Body Weight,Weight Self-Perception,Weight Teasing and Their Association with Health Behaviors among Chinese Adolescents—The Shanghai Youth Health Behavior Survey

Weight-related status has been associated with the physical and psychological health of adolescents. This cross-sectional study evaluated three different kinds of weight-related statuses (Body Mass Index (BMI), weight self-perception and weight teasing from others) among Chinese adolescents and identified their associations with health risk behaviors (lack of healthy dietary behavior, unhealthy dietary behavior, binge eating behavior, lack of physical activity (PA), sedentary behaviors (SB) and sleep disturbance). A stratified random cluster sampling method was used to select 10,070 students aged 11–18 years old from schools in Shanghai. Self-reported questionnaires were collected, weight-related statuses were divided into three categories and six specific health risk behaviors were classified into two groups: positive or negative. Overall, 27.82% of the adolescents were classified as being overweight and obese (35.61% of boys and 18.21% of girls), 43.45% perceived themselves as too heavy and 30.46% experienced weight teasing in the past. Among overweight or obese participants, 50.55% have been teased about their weight, and 77.48% perceived themselves as too heavy. Weight perception and weight teasing were significantly associated with health risk behaviors rather than the actual body weight status based on BMI, especially regarding binge eating behavior (body weight status (BMI): p > 0.05, underweight perception: OR = 1.18, 95%CI 1.03–1.34; weight teasing for more than once a year: OR = 2.00, 95%CI 1.76–2.27). In addition, weight perception and weight teasing were significantly associated with health risk behaviors, mainly in normal and overweight/obese groups but not in underweight groups. Weight teasing and weight self-perception play an independent and stronger role than actual body weight in the health behaviors of adolescents. This calls for more attention and intervention to reduce peer bullying and stigmas on weight among adolescents.     

Perception of overweight and obesity among Portuguese adolescents: an overview of associated factors

PURPOSE: A national, representative school-based sample of Portuguese youth was used to both identify psychosocial indicators that distinguish obese and overweight adolescents from their peers, and key explainers of body image among obese and overweight adolescents. METHODS: Data on 5697 sixth, eighth and tenth grade public school students, age 11-16 years, from Portugal who participated in the 1998 (HBSC/WHO) survey of adolescent health were analysed. Body mass index (BMI) was calculated based on self-reported weight and height. Body image was measured using a body image tool with a sequence of seven body silhouettes progressing from very thin to overweight. BMI was calculated by reported weight/height (kg/m2), and was categorized based on Cole normalization curve. Adolescents whose BMI was above the 95th percentile (obese) and those with a BMI between 85 and 95 (overweight) were compared with the remainder. Separate analyses of psychosocial variables were conducted by gender, using the chi2-test, t-tests, ANOVA and multiple linear regression. RESULTS: There was a significant difference in physical activity between obese and non-obese youth (P<0.05). Girls reported dieting more than boys (P<0.001), with 15.3% of overweight teens dieting versus 6% of non-overweight teens. Those classified as overweight were significantly more likely to describe themselves as not healthy (P<0.001). A significantly greater proportion of obese/overweight versus non-overweight youth reported difficulty in making friends (P<0.001). BMI (beta=0.491; P=0.000), age (beta=-0.413; P=0.000), involvement in dieting (beta=0.110; P=0.000) and attitude toward appearance (beta=0.032; P=0.007) were significantly associated with body image. CONCLUSIONS: Inaccurate perceptions of the need to diet, poorer self-perceived health status and potential social isolation of those who are overweight were found. The importance of these findings to health promotion strategies is discussed.     

Perceived health risk of excess body weight among overweight and obese men and women: differences by sex

OBJECTIVES: To describe perceptions of health risk from excess body weight among adults, and assess if lack of perceived risk was associated with trying to lose weight. METHODS: Sex-specific logistic regression models were used to determine odds of disagreement that one's weight is a health risk and odds of trying to lose weight among overweight (BMI=25.0-29.9 kg/m(2), n=1296) and obese (BMI> or =30 kg/m(2), n=1335) adult participants in the 2004 Styles' surveys. RESULTS: Men were more likely than women to disagree their body weight was a health risk (among the overweight, 62% vs. 43%; the obese 20% vs. 14% obese). Disagreement with risk was associated with good health status and race/ethnicity among both sexes and lower education and income among women. Odds of currently trying to lose weight were significantly lower among obese men who disagreed, and overweight men and women who were neutral or disagreed that their body weight was a health risk. CONCLUSIONS: Many overweight and obese adults do not perceive their weight to be a health risk; this perception was associated with lower prevalence of trying to lose weight, particularly among men. Discussion by clinicians about the health risks of excess weight may alter perceived risk and help promote weight loss efforts.     

