Copyright 1990 by The Cerontological Society of America
Data regarding perceived change were collected as part of a study of the effects of aerobic exercise training on psychological, cognitive, and physiological functioning among 101 healthy older adults. Subjects were assigned randomly to an aerobic exercise group, a yoga control group, or a waiting list group for 16 weeks, after which all subjects participated in aerobic exercise for another 16 weeks. Exercise participants perceived positive changes in a wide range of significant life areas, and perceived improvement was more closely related to objective improvement for physiological indicators than for indicators of cognitive functioning or psychological well-being. Key words: Aerobic exercise, Psychological well-being, Cognition
Charles F. Emery, PhD,2 and James A. Blumenthal, PhD2
Previous studies among older adults have found improvements following physical exercise in physiological functioning (Cunningham et al., 1987; Kavanaugh & Shephard, 1978), as well as in cognitive functioning (Dustman et al., 1984; Molloy et al., 1988) and psychological well-being (Buccola & Stone, 1975; Perri & Templer, 1985). Other recent studies (Blumenthal et al., 1989; Emery & Catz, 1990; Panton et al., 1990), however, have found little evidence of improved psychological or cognitive functioning in older adults following exercise. Studies frequently report significant subjective benefits among older adult exercisers, but few studies have directly assessed the impact of aerobic exercise on selfperceptions of mood and cognition, or other aspects of personal and social functioning among older adults. One recent study found that healthy middleaged subjects perceived improvements for physiological indicators following exercise, but that perceived improvement was not related to actual change in physical fitness (King et al., 1989). Also, there were no perceived improvements for either cognitive functioning or emotional well-being. Self-perceptions are an important aspect of individual functioning in that they are thought to be related to self-efficacy (Bandura, 1977), which is itself a useful indicator of psychological well-being. Indeed, it has been found that exercise is associated with increases in improved self-efficacy expectations for exercise and related physical activities among older adults with chronic obstructive pulmonary dis-
1 Supported by a grant (AC04238) from the National Institute on Aging. An earlier version of this paper was presented at the 41st Annual Scientific Meeting of the Cerontological Society of America, San Francisco, CA, 1988. We thank Janet Simon, Margaret Riddle, Robin Pomeroy, Susan Schniebolk, Bruce Burchett, Julia Whitaker, Cheri Rich, Sally Schnitz, and Ric Friedrich for technical assistance; and Janet Ivey for secretarial assistance. Send correspondence to: Charles F. Emery, PhD, Department of Psychiatry, Box 3119, Duke University Medical Center, Durham, NC 27710. ''Department of Psychiatry and Center for the Study of Aging and Human Development, Duke University Medical Center, Durham, NC 27710.
ease (Kaplan, Atkins, & Reinsch, 1984). Furthermore, it has been suggested that improved mastery or selfefficacy following exercise, in turn, may facilitate improvements in psychological well-being (de Coverley Veale, 1987). The present investigation was part of a larger study designed to examine the effect of aerobic exercise, using a randomized experimental design, on measures of physiological, psychological, and cognitive functioning. Results of objective change from the Duke Aging and Exercise Study have been reported elsewhere (Blumenthal et al., 1989). In addition to objective measures of functioning, the study included assessments of exercise participants' perception of change on a number of dimensions in order to explore the impact of the exercise program on perceived change. The purpose of the present paper is to examine in detail the findings from the subjective reports of perceived change. We hypothesized that participants in aerobic exercise would experience greater subjective gains than participants in the control conditions, and that subjective improvement would be correlated with objective changes. Furthermore, we hypothesized that subjects in the exercise condition would be most likely to perceive improvement in areas of functioning related to exercise, as was indicated in previous studies of middle-aged (King et al., 1989) and chronically ill older adults (Kaplan, Atkins, & Reinsch, 1984). Finally, we hypothesized that perceived improvement would be correlated with adherence to the exercise program. Methods
Subjects One hundred thirteen older adults were recruited to participate in the study through advertisements in local newspapers and on radio programs. Of those recruited, 12 were disqualified due to health prob516
The Gerontologist
Downloaded from http://gerontologist.oxfordjournals.org/ at Thomas Jefferson University, Scott Library on August 20, 2015
Perceived Change Among Participants in an Exercise Program for Older Adults1
