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Question 12 pts

The Roman emperor Constantine:

Group of answer choices

rejected all traditional Roman religious practices, and persecuted those that refused to convert to Christianity

required all Christian converts to follow Jewish laws and dietary restrictions

ordered the toleration of all religions, including Christianity, and was baptized as a Christian himself shortly before he died

raised taxes on the Christian Church in an effort to stop the spread of Christianity

Flag question: Question 2Question 22 ptsThe Arian interpretation of Christianity differed from Trinitarian Christianity because:Group of answer choicesArian Christians did not believe that Jesus was the son of God, but simply a gifted philosopher whose teachings were inspired by a divine forceArius of Alexandria argued that Jesus was inferior to God because he was born and died and that, because he was partly human, he served as an example to all humansArian Christians continued to follow Jewish law, observe Jewish dietary restrictions, and celebrate all Jewish holidaysArian Christians believed that it was acceptable for believers to worship the Roman gods as well as Jesus, and that all divine beings are essentially equal Flag question: Question 3Question 32 pts

Called by the emperor Constantine in 325 CE, the Council of Nicaea:

Group of answer choices

condemned the practice of Arian Christianity, and accepted the doctrine of the Trinity

banned the practice of Christianity in all Roman provinces

outlawed the practice of any religion other than Christianity, but accepted both Arian and Trinitarian Christianity as legitimate interpretations

required all Christian converts to follow Jewish laws and dietary restrictions

Flag question: Question 4Question 42 ptsHow was the Greek city of Byzantium transformed by the emperor Constantine in 330 CE?Group of answer choicesConstantine declared an end to the “New Roman” empire, established the Byzantine Empire in its place, and banned the practice of Christianity 

Byzantium was rededicated as Constantinople and became the imperial capital of the entire Roman Empire

Byzantium was given by treaty to the Persian Empire as a peace offeringConstantine designated Byzantium as a city where Roman citizens could worship the Roman gods freely, without fear of persecution Flag question: Question 5Question 52 pts

The Emperor Justinian’s program for revitalizing the Byzantine state included:

Group of answer choices

the revision and reorganization of existing Roman law into the Corpus Juris Civilus, or Justinian Code

a conscious attempt to revive the old Roman Empire by ordering military campaigns to reconquer Italy and North Africa from barbarian tribes

sponsoring large-scale building projects, like the construction of the great Church of Hagia Sophia

all of the other answers are true Flag question: Question 6Question 62 pts

Augustine of Hippo was:

Group of answer choices

the Christian monk who wrote the rule book which was used to organize most eastern European monastic communities

the military leader who united the northern and southern halves of the Roman Empire

the Catholic missionary responsible for introducing Christianity to Ireland

the North African scholar whose ideas became the foundation of Western Christian theology, and the author of City of God

Flag question: Question 7Question 72 ptsWhat does The Rule of St. Benedict say about monks owning personal property?Group of answer choicesThe Rule of St. Benedict allows monks to own some personal items that are meaningful to them, like books and pens, but discourages the ownership of expensive luxury goods The Rule of St. Benedict encouraged monks to accumulate personal wealth as a way to help fund the operating costs of the monasteryThe Rule of St. Benedict does not say anything specific about whether or not monks should own personal property, so some monks did and some didn’tThe Rule of St. Benedict refers to personal property as a “wicked vice” and prohibits monks from owning anything of their own Flag question: Question 8Question 82 ptsBenedictine monasteries became vitally important in medieval Europe as:Group of answer choicesmilitary bases used for the conquest of Islamic territories centers of religious life, but also as centers of political administration, economic development, and learningall of the other answers are truemanufacturing centers organized to supply the Byzantine army with weapons and tools Flag question: Question 9Question 92 pts

In Islamic tradition, the Qu’ran is:

Group of answer choices

the only acceptable source of information about the life of Muhammed

a book of inspirational sayings, but is not considered holy or divinely inspired

simply the Law Code of Hammurabi translated into Arabic

the direct word of God revealed to his Prophet, Muhammad

Flag question: Question 10Question 102 ptsAlthough the concept been interpreted by differently by different groups over time, many Muslims believe that an artist should not depict the human form, or the form of any creature. Why?Group of answer choicesBecause when an artist depicts the human form or the form of any creature, they are putting themselves in a role reserved for God – that of creatorBecause Islam is considered a universal religion, and drawing pictures of people or animals that live in a specific region tends to undermine Islam’s universal messageBecause human beings and animals are inherently weak and sinful, and depictions of them only remind the viewer of their sinsBecause living creatures are difficult to draw accurately, and Muslims should always strive for perfection  Flag question: Question 11Question 112 ptsAccording to the documentary The Hidden Art of Islam, what is the purpose behind the repetitions of geometric patterns found in Islamic art?Group of answer choicesTo teach mathematical principles to ordinary men and women who would not have access to other instructional materialsTo distract the viewer from the boredom of listening to religious texts being read aloud at mosques To bring the viewer to a contemplative state which allows them to think about the repetition of patterns within nature that God created, and to emphasize the importance of unity, logic, and orderTo glorify the political leaders who provided the money for the creation of art and architecture Flag question: Question 12Question 122 pts


