Health Promotion International Advance Access published July 4, 2014 Health Promotion International doi:10.1093/heapro/dau052
# The Author 2014. Published by Oxford University Press. All rights reserved. For Permissions, please email: [email protected]
Sources of strength-training information and strength-training behavior among Japanese older adults 1
Section for Motor Function Activation, National Center for Geriatrics and Gerontology, 35 Gengo, Morioka, Obu, Aichi 474-8511, Japan, 2Faculty of Health and Sport Sciences, University of Tsukuba, 1-1-1 Tennodai, Tsukuba, Ibaraki 305-8577, Japan and 3Faculty of Sport Sciences, Waseda University, 2-579-15, Mikajima, Tokorozawa, Saitama 359-1192, Japan *Corresponding author. E-mail: [email protected]
SUMMARY The promotion of strength training is now recognized as an important component of public health initiatives for older adults. To develop successful communication strategies to increase strength-training behavior among older adults, the identification of effective communication channels to reach older adults is necessary. This study aimed to identify the information sources about strength training that were associated with strength-training behaviors among Japanese older adults. The participants were 1144 adults (60 – 74 years old) randomly sampled from the registry of residential addresses. A cross-sectional questionnaire survey was conducted. The independent variables were sources of strength-training information (healthcare providers, friends, families, radio, television, newspapers, newsletters, posters, books, magazines, booklets,
the Internet, lectures, other sources), and the dependent variable was regular strength-training behavior. Logistic regression analysis was used to identify potential relationships. After adjusting for demographic factors and all other information sources, strength-training information from healthcare providers, friends, books and the Internet were positively related to regular strength-training behavior. The findings of the present study contribute to a better understanding of strength-training behavior and the means of successful communication directed at increasing strength training among older adults. The results suggest that healthcare providers, friends, books and the Internet are effective methods of communication for increasing strength-training behaviors among older adults.
Key words: health communication; exercise; behavior change; media
INTRODUCTION Strength training provides numerous health benefits, including the prevention of osteoporosis, cardiovascular disease and diabetes (Winett and Carpinelli, 2001). For this reason, the US Department of Health and Human Services (USDHHS) (United States Department of Health and Human Services, 2008) and the
Japanese Ministry of Health, Labour and Welfare (JMHLW) (Japanese Ministry of Health, Labour and Welfare, 2013) recommend strength training. In addition to the general benefits mentioned above, strength training can also reduce the risk of some geriatric health problems (Hurley and Roth, 2000; Chodzko-Zajko et al., 2009). Thus, the JMHLW recommends strength training for older Japanese adults in the program manual on the Page 1 of 8
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KAZUHIRO HARADA1*, AI SHIBATA2, EUNA LEE3, KOICHIRO OKA3 and YOSHIO NAKAMURA3
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between information and physical activity is insufficient. There are only a few studies (Redmond et al., 2010; Beaudoin and Hong, 2011; Ramı´rez et al., 2013) that have focused on the relationships between information sources and physical activities. Some of these studies (Redmond et al., 2010; Beaudoin and Hong, 2011) did not find significant relationships between any type of health information and physical activity. One possible reason is that they measured sources for general health information without identifying a specific type of physical activity (e.g. walking, cycling). The ecological model (Sallis et al., 2006) postulates that the correlates of physical activities differ by the type of activity. Identifying the behavior-specific information sources for the target population could provide more effective and efficient dissemination of health information. The present study aimed to identify the types of information sources associated with strength-training behavior. The population of frail older adults has increased dramatically in Japan. These individuals may more quickly lose their independence if they do not maintain muscle strength; therefore, strength training is an important health issue in Japan.
METHODS Participants and procedures A cross-sectional questionnaire was distributed through the post to 2092 individuals aged 60 –74 years living in the city of Tokorozawa ( population: 341 679; area: 72.0 km2), a typical suburb near Tokyo. A stratified, systematic random method was used to select residential addresses from the city registry. Stratification was performed according to agricultural promotion area (APA). An APA is an area where land use is limited to agriculture by a law (the use for other purposes is prohibited in an APA); thus, APAs can generally be regarded as rural areas. The city consists of 11 districts: 3 districts did not include an APA (Group A), 5 districts included APAs that were ,50% of the total area (Group B) and 3 districts included APAs that were .50% of the total area (Group C). One district was randomly selected from each group. The total population aged 60– 74 years in the three selected districts was 12 400. Every sixth person was selected as a participant, according to the order of residential addresses. The survey was conducted in
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improvement of motor function for long-term care prevention (JMHLW, 2012). Furthermore, a previous study (Harada et al., in press) implies that providing information about the health benefits of strength training would be an effective method to promote strength training among older adults. However, the number of people participating in strength training has remained low, especially for older adults (Chevan, 2008; Harada et al., 2008). Therefore, development of successful communication strategies to increase strength training (e.g. effective strategies of providing information about health benefits of strength training) is necessary among older adults. To develop such strategies, identification of effective communication channels for disseminating strength-training information among older adults is necessary. The US National Cancer Institute (National Cancer Institute, 2001) reported that selection of appropriate channels of communication to influence a specific target group is an important process in planning health-communication campaigns. Previous studies have examined the relationship between information source and health behaviors, including fruit and vegetable consumption (Freisling et al., 2009; Redmond et al., 2010; Ramı´rez et al., 2013), cancer screening (Coughlin et al., 2007; Redmond et al., 2010), beliefs regarding cancer (Ford and Kaphingst, 2009), attitudes toward tobacco control (Blake et al., 2010), smoking cessation (Redmond et al., 2010) and sun-protection behavior (Hay et al., 2009). For example, Freisling et al. (Freisling et al., 2009) found that newspaper articles, the Internet and booklets as sources of nutrition information were positively associated with fruit and vegetable consumption, and argued that the dissemination of healthy eating information should make use of both print media and the Internet. Similar to the information from the US National Cancer Institute (National Cancer Institute, 2001), examining the relationships between information sources for strength training and strength-training behavior is essential for the identification of the most effective channels of communication for increasing strength training among older adults. The ecological model of active living (Sallis et al., 2006) assumes that the information environment influence participation in physical activities, in addition to psychological factors, and social and physical environments. Numerous studies have identified the psychological, social and physical environment correlates of physical activities (Bauman et al., 2012). However, examination of the relationships
Sources of strength-training information
Measurement Sources of strength-training information Each respondent was asked to describe the sources from which they received strength-training information. The question was ‘In the past 12 months, have you seen or heard any information about strength-training? Please select all the sources from which you have seen or heard such information in the past 12 months. For each source, select “yes” or “no”’. The sources included were healthcare providers, friends, family, radio, television, newspapers, newsletters from the local government, posters in public places, books, magazines, booklets from hospitals or pharmacies, the Internet, lectures and other sources. The sources were developed using information from a previous study (Hesse et al., 2005) and from pilot interviews (n ¼ 15) with individuals who engaged in regular strength training. Strength-training behavior Based on previous studies (Bopp et al., 2004; Harada et al., 2008, 2011) and the definition in the current recommendation of the USDHHS (USDHHS, 2008), strength training was defined as all activities that serve to enhance muscular strength and endurance and regular training was defined as strength training occurring 2 days or more per week.
