Stage of readiness to exercise in ethnically

diverse women: a U.S. survey

FIONA C. BULL, AMY A. EYLER, ABBY C. KING, and ROSS C. BROWNSON
Department of Public Health, The University of Western Australia, Perth, AUSTRALIA; School of Public Health, Saint
Louis University, St. Louis, MO; and Department of Health Research and Policy, Stanford University School of Medicine,
Palo Alto, CA

ABSTRACT
BULL, F. C., A. A. EYLER, A. C. KING, and R. C. BROWNSON. Stage of readiness to exercise in ethnically diverse women: a U.S.
survey. Med. Sci. Sports Exerc., Vol. 33, No. 7, 2001, pp. 1147–1156. Purpose: To assess stage of readiness to exercise and readiness
to be physically active in a national survey of women aged 40 yr and over from various racial/ethnic groups (the U.S. Women’s
Determinants Study). Method: The prevalence of each stage was determined and compared across race/ethnicity. In addition, the level
of misclassification between self-report of stage of readiness to exercise/be physically active and self-reported participation in specific
exercise behavior was evaluated. Results: Data were collected from a total of 2912 U.S. women via telephone survey over a 1-yr period
(black 26%, American Indians/Alaskan Natives 25%, Hispanics 23%, and whites 26%). Over half the total sample was staged as
currently undertaking regular exercise (maintenance stage, 55%), 25% indicated they were in precontemplation, and 15% were in
contemplation stage. Few women were in preparation and action stages. There were statistically significant differences between the
minority groups. Specifically, black women (OR 0.53, 95% 0.31-0.91) were less likely to be in the active stages (e.g., preparation,
action, maintenance) than Hispanics and Alaskan Native/American Native women, and this was true after controlling for important
sociodemographic and health variables (age, education, BMI, and smoking). The additional analysis of a modified stage question
developed to assess readiness to be more physically active (150 min·wk⫺1) may have provided inflated results (82% in maintenance),
possibly due to the complexity of the questions. The level of misclassification between measures ranged from 5 to 20%. Conclusion:
These results have important implications for the use of stage of change measures with populations of older ethnically diverse women
particularly and the popularity of modifying stage questions to reflect “lifestyle” or moderate-intensity physical activity. Key Words:
EXERCISE, LIFESTYLE, PHYSICAL ACTIVITY, MINORITY WOMEN, STAGE OF EXERCISE, MEASUREMENT