Group of answer choicesall of the other answers are true

expanded the Carolingian Empire in western Europe so that only Britain, southern Italy, and parts of Spain lay outside his control

accepted the title of Holy Roman Emperor, and was crowned by Pope Leo III on Christmas Day in 800 CE

rose to power as the king of the Franks

Flag question: Question 13Question 132 ptsWhat changed because of the Carolingian Renaissance?Group of answer choicesLatin usage improved, and basic literacy was extended among some of the clergy and even among some of the Frankish nobilityall of the other answers are truea new form of writing known as Carolingian minuscule was developed, which used  both upper and lower case letters and took up less space on a handwritten pagenumerous books were copied for the library at the palace school at Aachen and for monastic communities, preserving many ancient texts Flag question: Question 14Question 142 ptsViking expansion was possible because:Group of answer choicesthe Vikings were the first to develop gunpowder, which was of limited use in battle but frightened local people into surrenderof Viking sailing technology, which produced strong, maneuverable, ships that could hold up to 60 men and were used not only to conduct raids, but also to connect a vast trading networkEurope had become largely uninhabited after the collapse of the Roman Empire, so Vikings were largely unopposed as they settled new areasthe Vikings adopted Roman military weapons and battle techniques that allowed them to dominate local Celtic tribes Flag question: Question 15Question 152 pts

Harald Bluetooth (Blåtand):

Group of answer choicesis the inspiration behind the naming of Bluetooth wireless technology, which was developed in Scandinaviaall of the other answers are truewas the Viking king who consolidated control of Denmark, and briefly ruled parts of modern Norwayis the credited with bringing Christianity to Denmark, although the nature of his conversion is unclear Flag question: Question 16Question 162 ptsWhat evidence suggests an overlap between the Viking and Islamic worlds?Group of answer choices

Researchers in Sweden have found Arabic characters woven into burial costumes from Viking boat graves

all of the other answers are true

A Viking ring with a Kufic inscription saying “for Allah” was found inside a 9th-century woman’s grave in Birka, Sweden.

Contact between the Viking and Muslim worlds has long been established by historic accounts and the discovery of Islamic coins across the northern hemisphere. DNA analysis from other Viking tomb excavations have shown some of the people buried in them originated from places like Persia, where Islam was dominant.

Flag question: Question 17Question 172 pts

William of Normandy’s conquest of England in 1066 is an example of the:

Group of answer choices

larger, more stable monarchies created in western Europe during the eleventh and twelfth centuries

inability of the British Popes to stop invasions

success of Islamic expansion into northern Europe

military power of the Byzantine emperors

Flag question: Question 18Question 182 ptsThe Bayeux Tapestry is significant because:Group of answer choicesit is a unique visual source of information about not just the Norman Conquest itself, but also about Norman dress, ship building, architecture, hair styles, and weaponrythe inscriptions embroidered into the tapestry are the first examples of English as a written languageit is the oldest surviving piece of woven cloth found anywhere in the world, and gives historians valuable information about ancient textile productionit illustrates how much influence the Byzantine empire had in western Europe Flag question: Question 19Question 192 pts

The Domesday Book:

Group of answer choices

is an invaluable source of historical information about 11th-century England

is a remarkably detailed survey of England conducted during William the Conqueror’s reign

was used for many centuries for both administrative and legal purposesall of the other answers are true Flag question: Question 20Question 202 pts

The impact of Norman rule on England included:

Group of answer choicesall of the other answers are truethe introduction of Norman French which, when mixed with Anglo-Saxon, has often resulted in two different words for the same thing in modern Englishthe redistribution of land and church offices to William of Normandy’s allies, often the second, third, or fourth sons of Norman nobles who would not inherit land in Normandy

the introduction of feudalism

Flag question: Question 21Question 212 pts

The Abbey of Cluny was important during the during the tenth and eleventh centuries because:

Group of answer choices

it was the last monastery to be established in Europe before the Islamic conquest of France

the pope lived there

it was the center of monastic reform, and the monks at Cluny strictly followed the Benedictine Rule

the monks at Cluny adopted elements of Islamic worship into their religious practices

Flag question: Question 22Question 222 pts

The Crusades:

Group of answer choicesbegan as a reaction to the Byzantine Empire’s invasion of Francehave often been portrayed as “clash of civilizations,” but the reality is more complex and recent scholarship has shown that there was widespread cooperation and exchange between Christians and Muslims in the Middle East

were organized to root out and eliminate Arian Christianity from Asia Minor

set off a “clash of civilizations” between Christians and Muslims that has lasted for many centuries Flag question: Question 23Question 232 ptsInto what three groups did medieval people tend to divide their society?Group of answer choicesThose who tax, those who pay, and those who have nothing.Those who legislate, those who enforce, and those who obey.Those who work, those who fight, and those who pray.Those who buy, those who sell, and those who produce. Flag question: Question 24Question 242 pts