For the assessment of the strength-training behavior, the stages of change for the strengthtraining behavior scale (Harada et al., 2008) were employed. This scale consists of five choices: precontemplation (not engaged in regular strength training and not intending to engage strength training within the next 6 months), contemplation (intending to engage in strength training within the next 6 months), preparation (irregularly engaged in strength training), action (engaged in regular strength training, but for ,6 months) and maintenance (engaged in regular strength training for the past 6 months or more). The respondents were asked to choose the one stage that best described their current situation. As in a previous study (Harada et al., 2011), those in the action and maintenance categories were classified as engaged in regular strength-training behavior, whereas those in the other three stages were classified as not engaged in regular strength-training behavior. Demographic variables Demographic variables were measured by the same questionnaire. The variables included age, gender, self-rated health status (very good, somewhat good, somewhat poor or very poor), number of hospital visits (more than once a week, once or twice a month, once every 2 or 3 months or less than once every 6 months), restriction of physical activity (yes or no), body pain (none, slight, light, moderate, vigorous or very vigorous), marital status (currently married, divorce or widowed or never married), smoking habits (currently a smoker, previously smoked or never smoked) and drinking habits (3 days per week, ,3 days per week or do not drink alcohol). Next, for the convenience of analysis and/or to compensate for a small sample size of the categories, some demographic variables were collapsed as follows: selfrated health status (good or poor), number of hospital visits (once a month and greater), body pain (moderate and greater pain), current marital status (married or not married), current smoking habits (smokes or not a smoker) and current drinking habits (3 days per week).
Data analysis The association of demographic factors with regular strength-training behavior was examined by chi-square tests. Bivariate logistic regression analyses were conducted to examine whether each communication variable was related to
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November and December 2009. Twelve of the 2092 individuals did not receive the questionnaire due to incorrect addresses. Of the remaining 2080 individuals, 1288 (61.9%) returned the questionnaire. Among these, 2.6% (n ¼ 33) did not answer the questionnaire for the following reasons: no interest in the survey (n ¼ 14), difficulty in writing or reading (n ¼ 6), lack of time (n ¼ 5), absence of respondent (n ¼ 4) or other (n ¼ 4). Furthermore, 11 individuals (0.9%) of the 1255 remaining respondents had missing data for a question about strength-training behavior. Thus, 1244 individuals (59.5% of 2092 individuals) were included in the analysis. A letter explaining the ethical considerations was enclosed with the questionnaire. Individuals answered the questionnaire anonymously if they understood the ethical considerations and agreed to participate. Return of the questionnaire thus indicated informed consent. This study received prior approval from the Waseda University Ethics Committee (2009 –108).
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(mean 66.3 years old, SD 4.3 years), 84.5% reported their health was good, 60.0% visited the hospital less than once a month, 93.7% were not restricted in terms of engagement in physical activity, 74.6% did not have more than moderate body pain, 85.7% were married, 83.6% did not have a smoking habit and 67.8% drank alcohol .3 days per week. The relationships between the demographic factors and regular strength-training behaviors are summarized in Table 1. Those with good health status ( p ¼ 0.037), without more than moderate body pain ( p ¼ 0.037) and not currently smoking ( p , 0.001) were more likely to engage in strength-training behavior.
RESULTS
Relationships between strength-training information sources and strength-training behaviors Table 2 shows the relationships between strength-training information sources and
Characteristics of the respondents Table 1 includes the characteristics of the respondents. With respect to gender, 51.5% were men
Table 1: Relationship between demographic factors with regular strength-training behavior
Participants Age (years) 64 65– 69 70 Gender Men Women Self-rated health status Very poor/somewhat poor Very good/somewhat good Hospital visit Once every 2 or 3 months/less than once every 6 months More than once a week/once or twice a month Restriction of physical activity No Yes Body pain None/slight/light Moderate/vigorous/very vigorous Current marital status Divorce or widowed/never married Currently married Smoking habits Previously smoker/never smoker Currently a smoker Drinking habits ,3 days per week/not drinking 3 days per week Note: sample sizes vary due to missing values. a Chi-squared test.
Total
Regular strength-training behavior
n (%)
No (%)
Yes (%)
1244 (100)
75.1
24.9
480 (38.8) 429 (34.7) 329 (26.6)
74.2 74.8 76.9
25.8 25.2 23.1
638 (51.5) 600 (48.5)
75.1 75.2
24.9 24.8
191 (15.5) 1045 (84.5)
81.2 74.1
18.8 25.9
742 (60.0) 494 (40.0)
75.6 74.5
24.4 25.5
1157 (93.7) 78 (6.3)
75.2 74.4
24.8 25.6
924 (74.6) 314 (25.4)
73.2 80.9
26.8 19.1
177 (14.3) 1059 (85.7)
80.8 74.2
19.2 25.8
1036 (83.6) 203 (16.4)
73.0 86.2
27.0 13.8
839 (67.8) 399 (32.2)
74.4 76.7
25.6 23.3
pa
0.667 0.971 0.037 0.657 0.869 0.006 0.061 ,0.001 0.378
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regular strength-training behavior. Subsequently, forced-entry multivariate logistic regression analyses were conducted to examine the relationship between each information variable and regular strength-training behavior. In the multivariate logistic regression analyses, all other information sources and the demographic factors significantly related to regular strength-training behavior in the chi-square tests were adjusted. Crude and adjusted odds ratios (ORs) and 95% confidence intervals (CIs) were calculated for each variable. Statistical significance was set at p , 0.05. All statistical analyses were conducted using SPSS (version 15.0).
