A Convergent Mixed Methods Study on Exercise Benefits, Barriers, and Self-Efficacy in Chinese Pregnant Women: Triangulating Self-Report Scales with Lived Experience

A Convergent Mixed Methods Study on Exercise Benefits, Barriers, and Self-Efficacy in Chinese Pregnant Women: Triangulating Self-Report Scales with Lived Experience | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article A Convergent Mixed Methods Study on Exercise Benefits, Barriers, and Self-Efficacy in Chinese Pregnant Women: Triangulating Self-Report Scales with Lived Experience Jing Li, Yanrong Wang, Xiaohui Liang, Hairong Lv, Jordan Tovera Salvador This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-9602132/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Background Instruments like the Exercise Benefits/Barriers Scale (EBBS) and the Pregnancy Exercise Self-Efficacy Scale (P-ESES) are commonly employed to evaluate psychosocial factors influencing physical activity in pregnant individuals. However, whether these scales fully capture the experiential reality of Chinese pregnant women remains underexplored. This study utilized a convergent parallel mixed methods approach to assess the alignment and discrepancies between questionnaire results and in-depth interview narratives. Methods A total of 335 pregnant women from three provinces in China (Guangdong, Zhejiang, Shanxi) completed the EBBS, P-ESES, and the Pregnancy Physical Activity Questionnaire (PPAQ). Concurrently, 30 participants purposively selected from the same quantitative pool participated in semi-structured interviews guided by the Health Belief Model.Thematic analysis was conducted on qualitative data using NVivo 12. Quantitative and qualitative datasets were integrated via a joint display table to examine convergence and divergence at the item level. Results Quantitative findings confirmed that perceived barriers significantly predicted physical activity inadequacy (adjusted OR = 0.93, 95% CI: 0.88–0.98), whereas perceived benefits and self-efficacy lost significance when barriers were controlled. Six qualitative themes emerged: (1) cognition of exercise during pregnancy, (2) motivations for exercise, (3) factors influencing exercise participation, (4) action inspiration and information sources, (5) post-exercise feelings, and (6) confidence in maintaining exercise. Triangulation revealed strong convergence for exercise benefits (all nine EBBS benefit items confirmed by interview quotes) and most barrier/self-efficacy items. However, two critical divergences were identified: (i) lack of specific exercise advice from healthcare providers (seven qualitative mentions, no corresponding EBBS item), and (ii) weather/climate as a major environmental barrier (14 qualitative mentions, no corresponding EBBS item). Additionally, one P-ESES item regarding self-efficacy without gym access received zero qualitative endorsement. Conclusions The EBBS and P-ESES demonstrate satisfactory content validity for Chinese pregnant women overall. Nevertheless, the scales contain notable blind spots regarding professional healthcare support and environmental/climatic barriers. These findings support the integration of mixed-methods approaches in maternity health behavior research and inform the development of targeted interventions. mixed methods pregnancy physical activity Exercise Benefits/Barriers Scale self-efficacy triangulation China 1. Introduction Engaging in regular physical activity(PA) during pregnancy is linked to lower risks of gestational diabetes mellitus, excessive gestational weight gain, pre-eclampsia, and postpartum depression [ 1 , 2 ] . The World Health Organization (WHO) advises pregnant women without contraindications to participate in a minimum of 150 minutes of moderate-intensity aerobic exercise weekly [ 3 ] . Global adherence to physical activity guidelines remains low despite recommendations. Meta-analytic evidence indicates that in China, only about 21% of pregnant women achieve the recommended physical activity levels [ 4 ] , with most of their activity being low-intensity household tasks rather than structured exercise [ 5 ] . Identifying the psychosocial factors influencing physical activity in pregnancy is crucial for developing effective behavioral interventions.The Exercise Benefits/Barriers Scale (EBBS), created by Sechrist, Walker, and Pender [ 6 ] , is a prominent tool for assessing perceived exercise benefits and barriers. It comprises two subscales: Exercise Benefits (29 items across physical, mental-emotional, and social domains) and Exercise Barriers (14 items across individual, interpersonal, and environmental domains). The Pregnancy Exercise Self-Efficacy Scale (P-ESES), was modified by Bland et al. [ 7 ] , assesses pregnant women’s confidence in maintaining exercise across ten challenging scenarios.The Chinese translation of the Pregnancy Exercise Self-Efficacy Scale (P-ESES) has shown satisfactory psychometric properties [ 8 ] . However, like all self-report questionnaires, they are vulnerable to construct underrepresentation—the risk that important domains of the target construct are omitted from the instrument [ 9 ] . Cultural, geographical, and healthcare-system contexts may generate unique barriers or benefits that the original scale developers did not anticipate. The convergent parallel mixed methods design offers a rigorous methodological solution to the question of whether questionnaires adequately capture lived experience [ 10 , 11 ] . By collecting and analysing quantitative and qualitative data concurrently, researchers can examine the extent to which statistical patterns converge with, diverge from, or complement narrative accounts [ 12 ] . When scale items and interview themes align, content validity is strengthened; when qualitative data reveal phenomena absent from the scale, instrument refinement and theory development are prompted [ 13 ] . This study aimed to: (i) explore, via in-depth interviews, pregnant women's lived experiences of exercise benefits, barriers, and self-efficacy; (ii)integrate quantitative and qualitative findings through item-level triangulation to determine the degree of convergence and divergence between scale scores and interview narratives; (iii) identify any qualitatively salient themes that are absent from the EBBS and P-ESES item sets. This study uses the same quantitative dataset as our previously published cross-sectional report [ 14 ] , which examined the predictive hierarchy of psychosocial factors for physical activity adherence. The present manuscript addresses a fundamentally different research question—not which factor predicts behavior, but whether the instruments we use to measure those factors adequately capture the lived experiential reality of the target population. The two contributions are thus complementary: the first paper identified what matters (perceived barriers), while the present paper examines whether our tools for assessing those factors are fit for purpose. No qualitative data, thematic analysis, or triangulation procedure has been reported previously. 2. Methods 2.1 Study design and participants This study utilized a convergent parallel mixed methods design, collecting quantitative and qualitative data concurrently, analyzing them separately, and integrating the results during interpretation using a joint display table for comparison and contrast [ 10,11 ] . A multi-center cross-sectional survey was conducted from January 27 to February 21, 2024, at three locations in China: Zhongshan, Guangdong Province (southern, subtropical); Ningbo, Zhejiang Province (eastern, temperate); and Xi'an, Shanxi Province (northern, continental). These sites were selected to capture geographical and climatic diversity. A total of 335 pregnant women attending routine antenatal visits at the participating hospitals were enrolled. Participants were eligible if they were aged 20–45 years, had a singleton pregnancy without complications or comorbidities that contraindicated physical activity, and were able to understand the study's purpose and procedures, demonstrating a willingness to participate voluntarily.Women with incomplete or inconsistent data submissions were excluded. The Ethics Committee of the Philippine Women's University (ERB2024_007) provided single IRB oversight and approved the multi-center protocol for all three data collection sites. The First Affiliated Hospital of Ningbo University granted additional local ethics approval (Approval No.).2024 035A-1), the site contributing the largest participant sample . Participants gave written informed consent before joining the study. 2.2 Sampling 2.2.1 Quantitative sampling All eligible pregnant women who attended routine antenatal visits at the three participating hospitals during the recruitment period were invited to participate. The sample size justification and power calculation are detailed in the companion cross-sectional paper [ 14 ] , utilizing the same quantitative dataset, provides the sample size justification and power calculation. In brief, the sample of 335 participants exceeded the minimum required based on an events-per-variable rule for logistic regression models with up to eight predictors, assuming a 20–30% physical activity adequacy rate as reported in previous Chinese studies [ 4 ] . 2.2.2 Qualitative sampling From the quantitative sample of 335 participants, a purposive subsample was recruited for semi-structured interviews. Sampling aimed to achieve diversity in parity (primipara vs. multipara),education level, and province(Table 3). Creswell [ 15 ] suggests that a reasonable sample size for a phenomenological study ranges from 5 to 25 participants, depending on data saturation. The study involved 30 participants, and data saturation was achieved as no new themes or insights emerged from the final interviews. 2.3 Measures and Data Collection 2.3.1 Quantitative measures Three validated instruments were used. The Pregnancy Physical Activity Questionnaire (PPAQ) in Chinese [ 16,17 ] evaluated the duration, frequency, and intensity of physical activity during pregnancy. The World Health Organization (2020) [ 3 ] recommends that pregnant women achieve adequate physical activity by participating in at least 150 minutes of moderate-intensity aerobic exercise weekly [ 18 ] . The Exercise Benefits/Barriers Scale (EBBS) [ 6 ] assesses perceived benefits (29 items) and barriers (14 items) to exercise. The Chinese Pregnancy Exercise Self-Efficacy Scale (P-ESES) [ 8 ] evaluated participants' confidence in sustaining exercise through ten difficult scenarios. An electronic questionnaire incorporating demographic data and the three scales was distributed through the 'Questionnaire Star' platform. The questionnaire's homepage provided explanations of the study's purpose and the definitions of physical activity and exercise. The questionnaire stated that initiation of the survey constituted voluntary consent to participate. Screening was automated: if a participant selected any option indicating ineligibility, the program exited; otherwise, the questionnaire continued until completion. 2.3.2 Qualitative data collection At the end of the electronic questionnaire, participants were asked whether they would be willing to participate in a follow-up telephone interview. Those who agreed provided their phone numbers. Researchers contacted participants within 24 hours of submission and confirmed the convenient time, conducted a semi-structured in-depth telephone interview. A total of 42 pregnant women were contacted; 12 declined the interview. Finally, after analyzing the data of the 30th interviewee and confirming no new information was available, the researchers stopped contacting the interviewees. The interview guide, informed by the Health Belief Model (HBM) constructs [ 19 ] (Supplementary File 2), encompassed perceived susceptibility, severity, benefits, barriers, cues to action, self-efficacy, and general exercise experience. Interviews, lasting 30–60 minutes, were audio-recorded with participants' verbal consent. The researcher maintained a neutral and objective attitude throughout and recorded not only the content of statements but also participants' tone, pauses, and repetitions. When questions or ambiguities arose, the researcher promptly clarified with participants. After each interview, the researcher summarized the main points for the participant to verify their accuracy. During the interviews, the researcher used flexible probing techniques to elicit richer and more specific responses. Example probes included: For perceived barriers: “Can you tell me about a specific time when you wanted to exercise but couldn't? What stopped you?” / “Did any healthcare provider talk to you about exercise during your prenatal visits? What did they say?” For perceived benefits: “You mentioned exercise is good for the baby—can you give me a specific example of what you mean by 'good'? How do you feel during or after a walk?” For self-efficacy: “You said you feel confident about exercising—what makes you feel that way? Can you think of a situation where you might feel less confident? What would help?” For cues to action: “Did anyone—such as your husband, your mother, or a doctor—encourage you to exercise? What did they say or do that made a difference?” For overall experience: “If you could change one thing about your exercise experience during this pregnancy, what would it be?” 2.4 Data analysis 2.4.1 Quantitative analysis SPSS version 26.0 was used for quantitative data analysis. Descriptive statistics (means, standard deviations, percentages) were calculated for all variables. A multivariable logistic regression analysis assessed the independent impacts of perceived benefits, perceived barriers, and exercise self-efficacy on meeting WHO physical activity guidelines, while adjusting for covariates such as age, pre-pregnancy BMI, parity, education, household income, and province. A p-value of less than 0.05 (two-tailed) was considered statistically significant. A correlation matrix of the psychosocial variables is provided as Supplementary Table S2. 2.4.2 Qualitative analysis Audio recordings were transcribed verbatim and imported into NVivo software version 12 (Lumivero, USA). Thematic analysis adhered to Braun and Clarke's six-phase method: familiarization, initial coding, theme generation, theme review, theme definition, and report writing [ 20 ] . The coding process was inductive, with themes emerging directly from the data instead of being based on pre-existing theoretical frameworks.The researcher listened to recordings while cross-checking field notes to ensure accuracy.In translating texts and extracting information, the participants' own perspectives were prioritized over the researcher's assumptions.The qualitative interview guide was structured according to the HBM constructs (Supplementary File 2), which served solely as a data collection framework to ensure comprehensive coverage of theoretical domains.The HBM constructs did not guide the coding process. The resulting themes were subsequently organized using Socio-Ecological Model (SEM) [ 21 ] as a descriptive reporting framework, with barriers mapped to the intrapersonal, interpersonal, and community/organizational levels. SEM was applied only at the theme-organization stage, not during theme generation. The qualitative component was reported in accordance with COREQ guidelines [ 22 ] (Supplementary File 1). 2.4.3 Integration (Triangulation) Integration occurred at the interpretation level via a joint display table (Table 4) [ 12,13 ] . Each item from the EBBS Benefits subscale, EBBS Barriers subscale, and P-ESES was listed alongside corresponding qualitative transcript quotes. A determination of "Convergence," "Divergence," or "Partial Convergence" was made for each item based on the following criteria: Convergence: Qualitative data contained at least one participant quote that directly endorsed the conceptual content of the scale item, and no contradictory evidence was present. Divergence: Qualitative data revealed a salient theme that was conceptually related to the scale domain but was not represented by any scale item; OR the scale item was not endorsed by any qualitative participant. Partial Convergence: Qualitative data both supported and contradicted the scale item OR the item was partially represented but with notable nuance or qualification. The amount of convergent, divergent, and partially convergent items was calculated for each scale. Qualitative themes lacking corresponding scale items were categorized as 'Emergent—Instrument Blind Spot' and analyzed for their theoretical and practical implications. For the interpretation of behavioral mechanisms underpinning the convergent and divergent findings, the COM-B model [ 23 ] was applied in the Discussion. 3. Results 3.1 Quantitative Results 3.1.1 Sample Characteristics and Descriptive Statistics Table 1 shows the characteristics of the 335 participants. They had a mean age of 30.57 ± 3.498 years and a mean pre-pregnancy BMI of 21.20 ± 2.89 kg/m². The majority were primiparous (72.8%), had attained tertiary education or above (85.7%), and were employed during pregnancy (67.8%). Mean gestational age at assessment was34.29 ± 4.87 weeks. The majority (94.6%) were in the third trimester. Table 1 Participant Characteristics (n = 335) Characteristic n (%) or Mean ± SD Age (years) 30.57 ± 3.498 Height (cm) 161.18 ± 5.528 Pre-pregnancy weight (kg) 55.092 ± 8.089 Current weight (kg) 66.627 ± 8.87 Pre-pregnancy BMI (kg/m²) 21.20 ± 2.89 Gestational age (weeks) 34.29 ± 4.87 Education Junior high and below 14(4.2%) High school/Technical secondary 34(10.1%) College/Undergraduate 259(77.3%) Graduate 28(8.4%) Current employment status Employed 227(67.8%) Unemployed 108(32.2%) Current stage of pregnancy First trimester(≤ 13 + 6 weeks) 6(1.8%) Second trimester(14 ~ 27 +6 ) 12(3.6%) Third trimester(≥ 28 weeks) 317(94.6%) Parity Primipara 244(72.8%) Multipara 91(27.2%) Residence type Urban 294(87.8%) Rural 41(12.2%) Living arrangements co‑residence with parents/in-laws 144(43.0%) Living separately from parents/in-laws 191(57.0%) Annual household income (RMB) 300k 62(18.5%) 3.1.2 Exercise-Related Psychosocial Factors and Physical Activity Levels On the EBBS, participants reported a high level of perceived exercise benefits (mean = 86.94 ± 11.37) and a medium level of perceived exercise barriers (mean = 29.96 ± 5.675). Exercise self-efficacy, measured by the P-ESES, was at a medium level (mean = 36.21 ± 5.484). The average total physical activity was 183.56 ± 87.01 MET-hours/week, with 29% (n = 97) meeting the WHO guideline of at least 150 minutes of moderate-intensity activity weekly. Table 2 presents the physical activity and psychosocial scale scores. Table 2 Physical activity and psychosocial scale scores (n = 335) Scale/Measure Mean ± SD Physical Activity (PPAQ) Sedentary Behavior (MET-hours/week) [100.12 ± 44.67] Low-intensity PA (MET-hours/week) [49.78 ± 38.61] Moderate-intensity PA (MET-hours/week) [33.09 ± 43.08] Vigorous-intensity PA (MET-hours/week) [0.57 ± 2.16] Total energy expenditure(MET-hours/week) [183.56 ± 87.01] Meeting WHO Recommendation (≥ 150 min/week), n (%) 97(29%) Psychosocial Scales EBBS — Exercise Benefits 86.94 ± 11.37 EBBS — Exercise Barriers 29.96 ± 5.675 P-ESES — Exercise Self-Efficacy 36.21 ± 5.484 Note.The EBBS Benefits subscale ranges from 29 to 116, the EBBS Barriers subscale ranges from 14 to 56, and the P-ESES ranges from 10 to 50.Elevated scores reflect increased levels of the corresponding construct.PA stands for physical activity, PPAQ refers to the Pregnancy Physical Activity Questionnaire, EBBS denotes the Exercise Benefits/Barriers Scale, and P-ESES is the Pregnancy Exercise Self-Efficacy Scale. 