Subject Groups Aerobic Exercise. — Each subject in the AE group was assigned a six-beat heart rate training range equivalent to 70% maximum heart rate reserve (Karvonen, Kentala, & Mustala, 1957), based on the maximum heart rate achieved during an initial bicycle exercise test. The following formula was used: Training range = (max. heart rate - resting heart rate x .70 + resting heart rate) ± 3 beats. For example, if the subject had a resting heart rate of 70, and a maximum heart rate of 150 on the bicycle test, a six-beat training range of 123-129 would be assigned. Heart rates were monitored via radial pulse and were recorded three times during each exercise session. All aerobic exercise sessions began with 10 minutes of warm-up exercises, including dynamic stretching of upper and lower body muscle groups. Following the warm-up period, subjects rode a stationary bicycle for 30 minutes at an intensity that would maintain heart rate within the assigned training range. (At the first exercise session, subjects rode the bicycle for 10 minutes. Thereafter, bicycle time was increased 2 minutes per session, reaching the full 30 minutes by the fourth week of the program.) Heart rate was monitored twice, at 10-minute intervals, during the bicycling. Following the bicycling at each session, subjects then participated in 7-8 minutes of brisk walking or jogging and 7-8 minutes of arm ergometry on a Schwinn Aerodyne bicycle, during which heart rate was checked a third time. The exercise sessions concluded with 5 minutes of cooldown exercises, including dynamic stretching exercises of upper and lower body muscle groups. Yoga. — The yoga classes were conducted by a certified yoga instructor who had had prior experience training older and younger adults in the pracVol. 30, No. 4,1990
517
tice of yoga. Yoga classes followed a routine of deep breathing exercises, progressive muscle relaxation, and static muscle stretching, with subjects trained in using visual imagery to enhance their relaxation skills. In addition, yoga classes focused on increasing subjects' range of motion. Waiting List. — Subjects assigned to the waiting list received brief monthly telephone contacts during the initial 16-week experimental period. Assessments Subjects underwent comprehensive physiological and psychological evaluations before initiating the program (Time 1) and after 16 weeks of training (Time 2). Following the second assessment all subjects participated in aerobic exercise for another 16 weeks, after which subjects were assessed a third time (Time 3), and the study was formally concluded. However, subjects were given the option of exercising for another 6 months, and nearly 50% of the original group chose to continue. After the 6-month extension, all subjects were encouraged to return for a fourth assessment (Time 4), regardless of whether or not they participated in the 6-month extension. At each assessment, measures included indicators of physiological functioning, psychological wellbeing, and cognitive functioning. The complete assessment battery, described briefly below, is described in detail in a previous publication (Blumenthaletal.,1989). The physiological battery included measures of cardiorespiratory fitness (as determined by bicycle ergometry with expired gas analysis), blood lipids, and bone density. Cognitive functioning was assessed with a battery of neuropsychological tests, including the Digit Symbol and Digit Span subtests from the Wechsler Adult Intelligence Scale-Revised (WAIS-R; Wechsler, 1981), and the Trail Making Test (Reitan, 1958). Psychological well-being was assessed with several standard psychometric tests, including the State-Trait Anxiety Inventory (Spielberger, Gorsuch, & Luschene, 1970), the Center for Epidemiological Studies-Depression Inventory (CES-D; Radloff, 1977), the Bradburn Affect Balance Scale (Bradburn, 1969), and a perceived change scale (Times 2, 3, and 4 only). The perceived change scale was composed of 19 dimensions of social, psychological, and physical functioning. For each of the 19 areas, subjects rated on a 7-point Likert scale (1 = much worse; 4 = no change; 7 = much improved) the degree to which they perceived that change had occurred since beginning the program. Data Analysis Perceived change data were analyzed by analysis of variance (ANOVA) with gender (male/female) and group (AE/YO/WL) as between-subject factors at the Times 2 and 3 assessments. At the Time 4 assessment, gender and exercise status (i.e., continued in 6month extension of exercise program versus discontinued) were between-subject factors. In addition,
Downloaded from http://gerontologist.oxfordjournals.org/ at Thomas Jefferson University, Scott Library on August 20, 2015
lems (e.g., hypertension, coronary heart disease) or outside conflicts (e.g., moving from the area), leaving 101 healthy men (N = 50) and women (N = 51) who entered the study. All subjects completed an informed consent form and were told that they would receive $100 at the conclusion of the study. Subjects ranged in age from 60 to 83 years (M = 67 ± 5), they were mostly white (96%), and all had at least a high school education. Subjects initially were assigned randomly to one of three groups: an aerobic exercise (AE) group (N = 33), a yoga (YO) control group (N = 34), or a waiting list (WL) control group (N = 34). Subjects in the AE group attended three 60-minute supervised group exercise sessions per week for 16 consecutive weeks. Subjects in the YO control group participated in 60 minutes of group yoga exercises two times per week for 16 weeks. Subjects in the WL control group were instructed to maintain their usual activity pattern for 16 weeks, but not to engage in any exercise until the completion of their assessments. Subjects in the AE and YO groups arranged for their own transportation to and from the training site, which was on the campus of Duke University.
