Identifying Indicators of the Construct for Motivation for Weight Loss: Designing a Questionnaire

*This study is based on the first author’s PhD thesis entitled “Development and Validation of Instrument to Assess Motivation for Weight Loss” and was written under the supervision of the other author. Abstract The prevalence of overweight and obesity is rising rapidly throughout both the developed and the developing world, and it is creating social, economic and health burden on society particularly in urban areas (Popkin, 2006 in Tesfalem, 2013). As a part of designing a questionnaire, the current research aims to identify the indicators of the latent construct motivation for weight loss. To achieve this, the paper raised the following two specific research questions: What are the indicators of the motivation for participation for weight loss program? And where do the indicators fit in the factors of social determination theory (SDT)? To gain a rich understanding of the motivation for the participation in weight loss program, semi-structured focus group discussions (FGD) were conducted with purposely recruited samples of two groups: overweight people and their interventionists. Based on the themes identified from the FGD the indicators were identified. Besides, from the consultations gained from the review of related literature the indicators were placed in SDT.

of lifestyle modification. According to Ogunbode et al (2011), regular exercise reduces the risk of coronary heart disease, diabetes mellitus, obesity, colon cancer and osteoporosis. It also helps to minimize anxiety and intensity of depression. Preventing obesity may reduce both the prevalence and severity of several of these illnesses, and reduce medical at individual and national level. Many findings have been reported from researches that have examined exercise alone, dietary restriction alone, or combination of the two to determine mechanisms for weight loss (Cox, 2017).
It is widely accepted that the combination of a healthy diet and regular exercise has been shown to improve weight loss (Silve et al., 2011in Tennant, 2014. Acknowledging the contribution of healthy diet and regular exercise for weight loss, Resnicow et al., (2008), in Ceccarini (2015, contend that the mere knowledge of dietary prescriptions and of physical activity programs is not enough to lose bodyweight. Ceccarini mentioned Castelmeoro et al., (2010) who reported that the weight losers went back to their original weight in three to five years of their last recorded weight loss. These researchers have called physiological mechanism such as the role of motivation into the attention of researchers to maintain weight loss effort. NHLRI (2015), in Andres, Saldana and Beeken, (2015), took a supporting position that weight loss management is better approached with the gold standard which is a combination of behavioral treatment with diet and physical activity. The current research of identifying the indicators for a questionnaire to assess motivation for weight loss was conducted with this existing status of the threatening prevalence of overweight in urban areas.

Study Setting and Participants
The target discussants were composed of two groups of people: interventionists and overweight people. The former included physical fitness practitioners, nutritionists, and medical staff. The latter were overweight people who had body mass index (BMI) between 26 and 37 inclusive and were aged between 22-34 inclusive. Besides, for accessibility of the discussants and for exclusion criteria (overweight people who were medically prohibited from involving in weight loss programs were excluded), fitness centers, clinics, and hospitals were research settings. The target population was situated in Addis Ababa for a reason that, as reported in Ethiopian Public Health Association (2012) and by Dagim and Minyahil (2017), overweight was high in Addis Ababa. It was close to 30% of its dwellers. The amount of the prevalence is likely to increase since then.

Types of Data Collected
The researchers believed that FGD could generate an in-depth understanding of the behaviors overweight people are required to get motivated. Semi-structured FGDs were used based on an outline structure of some key questions. This mode was intended to get discussants express their ideas in their own terms. The questions were formulated following the advice of the prominent scholar named Patton (2015) in the area of qualitative questions formation. Patton suggested six kinds of questions: experience questions, opinion and value questions, feeling questions, knowledge questions, sensory questions, and background/demographic questions. Advice from Patton (2015), consultation from the review of related literature, and the nature of the specific questions of the current research were considered to prepare the questions for the FGDs. Twelve questions were prepared in advance for the two groups of discussants in the FGDs.
We asked three researchers that used qualitative research methodology in their work to comment on the nature of the items. Besides, the principal researcher conducted a pilot test with one overweight person and one interventionist to see if the items were comprehensible to the discussants. These two procedures led the current researchers to remove and modify the items into nine items.
The questions were given to the discussants in written form because they would get time to activate the information they had in their mind. The researcher believed that reading would facilitate the processing of the questions in their mind. This might help them to respond to the questions easily and very well. The questions were given to them one-by-one in order to reduce the interference of the processing of the other questions on their processing of the question under discussion.
The moderator was jotting down the main points while the group members were talking about the discussion questions. She, then, reflected the points back to the discussants at the end of the discussion. To gain discussants' confirmation, she invited the members to add what they thought missed and to omit what they thought did not represent their ideas.

