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Journal of the New Zealand Medical Association, 03-June-2005, Vol 118 No 1216

Pacific women’s decisions about exercise adoption: utilising the stage-of-exercise-adoption model

Denise Kingi, Andy Towers, Renée Seebeck, Ross Flett

Abstract

Aims To analyse the exercise patterns of Pacific women utilising the stage-of-exercise-adoption model, and to investigate how the pros and cons of exercising, exercise self-efficacy, self-reported health, and sociodemographic barriers to exercise influence exercise adoption.

Methods A non-random questionnaire survey of 106 Pacific women living in the North Island of New Zealand.

Results Thirty percent of the sample was sedentary, 34% were participating in some exercise, and 35% were exercising regularly. The balance between pros and cons of exercise, exercise self-efficacy, self-rated health and levels of barriers reliably differentiated respondents at extreme stages of exercise adoption. In addition, two specific barriers to exercise (not having friends who exercise, and being unsatisfied with current income) were associated with reduced exercise self-efficacy.

Conclusions A large number of Pacific women are sedentary, but analysis of the factors associated with exercise adoption level and exercise-related self-confidence provides a platform for future intervention. Exercise adoption interventions tailored specifically to Pacific women should focus on broader community-based systems that include peer-group participation, and emphasise inexpensive options for exercise.

Ethnic differences in health behaviours (including physical exercise) have been comprehensively investigated in recent times.1–4 Specifically, concern is growing over the health behaviours of women of ethnic minority populations, given that women consistently exercise less than men, and women of ethnic minorities exercise less than women of European descent.1

In New Zealand, Pacific women have almost twice the rate of ischaemic heart disease, three times the risk of lethal stroke, and higher rates of diabetes and chronic obstructive pulmonary disease than any other female group.5 Regular physical exercise is a recommended preventative measure for all of these conditions, yet Pacific women are also less physically active and are far more likely to be overweight or obese than any other group of women.5

One way in which health promoters can redress this health imbalance is to identify the barriers to exercise adoption that these women face. This allows specific interventions to be aimed at reducing these barriers and increasing exercise adoption. This study provides the initial step in this process by examining the motivational and cognitive processes underlying (and barriers related to) exercise adoption in Pacific women.

This study utilised the transtheoretical model of behaviour change as a framework for understanding exercise adoption.6 The transtheoretical model has successfully been employed as a stage-of-exercise-adoption model and provides a clear framework for investigating intentional exercise behaviour change.7–9 Rather than conceptualising exercise adoption as an ‘all-or-nothing’ process, the model considers behaviour change as residing on a 5-stage continuum, starting with a precontemplation stage (not intending to exercise) and ending in the maintenance stage (sustaining the exercise behaviour over time). Movement through these 5 stages is not necessarily linear, but may be cyclical in pattern as individuals may remain focused at certain stages while others relapse into earlier ones.

An individual’s position on the stages of exercise adoption model is reflective of their decisional balance, which involves weighing up perceived pros (benefits) and cons (costs) of exercise. Unless the pros of exercise adoption exceed the cons, a person will not adopt or continue exercise routines. Several studies show that for precontemplators and contemplators, the cons of exercise outweigh the pros; for those in preparation the pros and cons are in balance; and the pros outweigh the cons for those in action and maintenance.7,10,11

In addition to decisional balance, stage membership is also reflective of individuals’ self-efficacy evaluations concerning their ability to undertake exercise behaviour.9,11,12 Individuals high in self-efficacy have greater confidence in performing a given behaviour, and therefore attempt exercise adoption with more effort, and persist longer when facing de-motivating factors.

The current study also utilised Andersen’s13 behavioural model of health utilisation as a framework for understanding how individual and wider sociodemographic factors might impact on exercise decision-making. We conceptualised exercise adoption as a function of three sets of characteristics: predisposing factors (demographics, social status, health beliefs/knowledge), enabling factors (personal and community resources) and perceived need for exercise. This study also investigated whether self-rated health would differentiate Pacific Island women on different stages of exercise behaviour change.