3.1.3 Logistic Regression Analysis of Psychosocial Predictors A multivariable logistic regression model was developed to assess the independent impacts of perceived exercise benefits, barriers, and self-efficacy on physical activity adequacy, while adjusting for factors such as age, education, employment, residence type, living arrangement, household income, gestational weeks, trimester, parity, and province (Supplementary Table S1 ). Among the three psychosocial variables, only perceived barriers emerged as a significant independent predictor.Increased perceived barriers correlated with decreased likelihood of adhering to PA guidelines (adjusted OR = 0.93, 95% CI 0.88–0.98, p = 0.004). After adjusting for barriers and covariates, perceived benefits (adjusted OR = 1.01, 95% CI 0.98–1.04, p = 0.368) and exercise self-efficacy (adjusted OR = 1.05, 95% CI 0.99–1.11, p = 0.137) were not statistically significant. Bivariate Spearman correlations among the psychosocial variables (Supplementary Table S2 ) provide context for these findings. Perceived benefits and exercise self-efficacy showed a moderate positive correlation (r = 0.576, p < 0.001), indicating shared variance that could account for their loss of significance when analyzed together with barriers. Perceived barriers showed a weak negative correlation with benefits (r = − 0.250, p < 0.001) and a non-significant correlation with self-efficacy (r = − 0.086, p = 0.118), consistent with its role as an independent predictor distinct from the benefits–self-efficacy pathway. 3.2 3.2 Qualitative Results 3.2.1 Characteristics of interviewees Table 3 presents the demographic details of the 30 interview participants. Most of them were primiparous in their late pregnancy. Table 3 Characteristics of interviewees (n = 30) Interviewees Age Gestational age Parity Education Working status Province 1# 32 33.0 Multipara Tertiary education Employed Shanxi 2# 31 37.0 Multipara Tertiary education Employed Shanxi 3# 22 38.0 Primipara Secondary Unemployed Zhejiang 4# 30 35.0 Primipara Tertiary education Unemployed Zhejiang 5# 26 37.0 Primipara Secondary Unemployed Zhejiang 6# 33 39.0 Primipara Tertiary education Employed Zhejiang 7# 31 32.0 Primipara Tertiary education Employed Shanxi 8# 30 36.0 Primipara Tertiary education Employed Zhejiang 9# 27 37.0 Primipara Tertiary education Employed Zhejiang 10# 35 39.0 Multipara Tertiary education Employed Zhejiang 11# 31 34.0 Primipara Tertiary education Employed Zhejiang 12# 29 34.0 Primipara Tertiary education Unemployed Zhejiang 13# 25 38.0 Primipara Secondary Unemployed Zhejiang 14# 30 24.0 Primipara Postgraduate Employed Shanxi 15# 30 36.0 Primipara Postgraduate Employed Guangdong 16# 31 37.0 Primipara Tertiary education Unemployed Guangdong 17# 39 37.0 Multipara Tertiary education Employed Guangdong 18# 32 36.0 Primipara Tertiary education Employed Shanxi 19# 32 33.0 Primipara Tertiary education Employed Shanxi 20# 31 37.0 Multipara Secondary Unemployed Guangdong 21# 35 31.0 Primipara Tertiary education Unemployed Zhejiang 22# 30 39.0 Primipara Postgraduate Employed Shanxi 23# 35 33.0 Multipara Tertiary education Employed Guangdong 24# 28 38.0 Primipara Tertiary education Employed Guangdong 25# 26 36.0 Primipara Secondary Unemployed Guangdong 26# 32 36.0 Primipara Tertiary education Employed Guangdong 27# 32 27.0 Primipara Secondary Unemployed Zhejiang 28# 30 16.0 Primipara Tertiary education Employed Guangdong 29# 34 33.0 Primipara Tertiary education Unemployed Shanxi 30# 28 35.0 Primipara Tertiary education Unemployed Guangdong 3.2.2.Themes from Qualitative Interviews Six themes emerged from the thematic analysis of the 30 interview transcripts. Each theme is presented below with illustrative quotes (participant number indicated in parentheses). Theme 1: Cognition of Exercise During Pregnancy Participants held heterogeneous definitions of what constituted “exercise” during pregnancy. Some equated exercise with structured, higher-intensity activities such as aerobics or jogging, while others considered everyday walking—even at a slow pace—as sufficient exercise. Awareness of the WHO's recommendation for 150 minutes per week of moderate-intensity physical activity was significantly limited. “I walk for half an hour every day, about 3 kilometres; I feel like I’m not exercising enough, but I’m not feeling comfortable walking too much.” (14#) “I follow the TikTok anchor to do aerobics 3–4 times a week, each time for an hour, and I think my exercise is enough.” (15#) Several participants emphasised individualised, medically guided decision-making over generic guidelines. Respect for bodily sensations and physician advice was prioritised above adherence to numerical recommendations. “Exercise should be customized to individual physical conditions, given varying exercise tolerances. You should talk to your doctor to see if you can exercise.” (20#) Theme 2: Motivations for Exercise The most frequently cited motivation was facilitative childbirth—exercising to build stamina and improve the likelihood of a smooth vaginal delivery. Weight management during pregnancy was the second most common reason. Multiparous women occasionally mentioned exercising as a shared activity with their existing children. “I exercise because I want to stay in shape and have more energy during labor. People who don’t exercise feel exhausted.” (3#) Interestingly, a multiparous participant stated, “I don't want to exercise because I plan on having a C-section later.” (2#) Theme 3: Factors Influencing Exercise Participation This was the most data-rich theme. Facilitators included family companionship (especially spousal support), peer companionship (walking with other pregnant women), reminders from medical staff, pre-pregnancy exercise habits, intrinsic willingness, and mood enhancement. “I am willing to go out if someone is with me, especially if my husband is with me. It feels very different when someone is with me…” (30#) “The medical staff reminded me to go out and exercise every day.” (20#) Barriers were multidimensional and intersecting. Weather was mentioned by more than half of participants as a primary deterrent. Time scarcity, physical fatigue, lack of companionship, absence of healthcare provider advice, fear of preterm labour, and pregnancy-related physical discomfort (back pain, pelvic pain, abdominal tightness, severe nausea) were also prominent. “I’m so tired after work, and I have to take care of the kids, so how can I find time to exercise?” (1#) “When I'm in a bad mood, I tend to avoid going out, and the medical staff did not provide guidance on exercising. ” (15#) “Whenever I walk, I get abdominal pain and pubic pain.” (24#) Theme 4: Action Inspiration and Information Sources One-third of participants reported receiving no exercise-related information or advice from medical staff during prenatal care. Information sources were predominantly informal: family members (especially sisters and mothers who had positive exercise experiences), the Internet (short video platforms such as TikTok), and personal physical sensations. “My sister and mom wanted me to exercise more during my pregnancy because my sister gave birth so quickly…” (3#) “I learned about stretching exercises from the internet… the hospital staff didn’t tell me how to do them.” (25#) Theme 5: Post-Exercise Feelings and Experiences Participants who exercised regularly reported predominantly positive somatic and affective outcomes: improved mood, quicker gastrointestinal motility, increased appetite, and better sleep quality. A minority reported feeling no particular change, and a few reported post-exercise fatigue requiring rest. One participant noted that sedentary work made her feel sluggish, and exercise restored agility. “After my walks, I feel less tired, sleep better, and have less pain.” (20#) “I sit a lot at work, and I become more agile after exercising…” (28#) Theme 6: Confidence in Maintaining Exercise Eleven participants expressed confident intentions to continue exercising until delivery. Two explicitly lacked confidence. Two made their confidence conditional on weather (“if it does not rain”). Several participants linked confidence directly to the availability of social support or habit strength rather than purely internal resolve. “You know, exercise is a habit of mine. I feel uncomfortable if I don’t move for a day.” (27#) “When the weather is good, I go for a walk or a swim. When the weather is terrible, I practice yoga or aerobics at home.” (10#) 3.3 Integrated Findings: Triangulation of Quantitative and Qualitative Data Table 4 presents the joint display of scale items, corresponding qualitative quotes, mention frequencies, and convergence/divergence determinations. 3.3.1 Convergence Exercise Benefits (EBBS). All nine benefit items examined across the three subscales (physical performance, mental-emotional, pregnancy/childbirth-related) demonstrated convergence with qualitative data. Interviewees spontaneously articulated benefits that mapped directly onto scale item content. The physical benefit of exercise in reducing fatigue (E29) was corroborated by five distinct statements, such as "I don’t feel that tired after exercise (lower back pain is relieved a bit)." Additionally, the pregnancy-related benefit of enhanced physical endurance through exercise (E31) emerged as the most commonly supported theme, with ten participants associating it with easier and quicker labor. This strong convergence suggests that the EBBS benefits subscale possesses robust content validity for Chinese pregnant women. Exercise Barriers—Individual, Interpersonal, and Community Domains. The majority of barrier items in the individual/intrapersonal, relationship/interpersonal, and community subscales converged with qualitative data. Time scarcity (E4), exercise-induced fatigue (E19), exercise difficulty (E40), spousal non-encouragement (E21), conflict with family responsibilities (E24), and family non-encouragement (E33) were all represented in interview transcripts. Mention frequencies ranged from 1 to 4 per item. Pregnancy Exercise Self-Efficacy (P-ESES). Six of the ten self-efficacy items converged with qualitative accounts. Items concerning the ability to overcome barriers (P1), find alternative exercise means (P2), and accomplish self-set goals (P3) were supported by participants’ descriptions of habit-driven exercise, weather-adaptive strategies, and goal-directed persistence. The statement “I am confident that I can exercise even without the support of my family and friends” (P7) was affirmed by 11 participants, indicating their autonomous confidence in maintaining exercise routines until delivery. 3.3.2 Divergence Three categories of divergence were identified, each representing a clinically and theoretically significant blind spot in the existing instruments. Divergence 1: Lack of Healthcare Provider Advice (Social/Environmental Barrier). Seven participants explicitly stated that medical staff had provided no specific exercise guidance. Representative quotes included: “The medical staff did not give me any specific exercise advice, and I don’t know what kind of exercise and when it is appropriate.” This theme was qualitatively salient and conceptually aligned with the social/environmental barrier domain, yet the EBBS contains no item addressing professional healthcare support or guidance. This divergence suggests that the scale underrepresents the healthcare system's role as a structural enabler or barrier. Divergence 2: Weather and Climate as Environmental Barriers. Fourteen participants spontaneously identified weather conditions (cold, rain) as major deterrents to outdoor exercise. Quotes such as “I don’t want to go out when the weather is terrible” and “The weather is too cold, and it’s raining these days” were common. Despite the high qualitative frequency, no EBBS item addresses climatic or environmental conditions. This omission is particularly significant for studies conducted in regions with extreme seasonal variation or tropical climates, where weather may constitute a primary ecological barrier. Divergence 3: Self-Efficacy Without Facility Access (P10). The P-ESES item P10, which states, 'I am confident that I can exercise even without access to a gym, exercise, training, or rehabilitation facility,' received no qualitative endorsements. No participant mentioned gym or facility access as a relevant factor in their exercise decisions. This divergence suggests that, in the Chinese cultural context, pregnant women conceptualize exercise as walking, a household activity, or online-guided home exercise rather than facility-dependent gym exercise. The item may have limited ecological validity for this population. 3.3.3 Partial Convergence One self-efficacy item demonstrated partial convergence. Participant expressed a strong belief in their ability to exercise independently (P7), as evidenced by 11 quotes highlighting autonomous confidence. However, two participants provided contradictory evidence: “I don’t have the confidence to stick to exercise unless someone accompanies me,” indicating that social support was not merely facilitative but psychologically necessary for some women. This partial convergence highlights the heterogeneity of self-efficacy sources within the sample. 4. Discussion 4.1 Summary of Key Findings This convergent mixed methods study triangulated questionnaire data from 335 pregnant women with in-depth interview accounts from 30 purposively selected participants across three Chinese provinces. The quantitative strand confirmed that perceived barriers were the dominant psychosocial predictor of physical activity inadequacy, a finding consistent with our previous multi-center report [ 14 ] . The qualitative strand enriched this statistical finding by revealing the specific contents, contexts, and textures of pregnant women’s exercise experiences. The integrated triangulation yielded three critical insights. First, the EBBS benefits subscale demonstrated robust content validity for Chinese pregnant women, with 100% item-level convergence. This finding supports the cross-cultural transportability of the benefits construct and suggests that Chinese pregnant women recognize and value the same physical, mental, and pregnancy-related benefits of exercise as women in Western contexts. Second, the EBBS barriers subscale and the P-ESES demonstrated satisfactory but incomplete content coverage. Two qualitatively dominant themes—lack of healthcare provider advice and weather/climate barriers—were entirely absent from the EBBS item pool. This absence represents a meaningful construct underrepresentation [ 24 ] with practical consequences: interventions designed solely around EBBS-identified barriers would fail to address the healthcare system and environmental ecology of physical activity behavior. Table 4 Convergence or Divergence of the Transcript Data to the Three Scales Results Scale Contents Items of the Scale Qualitative Transcript Quotes Mentioned times Convergence/Divergence Exercise Benefits Physical-benefits E7.Exercise increases my muscle strength. “I exercised to control my weight before I became pregnant and continued to exercise afterward to prevent muscle weakness.” 1 Convergence E23.Exercise improves my flexibility. “I always sit during work, and I feel more agile after exercise.” 1 Convergence E29.Exercise helps me decrease fatigue. “I don’t feel that tired after exercise (lower back pain is relieved a bit).” 5 Convergence Mental-emotional benefits E10.Exercising makes me feel relaxed. “After exercise, my body is not so tired; I feel much more relaxed.” 2 Convergence E2.Exercise decreases feelings of stress and tension for me. “Going out for a walk makes me feel much happier.” 5 Convergence E38.Exercise is good entertainment for me. “I'm bored at home alone, so I can kill time by going out for a walk.” 2 Convergence Benefits related to pregnancy and childbirth E31.My physical endurance is improved by exercising. “I exercise in the hope that I will have more energy and strength during labor, making the birth faster and smoother.” 10 Convergence E26 Exercising helps me sleep better at night. “I sleep better at night after taking a walk.” 7 Convergence E43 Exercise improves the way my body looks. “I want to stay in shape. ” 3 Convergence “Exercise is very important... If you want to control your weight, it is not enough to just control your diet.” 5 Convergence Exercise Barriers Individual/ Intrapersonal E4 Exercising takes too much of my time. “I'm too busy at work; I don't have time to exercise.” 3 Convergence E19 I am fatigued by exercise. “I walked pretty fast in the early stages of pregnancy but couldn't walk anymore in the later stages. I felt sore legs and back pain...” 2 Convergence E40 Exercise is hard work for me. “My body feels heavy, and I find exercise difficult.” 4 Convergence Relationship/ Interpersonal E21 My spouse (or significant other) does not encourage exercising. “My husband doesn't support me going out.” 1 Convergence “I'm alone at home,no one goes out to exercise with me.” 1 Convergence “I don't want to go out without my husband.” 1 Convergence Community E24 Exercise takes too much time from family relationships. “With my first child, I could participate in various activities and meet others. Now that I am pregnant with my second child, I need to do housework and take care of the child, so I cannot go out for exercise.” 4 Convergence E33 My family members do not encourage me to exercise “My family doesn't think it's necessary to exercise during pregnancy.” 2 Convergence Social /Environmental Some participants reported that the lack of specific advice from medical staff was a barrier,but the scale had no related item. “The medical staff did not give me any specific exercise advice, and I don’t know what kind of exercise and when it is appropriate.” 7 Divergence Climates were a major factor that prevented the participant from exercising, but the scale had no related item. “I don't want to go out when the weather is terrible.” “The weather is too cold, and it's raining these days.” 14 Divergence Pregnancy Exercise Self-efficacy P1 I am confident that I can overcome barriers and challenges to exercise if I try hard enough. “You know, exercise is a habit of mine. I feel uncomfortable if I don't move for a day.” 2 Convergence P2 I am confident that I can find means and ways to exercise during pregnancy. “When the weather is good, I go for a walk or a swim. When the weather is terrible, I practice yoga or aerobics at home.” 1 Convergence P3 I am confident that I can accomplish my exercise goals that I set. “To achieve my goal (control weight gain), I have to stick with it.” 2 Convergence P7 I am confident that I can exercise even without the support of my family and friends. “I don’t have the confidence to stick to exercise unless someone accompanies me…” 2 Partial Convergence “I am confident that I can continue exercising until delivery.” 11 P10 I am confident that I can exercise even if I do not have access to a gym, exercise, training, or rehabilitation facility. No one mentioned exercise equipment or gymnasium in the interview as a barrier. 