The manor:

Group of answer choices

was the basic unit of agricultural organization in much of medieval Europe

all of the other answers are true

often included fields set aside for the grazing of animals, forest land for the gathering of firewood, and a parish church

can be defined as the estate of a lord, or landholder, and his dependent tenants

This week, you examine research that applied a theory or model of health behavior at the intrapersonal level

Is There Something Beyond Stages of Change in the Transtheoretical Model? The State of Art for Physical Activity Ahmed Jérôme Romain Centre de Recherche du Centre Hospitalier de l’Université de Montréal, Montréal, Québec, Canada Johan Caudroit University of Lyon 1 Marie Hokayem Lebanese University Paquito Bernard Université du Québec a` Montréal and University Institute of Mental Health at Montréal, Montreal, Quebec, Canada Over the past 30 years, there has been a growing interest in the application of the transtheoretical model (TTM) in the domain of physical activity (PA). Even though this model has been widely used to implement PA interventions, most of these interventions have not used all of the TTM’s theoretical constructs. Indeed, several studies focused exclusively on the stages of change although this construct is only descriptive. Thus, in the present review, we wanted to encourage researchers to go beyond stages of change when they use the TTM. To do so, we aimed to provide an overview of the TTM, its constructs and to present on one hand, longitudinal studies examining the association between PA and TTM constructs and, on the other hand, summarising the efficacy of TTM-based interventions as to present future TTM challenges. Public Significance Statement Theory-based interventions, including those based on the transtheoretical model, showed their efficacy in physical activity promotion. However, although the transtheoretical model proposes key regulatory components (namely, processes of change, self-efficacy, decisional balance, and temptation) to implement interventions, most of research remains focused on the stages of change. It should be reiterated that stages of change are a construct, not a theory, and therefore should not be used to tailor physical activity interventions. The key regulatory components of the transtheoretical model should be used to individualize counseling to physical activity. Moreover, the specific role of the processes of change in health education towards a more physically active lifestyle represents a future area of research. Keywords: physical activity, transtheoretical model, stages of change, processes of change, mediators of change Supplemental materials: http://dx.doi.org/10.1037/cbs0000093.supp As recently evidenced, the world actually faces an increasing prevalence of physical inactivity (Andersen, Mota, & Di Pietro, 2016), which partly explains the ever-rising worldwide prevalence of major noncommunicable diseases (Sallis et al., 2016). This physical inactivity epidemic constitutes an economic burden to the international health care systems of up to US$53.8 billion in 2013 (Ding et al., 2016). Thus, there is a pressing urgency to promote physical activity (PA) by implementing interventions that take into account the reasons favouring its adoption. In this context, theory-based interventions constitute an interesting option, not only because they are assumed to be better than nontheoretical interventions but also because of the fact that they provide a framework that makes interventions easier to replicate and disseminate in real-life settings. A recent metaanalysis of randomized controlled trials (RCTs) concluded that theory-based interventions in PA promotion effectively increase PA and that none of the psychological theories included were found to be superior in PA promotion (Gourlan et al., 2016). This meta-analysis of 31 interventions (over the 82 included) using the transtheoretical model (TTM) also highlighted that this model is among the most used theories to promote PA Ahmed Jérôme Romain, Département de neurosciences, Centre de Recherche du Centre Hospitalier de l’Université de Montréal, Montréal, Québec, Canada; Johan Caudroit, Laboratoire sur la Vulnérabilité et L’innovation dans le Sport, Département des sciences de l’activité physique, University of Lyon 1; Marie Hokayem, Department of Nutrition, Faculty of Public Health, Lebanese University; Paquito Bernard, Département des sciences de l’activité physique, Université du Québec a` Montréal, and University Institute of Mental Health at Montréal, Montreal, Quebec, Canada. Correspondence concerning this article should be addressed to Ahmed Jérôme Romain, Département de neurosciences, Centre de Recherche du Centre Hospitalier de l’Université de Montréal, 900 rue St-Denis, 