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Table 2: Relationships between strength-training information sources and regular strength-training behavior n (%)
95% CI
p
Adjusted OR
95% CI
p
1244 (100) 889 (75.3) 291 (24.7)
1.00 1.87
1.40– 2.50
,0.001
1.00 1.80
1.27–2.56
0.001
691 (58.7) 487 (41.3)
1.00 1.74
1.34– 2.27
,0.001
1.00 1.40
1.02–1.92
0.037
758 (64.8) 411 (35.2)
1.00 1.38
1.05– 1.80
0.021
1.00 1.08
0.79–1.48
0.641
848 (72.9) 316 (27.1)
1.00 1.01
0.75– 1.36
0.955
1.00 0.73
0.51–1.04
0.080
314 (26.4) 875 (73.6)
1.00 1.13
0.84– 1.53
0.429
1.00 0.88
0.61–1.27
0.491
574 (49.1) 595 (50.9)
1.00 1.31
1.00– 1.70
0.047
1.00 1.09
0.79–1.52
0.602
851 (73.0) 314 (27.0)
1.00 1.36
1.02– 1.81
0.039
1.00 1.14
0.80–1.63
0.476
765 (65.6) 402 (34.4)
1.00 1.15
0.87– 1.51
0.319
1.00 0.87
0.62–1.22
0.429
702 (60.4) 461 (39.6)
1.00 1.72
1.32– 2.25
,0.001
1.00 1.58
1.09–2.28
0.015
636 (54.7) 527 (45.3)
1.00 1.39
1.06– 1.80
0.016
1.00 0.86
0.59–1.24
0.412
850 (73.1) 313 (26.9)
1.00 1.15
0.86– 1.55
0.336
1.00 0.89
0.62–1.27
0.523
1057 (91.2) 102 (8.8)
1.00 2.30
1.52– 3.50
,0.001
1.00 1.99
1.27–3.11
0.003
1081 (93.0) 81 (7.0)
1.00 1.17
0.71– 1.93
0.544
1.00 0.74
0.42–1.31
0.303
879 (76.0) 278 (24.0)
1.00 1.19
0.88– 1.61
0.261
1.00 1.03
0.72–1.47
0.869
638 (51.5) 600 (48.5)
1.00 1.51
1.02– 2.22
0.038
1.00 1.24
0.80–1.92
0.345
924 (74.6) 314 (25.4)
1.00 0.64
0.47– 0.88
0.006
1.00 0.67
0.47–0.95
0.025
1036 (83.6) 203 (16.4)
1.00 0.43
0.28– 0.66
,0.001
1.00 0.44
0.44–0.70
,0.001
Note: sample sizes vary due to missing values. OR, odds ratio; CI, confidence interval. Adjusted for other health information sources, self-rated health status, body pain and smoking habit. Model significance: x 2 ¼ 71.1, p , 0.001; model accuracy: 74.3%.
regular strength-training behavior. In unadjusted models, regular strength-training behavior was significantly related to information from
healthcare providers (OR ¼ 1.87; 95% CI ¼ 1.40 –2.50), friends (OR ¼ 1.74; 95% CI ¼ 1.34– 2.27), family (OR ¼ 1.38; 95% CI ¼ 1.05 –1.80),
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Participants Healthcare providers No Yes Friends No Yes Family No Yes Radio No Yes Television No Yes Newspapers No Yes Newsletters from local government No Yes Posters in public places No Yes Books No Yes Magazines No Yes Booklets from hospital or pharmacy No Yes Internet No Yes Lectures No Yes Others No Yes Self-rated health status Very poor/somewhat poor Very good/somewhat good Body pain None/slight/light Moderate/vigorous/very vigorous Smoking habits Previously smoker/never a smoker Currently a smoker
Crude OR
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DISCUSSION The present study examined the relationship between the sources of information about strength-training and strength-training behavior among Japanese older adults. To our knowledge, this is the first quantitative study to explore the effectiveness of a variety of communication channels in providing strength-training information to older adults. Previous studies have revealed that perceived benefits and barriers (Bopp et al., 2004; Harada et al., in press), behavioral intention (Dean et al., 2007), social support (Bopp et al., 2004) and some neighborhood environmental factors (Harada et al., 2011) are associated with strength-training behavior. Supporting the ecological model of active living (Sallis et al., 2006), the present study suggests that the information environment influences strength-training behavior among older adults in addition to psychological factors, and social and neighborhood environments. In particular, information from healthcare providers and friends were positively associated with strength-training behavior. Generally, these are classified as interpersonal channels (National Cancer Institute, 2001). These results indicate that providing strength-training information via interpersonal channels could be effective means of increasing strength training among older adults because interpersonal channels can provide not only information itself but also social support, which is an important correlate of physical activity (Trost et al., 2002). In fact, previous studies have
suggested the importance of interpersonal channels in providing cancer information (Mills and Davidson, 2002; Ford and Kaphingst, 2009). Ford and Kaphingst (Ford and Kaphingst, 2009) found that health information from interpersonal channels was associated with beliefs about cancer risks more strongly than information from mass media. Further, the results of a Mills and Davidson study (Mills and Davidson, 2002) indicated that interpersonal channels are important sources of information for cancer patients. Therefore, similar to the results of cancer-information studies, the present study found that interpersonal channels appeared to be effective means of encouraging strength training among older adults. Although family is also categorized as an interpersonal channel (National Cancer Institute, 2001), a significant relationship between family and strengthtraining behavior was not observed in the present study. Generally, family members are not health professionals and represent different age groups. Thus, one possible reason for the lack of relationship between family and behavior is that the influence of information from non-professionals and people of different age groups might be weaker than that of people from the same age group, such as friends or professional recommendations. In addition, books and the Internet were associated with strength-training behavior, and books and the Internet were more closely related to strength-training behavior than the interpersonal channels. Books and the Internet are generally used for active searching for information; only those actively seeking information use these channels. In contrast, both active and non-active seekers of information use interpersonal channels. Thus, these results may reflect that active seekers of information are more likely to be engaged or are contemplating engaging in strength training. In other words, it would be difficult to provide information via books and the Internet for non-active searchers, including less motivated people. Regarding another channels (radio, television, newspapers, newsletters from local government, posters in public spaces, magazines, booklets from hospitals or pharmacies, lectures and other), significant relationships with strengthtraining behavior were not observed. One review of the relationships between information and action found that mass-media campaigns increase awareness of the issue of physical activity, but may not have a population-level effect on behavior (Cavill and Bauman, 2004). Similarly, in a
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newspapers (OR ¼ 1.31; 95% CI ¼ 1.00 –1.70), newsletters from local government (OR ¼ 1.36; 95% CI ¼ 1.02– 1.81), books (OR ¼ 1.72; 95% CI ¼ 1.32– 2.25), magazines (OR ¼ 1.39; 95% CI ¼ 1.06– 1.80) and the Internet (OR ¼ 2.30; 95% CI ¼ 1.52– 3.50). After adjusting for demographic factors (selfrated health status, body pain and current smoking habits) and all other information sources, strength-training information from healthcare providers (OR ¼ 1.80; 95% CI ¼ 1.27–2.56), friends (OR ¼ 1.40; 95% CI ¼ 1.02 – 1.92), books (OR ¼ 1.58; 95% CI ¼ 1.09–2.28) and the Internet (OR ¼ 1.99: 95% CI ¼ 1.27 – 3.11) were positively related to regular strengthtraining behavior. The model significance was p , 0.001 (x 2 ¼ 71.1) and the model accuracy was 74.3%.
