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Reliability and Validity of the Behavioral Regulation in Exercise Questionnaire-2 for Nursing Home Residents in China

Open AccessPublished:December 30, 2019DOI:https://doi.org/10.1016/j.anr.2019.12.002

      Abstract

      Purpose

      This study aimed to examine the reliability and validity of the Chinese-translated Behavioral Regulation in Exercise Questionnaire-2 (BREQ-2) for nursing home residents.

      Methods

      A convenience sample of 204 nursing home residents were used for measuring the instrument performances. Demographics form and BREQ-2 developed by Markland were applied.

      Results

      The translated BREQ-2 model was a good fit for the results of confirmatory factor analysis, χ2 was 276.75, comparative fit index was .94, standardized root mean square residual was .05, and root mean square error of approximation was .07. Results in the BREQ-2 indicated good consistency, Cronbach's α coefficient of BREQ-2 was .78, and each of the five subscales were ranged from .78 to .83. The test–retest was valued .84, and the five subscales ranged from .75 to .89, which supporting the stability of instrument.

      Conclusion

      This study provided psychometric evidence for the application of BREQ-2 among nursing home residents in China.

      Keywords

      Introduction

      Regular physical activity has been confirmed to counteract frailty and sarcopenia; lower risk for many chronic diseases such as coronary heart disease, hypertension, osteoporosis, and type 2 diabetes; reduce the incidence of depression and dementia; and improve general well-being [
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      • Marzetti E.
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      • Cesari M.
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      Physical activity and exercise as countermeasures to physical frailty and sarcopenia.
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      • Schuch F.B.
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      • Simas V.
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      ]. Although the advantages of physical activity for older adults are well documented, investigations of nursing home residents in the United States, Australia, Canada, France, and Norway [
      • Benjamin K.
      • Edwards N.
      • Ploeg J.
      • Legault F.
      Barriers to physical activity and restorative care for residents in long-term care: a review of the literature.
      ,
      • De Souto Barreto P.
      • Demougeot L.
      • Vellas B.
      • Rolland Y.
      How much exercise are older adults living in nursing homes doing in daily life? A cross-sectional study.
      ,
      • Egerton T.
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      ,
      • Kjøs B.Ø.
      • Havig A.K.
      An examination of quality of care in Norwegian nursing homes - a change to more activities?.
      ] have shown that physical activity level barely meets the World Health Organization recommendations for older adults. Owing to the lack of physical activity data among the nursing home residents in Mainland China, researchers conducted a survey which using the pedometer to measure the physical activity among the nursing home residents. The study indicated that most of the nursing home residents were in the sedentary (85.7%) or low active (4.7%).
      There are many barriers to physical activity within nursing homes that have been summarized into three categories [
      • Chen Y.M.
      Perceived barriers to physical activity among older adults residing in long-term care institutions.
      ,
      • Kalinowski S.
      • Wulff I.
      • Kölzsch M.
      • Kopke K.
      • Kreutz R.
      • Dräger D.
      Physical activity in nursing homes-barriers and facilitators: a cross-sectional study.
      ]: individual, organizational, and environmental. At the individual factor level, motivation is deemed as the most important factor for initiation and maintenance of physical activity [
      • Elliot A.J.
      • Covington M.V.
      Approach and avoidance motivation.
      ]. As a form of motivation, self-determination theory (SDT) has received increased attention and has been applied to research of physical activity [
      • Ferrand C.
      • Nasarre S.
      • Hautier C.
      • Bonnefoy M.
      Aging and well-being in French older adults regularly practicing physical activity: a self-determination perspective.
      ,
      • Hartmann C.
      • Dohle S.
      • Siegrist M.