0 Divergence Third, the P-ESES item regarding gym/facility access (P10) may lack cultural relevance for Chinese pregnant women, who predominantly engage in walking, home-based activity, and online-guided exercise rather than facility-based fitness. This finding aligns with recent critiques suggesting that self-efficacy scales, designed in Western gym-focused contexts, may not correspond with activity patterns in low- and middle-income settings [ 25 , 26 ] . 4.2 Theoretical Implications The convergent and divergent findings are best understood through an integrated application of the Socio-Ecological Model (SEM) [ 27 ] and the COM-B model [ 23 ] . Our qualitative themes were organized by SEM's ecological levels (intrapersonal, interpersonal, community/organizational), revealing that barriers operate across multiple strata. However, SEM describes where barriers are situated; COM-B explains why certain barriers are captured by existing instruments while others of comparable salience are systematically omitted. Convergent barriers as Capability and Motivation deficits. The barriers that demonstrated strong convergence—time scarcity, exercise-induced fatigue, and spousal non-encouragement—span the intrapersonal and interpersonal levels of SEM. Under COM-B, these map onto Capability (physical fatigue limiting capacity) and Motivation (competing priorities, lack of encouragement) dimensions. The EBBS was developed within an individual-level cognitive tradition aligned with these constructs; it is therefore theoretically consistent that the instrument performs well here. Divergent barriers as Opportunity deficits. The two blind spots are fundamentally different in theoretical type: Lack of healthcare provider advice operates at the community/organizational level (SEM) and constitutes a social opportunity deficit (COM-B). In China's time-compressed, biomedical antenatal system [ 28 , 29 ] , women described not an individual perception but a structural void: "The medical staff did not give me any specific exercise advice." No EBBS item operationalizes social opportunity at the healthcare system level—the scale includes items on spousal and family discouragement but omits the provider dimension, reflecting its U.S. development context where exercise counseling is more standardized [ 30 ] . Weather/climate barriers operate at the environmental level (SEM) and constitute a physical opportunity deficit (COM-B). High temperatures, humidity, and rain are external ecological conditions, not psychological states. Weather was the most frequently mentioned environmental barrier across our three climatically diverse provinces, yet the EBBS contains no corresponding item. Physical opportunity deficits cannot be remedied by enhancing individual capability or motivation alone; they require environmental restructuring—a strategy the instrument cannot inform because the barrier itself is absent. P-ESES and cultural scenario mismatch. The gym/facility item (P10) received zero qualitative endorsements because its situational referent—facility-based exercise—does not correspond to Chinese pregnant women's reality of walking, household activity, and online-guided home exercise. This is a physical opportunity misalignment between the item's assumed context and the population's actual activity ecology, echoing cross-cultural critiques of Western-developed self-efficacy scales [ 25 , 26 ] . Reframing intervention logic. The integrated analysis reveals that the EBBS predominantly captures Capability-type and Motivation-type barriers at the intrapersonal and interpersonal levels. The blind spots are not random omissions but systematic exclusions of Opportunity-type deficits at the community and environmental levels. Interventions designed solely around EBBS-identified barriers would disproportionately target individual-level factors while leaving structural deficits—absent healthcare guidance and inhospitable environments—unaddressed. We therefore argue for theoretical pluralism in prenatal physical activity research, integrating individual-level models (HBM, Social Cognitive Theory) with ecological and systems-level frameworks (SEM, COM-B) to ensure that both types of determinants are captured in measurement and addressed in intervention. 4.3 Bridging Qualitative Themes and Instrument Coverage: Convergence, Gaps, and Beyond While Table 4 provides item-level evidence of convergence and divergence, a theme-level analysis reveals three distinct types of relationships between qualitative findings and instrument coverage. First, most themes demonstrated clear convergence with existing scale items. Theme 2 (motivations for exercise) aligned with the EBBS Benefits subscale—particularly items on improved body function (Item 31) and mental health (Item 9)—as reflected in participant statements linking exercise to easier delivery and better mood. Theme 5 (post-exercise feelings) converged with multiple benefit items describing physical and emotional well-being. Theme 6 (confidence in maintaining exercise) directly corresponded to P-ESES self-efficacy items. These findings indicate that the core constructs of perceived benefits and self-efficacy are adequately operationalized. Second, several themes revealed areas of tension where qualitative data added nuance absent from scale items. Theme 3 identified two barriers—lack of healthcare provider advice and weather/climate constraints—with no corresponding EBBS items. While the scale captures interpersonal discouragement from spouses and family, it is silent on professional healthcare guidance, which seven participants independently raised. Similarly, the EBBS addresses facility accessibility but omits climatic conditions, despite weather being the most frequently cited barrier (14 mentions). A participant expressed, “I want to exercise, but prolonged rain limits my options.” Third, and most importantly, certain salient themes fell entirely outside the conceptual boundaries of both instruments. Theme 1 revealed substantial heterogeneity in how participants defined "exercise" itself—some equated it solely with structured gym activity, while others considered walking and household chores as sufficient. This definitional variability has no corresponding item in either scale, yet it shapes how participants interpret all subsequent items. If a woman does not consider walking as "exercise," her responses to EBBS items may systematically underestimate the benefits she actually receives. This represents a construct validity threat at the item-interpretation level that no psychometric coefficient can detect. These patterns suggest that while the EBBS and P-ESES demonstrate acceptable content validity for the constructs they were designed to measure, exclusive reliance on these instruments may miss context-specific opportunity deficits and interpretive variability in how exercise is understood. Future instrument adaptation should incorporate qualitative pre-testing to identify such blind spots before quantitative validation. 4.4 Methodological Implications This study exemplifies the utility of convergent mixed methods designs for instrument validation in cross-cultural health behavior research. Traditional psychometric evaluation relies on factor analysis, reliability coefficients, and known-groups validity—tests of internal structure and criterion association. Our triangulation approach adds a “phenomenological validity” criterion: Validity criteria that use subjects' real-life experiences are used to examine whether the scale items are relevant to the life experiences and cultural context of the target population [ 31 , 32 ] . The joint display table format (Table 4 ) offers a transparent, auditable method for documenting convergence and divergence that can be applied to other scales and populations. We recommend that researchers adapting self-report instruments in new cultural contexts routinely incorporate qualitative triangulation as a complementary validation strategy, particularly for instruments measuring context-sensitive constructs such as barriers and self-efficacy. 4.5 Practical Implications for Intervention Design The convergent and divergent findings jointly inform a layered intervention architecture: Layer 1—Target convergent barriers with established EBBS-based strategies.Time management, fatigue coping, family communication, and spousal involvement are well-represented in both qualitative and quantitative data and can be addressed through education, modeling, and enablement. Layer 2—Fill divergent gaps with context-specific strategies. Healthcare provider training in pregnancy exercise counseling should be integrated into obstetric continuing education. Antenatal clinics should provide written, gestational-age-specific exercise prescriptions rather than vague verbal encouragement. Environmentally adaptive strategies—such as indoor exercise video libraries, community cool-space walking programs, and seasonal timing recommendations—should be developed for tropical and continental climates. Layer 3—Reframe self-efficacy measurement. Rather than assessing confidence in exercising without gym access, Chinese-adapted self-efficacy items might assess confidence in exercising at home, in humid weather, or without professional supervision—scenarios that are more ecologically representative of this population’s actual exercise ecology. 4.6 Limitations The study is subject to several limitations. The cross-sectional design limits causal inference, necessitating longitudinal and experimental approaches to determine if reducing barriers prospectively enhances physical activity. Second, although the qualitative subsample (n = 30) was sufficient for thematic saturation, it consisted solely of women who had consented to the quantitative survey, potentially excluding perspectives of women not involved in research or prenatal care. Third, all three study sites were urban or suburban; rural pregnant women may face additional barriers (agricultural labor, longer travel distances, fewer recreational facilities) not captured here. Fourth, the integration process was conducted at the item level rather than the participant level; future research could employ quantitative-qualitative person-level case analyses to examine individual profiles of convergence and divergence. Finally, the logistic regression results presented here are abbreviated; the full quantitative report will be published separately [ 14 ] , and readers are referred to that source for detailed modeling. 5. Conclusions This convergent mixed methods study indicates that the EBBS and P-ESES exhibit satisfactory content validity for Chinese pregnant women, as shown by strong qualitative-quantitative agreement on benefit items and most barrier/self-efficacy items.However, two critical blind spots were identified: the absence of healthcare provider exercise counseling from the EBBS barrier domain and the absence of weather/climate barriers from the instrument’s environmental subscale. Additionally, one P-ESES item regarding gym/facility access may lack cultural relevance. These findings support incorporating mixed-methods triangulation into cross-cultural instrument adaptation protocols and provide actionable guidance for refining both assessment tools and intervention targets in maternity physical activity promotion.We argue that future cross-cultural instrument adaptation protocols should incorporate qualitative triangulation as a minimum standard for establishing content validity, rather than relying solely on psychometric coefficients. Declarations Ethics approval and consent to participate The study was approved by the Ethics Committee of the Philippine Women's University (ERB2024_007), which provided institutional oversight for the doctoral project across all data collection sites. Additional local ethics approval was obtained from The First Affiliated Hospital of Ningbo University (Approval No. 2024 035A-1), the site contributing the largest participant sample. For the remaining two hospitals, data collection was conducted with institutional permission, and all participants provided written informed consent, in compliance with the Declaration of Helsinki. Consent for publication Not applicable. This manuscript does not contain any individual person’s data in any form (e.g., personal identifiers, images, or recordings). All data were anonymized prior to analysis, and participants consented to the use of their anonymized data for research and publication during the informed consent process. Availability of data and materials The data in this study comes from the doctoral dissertation (Philippine Women's University, 2024, printed archive, unpublished). The quantitative survey data reported in this manuscript overlap with those used in a companion cross-sectional paper [ 14 ] ; however, all qualitative interview data, thematic analysis codes, and triangulation findings presented herein are entirely original and have not been published previously. They are available from the corresponding author upon reasonable request after the two papers are published. Competing interests This research was not funded, and all the authors declare no competing financial interests. Funding This research was not funded. Authors’ contributions JL conceived and designed the study, supervised data collection, conducted the interview, analyzed the data, and drafted the manuscript. YRW, XHL, and HRL conducted the investigation.YRW checked and verified the encoding of the interview data. JS contributed to the study design and critically revised the manuscript. All authors reviewed and approved the final manuscript. Acknowledgements We would like to thank all the women who participated in the study. Clinical Trial Number Not applicable. References Davenport MH, Ruchat SM, Poitras VJ, Garcia AJ, Gray CE, Barrowman N, et al. Prenatal exercise for the prevention of gestational diabetes mellitus and hypertensive disorders of pregnancy: a systematic review and meta-analysis [Internet]. 2018 Nov 1. doi:10.1136/bjsports-2018-099355 Ruchat SM, Mottola MF, Skow RJ, Nagpal TS, Meah VL, James M, et al. Effectiveness of exercise interventions in the prevention of excessive gestational weight gain and postpartum weight retention: a systematic review and meta-analysis. Br J Sports Med. 2018 Nov;52(21):1347–56. doi:10.1136/bjsports-2018-099399 PubMed PMID: 30337461. World Health Organization. WHO guidelines on physical activity and sedentary behaviour. Geneva: World Health Organization; 2020. Zhang W, Zhang L, Xu P, Guo P, Mao M, Zhao R, et al. 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BMC Psychiatry. 2011 Aug 4;11:127–127. doi:10.1186/1471-244x-11-127 Palmieri P, Leyva-Moral J, Camacho-Rodriguez D, Granel-Giménez N, Ford E, Mathieson K, et al. Hospital survey on patient safety culture (HSOPSC): a multi-method approach for target-language instrument translation, adaptation, and validation to improve the equivalence of meaning for cross-cultural research. BMC Nurs. 2020 Apr 13;19. doi:10.1186/s12912-020-00419-9 Additional Declarations No competing interests reported. Supplementary Files SupplementaryFile1COREQChecklist.docx SupplementaryFile2.docx SupplementaryTableS1.docx SupplementaryTableS2.docx Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-9602132","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":635499290,"identity":"63241d66-ff48-4d09-814c-33b26e64edcf","order_by":0,"name":"Jing 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Introduction","content":"\u003cp\u003eEngaging in regular physical activity(PA) during pregnancy is linked to lower risks of gestational diabetes mellitus, excessive gestational weight gain, pre-eclampsia, and postpartum depression\u003csup\u003e[\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]\u003c/sup\u003e. The World Health Organization (WHO) advises pregnant women without contraindications to participate in a minimum of 150 minutes of moderate-intensity aerobic exercise weekly\u003csup\u003e[\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]\u003c/sup\u003e. Global adherence to physical activity guidelines remains low despite recommendations. Meta-analytic evidence indicates that in China, only about 21% of pregnant women achieve the recommended physical activity levels\u003csup\u003e[\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]\u003c/sup\u003e, with most of their activity being low-intensity household tasks rather than structured exercise\u003csup\u003e[\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]\u003c/sup\u003e.\u003c/p\u003e \u003cp\u003eIdentifying the psychosocial factors influencing physical activity in pregnancy is crucial for developing effective behavioral interventions.The Exercise Benefits/Barriers Scale (EBBS), created by Sechrist, Walker, and Pender\u003csup\u003e[\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]\u003c/sup\u003e, is a prominent tool for assessing perceived exercise benefits and barriers. It comprises two subscales: Exercise Benefits (29 items across physical, mental-emotional, and social domains) and Exercise Barriers (14 items across individual, interpersonal, and environmental domains). The Pregnancy Exercise Self-Efficacy Scale (P-ESES), was modified by Bland et al.\u003csup\u003e[\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]\u003c/sup\u003e, assesses pregnant women\u0026rsquo;s confidence in maintaining exercise across ten challenging scenarios.The Chinese translation of the Pregnancy Exercise Self-Efficacy Scale (P-ESES) has shown satisfactory psychometric properties\u003csup\u003e[\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]\u003c/sup\u003e. However, like all self-report questionnaires, they are vulnerable to construct underrepresentation\u0026mdash;the risk that important domains of the target construct are omitted from the instrument\u003csup\u003e[\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]\u003c/sup\u003e. Cultural, geographical, and healthcare-system contexts may generate unique barriers or benefits that the original scale developers did not anticipate.\u003c/p\u003e \u003cp\u003eThe convergent parallel mixed methods design offers a rigorous methodological solution to the question of whether questionnaires adequately capture lived experience\u003csup\u003e[\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e, \u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]\u003c/sup\u003e. By collecting and analysing quantitative and qualitative data concurrently, researchers can examine the extent to which statistical patterns converge with, diverge from, or complement narrative accounts\u003csup\u003e[\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e]\u003c/sup\u003e. When scale items and interview themes align, content validity is strengthened; when qualitative data reveal phenomena absent from the scale, instrument refinement and theory development are prompted\u003csup\u003e[\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e]\u003c/sup\u003e.\u003c/p\u003e \u003cp\u003eThis study aimed to: (i) explore, via in-depth interviews, pregnant women's lived experiences of exercise benefits, barriers, and self-efficacy; (ii)integrate quantitative and qualitative findings through item-level triangulation to determine the degree of convergence and divergence between scale scores and interview narratives; (iii) identify any qualitatively salient themes that are absent from the EBBS and P-ESES item sets.