Sources of strength-training information
2007; Ford and Kaphingst, 2009; Freisling et al., 2009; Hay et al., 2009; Blake et al., 2010; Redmond et al., 2010; Beaudoin and Hong, 2011; Ramı´rez et al., 2013). However, the quality, frequency and duration of information received are related to behavioral change regarding strength training. The fourth limitation is the operational definition of strength training, although it has been defined in previous studies (Bopp et al., 2004; Harada et al., 2008, 2011) and the current USDHHS recommendations (USDHHS, 2008). A final limitation is that the data were obtained from only one city. The city is located in a typical suburban area in Japan. Therefore, it is unclear whether the study findings could be generalized to urban or rural areas. Further studies should measure details of strength-training information and examine causal relationships using a nationally representative sample with no response bias. Despite the limitations, the findings of the present study contribute to a better understanding of strength-training behavior and effective communication strategies to increase strength training among older adults. The findings suggested that strength-training information provided by healthcare providers and friends, as well as books and the Internet, would be effective in increasing strength-training behaviors among older adults. Based on these findings, intervention studies using the identified methods of communication could be developed to increase strength training among older adults. ACKNOWLEDGEMENTS We wish to thank Hiroshi Kono (Faculty of Human Life Design, Toyo University), Kyota Takami (Faculty of Sports and Health Sciences, Hosei University), Shinpei Okada (Physical Education and Medicine Research Foundation), Yuko Kai (Physical Fitness Research Institute, Meiji Yasuda Life Foundation of Health and Welfare), Masamitsu Kamada (Japan Society for the Promotion of Science) and Soeko Sakurai (alumna of Graduate School of Sport Sciences, Waseda University) for helpful comments in the design of the present study. FUNDING This work was supported by a Grant-in-Aid for Research Fellow of the Japan Society for the
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published review of 25 studies, Baker et al. (Baker et al., 2011) concluded that communitywide interventions would not effectively increase population levels of physical activity. From these reviews and the findings of the present study, it becomes apparent that providing information through these channels is not an effective method of changing strength-training behavior at the population level. The findings of the present study imply that interpersonal channels, such as healthcare providers and friends, should be used for planning successful interventions to increase strength training among older adults. Moreover, the present study suggests that differential influences of communication channels on physical activity should be considered to understand physical activity behavior change. Well-designed prospective studies and examinations of other populations are also needed to confirm the most effective communication channels for increasing strength-training behavior among older adults. Compared with previous studies examining the relationships between information sources and physical activities (Redmond et al., 2010; Beaudoin and Hong, 2011; Ramı´rez et al., 2013), a strength of the present study was that information and behavior were specifically linked to strength training. According to the ecological model (Sallis et al., 2006), specifying the type of information and behavior is desirable when examining correlates of physical activity. However, the present study has several limitations. First, the analysis was cross-sectional; therefore, it is not possible to determine cause and effect. Secondly, response bias exists in questionnaire surveys. Our response rate (59.5%) was higher than other questionnaire-based surveys using the postal mailing method, such as 51.6% in Kamada et al. (Kamada et al., 2009) and 36.5% in Inoue et al. (Inoue et al., 2010). However, the document provided with the survey stated that the purpose of the survey was to evaluate beliefs regarding strength training among older adults. Those who were not interested in strength training would therefore be less likely to answer the questionnaire. Thirdly, our study did not measure the details of the strengthtraining information received by participants, such as quality, frequency or duration. Much like the present study, previous studies examining the relationships between the information variable and health behavior have not included the details of information received (Coughlin et al.,
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Promotion of Science (08J06333, 11J07878); Waseda University Grant for Special Research Projects (2010A-093); and Global COE Program ‘Sport Sciences for the Promotion of Active Life’ from the Japan Ministry of Education, Culture, Sports, Science and Technology.