Analysis
The current researchers have taken the inaugural type of instrumentation. The decision to develop a questionnaire from a scratch puts two approaches for the researcher to select and follow in the course of developing a questionnaire. The approaches are research-before-theory and theory-before-research. The current researchers adopted the former which can be presented by the following figure (Berg, 2001:18).
Journal of Education and Practice www.iiste.org ISSN 2222-1735 (Paper) ISSN 2222-288X (Online) Vol.12, No.28, 2021 16 The first step in data analysis was to explore the data. This provided the opportunity for the researchers to obtain a general sense of the data, and consider whether the researchers needed more data or not. The researchers read the transcribed data several times. This was immersing themselves in the details, trying to get a sense of the data as a whole before breaking it into parts (Agar, 1980in Creswell, 2012. This experience gave the current researchers crude criteria to identify important points among the bulk of the transcribed data. In an attempt to provide more useful context, phrases, a sentence or group of sentences were used as levels or units of analysis. Besides, coding frame was prepared to make the concepts specific for coding. Applying and consistently following the frame allowed the researchers to maintain the validity of the data (Wilkinson and Birmingham, 2003) on generating the indicators for the construct of motivation for weight loss.
The data from FGDs were analyzed with the help of another rater. The principal researcher and the rater compared the consistency of their rating. The researchers employed Miles and Huberman's (1994, p. 64) formula to calculate the raters' reliability. According to them, reliability equals the number of rater agreements divided by that number of agreements plus the number of disagreements.
On 17 of the indicators the raters agreed, but on 4 they did not. According to the reliability formula, the reliability was 17 divided by 21 plus 4, or 17 divided by 21 for a reliability of 0.81.
The two raters discussed the four disagreements and finally agreed on three of them resulting in a formula of 20 agreements and 1 disagreement for a final reliability of 0.96, which is a high level of inter-rater reliability.

Results and Discussion
The findings of the research will be presented in the following two consecutive sub-sections which stand for the two basic research questions this qualitative research aimed to address.

I. Indicators of Motivation for Weight Loss
We will raise each of the discussion questions and identify the indicators of the construct of motivation for weight loss with the purpose of addressing the first research question.
1. What are the characteristics of the participants? For the qualitative study, one of the two FGDs had to be composed of overweight people. This question was aimed at eliciting information about the illegibility of the people to participate in FGD. The question mainly targeted to recruit eligible participants who were overweight based on the measure of body mass index (BMI). Therefore, the moderator asked them about their height in meters (or centimeters) and weight in kilos. This question was forwarded for the clients in order to check whether they were overweight or not. They had body mass indices between 26 and 37.  Vol.12, No.28, 2021 items to be developed later in the stages of developing items for assessing the motivation to participate in a weight loss program.
The discussants forwarded a variety of responses which can be represented by the following headings: habits, goals, health, pleasure, people, and amotivation.

Habits
The following extracts are instances that show the discussants' habits in connection with their experience in weight loss.
I  (2017) have found out that cultivating the appropriate life style habits has increased the participants' confidence in their ability to manage their weight. Therefore, having and sustaining the appropriate habit was considered one of the indicators of motivation for weight loss.