Previous research shows that subjective ratings of health are positively related to exercise and health care practices14,15, and that low levels of self-rated health may even act as a barrier to exercise behaviour change.16

The specific hypotheses in the current study are that:

Women in the highest stage of exercise adoption will perceive greater levels of pros of exercise, and have greater decisional balance, self-efficacy, and self-rated health scores than women in the initial stages of exercise change.
Women in the highest stage of exercise adoption will perceive less cons of exercise and lower levels of barriers to exercise than women in the initial stages of exercise adoption.

Method

Respondents

The non-probability convenience sample consisted of 106 Pacific women residing in New Zealand. Age ranged from 20 to 51 years (mean=31 years, SD=9.2). Forty-eight percent (n=52) of the sample identified themselves as Samoan, 22% (n=24) indicated they were Tongan, 14% (n=15) Cook Island, 4% (n=4) Niuean, 2% (n=2) Fijian, and 8% (n=9) belonged to some other Pacific Island ethnic group.

Measures

Stages of adoption—An 8-point scale in the shape of a ladder was used to measure stage of exercise adoption.

Each rung had a number ranging from 0 to 8, and 5 rungs had written labels that were reflective of the 5-stages of exercise adoption and served as anchor points:

0 rung was labelled I currently do not exercise and do not intend to start exercising in the next 6 months (precontemplation),
2 was labelled I currently do not exercise but I am thinking about starting to exercise in the next 6 months (contemplation),
4 was labelled I currently exercise some, but not regularly (preparation),
6 was labelled I currently exercise regularly but have only begun doing so within the last 6 months (action), and
8 was labelled I currently exercise regularly and have done so for longer than 6 months (maintenance).

Respondents were instructed to select the rung that most accurately described their current exercise behaviour. Exercise was defined as activities which increase your heart rate (such as brisk walking, jogging, swimming, aerobics, biking, rowing) and the term regular exercise was defined as exercising three or more times a week for at least 20 minutes each time.17

Each anchor represented the minimum requirement for membership at each stage. Thus, a respondent indicating a ‘3’ on the ladder was classified as a contemplator (equal to rung 2) because the minimum requirements for membership in the preparation stage (rung 4) had not been met. Research shows a Kappa index of reliability over a 2-week period of 0.78 for the stages of exercise adoption measure.12

Decisional balance—An existing decisional balance measure11 was slightly modified to reflect Pacific perspectives in this study. For example, I would feel more comfortable exercising in church organised activities was considered a potential pro, and I would not enjoy exercising by myself was considered to be a potential con of exercising.

A 19-item measure was composed of a 12-item pro scale measuring the benefits of exercising, and a 7-item con scale measuring the costs of exercising. Items were rated on a 5-point Likert scale, ranging from (1) not at all important to (5) extremely important. High scores on the pro and cons scales indicated high benefits and high costs of exercise respectively. Pro and con items were mixed so as to minimise response acquiescence. To provide a standard metric, the pros and cons indices were converted to T-scores (M=50, SD=10). A decisional balance index was calculated by subtracting the T-score means of the con items from the T-score means of the pro items. Cronbach’s alpha reliability scores for the pros and cons scales in the present study were 0.76 and 0.92 respectively.

Exercise self-efficacy—An 8-item scale, similar to that used in previous research,18 was used to assess exercise self-efficacy. Items assessed levels of confidence that respondents could perform exercise regularly, even in the face of several potential de-motivating factors (e.g. criticism, tiredness). Items were rated on a 5-point Likert scale ranging from (1) not at all confident to (5) very confident.

A mean total score was calculated by scoring across items. Higher scores indicated greater self-efficacy for exercise. In the present study a Cronbach's alpha reliability of 0.94 was found for this measure.

Self-rated health—Self-rated health status was assessed using a 7-item scale ranging from (1) terrible through to (7) excellent'.

Barriers to exercise—In accordance with Andersen's13 behavioural model, this study identified nine potential sociodemographic and resource-related barriers to exercise. Respondents were allocated a score of '1' if they indicated on the questionnaire that they:

Had one or more children,
Did not have a telephone,
Did not have a motor vehicle,
Had some or a great deal of worry about their health,
Had some, very little, or no control over their health,
Were either dissatisfied or very dissatisfied with their overall standard of living,
Had just enough money to get along on or can't make ends meet,
Had no family who exercised regularly, or
Had no friends who exercised regularly.