Table 1 . Self-Ratings of Perceived Change at Time 2 and Time 3: Means and Standard Deviations
Time 2 Yoga (N = 34)
Overall health status Sleep patterns Energy level Mood Self-confidence Life satisfaction Bowel pattern Memory Ambitions Social life Eating habits Flexibility Physical endurance Loneliness Body weight Physical appearance Family relations Concentration Sex life
5.5 4.4 5.3 4.9 4.6 4.8 4.3 4.5 4.7 4.4 4.6 5.1 5.8 4.4 4.6 4.8 4.4 4.7 4.5
5.0 4.6 5.1 5.1 5.0 5.1 4.5 4.4 4.5 4.5 4.5 5.5 5.2 4.6 4.5 4.5 4.5 4.5 4.3
± ± ± ± ± ± ± ± ± ± ± ± ± ± ± ± ± ± ±
0.7 0.8 1.0 0.7 0.6 0.8 0.4 0.7 0.7 0.6 0.8 0.6 0.5 0.7 1.3 0.8 0.5 0.7 0.5
± ± ± ± ± ± ± ± ± ± ± ± ± ± ± ± ± ± ±
Time 3 Waiting list (N = 32) 4.0 4.0 3.9 4.1 4.3 4.1 4.0 4.0 4.1 4.0 4.2 4.0 4.0 4.0 4.3 4.1 4.0 4.0 4.0
1.0 0.9 0.8 0.9 0.9 0.8 0.9 0.7 0.7 0.7 0.9 0.7 0.9 0.8 0.8 0.8 0.7 0.9 0.7
± ± ± ± ± ± ± ± ± ± ± ± ± ± ± ± ± ± ±
0.2*** 0.0** 0.3*** 0.5*** 0.6*** 0.4*** 0.3** 0.3** 0.4** 0.0** 0.6 0.0*** 0.3*** 0.0** 0.7 0.4*** 0.0** 0.3*** 0.0**
Aerobic (N = 28)
Yoga (N = 31)
5.7 4.6 5.6 5.0 4.8 4.9 4.2 4.5 4.5 4.4 4.9 5.4 6.0 4.2 4.8 4.8 4.7 4.7 4.3
5.4 4.6 5.3 5.0 4.9 5.0 4.6 4.6 4.6 4.5 4.7 5.6 5.5 4.3 4.7 4.7 4.5 4.7 4.5
± ± ± ± ± ± ± ± ± ± ± ± ± ± ± ± ± ± ±
1.0 0.9 1.1 0.8 0.8 0.8 0.6 0.8 0.7 0.9 0.9 0.9 0.7 0.7 1.4 0.9 0.7 0.7 0.7
± ± ± ± ± ± ± ± ± ± ± ± ± ± ± ± ± ± ±
0.9 0.9 0.9 0.9 1.0 1.0 0.9 0.8 0.8 0.8 0.9 1.0 0.9 0.7 1.0 0.8 0.7 0.9 0.7
Waiting list (N = 31) 5.5 4.2 5.3 4.7 4.7 4.8 4.2 4.2 4.4 4.3 4.5 5.3 5.7 4.2 4.8 4.5 4.3 4.4 4.1
± ± ± ± ± ± ± ± ± ± ± ± ± ± ± ± ± ± ±
0.9 0.8 1.0 1.0 0.9 0.9 0.6* 0.6 0.8 0.7 0.8 0.8 0.8 0.5 1.0 0.6 0.5 0.9 0.4
Note. Ratings were anchored with 1 = "much worse/' 4 = "no change/' and 7 = "much improved.