      A self-determination theory approach to adults' healthy body weight motivation: a longitudinal study focussing on food choices and recreational physical activity.
      ]. Motivation in SDT is described as a continuum which moving back and forth between non-self-determined and self-determined regulation, and the six forms of regulation are amotivation, external, introjection, identification, integration, and intrinsic [
      • Ryan R.M.
      • Deci E.L.
      Intrinsic and extrinsic motivations: classic definitions and new directions.
      ]. Amotivation means no intention to engage in any physical activity. External regulation is close to amotivation, it occurs when behaviors are only performed after external pressures or to achieve a reward. Introjection involves the internalization of external pressures, and people perform it to avoid guilt and to attain self-esteem or feeling of worth. Identified regulation exists when a conscious acceptance of the behavior as being personally important for the sake of achieve the valued outcomes. Integrated regulation occurs when behavior is coordinated with people's other needs, values, and is fully self-determined. Intrinsic regulation exists when behaviors are performed for the satisfaction or enjoyment of engaging in the activity itself [
      • Ryan R.M.
      • Deci E.L.
      Intrinsic and extrinsic motivations: classic definitions and new directions.
      ].
      Several questionnaires have been developed to measure the motivational continuum of STD in the field of exercise, sport, and physical education, for instance, the Sport Motivation Scale (SMS) [
      • Pelletier L.G.
      • Tuson K.M.
      • Fortier M.S.
      • Vallerand R.J.
      • Briére N.M.
      • Blais MR.
      Toward a new measure of intrinsic motivation, extrinsic motivation, and amotivation in sports: the sport motivation scale (SMS).
      ], Exercise Motivation Scale (EMS) [
      • Li F.Z.
      The exercise motivation scale: its multifaceted structure and construct validity.
      ], and Behavioral Regulation in Sport Questionnaire (BRSQ) [
      • Lonsdale C.
      • Hodge K.
      • Rose E.A.
      The behavioral regulation in sport questionnaire (BRSQ): instrument development and initial validity evidence.
      ]. SMS is a 28-item self-report measure, and it is made up seven subscales, which includes three types of intrinsic motivation (to know, to accomplish things, and to experience stimulation), three types of extrinsic motivation (identified, introjected, and external regulation), and amotivation. It is used to measure self-determination motivation in competitive sports [
      • Pelletier L.G.
      • Tuson K.M.
      • Fortier M.S.
      • Vallerand R.J.
      • Briére N.M.
      • Blais MR.
      Toward a new measure of intrinsic motivation, extrinsic motivation, and amotivation in sports: the sport motivation scale (SMS).
      ]. BRSQ is used to measure amotivation, intrinsic motivation, and extrinsic motivation with respect to competitive sports. Both two questionnaires are used in the context of competitive sports and may not be suitable for assessing the motivation in regards to physical education or physical activity [
      • Lonsdale C.
      • Hodge K.
      • Rose E.A.
      The behavioral regulation in sport questionnaire (BRSQ): instrument development and initial validity evidence.
      ]. EMS is a 31-item self-report measure, and it made up eight subscales, which include intrinsic motivation to sensations, intrinsic motivation to accomplish, intrinsic motivation to learn, integrated regulation, identified regulation, introjected regulation, external regulation, and amotivation. It is used to measure self-determination motivation in the context of exercise [
      • Li F.Z.
      The exercise motivation scale: its multifaceted structure and construct validity.
      ]. EMS assesses three types of intrinsic motivation, which is different from Behavioral Regulation in Exercise Questionnaire-2 (BREQ-2) in that BREQ-2 assesses a general intrinsic motivation.
      Based on the literature review, BREQ/BREQ-2 was the most widely used instrument to measure the SDT motivation in the field of exercise or physical activity. BREQ was developed by Mullan et al. [
      • Mullan E.
      • Markland D.
      • Ingledew D.K.
      A graded conceptualisation of self-determination in the regulation of exercise behaviour: development of a measure using confirmatory factor analytic procedures.
      ] to measure the motivational continuum of SDT in the exercise domain, which is a 15-item self-report scale included external, introjected, identified, and intrinsic regulations. Markland et al. [
