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2200‘;

This is to certify that the
dissertation entitled

EXPERIENCES OF WOMEN WHO ARE CLASSIFIED AS
MAINTAINERS AND TRANSFORMERS FOR EXERCISE

presented by

HEATHER A. KESSELRING

has been accepted towards fulfillment
of the requirements for the

Doctoral degree in Kinesiology

 

 

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EXPERIENCES OF WOMEN WHO ARE CLASSIFIED AS
MAINTAINERS AND TRAN SFORIVIERS FOR EXERCISE

By

Heather A. Kesselring

A DISSERTATION
Submitted to
Michigan State University
in partial fulfillment of the requirements for the degree of
DOCTOR OF PHILOSOPHY
Department of Kinesiology

2006

ABSTRACT

EXPERIENCES OF WONIEN WHO ARE CLASSIFIED AS
MAINTAINERS AND TRANSFORMERS FOR EXERCISE

By
Heather A. Kesselring

The purpose of this study is to gain a greater understanding of the experiences of
women classified as late-in-stage maintainers and transformers for exercise (Cardinal &
Levy, 2000). The participants in this study were women 40 years of age or older who
were enrolled in a general fitness class at a community college or a chair exercise class
for people 50 years of age and older. Ten women were interviewed individually in an
attempt to discover how rearing or past experiences with exercise related to stage
classification. The concepts that were examined through the interview process included
family values and perceptions of exercise, periods of inactivity and the reasons for them,
and the role of intrinsic motivation, enjoyment, and ritual in exercise adherence. The
analysis did not fully support Cardinal’s (1999) Stage of Physical Activity Algorithm.
Next, the analysis revealed that childhood experiences, including family-sponsored
physical activity and the use of physical activity as a coping mechanism, set a standard
for lifetime physical activity. In addition, adaptability in the face of changing
circumstances, the process known as “environmental control” (Prochaska et al., 1994),
and ritual or routinized behavior played prominent roles in these women’s contimied
engagement in physical activities. Further, although the process known as “helping
relationships” was shown in previous studies to be under-utilized by maintainers
(Courneya & Bobick, 2000; F ahrenwald & Walker, 2003), the results provide evidence

that successful exercisers do use the “helping relationships" process.

 

Copyright by
Heather Ann Kesselring
2006

ACKNOWLEDGEMENTS

I wish to thank the members of my dissertation committee, Marty Ewing, Debra Feltz,
Terry Hagan, and Lorraine Robbins for all their insights and editing work that helped
make this a solid product. I would especially like to thank my major advisor, Marty
Ewing, for keeping the faith, encouraging, and guiding me when I was losing my way. A
debt of gratitude is also owed to the College of Education whose Dissertation Completion
Fellowship made all this possible. Thank you also goes to my parents, Dan and Betty
Kesselring, for being there and for the crazy gift basket that always offered up just the
right thing to keep me going. Finally, to Mark Quakenbush thank you for the “brain

food” dinners and for lifting me up when I was down.

iv

TABLE OF CONTENTS

LIST OF TABLES ................................................................................ vii
CHAPTER 1
INTRODUCTION .................................................................................... 1
Issues from the Transtheoretical Model .................................................. 6
Research Questions ........................................................................... 8
CHAPTER 2
REVIEW OF LITERATURE ...................................................................... 10
Major Components of the TTM ............................................................ l 0
Stages of Change .................................................................. 10
Decisional Balance ................................................................ 16
Self-efficacy ........................................................................ 1 7
Processes of Change ................................................................ 18
Characteristics of the Six Stages of Change ............................................. 20
Precontemplation .................................................................. 20
Contemplation ...................................................................... 26
Preparation .......................................................................... 3 1
Action ................................................................................. 36
Maintenance .......................................................................... 41
Long-term Maintenance ............................................................ 46
Transformation ...................................................................... 47
Relationships: The Transtheoretical Model and Intrinsic Motivation. . .....50
Intrinsic Motivation ................................................................ 50
Conclusion ................................................................................... 52
CHAPTER 3
METHODS ........................................................................................... 54
Participants ................................................................................... 54
Instrumentation ............................................................................... 58
Stage of Change Measure ......................................................... 58
Demographic Survey .............................................................. 59
Interview ............................................................................. 59
Procedures .................................................................................... 59
Data Analysis ................................................................................ 62
CHAPTER 4
RESULTS AND DISCUSSION .................................................................. 65
Issues with the Stage of Physical Activity Algorithm ................................. 65
Long-term Maintainers or “Realistic” Transformers? ........................ 66

 

Classic Transformers ............................................................. 71

 

Long-term Maintainers .......................................................... 75

Maintainers ........................................................................ 76
Under-reported Years Active Transformer .................................... 77

Childhood Issues and Influences ........................................................ 81
Family Life Impacts Stage ...................................................... 82

Family Dysfunction .................................................... 82

Parental Involvement ................................................... 84

Adult Life .................................................................................. 86
Enjoyment and Variety of Activity Relevant to Stage ...................... 86

Maintainers .............................................................. 87

Transformers ............................................................ 88

Routine Adherence, Adaptability, Environmental Control and Stage. ...91

Transformers and adaptable routines ................................. 91

Transformers and “environmental control” ......................... 95

Maintainers .............................................................. 97

Helping Relationships ......................................................... 101

Unanswered Questions ................................................................. 110

What ifmy Parents weren’t ...And I’m not...? .................................... 110

CHAPTER 5

SUMMARY AND IMPLICATIONS .......................................................... 113
APPENDICES .................................................................................... 119
LIST OF REFERENCES ........................................................................ 134

 

vi

LIST OF TABLES

Table 1 - The stages of change for exercise behavior as defined by Prochaska & Marcus,
(1994) ........................................................................................ 12

Table 2 - The processes of change as defined by Prochaska et a]. (1994) .................... 19
Table 3 - A cross study comparison of rankings from the PCQ for the processes of
change as prescribed by Prochaska et al. (1994) for the

precontemplation stage .................................................................... 24

Table 4 - A cross study comparison of rankings from the PCQ for the processes of
change as prescribed by Prochaska et a1. (1994) for the contemplation stage. . ...30

Table 5 - A cross study comparison of rankings from the PCQ for the processes of
change as prescribed by Prochaska et a1. (1994) for the preparation stage. . . . . ....35

Table 6 - A cross study comparison of rankings from the PCQ for the processes of
change as prescribed by Prochaska et al. (1994) for the action stage ................ 40

Table 7 - A cross study comparison of rankings from the PCQ for the processes of
change as prescribed by Prochaska et al. (1994) for the maintenance stage ....... 44

Table 8 - Demographic information .............................................................. 55
Table 9 - Stage and sub-stage definitions ........................................................ 80
Table 10 - Motive for childhood physical activity as it relates to stage ...................... 86
Table 11 - Number of activities engaged in versus number of activities enjoyed by

stage .......................................................................................... 90
Table 12 - Major trends in motivation for young life: 4-21 years of age, n=10 ........... 107

Table 13 - Major trends in motivation for work/child rearing life: 20-60 years of age,
n=10 ......................................................................................... 108

Table 14 — Major trends in motivation for retired life: 60-80 years of age, n=3 ........... 109

vii

Chapter 1
INTRODUCTION

Life-long physical activity and exercise is encouraged by health and fitness
practitioners to promote health, prevent chronic illnesses, and maintain independent
living (Center for Disease Control, 2001; US. Department of Health and Human
Services, 2000). In spite of obvious benefits, a continuum of people’s engagement in
exercise exists that ranges fi-om sedentary lifestyle to lifelong engagement in regular
exercise (Marcus & Owen, 1992). Older women in particular are at risk for developing
health issues associated with sedentary behaviors because, according to the Center for
Disease Control (1999b) who define recommended physical activity as that which burns
at least 150 kcal, 25% of women get no physical activity at all while 60% of women do
not meet the recommendations for physical activity. As women age, sedentary behaviors
increase dramatically. Forty percent of women over the age of 55 do not engage in any
physical activity during leisure time (Center for Disease Control, 2005).

Women, as a cultural group, have a unique set of issues that can become barriers
to exercise. A survey done by the National Women’s Resource Center (2005) showed
that women frequently placed their family’s needs ahead of their own health which
negatively impacted engagement in exercise. Similarly, O’Brien-Cousins and Keating
(1995) found that for some women marriage and child bearing were the “tmning point”
from physically active to more sedentary lifestyles. In addition, older women from
varying ethnic groups indicated that body image issues prevented them fi‘om exercising
(Heesch, Brown, & Blanton, 2000; King, Castro, Wilcox, Eyler, Sallis, & Brownson,

2000). Furthermore, the Center for Disease Control (1999a) found tlmt older people and

women exercised less frequently when they had strong concerns about neighborhood
safety.

In spite of these issues, some women still manage to engage in regular exercise.
Within the Stages of Change of the Transtheoretical Model (TTM), there are two stages
where women would be identified as “engaging in regular exercise” (Prochaska,
Norcross, & Diclemente, 1994): (a) Maintainers - those who have engaged in regular
exercise for 6 months to 5 years but are at risk for relapse into sedentary behavior
(Prochaska et al., 1994), and (b) Transformers - those who have engaged in regular
exercise for at least 5 years but are not at risk for relapse (Cardinal, 1999). For the
purpose of this study, transformers and a newly designated sub-category of maintainers
titled “late-in—stage maintainers” were considered. The TTM and the stages of change are
discussed at length in the next chapter.

“Late-in-stage maintainers” were labeled as such for ease of discussion. They are
defined as people who have engaged in exercisefor at least 3 years and are still at risk for
relapse into sedentary behavior. This redefined group is necessary because logic dictates
that issues that might cause a maintainer of 6 months to one year to relapse into sedentary
behavior could be dramatically different than those of a maintainer of 3 or more years.
For example, weather variations of clmnging seasons, holiday distractions, and boredom
could all serve to derail a new maintainer, but after she has had a few years’ experience
managing barriers, these types of challenges should no longer be a threat to adherence.
Logic also dictates that a maintainer of 3 or more years should possess characteristics
more similar to a transformer. Given this, once a woman has persisted in exercise for 3

or more years, what might cause her to cease and what could prevent it? Do major

 

changes in a woman’s life, as O’Brien-Cousins and Keating (1995) suggest, lead to a
cessation in exercise? Do women’s goals impact adherence? Does upbringing impact
long term adherence? Does culture or routine factor into determining adherence?
Late-in-stage maintainers and transformers engage in exercise, in part, because
they have goals they are working toward (Prochaska & Marcus, 1994; Prochaska et al.,
1994). These goals may include things like reaching a certain performance level,
changing physical appearance, or improving health. However, much can change in a
woman’s life that may impact her ability to reach an exercise goal. For instance, a health
issue, a reduction in discretionary income, a marriage or the addition of children
(O’Brien-Cousins & Keating, 1995) might cause a woman to cease engagement in
exercise either because her priorities changed or because she perceived that time or
money were lacking. If life events are the sole cause of behavior change, the difference
between women who continue to exercise and those who stop might be as simple as luck.
Yet some women suffer great hardships and still continue to do things that they enjoy or
are important to them, and other women continue to honor their commitment to exercise
after having children. If life changes cannot fully explain the difference between these
two groups, possibly the differences can be attributed to the motivation behind the goal.
According to Intrinsic Motivation theories, the source of the goal, e.g., intrinsic or
extrinsic, impacts goal completion and adherence (Deci & Ryan, 1985). People who are
extrinsically motivated find the inspiration for their goals fi'om an external source, e. g.,
doctors orders or peer pressure, and are less likely to adhere to their goals (Deci & Ryan,
1985). Intrinsically motivated people set and work toward goals based on an internally

focused rationale, e.g., personal challenge or enjoyment, and are more likely to adhere to

their goals (Deci & Ryan, 1985). Given that the complex behavior of human beings
rarely fits neatly into one theory, it is unlikely that intrinsic motivation is the only answer.
In fact, two issues stand in the way. First, studies exploring intrinsic motivation involved
activities that were inherently interesting to the participants (Weiss & Chaumeton, 1992).
Weiss and Chaumeton (1992) suggest that if an activity is not inherently interesting to the
individual, he or she may need external motivation like rewards, status, or social support
in order to initiate participation. Second, the motivation for the goal could shift over
time. Because intrinsic motivation can be reduced through the introduction of external
rewards (Deci & Ryan, 1985), it is possible tlmt extrinsic motivation could, likewise, be
decreased over time. If intrinsic motivation, which is related to adherence, can be
decreased and extrinsic motivation, which is related to dropout or relapse, can also be
decreased, the initial motivation for goal setting may not greatly impact adherence. The
final motivation, however, may play a role in determining long-term adherence.

In addition to intrinsic motivation, another possible reason people persist with an
activity may involve personal identity (Cardinal, 1999; Cardinal & Levy, 2000). Avid
runners always run because it is “who they are.” The weather never deters them nor does
any other factor. While some people who are avid runners may be addicted to the
activity (Morgan & O’Connor, 1988), others my adhere to running because it, in part,
defines who they are. Cardinal (1999) and Cardinal and Levy (2000) suggest that a main
factor separating maintainers or long-term maintainers (those who have exercised for
more than 5 years but are still subject to relapse) from transformers is self-image as a

“role model.”

Still other women may engage in daily exercise because it is a ritual behavior.
Enjoyment, challenge, and image may not figure into the mix as strongly as simple
routine. True daily rituals like showering, brushing teeth, and eating may not require
commitment or enjoyment to be performed. Instead, these tasks are performed more or
less automatically, i.e., they are done without the need for a motivating factor or
conscious effort. Rituals, however, are cultural in their construction. Ethnic background
can influence adoption of daily rituals. A study by the Women’s Sports Foundation UK
(2005) found that Bangladeshi women did not exercise because they could not wear
fitness clothing in public and because elders in their community did not value physical
activity. Lewis, Szabo, Weiner, McCall, and Piterman (1997) found that language and
the ability to do activities with people from their own group were salient to participation
for Indo-Chinese, Jewish, Italian, and Greek elderly people. Therefore, the adoption of
exercise as a daily ritual may be culturally constructed.

Other cultural issues that may influence women’s adherence to exercise may be
tied to upbringing and values. Women raised in families where exercise was valued and
actively pursued may be more likely to adhere to exercise (Snyder & Spreitzer, 1973).
Whereas, women raised to believe that exercise is not appropriate for women, may be
less likely to adhere to exercise (Dunlap & Barry, 1999).

Because human behavior is complex and multifaceted, a combination of the above
factors likely makes up the difference between late-in-stage maintainers and
transformers. The background of individuals and the path they took to get to their current

state of adherence may be the most revealing information about adherence.

Understanding the factors underlying the way in which long term adherence to
exercise occurs is an important issue to practitioners and educators in health care and
fitness. By knowing how people achieve long term adherence, practitioners and
educators will be better able to help their clients and students achieve long term
adherence to exercise and reap the benefits that a physically active lifestyle brings.
Issues fi'om the Transtheoretical Model

The TTM is a model of behavior change that is defined by six stages of change
(Prochaska et al., 1994). The stages range from precontemplation (Prochaska et al.,
1994), where the individual has no desire to change, to transformation (Cardinal, 1999),
in which the change is fully adopted. Relapse into old behaviors can occur anytime
during the first 5 stages, but once the individual reaches the transformed stage the
behavior is permanent (Prochaska et al., 1994).

Because relapse can happen at any time during the first 5 stages, there should be
recognizable differences between women who have engaged in exercise for 3 years (late-
in-stage maintainers) and those who have exercised for 5 years (transformers). However,
more recently, Cardinal and Levy (2000) discovered a sub-group of maintainers whom
they called “long-term maintainers.” Long-term maintainers have exercised for 5 or
more years but are not 100% confident in their abilities to continue their exercise
behaviors. This discovery indicates that something other than years spent in the activity
determines transformation, and it creates fiirther possibilities. If people who have
exercised for more than 5 years can still be maintainers, might people also reach the
transformed stage prior to the 5-year period? This possibility necessitates further

examination of late-in-stage maintainers and transformers.

While few studies have been performed to investigate the properties of the
transformation stage, research exploring exercise adherence and participation allows us to
deduce that transformers should have the following characteristics: intrinsic type goals
(Deci & Ryan, 1985), commitment to the activity (Prochaska et al., 1994), high level of
enjoyment derived from the activity (Buonamano, Cei, & Mussino, 1995; Ewing &
Seefeldt, 1988; Gill, Gross, & Huddleston, 1983; Gould, Feltz, & Weiss, 1985; Gould,
Feltz, Weiss, & Petlichkoff, 1982; Klint & Weiss, 1986; Koivula, 1999; Sapp &
Haubenstricker, 1978; Weiss & Chaumeton, 1992; Wold & Kaunas, 1993), a sense of
self-image tied to the activity, and 100% confidence in their ability to maintain exercise
for life (Cardinal, 1999; Cardinal & Levy, 2000). One might also expect that late—in-stage
maintainers would exhibit these characteristics to a lesser degree. However, if years
spent in the activity is not a reliable measure of adherence as Cardinal and Levy (2000)
suggest, then perhaps the transition between maintenance and transformation is more
fluid and less incrementally definable. Perhaps the gateway to the final stage transition is
best understood experientially.

Marcus, Dubbert, F orsyth, McKenzie, Stone, Dunn, and Blair (2000) recommend
that future research on the TTM “investigate factors associated with differential patterns
of adoption and mintenance of exercise” (p. 39) principally to discover whether there are
critical periods that help make exercise habitual and to discover the natural history of
change. Further, they recommend examining the influence of parents, school, and
significant others on the promotion of exercise. In addition, O’Brien-Cousins and
Keating (1995) point to the need for future research on the “turning points of women at

earlier stages of life that determine level of physical activity” (p. 357).

Research Questions

Based on Marcus et al.’s (2000) recommendation and findings from previously
conducted studies, this study was designed to answer the following questions concerning
older women who are either late-in-stage maintainers or transformers:

1. In what ways do life experiences impact stage placement?

a. How does the way in which women were raised, e. g., culture,
values, social support, and perceptions of exercise or physical
activity, influence their current stage placement?

b. What are the factors or stressors in adult life, such as career,

children, health, social support, etc., which impact current stage

placement?

c. How have relapse episodes impacted progress to their current
stage?

(1. How does the timetable in which intrinsic motivation was adopted

influence stage placement?

e. How does the timetable in which enjoyment of exercise or physical
activity was acknowledged impact stage placement?

2. What is the role of ritual or routine in adherence to exercise or physical

activity?

a. Are women in the transformed or late-in-stage maintenance stages
more likely to prefer or better utilize routines and schedules?

b. How does preference for routine aid adherence to exercise or

physical activity?

The answers to these questions may provide valuable information for practitioners and
educators who hope to help their patients, clients, and students adopt physically active

lifestyles.

Chapter 2
REVIEW OF LITERATURE

The Transtheoretical Model (TTM; Prochaska & Marcus, 1994; Prochaska et al.,
1994), as its name indicates, is a hybrid or blend of the systems of change identified
within psychoanalysis, behaviorism, cognitive therapy, existential analysis, and
humanism. The outcrop from this blend is a model that contains four major components:
Stages of Change, Decisional Balance, Self-efficacy, and Processes of Change. While
this model can be applied to many different aspects of life, for the purpose of this paper,
the focus will be limited to that of adherence to physical activity (Marcus & Simkin,
1993; Marcus & Simkin, 1994; Reed, 1999). The six stages of change indicate a person’s
level of readiness for and commitment to physical activity while the remaining three
components influence the progress of behavioral change.

It is important to note that the TTM was designed around the assumption that
there is a negative behavior in need of change. For exercisers, it is assumed that they
were once sedentary in order for the model to apply. However, the model itself does not
include a test of whether the negative behavior exists nor have researchers studying the
TTM for exercise included this type of screening in their studies.

Major Components of the TTM

Stages of Change. There are six stages of change that define a person’s behavior
during the change process (Prochaska et al., 1994). The behaviors range from
unwillingness to change through complete adoption of change. Each stage is associated
with a specific set of issues that must be addressed by the individual in order for him or

her to successfully transition into the next stage. Table 1 shows the six stages of change

used to identify a person’s level of readiness for and commitment to exercise. In depth

discussion of the characteristics of the individual stages is presented in the next section.

Table 1

The stages of change for exercise behavior (Prochaska & Marcus, 1994)

 

 

Stage Explanation

Precontemplation Not intending to exercise

Contemplation Intending to exercise in next 6 months

Preparation Planning to exercise in the next month

Action Actively engaging in exercise for up to 6
months

Maintenance Sustaining exercise for at least 6 months
and less than 5 years

Long-term Maintenance" 5 or more years of continuous exercise

involvement but less than 100% confidence
in ability to remain physically active for
lifeM

Termination (a.k.a. Transformed“) 5 or more years of continuous exercise
involvement and 100% confidence in

ability to remain physically active for life“

 

Note: * Cardinal (1999) “Cardinal & Levy (2000)

Placement into a specific stage has been determined by a number of different
instruments over time. Commonly used instruments included either 3-item (Clarke &
Eves, 1997), 4~item (Marcus, Selby, Niaura, & Rossi, I992; Mutrie & Caddell, 1994), 5-
item (Christopoulou, McKenna, & Naylor, 1996; Cowen, Logue, Milo, Britton, &

Smucker, 1997; Eves, Mant, & Clarke, 1996; Goldberg, Christopher, Aznar, Barnes,

l2

Simmonds, McKenna, Page, & Naylor, 1996; Ingledew, Markland, & Medley, 1998;
Juniper, Oman, Hamm, & Kerby, 2004; Marcus, Rossi, Selby, Niaura, & Abrams, 1992;
Naylor & McKenna, 1995; Naylor, McKenna, Barnes, & Christopher, 1995; Simmonds,
Naylor, Riddoch, & Vellman, 1996), or 32-item, 5-point Likert scale (Barke, & Nicholas,
1990) on which the subjects rated their agreement with statements that related to the
various stages. The Kappa index for reliability of the 3-, 4-, and 5-item versions was .78
over a 2-week period (Marcus, Selby et al., 1992). Reliability for the 32-item scale was
not reported (Barke, & Nicholas, 1990). From their responses, subjects were placed into
the stage connected with the statement they agreed with most strongly. For instance, an
individual who responded “strongly agree” to the statement “I currently do not exercise,
and I do not intend to start exercising in the next 6 months” (Marcus, Selby et al., 1992)
would be classified as a precontemplator.

Another similar instrument used to assess stage placement was a true/false design.
With this tool, subjects responded, true or false, to five statements that corresponded with
the stages (Cardinal, Engels, & Zhu, 1998; Hellman, 1997; Jue & Cunningham, 1998;
Marcus & Simkin, 1993; Titze, Martin, Seiler, Stronegger, & Marti, 2001). For example,
if a person responded “true” to the statement “I currently do not exercise” and to the
statement “I intend to exercise in the next 6 months,” he or she would be categorized as a
contemplator (Marcus & Simkin, 1993). The Kappa index for reliability for this tool
was .78 over a 2-week period (Marcus, Selby et al., 1992).

A variation of this tool was to have subjects respond to an algorithm of statements
that defined their stage (Courneya, Plotnikoff, Hotz, & Birkett, 2001; Kosma, Cardinal, &

McCubbin, 2004; Plotnikoff, Hotz, Birkett, & Coumeya, 2001; Sarkin, Johnson,

l3

Prochaska, & Prochaska, 2001; Walcott-McQuigg, & Prochaska, 2001). For instance,
subjects were first asked if they currently did any vigorous exercise. If the answer was
Wes,” they were then asked if the vigorous exercise was regular. If the answer was “no,”
they were placed in the preparation stage (Courneya et al., 2001). The Pearson
correlation of stage with energy expenditure was significant (Plotnikoff et al., 2001).

In yet another slight variation fiom the above designs, the subjects were asked to
select one statement, among several, that best described their current exercise status.
Their choice equaled their stage placement as each statement corresponded to a specific
stage (Booth, Macaskill, Owen, Oldenburg, Marcus, & Bauman, 1993; Boyle, O’Connor,
Nicolaas, & Tan, 1998; Burn, Naylor, & Page, 1999; Coumeya & Bobick, 2000; Gorely
& Gordon, 1995; Kearney, de Graaf, Damkjaer, & Engstrom, 1999; Marcus, Banspach,
Lefebvre, Rossi, Carleton, & Abrams, 1992; Nigg & Coumeya, 1998; Peterson, &
Aldana, 1999). For example, if a person selected “do not exercise regularly and do not
intend to start,” he or she would be categorized as a precontemplator (Booth et al., 1993).
For this tool, there was a significant systematic relationship between stage and activity
level (Booth et al., 1993). A modification on this design was to place the statements on a
ladder which allowed the subject to circle the number on the ladder that corresponded to
the statement of their choice (Cardinal, 1993; Cardinal 1995a; Cardinal 1995b; Cardinal,
1997; Marcus & Owen, 1992; Wyse, Mercer, Ashford, Buxton, & Gleeson, 1995).

In a slightly more sophisticated version of these tools, activity status was
measured through recall (Lee, 1993; Nguyen, Potvin, & Otis, 1997; Potvin, Gauvin, &
Nguyen, 1997) or an Exercise Participation Questionnaire (Myers & Roth, 1997) and was

intersected with a question about intention to exercise in order to place subjects into

14

stages (Fahrenwald & Walker, 2003; Lee, 1993; Myers & Roth, 1997; Nguyen et al.,
1997; Potvin et al., 1997). The overall effect for stage was significant (Lee, 1993).