A maximum 'barriers to exercise' score of '9' was obtainable for each respondent. A high score indicates more perceived barriers.

Procedure

Women of Pacific descent, aged between 20–60 years and living in Wellington, Auckland, Rotorua, or Palmerston North were approached through acquaintance networks of the first author (DK) and invited to complete a questionnaire. Respondents were told that the questionnaire concerned attitudes about (and motivation to) exercise in Pacific women, and were informed that the questionnaire would take around 15 minutes to complete. The study was conducted in accord with the Massey University Code of Ethical Conduct for Research involving Human Respondents (see http://humanethics.massey.ac.nz/code.htm). A mechanism for receiving feedback about the results of the study was outlined to respondents.

Results

Forty-one percent of the women in this study had at least an undergraduate degree while only 9% had no school qualifications. Employment status indicated 44% were employed full time, 15% part time, and 32% were students; 50% of the sample was single, 36% married, and the remainder either divorced or widowed. Fifty-six percent had no children, and 46% had attended church in the last 7 days.

A large portion of the sample owned a motor vehicle (85%), had a telephone (89%), and 59% were born in New Zealand. No significant differences in demographic categories across the stages of exercise adoption were revealed.

Thirty percent of the sample was sedentary (precontemplation and contemplation), 34% were participating in some exercise (preparation), and 35% were exercising regularly (action and maintenance). This compares favourably to recent national statistics that claim that up to 42% of Pacific Island females are sedentary.5

Results of one-way ANOVAs showed mean total scores on all scales differentiated Pacific Island women across the stages of exercise adoption. Table 1 presents the means and standard deviation statistics for all scale scores by stage-of-exercise adoption.

Scheffé post-hoc comparisons between the stages and the pro and con scale scores revealed no significant differences between the groups, but significant differences were revealed between stages and the decisional balance index.

Respondents in the maintenance stage had significantly higher decisional balance scores that those in precontemplation. Post-hoc analysis also revealed that compared to respondents across all stages of the model; those in the precontemplation stage scored significantly lower, while women in the maintenance stage had significantly higher, self-efficacy scores.

Post-hoc analysis on self-rated health scores revealed that respondents in the maintenance stage rated their health more highly than respondents in either the precontemplation, contemplation, or preparation stages. Finally, barrier scores for respondents in the precontemplation, contemplation, and preparation stages of exercise adoption were significantly higher than those scores for respondents in the maintenance stage.

The proportion of barriers faced by the stage-of-exercise-adoption model (as shown in Table 1) indicates that women in the precontemplation stage faced the greatest levels of barriers to exercise; that stage advancement coincided with barrier reduction.

Regarding the frequency of barrier ratings, the results for the present sample indicate that:

54% had just enough money to get by or ‘couldn’t make ends meet’,
44% had no family who exercised regularly,
44% had no friends who exercised regularly
44% had one or more children,
44% had some, or a great deal of ,worry about their health,
21% did not have a motor vehicle,
19% were either dissatisfied or very dissatisfied with their overall standard of living,
11% did not have a telephone, and
7% had some, very little, or no control over their health.

Chi-square analysis indicates that two barriers, in particular, are linked with stage membership. First, women in the maintenance stage were more likely than women in the lower stages to have friends that exercised, chi-square (4, n=103) = 13.24, p<0.05. Second, women in the maintenance stage were more likely to be satisfied with their current income than women in lower stages of exercise adoption, chi-square (4, n=106) = 14.18, p<0.01.

Independent samples t-tests revealed that self-efficacy towards exercise was significantly reduced in women whose friends do not exercise, t (99) = 2.36, p<0.05, and in women who were not satisfied with their current income, t (102) = 2.35, p<0.05.

Discussion

The aim of the present study was to explore (in a sample of Pacific women in New Zealand) the relationships between stages of exercise adoption and the pros and cons of exercise, decisional balance, exercise self- efficacy, self-rated health, and barriers to exercise.