Achieving Goal
The following episode from the discussants is an example to show their reason to participating in a weight loss program.
My first goal is …well…no other only the right BMI. This excerpt could be taken as one of the indicators for the construct of the motivation for weight loss. Aiming for a BMI of 25 kg/m 2 for their clients is one of the responsibilities of the interventionists (Ogunbode, Ladipo, Ajayi, and Fatiregun, 2011).

Improving Health
The discussants shared their reasons to involve in weight loss program. Among the many reasons the discussants mentioned, improving their health condition was salient. Their original words reflect this.
For me, I …did it for more than er…er…er… yes for more than 12 years. When I began, er… it was to…to..to improve my health status. I saw… I achieved this. I continued involving in the weight loss program. It is almost…er almost part of of my life….I don't know how life looks like without physical exercise and diet selection. Sand, Emaus, and Lian (2017) also found that fitness and the pursuit of looking healthy was the recurrent topic among the overweight people. Their commitment to be fit and look healthy could be taken as indicator for motivation to lose weight.
A further probing on "What will the success bring you?" for deeper understanding brought the following responses which are relevant to the research agenda.

Pleasure of Weight Loss
Some discussants reflected their delight in participating in a weight loss program.
…for the joy I…er… feel when I engage to…to…myself in the weight loss procedure Er…for me…the joy of involving in the weight loss … In fact, er…er… the weight loss is a secondary reason-my primary reason is er…er…er… the pleasure I get…get from coming here.
…my friend I …my friend takes the responsibility for his overweight… he blames nothing… he…yes enjoys the program In connection with these excerpts, Sand, Emaus, and Lian (2017) reported that the participants who were exercising on regular basis highlighted the pleasure of the activities. That is, they performed the activities for the joy they get from the physical exercises. The participants in Sand, Emaus, and Lian's (2017) research described the physical exercise as genuinely joyful pursuits.

People
The discussants said that their effort to lose weight could stem from their relationship with family (and friends) and other people around them. The following episodes substantiate this claim.
I  (2017) hold that parents, family members, and people around the overweight person can be important influencers in the practice of losing weight. These people are supportive motivators regarding losing weight. This is more important especially when the patient, the overweight person, is extrinsically motivated.

On Amotivation
The discussants forwarded an interesting point about the motivation of some people who participated in weight loss programs. The following excerpts from the words of the overweight people and the interventionists are instances to reflect this point.
I know a young boy who goes to a fitness center for no reason. So he sometimes comes sometimes does not….Teddy, added in a humorous tone there are many especially the teenagers. (others laugh) The interventionists also shared this. In this connection the following excerpt could be taken as evidence.
In fact, we have clients who come… I mean…er…er appear to the center, but er…they don't follow the schedules. This er….er… we tell them again and again…this won't bring the desired result. We don't… encourage…such behaviors. These episodes clarify that there were individuals who participated in a weight loss intervention for no reason. These people are amotivated.

What are the responsibilities of an overweighed person to be successful in losing weight?
This question was designed to come up with the focus and commitment areas of the overweighed people and their interventionists. Their responsibilities were believed to come out from their areas of focus. The responses showed the things they were required to perform as overweight people and as interventionists. The researchers believed that the responses would contribute to the content validity of the ideas generated to get the indicators of the construct of motivation for weight loss.
Concerning the responsibility of the over-weights to lose weight, the discussants forwarded their ideas among which the following are included.
My  (2000), Crane, Fate, Finkelstein, Linnon (2012) and Sand, Emaus, and Lian (2017) underlined the relevance of frequent contact with interventionists during modifying life style in general and during diet adjustment and selecting the types and intensity of physical exercise to do.