The family environment and American adolescents' risk of obesity as young adults

In this article, the effects of the family environment and adolescents' behaviors while in school grades 7 through 12 on their weight status 6 years later are examined using data from the United States National Longitudinal Study of Adolescent Health. Ordinal regression models of 6378 adolescents reveal that their family environments exert an influence on their weight that lasts into young adulthood. Parental obesity puts both males and females at greater risk for being overweight or obese as young adults, as does already having excessive weight in adolescence. The findings also reveal significant gender differences in the intergenerational transmission of body weight within families. Higher parental educational attainment, a stronger perception that parents care about them, and a higher self-esteem reduce female adolescents' risk for excessive weight as young adults, while being African American or Native American increases it. In contrast, only a perception that their parents are trying to control their diets and a higher degree of closeness with a parent put male adolescents at greater risk for excessive weight as young adults. Adolescents' participation in physical activities does not predict subsequent weight for either males or females, although the amount of time spent in sedentary activities does for females, but not males. The only adolescent behavior examined that influenced male weight in young adulthood was eating breakfast.     

Primary care of overweight children: the importance of parent weight and attitudes about overweight: a MetroNet study.

PURPOSE: The purpose of this study was to identify the association of parents' weight and attitude about their child's weight with the child's body mass index (BMI) status. DESIGN: Cross-sectional, clinic-based study in a practice-based research network. METHODS: One hundred seventy-one parents or adults accompanying children aged 5 to 17 years to a primary care visit in 4 family medicine centers completed a questionnaire. Parent/adult overweight status and attitudes were compared with child overweight status. RESULTS: Forty-eight percent of children were overweight or obese (BMI >or= the 85th percentile) as were 56% of mothers and 77% of fathers (BMI >or= 25 kg/m(2)). Child and parent overweight were significantly associated, as were mother overweight and beliefs about child overweight status. Children aged 5 to 13 years were more likely to be overweight than those aged >or=14 years. CONCLUSIONS: Parents of overweight children are often overweight and many do not recognize that their children are overweight. Suggestions are made for primary care physicians to engage parents of overweight children in family weight control efforts.     

Childhood Overweight/Obesity and Pediatric Asthma: The Role of Parental Perception of Child Weight Status

Childhood obesity and asthma are on the rise in the U.S. Clinical and epidemiological data suggest a link between the two, in which overweight and obese children are at higher risk for asthma. Prevention of childhood obesity is preferred over treatment, however, in order to be receptive to messages, parents must perceive that their child is overweight. Many parents do not accurately assess their child’s weight status. Herein, the relation between parental perceptions of child weight status, observed body mass index (BMI) percentiles, and a measure of child feeding practices were explored in the context of asthma, food allergy, or both. Out of the children with asthma or food allergy that were classified as overweight/obese by BMI percentiles, 93% were not perceived as overweight/obese by the parent. Mean scores for concern about child weight were higher in children with both asthma and food allergy than either condition alone, yet there were no significant differences among the groups in terms of pressure to eat and restrictive feeding practices. In summary, parents of children with asthma or food allergy were less likely to recognize their child’s overweight/obese status and their feeding practices did not differ from those without asthma and food allergy.     

Mothers' perceptions of their adolescents' weight status: are they accurate?

OBJECTIVE: To evaluate the accuracy of mothers' perceptions of adolescents' weight status. RESEARCH METHODS AND PROCEDURES: Parent interviews and adolescent surveys (755) were conducted in an ethnically diverse sample from Project EAT (Eating among Teens). RESULTS: Adolescent weight status was accurately assessed by 60% of mothers, underestimated by 35% of mothers, and overestimated by 5% of mothers. In multivariate analyses, mothers of female adolescents were about half as likely to underestimate their adolescent's weight status as mothers of male adolescents. Nonoverweight mothers were about half as likely as overweight mothers to underestimate their adolescent's weight status. DISCUSSION: Most mothers are able to accurately assess their adolescent's weight status; however, adolescent gender and mothers' weight status are related to accuracy. Mothers were more likely to underestimate their sons' weights than their daughters' weights, and overweight mothers were more likely to be inaccurate in their assessments than nonoverweight mothers. Findings suggest that the majority of parents do not need to be told that their children are overweight; instead, messages to parents of overweight teens should focus on how to provide support for healthy weight management.     