The results of the present study supported all of the hypotheses. Scores on pros items, the decisional balance measure (pros minus cons), self-efficacy measure, and self-rated health all positively differentiated respondents across the stages of exercise adoption. Furthermore, rating of the cons of exercise and perceived barriers to exercise decreased with an increase in stage adoption. Exercise adoption in Pacific women seems reliant upon identifying more benefits than costs to exercise, having greater belief in ones ability to perform exercise, having good self-rated health, and perceiving few practical barriers to exercise.

These results support previous research showing that ratings of the pros and cons of exercise, and subsequent decisional balance levels reliably differentiate exercisers from non-exercisers across the stages of exercise adoption.7,10,11 Previous research16 showing a differential spread of self-rated health across stages of exercise adoption was also supported in the present study, indicating that self-rated health may be a reliable sign of stage of exercise adoption.

Furthermore, the strength of exercise self-efficacy in differentiating women across stages of exercise adoption in the present study supports previous research findings indicating that belief in ones ability to undertake and maintain exercise programs is a key factor in successful exercise adoption.9

While the general level of barriers faced reliably differentiated women across the stages of exercise adoption, analysis revealed two barriers to exercise that were paramount for this population. Firstly, women in the lower stages-of-exercise-adoption had fewer friends that also exercised, and secondly, women in the lower stages were less satisfied with their current income.

Further analysis revealed that both a reduced number of friends exercising and dissatisfaction with income were associated with reduced self-efficacy to exercise. This indicates that reduced confidence to adopt and maintain personal exercise regimes may be linked to lack of peer modelling behaviour (or possibly peer support) and a lack of money or availability of inexpensive exercise options (e.g. gym membership).

Result of the current study and past research7,8,12 emphasise the strength of exercise self-efficacy in distinguishing individuals across stage of exercise adoption. This suggests that exercise interventions targeted at Pacific women should focus upon increasing this fundamental self-confidence. The present findings highlight two key areas for exercise interventions to target.

Firstly, peer-group influence may be a vital key in promoting exercise self-efficacy (and thus exercise adoption) in Pacific women. Exercise interventions tailored for increasing exercise self-efficacy in Pacific women need to highlight and utilise the motivational support garnered from peer groups, by operating within a community-based rather than individual-focused program.

Secondly, the income concerns of non-exercising Pacific women indicates that they may perceive regular exercise to be too expensive an option for them to consider seriously. Interventions promoting increased exercise adoption in this population should then focus upon readily available and inexpensive alternatives to gym-based exercise, such as community or church based exercise programs, or place an emphasis on simple cardiovascular exercises such as walking.

Feedback from respondents in the study suggests that collecting data via questionnaires meet with some resistance. For example, some respondents found the questionnaire too lengthy, and commented on the complexity of language and item relevance. This quantitative data collection approach thus runs the risk of introducing bias due to respondent confusion or misinterpretation.

Indeed, given the 'oral' characteristics of Pacific peoples, future research might establish community focus groups and semi-structured interviews aimed at identifying more accurately the sorts of individual and psychological variables that might impact on Pacific women's decisions to begin exercising.

For analysis purposes, this study has treated the sample as a homogeneous group. However, Pacific Peoples differ noticeably in their cultures and languages. Given that the majority of the sample in this research (70%) were of Samoan or Tongan ethnicity, it may be misleading to extrapolate these findings to the wider population of Pacific women. Therefore, future studies aimed at specific Pacific populations may provide more accurate information on exercise-related behaviour that reflects the realities of that particular cultural group.

Due to the cross-sectional design of this study, only some aspects of exercise behaviour change could be examined. Data analyses in this research reveal associations between variables (not cause and effect), and subsequently, the nature of casual relationships remains uncertain. However, this study has succeeded in initiating exploration of exercise habits in a group that has so far received little attention from researchers, and still remains one of our most health-challenged populations.

Author information: Denise Kingi, Clinical Psychologist, MidCentral District Health Board; Andy Towers, Assistant Lecturer; Renée Seebeck, Graduate Assistant; Ross Flett, Senior Lecturer, School of Psychology, Massey University, Palmerston North

Correspondence: Andy Towers, School of Psychology, Massey University, Private Bag 11 222, Palmerston North. Fax: (06) 350 5673; email: A.J.Towers@massey.ac.nz

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