In order to place individuals into the transformed stage, the method above was
modified. In this modification called the Stage of Physical Activity Algorithm, subjects
were placed into stages based on their responses to two criteria: how long the exercise
behavior had been maintained and how confident the subject was that he or she could
maintain the behavior (Cardinal, 1999; Cardinal & Levy, 2000). This modified technique
was necessary because no previous tool had incorporated the transformation stage.
MANOVA testing showed significant differences between all stages (Cardinal, 1999).
Fallon (2004) and Fallon and Hausenblas (2001) used this same method in their studies
of transformers, but they eliminated percent of confidence as a factor in categorizing
transformers.

Despite the use of a variety of instruments, all studies revealed that subjects,
regardless of demographic factors, were represented in each of the five stages. Studies
that targeted special populations, such as low socio-economic status women (Fahrenwald
& Walker, 2003), people living in rural and inner city locations (Potvin et al., 1997),
people with severe disabilities (Kosma et al., 2004), overweight people (Sarkin et al.,
2001), older adults (Gorely & Gordon, 1995), Afiican Americans (Heesch, Brown, &
Blanton, 2000; Juniper et al., 2004; Walcott-McQuigg, & Prochaska, 2001), Hispanic,
women (Heesch, Brown, & Blanton, 2000) and Native American/Native Alaskan women
(Heesch, Brown, & Blanton, 2000), all showed subjects distributed across the first five
stages of change. Even in studies done in other countries including Australia (Gorely &

Gordon, 1995; Lee, 1993; Marcus & Owen, 1992), Canada (Nguyen et al., 1997), the

15

European Union (Kearney et al., 1999), Greece (Christopoulou et al., 1996), and the
United Kingdom (Burn et al., 1999; Ingledew et al., 1998; Naylor et al., 1995; Wyse et
al., 1995), people were distributed across the stages.

Decisional Balance. One factor that relates to progress throughout the stages is
the decisional balance or the weighing of pros versus cons (Janis & Mann, 1977). As a
rule, the “pros” steadily increase from precontemplation to maintenance while the “cons”
decrease (Marcus & Owen, 1992).

Decisional balance or the “pros” and “cons” are commonly measured by either 6-
item (Herrick, Stone, & Mettler, 1997; Marcus, Eaton, Rossi, & Harlow, 1994; Marcus &
Owen, 1992), 8-item (Sarkin et al., 2001), lO-item (Eves et al., 1996; Kosma et al.,
2004), 16-item (Gorely & Gordon, 1995), or 43-item scales (F ahrenwald & Walker,
2003). In the 6—, 8-, and 10-item scales, half of the items on the scale represented a “con”
of exercise, e.g., “Physical activity would take up too much of my time” (Kosma et al.,
2004), and the other half of the items represented a “pro”, e. g., “I would be healthier if I
exercised regularly” (Marcus & Owen, 1992). Internal consistency for the 6-item scale
was .70 for pros and .56 for cons (Marcus & Owen, 1992). Internal consistency for the 8-
item scale was .87 for pros and .71 for cons (Sarkin et al., 2001 ). Internal consistency for
the 10-item scale was .82 for pros and .57 for cons (Kosma et al., 2004).

In the 16—item scale also known as the Decisional Balance Questionnaire, 10 of
the items were related to the “pros” of exercise while the remaining six related to the
“cons” (Gorely & Gordon, 1995). Internal consistency for this scale was .95 for pros and

.79 for cons. In the 43-item scale also known as the Exercise Benefits/Barriers scale, 29

of the items were related to the “benefits” of exercise while the remaining 14 related to

the “barriers” (Fahrenwald & Walker, 2003). Internal consistency for this scale was .95
for benefits and .89 for barriers. The “pro” and “con” statements were rated by
participants in all of the studies on a 5-point Likert scale except for the F ahrenwald and
Walker (2003) study in which a 4-point Likert scale was used.

Self-efi‘icacy. Another factor that relates to progress throughout the stages is self-
efficacy (Bandura, 1986). As a rule, self-efficacy steadily increases fiom
precontemplation to maintenance (Marcus & Owen, 1992; Marcus, Selby etal., 1992).

Self-efficacy was most commonly measured by a 5-item scale that used either a 5-
point (Gorely & Gordon, 1995; Herrick et al., 1997), 7-point (Marcus et al., 1994;
Marcus & Owen, 1992), or ll-point Likert scale (Burn etal., 1999; Christopoulou et al.,
1996; Marcus, Selby et al., 1992). Internal consistencies ranged from .76 (Herrick et al.,
1997) to .85 (Marcus, Selby et al., 1992). Variations on this measure included a 6-item,
5-point scale with an internal consistency of .88 (Sarkin et al., 2001) and a 7-item, 100-
point scale with an unreported internal consistency (Juniper et al., 2004). All of the
measures assessed subjects’ confidence in their abilities to exercise under a variety of
conditions such as poor weather, tiredness, time constraints, bad mood, and the like.

The self-efficacy portion of this model is the most controversial. Plotnikoff et a1.
(2001) argue that self-efficacy is the strongest indicator of the stage of change, and that
Prochaska has failed to explain the relationship between self-efficacy and the processes
of change (Plotnikoff et al., 2001). However, Prochaska and Marcus (1994) explain that
while self-efficacy scores increase linearly across the stages, high self-efficacy does not

always equal success. They note that high self-efficacy in the early stages is related to

17

the high use of the processes of change, whereas high self-efficacy in the later stages is
related to low use of the processes of change which increases the risk for relapse.

Processes of Change. The 10 processes of change are applied to help the
individual move into the subsequent stage. In each of the stages, a combination of the
processes is used to promote stage transitioning and prevent relapse; however, in no one
stage are all the tools used simultaneously. Table 2 lists the 10 processes of clmnge and
an explanation of each process. The processes will be discussed as they relate to the

stages of change in the next section.

18

Table 2

The processes of change as defined by Prochaska et a1. (1994)

 

Process

Definition

 

Commitment (a.k.a. Self-Liberation*)

Consciousness-raising

Countering (a.k.a. Counterconditioning“)
Emotional arousal (a.k.a. Dramatic
Relief")

Environmental Control (a.k.a. Stimulus
Control")

Environmental Reevaluation”

Helping Relationships

Self-Reevaluation

Social Liberation

Rewards (a.k.a. Reinforcement

Management“ or Contingency

Management")

Choosing and committing to act, or belief in ability
to change

Increasing information about self and problem
Substitution alternatives for problem behaviors
Experiencing and expressing feelings about one’s
problems and solutions

Avoiding stimuli that elicit problem behaviors

Consideration and assessment by the individual of
how the problem affects the physical and social
environment“

Enlisting the help of someone who cares
Assessing feelings and thoughts about self with
respect to the problem

Increasing social alternatives for behaviors that are
not problematic

Rewarding self, or being rewarded by others, for

making changes

 

Note: *Marcus, Banspach et al., (1992). "Prochaska & Velicer (1997).

A tool known as the Processes of Change Questionnaire (PCQ; Marcus, Rossi et

al., 1992) measures the 10 processes and is composed of 39 items. Each item is rated on

a 5-point Likert scale ranging fi'om 1 (never used) to 5 (repeatedly used). This tool has
been used in all studies to date that have examined the processes of change (Courneya &
Bobick, 2000; Goldberg et al., 1996; Gorely & Gordon, 1995; Jue & Cunningham, 1998;
Marcus, Rossi et al., 1992; Nigg & Coumeya, 1998) with one exception. In their study of
mothers enrolled in the Women, Infants, and Children (WIC) program, Fahrenwald and
Walker (2003) measured nine of the processes with the PCQ but measured the process
called “helping relationships” with the Social Support for Exercise Scale (SSE). The SSE
includes two subscales for measuring both family and fi'iends’ support. WIC is a
federally funded program for low income women, infants, and children that provides
food, nutrition counseling, and access to health resources/services.

Characteristics of the Six Stages of Change

Studies on the TTM and exercise have identified distinctive differences that
characterize each stage. These differences include progressively increased levels across
stages in areas like participation in exercise, perceptions of social support, enjoyment of
exercise, etc. For each stage, there is a specific set of issues that must be addressed by
the individual in order for him or her to successfirlly transition into the next stage. From
contemplation to maintenance, risk of relapse is acknowledged if these issues are not
addressed (Prochaska et al., 1994).

Precontemplation. In the first stage, known as precontemplation (Prochaska et
al., 1994), people are unwilling to consider, let alone commit to, any regular exercise.
They may even deny a problem at all. They view suggestions from others to change as
pointless or nagging. The following scenario illustrates the mindset of the

precontemplator:

20

Tara’s doctor and some of her fiiends talk at length about the importance

of daily exercise. She thinks that this concept is designed around people

who either don’t work or who are rich enough to hire a personal trainer to

force them to do exercise or both. She is tired when she comes home from

work and believes her reward for a long a day at work is putting her feet

up and watching television. She usually changes the channel if there is a

commercial on it that promotes exercise.

Studies confirm that precontemplators including those who are low income
women (Fahrenwald & Walker, 2003), people with disabilities (Kosma et al., 2004), and
college students (Myers & Roth, 1997; Naylor et al., 1995; Wyse et al., 1995) do
significantly less exercise than individuals in the other stages (Cardinal, 1995a; Clarke &
Eves, 1997; Eves et al., 1996; Fahrenwald & Walker, 2003; Kearney et al., 1999; Kosma
et al., 2004; Lee, 1993; Marcus & Simkin, 1993; Myers & Roth, 1997; Naylor et al.,
1995; Wyse et al., 1995). Studies also show that precontemplators dislike exercise more
than individuals in other stages (Clarke & Eves, 1997; Eves et al., 1996; Ingledew et al.,
1998; Nguyen et al., 1997) and have greater perceived barriers to exercise (Hellman,
1997; Juniper et al., 2004; Lee, 1993; Myers & Roth, 1997) including lack of social
support for exercise (Clarke & Eves, 1997; Hellman, 1997; Kearney et al., 1999; Lee,
1993; Myers & Roth, 1997).

Precontemplators deny their inactivity is a problem (Prochaska et al., 1994). This
response is likely to occur because both adults (Hellman, 1997; Kearney et al., 1999; Lee,
1993; Myers & Roth, 1997) and children (Cardinal et al., 1998) in this stage tend to be
less knowledgeable than people in other stages about the benefits of exercise.

Individuals can stay in this stage somewhere between 6 months to forever

(Prochaska et al., 1994). The actual time spent in this stage is largely related to

movement in the “decisional balance” meaning rankings of pros and cons. People in this

21

stage are said to rate the “cons” of changing their inactivity behavior much higher than
the “pros” in their decisional balance and have low self-efficacy for exercise.

Numerous studies done on the TTM and exercise behavior show that cons heavily
outweigh the pros in the precontemplator’s decisional balance rankings (Eves et al., 1996;
Fahrenwald & Walker, 2003; Gorely & Gordon, 1995; Herrick et al., 1997; Kosma et al.,
2004; Marcus et al., 1994; Marcus & Owen, 1992; Sarkin et al., 2001). This finding
remained consistent despite low socio-economic status (F ahrenwald & Walker, 2003),
severe physical disability (Kosma et al., 2004), or being overweight (Sarkin et al., 2001).

Low self-efficacy scores for exercise in this stage are equally supported across
studies (Burn et al., 1999; Christopoulou et al., 1996; Gorely & Gordon, 1995; Herrick et
al., 1997; Juniper et al., 2004; Marcus et al., 1994; Marcus & Owen, 1992; Marcus, Selby
et al., 1992; Sarkin et al., 2001). This finding remained consistent with African-American
women (Juniper et al., 2004) and overweight people (Sarkin et al., 2001).

The processes of change that help people transition from precontemplation to
contemplation are “consciousness-raising” and “social liberation” (Prochaska et al.,
1994). “Consciousness raising” is defined as increasing one’s awareness and increasing
the amount of information one has about the issue at hand (Prochaska et al., 1994).
Television commercials and other kinds of advertisements that boast the benefits of
engaging in exercise serve to help raise the consciousness of precontemplators. The other
process of change used in this stage is “social liberation” which is defined as societal
support/rejection of specific behaviors (Prochaska et al., 1994). “No Smoking” signs
indicate smoking is not an acceptable behavior. “Buckle-up” signs on the highway tell us

seatbelt use is an acceptable or required social behavior. In the United States Department

22

of Agriculture’s Dietary Guidelines for Americans 2005, the recommendation to engage
in at least 30 minutes of exercise on most days of the week indicates that exercise is a
desirable behavior. The desired effect of these two processes of change on the
precontemplator is to bring the issue to a conscious level allowing them to move into the
next stage.

Research aimed at testing the relationship between the stages of change and the
processes of change indicates that while “consciousness-raising” and “social liberation”
are used in precontemplation, they are not always the most preferred processes for
precontemplators. Table 3 shows where the two processes, prescribed by Prochaska et aL
(1994) for precontemplators, ranked in relationship to all 10 processes of change across

seven studies.

23

Table 3
A cross study comparison of rankings from the PCQ for the processes of change as

prescribed by Prochaska et aL (1994) for the precontemplation stage

 

Studies Subjects SL CR

 

Marcus, Rossi et al., 1992 Worksite study 1 5

Gorely & Gordon, 1995 Ages 50-65 N/R 2

.—a
£11

Coumeya & Bobick, 2000 College students
Jue & Cunningham, 1998 Bypass patients 3 3
Fahrenwald & Walker, 2003 WIC mothers 4 3
Goldberg et al., 1996 Ages 12 & 17 1 8

Nigg & Coumeya, 1998 HS students 7 8

 

Note. SL = social liberation; CR = consciousness raising; N/R = not reported.

In the precontemplation stage, where “social liberation” should have consistemly
ranked first or second, it actually ranked anywhere from first to seventh while
“consciousness-raising” ranged in ranking from second to eighth. However, scientific
knowledge that the use of certain processes are more beneficial to specific stages does not
guarantee that behavior in people. In general, many people fail at transforming their
exercise behavior simply because they are unaware of what steps should be taken to make
a permanent change. However, people in the precontemplation stage are faced with an
additional factor involving the desire to change. Those not wanting to change might
avoid processes that could cause them to change. In addition, some of the variation in
rankings for use of the processes of change may be due to the age differences between the

participants in the various studies.

24

Another possible explanation for the differences in process of change rankings
may have to do with group classification. Cardinal (1998) studied two groups of college
students across the first five stages of change. The first group had never relapsed into
sedentary behavior but the second group had. “Relapse” was identified by a yes or no
response to the statement “I have exercised in the past, but I am not doing so currently.”
The relapsers were significame different from non-relapsers in that relapsers did not
demonstrate the usual gradient pattern of improvement across the stages. Cardinal (1998)
speculated that relapsers might also differ in their use of the processes of change.
Therefore, the results from the process of change studies above may be confounded
because none of the studies controlled for relapsers. However, it is important to note tint
the term “relapse” was never operationalized. Intuitively, a person who ceases to engage
in physical activity due to an injury but plans to return to activity as soon as they recover
is categorically different fiom a person who ceases to engage in physical activity because
they no longer choose to engage. Further, duration of cessation should be considered.
Taking a 1-2 week break fi‘om physical activity is most likely not a relapse, but ceasing
activity for 6 months by choice clearly should be defined as relapse.

In addition to the information in Table 3, two items of note are outside of the
table. First, in a study by Jue and Cunningham (1998) of coronary artery bypass graft
patients who were 60 years of age or older, “commitment” was the process most
preferred by all stages across the board. The heavy emphasis on commitment is likely a
product of enduring a life-threatening situation. Second, Fahrenwald and Walker (2003)
studied mothers in the WIC program. In this study, Fahrenwald and Walker (2003)

measured 9 of the processes with the PCQ but measured a process called “helping

25

relationships” with the Social Support for Exercise Scale (SSE) which includes two
subscales that measure family and fi'iends’ support. “Helping relationships” emerged as
the most commonly used process by all stages across the board. While this finding is
likely resulting fi'om the special tool used to measure this process, it may also be due to
the fact that all the women in this study were recipients of WIC assistance and therefore
may have been more aware of the importance of “helping relationships” because of their
association with WIC.

This information raises the following questions with regard to the current study.
Ifa person was raised in an environment where daily exercise was the norm, did that
person ever spend time in the precontemplation stage or did the person skip directly to
the preparation or action stage? And if so, are transformers more likely to come from
that type of upbringing than people in the last 2 years of the maintenance stage? Lastly,
are transformers more or less likely to have relapsed in the past than people in the last 2
years of the maintenance stage, and when they relapsed, did they return to the
precontemplation stage or a later stage?

Contemplation. In the second stage called contemplation, people consider
committing to exercise (Prochaska et al., 1994). “Considering” fairly well defines the
stage. Here people do enormous amounts of thinking, considering, contemplating, and
information gathering. They talk at length about their intentions. They gather
information from print sources, experts in the field, significant others, and the media. The
following scenario describes a contemplator:

Lately, Tara has stopped changing the channel when an exercise

commercial or news report is airing. She is beginning to find them

interesting. She thinks that next time she sees the doctor she might strike
up a conversation about exercise, figuring it can’t hurt to get an expert’s

26

opinion. She also no longer scoffs at her fiiends who ask her to exercise
with them. Instead she tells them she might do that sometime.

Perhaps because of the information gathering done in this stage, children ages 5-
11 (Cardinal et al., 1998), cardiac rehabilitation patients aged 65 and older (Hellman,
1997), and college students (Myers & Roth, 1997) in this stage were all shown to view
exercise as having more benefits to them than people in the precontemplation stage but
less than people in the stages to follow. Information gathering may also soften
contemplators’ views of the barriers to exercise as people in this stage, including Afiican
American college women (Juniper et al., 2004) and older adults (Hellman, 1997; Lee,
1993), have fewer perceived barriers to exercise than precontemplators but more than
people in the other stages (Clarke & Eves, 1997; Hellman, 1997; Juniper et aL, 2004;
Lee, 1993; Myers & Roth, 1997). Similarly, contemplators believe they have more social
support for exercise than precontemplators do but less than the following three stages
(Clarke & Eves, 1997; Hellman, 1997; Nguyen et aL, 1997).

In general, contemplators do not act on any of the information they have gathered
until they have transitioned into the next stage which may leave an impression of
procrastination. However, contemplators, including those who are overweight (Sarkin et
aL, 2001), participate in exercise more than precontemplators but participate less than
people in the remaining stages, (Burn et aL, 1999; Cardinal 1995a; Eves et al., 1996;
Marcus & Simkin, 1993; Naylor et aL, 1995; Sarkin et al., 2001; Wyse et al., 1995), and
they dislike exercise less than precontemplators but more than people in the other stages
(Clarke & Eves, I997; Eves et aL, 1996).

The contemplator generally plans to engage in exercise within the next 6 months

or so. However in reality, the contemplator can stay in this stage anywhere from 6

27

months to forever. Contemplators, including low income status women (Fahrenwald &
Walker, 2003), severely disabled people (Kosma et al., 2004), and over weight people
(Sarkin et al., 2001) still tend to rank the cons of exercise higher than the pros but not as
heavily as they did in the previous stage (Herrick et aL, 1997; Marcus & Owen, 1992).
Self-efficacy for exercise is still low for contemplators, but this too begins to improve
over the previous stage (Burn et aL, 1999; Christopoulou et al., 1996; Gorely & Gordon,
1995; Herrick et al., 1997; Juniper et al., 2004; Kosma et al., 2004; Marcus, Selby et al.,
1992; Marcus & Simkin, 1994; Sarkin et al., 2001). This increase in self-efficacy is
consistent across groups including Afi'ican American college women (Juniper et al.,
2004), severely disabled people (Kosma et al., 2004), overweight people (Sarkin et al.,
2001), and older adults (Gorely & Gordon, 1995).

The processes of change presumed to help the contemplator move into the next
stage are “consciousness raising,” “social liberation,” “emotional arousal,” and “self-
reevaluation” (Prochaska et al., 1994). In this stage, “consciousness raising” and “social
liberation” are used to continue to increase awareness and provide fodder in the
decisional balance. “Emotional arousal,” which comes fiom dramatic, emotionally-
charged events, is used for motivation in this stage (Prochaska et al., 1994). “Emotional
arousal” for exercise might be the inability to keep up with children or grandchildren or
watching a significant other deal with a health problem that is related to inactivity.

The next process of change in this stage is “self-reevaluation” which is the
emotional and cognitive appraisal of both one’s problem and one’s self (Prochaska et aL,
1994). During this exercise, people compare the things they value and admire to their

current behavior and discover that there are inconsistencies between what they value and

28

what they do. This realization combined with the information gathered during
consciousness raising activities causes people to begin weighing the pros and cons of
ceasing their inactivity.

Research designed to test the relationship between the stages of change and the
processes of change indicates that contemplators use the prescribed processes more often
than in the previous stage, but inconsistencies in degree of reliance on the processes were
still present. Table 4 shows where the four processes, prescribed by Prochaska et al.
(1994) for contemplators, ranked in relationship to all 10 processes of change across
seven studies. The table reveals that “self-reevaluation” ranked well within the top four
and “consciousness raising” generally followed that same trend of rankings between
studies with two exceptions that may have to do with age/maturity factors. However,
“social liberation” and “emotional arousal” had a less consistent trend between studies
and the rankings tended to fall outside of the top four.

Again, discrepancies between the actual processes used by contemplators versus
those prescribed for contemplators may be due to level of the individual’s commitment to
change, knowledge of how to change successfully, age differences, or presence of
relapsers in the groups (Cardinal, 1998). Inconsistencies may also be an issue of length
of time one lms been in the contemplation stage. Contemplators who have just
transitioned from precontemplation may not yet be using all the processes designated for
that stage. The answer is not clear, but what is clear is that when the “pro” list grows and

becomes more equally balanced with the con list, the individual is ready to move into the

next stage.

29

Table 4
A cross study comparison of rankings fi'om the PCQ for the processes of change as

prescribed by Prochaska et a1. (1994) for the contemplation stage

 

Studies Subjects SR CR SL EA

 

Marcus, Rossi et al., 1992 Worksite study 1 3 4 6
Gorely & Gordon, 1995 Ages 50-65 1 3 N/R N/R
Coumeya & Bobick, 2000 College students 1 3 7 6
.Iue & Cunningham, 1998 Bypass patients 2 3 5 9
F ahrenwald & Walker, 2003 WIC mothers 2 4 6 8
Goldberg et al., 1996 Ages 12 & 17 1 6 3 2

Nigg & Coumeya, 1998 HS students 1 6 4 7

 

Note. SR = self-reevaluation; CR = consciousness raising; SL = social liberation; EA =
emotional arousal; N/R = not reported

This information raises the following questions with regard to the current study.
First, do people who were raised in an environment where daily exercise was the norm
ever spend time in the contemplation stage or do they skip directly to the preparation or
action stage? And if so, are transformers more likely to come fiom that type of
upbringing than people in the last 2 years of the maintenance stage? Second, if relapse
was accurately measured, are transformers more or less likely to have relapsed than
people in the last 2 years of the maintenance stage, and when they relapse, do they return
to the contemplation stage or a later one? And finally, how does this relapse pattern

impact their use of the processes of change?

30

Preparation. In this stage, people prepare to take part in exercise, generally
within a month’s time (Prochaska et aL, 1994). During this stage, individuals have trial
runs with the activity, engaging in it for short periods of time from 1 day to 1 week. They
do extensive planning and set goals for themselves. The time spent exploring issues and
obstacles that my cause the individual to fail and finding solutions for them is critically
important to preventing relapse. An example of failure due to improper preparation is
detailed in the following scenario:

Tara has decided that she is going to join her friends in their workout

program soon. She has even gone out and purchased gym shoes.

However she hasn’t made any firm plans as to a starting date. Saturday

morning she wakes and notices that it is a beautifirl sunny day. She

decides that today she will start her exercise program by going jogging.

After she returns fiom her run she thinks, “I’m going to do this every

morning.” On Sunday, she wakes up to find it raining and decides to

watch television instead. She doesn’t exercise Monday either nor the rest

of the week. She is left with a feeling of failure and decides she isn’t

ready for exercise yet.

In this scenario, Tara failed to do proper planning. In her zeal to begin a fitness
program, she forgot to examine the possible barriers to her success. Had she spent time
examining potential pitfalls, she would have already had a contingency plan in place for
dealing with barriers like inclement weather.