What do the interventionists do before starting the intervention?
This question was tailored to collect information on the values the interventionists prioritize for their clients to be successful in losing weight. The priority areas represented the issues that require motivation of the clients. Identifying these areas was believed to contribute to the content validity of the indicators of the construct of motivation for weight loss.
The discussions of both the overweight and the interventionists brought the following summary of points to the attention of the researcher. They were: • Measuring BMI • Interviewing the client on his/her health status • Reasons/goals for coming to the center • About dietary restrictions and selections • Scheduled physical exercises • Psychological readiness to be successful such as mental readiness and capability beliefs • Acquainting the clients with the rules and regulations of the fitness center such as being punctual when they come in and when they finish, being supportive to other people involving in the center, and using materials and machines properly. Various scholars (Apovian, 2016;Gurevich-Panigrahi, Panigrahi, Wiechec, Los, 2009;Ogunbode, Ladipo, Ajayi, and Fatiregun, 2011;Sand, Emaus, and Lian, 2017; and others) agree with interventionists that the going through the practice of physical exercises and diet restrictions could have a further irreversible damaging result on the participants if proper care has not been in place. For example, the food selection and restriction could be connected with their blood type on the one hand their health status on the other. If a client has a problem related to his/her backbone much care is required in choosing the types of sports to do.
Once we know that we are fit to enroll and decide to participate, the centers provide additional support for us to start and engage in the program. Some are: • Written schedule of dietary selection • Oral advice • Videos of successful clients • Videos of motivational speeches (or speakers) Ogunbode, Ladipo, Ajayi, and Fatiregun (2011) underlined that it is essential to maintain the overweight person's motivation throughout the course of the intervention. Ongoing follow up of the interventionist has been shown to help sustain weight loss. These supportive mechanisms could have significant impact, they believe, in taking the participants to achieving the desired target.

What are the advices you have received from your coach?
This question was tailored with almost the same purpose with question number 4. It was a further probing and resulted in the following summary of responses: to gather information about what their interventionists want them to do or to improve to be successful in their weight loss effort. Their responses are categorized into three related groups: modifying dietary and physical exercises, appropriate amount of food intakes and exercise doings, and being personally motivated.

Modifying Dietary and Physical Exercises
The interventionists advised the overweight people on the importance of modifying the food items they eat and the kind of physical exercises they engage themselves. To substantiate this, the following episode is worth quoting.
On dietary selection and on doing physical exercises NHLBI Obesity Education Initiative (2000) put it in a straight language saying, "Dietary therapy includes instructions of modifying diets" (p. 2) to lose weight. Apovian (2016) stated that consuming fruits and vegetables were protective against overweight. Those who consumed these food items were unlikely to develop overweight. Therefore, this piece of advice was relevant for the overweight people to lose weight.

Appropriate amount of food items and physical exercises
In addition to modifying dietary selection and doing physical exercise, the discussants also reflected their ideas on the amount of food they should eat and of physical exercise they should do to be successful in their target to reduce their weight.
The food items I am expected to eat with measured amount

On avoiding eating for my emotion. I shouldn't eat food because I like it but because my body needs it.
Journal of Education and Practice www.iiste.org ISSN 2222-1735 (Paper) ISSN 2222-288X (Online) Vol.12, No.28, 2021 20 Concerning physical exercises Er…Er… I said earlier my coach told me to do physical exercise with appropriate amount. Both too much and too little are ineffective. Apovian (2016) recommended that overweight people engage in different types of physical activities with appropriate intensity as recommended by the interventionists.

Personal motivation
According to the discussants, the interventionists advised on the relevance of being motivated to the process of the intervention to achieve their target of losing weight. The next episode is an instance in substantiating their responses.
Having motivation to the intervention is important Ogunbode, Ladipo, Ajayi, and Fatiregun (2011) stated that personal motivation of the overweight can dramatically influence the intervention procedure. Therefore, the advice is vitally important for the success of losing weight.