      • Markland D.A.
      • Tobin V.
      A modification to the behavioural regulation in exercise questionnaire to include an assessment of amotivation.
      ] revised and completed BREQ-2 by adding amotivation. Hence, BREQ-2 comprises five factors: amotivation, external, introjected, identified, and intrinsic regulation, with 19 items. BREQ and BREQ-2 are regarded as a means for extending the application of SDT worldwide [
      • Moustaka F.C.
      • Vlachopoulos S.P.
      • Vazou S.
      • Kaperoni M.
      • Markland D.A.
      Initial validity evidence for the behavioral regulation in exercise questionnaire-2 among Greek exercise participants.
      ], and the validity and reliability of BREQ and BREQ-2 have been examined in different countries, which provided good psychometric measurements [
      • Markland D.A.
      • Tobin V.
      A modification to the behavioural regulation in exercise questionnaire to include an assessment of amotivation.
      ,
      • Moustaka F.C.
      • Vlachopoulos S.P.
      • Vazou S.
      • Kaperoni M.
      • Markland D.A.
      Initial validity evidence for the behavioral regulation in exercise questionnaire-2 among Greek exercise participants.
      ,
      • Liu J.D.
      • Chung P.K.
      • Zhang C.Q.
      • Si G.
      Chinese-translated behavioral regulation in exercise questionnaire-2: evidence from university students in the Mainland and Hong Kong of China.
      ,
      • Wilson P.M.
      • Rodgers W.M.
      • Fraser S.N.
      Examining the psychometric properties of the behavioral regulation in exercise questionnaire.
      ,
      • Farmanbar R.
      • Niknami S.
      • Hidarnia A.
      • Lubans D.R.
      Psychometric properties of the Iranian version of the behavioral regulation in exercise questionnaire-2 (BREQ-2).
      ]. For instance, the results of the confirmatory factor analysis (CFA) revealed the 5-factor structure of the BREQ-2 among the Portuguese people with schizophrenia, the Iranian university students, the Hongkong public university students in China [
      • Farmanbar R.
      • Niknami S.
      • Hidarnia A.
      • Lubans D.R.
      Psychometric properties of the Iranian version of the behavioral regulation in exercise questionnaire-2 (BREQ-2).
      ,
      • Chung P.K.
      • Liu J.D.
      Examination of the psychometric properties of the Chinese translated behavioral regulation in exercise questionnaire-2.
      ,
      • Costa R.
      • Probst M.
      • Bastos T.
      • Vilhena E.
      • Seabra A.
      • Corredeira R.
      Behavioural regulation in exercise questionnaire in people with schizophrenia: construct validity of the Portuguese versions.
      ]. Cronbach α (from .48 to .88) which is used for assessing internal consistency across five subscales were accepted [
      • Moustaka F.C.
      • Vlachopoulos S.P.
      • Vazou S.
      • Kaperoni M.
      • Markland D.A.
      Initial validity evidence for the behavioral regulation in exercise questionnaire-2 among Greek exercise participants.
      ,
      • Farmanbar R.
      • Niknami S.
      • Hidarnia A.
      • Lubans D.R.
      Psychometric properties of the Iranian version of the behavioral regulation in exercise questionnaire-2 (BREQ-2).
      ]. Discriminant validity analysis reveals the separability of the five factors of BREQ-2 responses [
      • Markland D.A.
      • Tobin V.
      A modification to the behavioural regulation in exercise questionnaire to include an assessment of amotivation.
      ,
      • Moustaka F.C.
      • Vlachopoulos S.P.
      • Vazou S.
      • Kaperoni M.
      • Markland D.A.
      Initial validity evidence for the behavioral regulation in exercise questionnaire-2 among Greek exercise participants.
      ]. According to the above data, BREQ-2 can be used to measure physical activity motivation.
      Although the psychometric properties of BREQ-2 have been examined in university students and adolescents in China [
      • Liu J.D.
      • Chung P.K.
      • Zhang C.Q.
      • Si G.
      Chinese-translated behavioral regulation in exercise questionnaire-2: evidence from university students in the Mainland and Hong Kong of China.
      ,
      • Chung P.K.
      • Liu J.D.
      Examination of the psychometric properties of the Chinese translated behavioral regulation in exercise questionnaire-2.
      ], application among nursing home residents has not been investigated. The purpose of this study was to access psychometric properties of the Chinese-translated BREQ-2 among nursing home residents in China.