Studies show that preparers, including cardiac rehabilitation patients age 65 and
over (Hellman, 1997), college students (Cardinal 1995b; Naylor et al., 1995; Wyse et al.,
1995), and overweight people (Sarkin et al., 2001), engage in exercise more frequently
and more intensely than precontemplators and contemplators, but less so than actors or
maintainers (Cardinal, 1993; Cardinal 1995a; Clarke & Eves, 1997; Eves et al., 1996;
Hellman, 1997; Naylor et al., 1995; Sarkin et al., 2001; Wyse et aL, 1995). Preparers also

dislike exercise less than precontemplators and contemplators but more than actors and

31

maintainers (Clarke & Eves, 1997, Eves et al., 1995). In addition, they begin to show
some commitment to exercise (Prochaska et al., 1994), which could be a monetary
commitment like the purchase of gym memberships, equipment, and gear, or a time-
related commitment such as scheduling breaks for exercise. This new willingness to
commit money or time makes sense because preparers, including children 5-11 (Cardinal
et al., 1998), college students (Myers & Roth, 1997), and cardiac rehabilitation patients
age 65 and over (Hellman, 1997), all perceived more benefits to exercise than
precontemplators and contemplators but less than actors and maintainers. Commitment
also makes sense in this stage because the pros and cons for exercise in the preparation
stage become more evenly balanced for severely disabled people (Kosma et aL, 2004)
and the pros tending slightly to outweigh the cons for low income women (Fahrenwald &
Walker, 2003), overweight people (Sarkin et al., 2001), and people fi'om the United
States and Australia (Marcus & Owen, 1992). In addition, self-efficacy for exercise
continues to rise for all subject groups (Burn et al., 1999; Christopoulou et al., 1996;
Herrick et aL, 1997; Marcus & Owen, 1992; Marcus, Selby et aL, 1994) including
African American college women (Juniper et aL, 2004), older adults (Gorely & Gordon,
1995), severely disabled people (Kosma et al., 2004), and overweight people (Sarkin et
aL, 2001). Social support for exercise also increases (Clarke & Eves, 1997; Hellman,
1997; Myers & Roth, 1997) while barriers to exercise diminish from the previous stages
(Clarke & Eves, 1997; Hellman, 1997; Juniper et al., 2004; Myers & Roth, 1997).
Preparers also set goals and do planning to sort out when, where, and how they
will address their goals which is important for preventing relapse (Prochaska et aL, 1994).

This activity is reflected in the processes of change for this stage. The processes of

32

,3 6‘ 9’ 66

change used in preparation are “consciousness raising, social liberation, emotional
arousal,” “self-reevaluation,” “environmental reevaluation” (Marcus, Rossi et al., 1992),
and “commitment.”

In preparation, “consciousness raising” takes a slightly different form. Its primary
function is to provide information that will help the individual select the most appropriate
course of action, e.g., which type of fitness activity best fits personal interests, time
constraints, and expendable income. “Self-reevaluation” is also applied differemly in
that the individual begins to shift his or her focus to firture possibilities rather than on past
behaviors, e.g., “I know I don’t like to exercise outdoors in bad weather, so I will plan for
some indoor alternatives just in case.”

The processes of change new to this stage are “environmental reevaluation” and
“commitment.” In “environmental reevaluation,” one assesses the impact of one’s
behavior on others. For instance, an out-of-shape parent who limits his or her children’s
engagement in physical activities because that parent tires easily might feel that he or she
is negatively affecting the child. Recognizing the impact of one’s behavior on another
might provide the motivation to become physically fit. The second new process of
change for this stage, called “commitment,” can come in a number of forms.
“Commitment” might be setting a date, cg, “I will begin exercising next Monday,” or
making a financial investment in gym memberships. Once a thorough plan is in place,
the preparer is more likely to be successfirl in the action stage.

Research aimed at testing the relationship between the stages of change and the

processes of change indicates that preparers use the prescribed processes about as often

as in the previous stage with about half of the processes meeting expectations for use.

33

Table 5 shows where the six processes prescribed by Prochaska et a1. (1994) for preparers
ranked in relationship to all 10 processes of change across seven studies. The table
shows that the expected ratings occurred for “self-reevaluation,” “commitment,” and
largely for “social liberation.” However, “consciousness raising,” “environmental
reevaluation,” and “emotional arousal” did not meet expectations. Again, the possible
reasons for these inconsistencies include the level of one’s commitment to change, length
of time one has been in the preparation stage, knowledge of how to change successfully,

or presence of relapsers in the groups (Cardinal, 1998).

34

Table 5
A cross study comparison of rankings fiom the PCQ for the processes of change as

prescribed by Prochaska et al. (1994) for the preparation stage

 

Studies Subjects CM SR SL CR ER EA

 

Marcus, Rossi et al., 1992 Worksite study 2 1 4 3 7 9
Gorely & Gordon, 1995 Ages 50-65 1 3 NR 5 N/R N/R
Coumeya & Bobick, 2000 College students

Jue & Cunningham, 1998 Bypass patients

Fahrenwald & Walker, 2003 WIC mothers 3 2 5 3 6 9

N
....
00
051
U!
\l

....
U)
U)
\1
\O
00

Goldbergetal,1996 Age812&17 2 1 3 8 7 4

Nigg & Coumeya, 1998 HS students 1 2 6 7 5 8

 

Note. CM = commitment; SR = self-reevaluation; SL = social liberation; CR =
consciousness raising; ER = environmental reevaluation; EA = emotional arousal; N/R =
not reported.

This information raises the following questions with regard to the current study.
First, has a person raised in an environment where daily exercise was the norm ever spent
time in the preparation stage or did he or she skip directly to the action stage? Ergo, are
transformers more likely to be people who never experienced precontemplation,
contemplation, or preparation? And if so, has any real change occurred? Second, given
that relapsers behave differently than non-relapsers in the same stage and that relapse was
correctly identified, are transformers more or less likely to have relapsed in the past than
people in the last 2 years of the maintenance stage, and when they relapsed, did they

return to the preparation stage or an earlier one? Third, does this relapse pattern impact

35

the use of the processes of change that are necessary to stage transition? Finally, do the
low ratings for the process of change called “environmental reevaluation,” in which one
assesses the impact of one’s behavior on others, indicate the presence of intrinsic
motivation, hence rendering the perception that others’ opinions are less important?

Action. This stage is busy and unstable with a high risk for relapse, particularly if
not enough time was spent in the preparation stage (Prochaska et al., 1994). In this stage,
the individual starts to implement the plans made during the previous stage and engages
in his or her chosen activity. An example of failure that can occur due to a shortened
preparation stage is detailed in the following scenario:

Tara learned from her past failure and knows now that she needs to have a

backup plan for inclement weather. She now plans to work out with an

exercise video when the weather is not favorable for outdoor exercise, and

she has an exercise partner to help keep her motivated. She begins her

exercise program in June and is successful in maintaining regular exercise

until August. In August, her exercise partner goes on vacation. Tara

struggles to remain motivated while her partner is gone. Upon her return,

Tara learns her workout partner broke her leg and will not be returning to

exercise for some time. Tara decides she does not enjoy exercising alone

and decides to quit her exercise routine until her partner can return.

Although Tara was prepared with tools to combat some of her barriers to exercise,
she had not fiilly considered all the possible issues that could bar her success. More time
spent in the preparation stage would have helped her find a social support system that
would not derail her work out and would have helped her to establish motives beyond
socialization for sustaining exercise.

Studies show that actors, including college students (Cardinal, 1995b; Naylor et
al., 1995; Wyse et al., 1995), cardiac rehab patients age 65 and over (Hellman, 1997), and
overweight people (Sarkin et al., 2001), engage in exercise more than people in the

previous stages but less than people in the maintenance stage (Burn et al., 1999; Cardinal,

36

1993; Cardinal, 1995a; Eves et al., 1996). All groups studied, including African
American college women (Juniper et al., 2004), severely disabled people (Kosma et al.,
2004), older adults (Gorely & Gordon, 1995) and overweight people (Sarkin et al., 2001)
had higher self-efficacy for exercise than those in precontemplation, contemplation, or
preparation (Burn et al., 1999; Christopoulou et al., 1996; Herrick et al., 1997; Marcus &
Owen, 1992; Marcus, Selby et al., 1994).

Actors also perceived more benefits to exercise (Cardinal et al., 1998; Hellman,
1997; Myers & Roth, 1997) and fewer barriers to exercise (Hellman, 1997; Juniper et al.,
2004; Myers & Roth, 1997) than previous stages. In addition, they enjoyed exercise
more than in previous stages (Eves et al., 1996). For all groups studied including low-
income women (Fahrenwald & Walker, 2003), older adults (Gorely & Gordon, 1995),
severely disabled people (Kosma et al., 2004), and overweight people (Sarkin et al.,
2001), the pros simply outweighed the cons for exercise (Eves et al., 1996; Herrick et al.,
1997; Marcus & Owen, 1992).

Many tools are needed to help the actor stay focused on his or her goals. The

9’ ‘6

processes of change used in this stage are “social liberation, commitment,”

’9 6‘

“countering, environmental control,” “rewards,” and “helping relationships.” In this
stage, “social liberation” takes on a confirmatory role, helping to remind the actor that
what he or she is attempting is valid and worthwhile. The role of “commitment” changes
by becoming more traditional, taking on the form of sheer willpower. In this process,

some individuals will have daily, pre-exercise “pep-talks” to remind themselves of their

goals and purpose in order to maintain focus and avoid relapse.

37

The first new process used in this stage is called “countering.” “Countering” is
used to replace a problem behavior with a healthy response. One example of a problem
behavior related to inactivity might be watching television. If an individual identified
television watching as one of the biggest barriers to exercising, he or she would want to
establish a method for dealing with this temptation. To counter, an individual might
employ one of the following options: limit television time or go to the gym directly fiom
work, thereby eliminating the temptation to skip exercise and watch television instead.

The second new process in this stage is named “environmental control.” In
“environmental control,” one attempts to eliminate temptations that might cause a
relapse. Using “environmental control,” the television issue above might be addressed by
disconnecting the cable/ satellite service or selling the television. “Environmental
control” can also refer to relationships. In this stage, the actor may choose to avoid
people who are sedentary or who might criticize attempts at betterment.

The third process used in this stage, termed “reward,” is used to reinforce the
exercise behavior. “Rewards” also help the individual stay focused on small, readily
achievable steps rather than on the potentially overwhelming big-picture.

In the fourth new process, called “helping relationships,” significant others
become critically important. Here one. might ask family members or roommates to ask
daily about how the exercise routine is progressing. One might also find a workout
partner or personal trainer to help with motivation.

Research aimed at testing the relationship between the stages of change and the
processes of change indicates that actors use the prescribed processes much like the

previous two stages. Table 6 below shows where the six processes prescribed by

38

Prochaska et a1. (1994) for actors ranked in relationship to all 10 processes of change
across seven studies. Again because there are six processes prescribed for this stage, one
would expect to find actors ranking their use of each of these six processes somewhere in

the top 6 of the 10 total processes, but again only half of the processes met expectations.

,9 6‘

“Commitment, countering,” and “reward” all met expectations by ranking in the top six
of all processes used by actors, but “social liberation,” “helping relationships,” and
“environmental control” did not. F urtherrnore, “helping relationships” and
“environmental control” ranked nearly last among all processes. The ranking of “helping
relationships” is particularly perplexing because several studies found that actors believe
they have more social support than do precontemplators, contemplators, and preparers
(Hellman, 1997; Kearney et al., 1999; Myers & Roth, 1997). The inconsistencies may be

related to the length of time one has been in the action stage and knowledge of how to

change successfully.

39

Table 6
A cross study comparison of rankings from the PCQ for the processes of change as

prescribed by Prochaska et a1. (1994) for the action stage

 

Studies Subjects CM CT R SL HR EC

 

Marcus, Rossi et al., 1992 Worksite study 1 3 5 6 7 10
Gorely & Gordon, 1995 Ages 50-65 2 3 N/R N/R N/R 4
Courneya & Bobick, 2000 College students 2 3 4 8 9 10
Jue & Cunningham, 1998 Bypass patients 1 2 5 6 8 9
Fahrenwald & Walker, 2003 WIC mothers 3 4 6 10 1 9
Goldberg et al., 1996 Ages 12 & 17 2 5 4 3 9 10

Nigg & Coumeya, 1998 HS students 1 3 4 7 9 10

 

Note. CM = commitment; CT = countering; R = rewards; SL = social liberation; HR =
helping relationships; EC = environmental control; N/R = not reported.

This information raises the following questions with regard to the current study.
First, if a person was raised in an environment where daily exercise was the norm, does
that person have a different view of “helping relationships”? In other words, are “helping
relationships” for exercise so much a part of everyday life for someone who was raised in
a household that engaged in daily'exercise that those relationships are taken for granted,
or does this lack of emphasis on “helping relationships” in some way hint at strong
intrinsic motivation? And if so, are transformers more likely to come fiom a household
that engaged in daily exercise than people in the last 2 years of the maintenance stage?
Finally, although Cardinal (1998) indicated that relapse could occur in this stage, his

conclusions are suspect because in order to be classified as “relapsed” in the action stage,

40

one must simultaneously agree with the statement “I currently exercise on a regular basis,
but have only begun doing so within the past 6 months” which is required to be classified
in the “action” stage and agree with the statement “I have exercised regularly in the past,
but am not doing so currently” which is required to be considered relapsed. It is not
possible for these things to occur at the same time. Hence, we do not know what role
relapse might play in the findings.

Maintenance. Once the individual has successfully completed the action stage, he
or she is in the maintenance stage (Prochaska et al., 1994). The maintenance stage is a
relatively stable stage where people have continually engaged in exercise for a period of
time between 6 months to 5 years but are still somewhat susceptible to temptation and,
hence, relapse. Here, the individual continues to work on exercise goals until temptation
to be sedentary is no longer a threat. An example of failure that can occur due to a
shortened preparation stage is detailed in the following scenario:

Tara has learned from her past failure and knows now that she cannot be

reliant on an exercise partner for motivation. As before, she plans to work

out with an exercise video when the weather is not favorable for outdoor

exercise. She also has set aside a scheduled time each day for her

exercise, and although she exercises alone, has social support from both

family and friends which helps her stay motivated. She begins her

exercise program in April and remains faithful to the plan through

November. However, the month of November proves to be mostly

inclement which forces Tara to exercise with her video nearly every day.

Her video exercises, which at one point provided a nice break from her

outdoor exercises, have now become boring to her due to the repetition.

She finds herself dreading her planned exercise time. One morning, she

decides to quite exercising altogether rationalizing to herself that exercise

is over-rated and that she would rather spend her time doing something

enjoyable like sleeping in.

Although Tara was prepared with tools to combat the barriers to exercise she had

previously encountered, she had not fully considered all the possible issues that could bar

41

her success. More time spent in the preparation stage would have helped her identify
issues of boredom and how to manage them.

Studies show that maintainers, including older adults (Hellman, 1997), college
students (Cardinal, 1995b; Naylor et al., 1995; Wyse et al., 1995), and overweight people
(Sarkin et al., 2001), engage in exercise more than the previous stages (Burn et al., 1999;
Cardinal, 1993; Cardinal, 1995a; Eves et al., 1996). Maintainers who are children
(Cardinal et al., 1998), college students (Myers & Roth, 1997), and older adults
(Hellman, 1997) also perceive more benefits to exercise than previous stages. In
addition, maintainers, including African American women (Juniper et al., 2004) and
cardiac rehabilitation patients age 65 or older (Hellman, 1997), perceive fewer barriers to
exercise (Kearney et al., 1999; Myers & Roth, 1997). Overall, maintainers enjoy exercise
more than previous stages (Eves et al., 1996).

Based on this information, it is no surprise then that, despite low-income
(Fahrenwald & Walker, 2003) or severe disability (Kosma et al., 2004), the pros heavily
outweigh the cons for maintainers (Gorely & Gordon, 1995; Marcus & Owen, 1992).
Nor is it a surprise that self-efficacy for exercise is at its highest in this stage (Burn et al.,
1999; Christopoulou et al., 1996; Herrick et al., 1997; Marcus & Owen, 1992; Marcus et
al., 1994), which remains true regardless of whether the adults studied were severely
disabled (Kosma et al., 2004), overweight (Sarkin et al., 2001), or older (Gorely &
Gordon, 1995).

When temptation to relapse is no longer a threat, the exercise behavior is
considered to be transformed and therefore permanent. However, some individuals never

transition into the transformation stage and are considered to be “long term maintainers”

42

because they have maintained their engagement in exercise for 5 years or more but are
not 100% confident they will always be able to sustain exercise which leaves them prone
to temptation for relapse (Cardinal & Levy, 2000).

The processes of change used in this stage are similar to the previous stage with
the exception of “social liberation” which is no longer salient. The one major threat to
relapse for the maintainer is over-confidence. Maintainers may mistakenly believe their
exercise behaviors are permanent and that a break in their routine will have no impact on
adherence which can set off a relapse period (Prochaska et al., 1994).

Research aimed at testing the relationship between the stages of change and the
processes of change indicates that maintainers use the prescribed processes somewhat
more than the previous stages. Table 7 shows where the five processes prescribed by
Prochaska et a1. (1994) for maintainers ranked in relationship to all 10 processes of
change across seven studies. An examination of Table 7 reveals that “commitment,”
“countering,” and “rewards” all received rankings within the top five as expected, but
“helping relationships” and “environmental control” both ranked among the least used
processes. This phenomenon is most curious. Maintainers should be all but ready to
commit to exercise for life, so one would expect them to be using all the processes for
this stage with gusto. Instead, two of the prescribed processes rank near the bottom of the

list in terms of use.

43

Table 7
A cross study comparison of rankings from the PCQ for the processes of change as

prescribed by Prochaska et al. (1994) for the maintenance stage

 

Studies Subjects CM CT R HR EC

 

Marcus, Rossi et al., 1992 Worksite study 1 2 4 7 10
Gorely & Gordon, 1995 Ages 50-65 2 1 N/R N/R 4
Coumeya & Bobick, 2000 College students 2 1 5 8 10
Jue & Cunningham, 1998 Bypass patients 1 2 5 7 9
F ahrenwald & Walker, 2003 WIC mothers 2 4 7 1 9
Goldberg et al., 1996 Ages 12 & 17 l 2 5 9 10

Nigg & Coumeya, 1998 HS students 1 2 4 9 10

 

Note. CM = commitment; CT = countering; R = rewards; HR = helping relationships; EC
= environmental control; NR = not reported.

This information raises the following questions/issues with regard to the current
study. First, it appears that maintainers either underestimate the importance of the
process of change called “helping relationships,” take “helping relationships” for granted,
or they are not using this tool to its firllest. The underestimating or taking for granted of
“helping relationships” could also mean that maintainers have strong intrinsic motivation
and therefore do not view “helping relationships” highly because their internal motives
take center stage. Taking “helping relationships” for granted might also indicate that
maintainers come fiom families that supported engagement in exercise. Another
possibility is that these maintainers are not ready for transformation or that they are

headed for relapse. A firrther possibility is that because the original stage of change

measure did not screen for transformers, transformers may have been included in the
maintainer group. Mis-assignment is possible because inclusion into the maintainer
group requires only tlmt one have exercised for more than 6 months. Without a cap on
years defining a maintainer, a transformer of 12 years could be included in the maintainer
group thereby skewing the rankings. In addition, by failing to provide a cap on the
number of years active, the possibility exists that some of the “maintainers” may in fact
be physical activity “lifers” who have never been sedentary, never experienced change
with regard to physical activity, and should not be included in the maintainer group.

Length of time issues may exist within the accepted years-active range for
maintainers as well. For instance, 6-month maintainers may respond differently to the
“helping relationship” process than those who have been in the stage for 3-5 years. A
final possibility is that the ranking issues regarding “helping relationships” are due to the
presence of the long-term maintainers as defined by Cardinal and Levy (2000).

Similar questions can be raised about the process of change called “environmental
control.” For instance, are maintainers who forgo the use of this process over-confident
and hence headed for relapse? Or are low rankings for “environmental control” also an
indicator of the length of time maintainers have been in their stage or evidence of long-
terrn maintainers or transformers within the group? One of the reasons we do not know
the answers to these questions is that no study on exercise and the TTM has reflected on
the progress of an individual as they transition through the stages into maintenance and
transformation.

Finally, although Cardinal (1998) indicated that relapse could occur in this stage,

his conclusions are questionable because in order to be identified as a maintainer who had

45

relapsed, one must agree with the statement “I currently exercise on a regular basis, and
have been doing so for longer than 6 months” which is required to be classified as a
maintainer and while at the same time agreeing with the statement “I have exercised
regularly in the past, but am not doing so currently” which is required to be considered
relapsed. Clearly, these two statements cannot occur at the same time. Hence, we do not
know what role relapse might also play in these results.

Long-term maintenance. Cardinal and Levy (2000) found that people who had
exercised for 5 or more years were not automatically transformers. The key issue in
transformation of a behavior is that it becomes permanent and is unchangeable. This
permanence was measured by the degree of confidence one had in his or her ability to
maintain exercise behaviors for life. Transformers should be 100% confident that they
can maintain exercise behaviors for life. However, Cardinal found that some people who
had exercised for 5 years or more were not 100% confident in their ability to maintain
exercise behavior.

Cardinal and Levy (2000), using Cardinal’s (1999) participants, reclassified
individuals to reflect an additional stage called long-term maintainer. The criteria for
inclusion in this new stage was that the individuals had exercised for 5 or more years, but
were not 100% confident in their ability to maintain exercise behavior. Cardinal and
Levy (2000) concluded that this group was in fact a new stage group because the group
differed significantly from both maintainers and transformers in role modeling attitude,
and they differed from maintainers in their self-perceived fitness level and BMI. An
example of a long-term maintainer is offered in the following scenario:

Tara has learned fi'om her past failures and has a plan to combat all
barriers in her path. She has been exercising for 11 years, yet she still

46

feels like she has to force herself to meet her commitment to exercise. She

scoffs at co-workers who are impressed with her exercise record because

she does not feel successful. In truth, she does not believe she can

continue to exercise for the rest of her life, nor is she sure she wants to.

She says jokingly to her friends that when she retires she will quit

exercising and eat cheesecake. Deep inside she thinks this sounds like a

pretty good plan.

Although Tara is prepared with tools to combat the barriers to exercise she had
previously encountered, she is not fiilly committed to life-long exercise nor does she view
herself as a role model which under Cardinal and Levy’s (2000) method require her to be
labeled a long-term maintainer.

Transformation. The term “transformation” (Cardinal, 1999) will be used in
place of “termination” (Prochaska et al., 1994) in this discussion because “termination”
does not accurately describe the permanent adoption of exercise. People in the
transformation stage are said to regularly engage in exercise and will never relapse
(Prochaska et al., 1994). According to Prochaska et al. (1994), the characteristics of
transformers include a new self-image, no temptation of any kind to relapse into their old
behaviors, strong self-efficacy, and a generally healthier lifestyle. However, very few
studies have investigated exercisers in the transformation stage. An example of a
transformer is offered in the following scenario:

Tara learned long ago how to combat barriers to exercise adherence. Now

those potential barriers are no longer an issue. That is because she loves

exercising and believes it is a part of “who she is” as a person. She has

been exercising for 8 years, and gladly gives advice to others who are

struggling to adhere. She looks forward to retirement so that she can spend

more time engaging in exercise activities.

Tara has successfully transformed because she used the correct processes of

change at the appropriate times which helped her move through the stages of change and

become a successful adherent to exercise.

47

Some studies that have focused on exercisers in the transformed stage (Cardinal,
1999; Cardinal & Levy, 2000) also suggest that transformers have accepted a new self-
irnage as a role model. This idea was tested through a modified version of the Stage of
Physical Activity Algorithm (Cardinal, 1999) which included all six stages of change
defined by Prochaska et al. (1994). This new version was needed because the
transformed stage had been excluded fi'om previous stage algorithms. The participants
in Cardinal’s (1999) study were 551 members of a state specific sub-group of the
Association for Health, Physical Education, Recreation, and Dance (AHPERD), more
than half of which were female (61.6%), and were, 40.2 (SD=11.4) years of age.
Cardinal (1999) measured the transformed stage based on Prochaska et al.’s (1994),
characteristics of transformers which included new self-image, no temptation of any kind
to relapse into sedentary behaviors, strong self-efficacy, and a generally healthier
lifestyle. To reflect the lack of temptation and strong self-efficacy aspects of transformed
behavior, Cardinal (1999) added a question to an existing stage of change algorithm
about the percent of confidence the exerciser had that he or she could maintain his or her
current level of physical activity for the remainder of his or her life. Peripheral to the
algorithm, Cardinal (1999) tested the exercisers’ attitude toward role modeling as it
related to Prochaska et al. ’3 (1994) criterion for transformers of a “new self image.”
Because Cardinal’s (1999) study was conducted with a state level group of AHPERD
members, he used a tool to measure role-modeling attitudes as it related to them
professionally. Cardinal (1999) found that there was a significant difference between
maintainers and transformers in exercise METS and role modeling attitudes. In contrast,

Kearney et al. (1999) found that precontemplators were more likely to label themselves

48

as “not the sporty type” or “too old” to engage in exercise which in turn lends credence to
the role that self-image might play in the transformed stage.

This issue of transformed behavior was later examined in two other studies.
These studies did not use “percent of confidence” to categorize transformers (Fallon,
2004; Fallon & Hausenblas, 2001). The results of these studies showed that transformers
had significantly higher levels of confidence to overcome barriers to exercise than did
maintainers (Fallon, 2004; Fallon & Hausenblas, 2001) and less temptation not to
exercise (Fallon, 2004). In addition, transformers engaged in significantly more
strenuous (Fallon, 2004; Fallon & Hausenblas, 2001) and total exercise (Fallon &
Hausenblas, 2001) and had lower Body Mass Index (BMI) than maintainers (Fallon &
Hausenblas, 2001).

One fault with all 4 of the studies that researched the transformed stage was that
none of them provided any assurance that the people they were measuring as
“transformed” actually changed fi'om sedentary into active lives. This is a problem
because if one was raised in an environment where daily exercise was the norm and never
ceased to be physically active, it is difficult to determine when or whether any real
“change” occurred. Certainly non-smokers are not transformed for smoking, nor are non-
drinkers transformed for alcoholism. Therefore, proven “lifers” for physical activity
adherence should not be included in the transformed category.

