and women in the first year of college: a study of the ‘‘freshman 15.’’ J Am Coll Health. 2006;55:41-45. 13. Levitsky DA, Halbmaier CA, Mrdjenovic G. The freshman weight gain: a model for the study of the
Journal of Nutrition Education and Behavior Volume 41, Number 4, 2009
286 Greaney et al
14.
15.
16.
17.
18.
19.
20.
epidemic of obesity. Int J Obes Relat Metab Disord. 2004;28:1435-1442. American College Health Association National College Health Assessment Spring 2006 Reference Group Data Report (abridged). J Am Coll Health. 2007;55:195-206. Must A, Spadano J, Coakley EH, Field AE, Colditz G, Dietz WH. The disease burden associated with overweight and obesity. JAMA. 1999; 282:1523-1529. Must A, Strauss RS. Risks and consequences of childhood and adolescent obesity. Int J Obes Relat Metab Disord. 1999;23:S2-S11. United States Department of Health and Human Services. The Surgeon General’s Call to Action to Prevent and Decrease Overweight and Obesity 2001. Available at: http://www.surgeongeneral. gov/topics/obesity/. Accessed July 31, 2007. Campbell MK, Meier A, Carr C, et al. Health behavior change after colon cancer: a comparison of findings from faceto-face and online focus groups. Fam Community Health. 2001;24:88-103. Kenny AJ. Interaction in cyberspace: an online focus group. J Adv Nurs. 2005;49:414-422. Fox FE, Morris M, Rumsey N. Doing synchronous online focus groups with young people: methodological reflec-
21.
22.
23.
24.
25.
26.
27.
tions. Qual Health Res. 2007;17:539547. Foster GD, McGuckin BG. Nondieting approaches: principles, practices, and evidence. In: Wadden TA, Stunkard AJ, eds. Handbook of Obesity Treatment. New York: Guilford Press; 2002;494508. Cameron KA, Salazar LF, Bernhardt JM, Burgess-Whitman N, Wingood GM, DiClemente RJ. Adolescents’ experience with sex on the web: Results from online focus groups. J Adolesc. 2005;2:535-540. Keller J. The systematic process of motivational design. Performance and Instruction J. 1987;9/10:1-8. Greene G, Horacek T, White A, Ma J. Use of a diet interview method to define stages of change in young adults for fruit, vegetable and grain intake. Top Clin Nutr. 2003;18:32-41. Craig CL, Marshall AL, Sjostrom M, et al. International physical activity questionnaire: 12-country reliability and validity. Med Sci Sports Exerc. 2003;35:1381-1395. McLeroy KR, Bibeau D, Steckler A, Glanz K. An ecological perspective on health promotion programs. Health Educ Q. 1988;15:351-377. Horacek T, White A, Betts NM, et al. Decisional balance, self-efficacy and weight satisfaction discriminate stages
28.
29.
30.
31.
32.
33.
of change for fruit and vegetable intakes among young men and women. J Am Diet Assoc. 2002;102:1466-1470. US Department of Health and Human Services, US Department of Agriculture. Dietary Guidelines for Americans. 6th ed. Washington, DC: US Government Printing Office; 2005. Buckla C, Greene G. Assessment of fruit and vegetable intake and physical activity levels of young adults. Paper presented at: 5th Annual Conference of the International Society of Behavioral Nutrition and Physical Activity, Boston, MA; 2006. Grubbs L, Carter J. The relationship of perceived benefits and barriers to reported exercise behaviors in college undergraduates. Fam Community Health. 2002;25:76-84. Buckworth J, Nigg C. Physical activity, exercise, and sedentary behavior in college students. J Am Coll Health. 2004;53:28-34. Seo DC, Nehl E, Agley J, Ma SM. Relations between physical activity and behavioral and perceptual correlates among Midwestern college students. J Am Coll Health. 2007;56:187-197. Schneider S, Kerwin J, Frechtling J, Vivari B. Characteristics of the discussion in online and face-to-face focus groups. Soc Sci Comput Rev. 2002;20: 31-42.