\u003c/p\u003e \u003cp\u003eThis study uses the same quantitative dataset as our previously published cross-sectional report\u003csup\u003e[\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e]\u003c/sup\u003e, which examined the predictive hierarchy of psychosocial factors for physical activity adherence. The present manuscript addresses a fundamentally different research question\u0026mdash;not which factor predicts behavior, but whether the instruments we use to measure those factors adequately capture the lived experiential reality of the target population. The two contributions are thus complementary: the first paper identified what matters (perceived barriers), while the present paper examines whether our tools for assessing those factors are fit for purpose. No qualitative data, thematic analysis, or triangulation procedure has been reported previously.\u003c/p\u003e"},{"header":"2. Methods","content":"\u003cp\u003e2.1 Study design and participants\u003c/p\u003e\n\u003cp\u003eThis study \u0026nbsp;utilized a convergent parallel mixed methods design, collecting quantitative and qualitative data concurrently, analyzing them separately, and integrating \u0026nbsp;the \u0026nbsp;results during interpretation using a joint display table for comparison and contrast\u003csup\u003e[\u003c/sup\u003e\u003csup\u003e10,11\u003c/sup\u003e\u003csup\u003e]\u003c/sup\u003e.\u003c/p\u003e\n\u003cp\u003eA multi-center cross-sectional survey was conducted from January 27 to February 21, 2024, at three locations in China: Zhongshan, Guangdong Province (southern, subtropical); Ningbo, Zhejiang Province (eastern, temperate); and Xi\u0026apos;an, Shanxi Province (northern, continental). These sites were selected to capture geographical and climatic diversity. A total of 335 pregnant women attending routine antenatal visits at the participating hospitals were enrolled. Participants \u0026nbsp;were eligible if they were aged 20\u0026ndash;45 years, had a singleton pregnancy \u0026nbsp;without complications or comorbidities that contraindicated physical activity, and were able to understand the study\u0026apos;s purpose and procedures, demonstrating a willingness to participate voluntarily.Women with incomplete or inconsistent data submissions were excluded.\u003c/p\u003e\n\u003cp\u003eThe Ethics Committee of the Philippine Women\u0026apos;s University (ERB2024_007) \u0026nbsp; provided single IRB oversight and approved the multi-center protocol for all three data collection sites. The First Affiliated Hospital of Ningbo University granted additional local ethics approval (Approval No.).2024 035A-1), the site contributing the largest participant sample . Participants gave written informed consent before joining the study.\u003c/p\u003e\n\u003cp\u003e2.2 Sampling\u003c/p\u003e\n\u003cp\u003e2.2.1 Quantitative sampling\u003c/p\u003e\n\u003cp\u003eAll eligible pregnant women who attended routine antenatal visits at the three participating hospitals during the recruitment period were invited to participate. The sample size justification and power calculation are detailed in the companion cross-sectional paper\u003csup\u003e[\u003c/sup\u003e\u003csup\u003e14\u003c/sup\u003e\u003csup\u003e]\u003c/sup\u003e\u003csup\u003e\u0026nbsp;\u003c/sup\u003e, utilizing the same quantitative dataset, provides the sample size justification and power calculation. In brief, the sample of 335 participants exceeded the minimum required based on an events-per-variable rule for logistic regression models with up to eight predictors, assuming a 20\u0026ndash;30% physical activity adequacy rate as reported in previous Chinese studies\u003csup\u003e[\u003c/sup\u003e\u003csup\u003e4\u003c/sup\u003e\u003csup\u003e]\u003c/sup\u003e.\u003c/p\u003e\n\u003cp\u003e2.2.2 Qualitative sampling\u003c/p\u003e\n\u003cp\u003eFrom the quantitative sample of 335 participants, a purposive subsample was recruited for semi-structured interviews. Sampling aimed to achieve diversity in parity (primipara vs. multipara),education level, and province(Table 3). Creswell \u003csup\u003e[\u003c/sup\u003e\u003csup\u003e15\u003c/sup\u003e\u003csup\u003e]\u003c/sup\u003e suggests that a reasonable sample size for a phenomenological study ranges from 5 to 25 participants, depending on data saturation. The study involved 30 participants, and data saturation was achieved as no new themes or insights emerged from the final interviews.\u003c/p\u003e\n\u003cp\u003e2.3 Measures and Data Collection\u003c/p\u003e\n\u003cp\u003e2.3.1 Quantitative measures\u003c/p\u003e\n\u003cp\u003eThree validated \u0026nbsp;instruments were used. The Pregnancy Physical Activity Questionnaire (PPAQ) in Chinese \u003csup\u003e[\u003c/sup\u003e\u003csup\u003e16,17\u003c/sup\u003e\u003csup\u003e]\u003c/sup\u003e\u003csup\u003e\u0026nbsp;\u003c/sup\u003eevaluated the duration, frequency, and intensity of physical activity during pregnancy.\u0026nbsp;The World Health Organization (2020)\u003csup\u003e[\u003c/sup\u003e\u003csup\u003e3\u003c/sup\u003e\u003csup\u003e]\u003c/sup\u003erecommends that pregnant women achieve \u0026nbsp;adequate physical activity by participating in at least 150 minutes of moderate-intensity aerobic exercise weekly\u003csup\u003e[\u003c/sup\u003e\u003csup\u003e18\u003c/sup\u003e\u003csup\u003e]\u003c/sup\u003e. The Exercise Benefits/Barriers Scale (EBBS) \u003csup\u003e[\u003c/sup\u003e\u003csup\u003e6\u003c/sup\u003e\u003csup\u003e]\u003c/sup\u003e assesses perceived benefits (29 items) and barriers (14 items) to exercise.\u0026nbsp;The Chinese Pregnancy Exercise Self-Efficacy Scale (P-ESES) \u003csup\u003e[\u003c/sup\u003e\u003csup\u003e8\u003c/sup\u003e\u003csup\u003e]\u003c/sup\u003e evaluated participants\u0026apos; confidence in sustaining exercise through ten difficult scenarios.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eAn electronic questionnaire incorporating demographic data and the three scales was distributed through the \u0026apos;Questionnaire Star\u0026apos; platform. The questionnaire\u0026apos;s homepage provided explanations of the study\u0026apos;s purpose and the definitions of physical activity and exercise. The questionnaire stated that initiation of the survey constituted voluntary consent to participate. Screening was automated: if a participant selected any option indicating ineligibility, the program exited; otherwise, the questionnaire continued until completion.\u003c/p\u003e\n\u003cp\u003e2.3.2 Qualitative data collection\u003c/p\u003e\n\u003cp\u003eAt the end of the electronic questionnaire, participants were asked whether they would be willing to participate in a follow-up telephone interview. Those who agreed provided their phone numbers. Researchers contacted participants within 24 hours of submission and confirmed the convenient time, conducted a semi-structured in-depth telephone interview. A total of 42 pregnant women were contacted; 12 declined the interview. Finally, after analyzing the data of the 30th interviewee and confirming no new information was available, the researchers stopped contacting the interviewees. The interview guide, \u0026nbsp;informed by the Health Belief Model (HBM) constructs\u003csup\u003e[\u003c/sup\u003e\u003csup\u003e19\u003c/sup\u003e\u003csup\u003e]\u0026nbsp;\u003c/sup\u003e(Supplementary File 2), encompassed perceived susceptibility, severity, benefits, barriers, cues to action, self-efficacy, and general exercise experience. Interviews, lasting 30\u0026ndash;60 minutes, were audio-recorded with participants\u0026apos; verbal consent. The researcher maintained a neutral and objective attitude throughout and recorded not only the content of statements but also participants\u0026apos; tone, pauses, and repetitions. When questions or ambiguities arose, the researcher promptly clarified with participants. After each interview, the researcher summarized the main points for the participant to verify their accuracy.\u003c/p\u003e\n\u003cp\u003eDuring the interviews, the researcher used flexible probing techniques to elicit richer and more specific responses. Example probes included:\u003c/p\u003e\n\u003cp\u003eFor perceived barriers: \u0026ldquo;Can you tell me about a specific time when you wanted to exercise but couldn\u0026apos;t? What stopped you?\u0026rdquo; / \u0026ldquo;Did any healthcare provider talk to you about exercise during your prenatal visits? What did they say?\u0026rdquo;\u003c/p\u003e\n\u003cp\u003eFor perceived benefits: \u0026ldquo;You mentioned exercise is good for the baby\u0026mdash;can you give me a specific example of what you mean by \u0026apos;good\u0026apos;? How do you feel during or after a walk?\u0026rdquo;\u003c/p\u003e\n\u003cp\u003eFor self-efficacy: \u0026ldquo;You said you feel confident about exercising\u0026mdash;what makes you feel that way? Can you think of a situation where you might feel less confident? What would help?\u0026rdquo;\u003c/p\u003e\n\u003cp\u003eFor cues to action: \u0026ldquo;Did anyone\u0026mdash;such as your husband, your mother, or a doctor\u0026mdash;encourage you to exercise? What did they say or do that made a difference?\u0026rdquo;\u003c/p\u003e\n\u003cp\u003eFor overall experience: \u0026ldquo;If you could change one thing about your exercise experience during this pregnancy, what would it be?\u0026rdquo;\u003c/p\u003e\n\u003cp\u003e2.4 Data analysis\u003c/p\u003e\n\u003cp\u003e2.4.1 Quantitative analysis\u003c/p\u003e\n\u003cp\u003eSPSS version 26.0 was used for quantitative data analysis. Descriptive statistics (means, standard deviations, percentages) were calculated for all variables. A multivariable logistic regression analysis assessed the independent impacts of perceived benefits, perceived barriers, and exercise self-efficacy on meeting WHO physical activity guidelines, while adjusting for covariates such as age, pre-pregnancy BMI, parity, education, household income, and province. A p-value of less than \u0026nbsp;0.05 (two-tailed) was considered statistically significant. A correlation matrix of the psychosocial variables is provided as Supplementary Table S2.\u003c/p\u003e\n\u003cp\u003e2.4.2 Qualitative analysis\u003c/p\u003e\n\u003cp\u003eAudio recordings were transcribed verbatim and imported into NVivo software version 12 (Lumivero, USA). Thematic analysis adhered to Braun and Clarke\u0026apos;s six-phase method: familiarization, initial coding, theme generation, theme review, theme definition, and report writing\u003csup\u003e[\u003c/sup\u003e\u003csup\u003e20\u003c/sup\u003e\u003csup\u003e]\u003c/sup\u003e. The coding process was inductive, with themes emerging directly from the data instead \u0026nbsp;of \u0026nbsp; being based on pre-existing theoretical frameworks.The researcher listened to recordings while cross-checking field notes to ensure accuracy.In translating texts and extracting information, the participants\u0026apos; own perspectives were prioritized over the researcher\u0026apos;s assumptions.The qualitative interview guide was structured according to the HBM constructs (Supplementary File 2), which served solely as a data collection framework to ensure comprehensive coverage of theoretical domains.The HBM constructs did not guide the coding process. The resulting themes were subsequently organized using Socio-Ecological Model (SEM)\u003csup\u003e\u0026nbsp;[\u003c/sup\u003e\u003csup\u003e21\u003c/sup\u003e\u003csup\u003e]\u003c/sup\u003e as\u0026nbsp;\u0026nbsp;a descriptive reporting framework, with barriers mapped to the intrapersonal, interpersonal, and community/organizational levels. SEM was applied only at the theme-organization stage, not during theme generation. The qualitative component was reported in accordance with\u0026nbsp;COREQ guidelines\u003csup\u003e[\u003c/sup\u003e\u003csup\u003e22\u003c/sup\u003e\u003csup\u003e]\u003c/sup\u003e\u003csup\u003e\u0026nbsp;\u003c/sup\u003e(Supplementary File\u0026nbsp; 1).\u003c/p\u003e\n\u003cp\u003e2.4.3 Integration (Triangulation)\u003c/p\u003e\n\u003cp\u003eIntegration occurred at the interpretation level via a joint display table (Table 4)\u003csup\u003e\u0026nbsp;[\u003c/sup\u003e\u003csup\u003e12,13\u003c/sup\u003e\u003csup\u003e]\u003c/sup\u003e. Each item from the EBBS Benefits subscale, EBBS Barriers subscale, and P-ESES was listed alongside corresponding qualitative transcript quotes. A determination of \u0026quot;Convergence,\u0026quot; \u0026quot;Divergence,\u0026quot; or \u0026quot;Partial Convergence\u0026quot; was made for each item based on the following criteria:\u003c/p\u003e\n\u003cp\u003eConvergence: Qualitative data contained at least one participant quote that directly endorsed the conceptual content of the scale item, and no contradictory evidence was present.\u003c/p\u003e\n\u003cp\u003eDivergence: Qualitative data revealed a salient theme that was conceptually related to the scale domain but was not represented by any scale item; OR the scale item was not endorsed by any qualitative participant.\u003c/p\u003e\n\u003cp\u003ePartial Convergence: Qualitative data both supported and contradicted the scale item OR the item was partially represented but with notable nuance or qualification.\u003c/p\u003e\n\u003cp\u003eThe amount of convergent, divergent, and partially convergent items was calculated for each scale. Qualitative themes lacking corresponding scale items were categorized as \u0026apos;Emergent\u0026mdash;Instrument Blind Spot\u0026apos; and analyzed for their theoretical and practical implications. For the interpretation of behavioral mechanisms underpinning the convergent and divergent findings, the COM-B model\u003csup\u003e\u0026nbsp;[\u003c/sup\u003e\u003csup\u003e23\u003c/sup\u003e\u003csup\u003e]\u003c/sup\u003e was applied in the Discussion.\u003c/p\u003e"},{"header":"3. Results","content":"\u003cdiv id=\"Sec15\" class=\"Section2\"\u003e \u003ch2\u003e3.1 Quantitative Results\u003c/h2\u003e \u003cdiv id=\"Sec16\" class=\"Section3\"\u003e \u003ch2\u003e3.1.1 Sample Characteristics and Descriptive Statistics\u003c/h2\u003e \u003cp\u003eTable\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e shows the characteristics of the 335 participants. They had a mean age of 30.57\u0026thinsp;\u0026plusmn;\u0026thinsp;3.498 years and a mean pre-pregnancy BMI of 21.20\u0026thinsp;\u0026plusmn;\u0026thinsp;2.89 kg/m\u0026sup2;. The majority were primiparous (72.8%), had attained tertiary education or above (85.7%), and were employed during pregnancy (67.8%). Mean gestational age at assessment was34.29\u0026thinsp;\u0026plusmn;\u0026thinsp;4.87 weeks. The majority (94.6%) were in the third trimester.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eParticipant Characteristics (n\u0026thinsp;=\u0026thinsp;335)\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"2\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCharacteristic\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003en (%) or Mean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAge (years)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e30.57\u0026thinsp;\u0026plusmn;\u0026thinsp;3.498\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHeight (cm)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e161.18\u0026thinsp;\u0026plusmn;\u0026thinsp;5.528\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePre-pregnancy weight (kg)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e55.092\u0026thinsp;\u0026plusmn;\u0026thinsp;8.089\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCurrent weight (kg)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e66.627\u0026thinsp;\u0026plusmn;\u0026thinsp;8.87\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePre-pregnancy BMI (kg/m\u0026sup2;)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e21.20\u0026thinsp;\u0026plusmn;\u0026thinsp;2.89\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eGestational age (weeks)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e34.29\u0026thinsp;\u0026plusmn;\u0026thinsp;4.87\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eEducation\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eJunior high and below\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e14(4.2%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHigh school/Technical secondary\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e34(10.1%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCollege/Undergraduate\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e259(77.3%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eGraduate\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e28(8.4%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eCurrent employment status\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eEmployed\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e227(67.8%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eUnemployed\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e108(32.2%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eCurrent stage of pregnancy\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFirst trimester(\u0026le;\u0026thinsp;13\u0026thinsp;\u003csup\u003e+\u0026thinsp;6\u003c/sup\u003e weeks)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e6(1.8%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSecond trimester(14\u0026thinsp;~\u0026thinsp;27\u003csup\u003e+6\u003c/sup\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e12(3.6%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eThird trimester(\u0026ge;\u0026thinsp;28 weeks)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e317(94.6%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eParity\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePrimipara\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e244(72.8%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMultipara\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e91(27.2%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eResidence type\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eUrban\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e294(87.8%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eRural\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e41(12.2%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eLiving arrangements\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eco‑residence with parents/in-laws\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e144(43.0%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLiving separately from parents/in-laws\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e191(57.0%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eAnnual household income (RMB)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;100k\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e72(21.5%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e100kཞ300k\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e201(60%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026gt;\u0026thinsp;300k\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e62(18.5%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec17\" class=\"Section3\"\u003e \u003ch2\u003e3.1.2 Exercise-Related Psychosocial Factors and Physical Activity Levels\u003c/h2\u003e \u003cp\u003eOn the EBBS, participants reported a high level of perceived exercise benefits (mean\u0026thinsp;=\u0026thinsp;86.94\u0026thinsp;\u0026plusmn;\u0026thinsp;11.37) and a medium level of perceived exercise barriers (mean\u0026thinsp;=\u0026thinsp;29.96\u0026thinsp;\u0026plusmn;\u0026thinsp;5.675). Exercise self-efficacy, measured by the P-ESES, was at a medium level (mean\u0026thinsp;=\u0026thinsp;36.21\u0026thinsp;\u0026plusmn;\u0026thinsp;5.484). The average total physical activity was 183.56\u0026thinsp;\u0026plusmn;\u0026thinsp;87.01 MET-hours/week, with 29% (n\u0026thinsp;=\u0026thinsp;97) meeting the WHO guideline of at least 150 minutes of moderate-intensity activity weekly. Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e presents the physical activity and psychosocial scale scores.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003ePhysical activity and psychosocial scale scores (n\u0026thinsp;=\u0026thinsp;335)\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"2\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eScale/Measure\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePhysical Activity (PPAQ)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSedentary Behavior (MET-hours/week)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e[100.12\u0026thinsp;\u0026plusmn;\u0026thinsp;44.67]\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLow-intensity PA (MET-hours/week)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e[49.78\u0026thinsp;\u0026plusmn;\u0026thinsp;38.61]\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eModerate-intensity PA (MET-hours/week)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e[33.09\u0026thinsp;\u0026plusmn;\u0026thinsp;43.08]\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eVigorous-intensity PA (MET-hours/week)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e[0.57\u0026thinsp;\u0026plusmn;\u0026thinsp;2.16]\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTotal energy expenditure(MET-hours/week)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e[183.56\u0026thinsp;\u0026plusmn;\u0026thinsp;87.01]\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMeeting WHO Recommendation (\u0026ge;\u0026thinsp;150 min/week), n (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e97(29%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003ePsychosocial Scales\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eEBBS \u0026mdash; Exercise Benefits\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e86.94\u0026thinsp;\u0026plusmn;\u0026thinsp;11.37\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eEBBS \u0026mdash; Exercise Barriers\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e29.96\u0026thinsp;\u0026plusmn;\u0026thinsp;5.675\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eP-ESES \u0026mdash; Exercise Self-Efficacy\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e36.21\u0026thinsp;\u0026plusmn;\u0026thinsp;5.484\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"2\"\u003eNote.The EBBS Benefits subscale ranges from 29 to 116, the EBBS Barriers subscale ranges from 14 to 56, and the P-ESES ranges from 10 to 50.Elevated scores reflect increased levels of the corresponding construct.PA stands for physical activity, PPAQ refers to the Pregnancy Physical Activity Questionnaire, EBBS denotes the Exercise Benefits/Barriers Scale, and P-ESES is the Pregnancy Exercise Self-Efficacy Scale.\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec18\" class=\"Section3\"\u003e \u003ch2\u003e3.1.3 Logistic Regression Analysis of Psychosocial Predictors\u003c/h2\u003e \u003cp\u003eA multivariable logistic regression model was developed to assess the independent impacts of perceived exercise benefits, barriers, and self-efficacy on physical activity adequacy, while adjusting for factors such as age, education, employment, residence type, living arrangement, household income, gestational weeks, trimester, parity, and province (Supplementary Table \u003cspan refid=\"MOESM1\" class=\"InternalRef\"\u003eS1\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e Among the three psychosocial variables, only perceived barriers emerged as a significant independent predictor.Increased perceived barriers correlated with decreased likelihood of adhering to PA guidelines (adjusted OR\u0026thinsp;=\u0026thinsp;0.93, 95% CI 0.88\u0026ndash;0.98, p\u0026thinsp;=\u0026thinsp;0.004). After adjusting for barriers and covariates, perceived benefits (adjusted OR\u0026thinsp;=\u0026thinsp;1.01, 95% CI 0.98\u0026ndash;1.04, p\u0026thinsp;=\u0026thinsp;0.368) and exercise self-efficacy (adjusted OR\u0026thinsp;=\u0026thinsp;1.05, 95% CI 0.99\u0026ndash;1.11, p\u0026thinsp;=\u0026thinsp;0.137) were not statistically significant.\u003c/p\u003e \u003cp\u003eBivariate Spearman correlations among the psychosocial variables (Supplementary Table \u003cspan refid=\"MOESM2\" class=\"InternalRef\"\u003eS2\u003c/span\u003e) provide context for these findings. Perceived benefits and exercise self-efficacy showed a moderate positive correlation (r\u0026thinsp;=\u0026thinsp;0.576, p\u0026thinsp;\u0026lt;\u0026thinsp;0.001), indicating shared variance that could account for their loss of significance when analyzed together with barriers. Perceived barriers showed a weak negative correlation with benefits (r\u0026thinsp;=\u0026thinsp;\u0026minus;\u0026thinsp;0.250, p\u0026thinsp;\u0026lt;\u0026thinsp;0.001) and a non-significant correlation with self-efficacy (r\u0026thinsp;=\u0026thinsp;\u0026minus;\u0026thinsp;0.086, p\u0026thinsp;=\u0026thinsp;0.118), consistent with its role as an independent predictor distinct from the benefits\u0026ndash;self-efficacy pathway.\u003cb\u003e3.2\u003c/b\u003e 3.2 Qualitative Results\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec19\" class=\"Section3\"\u003e \u003ch2\u003e3.2.1 Characteristics of interviewees\u003c/h2\u003e \u003cp\u003eTable\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e presents the demographic details of the 30 interview participants. Most of them were primiparous in their late pregnancy.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eCharacteristics of interviewees (n\u0026thinsp;=\u0026thinsp;30)\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"7\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eInterviewees\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eAge\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eGestational age\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eParity\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eEducation\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003eWorking status\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c7\"\u003e \u003cp\u003eProvince\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e1#\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e32\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e33.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eMultipara\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eTertiary education\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eEmployed\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eShanxi\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e2#\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e31\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e37.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eMultipara\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eTertiary education\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eEmployed\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eShanxi\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e3#\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e22\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e38.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003ePrimipara\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eSecondary\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eUnemployed\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eZhejiang\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e4#\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e30\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e35.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003ePrimipara\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eTertiary education\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eUnemployed\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eZhejiang\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e5#\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e26\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e37.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003ePrimipara\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eSecondary\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eUnemployed\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eZhejiang\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e6#\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e33\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e39.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003ePrimipara\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eTertiary education\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eEmployed\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eZhejiang\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e7#\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e31\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e32.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003ePrimipara\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eTertiary education\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eEmployed\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eShanxi\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e8#\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e30\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e36.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003ePrimipara\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eTertiary education\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eEmployed\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eZhejiang\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e9#\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e27\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e37.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003ePrimipara\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eTertiary education\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eEmployed\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eZhejiang\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e10#\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e35\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e39.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eMultipara\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eTertiary education\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eEmployed\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eZhejiang\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e11#\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e31\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e34.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003ePrimipara\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eTertiary education\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eEmployed\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eZhejiang\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e12#\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e29\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e34.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003ePrimipara\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eTertiary education\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eUnemployed\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eZhejiang\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e13#\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e25\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e38.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003ePrimipara\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eSecondary\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eUnemployed\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eZhejiang\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e14#\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e30\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e24.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003ePrimipara\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003ePostgraduate\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eEmployed\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eShanxi\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e15#\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e30\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e36.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003ePrimipara\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003ePostgraduate\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eEmployed\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eGuangdong\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e16#\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e31\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e37.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003ePrimipara\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eTertiary education\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eUnemployed\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eGuangdong\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e17#\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e39\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e37.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eMultipara\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eTertiary education\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eEmployed\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eGuangdong\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e18#\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e32\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e36.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003ePrimipara\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eTertiary education\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eEmployed\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eShanxi\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e19#\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e32\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e33.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003ePrimipara\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eTertiary education\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eEmployed\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eShanxi\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e20#\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e31\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e37.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eMultipara\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eSecondary\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eUnemployed\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eGuangdong\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e21#\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e35\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e31.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003ePrimipara\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eTertiary education\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eUnemployed\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eZhejiang\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e22#\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e30\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e39.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003ePrimipara\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003ePostgraduate\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eEmployed\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eShanxi\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e23#\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e35\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e33.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eMultipara\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eTertiary education\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eEmployed\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eGuangdong\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e24#\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e28\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e38.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003ePrimipara\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eTertiary education\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eEmployed\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eGuangdong\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e25#\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e26\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e36.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003ePrimipara\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eSecondary\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eUnemployed\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eGuangdong\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e26#\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e32\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e36.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003ePrimipara\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eTertiary education\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eEmployed\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eGuangdong\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e27#\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e32\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e27.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003ePrimipara\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eSecondary\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eUnemployed\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eZhejiang\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e28#\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e30\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e16.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003ePrimipara\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eTertiary education\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eEmployed\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eGuangdong\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e29#\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e34\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e33.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003ePrimipara\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eTertiary education\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eUnemployed\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eShanxi\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e30#\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e28\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e35.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003ePrimipara\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eTertiary education\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eUnemployed\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eGuangdong\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec20\" class=\"Section3\"\u003e \u003ch2\u003e3.2.2.Themes from Qualitative Interviews\u003c/h2\u003e \u003cp\u003eSix themes emerged from the thematic analysis of the 30 interview transcripts. Each theme is presented below with illustrative quotes (participant number indicated in parentheses).