 (Prochaska & DiClemente, 1983). The TTM conceptualizes the process of intentional behaviour change by assuming that (a) a single theory cannot account for the complexity of human behaviour change, (b) behaviour change is a process that unfolds over time through several stages, (c) these stages are stable and open to change, and (d) specific processes should be used at specific stages to facilitate the efficacy of behaviour change (Prochaska, Redding, & Evers, 2008). It is interesting that the TTM speculates a nonlinear transition between the stages of change (SOC) with patterns of discontinuity (Lippke & Plotnikoff, 2006). Even though the TTM is widely used, it remains poorly implemented in interventions seeking to improve PA behaviour (Romain, Bortolon, et al., 2016), and this can be explained by the fact that many researchers are probably unaware of all the TTM’s constructs. In view of these observations, it was therefore necessary to explain how to use the TTM and its underlying mediators in research and intervention contexts. The objectives of the present narrative review were to (a) briefly provide an overview of the TTM and the mediators of change on which it is based, (b) discuss studies examining longitudinal associations between PA change and TTM mediators, (c) outline TTM-validated questionnaires, (d) examine the efficacy of TTM-based interventions for PA promotion, and (e) debate future TTM challenges. The Transtheoretical Model and Its Mediators The TTM identifies change as a progressive process through a series of five different SOC over time (Prochaska & DiClemente, 1983). Although the SOC are the most popular part of the TTM, notably because of their ease of use and scoring, they also constitute its most descriptive construct. The five SOC are precontemplation (not ready; not intending to change in the next six months), contemplation (getting ready; intention to change within the next six months), preparation (ready; intention to change within 30 days), action (new behaviour is initiated within the last six months), and maintenance (behaviour is sustained for more than six months). Thus, while going through the SOC, an individual starts by intending to adopt the behaviour criteria in the early preaction SOC (precontemplation, contemplation, and preparation) to later adopt and maintain this newly acquired behaviour throughout the action and maintenance stages (Prochaska & Velicer, 1997). If SOC represent the most descriptive part of the TTM, it is mainly because they explain “where” people are in terms of motivation but not “how” to motivate them or “why” they move across stages. Indeed, according to the TTM, the transition between the different SOC is influenced by its mediators of change (its theoretical constructs) that include decisional balance, temptation, self-efficacy, and processes of change (POC; Prochaska, DiClemente, & Norcross, 1992). Decisional balance is defined as the perception of advantages (pros) and/or disadvantages (cons) related to the decision of undertaking or not a behaviour (Prochaska et al., 1994). Temptation is the urge to engage in a specific behaviour in the midst of difficult barriers (Hausenblas et al., 2001). Self-efficacy, a component of social– cognitive theory (Bandura, 1977), is defined as a person’s judgment of his or her capabilities to organise and execute courses of action required to attain designated types of performance (Bandura, 1997). Finally, there are the POC that help clarify how behaviour changes take place, and SOC help pinpoint when those modifications occur. POC are comprised of a total of five experiential processes and five behavioural processes that need to be executed to ensure a certain progress through the SOC and achieve the desired behaviour change. Experiential processes are defined as processes in which individuals obtain information based on their own experiences, and behavioural processes regroup strategies used to modify the environment to help change the behaviour (Burkholder & Nigg, 2001; Romain, Chevance, Caudroit, & Bernard, 2016; see Table 1 for a definition of POC). In the TTM, the relationship between its mediators and the SOC has been tested extensively (Burkholder & Nigg, 2001; Marshall & Biddle, 2001), and was found to be consistent throughout different types of behaviour (e.g., smoking, diet). However, contrary to the assumptions formulated in tobacco cessation, the POC by SOC sequence was found to be different. Indeed, in smoking cessation, experiential and behavioural POC act sequentially, with experiential POC used in the early stages and behavioural POC in the later stages (action and maintenance). Inversely, in PA, this sequential order was not found with experiential and behavioural POC acting in tandem, with the use of both increasing across stages (Marshall & Biddle, 2001; Table 1 Processes of Change and Their Definitions Processes of change Definition Experiential processes of change Consciousness raising Efforts to better understand the problematic behavior Dramatic relief Affective aspects of behavior change Self-reevaluation Cognitive or emotional appraisal of the impact of the behavior on the individual Environmental reevaluation Impact of negative or positive behavior on individual’s social and physical environment Social liberation Recognition that actual social norms encourage individuals to reach/sustain their healthier lifestyle Behavioral processes of change Self liberation Committing to change and believing in this commitment Helping relationships Using the support of caring others to modify behaviour Counterconditioning Substituting unhealthy for healthy behaviour Reinforcement management Use of reinforcement and reward to support/sustain healthy behaviour Stimulus control Modifying the environment to encourage healthy behaviour A 