* p < .05. **p< .01. ***p
Data regarding perceived change were collected as part of a study of the effects of aerobic exercise training on psychological, cognitive, and physiological functioning among 101 healthy older adults. Subjects were assigned randomly to an aerobic exercise group, a yoga control group, or a waiting list group for 16 weeks, after which all subjects participated in aerobic exercise for another 16 weeks. Exercise participants perceived positive changes in a wide range of significant life areas, and perceived improvement was more closely related to objective improvement for physiological indicators than for indicators of cognitive functioning or psychological well-being. Key words: Aerobic exercise, Psychological well-being, Cognition
Charles F. Emery, PhD,2 and James A. Blumenthal, PhD2
Previous studies among older adults have found improvements following physical exercise in physiological functioning (Cunningham et al., 1987; Kavanaugh & Shephard, 1978), as well as in cognitive functioning (Dustman et al., 1984; Molloy et al., 1988) and psychological well-being (Buccola & Stone, 1975; Perri & Templer, 1985). Other recent studies (Blumenthal et al., 1989; Emery & Catz, 1990; Panton et al., 1990), however, have found little evidence of improved psychological or cognitive functioning in older adults following exercise. Studies frequently report significant subjective benefits among older adult exercisers, but few studies have directly assessed the impact of aerobic exercise on selfperceptions of mood and cognition, or other aspects of personal and social functioning among older adults. One recent study found that healthy middleaged subjects perceived improvements for physiological indicators following exercise, but that perceived improvement was not related to actual change in physical fitness (King et al., 1989). Also, there were no perceived improvements for either cognitive functioning or emotional well-being. Self-perceptions are an important aspect of individual functioning in that they are thought to be related to self-efficacy (Bandura, 1977), which is itself a useful indicator of psychological well-being. Indeed, it has been found that exercise is associated with increases in improved self-efficacy expectations for exercise and related physical activities among older adults with chronic obstructive pulmonary dis-
1 Supported by a grant (AC04238) from the National Institute on Aging. An earlier version of this paper was presented at the 41st Annual Scientific Meeting of the Cerontological Society of America, San Francisco, CA, 1988. We thank Janet Simon, Margaret Riddle, Robin Pomeroy, Susan Schniebolk, Bruce Burchett, Julia Whitaker, Cheri Rich, Sally Schnitz, and Ric Friedrich for technical assistance; and Janet Ivey for secretarial assistance. Send correspondence to: Charles F. Emery, PhD, Department of Psychiatry, Box 3119, Duke University Medical Center, Durham, NC 27710. ''Department of Psychiatry and Center for the Study of Aging and Human Development, Duke University Medical Center, Durham, NC 27710.
ease (Kaplan, Atkins, & Reinsch, 1984). Furthermore, it has been suggested that improved mastery or selfefficacy following exercise, in turn, may facilitate improvements in psychological well-being (de Coverley Veale, 1987). The present investigation was part of a larger study designed to examine the effect of aerobic exercise, using a randomized experimental design, on measures of physiological, psychological, and cognitive functioning. Results of objective change from the Duke Aging and Exercise Study have been reported elsewhere (Blumenthal et al., 1989). In addition to objective measures of functioning, the study included assessments of exercise participants' perception of change on a number of dimensions in order to explore the impact of the exercise program on perceived change. The purpose of the present paper is to examine in detail the findings from the subjective reports of perceived change. We hypothesized that participants in aerobic exercise would experience greater subjective gains than participants in the control conditions, and that subjective improvement would be correlated with objective changes. Furthermore, we hypothesized that subjects in the exercise condition would be most likely to perceive improvement in areas of functioning related to exercise, as was indicated in previous studies of middle-aged (King et al., 1989) and chronically ill older adults (Kaplan, Atkins, & Reinsch, 1984). Finally, we hypothesized that perceived improvement would be correlated with adherence to the exercise program. Methods
Subjects One hundred thirteen older adults were recruited to participate in the study through advertisements in local newspapers and on radio programs. Of those recruited, 12 were disqualified due to health prob516
The Gerontologist
Downloaded from http://gerontologist.oxfordjournals.org/ at Thomas Jefferson University, Scott Library on August 20, 2015
Perceived Change Among Participants in an Exercise Program for Older Adults1