\u003c/p\u003e \u003cp\u003e \u003cb\u003eTheme 1: Cognition of Exercise During Pregnancy\u003c/b\u003e \u003c/p\u003e \u003cp\u003eParticipants held heterogeneous definitions of what constituted \u0026ldquo;exercise\u0026rdquo; during pregnancy. Some equated exercise with structured, higher-intensity activities such as aerobics or jogging, while others considered everyday walking\u0026mdash;even at a slow pace\u0026mdash;as sufficient exercise. Awareness of the WHO's recommendation for 150 minutes per week of moderate-intensity physical activity was significantly limited.\u003c/p\u003e \u003cp\u003e \u003cem\u003e\u0026ldquo;I walk for half an hour every day, about 3 kilometres; I feel like I\u0026rsquo;m not exercising enough, but I\u0026rsquo;m not feeling comfortable walking too much.\u0026rdquo; (14#)\u003c/em\u003e \u003c/p\u003e \u003cp\u003e \u003cem\u003e\u0026ldquo;I follow the TikTok anchor to do aerobics 3\u0026ndash;4 times a week, each time for an hour, and I think my exercise is enough.\u0026rdquo; (15#)\u003c/em\u003e \u003c/p\u003e \u003cp\u003e Several participants emphasised individualised, medically guided decision-making over generic guidelines. Respect for bodily sensations and physician advice was prioritised above adherence to numerical recommendations.\u003c/p\u003e \u003cp\u003e \u003cem\u003e\u0026ldquo;Exercise should be customized to individual physical conditions, given varying exercise tolerances. You should talk to your doctor to see if you can exercise.\u0026rdquo; (20#)\u003c/em\u003e \u003c/p\u003e \u003cp\u003e \u003cb\u003eTheme 2: Motivations for Exercise\u003c/b\u003e \u003c/p\u003e \u003cp\u003eThe most frequently cited motivation was facilitative childbirth\u0026mdash;exercising to build stamina and improve the likelihood of a smooth vaginal delivery. Weight management during pregnancy was the second most common reason. Multiparous women occasionally mentioned exercising as a shared activity with their existing children.\u003c/p\u003e \u003cp\u003e \u003cem\u003e\u0026ldquo;I exercise because I want to stay in shape and have more energy during labor. People who don\u0026rsquo;t exercise feel exhausted.\u0026rdquo; (3#)\u003c/em\u003e \u003c/p\u003e \u003cp\u003e \u003cem\u003eInterestingly, a multiparous participant stated, \u0026ldquo;I don't want to exercise because I plan on having a C-section later.\u0026rdquo; (2#)\u003c/em\u003e \u003c/p\u003e \u003cp\u003e \u003cb\u003eTheme 3: Factors Influencing Exercise Participation\u003c/b\u003e \u003c/p\u003e \u003cp\u003eThis was the most data-rich theme. Facilitators included family companionship (especially spousal support), peer companionship (walking with other pregnant women), reminders from medical staff, pre-pregnancy exercise habits, intrinsic willingness, and mood enhancement.\u003c/p\u003e \u003cp\u003e \u003cem\u003e\u0026ldquo;I am willing to go out if someone is with me, especially if my husband is with me. It feels very different when someone is with me\u0026hellip;\u0026rdquo; (30#)\u003c/em\u003e \u003c/p\u003e \u003cp\u003e \u003cem\u003e\u0026ldquo;The medical staff reminded me to go out and exercise every day.\u0026rdquo; (20#)\u003c/em\u003e \u003c/p\u003e \u003cp\u003eBarriers were multidimensional and intersecting. Weather was mentioned by more than half of participants as a primary deterrent. Time scarcity, physical fatigue, lack of companionship, absence of healthcare provider advice, fear of preterm labour, and pregnancy-related physical discomfort (back pain, pelvic pain, abdominal tightness, severe nausea) were also prominent.\u003c/p\u003e \u003cp\u003e \u003cem\u003e\u0026ldquo;I\u0026rsquo;m so tired after work, and I have to take care of the kids, so how can I find time to exercise?\u0026rdquo; (1#)\u003c/em\u003e \u003c/p\u003e \u003cp\u003e \u003cem\u003e\u0026ldquo;When I'm in a bad mood, I tend to avoid going out, and the medical staff did not provide guidance on exercising. \u0026rdquo; (15#)\u003c/em\u003e \u003c/p\u003e \u003cp\u003e \u003cem\u003e\u0026ldquo;Whenever I walk, I get abdominal pain and pubic pain.\u0026rdquo; (24#)\u003c/em\u003e \u003c/p\u003e \u003cp\u003e \u003cb\u003eTheme 4: Action Inspiration and Information Sources\u003c/b\u003e \u003c/p\u003e \u003cp\u003eOne-third of participants reported receiving no exercise-related information or advice from medical staff during prenatal care. Information sources were predominantly informal: family members (especially sisters and mothers who had positive exercise experiences), the Internet (short video platforms such as TikTok), and personal physical sensations.\u003c/p\u003e \u003cp\u003e \u003cem\u003e\u0026ldquo;My sister and mom wanted me to exercise more during my pregnancy because my sister gave birth so quickly\u0026hellip;\u0026rdquo; (3#)\u003c/em\u003e \u003c/p\u003e \u003cp\u003e \u003cem\u003e\u0026ldquo;I learned about stretching exercises from the internet\u0026hellip; the hospital staff didn\u0026rsquo;t tell me how to do them.\u0026rdquo; (25#)\u003c/em\u003e \u003c/p\u003e \u003cp\u003e \u003cb\u003eTheme 5: Post-Exercise Feelings and Experiences\u003c/b\u003e \u003c/p\u003e \u003cp\u003eParticipants who exercised regularly reported predominantly positive somatic and affective outcomes: improved mood, quicker gastrointestinal motility, increased appetite, and better sleep quality. A minority reported feeling no particular change, and a few reported post-exercise fatigue requiring rest. One participant noted that sedentary work made her feel sluggish, and exercise restored agility.\u003c/p\u003e \u003cp\u003e \u003cem\u003e\u0026ldquo;After my walks, I feel less tired, sleep better, and have less pain.\u0026rdquo; (20#)\u003c/em\u003e \u003c/p\u003e \u003cp\u003e \u003cem\u003e\u0026ldquo;I sit a lot at work, and I become more agile after exercising\u0026hellip;\u0026rdquo; (28#)\u003c/em\u003e \u003c/p\u003e \u003cp\u003e \u003cb\u003eTheme 6: Confidence in Maintaining Exercise\u003c/b\u003e \u003c/p\u003e \u003cp\u003eEleven participants expressed confident intentions to continue exercising until delivery. Two explicitly lacked confidence. Two made their confidence conditional on weather (\u0026ldquo;if it does not rain\u0026rdquo;). Several participants linked confidence directly to the availability of social support or habit strength rather than purely internal resolve.\u003c/p\u003e \u003cp\u003e \u003cem\u003e\u0026ldquo;You know, exercise is a habit of mine. I feel uncomfortable if I don\u0026rsquo;t move for a day.\u0026rdquo; (27#)\u003c/em\u003e \u003c/p\u003e \u003cp\u003e \u003cem\u003e\u0026ldquo;When the weather is good, I go for a walk or a swim. When the weather is terrible, I practice yoga or aerobics at home.\u0026rdquo; (10#)\u003c/em\u003e \u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv id=\"Sec21\" class=\"Section2\"\u003e \u003ch2\u003e3.3 Integrated Findings: Triangulation of Quantitative and Qualitative Data\u003c/h2\u003e \u003cp\u003eTable\u0026nbsp;\u003cspan refid=\"Tab4\" class=\"InternalRef\"\u003e4\u003c/span\u003e presents the joint display of scale items, corresponding qualitative quotes, mention frequencies, and convergence/divergence determinations.\u003c/p\u003e \u003cdiv id=\"Sec22\" class=\"Section3\"\u003e \u003ch2\u003e3.3.1 Convergence\u003c/h2\u003e \u003cp\u003eExercise Benefits (EBBS). All nine benefit items examined across the three subscales (physical performance, mental-emotional, pregnancy/childbirth-related) demonstrated convergence with qualitative data. Interviewees spontaneously articulated benefits that mapped directly onto scale item content. The physical benefit of exercise in reducing fatigue (E29) was corroborated by five distinct statements, such as \"I don\u0026rsquo;t feel that tired after exercise (lower back pain is relieved a bit).\" Additionally, the pregnancy-related benefit of enhanced physical endurance through exercise (E31) emerged as the most commonly supported theme, with ten participants associating it with easier and quicker labor. This strong convergence suggests that the EBBS benefits subscale possesses robust content validity for Chinese pregnant women.\u003c/p\u003e \u003cp\u003eExercise Barriers\u0026mdash;Individual, Interpersonal, and Community Domains. The majority of barrier items in the individual/intrapersonal, relationship/interpersonal, and community subscales converged with qualitative data. Time scarcity (E4), exercise-induced fatigue (E19), exercise difficulty (E40), spousal non-encouragement (E21), conflict with family responsibilities (E24), and family non-encouragement (E33) were all represented in interview transcripts. Mention frequencies ranged from 1 to 4 per item.\u003c/p\u003e \u003cp\u003ePregnancy Exercise Self-Efficacy (P-ESES). Six of the ten self-efficacy items converged with qualitative accounts. Items concerning the ability to overcome barriers (P1), find alternative exercise means (P2), and accomplish self-set goals (P3) were supported by participants\u0026rsquo; descriptions of habit-driven exercise, weather-adaptive strategies, and goal-directed persistence. The statement \u0026ldquo;I am confident that I can exercise even without the support of my family and friends\u0026rdquo; (P7) was affirmed by 11 participants, indicating their autonomous confidence in maintaining exercise routines until delivery.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec23\" class=\"Section3\"\u003e \u003ch2\u003e3.3.2 Divergence\u003c/h2\u003e \u003cp\u003eThree categories of divergence were identified, each representing a clinically and theoretically significant blind spot in the existing instruments.\u003c/p\u003e \u003cp\u003eDivergence 1: Lack of Healthcare Provider Advice (Social/Environmental Barrier). Seven participants explicitly stated that medical staff had provided no specific exercise guidance. Representative quotes included: \u0026ldquo;The medical staff did not give me any specific exercise advice, and I don\u0026rsquo;t know what kind of exercise and when it is appropriate.\u0026rdquo; This theme was qualitatively salient and conceptually aligned with the social/environmental barrier domain, yet the EBBS contains no item addressing professional healthcare support or guidance. This divergence suggests that the scale underrepresents the healthcare system's role as a structural enabler or barrier.\u003c/p\u003e \u003cp\u003eDivergence 2: Weather and Climate as Environmental Barriers. Fourteen participants spontaneously identified weather conditions (cold, rain) as major deterrents to outdoor exercise. Quotes such as \u0026ldquo;I don\u0026rsquo;t want to go out when the weather is terrible\u0026rdquo; and \u0026ldquo;The weather is too cold, and it\u0026rsquo;s raining these days\u0026rdquo; were common. Despite the high qualitative frequency, no EBBS item addresses climatic or environmental conditions. This omission is particularly significant for studies conducted in regions with extreme seasonal variation or tropical climates, where weather may constitute a primary ecological barrier.\u003c/p\u003e \u003cp\u003eDivergence 3: Self-Efficacy Without Facility Access (P10). The P-ESES item P10, which states, 'I am confident that I can exercise even without access to a gym, exercise, training, or rehabilitation facility,' received no qualitative endorsements. No participant mentioned gym or facility access as a relevant factor in their exercise decisions. This divergence suggests that, in the Chinese cultural context, pregnant women conceptualize exercise as walking, a household activity, or online-guided home exercise rather than facility-dependent gym exercise. The item may have limited ecological validity for this population.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec24\" class=\"Section3\"\u003e \u003ch2\u003e3.3.3 Partial Convergence\u003c/h2\u003e \u003cp\u003eOne self-efficacy item demonstrated partial convergence. Participant expressed a strong belief in their ability to exercise independently (P7), as evidenced by 11 quotes highlighting autonomous confidence. However, two participants provided contradictory evidence: \u0026ldquo;I don\u0026rsquo;t have the confidence to stick to exercise unless someone accompanies me,\u0026rdquo; indicating that social support was not merely facilitative but psychologically necessary for some women. This partial convergence highlights the heterogeneity of self-efficacy sources within the sample.\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e"},{"header":"4. Discussion","content":"\u003cdiv id=\"Sec26\" class=\"Section2\"\u003e\n \u003ch2\u003e4.1 Summary of Key Findings\u003c/h2\u003e\n \u003cp\u003eThis convergent mixed methods study triangulated questionnaire data from 335 pregnant women with in-depth interview accounts from 30 purposively selected participants across three Chinese provinces. The quantitative strand confirmed that perceived barriers were the dominant psychosocial predictor of physical activity inadequacy, a finding consistent with our previous multi-center report\u003csup\u003e[\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e]\u003c/sup\u003e. The qualitative strand enriched this statistical finding by revealing the specific contents, contexts, and textures of pregnant women\u0026rsquo;s exercise experiences. The integrated triangulation yielded three critical insights.\u003c/p\u003e\n \u003cp\u003eFirst, the EBBS benefits subscale demonstrated robust content validity for Chinese pregnant women, with 100% item-level convergence. This finding supports the cross-cultural transportability of the benefits construct and suggests that Chinese pregnant women recognize and value the same physical, mental, and pregnancy-related benefits of exercise as women in Western contexts.\u003c/p\u003e\n \u003cp\u003eSecond, the EBBS barriers subscale and the P-ESES demonstrated satisfactory but incomplete content coverage. Two qualitatively dominant themes\u0026mdash;lack of healthcare provider advice and weather/climate barriers\u0026mdash;were entirely absent from the EBBS item pool. This absence represents a meaningful construct underrepresentation\u003csup\u003e[\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e]\u003c/sup\u003ewith practical consequences: interventions designed solely around EBBS-identified barriers would fail to address the healthcare system and environmental ecology of physical activity behavior.\u003c/p\u003e\n \u003cdiv class=\"gridtable\"\u003e\u0026nbsp;\u003ctable float=\"Yes\" id=\"Tab4\" border=\"1\"\u003e\n \u003ccaption language=\"En\"\u003e\n \u003cdiv class=\"CaptionNumber\"\u003eTable 4\u003c/div\u003e\n \u003cdiv class=\"CaptionContent\"\u003e\n \u003cp\u003eConvergence or Divergence of the Transcript Data to the Three Scales Results\u003c/p\u003e\n \u003c/div\u003e\n \u003c/caption\u003e\n \u003ccolgroup cols=\"6\"\u003e\u003c/colgroup\u003e\n \u003cthead\u003e\n \u003ctr\u003e\n \u003cth align=\"left\" colname=\"c1\"\u003e\n \u003cp\u003eScale\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\" colname=\"c2\"\u003e\n \u003cp\u003eContents\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\" colname=\"c3\"\u003e\n \u003cp\u003eItems of the Scale\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\" colname=\"c4\"\u003e\n \u003cp\u003eQualitative Transcript Quotes\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\" colname=\"c5\"\u003e\n \u003cp\u003eMentioned times\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\" colname=\"c6\"\u003e\n \u003cp\u003eConvergence/Divergence\u003c/p\u003e\n \u003c/th\u003e\n \u003c/tr\u003e\n \u003c/thead\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colname=\"c1\" morerows=\"9\" rowspan=\"10\"\u003e\n \u003cp\u003eExercise Benefits\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c2\" morerows=\"2\" rowspan=\"3\"\u003e\n \u003cp\u003ePhysical-benefits\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c3\"\u003e\n \u003cp\u003eE7.Exercise increases my muscle strength.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c4\"\u003e\n \u003cp\u003e\u003cem\u003e\u0026ldquo;I exercised to control my weight before I became pregnant and continued to exercise afterward to prevent muscle weakness.\u0026rdquo;\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c5\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c6\"\u003e\n \u003cp\u003eConvergence\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colname=\"c3\"\u003e\n \u003cp\u003eE23.Exercise improves my flexibility.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c4\"\u003e\n \u003cp\u003e\u003cem\u003e\u0026ldquo;I always sit during work, and I feel more agile after exercise.\u0026rdquo;\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c5\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c6\"\u003e\n \u003cp\u003eConvergence\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colname=\"c3\"\u003e\n \u003cp\u003eE29.Exercise helps me decrease fatigue.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c4\"\u003e\n \u003cp\u003e\u003cem\u003e\u0026ldquo;I don\u0026rsquo;t feel that tired after exercise (lower back pain is relieved a bit).\u0026rdquo;\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c5\"\u003e\n \u003cp\u003e5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c6\"\u003e\n \u003cp\u003eConvergence\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colname=\"c2\" morerows=\"2\" rowspan=\"3\"\u003e\n \u003cp\u003eMental-emotional benefits\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c3\"\u003e\n \u003cp\u003eE10.Exercising makes me feel relaxed.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c4\"\u003e\n \u003cp\u003e\u003cem\u003e\u0026ldquo;After exercise, my body is not so tired; I feel much more relaxed.\u0026rdquo;\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c5\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c6\"\u003e\n \u003cp\u003eConvergence\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colname=\"c3\"\u003e\n \u003cp\u003eE2.Exercise decreases feelings of stress and tension for me.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c4\"\u003e\n \u003cp\u003e\u003cem\u003e\u0026ldquo;Going out for a walk makes me feel much happier.\u0026rdquo;\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c5\"\u003e\n \u003cp\u003e5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c6\"\u003e\n \u003cp\u003eConvergence\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colname=\"c3\"\u003e\n \u003cp\u003eE38.Exercise is good entertainment for me.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c4\"\u003e\n \u003cp\u003e\u003cem\u003e\u0026ldquo;I\u0026apos;m bored at home alone, so I can kill time by going out for a walk.\u0026rdquo;\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c5\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c6\"\u003e\n \u003cp\u003eConvergence\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colname=\"c2\" morerows=\"3\" rowspan=\"4\"\u003e\n \u003cp\u003eBenefits related to pregnancy and childbirth\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c3\"\u003e\n \u003cp\u003eE31.My physical endurance is improved by exercising.