Bandura (1997) argues that true stage theories show transformation across stages
that are invariant in sequencing and nonreversible. Cardinal (1999) countered that if a
true transformed stage exists from which individuals would never relapse, the

nonreversibility issue would no longer be valid. Cardinal (1999) and Cardinal and Levy

49

(2000) offer evidence that a true transformed stage does exist. This stage, classified by
involvement in exercise for 5 years or more and 100% confidence in the ability to
maintain that activity for life, was significantly different fiom the maintenance stage for
both Exercise METS and role modeling. These studies also show that while exercise
transformers are a small segment of the population, 16.6% (Cardinal, 1999) and 15.1%
(Cardinal & Levy, 2000), the percentages for exercise transformers are consistent with
those for other behavior changes, e. g., 15% for smoking cessation and 17% for
overcoming substance abuse (Prochaska & Markus, 1994).

Relationships: The Transtheoretical Model and Intrinsic Motivation

While the majority of the studies using the TTM fit nicely into “stage of change”
discussions, a handful of studies are more clearly interpreted outside of the “stage”
discussions. These studies do not fit into the previous “stage of change” discussions
because the studies used the “stages of change” fiamework for testing other theories. The
advantage of testing other theories in the “stages” fiamework is that it highlights
limitations of strict adherence to any one model (Nguyen et al., 1997).

Intrinsic Motivation. Intrinsic motivation theories, like Cognitive Evaluation
Theory, have been studied at length and have provided some answers to the question of
adherence to exercise. According to Deci and Ryan (1985), individuals engage in
activities to satisfy their need for competence and self-determination. Competence is
tested and proven when people engage in activities that are optimally challenging.
Activities are deemed optimal challenges if engaging in them helps to correct
incongruities in a person’s existence. This concept applies to general fitness activities in

the following manner. If an individual desires to live a healthy, independent life and he

50

or she knows that physical fitness is required to reach this goal but he or she does not
engage in physical fitness, an incongruity exists for that person. If the individual chooses
to address the incongruity via engagement in physical activity, he or she should be
intrinsically motivated to do it because engagement in physical activity will help to
reduce the incongruity, thereby proving competence. However, there is no guarantee that
initiating a behavior aimed at reducing incongruity will automatically lead to intrinsic
motivation because the need of self-determination must also be satisfied. Self-
deterrnination is a person’s need to have control/choice over their decisions/actions.

Several studies indicate that when a person believes that he or she controls his or
her choices, intrinsic motivation is stronger than if an individual believes he or she has no
choice (Deci & Ryan, 1985; Swann & Pittman, 1977; Zuckerman, Porac, Lathin, Smith,
& Deci, 1978). Choice may be salient to individuals engaging in general fitness activities
because many of them may be motivated by extrinsic reasons. For instance, an
individual may participate in an activity per a doctor’s order, due to the cajoling of a
significant other, or to follow a peer group. Any of these scenarios could leave an
individual feeling like he or she had no true choice, hence eroding intrinsic motivation
and long term participation.

However, Weiss and Chaumeton (1992) argue that, in rmny of the initial studies
on intrinsic motivation, participants were given activities that were inherently interesting
to them i.e., children doing puzzles. They further suggest that if an activity is not
inherently interesting to the individual, he or she may need external motivation like

rewards, status, or social support in order to participate (Weiss & Chaumeton, 1992).

51

Studies on intrinsic motivation and the stages of change illustrate some interesting
relationships between the two theories. First, Mullan and Markland (1997) found that
actors and maintainers were significantly more self-determined than
precontemplators/contemplators and preparers. Ingledew et al. (1998) found that
preparers and actors were motivated by Appearance/ Weight, which was equated with
extrinsic motives, while maintainers were motivated by Enjoyment/Revitalization, which
was equated with intrinsic motives. This finding indicates that there is a relationship
between intrinsic motivation and stage progression.

This information raises some interesting questions with regard to the current
study. Did people in the transformation stage always have intrinsic motivation? If not,
when, how, and why did it change? Investigating the background of maintainers and
transformers and determining whether they have always been intrinsically motivated is
important to fully understanding how transformation of exercise evolves.

Conclusion

The TTM and the studies that have sprung fi'om this theory have provided a
detailed account of the activities that take place while people are attempting to modify
their exercise behaviors, but few studies have investigated exercisers in the
transformation stage, the final stage of change occupied by those who have no temptation
to relapse into sedentary behaviors (Prochaska et al., 1994). From other research on
exercise adherence and participation, one can infer that transformers should have the
following characteristics: intrinsic type goals (Deci & Ryan, 1985), commitment to the
activity (Prochaska et al., 1994), and a high level of enjoyment derived from the activity

(Buonamano et al., 1995; Ewing & Seefeldt, 1988; Gill et al., 1983; Gould et al., 1985;

52

1110 i1
Gold

Cour

1991

all

Upt

Fur

Gould et al., 1982; Klint & Weiss, 1986; Koivula, 1999; Sapp & Haubenstricker, 1978;
Weiss & Chaumeton, 1992; Wold & Kannas, 1993).

From studies done on the TTM, we know that transformers have a sense of
identity tied to the activity (Cardinal, 1999; Cardinal & Levy, 2000). We also know that
maintainers are intrinsically motivated (Ingledew et al., 1998; Mullan & Markland,
1997), are committed to the activity (Courneya & Bobick, 2000; Fahrenwald & Walker,
2003; Goldberg et al., 1996; Gorely & Gordon, 1995; Jue & Cunningham, 1998; Marcus,
Rossi et al., 1992; Nigg & Coumeya, 1998), and derive a high level of enjoyment fi‘om
the activity (Eves et al., 1996). In addition, we know that maintainers tend to under-use
two important processes of change: “helping relationships” (Courneya & Bobick, 2000;
Goldberg et al., 1996; Jue & Cunningham, 1998; Marcus, Rossi et al., 1992; Nigg &
Coumeya, 1998) and “environmental control” (Courneya & Bobick, 2000; Fahrenwald &
Walker, 2003; Goldberg et al., 1996; Jue & Cunningham, 1998; Marcus, Rossi et al.,
1992; Nigg & Coumeya, 1998).

What we do not know about maintainers and transformers is whether they began
the change process with intrinsic goals and likewise, whether they always enjoyed their
activity. In addition, there is no indication fiom any of the research whether personal
upbringing impacts transformation or whether ritualization is an issue in transformation.
Further, we do not know whether the under-use of “helping relationships” and

“environmental control” impacts transformation.

53

Chapter 3
METHODS

The design of this study was phenomenological. Phenomenology holds that truth
and understanding can emerge from examining people’s lived experiences (Byrne, 2001).
Phenomenological methods are used to “discover the shared lived experiences of one
quality or phenomenon in others” (McCaslin & Wilson-Scott, 2003, p. 450). The
phenomena of interest were the exercise behaviors of older women in the stages of
maintenance and transformation. Because this study was about influence of life
experiences on long-term exercise adherence, women across several decades of life were
studied.
Participants

A total of 10 women who were classified as either late-in-stage maintainers or
transformers, per Cardinal and Levy’s (2000) criteria, for physical activity were selected
for interviews. All of the women engaged in exercise at the current United States
government recommended rate, i.e., 30 minutes of exercise on most days of the week
(United States Department of Agriculture’s Dietary Guidelines for Americans, 2005).
“Most days of the week” is interpreted as 4 to 7 days a week. This criterion is consistent
with Cardinal’s (1999) and Cardinal and Levy’s (2000) studies of transformers. The
women’s ages ranged from 40 to 80 years of age. All the women in the study were
Caucasian, homeowners with a minimum of a high school education. All of the women in
the study were volunteers. Table 8 provides details on all the demographic data that were

assessed.

54

Table 8

 

 

Demographic information
ID Age Education Job 8 HH Marital Children Own/
size status rent
D14 40$ Assc. Skilled 50,000- 2 Married None Own
trade 79,999
K04 40s Assc. Clerical 80,000+ 2 Married 2 Own
L06 405 MS Admin 50,000- 2 Sig. other None Own
79,999
$15 503 1D. Admin 80,000+ 5 Married 2 + 1 grand Own
child
C01 50s Bach. + Educ. 80,000+ 4 Married 2 Own
L19 603 MS Admin 80,000+ 2 Married 2 Own
N10 603 MS Admin N/R 2 Married None Own
B3 1 705 HS Retired 35,000- 2 Married 3 Own
clerical 49,999
M27 705 Nursing Retired 35,000- 2 Married Yes qty N/R Own
school RN 49,999
M32 808 Some Retired 25,000- 1 Widow 3 Own
college teller 34,999

 

Note. Assoc. = Associates degree, Bach. + = Bachelors degree plus some masters degree

credits, HH size = Household size, HS = High school diploma, J .D. = Jurist Doctorate,

MS = Masters degree, N/R = Not reported

55

The participants were selected from two different fitness groups. One group of
participants was obtained fi'om a fitness class that is unusual in its structure. This fitness
class is held in two fitness centers of a Midwest community college. Often, students will
enroll in this class for repeated semesters over several years. The students meet their
attendance requirement by coming to either of the two fitness centers during any of the
open hours. Their workouts in the fitness centers are individualized and students work
with instructors on an individual basis. Hence, there is not a regular class time where the
instructor meets with the students as a group. During the fall semester, fiom which the
participants were recruited, the centers were open from 6:30 am until 9:00 pm and one of
them was also open on weekends. Enrollment in the course for the fall semester was 700
students.

In order to cover the classroom hours, an average of 15 instructors are assigned to
this course, one of which is the lead faculty for the course. The lead faculty is in charge
of coordinating grading, creating written assignments, and handling student issues.
Because of the great number of instructors and variety of times to attend class, an
instructor might never meet a number of the students. The researcher in this study was
formerly an instructor for, and currently substitute teaches in, this course. Because of this
relationship with the participants, only audit status students were asked to participate in
the study. There were 187 audit students in the fall semester: 103 females, 84 males. Of
the 103 women, 34 of them were removed fi‘om the pool because they did not meet the
age criteria for the study. Of the remaining group of 69 women ages 40 and older, 23
women agreed to participate in the study. This group of 23 women was fiirther narrowed

to those who were either late-in-stage maintainers or transformers leaving a group of 13

56

from which to select. Four of this group of 13 women were in their 403; one was a
transformer, and three were late-in-stage maintainers. Four of the 13 women were in
their 50s; one was a transformer, and the other three were late-in-stage maintainers. Five
of the 13 were in their 60s; two were transformers and three were late-in-stage
maintainers. From each of these age and stage groups, one woman was selected for an
interview so that stage and age would both represented in the analysis. Later after the
interviews had begun, one additional late-in-stage maintainer in her 403 was selected for
interview in the hopes that she might be a “true” late-in-stage maintainer. This late-in-
stage maintainer was added because statements made by the other late-in-stage
maintainers during the course of interviewing did not support that they were “true” late-
in-stage maintainers. A total of 7 women fiom the fitness center were selected for
interviews. The process of recruitment is discussed in the procedures’ section.

In addition, because women 70 years of age were not among the auditing
members of the fitness center class, another study site was included. This site, a
morning, chair-exercise class offered to people 50 years of age and older, was located in
an area mall. The exercises range from activities that improve flexibility and strength to
cardiovascular endurance. All exercises are performed in or around a chair. The class
meets 3 times per week in the mall food commons before regular shopping hours begin.
The class is provided free of charge by the local university as a public service. No grades
were given nor was forrml attendance taken. The researcher of record was also a former
instructor for this class. The number of students in this class varies fiom day to day, but
the average head count was around 40 students. Approximately half of the class was

female. The pool of chair exercisers was narrowed to women who were ages 70 and

57

older. From this group, 11 women agreed to participate in the study. Later, one woman
declined due to other commitments and another could not be reached. The final pool was
9 women ages 70 and older. This group of 9 women was further narrowed to those who
were late-in-stage maintainers. No transformers were identified in this group. This left a
group of 6 from which to select. Four of the 6 women were late-in-stage maintainers in
their 705. Two of the 6 women were late-in-stage maintainers in their 805. Two of the
women in their 703 and one woman in her 80s were selected for interviews. Although
there were no transformers fiom which to select, two of women in their 703 had a wide
gap between their confidences scores: 60% and 80%. The decision was made to select
these two women in the hopes that their testimonies about physical activity would be
dramatically different and somewhat akin to the difference between late-in-stage
maintainers and transformers. This method was also to be applied to the selection of
women in their 803. However, the confidence scores of the two women in their 80s were
so similar that it was determined that only one wormn was needed to represent age and
stage from this group. Therefore, a total of 3 women from the chair exercise class were
interviewed. The process of recruitment for this group is discussed in the procedures’
section.
Instrumentation

Stage of Change Measure. Stage of change was determined by using a modified
version of the Stage of Physical Activity Algorithm (see Appendix A) (Cardinal, 1999).
Test re-test reliability for the unmodified version was reported in an earlier study and was
adequately demonstrated (rs = .93-1 .00) (Cardinal, 1997). The questionnaire derived from

this algorithm consists of 3 questions (see Appendix B). In this questionnaire,

58

participants were asked to respond to the following criteria questions: (a) Do the
participants meet the recommendations for exercise participation? (b) How long has the
exercise behavior been maintained? (c) How confident are the participants that they can
always maintain the behavior? Classification into groups is described in the procedures’
section.

Demographic Survey. In the demographic survey, participants were asked to
categorize themselves in terms of age, gender, ethnicity, economic status, vocation,
household size, home ownership, and education level. They were also asked to indicate
the types of physical activities in which they engaged (see Appendix C).

Interview. Once participants were identified and placed into stage groups, they
were scheduled for an “one-on-one” interview. The guided interview consisted of 14
open-ended questions, and was approximately one hour in duration. Participants were
given a copy of the interview questions a few days prior to the interview (see Appendix
D). This step was important because the participants were asked to recall thoughts and
experiences from their pasts. The rationale for providing a preview of the interview
questions was that people often find it difficult to recall great detail fi'om the past within
an hour’s time, but given time to reflect, people are more likely be able to provide greater
and more accurate details. The interviews were recorded by audio recorders and later
transcribed. Notes were taken during the interview as a backup to the audio recorders.
Procedures

University Connnittee on Research Involving Human Subjects (UCRIHS)
approval to conduct the study was obtained before initiating any of the data gathering

procedures (see Appendix E). Prior to recruiting the participants fi'om the community

59

college fitness center class, verbal permission to recruit was requested from both the
college and department offering the class. This was especially important because the
study was conducted with students in a fitness class for which the researcher is a former
instructor and currently a substitute instructor. Because of the direct involvement of the
researcher, only audit status students were asked to participate. Once permission to
conduct the study was granted from the college and the department, the researcher
requested, from the lead instructor, a list of the names, e-mail addresses, and mailing
addresses of the 69 female audit students who were 40 years of age or older. Once this
list was obtained, potential participants were contacted for recruitment into the study by
an informational letter sent through the mail (Appendix F). The participants were asked
to indicate their interest in joining the study by emailing or calling the researcher.
Procedures for the selection of the participants were discussed previously in the
participants’ section.

Because the fitness center pool did not include any women in their 703, UCRIHS
approval to add a new pool of participants was obtained before initiating data gathering
procedures for the additional group (see Appendix E). The second group of exercisers
were members of a fitness class held in an area mall. Details about this group were
provided in the participants’ section of this chapter. Prior to recruiting the participants
fiom the mall chair exercise class, verbal permission to recruit was requested fi'om the
college offering the class. Once permission to conduct the study was granted from the
college, the researcher recruited a class member (a woman who had the responsibility of
setting up the holiday exercise schedule for the class and frequently made announcements

to the class) to announce the following: “There is a study being conducted on women

60

ages 70 and older and our group is being asked to participate.” The class member then
read the recruitment letter (see Appendix F) to the class and recorded the names and
phone numbers of 11 women who were interested in participating in the study.
Procedures for the selection of the participants were discussed previously in the
participants’ section.

Once the recruits from both groups had confirmed their interest in participating in
the study, they were mailed an informed consent form (Appendix E), a demographics
survey (Appendix C), and the modified Stage of Physical Activity Questionnaire (see
Appendix B). The forms and surveys were returned to the researcher in an enclosed self-
addressed stamped envelope that was mailed to the researcher’s home address. Of those
solicited from the two groups, a total of 32 candidates agreed to participate.

Based on their responses to the Stage of Physical Activity Questionnaire
(Appendix B), the candidates were placed into one of three groups: transformers, late-in-
stage maintainers, and does not meet criteria. The transformer group was defined as
people who have engaged in exercise for 30 minutes a day, 4 to 7 days a week for 5 years
or more and are 100% confident that they can continue this level of exercise for life. The
late-in-stage maintainer group was defined as people who have engaged in exercise for
30 minutes a day, 4 to 7 days a week for 3 or more years but are not 100% confident that
they can continue this level of exercise for life. All of the women who did not meetthe
criteria of the above two groups were placed in the “does not meet criteria” group.

Of the 32 candidates, 10 were selected for interviews. The selection process is
described in the participation section. Each of the 10 women selected was contacted by

phone to set up the day and time of the interview. The interviews were approximately

61

one hour in duration. Participants were given a copy of the interview questions a few
days prior to the interview (Appendix D). The interviews were recorded by audio
recorders and later transcribed. Notes were taken by the interviewer during the interview
process. The interviews for the fitness center women were held in one of several
conference rooms on the college campus. The interviews for the exercise class women
were held in classrooms in an area senior center. All participants who completed the
interview were offered a $25 gift certificate to a local sporting goods store. Two
participants declined the certificates. Emails with follow-up questions about their
perceived status as role models and individual questions in other areas, which needed
further clarification, were sent to five of the women a few days after the interview. One
of the five women did not respond to the follow-up email. She was contacted a second
time by e-mail to no avail.
Data Analysis

A professional transcriber transcribed the data from the interview tapes verbatim
except in instances where using exact words might jeopardize confidentiality. For
example, one wormn named the street and the town in which she lived and others named
their husbands or children. In these instances, suitable substitute words like “husband,”
“son,” or “daughter” replaced the names. In presenting the results, alias names were
given to each of the participants to personalize their statements without revealing
identities. For instance, the participant coded as B31 was given the alias name “Amy.”
In the results’ section, each participant is referred to by her alias and her code. However
in the tables, only the participant codes were used due to field size issues within the

tables.

62

Because the thrust of this research was to discover phenomena that were unique to
either maintainers or transformers, it was first necessary to confirm the participants
belonged in the stage assigned to them through the Stage of Physical Activity Algorithm
(see Appendix A) (Cardinal, 1999). In order to do this, the lead investigator and another
investigator, with background in qualitative studies, reviewed the participants’
testimonies about concepts relative to stage placement to determine if these matched the
criteria for the stage to which they were assigned. For instance, the women who were
classified as maintainers should have made statements that reflected the following
characteristics: (a) engagement in physical activity for less than 5 years, (b) less than
100% confidence in ability to continue physical activity for life, (c) does not view one’s
self as a role model, and (d) susceptible to relapse into sedentary behaviors. In contrast,
women who were classified as transformers should have shown evidence of these
characteristics in their statements: (a) engagement in physical activity for more than 5
years, (b) 100% confidence in ability to continue physical activity for life, (c) views one’s
self as a role model, and ((1) no risk of relapse into sedentary behaviors.

The analysis of the interview data was done via a method known as “ad hoc
meaning generation” wherein no one standard technique of analysis is used for all the
material (Kvale, 1996). This method is particularly useful to draw out connections when
interview data “lack an overall sense at the first reading” (Kvale, 1996, p. 204). The
techniques embraced by this method include, but are not limited to, “noting patterns,
clustering, counting, making contrasts/comparisons, noting relationships between
variables, and building a logical chain of evidence” (Kvale, 1996, p. 204). Using the

techniques called “noting patterns” and “making contrasts/comparisons” revealed that not

63

 

everyone matched the criteria for the two categories above and lent support for Cardinal
and Levy’s (2000) sub-stage known as “long-term maintainer.” In addition, one more
sub-stage, which will be referred to as “realistic” transformer, and an anomaly of under-
reporting of years active were identified. Based on these stages, sub-stages, and
anomalies, the two investigators independently analyzed the data using the “ad hoc”
techniques listed above (Kvale, 1996).

The two investigators then compared their results and looked for areas of
disagreement. In some cases, patterns and relationships undiscovered by one or the other
investigator were blended into the analysis (Kvale, 1996). The findings were then
organized based on theoretical implications (Rubin & Rubin, 1995) or as they related to

the research questions.

Chapter 4
RESULTS AND DISCUSSION

The purpose of this study was to discover the ways in which life experiences and
personal characteristics relate to the phenomena of stage placement, as defined by
Cardinal (1999), for physical activity or exercise in older women. First, the analysis did
not fully support Cardinal’s (1999) Stage of Physical Activity Algorithm (see Appendix
A). Next, analysis of the interview data revealed that childhood experiences, including
family-sponsored physical activity and the use of physical activity as a coping
mechanism, set a standard for lifetime physical activity. In addition, adaptability in the
face of changing circumstances, the process known as “environmental control”
(Prochaska et al., 1994), and ritual or routinized behavior played prominent roles in these
women’s continued engagement in physical activities. Further, though a process known
as “helping relationships” was shown in previous studies to be under-utilized by
maintainers Marcus, Rossi et al., 1992; Gorely & Gordon, 1995; Coumeya & Bobick,
2000; Jue & Cunningham, 1998; Fahrenwald & Walker, 2003; Goldberg et al., 1996;
Nigg & Coumeya, 1998), the results provided evidence that successful exercisers do use
the “helping relationships” process.

Issues with the Stage of Physical Activity Algorithm

Analysis of the interview data collected for the current study, in conjunction with
stage and demographic data collected prior to the interviews, suggested that the
differences between maintainers, long-term maintainers, and transformers may not be as

tidy as Cardinal (1999) and Cardinal and Levy (2000) suggest. Examples of women who

65

deviate from the classifications Cardinal (1999) and Cardinal and Levy (2000) described
are to follow.
Long-term Maintainers or Realistic Transformers?

The first set of women, whose testimonies cast doubt on Cardinal and Levy’s
(2000) model, possess most of the clmracteristics of transformers except their confidence
level. This, however, may have more to do with realism or modesty than with lagging
confidence. One example is Faith (L19), a married woman in her 608, who raised two
children while working and earning her master’s degree. She has been engaging in
physical activity for at least 50 years, and although she is reluctant to admit it, she is a
role model for physical activity as is made evident by the following statements about role
modeling. When asked an indirect question about role modeling, specifically whether
she thought her physical activity has left an impression on others, Faith (L19) responded
as follows:

Oh, yeah. Especially my daughter the 32-year-old. She plays ball now,

and she’s active and works out pretty regularly. Even my son the 30-year-

old, he likes to run. When he gets a chance, he likes to work out.
In contrast when she was asked a follow-up question that directly pointed to her status as
a role model, she responded more humbly:

Maybe a little, because I know waay too many 60 year olds who have

basically “hung it up” and are willing to sit and read or knit or watch TV

all the time. One the other hand, some of the 60 year olds I know from

softball and from around the fitness center and swimming are role models

for ME — especially those who are retired and have time to exercise like

I’d like to!

Although she has had a number of injuries to her feet that required her to cease

engaging in her favorite activity, jogging, she has persevered and found substitute

activities, like swimming and Nordic-track, that accommodate her physical constraints.

66

She engages in some form of exercise 5 or more days per week, yet she is cautious about
the future:

I worry that at some point, the injuries are going to get the best of me,

and then I’m not quite sure what I’m going to do. Now, I’ve always

morphed into something, which is why I’m 90% sure that someway,

somehow, I’ll still wriggle a finger here or there. (chuckles) Because,

otherwise, shoot me now. It wouldn’t be good for me. I’ll always do

something...

While she has concerns about her physical capabilities in the firture, clearly she
will find a way to remain active because she believes she must. She views it as critical to
her survival, and as a part of who she is:

I don’t have an option. I don’t feel good. I don’t think well. I don’t sleep

well. Nothing works as it should when I’m not active. When I have to
take a week off, if I’m sick or if I’m gone - the two weeks that I was in

California — the only thing I did was play ball, and then didn’t do one

damn thing. I came home, and I was wound up like a top. I cannot — it’s

an anathema to my body to not be active. It’s just wrong.

Despite the evidence that she has been physically active for the majority of her
life and cannot conceive of life without physical activity, her status as a role model and
clear evidence that she will find a way to be active in the future, the simple fact that she
recorded 90% confidence about her ability to maintain her level of physical activity for
life requires her, per Cardinal and Levy’s (2000) method, to be categorized as a long-term
maintainer who is still at risk for relapse into sedentary behaviors.

A similar case is found in Emily (L06), a woman in her 405. She has exercised
for 33 years, and considers herself to be a role model saying, “I would, actually [consider
myselfa role model]. I would, because I do it enough and because it is a part of my life.”

Like Faith (L19), she has suffered from severe injuries, including back surgery, that make

her cautiously optimistic about her ability to maintain physical activity:

67

She to

pllVSll
Mill
bagel

inli

Ilium

Is anything 100%? If everything goes along as it would go along right

now, then, yes, I will be active for the rest of my life. I’m confident of

that. But I also know my body parts are wearing out.

She too has modified her activities to conform to changing opportunities and abilities:

When I first started, it was very much the organized sports. I’d play

whatever kind of team sport was available at the time to me. Basketball,

volleyball, softball, and I did that through college. As I got older, that

wasn’t there, so I ran, biked, all kinds of things. I did marshal arts for a

while. And now being of the age that I am and my body is not as happy

with me, I’m doing a lot more lower impact exercise.