      Methods

      Study design

      This cross-sectional survey was designed to validate the reliability and validity of BREQ-2 to determine the adequacy of the scale for conducting research in measuring physical activity motivation within SDT among nursing home residents in Shenyang.

      Setting and sample

      The study was conducted from February to March 2018 among 204 nursing home residents (123 women and 81 men) from 102 nursing homes in Shenyang of China. According to the recommendations from Costello and Osborne for determining sample sizes of confirmatory factor analysis, the item ratio of 20:1 sample has a higher accuracy (70%) compared with the 10:1 (60%) and the 5:1 (40%) [
      • Costello A.B.
      • Osborne J.W.
      Best practices in exploratory factor analysis: four recommendations for getting the most from your analysis.
      ], and because of the constraints of expenditure, the item ratio of 10:1 sample was used. Hence, 238 samples were needed based on 19 items and a dropout rate of 20.0%.
      All the participants met the following inclusion criteria: (1) aged ≥ 60 years; (2) residing in the nursing home for > 6 months; (3) acting independently; (4) no signs of cognitive impairment (the score of the Chinese adapted Mini Mental State Examination >20) [
      • Xu G.
      • Meyer J.S.
      • Huang Y.
      • Du F.
      • Chowdhury M.
      • Quach M.
      Adapting mini-mental state examination for dementia screening among illiterate or minimally educated elderly Chinese.
      ]; (5) able to communicate; and (6) no severe disease.

      Instruments

      BREQ-2 comprised (1) amotivation (4 items); (2) external regulation (4 items); (3) introjected regulation (3 items); (4) identified regulation (4 items); and (5) intrinsic regulation (4 items). All the 19 items were positive scored, and it was rated on a five-point for each item from 0 (not true for me) to 4 (very true for me) to identify what the participants felt about exercise [
      • Markland D.A.
      • Tobin V.
      A modification to the behavioural regulation in exercise questionnaire to include an assessment of amotivation.
      ]. The relative autonomy index (RAI) is a single score derived from the subscales that gives an index of the degree to which respondents feel self-determined. The index is obtained by applying a weighting to each subscale and then summing these weighted scores. In other words, each subscale score is multiplied by its weighting, and then these weighted scores are summed. It should be borne in mind that a RAI score only makes sense if the subscales do reflect a continuum of ordered variations in self-determination.
      To keep the experiential equivalence of items in BREQ-2 for the nursing home residents, some items need to be revised, such as item 17 ″I feel ashamed when I miss an exercise session". Most of the nursing homes in China do not understand the meaning of "exercise session"; hence, "exercise item" was used instead of "exercise session" in our study.
      A panel of six judges included one nurse specialized in geriatric nursing, two nurses specialized in dementia and cognition, one professor who had studied motivation and emotion, and one associate professor who worked in sport psychology reviewed BREQ-2 for content validity.

      Ethical considerations

      Informed consent was signed by all the participants. Ethical approval was attained from the Research Ethics Committee of the Peking Union Medical College (Approval no. [2016]02).

      Data collection

      Among the 250 participants who were eligible based on the study criteria, 223 agreed to an interview of whom 204 provided data of physical activity that were valid and included in the analysis. All the participants signed an informed consent.
      Data were collected by face-to-face interviews using the self-designed questionnaire for sociodemographic information containing age and gender, the adjusted BREQ-2, and carried out by our team. The members in this team were trained before collecting data, such as unified and standard instructions during the process of interviews, how to control the time of interviews, and check the questionnaire after finished. Twenty minutes was needed to complete these questionnaires.
      BREQ-2 was readministered 7 days later to evaluate the test–retest reliability with the same participants [
      • Wu M.L.
      Structural equation modeling: operation and Application of AMOS software.
      ]. The number of nursing home residents participated the test–retest interview was 30.