Subject Groups Aerobic Exercise. — Each subject in the AE group was assigned a six-beat heart rate training range equivalent to 70% maximum heart rate reserve (Karvonen, Kentala, & Mustala, 1957), based on the maximum heart rate achieved during an initial bicycle exercise test. The following formula was used: Training range = (max. heart rate - resting heart rate x .70 + resting heart rate) ± 3 beats. For example, if the subject had a resting heart rate of 70, and a maximum heart rate of 150 on the bicycle test, a six-beat training range of 123-129 would be assigned. Heart rates were monitored via radial pulse and were recorded three times during each exercise session. All aerobic exercise sessions began with 10 minutes of warm-up exercises, including dynamic stretching of upper and lower body muscle groups. Following the warm-up period, subjects rode a stationary bicycle for 30 minutes at an intensity that would maintain heart rate within the assigned training range. (At the first exercise session, subjects rode the bicycle for 10 minutes. Thereafter, bicycle time was increased 2 minutes per session, reaching the full 30 minutes by the fourth week of the program.) Heart rate was monitored twice, at 10-minute intervals, during the bicycling. Following the bicycling at each session, subjects then participated in 7-8 minutes of brisk walking or jogging and 7-8 minutes of arm ergometry on a Schwinn Aerodyne bicycle, during which heart rate was checked a third time. The exercise sessions concluded with 5 minutes of cooldown exercises, including dynamic stretching exercises of upper and lower body muscle groups. Yoga. — The yoga classes were conducted by a certified yoga instructor who had had prior experience training older and younger adults in the pracVol. 30, No. 4,1990
517
tice of yoga. Yoga classes followed a routine of deep breathing exercises, progressive muscle relaxation, and static muscle stretching, with subjects trained in using visual imagery to enhance their relaxation skills. In addition, yoga classes focused on increasing subjects' range of motion. Waiting List. — Subjects assigned to the waiting list received brief monthly telephone contacts during the initial 16-week experimental period. Assessments Subjects underwent comprehensive physiological and psychological evaluations before initiating the program (Time 1) and after 16 weeks of training (Time 2). Following the second assessment all subjects participated in aerobic exercise for another 16 weeks, after which subjects were assessed a third time (Time 3), and the study was formally concluded. However, subjects were given the option of exercising for another 6 months, and nearly 50% of the original group chose to continue. After the 6-month extension, all subjects were encouraged to return for a fourth assessment (Time 4), regardless of whether or not they participated in the 6-month extension. At each assessment, measures included indicators of physiological functioning, psychological wellbeing, and cognitive functioning. The complete assessment battery, described briefly below, is described in detail in a previous publication (Blumenthaletal.,1989). The physiological battery included measures of cardiorespiratory fitness (as determined by bicycle ergometry with expired gas analysis), blood lipids, and bone density. Cognitive functioning was assessed with a battery of neuropsychological tests, including the Digit Symbol and Digit Span subtests from the Wechsler Adult Intelligence Scale-Revised (WAIS-R; Wechsler, 1981), and the Trail Making Test (Reitan, 1958). Psychological well-being was assessed with several standard psychometric tests, including the State-Trait Anxiety Inventory (Spielberger, Gorsuch, & Luschene, 1970), the Center for Epidemiological Studies-Depression Inventory (CES-D; Radloff, 1977), the Bradburn Affect Balance Scale (Bradburn, 1969), and a perceived change scale (Times 2, 3, and 4 only). The perceived change scale was composed of 19 dimensions of social, psychological, and physical functioning. For each of the 19 areas, subjects rated on a 7-point Likert scale (1 = much worse; 4 = no change; 7 = much improved) the degree to which they perceived that change had occurred since beginning the program. Data Analysis Perceived change data were analyzed by analysis of variance (ANOVA) with gender (male/female) and group (AE/YO/WL) as between-subject factors at the Times 2 and 3 assessments. At the Time 4 assessment, gender and exercise status (i.e., continued in 6month extension of exercise program versus discontinued) were between-subject factors. In addition,
Downloaded from http://gerontologist.oxfordjournals.org/ at Thomas Jefferson University, Scott Library on August 20, 2015
lems (e.g., hypertension, coronary heart disease) or outside conflicts (e.g., moving from the area), leaving 101 healthy men (N = 50) and women (N = 51) who entered the study. All subjects completed an informed consent form and were told that they would receive $100 at the conclusion of the study. Subjects ranged in age from 60 to 83 years (M = 67 ± 5), they were mostly white (96%), and all had at least a high school education. Subjects initially were assigned randomly to one of three groups: an aerobic exercise (AE) group (N = 33), a yoga (YO) control group (N = 34), or a waiting list (WL) control group (N = 34). Subjects in the AE group attended three 60-minute supervised group exercise sessions per week for 16 consecutive weeks. Subjects in the YO control group participated in 60 minutes of group yoga exercises two times per week for 16 weeks. Subjects in the WL control group were instructed to maintain their usual activity pattern for 16 weeks, but not to engage in any exercise until the completion of their assessments. Subjects in the AE and YO groups arranged for their own transportation to and from the training site, which was on the campus of Duke University.