She also views physical activity as a part of her life and believes she would suffer
greatly without it saying, “. . .But I don’t think there was ever a point where I thought I’d
have to give up exercising in general. I’m not sure I would do very well.” There seems
little doubt that this woman will continue her exercise behaviors for life, but again,
because she reported 90% confidence, under Cardinal and Levy’s (2000) standards, she
must be categorized as a long-term maintainer.

Then there is Gwen (M27), a married woman in her 705. Although moderately
physically active all her life: raising children and maintaining a 3 acre garden while
working part-time, she reports that she has been exercising for 11 years. She believes
herself to be a role model for physical activity, as well she should. Weekly, she engages
in 1.5 hours of walking and weight machines on Tuesdays, Thursdays, and most
weekends, and 6 hours of several different types of activities on Mondays, Wednesdays,
and Fridays. Unlike Faith (L19) and Emily (L06), she is not cautious about the firture
because of past experiences with injury or serious illness; she has never lurd either. She,

however like Emily (L06), believes that one never knows what the future will hold:

Well, why not 100% -- if vision goes and you are not able to drive. ...And,
if your mental — dementia or Alzheimer’s or something set in, you

68

wouldn’t be able to do it. But I told my kids, if you have to place me
anyplace, make sure they have some exercise things going on.

Even if she had to be placed in a nursing home for Alzheimer’s Disease, she wants to be
sure that she can still exercise, and if anything did happen to her vision, she also has a
plan:

Well one thing, I think it would have to be an apartment maybe close to

[my gym] so that I could walk. Or we do have various types of

transportation and I do have my son [who] lives nearby and his family and

I think my daughter is going to be moving back fiom California in a year,

a year and a half — she’s retiring fiom there. She’s got plans of moving

back, so family, also [could drive me].

But again, because she’s only 80% confident she can maintain her exercise behaviors,
under Cardinal and Levy’s (2000) model, she would be classified as a long-term
maintainer.

These women, classified by Cardinal and Levy’s (2000) model as long-term
maintainers, are most likely transformers who suffer from realism. They may also be
afflicted with humility, modesty, or low self-worth depending upon one’s perspective.
This may be due to the fact that these women all have one firrther thing in common. In
spite of the considerable time these women spend exercising, they do not place
themselves as their first priority.

When asked where they placed themselves among all the other priorities in their
lives, they responded as follows:

Faith (L19): I’d love to lie and say first, but it’s not true. I think far too

often work is first in terms of time commitment on a daily basis (and that’s

embarrassing to admit, because I really would like it to be my husband

who comes first. Of course, my husband and my kids/kids-in-law would

be first if there were anything serious to attend to: illness, (babiesl), etc. I

think I’m in here someplace with my friends and co-workers, softball
organizational stuff, and Choral Union. That’s about it.

69

Gwen (M27): Physical activity I would say is third. . ..Family would be
number one, and my religion would be number two.

Emily (L06): At this point in my life, I would say that I would place

myself pretty high among my priorities. I would give that a 7 on a 1-10

scale (where 10 equals - I am my only priority). I figure if I don’t or can’t

take care of myself, there is no way that I can help others.

There are several ways one could interpret their priorities. One possibility is that
the tendency of these women to be self-sacrificing impacts their confidence level.
Placing other’s needs ahead of their own might cause them to be less confident about
adherence simply because they always want to be available when they get the “call to
duty” to care for a family member (National Women’s Resource Center, 2005). Others
might view these statements as evidence of humility or modesty because despite their
claims of placing others ahead of themselves, all of these women invest a considerable
amount of time in themselves via the physical activities in which they engage. Whatever
the reason, the Cardinal and Levy (2000) model does not appear to work for these
women.

One possible explanation as to why the model seems to have failed may be that
the 100% confidence criteria is faulty. Fallon and Hausenblas (2001) and Fallon (2004)
believe that 100% confidence is not realistic. These studies suggest that the only
measurement needed to place individuals into the transformed stage is evidence of
adherence to exercise or physical activity for more than 5 years. This is because the
researchers doubt that there are people with 100% confidence to continue exercise for life

which is, in part, because in F allon’s (2004) study, there was only 1 person, out of 121

people who were classified as transformers, who was 100% confident. However, 4 of the

70

individuals interviewed in the current study were 100% confident, and 1 of them was a
maintainer (based on reported years of physical activity).
Classic Transformers
The next set of women to be discussed are transformers who are 100%
confident in their ability to continue physical activity for life. While the stories of
the transformed women do not differ greatly from those of the “realistic
transformers” above, there are some interesting variations. In addition to
devoting themselves to physical activity and serving as role models - reluctant or
otherwise, this next set of women all have clearly defined goals with regard to
their confidence statements and resoundingly place themselves as their first
priority among all the other priorities in their lives. For example, Ingrid (N 10), a
married woman in her 603, has been injury fi'ee and physically active for most of
her life. Though she exercises 6 days per week, she too is a reluctant role model.
Like Faith (L19), when asked indirectly about her status as a role model, she was
more comfortable with her role model status than when asked directly. The
statement below is in response to a question about whether she believed co-
workers looked up to her with regard to exercise:
Some of them might, but I don’t know that all of them do because I
generally, on my lunch hour, come over here and work out. Other people
choose to use their lunch hours differently. What they think of that I’m
not sure, but I just go do my own thing. I just figure whatever’s going on
will be there when I get back. I just do my thing. It’s hard to know if
you’ve inspired anyone or not because they don’t usually come and tell
you, although some people have occasionally. And I think I have inspired

a couple of people in my work group to be active, to be more physically
active. There is sort of a transfer effect on some level.

71

Yet, when asked directly whether she viewed herself as a role model, she recanted saying
“No, not really. I exercise for my own needs.”

However, in contrast to the realistic transformers, she placed her “health
and well-being as number 1 priority” in her life, and when it comes to being 100%
confident about continuing physical activity, she is clear and has a goal in mind:

Well, I enjoy it. I know I need to do it for my health and fitness. And I

want to maintain my physical independence as I get older. . . .. I want to

croak in my swimming pool at 91. That’s my plan. (laughter)

Some people, in talk around the water cooler, suggest that people who place their
health in high priority are selfish, but for Brenda (C01), a woman in her 508, this does not
seem to be the case. She’s raised 2 children, been a devoted and attentive daughter, and
worked together with her husband on numerous home projects. In addition, she’s earned
a master’s degree, had a cesarean birth, two hemorrhoid surgeries - one with serious
complications, and problems with her knees that required surgery, yet she has sustained
an exercise program for 20 years. She exercises nearly every day, and is more
comfortable with her status as a role model:

Uh, maybe. Yeah. I just hadn’t thought about it. But many of the

students know my age and know all the things I do. I would want to

model positive things for my students as far as their lives and their career,

and their health and their happiness. . ..

She is also comfortable with her commitment to physical activity for life and
100% sure she will stay active:

because of past history... now, that’s barring that I got some hideous

disease or got run over by a truck or something. But my mother is almost

82, and has had physical things happen, etc., and we raked leaves Sunday.

We shoveled snow when I was a kid. We had a mile long driveway at the

farm. There just wouldn’t be anything that would stop me. And, like I

said, someday, when I retire, I’ll take a yoga class regularly. . ..And the
NIA (Neuromuscular Integrative Action) stuff I just started a couple of

72

years ago. If I could do that every semester, that would just really be
great. If I had more time, there would be a lot more that I would do.

She also knows why she places herself first. “. .. I’ve got to say that if you live in
your body, you always come first. I can’t do things for other people if I’m not
taking care of myself.”

Another example of a classic transformer is Diane (K04), a married women in her
40s who has 2 children who do not live with her. She has exercised for 22 years, and
modestly considers herself a role model for physical activity:

I think, in some people’s eyes, perhaps. I mean I don’t preach it, and

maybe I am and I don’t realize it. I don’t try to be. I’m just who I want to

be. If people do view me as that, that’s okay. But I don’t promote that.

She has had back surgery and at one point could barely walk, and this has
required her to become involved in different activities than she did in her youth “I don’t
play softball anymore because I don’t run so well anymore. I pretty much like to do
aerobics, treadmill, the elliptical machine, the bike, Pilate’s. Total body fitness. That
sort of thing. Strength training.” Yet in spite of changes and challenges, she has clear
goals that guide her in her belief about why she will continue physical activity for life:

I want to be in good condition when I get into my older years. That’s

really important to me. I want to be active. 1 want to enjoy my life to

the fullest. I mean now, I want to enjoy it, but as I grow older, I still want

to be able to enjoy, and not be someone that’s sitting on the sidelines

wishing that I could do that stuff. I want to be in there... I want to be

strong. I want to be going places. I want to be traveling. I want to do

stuff. I want to be able to enjoy the rest of my life actively.

This set of women would be considered truly transformed according to Cardinal
and Levy’s (2000) model. They differ from the “realistic” transformers or long-term

maintainers in that they make firmer statements about their futures as exercisers, and they

rank themselves first relative to all their other priorities. Perhaps these differences are

73

merely indicators of personality. The women who are 100% confident may share
personality characteristics like being driven, bold, or willfirl, whereas the “realistic”
women might share characteristics like concrete reasoning, openness to change, or worry
(Russell, & Karol, 1993). On the other hand, these women who rank themselves first
among their priorities may have been raised under a different set of social norms than
those who rank themselves lower. Regardless of the reason, the real question is do these
differences indicate that the 100% confidence women will persevere and the “realistic”
women will not? The testimony of the “realistic” women gives one legitimate reason to
doubt that they will cease physical activity, and would lend support for Fallon’s (2004)
argument that 100% confidence is not realistic were it not for one last set of women that
aggravate the confidence argument.

One potential problem with Fallon and Hausenblas’ study (2001) and Fallon’s
study (2004) is that individuals were categorized as transformed prior to testing for
confidence. This very likely gave them an inflated sample. In Fallon and Hausenblas
(2001), 65% of participants were classified as transformers while in Fallon (2004), 45%
of the participants were in the transformed stage. Yet the expected norm for the
transformed stage is that it will be a small segment of the population. For example in
exercise behavior, Cardinal (1999) found 16.6% were transformed while Prochaska and
Markus (1994) reported 15% transformed for smoking cessation and 17% for overcoming
substance abuse. By failing to screen for confidence before categorizing people as
transformed, they likely included people who were not truly transformed. It should be
noted that in discussing her study, Fallon (2004) states that transformers should have high

efficacy, but does not indicate what percent would be required.

74

Long-term Maintainers

In the current study, 2 people who more closely matched Cardinal and Levy’s
(2000) criteria for long-term maintainers would have been counted as transformed using
Fallon’s (2004) method. One example is Amy (B31), a married woman in her 703, who
has exercised for 11 years. She has had a number of different surgeries that have
required her to go through physical therapy. She does not consider herself to be a role
model for physical activity saying, “No. I don’t sit up on the front row [of class]. No, I
wouldn’t consider myself a role model. I am probably better than some but not near as
good as some.” But unlike the women in the previous two sets, she does not exude
commitment to physical activity or talk about physical activity in terms of the pinnacle
role it plays in her life. In fact, she sometimes has a difficult time attending her exercise
classes particularly when her husband cannot join her, and she has an even harder time
getting motivated to do her exercises at home.

Yeah, I’ve had, over this 11 year period, I’ve had periods where it was

difficult for me to walk so I’d use a cane or I’d hang onto my husband or

something, so if he wasn’t going [to exercise class], I could talk myself

into staying home, it was easier ...and what am I going to do if I stay

home? Am I going to get in there and ride on the exercycle and do the

balance ball and all this sort of thing? Maybe not. I’ll find an excuse to

do something else
She is 60% confident she can maintain her exercise routine for life, and while it seems
she meets the criteria to be considered a long-term maintainer, she is clearly not
transformed. Yet, under Fallon’s (2004) standards she would have been classified as a
transformer.

Another example is Heidi (M32), a widow in her 805, who has been injury-free

and moderately physically active for most of her life. She reported that she has been

75

exercising for 6 years, and does not consider herself to be a role model. When asked
about strategies she uses to motive herself to exercise when the weather or other factors
are unfavorable, she replied “I stay home.” Clearly she is no “Jack LaLanne,” and there
is reason to doubt her commitment to physical activity. Even so she reported 80%
confidence that she can maintain her exercise behaviors, and again under Fallon’s (2004)
model, she would be considered a transformer.
Maintainers

In the midst of all the confusion of classifying transformers and variations thereof,
one woman in the study was shown to be a plain and simple maintainer. Maintainers are
defined as having engaged in physical activity for more than 6 months but less than 5
years. They are susceptible to relapse into sedentary behavior, are less than 100%
confident in their ability to maintain physical activity for life, and do not consider
themselves a role model for physical activity. Cindy (D14), a married women in her 403,
engaged in regular physical activity for 4 years, but does not consider herself to be a role
model. She is only 70% confident that she will be able to maintain physical activity for
life. Her confidence rating is no surprise because she struggles even to maintain her
current workout schedule saying, “There is a fight of time management each day. Things
get busy, and I can’t get to the gym, and I know it’s prioritizing things.” When asked to
explain her confidence level rating she replied with the following:

One, would be if something happened to me physically, if I couldn’t continue

some sort of activity. Another one would be — I don’t know what type of older

woman I will grow to be. Will health still be as important to me today as it is

tomorrow? I’m not sure I can keep the same mindset. I don’t know who I’ll be
when I’m 80.

76

Her statement of uncertainty about the firture of her physical activity adherence combined
with the number of years she has been engaged in physical activity and the difficulties
she faces adhering to her workout schedule make her a classic example of a maintainer
for physical activity
Under-reported Years Active Transformer

There is one last issue at play with regard to the stage classification. During the
interview process, several of the women revealed that they were engaging in physical
activity for longer periods than were reported on their Stage of Physical Activity
Questionnaire. For instance, Jenny (815), a married woman in her 505, said that she had
a regular jogging routine through her 205 and into her late 305 and then she was inactive
until her 503 when she joined the fitness center. Based on this, she reported her years of
physical activity as 3.5 years. The following is a discussion of the physical activities she
engaged in when she was “inactive”:

...we have 4 ‘/2 acres out in the country, and before that we had like 12

acres on the river, but we never had a riding lawn mower, and I mowed

lawn four hours a week. One of our neighbors is a tree guy, and he dumps

all his wood chips at my house, so for my upper body, I move wood chips

around. One summer I moved 100 yards of wood chips around. So, I’m

very active with yard work, and I have a huge flower garden that takes a

lot of my time . . .we grow a lot of our own food and can it, etc. . .. Cross-

country skiing [around the property].

When asked why she reported 3.5 years of physical activity, she
responded: “All of those other things I never considered to be exercise (laughter). ’
Intellectually, of course, I know that they are... So, I was doing a lot of things,...
but it wasn’t a formal exercise program.” Hence, the 3.5 years signifies time in a

formal exercise program that averages 2 hours of exercise per day 7 days per

week. In addition, she still does gardening, mowing, moving wood chips, and

77

skiing. Because she only included formal exercise in the years she reported, she
is categorized as a maintainer, but she is more likely a transformer because she is
both 100% confident she can continue exercise for life and because she considers
herself a role model for physical activity.

Although it did not effect their stage placement, there were others who viewed
themselves inactive at certain periods when the evidence suggests otherwise. One
example is Gwen (M27), who has been a member of a gym since 1976. From 1976 until
1994, she balanced time at the gym with raising children, doing housework, tending a
half-acre vegetable garden that was started in 1959, and working part-time as a nurse.
She does not count these years as physically active because “I didn’t get in it as steady as
I have within the last 11 years [since retirement] because of the working situation and the
family.” “Steady like the last 11 years” amounts to 7 days per week, 1.5 to 6 hours per
day which is an achievement few women with jobs and families could attain. Her
statements provide strong evidence that she has been physically active for longer than her
reported 11 years.

The statements provided by these two women suggest that changes need to be
made to the Stage of Physical Activity Questionnaire in order to make it more effective in
determining stage. Specific language about what constitutes physical activity as well as
examples of physical activities need to be made a standard part of the questionnaire so
that years engaged in physical activity is not under-reported.

The above five categories of women, 100% confident transformers, “realistic”
transformers, long-term mintainers, maintainers, and under-report years transformer,

demonstrate that which has long been known; human beings are complicated. It is

78

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new

guide

evident that a more complex and sophisticated method for discovering transformed
exercisers needs to be developed. While years committed to a behavior is a good starting
point for determining transformed status, some refinements need to be added. First, the
Stage of Physical Activity Questionnaire needs to be modified to reduce errors in
reported years of physical activity. Next, while the findings from this study suggest that
confidence is an important factor in transformed behavior, they also indicate that 100%
confidence may not apply to all transformers. The confidence tool needs to be modified
either to reflect a realistic person’s views about aging, i.e., How confident are you that
you will be able to maintain some form of physical activity for the rest of your life?, or to
encompass a range of acceptable confidence levels. In addition to this, another modifier,
like role modeling attitudes, self-worth assessments or both, is needed to confirm the
exerciser’s place among the truly transformed. Table 9 is provided as a quick reference

guide to the various stages and sub stages discussed in this section.

79

Table 9

Stage and sub-stage definitions

 

Stage Definition

 

M Sustaining physical activity for at least 6 months but less than 5 years;
Susceptible to relapse into sedentary behavior (Prochaska et al., 1994).
LTM Sustaining physical activity for at least 5 years;
Susceptible to relapse into sedentary behavior;
Less than 100% confidence (Cardinal & Levy, 2000).
LSM Sustaining physical activity for at least 3 years - also classified as M or LTM;
Susceptible to relapse into sedentary behavior;
Less than 100% confidence in ability to continue physical activity for life.
T Sustaining physical activity for at least 5 years;
No risk of relapse into sedentary behavior;
100% confidence;
Role model for physical activity (Cardinal, 1999).
RT Sustaining physical activity for at least 5 years;
No risk of relapse into sedentary behavior;
Less than 100% confidence;
Role model for physical activity.

URT Identical to T, but under-reported years engaged in physical activity.

 

Note. M = Maintainer, LTM = Long-term maintainer, LSM = Late-in-stage maintainer, T

= Transformer, RT = “Realistic” transformer, URT = Under-reported years transformer

80

Childhood Issues and Influences

In order to understand how adult women developed into late-in-stage maintainers
and transformers for physical activity, it is necessary to understand something of the
history of women’s lives. Therefore, during the interviews, questions were asked about
childhood physical activity such as how old they were when they first began engaging in
physical activity and what sorts of things prompted or motivated them to engage in
physical activity (see Appendix D). These questions were designed to address questions
“In what ways do life experiences impact stage placement?” and “How does the way in
which women were raised, e. g., culture, values, social support, and perceptions of
exercise or physical activity, influence their current stage placement?”.

Analysis of the interview data revealed that all 10 women engaged in physical
activity at a young age. Some of the women indicated specific ages, between 4 and 10
years old, where they remembered being physically active. Others recalled that they
were always active as children and could not name an age, as was the case in the
following examples:

Brenda (C01): I grew up on a farm, so there is not a clear memory of

anything but being active. Swinging on ropes in the haymow. If you’re a

farm kid, everybody pitches in. So, getting burrs in my hair and braids.

Having my mother having to cut off part of my hair. (laughter) So always

active.

Faith (L19): I don’t know. I was young enough that I don’t remember.

I just spent the better part of my young kid’s life outdoors or pounding

things. There was no time that I remember not being on a bike, or being

outside. I just don’t know.

While all women engaged in physical activity at a young age, they did so for

different reasons. Like many children, some of the women engaged in physical activity

because they thought it was fun, or they engaged to be with their friends. Others engaged

81

because it was necessary as a mode of transportation. For instance, Heidi (M32) said

“. . .And then I had a long walk to school, a long walk to school....Oh goodness, 2 miles,
in all kinds of weather” while Jenny (SIS) said “ . .. But I had always walked to school as
a kid. I walked every day over two miles fiom grade school right through high school.”
However, none of these motivators were exclusive to either maintainers or transformers.
This finding is consistent with previous research which showed that engagement in
physical activity during youth was not an influencing factor on adult women’s exercise
behavior patterns as both inactive and active adult women were active in childhood
(O’Brien-Cousins & Keating, 1995).

Family Life Impacts Stage

Although, engagement in physical activity during youth was not a predictive
factor in adult women’s exercise behavior, youth activity, in conjunction with other
modifying variables like family dynamics, provided some answers regarding the ways in
which life experiences, and rearing in particular, impact stage placement.

Family dysfunction. Some of the women interviewed used physical activities as a
means of escape fi'om family tensions or to establish independence. Three women, one in
her 50s and two in their 603, engaged in physical activity as a means of coping with
family tensions and/or to establish their independence as children:

Faith (L19): ...I didn’t like spending time inside. I never wanted to be

inside. Part of that might have been - I think there was a certain tension in

our household. And I think part of it was me escaping from my family’s

tension. But that kind of awareness didn’t come until later.

Ingrid (N 10): My father’s passing and relationship with my mother (we

did not get along well after his death either) mostly focused me on my

need to be personally responsible for myself. I did some bike riding, etc.
partly because I enjoyed it, but also wanted to be out of the house.

82

Jenny (SIS): When I was real young, in grade schooL I did it because
it was something I could do to be independent from my parents. Even to
walk three miles to a fi'iend’s house, I’d walk it. So, I guess you could
say I did it to get out of the house then, too. Because I had a pretty crazy

household with 12 kids. ...As one of 12 kids, I’ve always NEEDED to pull

myself away and have some private time.

The women, who used physical activity as a coping mechanism for dealing with
family tensions, continued to apply this coping skill to deal with daily stressors
throughout their lives. Their responses below provide some answers to the question
“What are the factors or stressors in adult life, such as career, children, health, social
support, etc., which impact current stage placement?”. :

Faith (L19): Having little kids at home, I was a stay at home mom at

that time, and it was really tough. That’s why I kind of got into the

running because I could do it when my husband got home from work. It

didn’t take a lot of time, and it was time for me. I go out and run my two

miles and be back home in 20-25 minutes. It was quick and it felt so

good, and I could be a mom again.

Ingrid (N 10): Stress. Whatever's troubling me that day, big or smll.

And anything that goes wrong, I GO to the pool! Whenever there’s

trouble, I swim. Or I walk the dog. But usually I swim.

Jenny (SIS): But I worked fulltime. I had these little kids. I had a

big job at the hospital. I was a manager in radiology. It was a very

stressful hospital job, and I just needed to decompress when I got home. I

usually did it [jogged] right before dark.

The three women who engaged in physical activity as a means of escaping their
families came either from the classic transformer category, the under-reported category,
or the “realistic” transformer category. This suggests that lessons learned at an early age
about the value of physical activity as a stress coping too] have lasting power. Clearly,
the women, who came fiom families where tensions ran high, learned that physical

activity was an effective way to cope with life’s stressors and continued using this coping

mechanism throughout their lives.

83

Parental involvement. While negative aspects of rearing were related to stage
placement, positive aspects of rearing also exerted influence over stage placement. Five
of the women interviewed were raised in families where either both of the parents or the
father alone engaged in physical activities together with the children. In farming
families, typically all members of the family unit engage together in the various physical
activities required for farming as was the case for Gwen (M27), a woman in her 703. The
following women, Diane (K04), a wonum in her 403, and Brenda (C01), a woman in her
50s, also came fi'om active families where both parents engaged in physical activities
with the children:

Diane (K04): We played softball in the backyard and stuff like that. And
we had a pool, so we were always out there swimming, things like that.
And family bike rides after supper. Everybody would get their bikes out,
and we would ride around town and then come home.

Brenda (C01): We always had a garden, But working in the garden
as a family was actually firn. Maybe at the time I’d complain about it, but
we had some pretty good tomato fights! (laughter) we had very, very
active vacations. We would go places where we would do a day hike type
of thing. . .Water skiing. We were just always very, very active together.

Two of the women, Faith (L19), a woman in her 608 and Emily (L06), a woman
in her 40’s, came from families where only the father engaged in physical activity with

the children.

Faith (L19): My dad was an avid gardener. A very active gardener. So,
he was outdoors most of the time in the garden. I spent a lot of time with
him. My dad always watched football on TV, and I watched football with
him because I enjoyed it. And I enjoyed playing it. My dad taught me
how to throw - I used to play catch with my dad.

Emily (L06): He [dad] and I actually played a lot together when I was a
kid. He was very supportive. But never did really any organized exercise.

We were always busy doing something. . .my dad, my sister, and I would
do things together, and my dad and I would do things together.

84

The five women who engaged in physical activity as a family group with both
parents or with their fathers were members of either classic transformers or “realistic”
transformers. This commonality suggests that lessons learned at an early age about the
value of physical activity have lasting power. Clearly, the women, whose family rearing
included regular engagement in physical activities with the children by one or more
parent, learned that physical activity was a normal, expected part of daily life and
continued to be active into adulthood. Table 10 displays the connections between
motives for engaging in physical activity and factors related to transformed behavior as

described in the previous section.

85

Table 10

Motives for childhood physical activity as it relates to stage placement.