 osen, 2000; see Figure 1 for an illustration). This crucial point will be discussed further subsequently. In the TTM, mediators explain “why” people modify their behaviour. In order to better understand how changes occur, it is essential to focus on longitudinal, interventional, or observational studies (Rhodes & Quinlan, 2015) rather than cross-sectional research designs. What Do Longitudinal Observational Studies Using TTM Mediators Tell Us About the Transition Between SOC of Physical Activity? Observational studies provide a primary insight to understand the complex associations between SOC and the mediators of the TTM. For this purpose, in this section, only observational studies having investigated the role of these mediators in the transition between SOC were included. Plotnikoff, Hotz, Birkett, and Courneya (2001) assessed whether self-efficacy, decisional balance, and POC predicted the transition between exercise SOC within a 12-month period among 1,602 adults. Results showed that self-efficacy, decisional balance, and both experiential and behavioural POC were predictors of the transition between SOC. To be more precise, the transition out of the precontemplation and contemplation stages was predicted by higher levels of self-efficacy, perception of advantages (pros), and behavioural POC. Also, the transition out of the preparation stage was predicted by higher levels of self-efficacy and pros. Moreover, retention in postaction stages was predicted by higher levels of pros versus lower cons, and by the activation of both experiential and behavioural POC. Thus, Plotnikoff, Hotz, et al. (2001) study partially supports the validation of TTM in exercise. A similar study testing the TTM’s capacity for predicting PA transitions was performed among 1,674 adults with Type 1 or Type 2 diabetes over six months (Plotnikoff, Lippke, Johnson, & Courneya, 2010). Findings provided moderate support for the TTM constructs in predicting PA stage transitions, with very few differences between Type 1 and 2 diabetic groups. Indeed, the transition from precontemplation to contemplation was predicted by the pros and the experiential POC. The transition out of preparation was only predicted by higher self-efficacy. Transition out of the action stage was predicted by the pros and the behavioural POC, whereas remaining in the maintenance stage was predicted by higher levels of self-efficacy, pros, and experiential and behavioural POC. Analogous results were found in a prospective investigation in which TTM showed significant potential for motivating women with multiple sclerosis to increase their PA over a period of 12 months (Levy, Li, Cardinal, & Maddalozzo, 2009). In addition, Dishman, Vandenberg, Motl, and Nigg (2010) assessed TTM constructs relating to the 2010 guidelines for regular moderate or vigorous PA, at 6-month intervals three or more times over 24 months, among a cohort of 497 multiethnic participants. The results provided great support for core TTM constructs by showing that people meeting, or partially meeting, PA guidelines had a decrease in temptation, an increase in self-efficacy, and also a higher use of both experiential and behavioural POC. Only decisional balance was not associated with PA guidelines. Nevertheless, the absence of results regarding decisional balance is not supported by one of the first longitudinal studies on TTM showing that pros, cons, and self-efficacy, but not POC, were associated with leisure exercise three years after initial assessment in adolescents (Nigg, 2001). The aforementioned studies provide important information to consider, including the fact that all TTM constructs were predictors of the transition between the different SOC, but to different extents. Thus, regarding PA, to progress through SOC, people need to find more reasons to exercise (the pros) than not to (the cons), and to feel more confident (self-efficacy) by increasing the use of both experiential and behavioural strategies (POC). These arguments are corroborated by findings from a previous meta-analysis of cross-sectional studies on TTM applications to PA (Marshall & Biddle, 2001). The precited research supports the use of TTM interventions in the context of PA by demonstrating that all TTM constructs are necessary in order to adopt or sustain a physically active lifestyle. However, it should be noted that these observations were drawn from observational studies, so to confirm them it is necessary to analyse results from interventional studies. 1 2 3 4 5 PC C P A M Behavioral Experiential 1 2 3 4 5 PC C P A M Behavioral Experiential Figure 1. Schematic representation of the relationship between processes and stages of change in tobacco use (left figure; sequential association) and physical activity (right figure; tandem association). This figure has been adapted from Romain, Chevance et al. (2016) with their authorization. PC  precontemplation; C  contemplation; P  preparation; A  action; M  maintenance. See the online article for the color version of this figure. 44 R 