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c4\"\u003e\n \u003cp\u003e\u003cem\u003e\u0026ldquo;I exercise in the hope that I will have more energy and strength during labor, making the birth faster and smoother.\u0026rdquo;\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c5\"\u003e\n \u003cp\u003e10\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c6\"\u003e\n \u003cp\u003eConvergence\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colname=\"c3\"\u003e\n \u003cp\u003eE26 Exercising helps me sleep better at night.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c4\"\u003e\n \u003cp\u003e\u003cem\u003e\u0026ldquo;I sleep better at night after taking a walk.\u0026rdquo;\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c5\"\u003e\n \u003cp\u003e7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c6\"\u003e\n \u003cp\u003eConvergence\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colname=\"c3\" morerows=\"1\" rowspan=\"2\"\u003e\n \u003cp\u003eE43 Exercise improves the way my body looks.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c4\"\u003e\n \u003cp\u003e\u003cem\u003e\u0026ldquo;I want to stay in shape. \u0026rdquo;\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c5\"\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c6\"\u003e\n \u003cp\u003eConvergence\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colname=\"c4\"\u003e\n \u003cp\u003e\u003cem\u003e\u0026ldquo;Exercise is very important... If you want to control your weight, it is not enough to just control your diet.\u0026rdquo;\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c5\"\u003e\n \u003cp\u003e5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c6\"\u003e\n \u003cp\u003eConvergence\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colname=\"c1\" morerows=\"9\" rowspan=\"10\"\u003e\n \u003cp\u003eExercise Barriers\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c2\" morerows=\"2\" rowspan=\"3\"\u003e\n \u003cp\u003eIndividual/\u003c/p\u003e\n \u003cp\u003eIntrapersonal\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c3\"\u003e\n \u003cp\u003eE4 Exercising takes too much of my time.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c4\"\u003e\n \u003cp\u003e\u003cem\u003e\u0026ldquo;I\u0026apos;m too busy at work; I don\u0026apos;t have time to exercise.\u0026rdquo;\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c5\"\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c6\"\u003e\n \u003cp\u003eConvergence\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colname=\"c3\"\u003e\n \u003cp\u003eE19 I am fatigued by exercise.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c4\"\u003e\n \u003cp\u003e\u003cem\u003e\u0026ldquo;I walked pretty fast in the early stages of pregnancy but couldn\u0026apos;t walk anymore in the later stages. I felt sore legs and back pain...\u0026rdquo;\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c5\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c6\"\u003e\n \u003cp\u003eConvergence\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colname=\"c3\"\u003e\n \u003cp\u003eE40 Exercise is hard work for me.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c4\"\u003e\n \u003cp\u003e\u003cem\u003e\u0026ldquo;My body feels heavy, and I find exercise difficult.\u0026rdquo;\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c5\"\u003e\n \u003cp\u003e4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c6\"\u003e\n \u003cp\u003eConvergence\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colname=\"c2\" morerows=\"2\" rowspan=\"3\"\u003e\n \u003cp\u003eRelationship/\u003c/p\u003e\n \u003cp\u003eInterpersonal\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c3\" morerows=\"2\" rowspan=\"3\"\u003e\n \u003cp\u003eE21 My spouse (or significant other) does not encourage exercising.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c4\"\u003e\n \u003cp\u003e\u003cem\u003e\u0026ldquo;My husband doesn\u0026apos;t support me going out.\u0026rdquo;\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c5\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c6\"\u003e\n \u003cp\u003eConvergence\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colname=\"c4\"\u003e\n \u003cp\u003e\u003cem\u003e\u0026ldquo;I\u0026apos;m alone at home,no one goes out to exercise with me.\u0026rdquo;\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c5\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c6\"\u003e\n \u003cp\u003eConvergence\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colname=\"c4\"\u003e\n \u003cp\u003e\u003cem\u003e\u0026ldquo;I don\u0026apos;t want to go out without my husband.\u0026rdquo;\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c5\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c6\"\u003e\n \u003cp\u003eConvergence\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colname=\"c2\" morerows=\"1\" rowspan=\"2\"\u003e\n \u003cp\u003eCommunity\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c3\"\u003e\n \u003cp\u003eE24 Exercise takes too much time from family relationships.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c4\"\u003e\n \u003cp\u003e\u003cem\u003e\u0026ldquo;With my first child, I could participate in various activities and meet others. Now that I am pregnant with my second child, I need to do housework and take care of the child, so I cannot go out for exercise.\u0026rdquo;\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c5\"\u003e\n \u003cp\u003e4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c6\"\u003e\n \u003cp\u003eConvergence\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colname=\"c3\"\u003e\n \u003cp\u003eE33 My family members do not encourage me to exercise\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c4\"\u003e\n \u003cp\u003e\u003cem\u003e\u0026ldquo;My family doesn\u0026apos;t think it\u0026apos;s necessary to exercise during pregnancy.\u0026rdquo;\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c5\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c6\"\u003e\n \u003cp\u003eConvergence\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colname=\"c2\" morerows=\"1\" rowspan=\"2\"\u003e\n \u003cp\u003eSocial /Environmental\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c3\"\u003e\n \u003cp\u003eSome participants reported that the lack of specific advice from medical staff was a barrier,but the scale had no related item.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c4\"\u003e\n \u003cp\u003e\u003cem\u003e\u0026ldquo;The medical staff did not give me any specific exercise advice, and I don\u0026rsquo;t know what kind of exercise and when it is appropriate.\u0026rdquo;\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c5\"\u003e\n \u003cp\u003e\u003cstrong\u003e7\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c6\"\u003e\n \u003cp\u003eDivergence\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colname=\"c3\"\u003e\n \u003cp\u003eClimates were a major factor that prevented the participant from exercising, but the scale had no related item.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c4\"\u003e\n \u003cp\u003e\u003cem\u003e\u0026ldquo;I don\u0026apos;t want to go out when the weather is terrible.\u0026rdquo; \u0026ldquo;The weather is too cold, and it\u0026apos;s raining these days.\u0026rdquo;\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c5\"\u003e\n \u003cp\u003e14\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c6\"\u003e\n \u003cp\u003eDivergence\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colspan=\"2\" morerows=\"5\" nameend=\"c2\" namest=\"c1\" rowspan=\"6\"\u003e\n \u003cp\u003ePregnancy Exercise\u003c/p\u003e\n \u003cp\u003eSelf-efficacy\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c3\"\u003e\n \u003cp\u003eP1 I am confident that I can overcome barriers and challenges to exercise if I try hard enough.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c4\"\u003e\n \u003cp\u003e\u003cem\u003e\u0026ldquo;You know, exercise is a habit of mine. I feel uncomfortable if I don\u0026apos;t move for a day.\u0026rdquo;\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c5\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c6\"\u003e\n \u003cp\u003eConvergence\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colname=\"c3\"\u003e\n \u003cp\u003eP2 I am confident that I can find means and ways to exercise during pregnancy.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c4\"\u003e\n \u003cp\u003e\u003cem\u003e\u0026ldquo;When the weather is good, I go for a walk or a swim. When the weather is terrible, I practice yoga or aerobics at home.\u0026rdquo;\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c5\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c6\"\u003e\n \u003cp\u003eConvergence\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colname=\"c3\"\u003e\n \u003cp\u003eP3 I am confident that I can accomplish my exercise goals that I set.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c4\"\u003e\n \u003cp\u003e\u003cem\u003e\u0026ldquo;To achieve my goal (control weight gain), I have to stick with it.\u0026rdquo;\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c5\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c6\"\u003e\n \u003cp\u003eConvergence\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colname=\"c3\" morerows=\"1\" rowspan=\"2\"\u003e\n \u003cp\u003eP7 I am confident that I can exercise even without the support of my family and friends.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c4\"\u003e\n \u003cp\u003e\u003cem\u003e\u0026ldquo;I don\u0026rsquo;t have the confidence to stick to exercise unless someone accompanies me\u0026hellip;\u0026rdquo;\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c5\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c6\" morerows=\"1\" rowspan=\"2\"\u003e\n \u003cp\u003ePartial Convergence\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colname=\"c4\"\u003e\n \u003cp\u003e\u003cem\u003e\u0026ldquo;I am confident that I can continue exercising until delivery.\u0026rdquo;\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c5\"\u003e\n \u003cp\u003e11\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colname=\"c3\"\u003e\n \u003cp\u003eP10 I am confident that I can exercise even if I do not have access to a gym, exercise, training, or rehabilitation facility.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c4\"\u003e\n \u003cp\u003e\u003cem\u003eNo one mentioned exercise equipment or gymnasium in the interview as a barrier.\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c5\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colname=\"c6\"\u003e\n \u003cp\u003eDivergence\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003c/table\u003e\n \u003c/div\u003e\n \u003cp\u003eThird, the P-ESES item regarding gym/facility access (P10) may lack cultural relevance for Chinese pregnant women, who predominantly engage in walking, home-based activity, and online-guided exercise rather than facility-based fitness. This finding aligns with recent critiques suggesting that self-efficacy scales, designed in Western gym-focused contexts, may not correspond with activity patterns in low- and middle-income settings\u003csup\u003e[\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e, \u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e]\u003c/sup\u003e.\u003c/p\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec27\" class=\"Section2\"\u003e\n \u003ch2\u003e4.2 Theoretical Implications\u003c/h2\u003e\n \u003cp\u003eThe convergent and divergent findings are best understood through an integrated application of the Socio-Ecological Model (SEM) \u003csup\u003e[\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e]\u003c/sup\u003e and the COM-B model \u003csup\u003e[\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e]\u003c/sup\u003e. Our qualitative themes were organized by SEM\u0026apos;s ecological levels (intrapersonal, interpersonal, community/organizational), revealing that barriers operate across multiple strata. However, SEM describes where barriers are situated; COM-B explains why certain barriers are captured by existing instruments while others of comparable salience are systematically omitted.\u003c/p\u003e\n \u003cp\u003eConvergent barriers as Capability and Motivation deficits. The barriers that demonstrated strong convergence\u0026mdash;time scarcity, exercise-induced fatigue, and spousal non-encouragement\u0026mdash;span the intrapersonal and interpersonal levels of SEM. Under COM-B, these map onto Capability (physical fatigue limiting capacity) and Motivation (competing priorities, lack of encouragement) dimensions. The EBBS was developed within an individual-level cognitive tradition aligned with these constructs; it is therefore theoretically consistent that the instrument performs well here.\u003c/p\u003e\n \u003cp\u003eDivergent barriers as Opportunity deficits. The two blind spots are fundamentally different in theoretical type: Lack of healthcare provider advice operates at the community/organizational level (SEM) and constitutes a social opportunity deficit (COM-B). In China\u0026apos;s time-compressed, biomedical antenatal system \u003csup\u003e[\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e, \u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e]\u003c/sup\u003e, women described not an individual perception but a structural void: \u0026quot;The medical staff did not give me any specific exercise advice.\u0026quot; No EBBS item operationalizes social opportunity at the healthcare system level\u0026mdash;the scale includes items on spousal and family discouragement but omits the provider dimension, reflecting its U.S. development context where exercise counseling is more standardized \u003csup\u003e[\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e]\u003c/sup\u003e.\u003c/p\u003e\n \u003cp\u003eWeather/climate barriers operate at the environmental level (SEM) and constitute a physical opportunity deficit (COM-B). High temperatures, humidity, and rain are external ecological conditions, not psychological states. Weather was the most frequently mentioned environmental barrier across our three climatically diverse provinces, yet the EBBS contains no corresponding item. Physical opportunity deficits cannot be remedied by enhancing individual capability or motivation alone; they require environmental restructuring\u0026mdash;a strategy the instrument cannot inform because the barrier itself is absent.\u003c/p\u003e\n \u003cp\u003eP-ESES and cultural scenario mismatch. The gym/facility item (P10) received zero qualitative endorsements because its situational referent\u0026mdash;facility-based exercise\u0026mdash;does not correspond to Chinese pregnant women\u0026apos;s reality of walking, household activity, and online-guided home exercise. This is a physical opportunity misalignment between the item\u0026apos;s assumed context and the population\u0026apos;s actual activity ecology, echoing cross-cultural critiques of Western-developed self-efficacy scales \u003csup\u003e[\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e, \u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e]\u003c/sup\u003e.\u003c/p\u003e\n \u003cp\u003eReframing intervention logic. The integrated analysis reveals that the EBBS predominantly captures Capability-type and Motivation-type barriers at the intrapersonal and interpersonal levels. The blind spots are not random omissions but systematic exclusions of Opportunity-type deficits at the community and environmental levels. Interventions designed solely around EBBS-identified barriers would disproportionately target individual-level factors while leaving structural deficits\u0026mdash;absent healthcare guidance and inhospitable environments\u0026mdash;unaddressed. We therefore argue for \u003cstrong\u003etheoretical pluralism\u003c/strong\u003e in prenatal physical activity research, integrating individual-level models (HBM, Social Cognitive Theory) with ecological and systems-level frameworks (SEM, COM-B) to ensure that both types of determinants are captured in measurement and addressed in intervention.\u003c/p\u003e\n \u003cp\u003e\u003cem\u003e4.3 Bridging Qualitative Themes and Instrument Coverage: Convergence, Gaps, and Beyond\u003c/em\u003e While Table \u003cspan refid=\"Tab4\" class=\"InternalRef\"\u003e4\u003c/span\u003e provides item-level evidence of convergence and divergence, a theme-level analysis reveals three distinct types of relationships between qualitative findings and instrument coverage.\u003c/p\u003e\n \u003cp\u003eFirst, most themes demonstrated clear convergence with existing scale items. Theme 2 (motivations for exercise) aligned with the EBBS Benefits subscale\u0026mdash;particularly items on improved body function (Item 31) and mental health (Item 9)\u0026mdash;as reflected in participant statements linking exercise to easier delivery and better mood. Theme 5 (post-exercise feelings) converged with multiple benefit items describing physical and emotional well-being. Theme 6 (confidence in maintaining exercise) directly corresponded to P-ESES self-efficacy items. These findings indicate that the core constructs of perceived benefits and self-efficacy are adequately operationalized.\u003c/p\u003e\n \u003cp\u003eSecond, several themes revealed areas of tension where qualitative data added nuance absent from scale items. Theme 3 identified two barriers\u0026mdash;lack of healthcare provider advice and weather/climate constraints\u0026mdash;with no corresponding EBBS items. While the scale captures interpersonal discouragement from spouses and family, it is silent on professional healthcare guidance, which seven participants independently raised. Similarly, the EBBS addresses facility accessibility but omits climatic conditions, despite weather being the most frequently cited barrier (14 mentions). A participant expressed, \u0026ldquo;I want to exercise, but prolonged rain limits my options.\u0026rdquo;\u003c/p\u003e\n \u003cp\u003eThird, and most importantly, certain salient themes fell entirely outside the conceptual boundaries of both instruments. Theme 1 revealed substantial heterogeneity in how participants defined \u0026quot;exercise\u0026quot; itself\u0026mdash;some equated it solely with structured gym activity, while others considered walking and household chores as sufficient. This definitional variability has no corresponding item in either scale, yet it shapes how participants interpret all subsequent items. If a woman does not consider walking as \u0026quot;exercise,\u0026quot; her responses to EBBS items may systematically underestimate the benefits she actually receives. This represents a construct validity threat at the item-interpretation level that no psychometric coefficient can detect.\u003c/p\u003e\n \u003cp\u003eThese patterns suggest that while the EBBS and P-ESES demonstrate acceptable content validity for the constructs they were designed to measure, exclusive reliance on these instruments may miss context-specific opportunity deficits and interpretive variability in how exercise is understood. Future instrument adaptation should incorporate qualitative pre-testing to identify such blind spots before quantitative validation.