 

 

ID Escape Parent(s) Role Years Confidence New
active w/kids model active Stage
D14 no 4 70% M
B31 no 11 60% LTM
M32 no 6 80% LTM
M27 yes yes 11 80% RT
L19 yes yes yes 50 90% RT
L06 yes yes 33 90% RT
SIS yes yes 3.5 100% URT
N10 yes yes 40 100% T
K04 yes yes 22 100% T
C01 yes yes 20 100% T

 

M = Maintainer; LTM = Long-term maintainer; RT = “Realistic” transformer; URT =
Under-reported years transformer; T = Transformer
Adult Life

Enjoyment and Variety of A ctivities Relevant to Stage

While children often engage in physical activity because it is enjoyable
(Buonamano et al., 1995; Ewing & Seefeldt, 1988; Gill et al., 1983; Gould et al., 1985;
Gould et al., 1982; Sapp & Haubenstricker, 1978; Wold & Kannas, 1993), this is not
necessarily true of adults. Although all of the participants enjoyed some of the activities

in which they engaged, there was sharp contrast in both the quantity of activities and

86

enjoyment of those activities between the women who were categorized in either of the
maintainer categories and the women categorized in any of the transformer categories.
Although timetable information was not revealed, this finding answers aspects of the
question “How does the timetable in which enjoyment of exercise or physical activity
was acknowledged impact stage placement?”.

Maintainers. Maintainers and long-term maintainers engaged in fewer activities
and/or did not enjoy all the activities they did. For instance, Amy (B31) is a long-term
maintainer in her 705. She engages in a chair exercise class at a mall, and at home, she
works out with an exercycle and an exercise ball. She struggles with attending the mall
exercise class if her husband cannot also go. She does not enjoy all of her activities
saying, “Yeah. Actually, I enjoy the class and those exercises the most. The others
[exercycle, exercise ball] I do it because I think I should.” She also notes that she
engages in the exercises at home on an infi'equent basis because there are other things she
would rather do.

Another maintainer who does not enjoy her activities is Cindy (D14), a true
maintainer in her 405. She frequently engages in walking outdoors and exercises on the
treadmill or the elliptical, and does weight training in a fitness center. Occasionally, she
does step aerobics. She enjoys walking outdoors, but is not that fond of the rest of the
activities:

That’s the hardest question. I enjoy walking, and I can do a fast brisk

walk, and I can do it by myself or with somebody. That I enjoy. I’ve been

trying to get my heart rate up and keep it up and do those kinds of things.

And sometimes it takes everything I have to do it. When I am done, I’m

like, that’s a good feeling. Driving to the fitness center and getting in

there, it’s like, oh, I could do so many other things. So, I still struggle

with getting over and doing it. When I am done, or when I’m doing it, I
feel good about what I’m doing because it’s a positive thing. So, in that

87

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way, I like it. But do I like lifting weights and the pain of it all? Maybe
not (chuckles) or it would be easier for me to get there.

When asked a clarifying question about disliking weight lifting, Cindy (D14)
responded with further activities she did not favor.

Right. Or like I do the treadmill or the ones that are low impact on your
joints. I try to do them for 1/2 hour as intense as I can get. That might not
be the most firn thing to do.

When fiirther clarifying questions about her dislikes, Cindy (D14) provided criteria as to

her likes and dislikes.

But a nice three-mile walk, and I can do a nice steady pace and I’m not
winded. And I can do that fast walk because I do the other thing, too.
Sacrifice one to do the other. So, I do a little bit of everything. And if it’s
cold outside — right now, the weather’s changed, I will start doing it. But
I’d rather be outdoors doing it than indoors. But when the weather
switches like this, I’ve got to get acclimated. But, usually when I take my
brisk walk, by the time I get back, I’m warm and sweating. I’ve just got to
get motivated to go and do that. So, I’m indoors now. I enjoy [outdoors]
because I’m not breathing hard; I’m not focused on the fatigue, because
I’m not fatigued when I’m doing that. The other, I’m fatigued and then
focused on getting the fatigue out of my mind and keep going. And the
walking, I’m not fatigued, so, therefore, I can kind of walk fast and do the
arms. But I’m also looking at — if I do it at our cottage, it’s woodsy, it’s
beautiful; I’ll probably rim across a deer or some wild turkeys, that sort of
thing. It’s just peaceful, helps the stress, etc. But the biggest thing is I’m
fighting fatigue, and I’m doing a brisk walk.

The unifying factor for these maintainers is that while they acknowledge the
importance of physical activity in their lives, maintaining regular fitness routines is a
struggle for them because they did not enjoy many of the activities in which they
engaged.

Transformers. In contrast, all women in the three transformer categories enjoyed
essentially all the activities they did, and all engaged in a variety of 5 or more activities.

For example, Emily (L06), a realistic transformer in her 403, enjoyed all the activities in

88

YE

which she engaged including swimming, elliptical, exercise ball class, weights, and
teaching a cardiac rehab class 3 times per week. Her response to a question about
enjoyment of physical activity is below:

Yes, I do very much, actually. I really do. And one of the things that I found for
me is I only do things I like to do. Because it really is the only way that I will
continue to do them. And I also cannot do the same thing all the time. I have to
do variety because I need variety in my exercise routine. So, yeah, I really
actually enjoy it. [pause] Well, for one thing, the swimming piece I’m enjoying
for three reasons: one, it doesn’t hurt me. It gives me a new exercise challenge.
And I guess what goes with that, it also kind of helps with the little bit of
competitiveness that I have with myself. Being an athlete all of my life, there’s
obviously competitiveness and I needed that, so swimming does that for me,
because I compete all the time with myself. The other things: the elliptical
because it was something I could do at home, and I like doing it at home. The
ball class that I do, I do with fiiends. And it’s just a great time. We work hard
and we have firn! So, it is very different and, yet, it works really well for me.

Another transformer who relishes variety is Jenny (SIS), an “under-reported years
of exercise transformer” in her 503. At the fitness center, she does the treadmill, stair
climber, elliptical, exercise bike, rowing machines as well as weights. She also takes a
yoga class and a core conditioning class. At home, she does calisthenics, walking, and
yard work including gardening. She also rides her bicycle and does cross country skiing.
Her response to a question about enjoyment of physical activities is below:

Yeah The beauty of it for me is the variety. You don’t get sick of it. If I had to

go in and walk on that treadmill everyday, or if I knew I was going to do 30

minutes on the stepping machine everyday, I’d go crazy because it’s so boring.

The hardest part for me, in fact, is the bike. And a lot of days I’ll warm up for 10

minutes on the bike, and it’s the worst 10 minutes of my day. For some reason, I

really dislike the bike. But I like a real bike. I get on a bike all the time with my

kids. Just to mix it up, when I do my cardio now, I try and do a different machine
every time I do it.

Table 11 shows the distinct difference in both number of activities engaged in and

enjoyment of those activities by all groups of maintainers and transformers.

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Table 11

Number of activities engaged in versus number of activities enjoyed by stage

 

 

ID Stage # Activities # Enjoyed
D14 M 5 1
B31 LTM 3 1
M32 LTM 3 3
M27 RT 5 5
L06 RT 5 5
L19 RT 7 7
C01 T 7 7
K04 T 7 7
N10 T 6 6
SIS URT 13 12

 

Note. LTM = Long-term maintainer, M= Maintainer, RT = Realistic transformer, T =

Transformer, UR = Under-reported years transformer.

Although previous studies indicated that enjoyment of physical activity increases

progressively from precontemplation through maintenance (Clarke & Eves, 1997; Eves,

et al., 1996; Ingledew et al., 1998), level of enjoyment has not been considered as a

criteria for transformed behavior. Testing for “enjoyment,” in conjunction with the stage

algorithm to determine the transformed stage, may be a valid option for firture studies.

In addition, people who engage in a wide variety of activities may be less likely to

relapse into sedentary behaviors when faced with issues like back surgery, in the case of

Emily (L06) and Diane (K4), that force them to cease engagement in a given activity

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.because they already possess alternative activity choices. Hence, identifying the number
of activities in which an individual engages may also be useful in identifying
transformers.

Routine Adherence, Adaptability, Environmental Control and Stage

One way to understand how adult women develop into late-in-stage maintainers
and transformers for physical activity is to examine the role of “routines” in their lives.
Therefore, during the interviews, questions were asked about preference for routine (see
Appendix D). These interview questions were designed to address the question “What is
the role of ritual or routine in adherence to exercise or physical activity?” and “Are
women in the transformed or late-in-stage maintenance stages more likely to prefer or
’ better utilize routines and schedules?”.

Transformers and adaptable routines. While all the women in this study
identified themselves as following a more routinized lifestyle, they did not all strictly
incorporate physical activity into their routines. One characteristic that was unique to all
categories of transformers was that physical activity was a priority to which they strictly
adhered as a part of their daily routine. An example of this is Gwen (M27), a realistic
transformer in her 703. In her discussion of her exercise time, it is clear that she both
prioritizes physical activity in her daily routine and that she strictly adheres to this
routine:

You get in the routine of it. This is my routine. I get up, try to get up

between 7 and 7:30 in the morning, and then it’s at least an hour there, and

then it’s about time for the exercise classes there. And the days that they
don’t have exercises classes I’m usually there by 7, 7:30 and then do my
walking and things and then I can go on about my things on Tuesdays and
Thursdays. That’s when I usually end up volunteering afterwards in the
places I do that. Tuesdays and Thursdays I’m usually home by 9:00 unless
I go out.

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On Monday, Wednesday and Friday, I usually start by 7:30 and end at
2:00. [pause] But there’s transportation in there, too. Let’s see, I do my
walking which takes an hour, and then the exercise goes to 9:30. And then
I usually go hit the book store for a little bit between 9:30 or 10 o’clock or
just visit with someone for a little while and then by 10 o’clock or so why
I go to the spa and take my time up there until 1:00 and then on Mondays
and Fridays when we start yoga.

Gwen (M27) also indicated that she continued her exercise activities on the
weekend, and laughed as she noted that she had conditioned her children not to
call her at home until after 3pm when her exercise routine was completed.

Jenny (S l 5), an under-reported years transformer in her 503, also demonstrates
strict adherence to an exercise routine:

I think I’m a victim of routine. I know that when my kids were young,

they did better when they had routine that they followed everyday. But

I’m the same. When I get ready for bed at night, I do the same things. I

guess there’s comfort in routine. [Exercise is] one of those routines that I

have to do.

In addition to strict adherence to routine, transformers demonstrate adaptability
when circumstances bring about change or challenge, i.e., location, illness, injury, time
constraints. Adherence to routine with the ability to adapt to changing environments is
demonstrated by Brenda (C01), a transformer in her 503:

Well, it’s [exercise] something I look forward to, so you kind of make

appointments — plan what you’re going to do. And if you can’t, like I said,

have some sort of alternative. Like if I go to conferences, etc. I’m active

in our union. I am the State secretary, so I travel a lot with that. But I hate ~

sitting in meetings. I would never be able to be an administrator. So, if

there’s a lunch break or something, I’ll eat and then go out and walk. Or,

sometimes if it’s at a hotel, and you can plan after the meetings a time to
go and use their exercise room.

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Strict adherence to routine is also clear in this first statement by Ingrid (N 10), a
transformer in her 603, and in her second statement, she shows the ability to adapt and

modify her behavior under circumstance of illness:

Oh, I’m very structured. That maybe helps with this kind of thing. My
husband says I could be happy in the military — get up the same time and
go to bed the same time. I like doing my same routine. I try to be
flexible, but I’m not all that flexible. I’m just very structured, so getting
into an exercise program isn’t hard for me. I just stick with it because it’s
the kind of nature I have.

If I truly have a bad cold — there was a time in my 403 when I got a lot of
bronchitis, and when that would strike, if I didn’t feel too sick, I’d do the
weights. But if I was really beyond that, I’d just lay low. Sometimes you
just have to know when it’s time to let your body rest and heal. It wasn’t
much a decision of choosing not to exercise as it was choosing to lay low
so you could heal up so you CAN exercise. Using basic common sense
and lay low if you have to.

Emily (L06) demonstrates adaptability in the changing circumstances of opportunity and
injury:

When I first started, it was very much the organized sports. I’d play
whatever kind of team sport was available at the time to me. Basketball,
volleyball, softball. And I did that through college. A3 I got older, that
wasn’t there, so I ran, biked, all kinds of things. I did marshal arts for a
while. And now being of the age that I am and my body is not as happy
with me, I’m doing a lot more lower impact exercise.

Faith (L19) demonstrates adaptability in planning her physical activity around the

time conflicts of a demanding schedule:

That part of the routine, I think, is good. I mean, the knowledge that it’s
Monday morning and I need to get out of bed and do something is good
And right now, because I don’t have time to lift weights in the morning, I
also lifted weights last night. So, I did a couple hours yesterday. Thirty
minutes on the Nordic track of stretching in the morning, and then I did
probably an hour of weights last night and some stretching. This morning
I swam. Tonight I’m going with a fiend to the batting cages because we
have a tournament this weekend. Tomorrow morning I ’ll get up and do
[Nordic track and stretching]. Wednesday night I can’t. Thursday
morning I’ll get up and swim. Thursday night I can’t. Friday morning
will be [teaching] cardiac [rehab], etc. So, I have a knowledge that if I

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don’t front-load the week, I’m not going to make it into what I want to
make it. It won’t be the same. But the routine — that part of the routine, I
think, is essential. Because there has to be some discipline that goes with
that. What’s inside those workouts should be varied for me. I get bored.
I don’t want to do the same thing I did two days ago.

Another take on adherence with adaptability comes fi'om Diane (K04), a
transformer in 403, who implies that rigid adherence to exercise programs, without the
ability to adapt, may be unhealthy:

Everybody has routines in their life that they have to do. Structure is
important, but I won’t let it control my life. I’ve been there, done that in
the past, and it’s like you miss out on a lot of things. But I know that —
everybody has some kind of routine, structure in their life. There are some
things that you have to do everyday, but if something comes up and I’m
not able to — it kind of gets you out of your routine, that’s okay. Because I
know that I’ll get back on track the next day.

To clarify that she adhered to an exercise “routine” rather than exercising in a “hit or
miss” fashion, Diane (K04) was asked whether she had a set time of day when she
exercised to which she replied, “After work, on my way home.” To further clarify her
meaning when she stated now she might skip her routine if “something came up” which
was not something she would have done in the past, the interviewer paraphrased her
statement above.

Right. I would say ‘Oh, I can’t do that because I have to go work out. I

don’t want to get bad.’ And I’ve learned that it’s important to exercise,

but it’s important not to let it control your life. Because there are other

things out there other than just working out.
Following the sense of her statement, the interviewer inquired whether K14
thought she may have been “addicted” to exercise at any point.

Oh, yeah. Absolutely. But now, it’s okay if [I] miss a day. It’s all right.

It’s okay if [I] put on a few pounds, because I think it’s important to

branch out and do other things. But exercise is important. But you can’t
let it interfere with your life, with living, with doing other things.

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By acknowledging her addiction to exercise, she provided evidence of that strict
adherence to routine, without adaptability, is critical to healthy behavioral change
denoted as transformed behavior.

Being adaptable is important to these transformers to help keep them physically
active even when circumstances change. Strict adherence with adaptability may be easier
for these transformers because, per the previous section, they have numerous activities
they enjoy. This gives them an advantage in adherence because they have a wide variety
of options from which to choose when they have location changes or time crunches. This
variety may also be helpful to them when recovering from illness or injury because they
are able to quickly switch into a new activity better suited to their changing needs.

Transformers and “environmental control. ” Transformers in this study also
showed that they had a keen understanding of themselves and used this understanding to
inform their exercise habits in ways that led to success. This skill is an aspect of the
process of change known as “environmental control” (Prochaska et al., 1994). In
“environmental control,” one attempts to eliminate temptations that might cause a relapse
(Prochaska et al., 1994). Adherence to routine through “environmental control” is
demonstrated by Emily (L06), a realistic transformer in her 403, through the realization
that if she does not have a scheduled exercise “appointment,” she is less likely to initiate
the behavior:

Oh yeah, [routines are] very important. I don’t like change. (chuckling)

Yeah, routine is really important to me. One of the reasons I take the

swimming class here — one of the biggest reasons — is that I know that on

two mornings a week, I will get up and go. One of the reasons I’m not

very successful with the fitness center is that I don’t lmve a set time to do

it. And so, having that routine, I know that’s what I’m going to do and

that’s what I have to do. And I get myself geared up for that. But if I
don’t have that routine where I say, ‘Today I’ll do this at this time,’ I

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won’t do it. I tend to just go, ‘Okay, I’m done for the day. I’m going to

sit down.’ So, yeah, routine is incredibly important because I have to

factor it in to my life. As much as [exercise] is important to me, I also

know that it’s something that if I don’t, it will go away.

Faith (L19), a realistic transformer in her 603 who had earlier described the
importance of routine with regard to scheduling physical activity, also expressed the need
to have a variety of activities and work out routines within that schedule to manage
boredom. Knowledge of her needs and her realization of the consequences that a
repetitive workout would bring demonstrates her ability to use “environmental control” to
achieve success in adherence to physical activity.

Well, one of the things I discovered about myself over the last two years is

that I don’t want a routine. I want variety. I think I respond better to

variety, so I try to just — when I’m doing weights, for example, I don’t do

the same things. I try to say, ‘Okay, I’m going to do this today for my

biceps.’ In general now. When I get later on down the road, I’ll probably

split this up and do legs one day and arms and trunk the next. But right

now I just kind of try to hit major muscle groups and because I need to

keep it more interesting, different exercises for each one each day. And

then, just depending on howl feel, adjusting the number of reps and sets

with the weights what I feel I want to do. Some days I’ll go fewer reps,

and some days I don’t feel like doing reps; I’ll do more reps with the

lighter weights.

Like Faith (L19), Brenda (C01), a transformer in her 603, manages boredom via
“environmental controls” saying “that’s sometimes why I multi-task - I’ll sit there with
my iPod on or the TV on, or I’ll be drying my hair with the close captioning on, on the
exercise bike - because I could get bored.”

Jenny (SIS), an “under-reported years transformer” in her 503, exerts
“environmental control” by refusing to shower on the weekends until she has exercised in

her first statement and by refusing to exercise with others in her second statement:

People say, ‘You don’t do [exercise] on the weekends?’ I say, ‘Yeah, I
do.’ And the way I do it on the weekends is I don’t take my shower until

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I’ve got my workout done. Sometimes it’s 1 o’clock in the afternoon, and

I’m still padding around in my bathrobe. Because once you take a shower,

it’s all over. You’re not going to work out. Just to sweat again. At least,

that’s what I’ve found.

I’m a singular exerciser. I don’t want to wait for someone to show up

before I start exercising. If you call in sick, I’m not going to use that as an

excuse to not exercise. So, people would see me taking off my shoes and

leaving at lunch, and say, ‘Are you going to go running? [or] Oh, can]

start walking with you?’ I said to my husband that I don’t want to walk

with anybody else. It’s not just for the exercise of walking, it’s the mental

time... And I’ve got a really busy household, and so private time is a big

part of it. I don’t mind doing it a day or two a week, just to be social. But

if I’ve got an hour for lunch, and you’re not going to be ready for 10

minutes, I don’t want to wait for you. Because that means I’ve only got

50 minutes. I’m very conscious of what I want to accomplish everyday,

and I don’t want anyone holding me back.

Maintainers. In contrast to the strict adherence of exercise practices by
transformers, the maintainers in this study had more difficulty sticking to exercise
routines. In particular, they had difficulty adapting to changing variables. Heidi (M32), a
long-term maintainer in her 803, engages in physical activities offered at her local mall.
She describes herself as being a very routinized person, but seems to have no qualms
about breaking her exercise routine. This contradiction becomes clear in her dialog with
the interviewer. When asked about strategies for motivation for going to the mall for
exercise when conditions are unfavorable, she replied “I stay home.” As a follow-up to
confirm preference for routines, the interviewer asked whether routines in general were
important to Heidi (M32). She answered, “Very. I’m a routine person. Dull as all get
out.”

Amy (B31), a long-term maintainer in her 703, also found it difficult to stick to

her routine especially when breaks in her schedule were imposed on her or when her

husband was not available to go to the mall with her. In previous statements, she had

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asserted her preference for routine. The interviewer then asked Amy (B31) whether
“routine” was related to her exercise behavior. She responded saying, “Yes, because I
get myself maybe mentally prepared for doing the exercises.” The interviewer probed
firrther asking her to reflect on an earlier statement she had made about her inability to
continue her exercises if they were not a scheduled and structured part of her day, i.e.,
attending a class at a set time of day as opposed to self-initiated exercise. She responded
with the following:

Yeah, I would procrastinate and find something else to do, but if I know, with a

routine, well it’s like in the winter when we have that month that we can’t use the

mall and we can use another facility, let’s see this time I think we had it for 7 or 9
sessions but there was over probably 10 days that we didn’t have any class or

anything at all. I was just kind of lost. Yeah, I should be able to find other things

to do to take up that time, but no. And we all said that when we got to the mall

and got back into, not all but most of us, said, Oh, we are glad to be back to a

routine.

Following this same track, the interviewer asked about her ability to maintain exercise
when conditions are unfavorable.

Yeah, I’ve had over this 11 year period I’ve had periods where it was

difficult for me to walk so I’d use a cane or I’d hang onto my husband or

something, so if he wasn’t going, I could talk myself into staying home, it

was easier. But, then again, you just have to keep at it and keep trying and

know that you just can do better.

Amy (B31) demonstrates her inability to adapt to changing circumstances in
several ways. First, she is not able to create a way to be physically active while the class
is on holiday break. She also has a difficult time attending class when her husband is
unable to go, and does not find an alternative activity to do at home when she chooses not
to attend class.

Cindy (D14), a maintainer in her 403, has similar issues of inability to adapt when

multiple tasks create time issues for her. In addition, while she appears to understand

98

herself in terms of some of her “environmental control” factors, she is not able to use this
knowledge in ways that contribute to her success:

There is a fight everyday of time management. Things get busy and I can’t get to
that gym, and I know it’s prioritizing things, or if I would get up when my
husband would do it — because there’s nothing to do at 6 o’clock in the morning
but exercise — then I could fit it in the day. But there are times - like if you’re
preparing to go on vacation and you’ve got to get all this done. There was the
closing on the house, or we were doing construction that I couldn’t go over there
because I had to go do those things. I have gone a couple of weeks without
exercising, and I get really angry that I can’t go do it. It’s like, ‘All I’m asking is
one hour out of every day to go do something.’ And the fact that I can’t go do it
can make me angry. But not ever doing exercise — and why I said 80% continue it
is for any health reasons.

I focus better on routine. If I have a routine, I’m a little better. My exercises —
where a lot of people like variety, I go do the same things over and over. Mostly
because I can measure myself okay. I can do more reps by measuring myself
more. But I go to the gym and do the same thing over and over and over again,
where a lot of people like to have the variety and the same thing bothers them.

I do better in mid-afternoon. Probably around 2:00. I’ve been going over there
more on my way home — I used to be able to make it over here on lunch, but the
job is getting a little bit so I can’t. So on my way home, I’ll probably stop. It
takes a little more for me to do it after 5:00. And then in the morning, I’m just not
a morning person where my husband is. I will hate it if I have to do it in the
morning. I will dread it more. So, I won’t even attempt to do it, because I don’t
want to hate it, hate it. So, I’m best at 2:00 in the afternoon, if I could go do it
then And it is kind of a pick-me-upper, too. And it actually suppresses my

appetite.

The transformers in this study showed that the following skills were key to their
success in exercise adherence. First, they must possess the ability to prioritize physical
activity as a daily routine and to adhere to that routine. At the same time, they must be
able to adapt to changing circumstances and utilize “environmental control.” According
to Proclmska et al. (1994), evidence of the use of the “environmental control” process by
successful exercisers should not be surprising, but in the review of literature, 7 studies

which examined the use of the processes of change all showed that the “environmental

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control” process was not being well used by maintainers (Courneya & Bobick, 2000;
Fahrenwald & Walker, 2003; Goldberg et al., 1996; Gorely & Gordon, 1995; Jue &
Cunningham, 1998; Marcus, Rossi et al., 1992; Nigg & Coumeya, 1998). In this study,
maintainers also under-used the “environmental control” process, but transformers, on-
the-other-hand, did appear to use it. From this study’s review of literature chapter, the
following questions were raised about “environmental control.” Do maintainers forgo the
use of “environmental control” because they are overly confident and hence headed for
relapse, or are low rankings for “environmental control” an indicator of the length of time
maintainers have been in their stage? As all of the subjects in this study had been
exercising at least 4 years, we cannot assess whether maintainers who are new to the
stage are more or less likely to use “environmental control” than those further into the
stage, nor was there any indication that over confidence was an issue with any of the
maintainers. Nevertheless, the curious fact remains that the transformers, rather than
maintainers in this study, were the ones to use this process. If successful exercisers use
“environmental control” and if the use of “environmental control” is critical to
transitioning into transformed exercisers (Prochaska et al., 1994), then one of two issues
are at play. One possibility with regard to the low use of “environmental control” by
maintainers may be that the tool used to measure “environmental control” does not reflect
the way exercisers use the process of “environmental control” and therefore needs to be
modified. Another possibility is that lack of use of “environmental control” is due to
either over-confidence with regard to their need to enact “environmental control” or lack
of knowledge of the process and may be an indication that exercise practitioners need to

educate students and clients about this process.