      Data analysis

      Content validity of instruments was examined by computing a content validity index (CVI) on the basis of six experts’ ratings of item relevance [
      • Polit D.F.
      • Beck C.T.
      • Owen S.V.
      Is the CVI an acceptable indicator of content validity? Appraisal and recommendations.
      ]. Each item of BREQ-2 was evaluated by expert panel for content equivalence by using a 4-point rating scale: 1 = not relevant, 2 = somewhat relevant, 3 = quite relevant, 4 = highly relevant. Then, the number of experts who giving a score of either 3 or 4 divided by the number of all the experts was calculated. According to the recommended, there could be one “not relevant” rating with six experts (I-CVI = .83) [
      • Polit D.F.
      • Beck C.T.
      • Owen S.V.
      Is the CVI an acceptable indicator of content validity? Appraisal and recommendations.
      ]. According to the criteria recommended in Polit and Beck [
      • Polit D.F.
      • Beck C.T.
      The content validity index: are you sure you know what's being reported? Critique and recommendations.
      ], a minimum I-CVI of .83 and S-CVI of .80 can be accepted.
      CFA method was used for express construct validity and analyzed in AMOS, version 23.0, software [
      ]. Maximum likelihood estimate was used for CFA coupled with bootstrapping approach. In line with the recommendations of Hoyle and Panter [
      • Hoyle R.H.
      • Panter A.T.
      Structural equation modeling: concepts, issues, and applications.
      ], the model assessment was evaluated using multiple goodness-of-fit indexes including the χ2 value, comparative fit index (CFI), standardized root mean square residual (SRMR), and root mean square error of approximation (RMSEA) accompanied by its 90% confidence interval. It is commonly accepted that thresholds of > .90 [
      • Hu L.
      • Bentler P.M.
      Structural equation modeling: concepts, issues, and applications.
      ] close to (or less than) .08 [
      • Bentler P.M.
      EQS structural equations program manual.
      ] and up to .08 [
      • Browne M.W.
      • Cudeck R.
      Testing structural equation models.
      ] for CFI, SRMR, and RMSEA, respectively, are indicative of acceptable model fit.
      Internal consistency reliabilities of BREQ-2 was analyzed by Cronbach α coefficient of > .70 was considered satisfactory [
      • Polit D.F.
      • Beck C.T.
      Nursing research: generating and assessing evidence for nursing practice.
      ]. Test–retest reliability of BREQ-2 was assessed by using intraclass correlation. The results with an intraclass correlation greater than .70 are acceptable [
      • Polit D.F.
      • Beck C.T.
      Nursing research: generating and assessing evidence for nursing practice.
      ]. Item analysis was assessed using critical ration, independent sample t test was used for comparing the score of high score group (27%) and low score group (27%), then delete the item which CR does not reach 3 [
      • Wu M.L.
      Statistical analysis for questionnaire: operation and Application of SPSS software.
      ]. Convergent validity was performed to analyze the average variance extracted of > .50 [
      • Wu M.L.
      Structural equation modeling: operation and Application of AMOS software.
      ].
      SPSS software of version 12.0 and AMOS 23.0 (IBM Corp., Armonk, NY, USA) were used for data inputting, cleaning, and analyzing. Sociodemographic information was expressed by descriptive statistics. p < .05 was considered as the cutoff level for statistical significance. Parameter estimation was used for the missing data treatment.