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Harada, K., Oka, K., Shibata, A., Ota, A., Okada, J. and Nakamura, Y. (2008) Factors associated with the stages of change for strength training behavior among Japanese adults. International Journal of Sports and Health Sciences, 6, 251–263. Harada, K., Oka, K., Shibata, A., Ishii, K., Nakamura, Y., Inoue, S. and Shimomitsu, T. (2011) Strength-training behavior and perceived environment among Japanese older adults. Journal of Aging and Physical Activity, 19, 262–272. Harada, K., Shibata, A., Lee, E., Oka, K. and Nakamura, Y. (in press) Associations between perceived health benefits and barriers to strength training, and stages of change for strength-training behavior among older Japanese adults. Journal of Physical Activity and Health. Hay, J., Coups, E. J., Ford, J. and DiBonaventura, M. (2009) Exposure to mass media health information, skin cancer beliefs, and sun protection behaviors in a United States probability sample. Journal of the American Academy of Dermatology, 61, 783– 792. Hesse, B. W., Nelson, D. E., Kreps, G. L., Croyle, R. T., Arora, N. K., Rimer, B. B. and Viswanath, K. (2005) Trust and sources of health information. Archives of Internal Medicine, 165, 2618–2624. Hurley, B. F. and Roth, S. M. (2000) Strength training in the elderly. Sports Medicine, 30, 249–268. Japanese Ministry of Health, Labour and Welfare. (2012) Revised Manual for the Improvement of Motor Function (in Japanese). http://www.mhlw.go.jp/topics/2009/05/dl/ tp0501-1_03.pdf (last accessed 26 March 2014). Japanese Ministry of Health, Labour and Welfare. (2013) Physical activity guide for health promotion 2013 (in Japanese). http://www.mhlw.go.jp/stf/houdou/2r9852000 002xple-att/2r9852000002xpr1.pdf (last accessed 26 March 2014). Mills, M. E. and Davidson, R. (2002) Cancer patients’ sources of information: use and quality issues. PsychoOncology, 11, 371– 378. National Cancer Institute. (2001) Making Health Communication Programs Work. Bethesda, MD: National Institutes of Health, US Department of Health and Human Services. Ramı´rez, A. S., Freres, D., Martinez, L. S., Lewis, N., Lewis, N., Bourgoin, A. et al. (2013) Information seeking from media and family/friends increases the likelihood of engaging in healthy lifestyle behaviors. Journal of Health Communication, 18, 527–542. Redmond, N., Baer, H. J., Clark, C. R., Lipsitz, S. and Hicks, L. S. (2010) Sources of health information related to preventive health behaviors in a national study. American Journal of Preventive Medicine, 38, 620–627. Sallis, J. F., Cervero, R. B., Ascher, W., Henderson, K. A., Kraft, M. K. and Kerr, J. (2006) An ecological approach to creating active living communities. Annual Review of Public Health, 27, 297–322. Trost, S. G., Owen, N., Bauman, A. E., Sallis, J. F. and Brown, W. (2002) Correlates of adults’ participation in physical activity: review and update. Medicine and Science in Sports and Exercise, 34, 1996– 2001. United States Department of Health and Human Services. (2008) 2008 Physical activity guide for Americans. http:// www.health.gov/paguidelines/pdf/paguide.pdf (last accessed 14 February 2012). Winett, R. A. and Carpinelli, R. N. (2001) Potential health-related benefits of resistance training. Preventive Medicine, 33, 503–513.
# The Author 2014. Published by Oxford University Press. All rights reserved. For Permissions, please email: [email protected]
Sources of strength-training information and strength-training behavior among Japanese older adults 1
Section for Motor Function Activation, National Center for Geriatrics and Gerontology, 35 Gengo, Morioka, Obu, Aichi 474-8511, Japan, 2Faculty of Health and Sport Sciences, University of Tsukuba, 1-1-1 Tennodai, Tsukuba, Ibaraki 305-8577, Japan and 3Faculty of Sport Sciences, Waseda University, 2-579-15, Mikajima, Tokorozawa, Saitama 359-1192, Japan *Corresponding author. E-mail: [email protected]
SUMMARY The promotion of strength training is now recognized as an important component of public health initiatives for older adults. To develop successful communication strategies to increase strength-training behavior among older adults, the identification of effective communication channels to reach older adults is necessary. This study aimed to identify the information sources about strength training that were associated with strength-training behaviors among Japanese older adults. The participants were 1144 adults (60 – 74 years old) randomly sampled from the registry of residential addresses. A cross-sectional questionnaire survey was conducted. The independent variables were sources of strength-training information (healthcare providers, friends, families, radio, television, newspapers, newsletters, posters, books, magazines, booklets,
the Internet, lectures, other sources), and the dependent variable was regular strength-training behavior. Logistic regression analysis was used to identify potential relationships. After adjusting for demographic factors and all other information sources, strength-training information from healthcare providers, friends, books and the Internet were positively related to regular strength-training behavior. The findings of the present study contribute to a better understanding of strength-training behavior and the means of successful communication directed at increasing strength training among older adults. The results suggest that healthcare providers, friends, books and the Internet are effective methods of communication for increasing strength-training behaviors among older adults.
Key words: health communication; exercise; behavior change; media
INTRODUCTION Strength training provides numerous health benefits, including the prevention of osteoporosis, cardiovascular disease and diabetes (Winett and Carpinelli, 2001). For this reason, the US Department of Health and Human Services (USDHHS) (United States Department of Health and Human Services, 2008) and the
Japanese Ministry of Health, Labour and Welfare (JMHLW) (Japanese Ministry of Health, Labour and Welfare, 2013) recommend strength training. In addition to the general benefits mentioned above, strength training can also reduce the risk of some geriatric health problems (Hurley and Roth, 2000; Chodzko-Zajko et al., 2009). Thus, the JMHLW recommends strength training for older Japanese adults in the program manual on the Page 1 of 8
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KAZUHIRO HARADA1*, AI SHIBATA2, EUNA LEE3, KOICHIRO OKA3 and YOSHIO NAKAMURA3
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between information and physical activity is insufficient. There are only a few studies (Redmond et al., 2010; Beaudoin and Hong, 2011; Ramı´rez et al., 2013) that have focused on the relationships between information sources and physical activities. Some of these studies (Redmond et al., 2010; Beaudoin and Hong, 2011) did not find significant relationships between any type of health information and physical activity. One possible reason is that they measured sources for general health information without identifying a specific type of physical activity (e.g. walking, cycling). The ecological model (Sallis et al., 2006) postulates that the correlates of physical activities differ by the type of activity. Identifying the behavior-specific information sources for the target population could provide more effective and efficient dissemination of health information. The present study aimed to identify the types of information sources associated with strength-training behavior. The population of frail older adults has increased dramatically in Japan. These individuals may more quickly lose their independence if they do not maintain muscle strength; therefore, strength training is an important health issue in Japan.