Weight status and body image perception in Italian children.

BACKGROUND: Previous research suggests there is a tendency in overweight subjects to underestimate their weight status. This study investigated the perception of body image in Italian children, with particular regard to overweight children. METHODS: Primary school children (n = 866) were recruited for this cross-sectional nutritional survey in northern Italy. Anthropometric measurements were performed to determine body mass index (BMI). Body image perception was assessed with the Body Silhouette Chart for preadolescent children shown to the children and to their mothers (n = 778) during an interview. A new scheme to identify wrong (F.1, F.2) or inappropriate (F.3) self figure responses in overweight subjects was used. RESULTS: More than one-third of the Italian children examined were above the normal BMI range (prevalence of overweight: 35.8%, girls; 37.2%, boys). A higher degree of dissatisfaction was expressed by girls than by boys, and the percentage increased in overweight/obese children. A discrepancy between the self figure perception and the real nutritional status of the subject occurred in 6-9% of the overweight/obese children. CONCLUSION: The comparison of body image perception and anthropometric assessment of nutritional status could play an important role in future programs of nutritional surveillance as they provide indications of dissatisfaction and body image disturbances.     

Comparisons of attitudes and practices between obese and normal weight women in Taiwan

This study was designed to obtain baseline data regarding self-reported body image, attitudes toward overweight people, and dietary behaviors of normal-weight and obese women in Taiwan. Fifty obese women (BMI >= 27) and age-matched normal-weight women participated in this study. Written questionnaires were used for data collection. Simple frequency and t-test were used to analyze data. In general, the majority of normal-weight women perceived themselves as being heavier than their actual body weight. The normal-weight group had more high inaccurate images of their bodies than that of the obese group (72% vs. 24%). Obese and normal-weight women had similar attitudes to overweight people, but some of their attitudes showed significant differences. Obese women would prefer to consume more fried foods and drink sugar-containing foods than would normal-weight women (p < 0.05). Education about accurate perceptions of what is normal weight for women and adopting energy-diluted foods for obese women is needed in the future.     

Discrepancies in body image perception among fourth-grade public school children from urban, suburban, and rural Maryland

OBJECTIVE: The objective of this study was to determine whether there is an association between body image perception and weight status as measured by the body mass index among a group of fourth graders in Maryland. DESIGN: Cross-sectional data on height, weight, and body image were collected in the classroom. At risk for being overweight and being overweight designations were assigned to participants with body mass index (BMI) percentile values for age and sex of >/=85 to <95 and BMI >/=95, respectively. Students selected a figure (range 1 to 7) to represent their current and ideal images. SUBJECTS: The subjects of this study were 524 fourth-grade public school students (54% girls; 61% white; mean age, 9.2 years) from three geographically distinct regions in Maryland (38.6% urban, 30.7% suburban, 30.7% rural).Statistical analyses chi(2) tests were used to compare weight status with sex, race, geographic location, and body image discrepancy categories. One-way analysis of variance was used to compare BMI and body image scores with sex and race/ethnicity to geographic location. RESULTS: Thirteen percent of students were overweight, and 15% were at risk of overweight. There was no association between weight status and race, body image perception, or geographic location. African Americans chose larger figures than whites and other races to represent their current and ideal images and were most satisfied with their body size. CONCLUSIONS: Perceptions of body image are formed early in life. Dietitians can provide guidance on appropriate weight and body size to children, parents, and school professionals. Dietitians can also use their influence to secure funding for nutrition education programs.     