      Results

      Demographics

      The mean age of all the 204 participants was 79.61 ± 8.73 years (range 61–94 years), 74.57 ± 5.17 years for 91 men, and 82.63 ± 9.49 years in 113 women. About 61.3% were older than 80 years, 67.2% had normal weight, and 76.0% were single (Table 1).
      Table 1Characteristic for the Seniors (N = 204).
      CharacteristicsTotal (N = 204)

      n (%)
      Men (n = 91)

      n (%)
      Women (n = 113)

      n (%)
      Age (yrs)60∼696 (2.9)4 (4.4)2 (1.8)
      70∼7973 (35.8)36 (39.6)37 (32.7)
      ≥80125 (61.3)51 (56.0)74 (65.5)
      BMIUnderweight5 (2.4)2 (2.2)3 (2.6)
      Normal weight137 (67.2)65 (71.4)72 (63.8)
      Overweight48 (23.5)18 (19.8)30 (26.5)
      Obese14 (6.9)6 (6.6)8 (7.1)
      Educational levelElementary or lower125 (61.3)46 (50.5)79 (69.9)
      Junior high52 (25.5)29 (31.9)23 (20.4)
      Senior high23 (11.3)13 (14.3)10 (8.8)
      College or higher4 (1.9)3 (3.3)1 (0.9)
      Marital statusMarried49 (24.0)28 (30.8)21 (18.6)
      Single (unmarried, widowed, or divorced)155 (76.0)63 (69.2)92 (81.4)
      Note. BMI = body mass index; yrs = years.

      Content validity

      I-CVI of 19 items ranged from .83 to 1.00, and S-CVI of BREQ-2 was .97. According to the criteria recommended in Polit and Beck [
      • Polit D.F.
      • Beck C.T.
      The content validity index: are you sure you know what's being reported? Critique and recommendations.
      ], a minimum I-CVI of .83 and S-CVI of .80 can be accepted; hence, BREQ-2 can be judged as having excellent content validity.

      Item analysis

      Item analysis was assessed using critical ration, all the items of CR reached 3 and the 95% confidence interval with value were not including ± 1 (Table 2).
      Table 2Item-analysis for BREQ-2 (N = 204).
      ItemCR (95% CI)
      Amotivation
      5. I don't see why I should have to exercise19.40 (2.23-2.73)
      9. I can't see why I should bother exercising18.55 (2.32-2.87)
      12. I don't see the point in exercising17.66 (2.00-2.51)
      19. I think exercising is a waste of time18.15 (2.11-2.62)
      External regulation
      1. I exercise because other people say I should25.10 (2.27-2.66)
      6. I take part in exercise because my friends/family say I should35.16 (2.33-2.61)
      11. I exercise because others will not be pleased with me if I don't26.10 (1.79-2.08)
      16. I feel under pressure from my friends/family to exercise26.76 (1.96-2.27)
      Introjected regulation
      2. I feel guilty when I don't exercise11.92 (1.06-1.48)
      7. I feel ashamed when I miss an exercise session11.62 (1.13-1.60)
      13. I feel like a failure when I haven't exercised in a while10.34 (1.01-1.49)
      Identified regulation
      3. I value the benefits of exercise23.49 (1.87-2.21)
      8. It's important to me to exercise regularly26.78 (2.44-2.82)
      14. I think it is important to make the effort to exercise regularly19.98 (2.04-2.48)
      17. I get restless if I don't exercise regularly15.76 (1.24-1.60)
      Intrinsic regulation
      4. I exercise because it's fun24.10 (2.45-2.88)
      10. I enjoy my exercise sessions28.51 (2.62-3.01)
      15. I find exercise a pleasurable activity14.03 (1.81-2.41)
      18. I get pleasure and satisfaction from participating in exercise28.85 (2.64-3.03)
      Note. CI = confidence interval; CR = critical ratio.
      All critical ratios are statistically significant (p < .05).