 that after 24 months, behavioural POC were the only mediators of the relationship between the TTM intervention and PA/cardiorespiratory fitness relationship in sedentary adults. Thus, these two studies support the use of TTM, and more particularly behavioural POC in PA behaviour modulation. Consequently, although the TTM provides information about its mediators, few studies have really addressed this relevant issue (Rhodes & Pfaeffli, 2010). Although some research failed to show any mediation effects, most studies showed that TTM mediators significantly modified PA level even though the sample size was too small to provide any robust conclusion (Fahrenwald, Atwood, Walker, Johnson, & Berg, 2004; Rabin, Pinto, & Frierson, 2006). Among the most prominent TTM mediators, self-efficacy and behavioural POC were found to be of great importance in PA interventions, even though further explanations are necessary to understand the extent of their impact. The consistent association between these variables/mediators may be explained by the fact that they are often well correlated. Nevertheless, other assumption can be drawn from their significant relation. Loprinzi and Cardinal (2013) performed a study on the supposition that behavioural POC and self-efficacy are important in PA behaviour change and that the literature does not really provide any clear explanation. Thus, among breast cancer patients, they examined the mediation link between PA, behavioural POC, and self-efficacy, and highlighted that behavioural POC were related to PA and that this relationship was mediated by self-efficacy. This result was also confirmed by the Training Interventions and Genetics of Exercise Response study, in which self-efficacy and experiential and behavioural POC were correlated with PA at the baseline period of their trial, with only behavioural POC mediating the relationship between selfefficacy and adherence to exercise (defined as the number of exercise sessions attended compared with the possible number of exercise sessions offered; Dishman, Jackson, & Bray, 2014). Consequently, even though these findings further solidify our understanding of the TTM when relating to PA change, they do not negate the role of experiential POC that can trigger the intention to exercise in different populations (Nigg, 2005). Initial TTM Instruments Development for Physical Activity Behaviour Change In the TTM, one of the undeniable limitations is that most assessment tools are presented in English, which restricts their use to English-speaking countries; in addition, not all studies used validated questionnaires in their surveys. Thus, to overcome this issue, in the following paragraphs, we present a systematic overview of the different worldwide validations that exist. TTM research in the context of PA was initiated by Marcus, Rakowski, and Rossi (1992), who published three validation studies for assessing the four key TTM constructs with cross-sectional designs across work-site samples in Rhode Island. Except for the Temptation scale, these questionnaires have been extensively used, examined, and adapted. As recommended by Reed, Velicer, Prochaska, Rossi, and Marcus (1997), the SOC measure was developed as an algorithm to categorise individuals in one of five SOC. This scale consists of one item with five statements representing each a stage, going from the “precontemplation” to the “maintenance” stage. Thus, a reliable SOC algorithm should include a clear definition of PA and its frequency and duration. PA defined as a 30 min session at least four times per week is generally recommended (Nigg et al., 2005; Romain et al., 2012), and the validity of this SOC algorithm has been shown with self-reported PA and anthropometrical measures in adults (Hellsten et al., 2008; Nigg et al., 2005). Regarding POC, Marcus et al. (1992) adapted the initial scale developed for smoking cessation by Prochaska, Velicer, DiClemente, and Fava (1988) for the context of PA. The scale contained 39 items measuring both experiential and behavioural POC ( .62–.88). Later, Nigg, Norman, Rossi, and Benisovich (1999) created a new and shorter measure of POC, which contains 30 items measuring the 10 POC for PA (  .62–.85). Regarding self-efficacy, Marcus et al. (1992) validated a fiveitem-measure scale assessing self-efficacy for PA (  .82). In addition, Benisovich, Rossi, Norman, and Nigg (1998) developed the multidimensional self-efficacy questionnaire, which comprises 18 items measuring the individual’s confidence in his ability to overcome PA-related barriers (e.g., excuse making, bad weather;  .77–.85). Finally, Marcus et al. (1992) validated a 16-item Decisional Balance scale for PA, with 10 items for the perceived benefits of PA (pros;  .95) and six items for the perceived costs (cons;  .79). Plotnikoff, Blanchard, Hotz, and Rhodes (2001) updated this scale by using 10 items (five pros,  .79; five cons,  .71) for PA. The temptation measure was validated by Hausenblas et al. (2001). In their initial development and validation, two factors were reported: affect (five items;  .81) and competing demands (five items;  .86). Another seven-item version showed a similar structure (Geller, Nigg, Motl, Horwath, & Dishman, 2012). Regarding the validation of TTM scales in PA, several studies have investigated the validity, adaptation, translation, and application of TTM constructs in different populations and languages (see Table 2 for summary and Supplementary File 1 of the online supplemental materials for the complete table). TTM Questionnaires Available in 11 Different Languages Among studies presented in the Table 2, several researchers have used the original TTM questionnaires validated in English (Blaney et al., 2012; Carnegie et al., 2002; Dishman, Jackson, et al., 2010; Geller et al., 2012; Kearney, de Graaf, Damkjaer, & Engstrom, 1999; Maddison & Prapavessis, 2006; Norman, Velicer, Fava, & Prochaska, 1998; Pickering & Plotnikoff, 2009; Rhodes, Berry, Naylor, & Wharf Higgins, 2004; Sallis, Pinski, Grossman, Patterson, & Nader, 1988; Skaal, 2013; Skaal & Pengpid, 2012; Vita & Owen, 1995). TTM scales were then translated into 11 different languages (see Table 2). Psychometric studies have validated TTM constructs from English to French (Bernard et al., 2014; Eeckhout, Francaux, Heeren, & Philippot, 2013; Eeckhout, Francaux, & Philippot, 2012a, 2012b; Romain, Bernard, Hokayem, Gernigon, & Avignon, 2016), Finnish (Cardinal, Tuominen, & Rintala, 2003, p. 200), Dutch (Ronda, Van Assema, & Brug, 2001), German (Bucksch, Finne, & Kolip, 2008; Fuchs & Schwarzer, 1994; Kanning, 2010; Tergerson & King, 2002), Greek (Bebetsos & Papaioannou, 2009; Korologou, Barkoukis, Lazuras, & Tsorbatzoudis, 2015), Persian (Farmanbar, Niknami, Lubans, & Hidarnia, 2013; Sanaeinasab, Saffari, Nazeri, Karimi Zarchi, & Cardinal, 2013), Korean (Y. Kim, Cardinal, & Lee, 2006; Y.-H. Kim, 2007), Chinese (Si et al., 2011; 46 R 