Perception of Weight and Health Status among Women Working at Health Centres of Tehran

Perception of body-weight status is an important determinant of weight-related behaviours and may affect the burden of weight disturbances as a public-health problem. No study has assessed self-perception of the weight status regarding body-fat distribution among health workers to date. The aim of this study was to evaluate the association of the perception of weight and health status among 542 women working at health centres of Tehran. We assessed their perceived body-weight and health status and measured waist- and hip-circumference, weight, and height to calculate waist-to-hip ratio (WHR) as a measure of fat distribution and body mass index (BMI, kg/m²). Women reported their sociodemographic information, and the perceived weight and health status were compared with their actual fatness status, defined based on WHR and BMI, to determine misperception of weight status. Multivariate logistic regression models were performed to assess the predictive effects of various sociodemographic factors and actual fatness on the perception of weight and health status. The results showed that more than 40% of women with normal BMI overestimated their body-weight status while only 15.8% of these women had central obesity. BMI was the most important variable associated with misperceived weight status as normal-weight women had significantly more misperception (OR 8.16, 95% CI 4.82-13.82) than overweight/obese women. WHR did not show any significant relationships with perceived weight status. In addition, perception of health status was not associated with actual fatness indices. It is concluded, BMI was the main predictor of the perception of weight status in female employees. The importance of using body-fat distribution in the perceptions of weight and health status should be emphasized.Key words: Body mass index, Health centres, Perception of health status, Perception of weight status, Waist-to-hip ratio, Iran     

Intergenerational perceptions of body image in hispanics: role of BMI, gender, and acculturation

OBJECTIVE: To assess role of BMI, gender, and acculturation on maternal and children's perception of body size, body ideal, and attractiveness. RESEARCH METHODS AND PROCEDURES: Eighty mothers and their 6- to- 12-year-old children (41 boys, 39 girls) participated. Maternal and children's perceptions of body size (actual and ideal) and attractiveness were assessed through a pictorial instrument. Mother and child height and weight, demographic, and acculturation characteristics were also assessed. RESULTS: Seventy-nine percent of the mothers were overweight, and 32% of the boys and 34% of the girls were overweight or at-risk for overweight. BMI influenced the children's selection of perceived ideal size. Overweight or at-risk for overweight children were more likely to select thinner figures as the ideal size than non-overweight children. Gender and acculturation differences concerning children's perceptions of body size and attractiveness were also found. Girls perceived the obese figure as being less attractive than did the boys. More acculturated children were likely to select thinner figures as more attractive than their less acculturated counterparts. Maternal acculturation was associated positively with the girls' choice of thinner figures as an ideal body size, but not with the boys. Mothers viewed their daughters' actual body size and BMI as ideal, although 34% of the girls were at-risk for overweight. Mothers perceived average body size figures as more attractive for their sons. DISCUSSION: Findings from this study provide empirical data about the role of BMI, gender, acculturation, and familial influences on children's perceptions of actual and ideal body sizes and attractiveness.     

Assessing weight perception accuracy to promote weight loss among U.S. female adolescents: A secondary analysis

Background  

Overweight and obesity have become a global epidemic. The prevalence of overweight and obesity among U.S. adolescents has almost tripled in the last 30 years. Results from recent systematic reviews demonstrate that no single, particular intervention or strategy successfully assists overweight or obese adolescents in losing weight. An understanding of factors that influence healthy weight-loss behaviors among overweight and obese female adolescents promotes effective, multi-component weight-loss interventions. There is limited evidence demonstrating associations between demographic variables, body-mass index, and weight perception among female adolescents trying to lose weight. There is also a lack of previous studies examining the association of the accuracy of female adolescents' weight perception with their efforts to lose weight. This study, therefore, examined the associations of body-mass index, weight perception, and weight-perception accuracy with trying to lose weight and engaging in exercise as a weight-loss method among a representative sample of U.S. female adolescents.     

Adolescents' perceptions of maternal disapproval of sex: relationship to sexual outcomes.