Is there anything you are not comfortable with?
This question was intended to elicit (generate) data which might reveal the depth of their motivation to push forward through the challenges until they achieve their set target in the weight loss program. Following are three excerpts taken from the responses of the discussants.
Some of the food stuffs I am restricted from were pleasure inducing for me. And it is still a challenge to avoid them from my dining Through interview, some are not serious about the restrictions and selections. It is expected for the overweight people to face such challenges while participating in the weight loss intervention. But the interventionist is responsible to professionally handle this. If exercise levels are unsatisfactory, the interventionist should motivate the overweight to increase physical activity.
The discomforts possibly stemmed from food restrictions and selections and the intensity of physical exercises and the behavior of the client.

What do you expect from the intervention?
This question was formulated to find out what they expected to see at the end of the intervention. This came up with the ideas they held as measures of their success. In other words, the responses of the discussants would be relevant in exposing their final goals. These goals might reflect the type of motivation they had. By extension, the responses would contribute to the content validity of the indicators of motivation for weight loss. The expectations of the discussants in the overweight group are demonstrated through the following words.
I expect to be in good shape  (2017) reported that participants had positive expectations from participating in a weight loss program. Therefore, the above list includes some of them and it cannot be exhaustive.

What are the challenges you are facing?
This question was phrased to elicit data on the challenges the overweight people faced while attempting to lose weight. These expressed challenges were believed to reflect the types of motivation they had towards losing weight.

Long Distance
The discussants said that they were facing the challenges of the long distance between their home and the fitness centers they got support. Look the following excerpt: For me, I've changed my living area which is far away from the center where my coach is working. The long distance prohibited me from getting regular support from my coach. I'm sad for this. The interventionists also agreed with the challenges of long distance. Following the government's construction and distribution of condominium to the people, many of our clients changed their living areas and this caused them to travel long distances. It is well documented that when facilities are far from one's permanent address, getting the service regularly will not be easy.
Friends and family members comment on my physical appearance. This sometimes makes me emotional which might interfere on my diet selection and the will to intensify the exercise.
Here I have made friends. We encourage one another. When I am forced to shift to other sessions, I miss them and their encouraging words. This discomforts me. The contribution of the people around the overweight person on the motivation of him/her to lose weight cannot be ignored. In these excerpts, the discussants revealed their discomforts which stemmed from the discouraging comments forwarded from friends. When the people around us are encouraging to our efforts, it is more likely that we make significant positive changes through losing weight.

Amount of physical exercises
The amount of physical exercises they were required to do was among the challenges the discussants mentioned during their discussion.
Depth of physical exercises. I mean length of time for physical exercise Apovian (2016) reported that overweight people need to engage in physical activity with moderate intensity appropriate to the overweight person. The level might be challenging if the interventionist does not handle it professionally or if the overweight person is not well motivated to involve in physical exercise. Both are manageable, however.

Selecting Dietary
The other challenge emanated from the struggle to be in line with the dietary schedule suggested from fitness centers the overweight people received support.

Being off schedule of the some food items which I enjoy eating
When food items I don't like eating are included in the schedule An individual's dietary choices could be impacted by past experiences with food selection. If those habits are unhealthy, bringing behavioral change in dietary selection could be a major challenge (Beck, 2015). There will be a temptation to be attracted to the previous likes of food items.

On Behavioral and Financial Challenges
The discussants mentioned the following challenges. These challenges could be summarized as behavioral and financial. The excerpts presented next reveal these challenges.
Unable to be punctual, except this I have no other problem.

On being on time
These days life is difficult. The price of everything, including daily consumptions, is soaring. This may cause financial burden to the level of failing to settle fee for the center.
We heard that some dropped from the intervention due to shortage of money to pay for the center. If they had shared us, we would have had different paying modalities which can accommodate them.
9. Did you quit from participating in weight loss program? Do you know people who did so? What were the reasons? This question was aimed at gleaning information about if they dropped from participating in a weight loss program. Their responses revealed the type of motivation they held to stop or to continue with the intervention. These Journal of Education and Practice www.iiste.org ISSN 2222-1735 (Paper) ISSN 2222-288X (Online) Vol.12, No.28, 2021 22 responses were believed to contribute to the content validity of the indicators to be generated.