I
ncreasing levels of participation in physical activity is
now recognized as a major public health challenge
(4,19,36,48). Interventions and strategies have been de-
veloped and tested to help increase level of participation
across diverse settings and target populations using different
theoretical frameworks and media (43). Although there is
evidence of success in some areas, a major review uncov-
ered a lack of studies on ethnic minorities, low-income
groups, and moderate-intensity activity targets (43,47). It is
well accepted that psychological theory, in combination
with the epidemiology of physical activity, can guide the
development of successful interventions (24). However, in
the United States, there are little data available on the
patterns of participation among women from different eth-
nic minorities. Nor are there sufficient data on the barriers
and motivators related to increasing physical activity. To
address this gap in knowledge, a large, cross-sectional sur-
vey of physical activity was undertaken with a nationally
representative survey of women over 40 yr of age from
various racial/ethnic groups. This project is known as the
U.S. Women’s Determinants Study (5).
0195-9131/01/3307-1147/$3.00/0
MEDICINE & SCIENCE IN SPORTS & EXERCISE®
Copyright © 2001 by the American College of Sports Medicine
Received for publication February 1998.
Accepted for publication October 2000.
1147
The transtheoretical model, referred to here as stages of
change, attempts to explain the process of intentional health
behavior change (38). The model suggests that individuals
engaging in a new behavior move through a series of five
stages of change, namely: I, precontemplation (not intend-
ing to make changes); II, contemplation (considering a
change); III, preparation (making small changes); IV, action
(actively engaging in behavior change); and V, maintenance
(sustaining change over time). The stages of change model
or framework has been applied to behaviors such as smok-
ing cessation (34,35,37), alcohol consumption (23), safe sex
practices (22,39), and nutrition (21,39). More recently it has
been applied to interventions aimed at the promotion of
exercise (2,13,15,17,26,27,29,30,33,42). Correctly identify-
ing stage of readiness to change in the target population can
help refine and target the components of an intervention
aimed at increasing levels of activity and promote more
effective use of resources. Thus, measurement of stage has
become an integral part of contemporary interventions and
evaluation and in some countries population surveys (1,3).
Sometimes surveys include a measure of stage as a proxy
measure for level of exercise, particularly when limited
space is available for questions, or because change in stage
(i.e., progression from precontemplation to contemplation)
may be an intermediate outcome measure that occurs before
an actual change in the behavior (13).
 Despite the widespread popularity of the transtheoretical
model and its usefulness in planning interventions aimed at
increasing levels of participation in exercise, U.S. data at a
population level are sparse. To date, estimates of the prev-
alence of each stage of readiness to exercise is limited to
relatively small samples of predominantly white adults, and
often limited to data collected in specific settings (e.g.,
worksites, universities, HMO) (7,9,26,27,29,30,39). No na-
tional assessment of stage of change in relation to exercise
exists in the United States. Therefore, the purpose of the
current study was to analyze data on stages of readiness to
exercise collected as part of the U.S. Women’s Determi-
nants Study. The primary objective was to determine, and
then compare, the prevalence of each stage of readiness to
exercise across racial/ethnic groups. Because this survey of
women also contained standard questions on the frequency
and duration of participation in specific types exercises
using Behavioral Risk Factor Surveillance Survey (BRFSS)
items, a secondary objective was to assess the congruence
between self-report of stage and self-reported actual exer-
cise behavior. Other studies have reported the reliability
(16) and validity (10,52) of various versions of the stage of
change measures, but to date there has been minimal scien-
tific discussion of the robustness of the stage measures and
the magnitude of misclassification (6,41,50). Richards-Reed
et al. (41) retrospectively compared prevalence estimates
from eight different stage questions and reported variability
depending on question format and response scale. Criterion
validity was assessed by comparison against the criterion
amount of exercise in min·h⫺1, and the results revealed only
“medium” effect size (omega squared 0.13) (12). We ex-
plored this important issue in the second part of this study.
MATERIALS AND METHODS
Data for this study were collected as part of the U.S.
Women’s Determinant study, using a modified version of
the sampling plan of the BRFSS (11). These methods have
been described in detail elsewhere (5); however, a brief
summary is provided below.
Sampling plan. Data were collected via telephone sur-
vey using a cluster sample drawn from a CD-ROM version
of the 1990 U.S. Census data by zip code. To get a nation-
ally representative, yet cost-efficient, sample of minority
women aged 40 and older, zip codes were selected if they
contained greater than 20% of one of the following racial/
ethnic categories: American, American Indian/Alaskan Na-
tive, Asian, and Hispanic. These lists of zip codes were
computer-matched with telephone prefixes, and from this
sampling frame, a standard multistage cluster technique for
random telephone numbers was followed as used in the
standard BRFSS (20,40,49). However, because zip codes