\u003c/p\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec28\" class=\"Section2\"\u003e\n \u003ch2\u003e4.4 Methodological Implications\u003c/h2\u003e\n \u003cp\u003eThis study exemplifies the utility of convergent mixed methods designs for instrument validation in cross-cultural health behavior research. Traditional psychometric evaluation relies on factor analysis, reliability coefficients, and known-groups validity\u0026mdash;tests of internal structure and criterion association. Our triangulation approach adds a \u0026ldquo;phenomenological validity\u0026rdquo; criterion: Validity criteria that use subjects\u0026apos; real-life experiences are used to examine whether the scale items are relevant to the life experiences and cultural context of the target population\u003csup\u003e[\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e, \u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e]\u003c/sup\u003e. The joint display table format (Table \u003cspan refid=\"Tab4\" class=\"InternalRef\"\u003e4\u003c/span\u003e) offers a transparent, auditable method for documenting convergence and divergence that can be applied to other scales and populations. We recommend that researchers adapting self-report instruments in new cultural contexts routinely incorporate qualitative triangulation as a complementary validation strategy, particularly for instruments measuring context-sensitive constructs such as barriers and self-efficacy.\u003c/p\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec29\" class=\"Section2\"\u003e\n \u003ch2\u003e4.5 Practical Implications for Intervention Design\u003c/h2\u003e\n \u003cp\u003eThe convergent and divergent findings jointly inform a layered intervention architecture:\u003c/p\u003e\n \u003cp\u003eLayer 1\u0026mdash;Target convergent barriers with established EBBS-based strategies.Time management, fatigue coping, family communication, and spousal involvement are well-represented in both qualitative and quantitative data and can be addressed through education, modeling, and enablement.\u003c/p\u003e\n \u003cp\u003eLayer 2\u0026mdash;Fill divergent gaps with context-specific strategies. Healthcare provider training in pregnancy exercise counseling should be integrated into obstetric continuing education. Antenatal clinics should provide written, gestational-age-specific exercise prescriptions rather than vague verbal encouragement. Environmentally adaptive strategies\u0026mdash;such as indoor exercise video libraries, community cool-space walking programs, and seasonal timing recommendations\u0026mdash;should be developed for tropical and continental climates.\u003c/p\u003e\n \u003cp\u003eLayer 3\u0026mdash;Reframe self-efficacy measurement. Rather than assessing confidence in exercising without gym access, Chinese-adapted self-efficacy items might assess confidence in exercising at home, in humid weather, or without professional supervision\u0026mdash;scenarios that are more ecologically representative of this population\u0026rsquo;s actual exercise ecology.\u003c/p\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec30\" class=\"Section2\"\u003e\n \u003ch2\u003e4.6 Limitations\u003c/h2\u003e\n \u003cp\u003eThe study is subject to several limitations. The cross-sectional design limits causal inference, necessitating longitudinal and experimental approaches to determine if reducing barriers prospectively enhances physical activity. Second, although the qualitative subsample (n\u0026thinsp;=\u0026thinsp;30) was sufficient for thematic saturation, it consisted solely of women who had consented to the quantitative survey, potentially excluding perspectives of women not involved in research or prenatal care. Third, all three study sites were urban or suburban; rural pregnant women may face additional barriers (agricultural labor, longer travel distances, fewer recreational facilities) not captured here. Fourth, the integration process was conducted at the item level rather than the participant level; future research could employ quantitative-qualitative person-level case analyses to examine individual profiles of convergence and divergence. Finally, the logistic regression results presented here are abbreviated; the full quantitative report will be published separately\u003csup\u003e[\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e]\u003c/sup\u003e, and readers are referred to that source for detailed modeling.\u003c/p\u003e\n\u003c/div\u003e"},{"header":"5. Conclusions","content":"\u003cp\u003eThis convergent mixed methods study indicates that the EBBS and P-ESES exhibit satisfactory content validity for Chinese pregnant women, as shown by strong qualitative-quantitative agreement on benefit items and most barrier/self-efficacy items.However, two critical blind spots were identified: the absence of healthcare provider exercise counseling from the EBBS barrier domain and the absence of weather/climate barriers from the instrument\u0026rsquo;s environmental subscale. Additionally, one P-ESES item regarding gym/facility access may lack cultural relevance. These findings support incorporating mixed-methods triangulation into cross-cultural instrument adaptation protocols and provide actionable guidance for refining both assessment tools and intervention targets in maternity physical activity promotion.We argue that future cross-cultural instrument adaptation protocols should incorporate qualitative triangulation as a minimum standard for establishing content validity, rather than relying solely on psychometric coefficients.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe study was approved by the Ethics Committee of the Philippine Women\u0026apos;s University (ERB2024_007), which provided institutional oversight for the doctoral project across all data collection sites. Additional local ethics approval was obtained from The First Affiliated Hospital of Ningbo University (Approval No. 2024 035A-1), the site contributing the largest participant sample. For the remaining two hospitals, data collection was conducted with institutional permission, and all participants provided written informed consent, in compliance with the Declaration of Helsinki.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable. This manuscript does not contain any individual person\u0026rsquo;s data in any form (e.g., personal identifiers, images, or recordings). All data were anonymized prior to analysis, and participants consented to the use of their anonymized data for research and publication during the informed consent process.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe data in this study comes from the doctoral dissertation (Philippine Women\u0026apos;s University, 2024, printed archive, unpublished). The quantitative survey data reported in this manuscript overlap with those used in a companion cross-sectional paper\u003csup\u003e[\u003c/sup\u003e\u003csup\u003e14\u003c/sup\u003e\u003csup\u003e]\u003c/sup\u003e; however, all qualitative interview data, thematic analysis codes, and triangulation findings presented herein are entirely original and have not been published previously. They are available from the corresponding author upon reasonable request after the two papers are published.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis research was not funded, and all the authors declare no competing financial interests.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis research was not funded.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors\u0026rsquo; contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eJL conceived and designed the study, supervised data collection, conducted the interview, analyzed the data, and drafted the manuscript. YRW, XHL, and HRL conducted the investigation.YRW checked and verified the encoding of the interview data. JS contributed to the study design and critically revised the manuscript. All authors reviewed and approved the final manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgements\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWe would like to thank all the women who participated in the study.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eClinical Trial Number\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eDavenport MH, Ruchat SM, Poitras VJ, Garcia AJ, Gray CE, Barrowman N, et al. Prenatal exercise for the prevention of gestational diabetes mellitus and hypertensive disorders of pregnancy: a systematic review and meta-analysis [Internet]. 2018 Nov 1. doi:10.1136/bjsports-2018-099355\u003c/li\u003e\n\u003cli\u003eRuchat SM, Mottola MF, Skow RJ, Nagpal TS, Meah VL, James M, et al. Effectiveness of exercise interventions in the prevention of excessive gestational weight gain and postpartum weight retention: a systematic review and meta-analysis. 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Res Nurs Health. 1987 Dec;10(6):357\u0026ndash;65. doi:10.1002/nur.4770100603\u003c/li\u003e\n\u003cli\u003eBland HW, Melton BF, Marshall ES, Nagle JA. Measuring Exercise Self-Efficacy in Pregnant Women: Psychometric Properties of the Pregnancy-Exercise Self-Efficacy Scale (P-ESES). J Nurs Meas. 2013;21(3):349\u0026ndash;59. doi:10.1891/1061-3749.21.3.349\u003c/li\u003e\n\u003cli\u003eYang H, Deng Y, Gao L. Reliability and validity of the Chinese version of the Pregnancy Exercise Self-Efficacy Scale. Chin J Nurs. 2017;52(5):632\u0026ndash;5.(in Chinese)\u003c/li\u003e\n\u003cli\u003eB. Goecke, S. Weiss, B. Barbot. Content Validity of Creativity Self‐Report Questionnaires From PISA 2022. The Journal of Creative Behavior. 2025;59(2):p e70026. doi:10.1002/jocb.70026\u003c/li\u003e\n\u003cli\u003eFetters MD, Curry LA, Creswell JW. Achieving Integration in Mixed Methods Designs\u0026mdash;Principles and Practices. Health Serv Res. 2013 Dec;48(6 Pt 2):2134\u0026ndash;56. doi:10.1111/1475-6773.12117 \u003c/li\u003e\n\u003cli\u003eCreswell JW, Clark VLP. Designing and Conducting Mixed Methods Research [Internet]. SAGE Publications; 2017. Available from: https://books.google.co.uk/books?id=eTwmDwAAQBAJ\u003c/li\u003e\n\u003cli\u003eO\u0026rsquo;Cathain A, Murphy E, Nicholl J. Why, and how, mixed methods research is undertaken in health services research in England: a mixed methods study. BMC Health Serv Res. 2007 Jun 14;7:85. doi:10.1186/1472-6963-7-85\u003c/li\u003e\n\u003cli\u003eGuetterman TC, Fetters MD, Creswell JW. Integrating Quantitative and Qualitative Results in Health Science Mixed Methods Research Through Joint Displays. Ann Fam Med. 2015 Nov;13(6):554\u0026ndash;61. doi:10.1370/afm.1865 \u003c/li\u003e\n\u003cli\u003eLi J, Wang Y, Liang X, Lv H, Salvador JT. Barriers, Not Benefits: Perceived Barriers as the Primary Predictor of Physical Activity Guideline Adherence among Pregnant Women in Three Chinese Provinces: A Cross-Sectional Study. Research Square[Preprint]; 2026. doi:10.21203/rs.3.rs-9418228/v1\u003c/li\u003e\n\u003cli\u003eCreswell JW. Qualitative inquiry and research design: choosing among five approaches. third edition. SAGE; 2013.\u003c/li\u003e\n\u003cli\u003eChasan-Taber L, Schmidt MD, Roberts DE, Hosmer D, Markenson G, Freedson PS. Development and validation of a Pregnancy Physical Activity Questionnaire. Med Sci Sports Exerc. 2004 Oct;36(10):1750\u0026ndash;60. doi:10.1249/01.mss.0000142303.49306.0d\u003c/li\u003e\n\u003cli\u003eZhang Y, Zhao Y, Dong SW, Xiong Y, Hu XQ. Reliability and validity of the Chinese version of the Pregnancy Physical Activity Questionnaire(PPAQ). Chin J Nurs. 2013;48(9):825\u0026ndash;7.(in Chinese)\u003c/li\u003e\n\u003cli\u003eWendy J Brown, Melanie Hayman, Lene A H Haakstad, Gregore I Mielke, Gabriela P Mena, Tayla Lamerton, et al. Evidence-based physical activity guidelines for pregnant women. Rep Aust Gov Dep Health March 2020.\u003c/li\u003e\n\u003cli\u003eRosenstock IM, Strecher VJ, Becker MH. Social learning theory and the Health Belief Model. Health Educ Q. 1988;15(2):175\u0026ndash;83. doi:10.1177/109019818801500203 PubMed PMID: 3378902.\u003c/li\u003e\n\u003cli\u003eBraun V, Clarke V. Using thematic analysis in psychology. Qual Res Psychol. 2006 Jan 1;3(2):77\u0026ndash;101. doi:10.1191/1478088706qp063oa\u003c/li\u003e\n\u003cli\u003eMcLeroy KR, Bibeau D, Steckler A, Glanz K. An ecological perspective on health promotion programs. Health Educ Q. 1988;15(4):351\u0026ndash;77. doi:10.1177/109019818801500401 \u003c/li\u003e\n\u003cli\u003eTong A, Sainsbury P, Craig J. Consolidated criteria for reporting qualitative research (COREQ): a 32-item checklist for interviews and focus groups. Int J Qual Health Care J Int Soc Qual Health Care. 2007 Dec;19(6):349\u0026ndash;57. doi:10.1093/intqhc/mzm042 \u003c/li\u003e\n\u003cli\u003eMichie S, van Stralen MM, West R. The behaviour change wheel: a new method for characterising and designing behaviour change interventions. Implement Sci IS. 2011 Apr 23;6:42. doi:10.1186/1748-5908-6-42 \u003c/li\u003e\n\u003cli\u003eMessick S. Validity of psychological assessment: Validation of inferences from persons\u0026rsquo; responses and performances as scientific inquiry into score meaning. Am Psychol. 1995;50(9):741\u0026ndash;9. doi:https://doi.org/10.1037/0003-066X.50.9.741\u003c/li\u003e\n\u003cli\u003eDam\u0026aacute;sio BF, Valentini F, N\u0026uacute;\u0026ntilde;es-Rodriguez SI, Kliem S, Koller SH, Hinz A, et al. Is the General Self-Efficacy Scale a Reliable Measure to be used in Cross-Cultural Studies? Results from Brazil, Germany and Colombia. Span J Psychol. 2016 Jan;19:E29. doi:10.1017/sjp.2016.30\u003c/li\u003e\n\u003cli\u003eHakim AR, Wang ST, Widiantoro FX, Hannan M, Wang CJ, Fetzer SJ. The Indonesian Version of the Exercise Self-Efficacy Scale: Cross-cultural Adaptation and Psychometric Testing. Asian Nurs Res. 2020 Dec 1;14(5):300\u0026ndash;5. doi:10.1016/j.anr.2020.08.008\u003c/li\u003e\n\u003cli\u003eSallis J, Owen N, Fisher E. Ecological models of health behavior Health Behavior and Health Education: Theory, Research, and Practice. 4th Edition. In. San Francisco: Jossey-Bass; 2008. p. 465\u0026ndash;552.\u003c/li\u003e\n\u003cli\u003eMo X, Cao J, Tang H, Miyazaki K, Takahashi Y, Nakayama T. Inability to control gestational weight gain: an interpretive content analysis of pregnant Chinese women. BMJ Open. 2020 Dec;10(12):e038585. doi:10.1136/bmjopen-2020-038585\u003c/li\u003e\n\u003cli\u003eZhai J, Hu X, Wen Z, Chen L, Ye R, Zheng X, et al. Promoting healthy lifestyle considerations during pregnancy in Midwifery clinics in China: a best practice implementation project. JBI Evid Implement. 2021 Sep;19(3):219. doi:10.1097/XEB.0000000000000247\u003c/li\u003e\n\u003cli\u003eBowen PG, Mankowski RT, Harper SA, Buford TW. Exercise Is Medicine as a Vital Sign: Challenges and Opportunities. Transl J Am Coll Sports Med. 2019 Jan 1;4(1):1. doi:10.1249/TJX.0000000000000076\u003c/li\u003e\n\u003cli\u003eKohrt B, Jordans M, Tol W, Luitel N, Maharjan S, Upadhaya N. Validation of cross-cultural child mental health and psychosocial research instruments: adapting the Depression Self-Rating Scale and Child PTSD Symptom Scale in Nepal. BMC Psychiatry. 2011 Aug 4;11:127\u0026ndash;127. doi:10.1186/1471-244x-11-127\u003c/li\u003e\n\u003cli\u003ePalmieri P, Leyva-Moral J, Camacho-Rodriguez D, Granel-Gim\u0026eacute;nez N, Ford E, Mathieson K, et al. Hospital survey on patient safety culture (HSOPSC): a multi-method approach for target-language instrument translation, adaptation, and validation to improve the equivalence of meaning for cross-cultural research. BMC Nurs. 2020 Apr 13;19. doi:10.1186/s12912-020-00419-9\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":true,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"mixed methods, pregnancy, physical activity, Exercise Benefits/Barriers Scale, self-efficacy, triangulation, China","lastPublishedDoi":"10.21203/rs.3.rs-9602132/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-9602132/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e \u003cp\u003eInstruments like the Exercise Benefits/Barriers Scale (EBBS) and the Pregnancy Exercise Self-Efficacy Scale (P-ESES) are commonly employed to evaluate psychosocial factors influencing physical activity in pregnant individuals. However, whether these scales fully capture the experiential reality of Chinese pregnant women remains underexplored. This study utilized a convergent parallel mixed methods approach to assess the alignment and discrepancies between questionnaire results and in-depth interview narratives.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003eA total of 335 pregnant women from three provinces in China (Guangdong, Zhejiang, Shanxi) completed the EBBS, P-ESES, and the Pregnancy Physical Activity Questionnaire (PPAQ). Concurrently, 30 participants purposively selected from the same quantitative pool participated in semi-structured interviews guided by the Health Belief Model.Thematic analysis was conducted on qualitative data using NVivo 12. Quantitative and qualitative datasets were integrated via a joint display table to examine convergence and divergence at the item level.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eQuantitative findings confirmed that perceived barriers significantly predicted physical activity inadequacy (adjusted OR\u0026thinsp;=\u0026thinsp;0.93, 95% CI: 0.88\u0026ndash;0.98), whereas perceived benefits and self-efficacy lost significance when barriers were controlled. Six qualitative themes emerged: (1) cognition of exercise during pregnancy, (2) motivations for exercise, (3) factors influencing exercise participation, (4) action inspiration and information sources, (5) post-exercise feelings, and (6) confidence in maintaining exercise. Triangulation revealed strong convergence for exercise benefits (all nine EBBS benefit items confirmed by interview quotes) and most barrier/self-efficacy items. However, two critical divergences were identified: (i) lack of specific exercise advice from healthcare providers (seven qualitative mentions, no corresponding EBBS item), and (ii) weather/climate as a major environmental barrier (14 qualitative mentions, no corresponding EBBS item). Additionally, one P-ESES item regarding self-efficacy without gym access received zero qualitative endorsement.\u003c/p\u003e\u003ch2\u003eConclusions\u003c/h2\u003e \u003cp\u003eThe EBBS and P-ESES demonstrate satisfactory content validity for Chinese pregnant women overall. Nevertheless, the scales contain notable blind spots regarding professional healthcare support and environmental/climatic barriers. These findings support the integration of mixed-methods approaches in maternity health behavior research and inform the development of targeted interventions.\u003c/p\u003e","manuscriptTitle":"A Convergent Mixed Methods Study on Exercise Benefits, Barriers, and Self-Efficacy in Chinese Pregnant Women: Triangulating Self-Report Scales with Lived Experience","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2026-05-08 05:29:37","doi":"10.21203/rs.3.rs-9602132/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"8b8e2b33-0202-4033-8c63-04f45dc494f3","owner":[],"postedDate":"May 8th, 2026","published":true,"recentEditorialEvents":[{"type":"editorInvited","content":"","date":"2026-05-08T18:28:46+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2026-05-06T12:14:40+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2026-05-06T12:13:52+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Pregnancy and Childbirth","date":"2026-05-03T18:51:36+00:00","index":"","fulltext":""}],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2026-05-08T05:29:37+00:00","versionOfRecord":[],"versionCreatedAt":"2026-05-08 05:29:37","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-9602132","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-9602132","identity":"rs-9602132","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}