 Tung, Gillett, & Pattillo, 2005; Yang & Chen, 2005), Malaysian (Phing, 2014), Japanese (Horiuchi, Tsuda, Kobayashi, Fallon, & Sakano, 2017; Oka, 2000, 2003), Taiwanese (Sechrist, Walker, & Pender, 1987), and Spanish (Gonzalez & Jirovec, 2001). No psychometric investigation has, to our knowledge, interpreted or adapted the temptation scale in other languages. Investigating Invariance of TTM Questionnaires The different types of invariance (configural, metric, and scalar) of TTM questionnaires (see Table 2) have been investigated across various time sets and subgroup characteristics, with results showing that TTM constructs were invariant according to sex, student status, ethnicity, age, body mass index, employment, PA level, protocol adherence, level of education, and diabetes type (Bernard et al., 2014; Dishman, Jackson, & Bray, 2010; Geller et al., 2012; Paxton et al., 2008; Pickering & Plotnikoff, 2009). These analyses were performed with English and French versions of TTM questionnaires (Bernard et al., 2014; Geller et al., 2012). Moreover, the longitudinal invariance of TTM constructs has also been provided across 3- and 6-month periods, with studies showing that any temporal differences or modifications identified can be interpreted as changes related to time or intervention mistakes, but not measurement errors (Dishman, Jackson, et al., 2010; Geller et al., 2012). Are TTM-Based Interventions Effective in Promoting PA? Over the last decade, interventional researchers in health psychology and behavioural medicine have gradually integrated the specific methodological requirements of evidence-based medicine (Keefe & Blumenthal, 2004). In this methodological paradigm, the RCT design is recognised as the highest level of investigative methodology to establish the efficacy or effectiveness of health behaviour change interventions (Davidson et al., 2003). In this context, several critics have questioned the worth of TTM interventions in promoting PA, arguing that SOC may not be applied to PA change because of the complexity of this behaviour, the lack of validated staging algorithms, and the possibility that the most reliable determinants of PA change are not included in the TTM (Adams & White, 2005; Armitage, 2009; Brug et al., 2005). However, two systematic reviews including only RCTs examined the efficacy of TTM interventions on PA promotion, with findings indicating that TTM-based interventions induce a small to medium effect size for PA behaviour change. The most recent review (Romain, Bortolon, et al., 2016) included 33 RCTs, with 4,950 and 5,400 participants in the interventional and control groups, respectively. Fourteen studies included exclusively adults with chronic illness (e.g., multiple sclerosis). The length of intervention ranged from 2 to 100 weeks, and PA level was an inclusion criterion but stage progression was not. In addition, all constructs related to PA were self-reported. This review obtained an overall effect size of d  0.33 (95 % confidence interval [CI] [0.22, 0.43]) for PA behaviour change, which was consistent with Gourlan et al. (2016) (d  0.31, 95 % CI [0.20, 0.42]). These effect sizes need to be interpreted in the context of public health (Prentice & Miller, 1992), seeing that even a slight PA increase may lead to a major health impact (Khan et al., 2012). Evidence-Based Rather Than Evidence-Inspired TTM Interventions to Change Physical Activity Behaviour In line with previous recommendations (Michie & Johnston, 2012), a thorough analysis of theoretical moderators of TTMbased interventions has been performed in the present narrative review. Romain, Bortolon et al. (2016) observed that TTM-based interventions implementing at least three constructs (e.g., selfefficacy, decisional balance, POC) obtained a 3-times larger effect size (d  0.49, 95 % CI [0.29, 0.69]) versus applying two constructs or less (d  0.16, 95 % CI [0.06, 0.25]) regarding PA promotion. Moreover, bivariate metaregressions showed that selfefficacy and POC were the most active and effective components T 

Theories play a critical role in health-promotion program planning, implementation, and evaluation. They also help answer important questions such as why people don’t engage in healthy behaviors. However, before theories officially became theories, they were tested through research for their ability to predict and explain health behavior. They were also examined through research for their efficacy in health promotion program development. It is through research that we examine current theories, create new theories, and collect evidence concerning the effectiveness of theory-based public health and health promotion programs. Therefore, understanding how to analyze and interpret research is important to our professional practice. This Assignment will also help you analyze research in other courses in your program.

This week, you examine research that applied a theory or model of health behavior at the intrapersonal level.

To prepare:

  • Review Chapters 3, 4, and 6 in your textbook.
  • Consider the constructs of the different theories and models and how they relate to the intrapersonal level of influence on health behavior.
  • Review your assigned article.
  • Review the Research Article Review worksheet located in the Learning Resources for the specific article you were assigned.
  • Familiarize yourself with the questions on the worksheet prior to reading the article.


  • Complete the assigned Research Article Review Worksheet.
  • Use critical thinking to analyze, assess, and evaluate the article and to respond to the questions in the worksheet. Be specific and use examples in your answers.

HLTH 2500: Theories of Health Behavior

Research Article Review (RAR) Worksheet 

Week 2: Transtheoretical Model 

Name: ­­­­­­­­[Type your name here.]