Table 1 . Self-Ratings of Perceived Change at Time 2 and Time 3: Means and Standard Deviations
Time 2 Yoga (N = 34)
Overall health status Sleep patterns Energy level Mood Self-confidence Life satisfaction Bowel pattern Memory Ambitions Social life Eating habits Flexibility Physical endurance Loneliness Body weight Physical appearance Family relations Concentration Sex life
5.5 4.4 5.3 4.9 4.6 4.8 4.3 4.5 4.7 4.4 4.6 5.1 5.8 4.4 4.6 4.8 4.4 4.7 4.5
5.0 4.6 5.1 5.1 5.0 5.1 4.5 4.4 4.5 4.5 4.5 5.5 5.2 4.6 4.5 4.5 4.5 4.5 4.3
± ± ± ± ± ± ± ± ± ± ± ± ± ± ± ± ± ± ±
0.7 0.8 1.0 0.7 0.6 0.8 0.4 0.7 0.7 0.6 0.8 0.6 0.5 0.7 1.3 0.8 0.5 0.7 0.5
± ± ± ± ± ± ± ± ± ± ± ± ± ± ± ± ± ± ±
Time 3 Waiting list (N = 32) 4.0 4.0 3.9 4.1 4.3 4.1 4.0 4.0 4.1 4.0 4.2 4.0 4.0 4.0 4.3 4.1 4.0 4.0 4.0
1.0 0.9 0.8 0.9 0.9 0.8 0.9 0.7 0.7 0.7 0.9 0.7 0.9 0.8 0.8 0.8 0.7 0.9 0.7
± ± ± ± ± ± ± ± ± ± ± ± ± ± ± ± ± ± ±
0.2*** 0.0** 0.3*** 0.5*** 0.6*** 0.4*** 0.3** 0.3** 0.4** 0.0** 0.6 0.0*** 0.3*** 0.0** 0.7 0.4*** 0.0** 0.3*** 0.0**
Aerobic (N = 28)
Yoga (N = 31)
5.7 4.6 5.6 5.0 4.8 4.9 4.2 4.5 4.5 4.4 4.9 5.4 6.0 4.2 4.8 4.8 4.7 4.7 4.3
5.4 4.6 5.3 5.0 4.9 5.0 4.6 4.6 4.6 4.5 4.7 5.6 5.5 4.3 4.7 4.7 4.5 4.7 4.5
± ± ± ± ± ± ± ± ± ± ± ± ± ± ± ± ± ± ±
1.0 0.9 1.1 0.8 0.8 0.8 0.6 0.8 0.7 0.9 0.9 0.9 0.7 0.7 1.4 0.9 0.7 0.7 0.7
± ± ± ± ± ± ± ± ± ± ± ± ± ± ± ± ± ± ±
0.9 0.9 0.9 0.9 1.0 1.0 0.9 0.8 0.8 0.8 0.9 1.0 0.9 0.7 1.0 0.8 0.7 0.9 0.7
Waiting list (N = 31) 5.5 4.2 5.3 4.7 4.7 4.8 4.2 4.2 4.4 4.3 4.5 5.3 5.7 4.2 4.8 4.5 4.3 4.4 4.1
± ± ± ± ± ± ± ± ± ± ± ± ± ± ± ± ± ± ±
0.9 0.8 1.0 1.0 0.9 0.9 0.6* 0.6 0.8 0.7 0.8 0.8 0.8 0.5 1.0 0.6 0.5 0.9 0.4
Note. Ratings were anchored with 1 = "much worse/' 4 = "no change/' and 7 = "much improved.
* p < .05. **p< .01. ***p