PURPOSE: To examine the relationship between adolescents' perceptions of maternal abstinence attitudes, adolescent-maternal relationship satisfaction, and the occurrence in the ensuing 12 months of: (a) sexual intercourse, (b) the use of birth control at intercourse, and (c) the occurrence of pregnancy. We also examined the accuracy of adolescents in perceiving the attitudes of their mothers as well as factors that predicted underestimations of these attitudes. Finally, the study evaluated the relative predictive power of adolescent perceptions of maternal abstinence attitudes and the actual maternal abstinence attitudes. METHODS: This was a prospective study using a subsample of the Longitudinal Study of Adolescent Health database, which is a nationally representative school-based sample. The sample for the present study was approximately 10,000 adolescents in grades 7 to 11 who completed 2 interviews in their homes at a 1-year interval. Mothers of the adolescents were interviewed only during Wave 1. Interviews covered a variety of topics, including adolescent risk behaviors and family relationships. Measures at Wave 1 were used to predict outcomes at Wave 2, employing logistic and multiple regression techniques. RESULTS: Adolescents' perceptions of maternal attitudes toward the adolescents' engaging in sexual intercourse, and adolescent satisfaction with the maternal relationship were predictive of the occurrence of sexual intercourse between Wave 1 and Wave 2, as well as the occurrence of pregnancy. The more disapproving adolescents perceived their mothers to be toward their engaging in sexual intercourse and the more satisfied adolescents were with their relationship with their mothers, the less likely adolescents were to initiate sexual activity or to become pregnant. Only relationship satisfaction was predictive of the use of birth control, such that more satisfied adolescents were more likely to use birth control at their most recent intercourse. The correlation between adolescent perceptions of maternal abstinence attitudes and actual maternal attitudes was .26. Adolescent perceptions of maternal attitudes tended to be a more consistent predictor of outcomes than actual maternal attitudes. CONCLUSIONS: The results are consistent with a growing body of literature that suggests the importance of adolescents' perceptions of maternal attitudes in determining sexual risk behaviors. Adolescents may misperceive the attitudes of parents, suggesting the need for communication between parent and teen.     

Self-rated health and life satisfaction among Canadian adults: associations of perceived weight status versus BMI

Purpose

Obesity is associated with impaired health-related quality of life (HRQL). As perceived constructs, self-rated health (SRH) and general life satisfaction (LS) might be more strongly related to perceived weight status than actual weight status. The aim was to assess agreement between perceived weight status and self-reported body mass index (BMI), and to investigate their associations with SRH and LS as indicators of HRQL.

Methods

Cross-sectional data included 87,545 adults aged 18–65 years from the 2005 Canadian Community Health Survey. Agreement between perceived weight status and self-reported BMI was assessed. Prevalence of suboptimal SRH and LS was estimated by perceived weight status and BMI, and adjusted logistic regression used to assess the odds of suboptimal outcomes.

Results

Overall agreement between perceived weight status and self-reported BMI was only moderate (females: κ = 0.58; males: κ = 0.42). The lowest prevalences of suboptimal SRH and LS were in those who reported both a healthy weight BMI and “about right” weight perception. Discordance between perceived weight status and BMI status, and congruence (i.e. perceived weight status = BMI) around underweight or overweight/obese were associated with poorer SRH and LS. For weight perceptions of “about right”, BMI status had minimal influence on suboptimal SRH or LS, while perceptions of underweight or overweight were associated with higher odds of suboptimal SRH and LS, independent of BMI.

Conclusions

Adults’ weight status perceptions often do not agree with their actual weight status, even when self-reported. While both perceived and actual weight status influence self-rated health and life satisfaction, perceptions are more strongly associated with these HRQL indicators and should be considered when informing obesity-targeted policies and programmes.     

Childhood obesity among Puerto Rican children: discrepancies between child's and parent's perception of weight status

Public concern about childhood obesity and associated health problems calls for the identification of modifiable factors that could halt this epidemic. Parental perceptions of their children's weight status could be associated to how parents influence children's eating patterns. We aimed to identify the perceptions Puerto Rican parents have of their children's weight and children's own perceptions of weight status as compared to real weight. A cross sectional survey was performed in a representative sample of 1st-6th grade students. Only half of the children correctly identified their weight, and only 62.4% of the parents correctly classified their children's weight. Most obese/overweight children did not perceive themselves as such. Almost half of obese/overweight children were identified by the parents as normal weight while over half of the underweight children were perceived by their parents at normal weight. More girls than boys perceived themselves as obese/overweight and more parents of girls than of boys perceived them as such. Higher-educated parents were better at recognizing overweight/obesity among their children compared to less-educated parents. This study suggests an influence of parents' SES characteristics on their perceptions of children's weight status as well as on children's own perceptions of their weight status.     