METHODS Participants and procedures A cross-sectional questionnaire was distributed through the post to 2092 individuals aged 60 –74 years living in the city of Tokorozawa ( population: 341 679; area: 72.0 km2), a typical suburb near Tokyo. A stratified, systematic random method was used to select residential addresses from the city registry. Stratification was performed according to agricultural promotion area (APA). An APA is an area where land use is limited to agriculture by a law (the use for other purposes is prohibited in an APA); thus, APAs can generally be regarded as rural areas. The city consists of 11 districts: 3 districts did not include an APA (Group A), 5 districts included APAs that were ,50% of the total area (Group B) and 3 districts included APAs that were .50% of the total area (Group C). One district was randomly selected from each group. The total population aged 60– 74 years in the three selected districts was 12 400. Every sixth person was selected as a participant, according to the order of residential addresses. The survey was conducted in
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improvement of motor function for long-term care prevention (JMHLW, 2012). Furthermore, a previous study (Harada et al., in press) implies that providing information about the health benefits of strength training would be an effective method to promote strength training among older adults. However, the number of people participating in strength training has remained low, especially for older adults (Chevan, 2008; Harada et al., 2008). Therefore, development of successful communication strategies to increase strength training (e.g. effective strategies of providing information about health benefits of strength training) is necessary among older adults. To develop such strategies, identification of effective communication channels for disseminating strength-training information among older adults is necessary. The US National Cancer Institute (National Cancer Institute, 2001) reported that selection of appropriate channels of communication to influence a specific target group is an important process in planning health-communication campaigns. Previous studies have examined the relationship between information source and health behaviors, including fruit and vegetable consumption (Freisling et al., 2009; Redmond et al., 2010; Ramı´rez et al., 2013), cancer screening (Coughlin et al., 2007; Redmond et al., 2010), beliefs regarding cancer (Ford and Kaphingst, 2009), attitudes toward tobacco control (Blake et al., 2010), smoking cessation (Redmond et al., 2010) and sun-protection behavior (Hay et al., 2009). For example, Freisling et al. (Freisling et al., 2009) found that newspaper articles, the Internet and booklets as sources of nutrition information were positively associated with fruit and vegetable consumption, and argued that the dissemination of healthy eating information should make use of both print media and the Internet. Similar to the information from the US National Cancer Institute (National Cancer Institute, 2001), examining the relationships between information sources for strength training and strength-training behavior is essential for the identification of the most effective channels of communication for increasing strength training among older adults. The ecological model of active living (Sallis et al., 2006) assumes that the information environment influence participation in physical activities, in addition to psychological factors, and social and physical environments. Numerous studies have identified the psychological, social and physical environment correlates of physical activities (Bauman et al., 2012). However, examination of the relationships
Sources of strength-training information
Measurement Sources of strength-training information Each respondent was asked to describe the sources from which they received strength-training information. The question was ‘In the past 12 months, have you seen or heard any information about strength-training? Please select all the sources from which you have seen or heard such information in the past 12 months. For each source, select “yes” or “no”’. The sources included were healthcare providers, friends, family, radio, television, newspapers, newsletters from the local government, posters in public places, books, magazines, booklets from hospitals or pharmacies, the Internet, lectures and other sources. The sources were developed using information from a previous study (Hesse et al., 2005) and from pilot interviews (n ¼ 15) with individuals who engaged in regular strength training. Strength-training behavior Based on previous studies (Bopp et al., 2004; Harada et al., 2008, 2011) and the definition in the current recommendation of the USDHHS (USDHHS, 2008), strength training was defined as all activities that serve to enhance muscular strength and endurance and regular training was defined as strength training occurring 2 days or more per week.
For the assessment of the strength-training behavior, the stages of change for the strengthtraining behavior scale (Harada et al., 2008) were employed. This scale consists of five choices: precontemplation (not engaged in regular strength training and not intending to engage strength training within the next 6 months), contemplation (intending to engage in strength training within the next 6 months), preparation (irregularly engaged in strength training), action (engaged in regular strength training, but for ,6 months) and maintenance (engaged in regular strength training for the past 6 months or more). The respondents were asked to choose the one stage that best described their current situation. As in a previous study (Harada et al., 2011), those in the action and maintenance categories were classified as engaged in regular strength-training behavior, whereas those in the other three stages were classified as not engaged in regular strength-training behavior. Demographic variables Demographic variables were measured by the same questionnaire. The variables included age, gender, self-rated health status (very good, somewhat good, somewhat poor or very poor), number of hospital visits (more than once a week, once or twice a month, once every 2 or 3 months or less than once every 6 months), restriction of physical activity (yes or no), body pain (none, slight, light, moderate, vigorous or very vigorous), marital status (currently married, divorce or widowed or never married), smoking habits (currently a smoker, previously smoked or never smoked) and drinking habits (3 days per week, ,3 days per week or do not drink alcohol). Next, for the convenience of analysis and/or to compensate for a small sample size of the categories, some demographic variables were collapsed as follows: selfrated health status (good or poor), number of hospital visits (once a month and greater), body pain (moderate and greater pain), current marital status (married or not married), current smoking habits (smokes or not a smoker) and current drinking habits (3 days per week).
Data analysis The association of demographic factors with regular strength-training behavior was examined by chi-square tests. Bivariate logistic regression analyses were conducted to examine whether each communication variable was related to
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November and December 2009. Twelve of the 2092 individuals did not receive the questionnaire due to incorrect addresses. Of the remaining 2080 individuals, 1288 (61.9%) returned the questionnaire. Among these, 2.6% (n ¼ 33) did not answer the questionnaire for the following reasons: no interest in the survey (n ¼ 14), difficulty in writing or reading (n ¼ 6), lack of time (n ¼ 5), absence of respondent (n ¼ 4) or other (n ¼ 4). Furthermore, 11 individuals (0.9%) of the 1255 remaining respondents had missing data for a question about strength-training behavior. Thus, 1244 individuals (59.5% of 2092 individuals) were included in the analysis. A letter explaining the ethical considerations was enclosed with the questionnaire. Individuals answered the questionnaire anonymously if they understood the ethical considerations and agreed to participate. Return of the questionnaire thus indicated informed consent. This study received prior approval from the Waseda University Ethics Committee (2009 –108).
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(mean 66.3 years old, SD 4.3 years), 84.5% reported their health was good, 60.0% visited the hospital less than once a month, 93.7% were not restricted in terms of engagement in physical activity, 74.6% did not have more than moderate body pain, 85.7% were married, 83.6% did not have a smoking habit and 67.8% drank alcohol .3 days per week. The relationships between the demographic factors and regular strength-training behaviors are summarized in Table 1. Those with good health status ( p ¼ 0.037), without more than moderate body pain ( p ¼ 0.037) and not currently smoking ( p , 0.001) were more likely to engage in strength-training behavior.
RESULTS
Relationships between strength-training information sources and strength-training behaviors Table 2 shows the relationships between strength-training information sources and
Characteristics of the respondents Table 1 includes the characteristics of the respondents. With respect to gender, 51.5% were men
Table 1: Relationship between demographic factors with regular strength-training behavior
Participants Age (years) 64 65– 69 70 Gender Men Women Self-rated health status Very poor/somewhat poor Very good/somewhat good Hospital visit Once every 2 or 3 months/less than once every 6 months More than once a week/once or twice a month Restriction of physical activity No Yes Body pain None/slight/light Moderate/vigorous/very vigorous Current marital status Divorce or widowed/never married Currently married Smoking habits Previously smoker/never smoker Currently a smoker Drinking habits ,3 days per week/not drinking 3 days per week Note: sample sizes vary due to missing values. a Chi-squared test.