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Helping Relationships

In the process called “helping relationships,” significant others become critically
important. The process, which is one of five prescribed for maintainers, is defined as
“enlisting the help of someone who cares” (Prochaska et al., 1994). In a review of the
literature, maintainers were shown to be less dependent on this process than most of the
other five processes recommended for transitioning fi'om maintained to transformed
behavior, (Courneya & Bobick, 2000; F ahrenwald & Walker, 2003; Goldberg et al.,
1996; Gorely & Gordon, 1995; Jue & Cunningham, 1998; Marcus, Rossi et al., 1992;
Nigg & Coumeya, 1998) but it was unclear why this was so. The following finding on
“helping relationships,” in part, answers the question “What are the factors or stressors in
adult life, such as career, children, health, social support, etc., which impact current stage
placement?”

In the review of literature chapter of this study, several ideas were discussed in an
attempt to explain why maintainers might not be using the “helping relationships”
process. The first suggestion was that maintainers might underestimate the importance of
or take for granted “helping relationships.” The interview data indicate that some women
were very aware of the importance of “helping relationships.” Two women, Amy (B31),
a long-term maintainer in her 703 and Faith (L19), a “realistic” transformer in her 603,
discussed the pinnacle role their spouses played in encouraging them to be active:

Amy (B31): we thought it would be kind of fun just to go and check

it out. Well, we did, and we knew one gal in the [exercise] class and she

encouraged us, you know, to come back. And I was a little hesitant. I

thought, uh I don’t know if I want to come again and my husband said, no

I think it will be good for us. And I know that he meant it will be good for

ME, which was very true. So, he more or less kind of pushed a little bit,

but then after I got into it I realized that it really did help me — in the social
as well as the physical way of life. . ..sometirnes he’s busy doing other

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things so he encourages me to go anyway and I usually do unless there’s
some reason that I can’t. So yeah, he’s been very supportive. Like I say,
he’s the one who talked me into continuing with the class. NowI don’t
know what I’d do without it...

Faith (L19): . .. I found a [ball] glove on the playground, and it was the
only glove I ever owned until my husband bought me one. . ..And then,
when I got out of school and got married, I married a man who saw the
athletic side of me. I married him because we could play ‘king of the
mountain’ on the telephone pole in my parents’ driveway, and it was a
good thing. And I married him because he saw me for who I am, because
it was so important to me. I mean, sometimes life gives you what you
really need and, in the guy that I nmrried, I lave what I need. I needed,
especially then, to realize that I didn’t have to be what anybody else
wanted me to be. We did a lot of stuff together. We played tennis
together. We went to the beach. He doesn’t swim, but I would swim. We
played football. We just did — it fed a side of me that I had missed for
close to 15 years. Even when I was active, it just fed a side of me that just
said, ‘Damn! I can do this stuff, and I can have fun, and he doesn’t think
less of me for a woman. I’m still a woman.’ So, when he bought me my
first glove, it was like, ‘Holy shit!’ I didn’t know I could do tlmt. It was
almost like permission, again, to be in touch with who I really have in my
core, which is a really active, much more vibrant human being than I had
been for 15 years.

Other women indicated that their husbands engaged in physical activities with
them, again indicating a presence of “helping relationships.” Like Faith (L19) and Amy
(B31) above, Brenda (C01), a transformer in her 403, and Heidi (M32), a long-term
maintainer in her 803, talked about activities in which they participated with their
husbands.

Brenda (C01): . . .my husband, is really, really supportive of anything that I
want to do. We partner well together. Our house is really homemade.

We sided it, we did all the floors - hardwood floors, and I participate just
as much as he does. It’s not like there’s women’s work and men’s work at
my house.

Heidi (M32): I think [my husband and I] walked around the mall a lot —
We got bikes with big tires and different people kidded us about them, and
we’d just very leisurely ride them.

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Still other women demonstrated the presence of “helping relationships” in that
they were not held back or prevented in any way from engaging in physical activity by
their significant others. Diane (K04), a transformer in her 403, Emily (L06), a “realistic”
transformer in her 403, and Ingrid (N 10), a transformer in her 603, discussed their
significant other’s attitudes toward their involvement in physical activity:

Diane (K04): [my husband thinks physical activity is] important for your
well-being. Pretty much point blank.

Emily (L06): Seeing there are only 2 women in my household, we view a
woman’s physical activity as extremely important as both of us engage in
some form of exercise.

Ingrid (N 10): Spouse is supportive. He’s not a physical exerciser
himself. He lets me do it for both of us. He’s very supportive of whatever
I do.

Finally, some women demonstrated the existence of “helping relationships”
through their instructors. Two women, Jenny (SIS), a woman in her 503 who had under-
reported years active and Ingrid (N 10), a transformer in her 603, indicated that support
fi‘om their instructors was important to them.

Jenny (SIS): And the first day I went in there, I got this great instructor
and he stepped me up on a program. He was so wonderful. I was
nervous, and I think most women are like that. They’re very nervous
about going into the fitness center and all those machines. You feel very
awkward and out of your element, especially a woman, I think. And so,
for this instructorto be so nurturing —a great big guyand so nurtming
And then following up on my progress and making me so welcome. That
was so important to me being comfortable there.

Ingrid (N 10): I’m kind of getting used to the weight stuff. It takes a
while. Actually, one of the instructors at the college, last summer, when
the total fitness room is closed down, one of the male instructors in there
taught me how to do fiee weights. And he was very, very helpful. And
once you know what you’re doing, you develop a liking for it. And
somebody’s there to watch you so you’re not going to injure yourself.
Very important. He was very helpful.

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From these statements it seems clear that “helping relationships” are not only
present, but, in some cases, they are profoundly important to success in maintaining
physical activity. This stands in stark contrast to the seven studies (Courneya & Bobick,
2000; Fahrenwald & Walker, 2003; Goldberg et al., 1996; Gorely & Gordon, 1995; Jue &
Cunningham, 1998; Marcus, Rossi et al., 1992; Nigg & Courneya, 1998) discussed in the
review of literature where maintainers were not using helping relationships. If
maintainers and transformers use the “helping relationships” process as this data implies,
it calls into question the effectiveness of the Processes of Change Questionnaire (PCQ)
(Marcus, Rossi et al., 1992) in accurately reflecting the way an exerciser in the
maintenance or transformed stage utilizes “helping relationships.” However, given that
only one of the maintainers in the current study was a “classic” maintainer, meaning that
she had exercised for less than 5 years and was less than 100% confident in her ability to
maintain exercise, opens the interpretation to other possibilities as well. For instance, the
low rankings for “helping relationships” in the previous studies may indicate the length
of time the maintainers have been in their stage. It is possible that long-term maintainers
and transformers would respond differently to questions about the “helping relationship”
process than those who are “classic” maintainers.

Another suggestion fi'om this study’s review of literature chapter was that
maintainers might take “helping relationships” for granted due to high intrinsic
motivation. This still remains a possibility as the women studied reported more intrinsic
motivational sources than extrinsic sources throughout their adult lives. However, there
appear to be no differences in the reporting of intrinsic motivational sources between

maintainers and transformers. Although no timetable finding could be discerned, these

104

results answered the stage placement aspect of the question “How does the timetable in
which intrinsic motivation was adopted influence stage placement?”.

Tables 12, 13, and 14 catalog the major motives for engaging in physical activity
during major time periods for each of the women. These tables present some puzzling
findings. For instance, Ewing and Seefeldt (1988) found that youth sports participants
were motivated by a wide variety of largely intrinsic factors. However, Table 12 shows
that, for all 10 women in the current study, a small number of mainly extrinsic motivators
were prominent during their youth. The reason for this difference may be due to
differences in data collection. The subjects in the Ewing and Seefeldt (1988) study were
asked questions about their current motivation whereas the women in this study were
answering questions about youth motivation retrospectively. Also, the subjects in the
youth sport study were given a series of motivation options to rank. Given a list of
options, the women in the Ewing and Seefeldt’s (1988) study may have recognized more
motivating factors than through the self-discovery method used in the current study.
Finally, Ewing and Seefeldt’s (1988) study reported motives of youth sport participants.
Motives for children enrolled in sports programs simply may not be comparable with the
motives of children who engaged in general, informal physical activity.

Another interesting phenomenon is revealed in the comparison of the three tables.
In examining the three tables, a pattern emerges that reveals an increase in reliance on
intrinsic motives during “work/child rearing life” (see Table 13) and then a decrease in
use of intrinsic motivators and a decrease in the variety of motivators during “retired life”
(see Table 14). One possible explanation for the increase in the number of intrinsically

motivating factors identified during “work/child rearing life” (see Table 13) may again

105

have to do with retrospective reporting for youth motives. Another possibility is that the
adult women discovered new reasons to engage in physical activity once it was no longer
a requirement of “family time” as it was in their childhood. The puzzling decrease in
motivators during “retired life” (see Table 14) may be due to the low number of
participants in that age range. However, these findings are consistent with those of a
study done on older adult mall walkers where the major motivating factors were health,
providing a daily purpose/routine, and social opportunity (Duncan, Travis, & McAuley,
1995). It is possible that in addition to downsizing and simplifying their households in

retirement, older adults simplify their needs as well.

106

Table 12

Major trends in motivation for young life: 4-21 years of age, n=10

 

 

Extrinsic motivation Intrinsic motivation
Socialize Family time/ Necessity: PA as coping Identity Physical Fun Appearance
time with dad travel or mechanism for health
work stress
K04 C01 B31 L19 L19 B31
L06 K04 C01 N 10 D14
L19 L06 014 S15 K04
M32 L19 M27 L19
S15 M27 M32 N 10
SI 5 M27
M32

 

 

107

Table 13

Major trends in motivation for work/child rearing life: 20-60 years of age, n=10

 

 

Extrinsic motivation Intrinsic motivation
Socialize Family time/ Necessity: PA as coping Identity Physical Fun Appearance
time with dad travel or mechanism for health
work stress
D14 B31 M27 B31 C01 B31 B31 D14
L06 M32 C01 [(04 C01 D14 C01
M32 D14 L06 D14 L06 K04
L06 L19 K04 M32 M32
L19 M32 L19 N10
N10 M27 S15
S15 N10
SIS

 

 

108

Table 14

Major trends in motivation for retired life: 60-80 years of age, n=3

 

Extrinsic motivation

Intrinsic motivation

 

Socialize Family time/ Necessity:

time with dad travel or

work

B31

M32

PA as coping
mechanism. for

stress

 

Identity Physical Fun Appearance

health

B3 1
M27

M32

 

109

The last two conclusions fiom this study’s review of literature could neither be
supported or refuted. Although several of the women came from active families, there
was no evidence to suggest that this rearing caused the women to take “helping
relationships” for granted, nor was there evidence to suggest that the women who did not
indicate the existence of “helping relationships” were headed for relapse. However these
findings do suggest a need for further research

Unanswered Questions

Although the interview questions were designed to answer the research
questions, one question “How have relapse episodes impacted progress to their
current stage?” bore no fruit in the interview process. A greater focus on this
topic with more in-depth questions may shed light on this issue. Two other
research questions, “How does the timetable in which intrinsic motivation was
adopted influence stage placement?” and “How does the timetable in which
enjoyment of exercise or physical activity was acknowledged impact stage
placement?,” were only partially answered as the timetable aspect of these
questions did not come to light. Again greater focus on this topic with more in-
depth questions may draw out these answers.

What if my Parents weren’t... and I’m not ..... ?

The previous discussions about experiences unique to transformers could
leave women reared in functional families with parents who did not engage in
activity with them feeling like their exercise aspirations are hopeless. Having
discussed what experiences and characteristics separate maintainers from

transformers, it is important to also reflect on what they have in common because

110

 

both groups have experienced success with adherence to physical activity. One
area these women have in common is a “never say die” type of attitude with
regard to physical activity. Regardless of the circumstances that may cause them
to be temporarily inactive, they all returned to physical activity. The following
women suffered severe injuries that caused them to cease activity for a time, but
they all found solutions that allowed them to return to some form of physical
activity. Of the 10 participants in this study, 6 of them had injuries or surgeries
that took them away from their physical activities for extended periods, and all of
them returned to some form of physical activity.

One example is Amy (B31), a long-term maintainer in her 703. She has
had several surgeries that have forced her to become inactive for a while, but each
time she has found a way to come back:

Well, it would be temporary physical problems, then therapy, then I was

back into the exercising. Then I had carpal tunnel surgery last summer so

he said “No exercising at all for. . .”, I can’t remember maybe six weeks or
so, but then I got so I would go to class and I would gradually start doing
some things until I could work back into it gradually. I really missed it,
having that time off and not exercising, I really missed it and I could tell
when I went back. I thought whoa, how come it’s so hard to do this?

Another example is Diane (K04), a transformer in her 403. When asked whether
she had ever had times where she could not continue to exercise, she responded:

Probably when I was recuperating from my back surgery. I was in

physical therapy, but I couldn’t go to the gym and workout. It was

probably 9 months later when I started going back to the gym. And kind
of slowly getting back into it. And I remember the first time I went on my
two-rrrile walk again, and it was really hard but I made it. It seemed like

after that it got easier and easier again. I wasn’t going to let it get me
down. I had to keep going.

111

A further example comes from Emily (L06), a realistic transformer in her 403 who
also had back surgery:

Yup. When I don’t feel well, I won’t exercise. When I had my back

surgery, that was probably the longest period of time when I didn’t really

do much of anything. But I got to the point where I said, ‘Okay. It’s now
time. I have to get up and do something.’ But for truly very short periods
of time will I do that, because I can tell, in my own self, when I haven’t
exercised.

The Transtheoretical Model (Prochaska et al., 1994) originally was used to
explain smoking cessation, and drug and alcohol rehabilitation. These are all
behaviors that have high incidences of relapse, and because of this, catch phrases
have been created to help those who fail to maintain behavioral change get back
on track. When smokers fail, they are told “Don’t quit quitting” (Henry Ford
Health System, 2006). A similar saying is associated with alcoholism “if you fall
off the wagon, get back on” (Conley, 2003). However, failure to maintain
exercise behaviors has not been regarded so sympathetically. But perhaps it
should be. As these 10 women have all demonstrated, when circumstances like
children, injuries, illness, or time conflicts caused them to take brief breaks from
their activities, they did not give up hope and quit for good. Instead, they returned

to physical activity as soon as they could. The lesson and possibly the slogan that

these women leave with us is “don’t stop starting.”

112

Chapter 5
SUMMARY AND IMPLICATIONS

The purpose of this study was to discover the ways in which life experiences and
personal characteristics relate to the phenomena of stage placement for maintainers and
transformers, as defined by Cardinal (1999), for physical activity in older women. While
the results of this study lent support for the existence of a sub-stage known as “long-term
maintainer” (Cardinal & Levy, 2000), the results also shed doubt on both Cardinal’s
(1999) and F allon’s (2004) criteria for transformers, and suggest that future studies are
needed to fine-tune the criteria used in identifying female transformers. One area of the
Stage of Physical Activity Questionnaire that requires firrther study is the confidence
portion of the questionnaire. Cardinal (1999) suggests that all that is needed to determine
transformed behavior is evidence of 5 or more years of engagement in physical activity
and 100% confidence in one’s ability to maintain the behavior. On-the-other-hand,
Fallon (2004) suggests that confidence rankings should be removed fiom the criteria for
transformers and only the years active criteria should remain. The results of this study
clearly indicate that these simplistic approaches are not effective in accurately identifying
transformers. Studies are needed to determine whether confidence levels for transformers
should be modified either to reflect a more “realistic” view of activity and aging, i.e.,
“How confident are you that you will be able to maintain some form of physical activity
for the rest of your life?”, or to establish an acceptable range of confidence levels for the
transformed stage. Additional research is also needed to explore the experiences of men
in these two stages to determine if men also have difficulty identifying with 100%

confidence, and hence, whether the Stage of Physical Activity Questionnaire needs to be

113

modified for both genders or a separate tool is needed to reflect women’s views of long-
term adherence.

In addition to research on confidence levels, other variables including role-
modeling attitudes, self-worth assessments, enjoyment of physical activities, variety of
physical activity interests, routinized exercise behavior, adaptability to changing
circumstances, and “environmental control” need to be studied to determine their role in
identifying transformed behavior. Also, because this study was performed with women
who were either childless or had a parenting partner, a similar study directed at the
experiences of single mothers is needed. Single mother’s face special challenges with
regard to free time to address their exercise needs (National Women’s Resource Center,
2005). Research that examined the strategies and coping skills that single mothers use to
maintain exercise behavior is needed to broaden our understanding of how women
achieve long-term adoption of exercise.

A further area for firture research is to study the Stage of Physical Activity
Questionnaire to determine how it might be successfully modified to reduce errors in
reported years of physical activity. These modifications might include specific language
about what constitutes physical activity and/or examples of qualifying physical activities.

In conjunction with clarifying years of physical activity reported, future studies
need to address how to differentiate between transformers, i.e., people who wereonce
sedentary but have now transformed into permanent adherers to physical activity, and
physical activity “lifers,” i.e., people who have always engaged in physical activity all
their lives and therefore have not changed or transformed. This is an important issue

because the TTM was created to help individuals “transform” negative behaviors into

114

positive ones, e.g., smokers become non-smokers and sedentary people become active.
Therefore, true measurement of transformed behavior for physical activity must begin
with the assertion that a transformer for physical activity was once a sedentary person.
This presents a firrther issue because the concept of sedentary behavior has not been
operationalized. Issues that need to be addressed are the length of time one must be
sedentary in order to meet the criteria for sedentary status and whether extenuating
circumstances should be considered in the determination of sedentary status. For
instance, if one takes a two-week vacation and does not engage in physical activity,
should he or she be classified as sedentary? Further, if one took a three-month break
from physical activity for back surgery, would he or she be considered sedentary? In
addition, future studies need to determine what duration, fiequency, and type of activities
qualify a person as active or sedentary. These same types of questions need to be
addressed to operationalize and validate the concept of “relapse.”

The issue of sedentary status introduces a limitation to the current study.
Although some of the interview questions addressed sedentary status, e. g., “Have you
ever had a time or times where you were unsure of your ability to continue to be
physically active or to exercise?” and “Did you become inactive during that time?,” lack
of an established definition of sedentary or relapsed behavior made it impossible to
classify the participants as such. Therefore, it is possible that some of the individuals
classified in any of the transformed categories may instead be a “lifer” for physical
activity.

Another measurement tool of the TTM appears to need some modification as

well. The results of this study shed doubt on the effectiveness of the Processes of Change

115

Questionnaire (PCQ) (Marcus, Rossi et al., 1992) in measuring the processes known as
“helping relationships” and “environmental control” for maintainers in physical activity.
Studies that pair responses to the Processes of Change Questionnaire (PCQ; Marcus,
Rossi et al., 1992) for the “helping relationships” and/or the “environmental control”
process with interview questions designed to get at issues salient to these processes
should shed light on any problems with the measurement of the “helping relationships”
and “environmental control” processes for physical activity in maintainers.

As this study was performed with women who were either childless or had a
parenting partner, a similar study directed at the experiences of single mothers is needed
to broaden our understanding of the role “helping relationships” plays in exercise
adherence for women. Additional studies directed at the exercise experiences of men are
needed to determine whether the “helping relationships” process is faulty and in need of
modification for both genders or whether special modifications are necessary for women
only. As the older adult population grows, another important area of research in “helping
relationships” and exercise adherence for women is the impact that the death of aspouse
has on adherence.

Practitioners of physical activity can also benefit fiom the knowledge of the role
“helping relationships” play in adherence. For instance, while the majority of the women
in this study worked out regularly without the benefit of a work out partner, they all
provided statements that suggested that “helping relationships” in the form of moral
support and babysitting were extremely important to their success. This means that,

rather than encouraging that their exercise clients find work out partners as a means of

116

addressing “helping relationships,” practitioners should focus on verbal encouragement
of their cheats exercise behaviors and provide day care within their facilities.

In addition to offering direction for future research, the results also revealed some
important information for parents. Many of the women in this study who successfully
adhered to physical activity routines did so in part because either both of their parents or
their fathers alone engaged in physical activities with them when they were children.
This means that it is important for parents, who are concerned about their children’s If
future health, to make a regular habit of doing physical activities with their children so
that their children will learn that daily physical activity is a valuable and expected part of

daily life. This finding may be of particular concern to single mothers as the finding

 

suggests that fathers, rather than mothers, heavily influence their daughter’s decisions
about engagement in physical activity. Single mothers may fear that their daughters will
ignore physical activity without the presence of a father in the home. Further studies are
needed to determine whether there is something special about the father/daughter
relationship that promotes involvement in physical activity, e.g., does engagement in
physical activity with the father send a message to young girls that physical activity is
accepted by males in society?, or whether the fathers’ role in their daughter’s adoption of
physical activity is simply an issue of spare time, i.e., father plays in yard with children
while mother cooks, cleans, etc.

Further, society needs to make parent/chfld engagement in physical activity easier
for parents in the following ways. Schools and community groups need to provide more
opportunities for parents and children to engage in physical activity together by offering a

wide variety of parent/child classes that involve physical activity. In addition, schools

117

that require “homework” for their Physical Education classes should encourage the
parents to do the physical activities with their children, working along side them as they
might with other types of homework. Gyms and fitness centers can also help influence
exercise behavior in young people by providing “junior” gyms where children can
“workout” at the same time as their parents in a safe environment.

The findings of this study present questions as to the future exercise habits of
today’s young people. The women in this study generally engaged in unstructured
physical activity during their childhood. In today’s society, many children fall into two
extreme categories of engagement in physical activity. They are either heavily scheduled
in formal physical activities, i.e., soccer, karate, dance class, or they are tied to inactive
digital entertainment, i.e., television, computer, video games. Given these two extremes,
will future generations be able to make the connection between exercise and stress
reduction or in the case of the over-scheduled children, will exercise be equated with
stress and hence, impact their ability to enjoy physical activity?

On the other end of the age spectrum are some questions about engagement in
physical activity by menopause-aged women. One topic related to this group, which
presented itself in the data but was not found to relate to stage adoption, was the
particular challenges women face with regard to exercise adherence during and post
menopause. Several women discussed how much more difficult it was for them to
maintain their fitness levels after menopause. Others discussed increasing their levels of
physical activity due to menopause related health concerns. Again, as the older adult
population grows, studies that increase our understanding of the exercise experiences of

older women will be beneficial in helping practitioners best serve their clients.

118

APPENDICES

119

APPENDIX A

Modified Stage of Physical Activity Algorithm (Cardinal, 1999)

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APPENDIX B
Stage of Change for Physical Activity Questionnaire

Name

 

This survey is designed to assess level of participation in moderate to vigorous physical
activity. According to the Rate of Perceived Exertion Scale (Borg, 1983). Moderate
intensity physical activity is that which is somewhat hard for you to do meaning that your
rate of breathing should increase slightly and you may begin to sweat lightly. Vigorous
intensity physical activity is that which is hard for you to do which would include a
breathing rate higher than the one associated with moderate exercise and increased
sweating.

1. For the following statement, please indicate whether the statement is true or false
as it pertains to you:

I presently accumulate 30 minutes or more of moderate to vigorous intensity
physical activity, 4 or more days per week. (please circle one choice below)

a. True

b. False

If you answered “true,” continue to question 2.

If you answered “false,” please stop here.

2. In the spaces provided below, indicate how many months or years have you been
continuously engaged in physical activity or exercise for 30 minutes or more, 4 or -
more days per week without stopping.

months years

3. How confident are you that you will be able to maintain this level of exercise for
the remainder of your life? (please circle the percentage that best describes your
level of confidence)

0% 40% 80%
10% 50% 90%

20% 60% 100%

30% 70% __other %

122

 

APPENDIX C
Demographic Survey

Code

 

For the following items, please circle the response that best describes you.
1. Are you:

Male

Female
2. Which racial or ethnic group best describes you?

Afiican American

Asian American

 

Latino/Hispanic
American Indian/Alaskan Native
White

Other

 

3. Which age group are you?
18-19
20-29
30-39

40-49

 

50-59

60-69

70-79

80-89

123

4.

5.

Which of the following best describes your highest level of education?

High school graduate or GED
Trade school

Some college

Associates degree

Bachelor’s degree

Master’s degree

PhD.

Other

Do you currently work outside of the home?

Yes (go to question A)

No (go to question B)

A. Which best describes your current vocation?

Educator
Administrator/Manager
Clerical

Skilled trade

Business owner/Self-employed

Other (please specify)

 

124

 

..IE

B. Did you ever work outside the home?
Yes (go to question a.)
No (go to question 6)
3. Which best describes your former vocation?

Educator
Administrator/Manager
Clerical
Skilled trade
Business owner/Self-employed

Other (please specify)

 

b. Why did you leave your former vocation?
Children
Retired

Other (please specify)

 

6. Which best defines your annual household income level?
Less than $25,000
$25,000-$34,999
$35,000-$49,999
$50,000-$79,999
$80,000 and up

7. How many people currently live in your household?

 

125

 

.1

10.

11.

12.

13.

What is your current martial status?
Single
Live with significant other
Divorced
Married
Widowed
Do you currently have children under your care in your home?
Yes (how many? )
No (go to question A)
A. Did you ever have children under your care in your home?
Yes (how many? )
No
Do you currently own a home or rent?

In the space provided below list the types of exercise you currently do.

Which of those activities listed in question 11 do you most frequently engage
in?

Which of those activities listed in question 11 is your
favorite?

126

 

 

14. Please check the best way to contact you for an interview:
phone (enter your preferred phone number in the space provided)
___e-rnail (enter your preferred e-mail address in the space provided)

_mail (enter your preferred mailing address in the space provided)

 

 

 

 

127

APPENDIX D

Interview Questions
How old were you when you first became involved in physical activity or
exercise?
(for the purposes of this interview, physical activity is defined as any activity that
requires an exertion of energy that is moderate to vigorous in its intensity
meaning that engaging in the activity causes your rate of breathing to increase and
should involve some sweating)
What or who prompted you to become involved in physical activity or exercise?