Romain, A. J., Caudroit, J., Hokayem, M., & Bernard, P. (2018). Is there something beyond
 stages of change in the transtheoretical model? The state of art for physical activity.
 Canadian Journal of Behavioural Science, 50(1), 42 – 53. http://dx.doi.org/10.1037/


1. Read the research article, which you will access this article from the Walden Library databases.

2. Type your answers under each question. The space between questions will expand as you write your response. 

3. Be sure to type your full name above. 

4. Save the worksheet as: WK2_RAR_TTM [your last name_first name initial]
(for example: WK2_RAR_TTM_Gallien_T)


1. What is the purpose of the article? 

2. Respond to the following three questions:

a. Which theoretical constructs of TTM are discussed in the article? 

b. Which constructs are considered the “mediators of change”? 

c. Explain what is meant by “mediators of change.” 

3. Choose only one (1) of the following questions to answer.

a. What do studies using TTM mediators tell us about the transition between stages of change (SOC) of physical activity?

b. What did the authors conclude after reviewing the research about the effectiveness of TTM-based interventions on physical activity level? 

4. Even though the Transtheoretical Model (TTM) is widely used in research and in the development of interventions, the authors of the article noted several weaknesses of TTM’s implementation. What are some of the weaknesses identified by the authors? Be specific. 

5. What suggestions do the authors give for creating a physical-activity-specific Transtheoretical Model? 

In addition, answer the following:

1. What was the most challenging aspect of this assignment? 

2. Describe a strategy you might use to overcome this challenge. 


You rеcentlу did а research paper for me on “Providing Mental Health Care to Veterans in Rural Areas”. What I need is an “Executive Summary on the Above Paper by answering the following questions:

1. Introducton, by Clearly defining the TOPIC (What Is Health Care In Rural Areas? (This introduction requires more than 2 paragraph).

2. Why is this topic or subject important today in health care for Veterans?

3. Why would a topic such as “Ethical Care” be of importance in the culture of medical care where mental health is concern?

4. Who and Why would one be interested in such a topic?

5. How does this health care service affect or compare to every day ethical health care? — does ethical care for Veterans impacts the rural areas as compared to urban areas? (More than one paragraph is required to summarize this question).

6. How does the APA Code Of Ethics TIE into my original paper in similarities and contrast using SECTION “A” and SECTION “B” of the APA Code of Ethics.

7. What 2 recommendation can the Department of Veterans use to educate, and expand health care in rural areas.

8. Conclusion. Please note that I am requesting my Executive Summary to be sent as a WORD DOCUMENT. Any other method I will not be able to retrieve. Pls ensure my request is followed.


You will select a concept related to a practice problem of interest to you. You will then have an opportunity to explore how concept analysis applies to research involving this practice problem.

Next week, you will consider how concept analysis relates to theory development.

To prepare: Brainstorm a list of concepts you use or see in practice that pertain to a practice problem of interest to you. Then select one concept to focus on for this Discussion. Using the concept analysis strategies presented in the Learning Resources, analyze your selected concept and clarify its meaning. With your selected concept in mind, formulate a research topic to address the related practice problem. Identify the concept and the related practice problem that you have selected for this Discussion. Provide a summary of your concept analysis (sharing your clarified concept) and the related research topic.

Describe the importance of this concept and research topic to nursing practice.


You will have an opportunity to weigh in on the discussion about the criteria for evaluating the quality of qualitative research designs. You will also consider the relationship between quality criteria, philosophical orientations, and discipline standards. You will also consider ethical issues in qualitative research, the implications these issues have on design decisions, and the strategies used to address them. You will also annotate a qualitative journal article on a research topic of your interest. • Explain criteria for evaluating the quality of qualitative research designs • Explain relationship between quality criteria and philosophical orientations and discipline standards • Identify ethical issues in qualitative research • Explain how ethical issues influence design decisions in qualitative research • Explain criteria for a research topic to be amenable to scientific study using a quantitative approach • Apply strategies for addressing ethical issues in qualitative research • Annotate a qualitative research article •

Apply APA Style to writing an explanation of two criteria for evaluating the quality of qualitative research designs. Next, explain how these criteria are tied to epistemological and ontological assumptions underlying philosophical orientations and the standards of your discipline. Then, identify a potential ethical issue in qualitative research and explain how it might influence design decisions.

Finally, explain what it means for a research topic to be amenable to scientific study using a qualitative approach.

References Chenail, R. (2010). Getting specific about qualitative research generalizability. Journal of Ethnographic & Qualitative Research, 5(1), 1–11. Retrieved from Academic Search Complete. Maxwell, J. A. (1992). Understanding and validity in qualitative research. Harvard Educational Review, 62(3), 279–299. Merriam, S. B. (1995). What can I tell you from an N of 1? Issues of validity and reliability in qualitative research. PAACE Journal of Lifelong Learning, 4, 51–60. Retrieved from http://www.iup.edu/templates_old/page.aspx?id=17469 Smith, J. K. (1984). The problem of criteria for judging interpretive inquiry. Educational Evaluation and Policy Analysis, 6(4), 379–391