Total
Regular strength-training behavior
n (%)
No (%)
Yes (%)
1244 (100)
75.1
24.9
480 (38.8) 429 (34.7) 329 (26.6)
74.2 74.8 76.9
25.8 25.2 23.1
638 (51.5) 600 (48.5)
75.1 75.2
24.9 24.8
191 (15.5) 1045 (84.5)
81.2 74.1
18.8 25.9
742 (60.0) 494 (40.0)
75.6 74.5
24.4 25.5
1157 (93.7) 78 (6.3)
75.2 74.4
24.8 25.6
924 (74.6) 314 (25.4)
73.2 80.9
26.8 19.1
177 (14.3) 1059 (85.7)
80.8 74.2
19.2 25.8
1036 (83.6) 203 (16.4)
73.0 86.2
27.0 13.8
839 (67.8) 399 (32.2)
74.4 76.7
25.6 23.3
pa
0.667 0.971 0.037 0.657 0.869 0.006 0.061 ,0.001 0.378
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regular strength-training behavior. Subsequently, forced-entry multivariate logistic regression analyses were conducted to examine the relationship between each information variable and regular strength-training behavior. In the multivariate logistic regression analyses, all other information sources and the demographic factors significantly related to regular strength-training behavior in the chi-square tests were adjusted. Crude and adjusted odds ratios (ORs) and 95% confidence intervals (CIs) were calculated for each variable. Statistical significance was set at p , 0.05. All statistical analyses were conducted using SPSS (version 15.0).
Sources of strength-training information
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Table 2: Relationships between strength-training information sources and regular strength-training behavior n (%)
95% CI
p
Adjusted OR
95% CI
p
1244 (100) 889 (75.3) 291 (24.7)
1.00 1.87
1.40– 2.50
,0.001
1.00 1.80
1.27–2.56
0.001
691 (58.7) 487 (41.3)
1.00 1.74
1.34– 2.27
,0.001
1.00 1.40
1.02–1.92
0.037
758 (64.8) 411 (35.2)
1.00 1.38
1.05– 1.80
0.021
1.00 1.08
0.79–1.48
0.641
848 (72.9) 316 (27.1)
1.00 1.01
0.75– 1.36
0.955
1.00 0.73
0.51–1.04
0.080
314 (26.4) 875 (73.6)
1.00 1.13
0.84– 1.53
0.429
1.00 0.88
0.61–1.27
0.491
574 (49.1) 595 (50.9)
1.00 1.31
1.00– 1.70
0.047
1.00 1.09
0.79–1.52
0.602
851 (73.0) 314 (27.0)
1.00 1.36
1.02– 1.81
0.039
1.00 1.14
0.80–1.63
0.476
765 (65.6) 402 (34.4)
1.00 1.15
0.87– 1.51
0.319
1.00 0.87
0.62–1.22
0.429
702 (60.4) 461 (39.6)
1.00 1.72
1.32– 2.25
,0.001
1.00 1.58
1.09–2.28
0.015
636 (54.7) 527 (45.3)
1.00 1.39
1.06– 1.80
0.016
1.00 0.86
0.59–1.24
0.412
850 (73.1) 313 (26.9)
1.00 1.15
0.86– 1.55
0.336
1.00 0.89
0.62–1.27
0.523
1057 (91.2) 102 (8.8)
1.00 2.30
1.52– 3.50
,0.001
1.00 1.99
1.27–3.11
0.003
1081 (93.0) 81 (7.0)
1.00 1.17
0.71– 1.93
0.544
1.00 0.74
0.42–1.31
0.303
879 (76.0) 278 (24.0)
1.00 1.19
0.88– 1.61
0.261
1.00 1.03
0.72–1.47
0.869
638 (51.5) 600 (48.5)
1.00 1.51
1.02– 2.22
0.038
1.00 1.24
0.80–1.92
0.345
924 (74.6) 314 (25.4)
1.00 0.64
0.47– 0.88
0.006
1.00 0.67
0.47–0.95
0.025
1036 (83.6) 203 (16.4)
1.00 0.43
0.28– 0.66
,0.001
1.00 0.44
0.44–0.70
,0.001
Note: sample sizes vary due to missing values. OR, odds ratio; CI, confidence interval. Adjusted for other health information sources, self-rated health status, body pain and smoking habit. Model significance: x 2 ¼ 71.1, p , 0.001; model accuracy: 74.3%.
regular strength-training behavior. In unadjusted models, regular strength-training behavior was significantly related to information from
healthcare providers (OR ¼ 1.87; 95% CI ¼ 1.40 –2.50), friends (OR ¼ 1.74; 95% CI ¼ 1.34– 2.27), family (OR ¼ 1.38; 95% CI ¼ 1.05 –1.80),
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Participants Healthcare providers No Yes Friends No Yes Family No Yes Radio No Yes Television No Yes Newspapers No Yes Newsletters from local government No Yes Posters in public places No Yes Books No Yes Magazines No Yes Booklets from hospital or pharmacy No Yes Internet No Yes Lectures No Yes Others No Yes Self-rated health status Very poor/somewhat poor Very good/somewhat good Body pain None/slight/light Moderate/vigorous/very vigorous Smoking habits Previously smoker/never a smoker Currently a smoker
Crude OR
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DISCUSSION The present study examined the relationship between the sources of information about strength-training and strength-training behavior among Japanese older adults. To our knowledge, this is the first quantitative study to explore the effectiveness of a variety of communication channels in providing strength-training information to older adults. Previous studies have revealed that perceived benefits and barriers (Bopp et al., 2004; Harada et al., in press), behavioral intention (Dean et al., 2007), social support (Bopp et al., 2004) and some neighborhood environmental factors (Harada et al., 2011) are associated with strength-training behavior. Supporting the ecological model of active living (Sallis et al., 2006), the present study suggests that the information environment influences strength-training behavior among older adults in addition to psychological factors, and social and neighborhood environments. In particular, information from healthcare providers and friends were positively associated with strength-training behavior. Generally, these are classified as interpersonal channels (National Cancer Institute, 2001). These results indicate that providing strength-training information via interpersonal channels could be effective means of increasing strength training among older adults because interpersonal channels can provide not only information itself but also social support, which is an important correlate of physical activity (Trost et al., 2002). In fact, previous studies have
suggested the importance of interpersonal channels in providing cancer information (Mills and Davidson, 2002; Ford and Kaphingst, 2009). Ford and Kaphingst (Ford and Kaphingst, 2009) found that health information from interpersonal channels was associated with beliefs about cancer risks more strongly than information from mass media. Further, the results of a Mills and Davidson study (Mills and Davidson, 2002) indicated that interpersonal channels are important sources of information for cancer patients. Therefore, similar to the results of cancer-information studies, the present study found that interpersonal channels appeared to be effective means of encouraging strength training among older adults. Although family is also categorized as an interpersonal channel (National Cancer Institute, 2001), a significant relationship between family and strengthtraining behavior was not observed in the present study. Generally, family members are not health professionals and represent different age groups. Thus, one possible reason for the lack of relationship between family and behavior is that the influence of information from non-professionals and people of different age groups might be weaker than that of people from the same age group, such as friends or professional recommendations. In addition, books and the Internet were associated with strength-training behavior, and books and the Internet were more closely related to strength-training behavior than the interpersonal channels. Books and the Internet are generally used for active searching for information; only those actively seeking information use these channels. In contrast, both active and non-active seekers of information use interpersonal channels. Thus, these results may reflect that active seekers of information are more likely to be engaged or are contemplating engaging in strength training. In other words, it would be difficult to provide information via books and the Internet for non-active searchers, including less motivated people. Regarding another channels (radio, television, newspapers, newsletters from local government, posters in public spaces, magazines, booklets from hospitals or pharmacies, lectures and other), significant relationships with strengthtraining behavior were not observed. One review of the relationships between information and action found that mass-media campaigns increase awareness of the issue of physical activity, but may not have a population-level effect on behavior (Cavill and Bauman, 2004). Similarly, in a