      Validity

      The translated BREQ-2 model was a good fit for the CFA results as χ2 = 276.75, df = 142, CFI = .94, SRMR = .05, and RMSEA = .07. Factor loading of the 19 items ranging from .63 to .90 indicated that all factors were statistically significant (p ≤ .05) (Table 3). Convergent validity was performed to analyze the average variance extracted value of > .50, and was good for the five subscales ranged from .59 to .72 (Table 3).
      Table 3CFA item means, standard deviation, factor loadings, and average variance extracted (N = 204).
      ItemMSDFLAVE
      Amotivation
      5. I don't see why I should have to exercise0.900.95.76.62
      9. I can't see why I should bother exercising0.891.02.77
      12. I don't see the point in exercising0.850.98.77
      19. I think exercising is a waste of time0.710.95.85
      External regulation
      1. I exercise because other people say I should1.641.22.84.67
      6. I take part in exercise because my friends/family say I should1.611.10.88
      11. I exercise because others will not be pleased with me if I don't1.601.18.81
      16. I feel under pressure from my friends/family to exercise1.691.13.78
      Introjected regulation
      2. I feel guilty when I don't exercise2.231.05.78.63
      7. I feel ashamed when I miss an exercise session2.171.04.72
      13. I feel like a failure when I haven't exercised in a while2.271.02.87
      Identified regulation
      3. I value the benefits of exercise3.140.76.83.59
      8. It's important to me to exercise regularly3.110.85.81
      14. I think it is important to make the effort to exercise regularly3.030.92.78
      17. I get restless if I don't exercise regularly2.930.91.63
      Intrinsic regulation
      4. I exercise because it's fun2.911.03.73.72
      10. I enjoy my exercise sessions3.050.99.90
      15. I find exercise a pleasurable activity2.971.08.84
      18. I get pleasure and satisfaction from participating in exercise3.000.95.90
      Note. AVE = average variance extracted; CFA = confirmatory factor analysis; FL = factor loading; M = mean; SD = standard deviation.
      All factor loadings are statistically significant (p < .05).

      Reliability

      Internal consistency reliability was estimated using Cronbach α coefficient. Results in the BREQ-2 indicated good consistency, and the Cronbach α coefficient of BREQ-2 was .78, and each of the five subscales ranged from .78 to .83. The test–rest reliability was assessed to measure the intraclass correlation (Table 4) and was good for the scale value .84, and the five subscales ranged from .75 to .89.
      Table 4Intraclass correlation for BREQ-2 (N = 204).
      ItemICC (95% CI)
      Amotivation.87 (.74- .93)
      External regulation.78 (.59- .89)
      Introjected regulation.89 (.79- .95)
      Identified regulation.77 (.58- .89)
      Intrinsic regulation.75 (.54- .87)
      Note. CI = confidence interval; ICC = intraclass correlation.