When you were growing up, did your family engage in physical activity or

 

exercise together as a group?
a. Did any of the members engage in physical activity or exercise on their
own?
i. If yes, how were family members who engaged in these activities
viewed by other members of the family?
What were your views of physical activity or exercise for women when you were
growing up?
What were your parents’ and/or siblings’ views of physical activity or exercise for
women when you were growing up?
What were your friends’ views of physical activity or exercise for women when
you were growing up?
What views were reflected by your school and/or teachers about physical activity

or exercise for women when you were growing up?

128

10.

ll.

12.

13.

14.

How do your current household members view physical activity or exercise for
women?
What do you believe is the value of physical activity or exercise for women?
a. What or who has influenced these values?
Have you always engaged in the same kinds of physical activities or exercises?
a. If no, why did you change activities?
Do you enjoy the physical activities or exercises you currently engage in?
a. If no, what about these activities do you dislike?
b. If yes, what about these activities do you enjoy?
i. Have you always enjoyed these activities?
-If no, when and why did you begin enjoying them?
What are your main motivators for engaging in daily physical activity or exercise?
a. When you first began to be active, were you motivated by the same things
that motivate you now?
i. If no, when and why did this change?
Have you ever had a time or times where you were unsure of your ability to
continue to be physically active or to exercise? (If yes, go to 14. If no, go to 15)
Did you become inactive during that time?
a. If yes,
i. How many times has this happened?
ii. How long did it take you to return to regular exercise or physical

activity?

129

 

 

15.

l6.

17.

18.

19.

iii. What facilitated or convinced you to return to regular exercise or
physical activity?
b. If no, why not?
i. What kept you from becoming inactive?
ii. What strategies did you use to prevent this fi'om happening?
iii. What advice would you give others who are struggling to
persist?
When conditions for physical activity or exercise are less than ideal, i.e., poor
weather, illness, tiredness, what strategies do you use to prevent “skipping” a
day?
How important are “routines” in your life?
How would you describe yourself in terms of the role physical activity plays in
your life?
How would others describe you in terms of your relationship with physical
activity or exercise?
On the survey you completed prior to being invited to interview, you indicated
that your were _% confident that you could continue physical activity or

exercise for life. What factors make you % confident?

130

APPENDIX E

Participant Consent Form

131

 

CLL‘

Participant Consent Form

You are being asked to participate in a study being conducted by Heather Kesselring, a
doctoral student, under the supervision of Dr. Martha Ewing from Michigan State University.
The purpose of this study is to broaden the understanding of long-term exercise participation.
As a part of this study, you will be asked to complete two brief questionnaires
(approximately 5 minutes each), and if you meet the study criteria, you may be asked to
participate in an interview. Upon the completion of the interview, you will receive a $25 gift
certificate to Playrnakers. If a partial interview is completed, arrangements will be made to 1
schedule another time to complete the interview. However, if the interview cannot be completed,
the gift certificate will not be awarded. The interviews will be scheduled for one hour, however
individual interviews may go over the allotted time period depending on the volume of
information each individual has to share. The questions in the interview will be specific to your
experience as an exerciseparticipant. The interview will be audio taped and transcribed. If you
wish, you can refuse to have the interview audio taped. You can also ask that the audio tape be - Fr:
tumed off at any point during the interview. Audio tapes will be erased once the study is
completed. After the interview, you may be contacted to clarify your responses to the questions.
Your responses to the interview will be kept confidential; no one except the primary
investigators will have access to these responses. Results will be based on the responses given by
all the participants as a group insuring confidentiality of individual responses. Group-based
findings will be made available to those who are interested. Your privacy will be protected to the
maximum extent allowable by law.
Your participation in this study would be greatly appreciated. However, please know that 54
you may withdraw from participation at anytime without penalty. Furthermore you may refuse
questions on the questionnaire and/or interview that you feel uncomfortable answering and still
be a part of the study. If you have any questions concerning your participation this study, please
contact the principle investigator Dr. Martha Ewing at (517) 333-4652 or Heather Kesselring at
(517) 267-5 906 or kesselrh@lcc.edu. If you have any questions or concerns regarding your 1
rights as a study participant, or are dissatisfied at any time with any aspect of this study, you may
contact-anonymously if you wish- Peter Vasilenko, Ph.D., Chair of the University Committee on
Research Involving Human Subjects (UCRIHS) by phone: (517) 355-2180, fax: (517) 432-4503,
e-mail: ucrihs@msu.edu, or regular mail: 202 Olds Hall, East Lansing, MI 48824.

 

Thank you for your time and cooperation,

M 9 ' // , I

Dr. Martha Ewing, Principle In tigator ate

1]] f | ’0 3/
ate

Your signature below indicates your voluntary agreement to participate in this study.

   

 

eather Kesselring, Graduate Student

    

 

 

Participant Signature - Date

UCRIHS APPROVAL FOR
THIS project EXPIRES:

JUL_ 2 8 2005

SUB IT RENEWAL APPLICATION
MONTH PRIOR TO

132 fiBOVEDATETO CONTINUE

APPENDIX F

Recruiting Letter

Date

Heather Kesselring
108 S. Elm
Ithaca, NH 48847

Participant name
Participant address

You are receiving this letter because you are enrolled in an exercise course and
are being asked to consider participating in a research study about participation in
exercise. Your participation in this study will help to further broaden our understanding
of exercise participation.

Should you decide to become a part of this study, you will be asked to sign a
consent form and complete two short written surveys, one with 3 questions and one with
14 questions. If you are selected for participation in this study, you will also be asked to
participate in an interview that could last approximately an hour in duration.

Following the completion of that interview, you will receive a $25 gift certificate
to Playmakers. If you are interested in participating in this opportunity, please contact
Heather Kesselring at 517-267-5906 or kesselrh@lcc.edu.

Sincerely,

Heather Kesselring

133

 

REFERENCES

Bandura, A. (1986). Social foundations of thought and action. Englewood Cliffs, NJ:
Prentice-Hall.

Bandura, A. (1997). The anatomy of stages of change. American Journal of Health
Promotion, 12(1), 8-10.

Barke, C. R. & Nicholas, D. R. (1990). Physical activity in older adults: The stages of
change. Journal of Applied Gerontology, 9(2), 216-223.

Booth, M. L., Macaskill, P., Owen, N., Oldenburg, B., Marcus, B. H., & Bauman, A.
(1993). Population prevalence and correlates of stages of change in physical
activity. Health Education Quarterly, 20(3), 431-440.

Borg, G. (1983). Perceived exertion: A note on history and methods. Medicine and
Science in Sport Exercise, 5, 90-93.

Boyle, R. G., O’Connor, P. J. Nicolaas, P. P., & Tan, A. (1998). Stages of change for
physical activity, diet, and smoking among HMO members with chronic
conditions. American Journal of Health Promotion, 12(3), 170-175.

 

Buonamano, R., Cei, A., & Mussino, A. (1995). Participation motivation in Italian
youth sport. The Sport Psychologist, 9, 265-281.

Burn, G. E., Naylor, P. J ., & Page, A. (1999). Assessment of stages of change for
exercise within a worksite lifestyle screening program. American Journal of
Health Promotion, 13(3), 143-145.

Byrne, M. M. (2001). Understanding life experiences through a phenomenological
approach to research. Association of periOperative Registered Nurses Journal,
April, Research Corner. Retrieved June 30, 2005 from
http://www.aorn.org/journal/2001/aprrc.htm

Cardinal, B. J. (1993). Validation of a stages of exercise adoption scale. Research
Quarterly for Exercise and Sport, 64 ( 1 supplement), A-50-A-51.

Cardinal, B. J. (1995a). The stages of exercise scale and stages of exercise behavior in
female adults. Journal of Medicine and Physical Fitness, 35, 87-92.

Cardinal, B. J. (1995b). Behavioral and biometric comparisons of the preparation, action,
and maintenance stages of exercise. Wellness Perspectives: Research Theory,
and Practice, 11(3), 36-43.

134

Cardinal, B. J. (1997). Predicting exercise behavior using components of the

transtheoretical model of behavior change. Journal of Sports Behavior, 20(3),
272-283.

Cardinal, B. J. (1998). Interaction between stage of exercise and history of exercise
relapse. Journal of Human Movement Studies, 34, 175-185.

Cardinal, B. J. (1999). Extended stage model of physical activity behavior? Journal of
Human Movement Studies, 3 7, 37-54.

Cardinal, B. J., Engels, H. J., & Zhu, W. (1998). Application of the transtheoretical
model of behavior change to preadolescents’ physical activity and exercise
behavior. Pediatric Exercise Science, 10, 69-80.

Cardinal, B. J ., & Levy, S. S. (2000). Are sedentary behaviors terrninable? Journal of
Human Movement Studies, 38, 137-150.

Center for Disease Control. (1999a, Feb 26). Neighborhood safety and the prevalence of
physical activity in selected states, 1996. Morbidity and Mortality Weekly Report,
48 (7), 143-146. Retrieved October 8, 2005 from
http://www.cdc.gov/mmwr/preview/mmwrhtml/00056S82.htm

Center for Disease Control. (1999b, Nov 17). Physical activity and health: A report of
the Surgeon General. Retrieved October 8, 2005 fiom
http://www.cdc.gov/nccdphp/sgr/womenhtm

Center for Disease Control. (2001, Jun 20). The eflects of physical activity on health and
disease. Retrieved February 12, 2005 from

http://www.cdc.gov/nccdphp/sgr/pdf/chap4.pdf

Center for Disease Control. (2005). Health, United States, 2005 with chartbook on
trends in the health of Americans. Retrieved February 12, 2005 from
http://www.cdc.gov/nchs/data/hus/hu305.pdf

Christopoulou, M., McKenna, J., & Naylor, P. J. (1996). Assessing self-efficacy and the
stages of exercise behavior change. Journal of Sports Sciences, 14(1), 23-24.

Clarke, R, & Eves, F. (1997). Applying the transtheoretical model to the study of
exercise on prescription. Journal of Health Psychology, 2(2), 195-207.

Conley, T. (2003, May 24). Behavioral Health Articles: Relapse. Mount Regis Center.

Retrieved April 26, 2006 from
http://www.mtregis.com/display_article.asp?article=663S

13S

- -..I -:r_'. ...‘Lv .1"an
.

 

Coumeya, K S., & Bobick, T. M. (2000). Integrating the theory of planned behavior
with the processes and stages of change in the exercise domain. Psychology of
Sport and Exercise, 1, 41 -56.

Coumeya, K. S., Plotnikoff, R. C., Hotz, S. B., & Birkett, N. J. (2001). Predicting
exercise stage transitions over two consecutive 6-month periods: A test of the
theory of planned behavior in a population-based sample. British Journal of
Health Psychology, 6, 135-150.

Cowen, R., Logue, E., Milo, L., Britton, P. J. & Smucker, W. (1997). Exercise stage of
change and self-efficacy in primary care: Implications for intervention. Journal
of Clinical Psychology in Medical Settings, 4(3), 295-311.

Deci, E. L., & Ryan, R. M. (1985). Intrinsic motivation and self-determination in human
behavior. New York, NY: Plenum Press.

Duncan, H. H., Travis, S. S., & McAuley, W. J. (1995). An emergent theoretical model
for interventions encouraging physical activity (mall walking) for older adults.
Journal of Applied Gerontology, 14 (1), 64-77.

Dunlap, J, & Barry, H. C. (1999). Overcoming exercise barriers in older adults. The
Physician and Sportsmedicine, 27(11), 69-75.

Eves, F ., Mant, S., & Clarke, P. (1996). Barriers to exercise at different stages of
exercise behavior. Journal of Sports Sciences, 14(1), 29.

Ewing, M. E., & Seefeldt, V. (1988). Participation and attrition patterns in American
agency-sponsored and interscholastic sports — An executive summary. East
Lansing, Michigan: Michigan State University, Institute for the Study of Youth
Sports.

Fahrenwald, N. L., & Walker, S. N. (2003). Application of the transtheoretical model of
behavior change to physical activity behavior of WIC mothers. Public Health
Nursing, 20(4), 307-317.

Fallon, E. A. (2004). Transtheoretical Model: 13 termination applicable to exercise?
American Journal of Health Issues. Retrieved October 2, 2005 fi’om
http://www. findarticles.co m/p/articles/mi__m0CTG/ is_1_1 9/ai_n6072021 6/print

Fallon, E. A., & Hausenblas, H. A. (2001). Transtheoretical model of behavioral change:
Does the termination stage exist for exercise? Journal of Human Movement
Studies, 40, 465-479.

Gill, D. L., Gross, J. B., & Huddleston, S. (1983). Participation motivation in youth
sports. International Journal of Sport Psychology, 14, 1-14.

136

Goldberg, J. M., Christopher, M. R. J., Aznar, S., Barnes, J. K., Simmonds, G. J.,
McKenna, J., Page, A., & Naylor, P. J. (1996). The processes of exercise
behaviour change used by years 7 and 12 adolescents. Journal of Sports Sciences,
14(1), 30.

Gorely, T., & Gordon, S. (1995). An examination of the transtheoretical model and
exercise behavior in older adults. Journal of Sport and Exercise Psychology, 1 7,
312-324.

Gould, D., Feltz, D., & Weiss, M. (1985). Motives for participating in competitive youth
swimming. International Journal of Sport Psychology, 16, 126-140.

Gould, D., Feltz, D., Weiss, M., & Petlichkoff, L. (1982). Participation motives in
competitive youth swimmers. In T. Orlick, J. T. Partington, & J. H. Salrnela
(Eds.), Mental training for coaches and athletes. Champaign, IL: Human
Kinetics.

Heesch, K. C., Brown, D. R., & Blanton, C. J. (2000). Perceived barriers to exercise and
stage of exercise adoption in older women of different racial/ethnic groups.
Women & Health, 30 (4), 61-76.

Hellman, E. A. (1997). Use of the stage of change in exercise adherence model among
older adults with a cardiac diagnosis. Journal of Cardiopulmonary
Rehabilitation, 1 7, 145-155.

Henry Ford Health System. Factors that can be changed or controlled: Cigarette
smoking. Retrieved April 28, 2006 fi'om
http://www.henryford.com/body.cfin?id=45497

Herrick, A. B., Stone, W. J., & Mettler, M. M. (1997). Stages of change, decisional
balance, and self-efficacy across four health behaviors in a worksite environment.
American Journal of Health Promotion, 12(1), 49-56.

Ingledew, D. K., Markland, D., & Medley, A. R. (1998). Exercise motives and stage of
change. Journal of Health Psychology, 3(4), 477-489.

Janis, I. L., & Mann, L. (1977). Decision making: A psychological analysis of conflict,
choice and commitment. New York: Free Press.

Jue, N. H., & Cunningham, S. L. (1998). Stages of exercise behavior change at two time

periods following coronary artery bypass graft surgery. Progress in
Cardiovascular Nursing, 13(1), 23-33.

137

Juniper, K. C., Oman, R. F., Hamm, R. M., & Kerby, D. S. (2004). The relationship
among constructs in the health belief model and the transtheoretical model among
Afi'ican-American college women for physical activity. American Journal of
Health Promotion, 18(5), 354—357.

Kearney, J. M., de Graaf, C., Damkjaer, S., & Engstrom, L. M. (1999). Stages of change
towards physical activity in a nationally representative sample in the European
Union. Public Health Nursing, 2(1), 115-124.

King, A. C., Castro, G, Wilcox, S., Eyler, A. A., Sallis, J. F ., & Brownson, R. C. (2000).
Personal and environmental factors associated with physical inactivity among

different racial-ethnic groups of US. middle-aged and older women. Health
Psychology, 19(4), 354-364. 1:.

Klint, K. A., & Weiss, M. R. (1986). Perceived competence and motives for sports: A

test of Harter’s Competence Motivation Theory. Journal of Sport Psychology, 9,
55-65.

 

Koivula, N. (1999). Sport participation: Differences in motivation and actual
participation due to gender typing. Journal of Sport Behavior, 22, 360-3 80.

_

Kosma, M., Cardinal, B., & McCubbin, J. A. (2004). Predictors of physical activity
stage of change among adults with physical disabilities. American Journal of
Health Promotion, 19(2), 114-117.

Kvale, S. (1996). Interviews: An introduction to qualitative research interviewing.
Thousand Oaks, CA: Sage Publications.

Lee, C. (1993). Attitudes, knowledge, and stages of change: A survey of exercise
patterns in older Australian women. Health Psychology, 12(6), 476-480.

Lewis, M. V., Szabo, R. A., Weiner, K. R., McCall, L., & Piterman, L. (1997). Cultural
barriers to exercise among the ethnic elderly. Internet Journal of Health
Promotion. Retrieved October 8, 2005 from http://www.rhpeo.org/ijhp-
articles/ 1 997/4/

Marcus, B. H., Banspach, S. W., Lefebvre, R. C., Rossi, J. S., Carleton, R. A., & Abrams,
D. B. (1992). Using the stages of change model to increase the adoption of

physical activity among community participants. American Journal of Health
Promotion, 6(6), 424-429.

 

Marcus, B. H., Dubbert, P. M., Forsyth, L. H., McKenzie, T. L., Stone, E. J., Dunn, A. L.,
& Blair, S. N. (2000). Physical activity behavior change: Issues in adoption and
maintenance. Health Psychology, 19(1 supplement), 32-41.

138

Marcus, B. H., Eaton, C. A., Rossi, J. S., & Harlow, L. L. (1994). Self-efficacy,
decision-making, and stages of change: An integrative model of physical exercise.
Journal of Applied Social Psychology, 24, 489-508.

Marcus, B. H., & Owen, N. (1992). Motivational readiness, self-efficacy, and decision
making for exercise. Journal of Applied Social Psychology, 22, 3-16.

Marcus, B. H., Rossi, J. Selby, V. C., Niaura, R. S., & Abrams, D. B. (1992). The
stages and processes of exercise adoption and maintenance in a worksite sample.
Health Psychology, 11(6), 386-395.

Marcus, B. H., Selby, V. C., Niaura, R. S., & Rossi, J. S. (1992). Self-efficacy and the
stages of exercise behavior change. Research Quarterly for Exercise and Sport,
63, 60-66.

Marcus, B. H., & Simkin, L. R. (1993). The stages of exercise belmvior. The Journal of
Sports Medicine and Physical Fitness, 33, 83-88.

Marcus, B. H., & Simkin, L. R. (1994). The transtheoretical model: Applications to
exercise behavior. Medicine and Science in Sports and Exercise, 26, 1400-1404.

McCaslin, M. L., & Wilson-Scott, K. (2003). The five-question method for fi'aming a
qualitative research study. The Qualitative Report, 8, 447-461. Retrieved June 30,
2005 from http://www.nova.edu/sss/OR/QR8-3/mccaslin.pdf

Morgan, W. P., & O’Connor, P. J. (1988). Exercise and mental health. In R. Dishman
(Ed.), Exercise adherence: Its impact on public health (pp. 91-121). Champaign,
IL: Human Kinetics.

Mullan, E. & Markland, D. (1997). Variations in self-determination across the stages of
change for exercise in adults. Motivation and Emotion, 21(4), 349-362.

Mutrie, N., & Caddell, C. (1994). Stages of exercise behaviour change in corporate
employees. Journal of Sport Sciences, 12(2), 202-203.

Myers, R. S., & Roth, D. L. (1997). Perceived benefits of and barriers to exercise and
stage of exercise adoption in young adults. Health Psychology, 16(3), 277-283.

National Women’s Resource Health Center. (2005, May 4). First annual health survey:
Women talk. Retrieved October 8, 2005 from
http://www.healthywomen.org/womentalk/05042005_02.html

Naylor, P. J., & McKenna, J. (1995). Stages of change, self-efficacy and behavioural

preferences for exercising among British university students. Journal of Sport
Sciences, 13(1), 68-69.

139

 

Naylor, P. J ., McKenna, J., Barnes, K., & Christopher, M. (1995). Decision balance and
self-reported physical activity levels: Validating the stages of change for exercise
in British university students. Journal of Sport Sciences, 13(1), 68-69.

Nguyen, M. N., Potvin, L., & Otis, J. (1997). Regular exercise in 30- to 60-year-old
men: Combining the stages-of-change model and the theory of planned behavior
to identify determinants for targeting heart health interventions. Journal of
Community Health, 22(4), 233-246.

Nigg, C. R., & Coumeya, K. S. (1998). Transtheoretical model: Examining adolescent
behavior. Journal of Adolescent Health, 22, 214-224.

O’Brien-Cousins, S., & Keating, N. (1995). Life cycle patterns of physical activity
among sedentary and active older women. Journal of A ging and Physical
Activity, 3, 340-359.

Peterson, T. R., & Aldana, S. G. (1999). Improving exercise behavior: An application of
the stages of change model in a worksite setting. American Journal of Health
Promotion, 13(4), 229-232.

 

Plotnikoff, R C., Hotz, S. B., Birkett, N. J., & Coumeya, K. S. (2001). Exercise and the
transtheoretical model: A longitudinal test of a population sample. Preventive
Medicine, 33, 441-452.

Potvin, L., Gauvin, L., & Nguyen, N. M. (1997). Prevalence of stages of change for
physical activity in rural, suburban and inner-city communities. Journal of
Community Health, 22(1), 1-13.

Prochaska, J. O., & Marcus, B. H. (1994). The transtheoretical model: Applications to
exercise. In R. K. Dishman (Ed), Advances in exercise adherence (pp. 161-180).
Champaign, IL: Human Kinetics.

Prochaska, J. O., Norcross, J. C., & Diclemente, C. C. (1994). Changing for good: A
revolutionary six-stage program for overcoming bad habits and moving your life
positively forward. New York: Avon Books.

Prochaska, J. O., & Velicer, W. F. (1997). The transtheoretical model of health behavior
change. American Journal of Health Promotion, 12, 38-48.

 

Russell, M., & Karol, K. (1993). 16 PF fifth edition administrators manual.
Champaign, IL: Institute for Personality and Ability Testing, Inc.

Reed, G. R. (1999). Adherence to exercise and the transtheoretical model of behavioral

change. In S. J. Bull (Ed), Adherence Issues in Sport and Exercise (pp. 19-45).
Chichester, England: John Wiley & Sons Ltd.

140

Rubin, H. J., & Rubin, I. S. (1995). Qualitative interviewing: The art of hearing data.
Thousand Oaks, CA: Sage Publications.

Sapp, M., & Haubenstricker, J. (1978, April). Motivation for joining and reasons for not
continuing in youth sports programs in Michigan. Paper presented at the
American Alliance for Health, Physical Education, Recreation and Dance
National Conference, Kansas City, MO.

Sarkin, J.A., Johnson, S. S., Prochaska, J. O., & Prochaska, J. M. (2001). Applying the
transtheoretical model to regular moderate exercise in an overweight population:
Validation of a stages of change measure. Preventive Medicine, 33, 462-469.

Simmonds, G. J., Naylor, P. J., Riddoch, C. J., & Vellman, G. (1996). Stage-based
counseling for exercise in primary care: A controlled trial. Journal of Sports
Sciences, 14(1), 45-46.

Snyder, E. E., & Spreitzer, E. A. (1973). Family influence and involvement in sports.
Research Quarterly, 44 (3), 249-255.

Swarm, W. B., & Pittman, T. S. (1977). Initiating play activity of children: The
moderating influence of verbal cues on intrinsic motivation. Child Development,
48, 1128-1132.

Titze, S., Martin, B. W., Seiler, R., Stronegger, W., & Marti, B. (2001). Effects of a
lifestyle physical activity intervention on stages of change and energy expenditure
in sedentary employees. Psychology of Sport and Exercise, 2, 103-116.

United States Department of Agriculture. (2005). Dietary guidelines for Americans
2005. Retrieved January 14, 2005 from
http://www.health.gov/dietaryguidelines/dga2005/document/html/executivesumm
ary.htm

United States Department of Health and Human Services. (2000). Healthy people 2010.
Retrieved February 12, 2005 fi'om http://www.healthypeople.gov/LI-II/

Walcott-McQuigg, J. A., & Prochaska, T. R. (2001). Factors influencing participation of
African American elders in exercise behavior. Public Health Nursing, 18, 194-
203.

Weiss, M. R., & Chaumeton, N. (1992). Motivational orientations in sport. In T. S. Horn
(Ed.), Advances in sport psychology (pp. 61-99). Champaign, IL: Human
Kinetics.

Wold, B., & Kannas, L. (1993). Sport motivation among young adolescents in Finland,

Norway and Sweden. Scandinavian Journal of Medicine and Science in Sports, 3,
283-291.

141

Women’s Sports Foundation UK. (2005). Research into the barriers that prevent young
mothers from participating in physical activity: The final report. Retrieved
October 8, 2005 from http://www.cre.gov.uk/sportingequals/spa_research.html

Wyse, J., Mercer, T., Ashford, B., Buxton, K., & Gleeson, N. (1995). Evidence for the
validity and utility of the stages of exercise behavior change scale in young adults.
Health Education Research, 10(3), 365-377.

Zuckerman, M., Porac, J., Lathin, D., Smith, R., & Deci, E. L. (1978). On the
importance of self-deterrrrination for intrinsically motivated behavior. Personality
and Social Psychology Bulletin, 4, 443-446.

 

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