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newspapers (OR ¼ 1.31; 95% CI ¼ 1.00 –1.70), newsletters from local government (OR ¼ 1.36; 95% CI ¼ 1.02– 1.81), books (OR ¼ 1.72; 95% CI ¼ 1.32– 2.25), magazines (OR ¼ 1.39; 95% CI ¼ 1.06– 1.80) and the Internet (OR ¼ 2.30; 95% CI ¼ 1.52– 3.50). After adjusting for demographic factors (selfrated health status, body pain and current smoking habits) and all other information sources, strength-training information from healthcare providers (OR ¼ 1.80; 95% CI ¼ 1.27–2.56), friends (OR ¼ 1.40; 95% CI ¼ 1.02 – 1.92), books (OR ¼ 1.58; 95% CI ¼ 1.09–2.28) and the Internet (OR ¼ 1.99: 95% CI ¼ 1.27 – 3.11) were positively related to regular strengthtraining behavior. The model significance was p , 0.001 (x 2 ¼ 71.1) and the model accuracy was 74.3%.
Sources of strength-training information
2007; Ford and Kaphingst, 2009; Freisling et al., 2009; Hay et al., 2009; Blake et al., 2010; Redmond et al., 2010; Beaudoin and Hong, 2011; Ramı´rez et al., 2013). However, the quality, frequency and duration of information received are related to behavioral change regarding strength training. The fourth limitation is the operational definition of strength training, although it has been defined in previous studies (Bopp et al., 2004; Harada et al., 2008, 2011) and the current USDHHS recommendations (USDHHS, 2008). A final limitation is that the data were obtained from only one city. The city is located in a typical suburban area in Japan. Therefore, it is unclear whether the study findings could be generalized to urban or rural areas. Further studies should measure details of strength-training information and examine causal relationships using a nationally representative sample with no response bias. Despite the limitations, the findings of the present study contribute to a better understanding of strength-training behavior and effective communication strategies to increase strength training among older adults. The findings suggested that strength-training information provided by healthcare providers and friends, as well as books and the Internet, would be effective in increasing strength-training behaviors among older adults. Based on these findings, intervention studies using the identified methods of communication could be developed to increase strength training among older adults. ACKNOWLEDGEMENTS We wish to thank Hiroshi Kono (Faculty of Human Life Design, Toyo University), Kyota Takami (Faculty of Sports and Health Sciences, Hosei University), Shinpei Okada (Physical Education and Medicine Research Foundation), Yuko Kai (Physical Fitness Research Institute, Meiji Yasuda Life Foundation of Health and Welfare), Masamitsu Kamada (Japan Society for the Promotion of Science) and Soeko Sakurai (alumna of Graduate School of Sport Sciences, Waseda University) for helpful comments in the design of the present study. FUNDING This work was supported by a Grant-in-Aid for Research Fellow of the Japan Society for the
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published review of 25 studies, Baker et al. (Baker et al., 2011) concluded that communitywide interventions would not effectively increase population levels of physical activity. From these reviews and the findings of the present study, it becomes apparent that providing information through these channels is not an effective method of changing strength-training behavior at the population level. The findings of the present study imply that interpersonal channels, such as healthcare providers and friends, should be used for planning successful interventions to increase strength training among older adults. Moreover, the present study suggests that differential influences of communication channels on physical activity should be considered to understand physical activity behavior change. Well-designed prospective studies and examinations of other populations are also needed to confirm the most effective communication channels for increasing strength-training behavior among older adults. Compared with previous studies examining the relationships between information sources and physical activities (Redmond et al., 2010; Beaudoin and Hong, 2011; Ramı´rez et al., 2013), a strength of the present study was that information and behavior were specifically linked to strength training. According to the ecological model (Sallis et al., 2006), specifying the type of information and behavior is desirable when examining correlates of physical activity. However, the present study has several limitations. First, the analysis was cross-sectional; therefore, it is not possible to determine cause and effect. Secondly, response bias exists in questionnaire surveys. Our response rate (59.5%) was higher than other questionnaire-based surveys using the postal mailing method, such as 51.6% in Kamada et al. (Kamada et al., 2009) and 36.5% in Inoue et al. (Inoue et al., 2010). However, the document provided with the survey stated that the purpose of the survey was to evaluate beliefs regarding strength training among older adults. Those who were not interested in strength training would therefore be less likely to answer the questionnaire. Thirdly, our study did not measure the details of the strengthtraining information received by participants, such as quality, frequency or duration. Much like the present study, previous studies examining the relationships between the information variable and health behavior have not included the details of information received (Coughlin et al.,
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Promotion of Science (08J06333, 11J07878); Waseda University Grant for Special Research Projects (2010A-093); and Global COE Program ‘Sport Sciences for the Promotion of Active Life’ from the Japan Ministry of Education, Culture, Sports, Science and Technology.
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