Body image of adolescents in a multi-ethnic Caribbean population

OBJECTIVE: To examine the perceptions of body size among adolescents in Trinidad and to determine whether there were ethnic differences. DESIGN: Cross-sectional survey. SETTING: Secondary schools in Trinidad. SUBJECTS: A stratified random sample of 1139 adolescents, aged 14-17 y. MEASUREMENTS: Silhouettes of different body sizes were used to determine perceptions of body size, while weights and heights were measured to determine actual body size. RESULTS: A total of 1090 students (96% response rate) participated, comprising 578 (53%) females. The main ethnic groups were South Asian (49%), African (25%) and persons of mixed ethnicity (23%). The calculated body mass index (BMI) indicated that 14% were thin, 73% normal and 13% overweight; however there was a preponderance of thinness among South Asian males (28%). Whereas 68% of students correctly identified their body size, South Asian males were also more likely to overestimate their body size than the other adolescents, ie they were thinner than they thought. Overall, 64% of the sample was satisfied with their current size, but thin South Asians were more likely to be satisfied with their size than other thin adolescents (P=0.04), while overweight Africans were more likely to be satisfied than other overweight persons (P=0.03). The majority of the sample associated the normal body size with good health, but the majority also associated the overweight and obese silhouettes with wealth. In addition, 40% of them associated the male overweight and obese silhouettes with happiness. CONCLUSION: Although the prevalence of overweight/obesity was not high, the perception of the Trinidadian adolescent that obesity was associated with wealth, and to a lesser extent happiness, and the satisfaction of the overweight African females with their size, were all causes for concern.     

Overweight status,self-perception,and suicidal behaviors among adolescents

Suicide is the third leading cause of death among adolescents in the USA. The suicide rate for individuals 15–19 years of age, while having declined since the early 1990s, has recently shown signs of an increasing trend. The prevalence of being overweight has also steadily risen among adolescents, and has tripled since 1960. This study utilizes data from the Youth Risk Behavioral Surveillance System (1999–2007) to explore the relationship between the perception of being overweight and suicidal behaviors. Studies have shown a high degree of correlation between overweight status, depressive disorders, and suicidal behaviors. This study analyzes these indicators in conjunction with individuals' perception of their weight. The empirical methodology is based on simultaneous-equations models and stratified samples to gauge whether the link between overweight indicators and suicide is causal or whether it is driven by other factors. Results indicate that body dissatisfaction, as measured by the perception of being overweight, has a strong impact on all suicidal behaviors for girls. It raises the risk of suicide ideation by 6.1 percentage points, suicide attempt by 3.6 percentage points, and a serious suicide attempt by 0.5 percentage points. Results are generally insignificant for males. Conditional on overweight perception, actual weight does not generally have an independent effect on suicidal behaviors. Policies aimed at reducing the prevalence of overweight among adolescents may further reduce suicidal behaviors by limiting overweight perception, especially among girls. However, the independent role of perception also highlights the importance of educating youths and fostering healthy attitudes regarding body image.     

"Childhood overweight and obesity: maternal perceptions of the time for engaging in child weight management"

ABSTRACT: BACKGROUND: There is an increasing awareness of the impact of parental risk perception on the weight course of the child and the parent's readiness to engage in preventive efforts, but only less is known about factors related to the parental perception of the right time for the implementation of preventive activities. The aim of this study was to examine parental perceptions of the appropriate time to engage in child weight management strategies, and the factors associated with different weight points at which mothers recognize the need for preventive actions. METHODS: 352 mothers with children aged 2-10 years took part in the study. We assessed mothers' perceptions of the actual and preferred weight status of their child, their ability to identify overweight and knowledge of its associated health risks, as well as perceptions of the right time for action to prevent overweight in their child. A regression analysis was conducted to examine whether demographic and weight related factors as well as the maternal general risk perception were associated with recognizing the need to implement prevention strategies. RESULTS: Although most of the parents considered a BMI in the 75th to 90th percentile a valid reason to engage in the prevention of overweight, 19% of the mothers were not willing to engage in prevention until their child reached the 97th percentile. Whereas the child's sex and the identification of an elevated BMI were significant predictors for parents' recognition of the 75th percentile as right point to engage in prevention efforts, an inability to recognize physical health risks associated with overweight silhouettes emerged as a significant factor predicting which parents would delay prevention efforts until a child's BMI reached the 97th percentile. CONCLUSION: Parental misperceptions of overweight and associated health risks constitute unfavorable conditions for preventive actions. Feedback on the health risks associated with overweight could help increase maternal readiness for change.