      Discussion

      BREQ-2 was designed to measure self-determined motivation in the domain of sport, exercise, and physical activity, and it can help to explore the reasons why people engage or not in physical activity. Hence, a valid instrument is needed for nursing home residents in China. The purpose of this study was to access psychometric properties of the Chinese-translated BREQ-2 among nursing home residents in China.
      The five-factor model was confirmed by CFA, and coefficients in this factor analysis were similar to the study results of Markland et al. [
      • Markland D.A.
      • Tobin V.
      A modification to the behavioural regulation in exercise questionnaire to include an assessment of amotivation.
      ]. A self-determination continuum also existed in the Chinese context. However, the results differed from a previous study in Hong Kong [
      • Liu J.D.
      • Chung P.K.
      • Zhang C.Q.
      • Si G.
      Chinese-translated behavioral regulation in exercise questionnaire-2: evidence from university students in the Mainland and Hong Kong of China.
      ], which removed item 17 because of cross-loading on an unintended factor. It is considered that identified regulation items reflect the importance of physical activity, whereas amotivation items are related to a lack of such importance; hence, it might be a little ambiguous to understand the importance or value of physical activity for respondents [
      • Liu J.D.
      • Chung P.K.
      • Zhang C.Q.
      • Si G.
      Chinese-translated behavioral regulation in exercise questionnaire-2: evidence from university students in the Mainland and Hong Kong of China.
      ]. Furthermore, item 17 is a double-negative sentence. Compared with the populations in the previous research, the present study comprised the elderly living in the nursing home, and face-to-face interview was used to fill in the BERQ-2 to reduce missing data, and also it can help the elderly have a better understanding about the items. For instance, our research member stated the item 17 with the positive sentence to the elderly. Furthermore, the physical activity of elderly is motivated by the medical advices or the knowledge that they could get the benefits from exercise other than the interests. Amotivation means no intention to engage in any physical activity, and identification regulation means an action is motivated by its value or importance, and it is not difficult to distinguish the identification and amotivation regulation. Discriminant validity was also examined by CFA method and was supported in the current study, and it was similar to the study results of Chung [
      • Chung P.K.
      • Liu J.D.
      Examination of the psychometric properties of the Chinese translated behavioral regulation in exercise questionnaire-2.
      ].
      Internal consistency reliabilities of BREQ-2 was assessed by using the Cronbach α coefficient. BREQ-2 and each of the five subscales in the present study indicated good internal consistency (Cronbach α coefficient was from .78 to .83) and were similar to the study results of Murcia et al [
      • Murcia J.A.
      • Gimeno E.C.
      • Camacho A.M.
      Measuring self-determination motivation in a physical fitness setting: validation of the Behavioral Regulation in Exercise Questionnaire-2 (BREQ-2) in a Spanish sample.
      ].
      The present study has provided empirical support for the first applicability of the Chinese version BREQ-2 using in the nursing home residents. Compared with the seniors living in the community, nursing home residents have poor physical and mental health and higher readmission rates [
      • Xie G.X.
      • Fu L.P.
      Correlation analysis on the depression between the nursing home residents and homebound elderly.
      ,
      • Bogaisky M.
      • Dezieck L.
      Early hospital readmission of nursing home residents and community-dwelling elderly adults discharged from the geriatrics service of an urban teaching hospital: patterns and risk factors.
      ]. They cannot lead self-determined, active, and stimulating lives [
      • Bogaisky M.
      • Dezieck L.
      Early hospital readmission of nursing home residents and community-dwelling elderly adults discharged from the geriatrics service of an urban teaching hospital: patterns and risk factors.
      ] and have a lower level of physical activity [
      • Bates-Jensen B.M.
      • Alessi C.A.
      • Cadogan M.
      • Levy-Storms L.
      • Jorge J.
      • Yoshii J.
      • et al.
      The minimum data set bedfast quality indicator: differences among nursing homes.
      ]. BREQ-2 can provide greater insight into the mechanisms which impacted the physical activity among the nursing home residents and understand the reasons why the seniors decide to engage or not in physical activity and also provide evidences for the motivational intervention in the future research.
      Owing to the constraints of expenditure, 10:1 sample to item ratio was used at this study. According to the recommendations of confirmatory factor analysis, sample size should be enlarged in the future research.

      Conclusion

      The findings of this study provided psychometric evidence for the application of BREQ-2 among nursing home residents in China. Assessing the motivation of physical activity is important for research. It can help researchers to identify the motivational process, namely, which forms of regulation such as amotivation, external, introjection, identification, integration, and intrinsic the seniors be. Then, researchers can make the interventions according to the type of motivation.
      Further study is to facilitate more research on SDT with physical activity in the Chinese context, especially some investigations of the antecedents and consequences of motivation in physical activity domain.

      Conflicts of interest

      The authors have no conflicts of interest in relation to this study.

      Acknowledgments

      The authors thank the Civil Affairs Bureau and the Nursing Home Association of Shenyang City for their assistance in supporting this research by providing information on all of the nursing homes that participated in this study. They also thank the School of Nursing, Peking Union Medical College for their assistance in acquiring the gifts for the elderly. Our appreciation also goes to the School of Nursing, Shenyang Medical College, for their assistance in print questionnaires and collecting the data. This manuscript is original, has not been published before, and is not currently being considered for publication elsewhere. This manuscript also has no conflicts of interest associated with this publication, and there has been no significant financial support for this work that could have influenced its outcome.

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