and telephone prefixes do not match with absolute certainty,
a zip code screening question was included at the beginning
of the survey. Only women who lived within the chosen zip
codes and met the other survey criteria (i.e., 40 yr or older,
black, American Indian/Alaskan Native, Asian, or Hispanic)
were surveyed. In addition to the minority groups, a com-
1148 Official Journal of the American College of Sports Medicine
parison group of white women (40 yr and older) was also
surveyed. Because not enough Asian respondents were
reached to achieve a representative sample, the Asian sub-
group was deleted from subsequent analysis.
Questionnaire. The survey instrument (92 questions
including skip patterns) was developed using a combination
of questions from the Behavioral Risk Factor Surveillance
Survey (BRFSS), the National Health Interview Survey
(NHIS), and other surveys. Every effort was made to use
valid and reliable scales; however, several questions (not on
exercise) required modification for this survey method (tele-
phone) and population (middle- and older-aged minority
women). The final instrument had an average administration
time of 29 min. Ten items from the BRFSS were used to
assess participation in “exercise, sports, or other physically
active hobbies,” and data collected included number of days
per week and minutes per session. Perceived intensity of
exercise was assessed using an NHIS item. Two items
assessed occupational activity and activities around the
home, and these were developed specifically for this survey.
Two multipart items measured stage of readiness to exercise
and to be physically active, and the remaining 78 items
assessed attitudes toward policies related to physical activ-
ity, questions on history of tobacco use, and exposure to
environmental tobacco smoke, dietary and weight control
practices, and mammography and other preventive
screenings.
Measurement of stage of readiness for exercise
and physical activity. The item on stage of readiness to
exercise has been used in previous research and included
five statements each with a Yes/No response format (see
Appendix 1). The terms “exercise” and “regular” were de-
fined as “activities such as power walking, jogging, aerobic
dancing, biking, rowing, weight lifting, etc.” and “3 times or
more per week for 20 min or longer each time,” respec-
tively. Stage of readiness to be physically active was also
taken from a previous survey (17) and used the same ques-
tion and response format as used for readiness to exercise
(see Appendix 1). In this study “physical activity” and
“regular physical activity” were defined as follows:
Physical activity means walking briskly, vacuuming, dig-
ging in the garden, general housework, or any other physical
activity with similar exertion. These physical activities are
less strenuous than “exercise.”
Regular physical activity means accumulating 30 min or
more in the above activities 5 or more days of the week. For
example, to accumulate 30 min one day you could: work in
the garden for 30 min or take three10-min walks or complete
10 min of walking, 10 min of vacuuming, and 10 min of
digging.
For both stage of exercise and physical activity questions,
the responses to the first four statements were used to
categorize respondents into a stage using an algorithm from
Marcus and colleagues (28) (see Appendix 1). The fifth
statement is pertinent to relapse from regular exercise and is
not used to categorize current stage of readiness. Stage of
readiness to be physically active was included in this survey
as it reflects the most recent recommendation from the U.S.
http://www.acsm-msse.org
Surgeon General (48) and is already being used as part of
major trials of interventions on physical activity (e.g.,
Project “Active” Cooper Institute) (17).
In addition to items on stage of readiness, respondents were
asked several questions from the BRFSS to assess participation
in different types of leisure time physical activities that were
estimated to be of at least moderate intensity (⬎3 METs).
Subjects were first asked “In the past 2 weeks, have you done
any exercises, sports, or physically active hobbies?” Women
who responded “Yes” were asked additional questions con-
cerning the frequency, intensity, and duration of up to two
different types of exercise they had undertaken in the preceding
2-wk period. Women who replied in the negative (“No”) were
classified as sedentary. Total number of hours of participation
in other potentially beneficial types of physical activities un-
dertaken around the home was assessed using the following
question: “In an average week, about how many hours do you
spend doing: vacuuming and mopping? digging/planting in the
garden? lifting/carrying laundry? or other vigorous household
chores?”
Data collection. Because physical activity behavior
and dietary practices may show seasonal variation, the data
for this study were collected over a 1-yr period. Interviews
were completed during the first 2 wk of every month from
July 1996 through June 1997. The survey was pilot tested (N
⫽ 47) with the same sampling plan used for the full survey.
As a measure of test-retest reliability, we attempted to
reinterview 10% of survey respondents. A total of 199
usable reliability surveys were completed and analyzed us-
ing Kappa (␬) statistics and measures of discordance. These
methods and results on reliability have been published in
full elsewhere (5). By using the adjectival rating from Lan-
dis and Koch (25), items pertaining to physical activity
behavior had Kappa’s ranging from fair agreement (0.26) to
substantial agreement (0.63); specifically they were: no
leisure time activity 0.44; regular physical activity 0.26;
vigorous activity 0.30; occupational activity 0.51; and