Shortage of time
These days life is difficult. The price of everything, including daily consumptions, is soaring. This may cause financial burden to the level of failing to settle fee for the center. I know someone who quitted for this reason.
I have friends er…er… who er…er…er…withdrew from going to…to fitness centers er…because ….er…er… they don't see changes on their physical appearance.

II. Indicators in SDT
The analysis under this subsection is to address the second research question which runs, "Where do the indicators fit in the factors of social determination theory (SDT)?" According to SDT, the indicators show the adherence to weight loss. Adherence to weight loss practices distributes along a continuum from intrinsic motivation to amotivation (Deci & Ryan, 1985): Intrinsic motivation, extrinsic motivation, which includes integrated motivation, identified motivation, introjected motivation and external motivation, and amotivation. These types of motivations are briefly discussed one by one.
Someone is intrinsically motivated when he/she does something for the pleasure experienced in the process (Deci, 1975 in Lavesque andVallerand, 2007). This refers to the type of behavioral regulation in which it is chosen freely. The reward is the behavior itself and it is something pleasant. For instance, an overweight man might decide to participate in an intervention because he wants to challenge himself and he really enjoys the process. According to Teixeira, Silva, Mata, Palmeira, and Markland (2012), research on SDT and weight control show that there is a positive association between autonomy (intrinsic motivation) and long term weight loss. This leads to a greater association of intrinsic motivation with the satisfaction of needs which in turn shapes the individual's adherence to weight loss practices.
Integrated motivation represents the most independent form of extrinsic motivation that happens when there is heterogeneity between behavior rules and needs, goals and personal confirmed values which are part of the person. For example, overweight people might participate in a weight loss program because participation is an integral part of their life.
Identified motivation refers to an individual thinking that the behavior is valuable, but it is done as it is considered to be an advantage for the subject. There might be overweight individuals who might follow this cause. Their behavior reflects conscious values and is internalized as personally important (Lavesque and Vallerand, 2007). For example, the overweight man might participate in weight loss programs to eventually reach his target of scoring the right BMI.
Introjected motivation refers to a person performing the behavior so as not to feel guilty or uneasy about not having exercised. Some overweight people might engage themselves in weight loss programs and reflect introjected regulation which represents a partial internalization without completely accepting it as one's own (Lavesque and Vallerand, 2007). An overweight man may begin to keep a journal of the food he consumes on a daily basis because the overweight people in his weight loss group do so. To give another example, students who go to a science class to avoid feeling of guilty.
External motivation refers to the way a person performs behaviors as a means of obtaining an external reward or due to influence by external subjects or factors. In other words, the behavior is controlled by external forces. Some obese people might be externally motivated to involve in the practice of weight loss. Their behavior to participate in such practices is for external rewards. For example, an overweight man may change his diet and add physical exercise as part of the intervention to weight loss in order to avoid criticism from physician.
Still there might be amotivated overweight people whose behavior is characterized by a relative lack of motivation (Lavesque and Vallerand, 2007

Limitations and Further Research
The current study used BMI to recruit overweight people. However, this index is known to fail to distinguish between fat and fat-free mass. Besides, waist circumference was not employed to select overweight people. Future researchers can consider these criteria to recruit their participants. The current research did not consider excess body weight affected by genetic factors, health conditions, and drug use. These could also be target areas for future research.

Conclusion
We showed that it is possible to use qualitative research, more specifically FGDs, to generate possible indicators for a construct of motivation for participating in a weight loss program. Scientific procedures were employed to make these indicators represent the real life domain of the target respondents' reason to involve in a weight loss program. Besides, these indicators were coded against the types of motivations explained under social determination theory (SDT). www.iiste.org ISSN 2222-1735 (Paper) ISSN 2222-288X (Online) Vol.12, No.28, 2021