housework activity 0.45, and these are consistent with other
studies with similar methods (44,45). Stage of readiness for
exercise was found to have fair to moderate reliability
(Kappa’s of 0.38 for precontemplation and contemplation
and 0.63 for maintenance). Stage of readiness for physical
activity was found to have mostly fair agreement (precon-
templation 0.25, contemplation 0.38, and maintenance 0.28)
but poor agreement for action (⫺0.007), probably due to
very low numbers in this cell.
Concurrent validity of stage of change questions has been
tested in previous work (16,41,52), and the results have
shown the expected relationships. Namely, those subjects
classified into earlier stages had significantly lower energy
expenditure and lower scores on “vigorous” exercise and
“very hard” physical activity (52). However, there are con-
cerns because previous studies use only small subpopula-
tions and because significant differences between stages
have not been found across the stage continuum (52).
Analysis. Women were classified into one of five stages
for both readiness to exercise and readiness to be physically
active by using the algorithm developed by Marcus et al.
STAGE OF READINESS TO EXERCISE
(28). Frequency of each stage by racial ethnic group and by
age, education, body mass index (BMI), and two health
behaviors (current smoking status and consumption of five
or more servings of fruits and vegetables a day) were com-
puted. Chi-square statistics were used to determine whether
differences existed among the levels of each of these socio-
demographic and behavioral variables across the stages.
Participants with missing data from one or more statements
within the stage questions (readiness to exercise N ⫽ 67;
readiness to be physically active, N ⫽ 36) and those with
combinations of responses that did not meet any of the
algorithm statement (N ⫽ 292,10%) were excluded from the
sample, and only valid percentages are reported.
To determine whether there were any differences between
the proportion of women from each race/minority group, in
each stage chi-square statistics were conducted. Each stage
was selected and compared with all other stages combined,
and a Mantel-Haenszel test for trend was computed (e.g.,
precontemplation was compared with contemplation, prep-
aration, action, and maintenance combined).
Logistic regression analyses were conducted to look for
differences between those women who intended to be active
(contemplators) and those who did not (precontemplators)
and those women categorized into the early sedentary stages
compared with those in the later active stages. Two crude
odds ratios (ORs) were calculated. The first compared
women in precontemplation (coded as 0) with those in
contemplation (coded as 1). Second, women in precontem-
plation and contemplation were combined (sedentary) and
compared with participants in preparation, action, and main-
tenance stages combined (active). The selected break point
for collapsing this variable represents the division between
those participants who do no activity and those who do at
least some activity and is consistent with analyses in pre-
vious research (52). Race was the first independent variable
added to the logistic model, with white women as the
referent group. After calculating the unadjusted OR, the
individual sociodemographic and behavioral variables (e.g.,
age, education, smoking status, etc.) were sequentially
added to the model. Those variables that substantially
changed the unadjusted OR (at least a 10% relative change)
were kept in the model. Adjusted OR were calculated com-
paring precontemplators with contemplators and sedentary
with active.
In addition to calculating the prevalence estimates across
stage of exercise and physical activity, we assessed the level
of congruence or misclassification between stage data and
self-reported frequency and duration of activity during the
past 2 wk obtained from BRFSS items. Women staged as
sedentary and active were cross-tabulated with their re-
sponse to the question on leisure time exercise. Responses
were deemed inconsistent if women classified in sedentary
stated they had done exercise in the past 2 wk, and women
in active indicated that they had not done any exercise in the
past 2 wk. Furthermore, concordance between classification
in the action and maintenance stages of exercise (with the
criteria being “3 times a week for at least 20 min or more”)
and self-reported exercise from the BRFSS items was
Medicine & Science in Sports & Exercise姞 1149
TABLE 1. Distribution of women across the five stages of readiness to exercisea by race/ethnicity.
Column % White Black AI/ANb Hispanic Total
(Row %) (N ⴝ 702) (N ⴝ 659) (N ⴝ 656) (N ⴝ 603) (N ⴝ 2620)
Precontemplatorsc 22.6 24.4 27.6 19.4 23.6
(N ⫽ 618) (25.7) (26.1) (29.3) (18.9) (100)
Contemplatorsd 13.5 18.4 18.8 14.9 16.4
(N ⫽ 429) (22.1) (28.2) (28.7) (21.0) (100)
Preparation 3.6 5.0 5.0 5.5 4.7
(N ⫽ 124) (20.2) (26.6) (26.6) (26.6) (100)
Action 6.1 5.5 5.6 8.1 6.3
(N ⫽ 165) (26.1) (21.1) (22.4) (29.7) (100)
Maintenancee 54.1 46.7 43.0 52.1 49.0
(N ⫽ 1284) (29.6) (24.0) (22.0) (24.5) (100)
a
Exercise was defined as activities such as power walking, jogging, aerobic dancing, biking, rowing, weight lifting, etc., and regular was defined as 3 times or more per week for 20
min or longer each time.
b
American Indian/Alaskan Native. Repeated Chi square analyses compared each stage with all other stages combined.
␹ ⫽ 12.3, df ⫽ 3, P ⬍ 0.006.
c 2

␹ ⫽ 9.7, df ⫽ 3, P ⬍ 0.02.
d 2

␹ ⫽ 20.5, df ⫽ 3, P ⬍ 0.0001.
e 2

assessed. Total exercise was calculated using the fre-
quency and duration of up to two types of exercise
undertaken in the previous 2 wk. A dichotomous variable
(“60 min”) was created with a participant coded as 1 if
they met the criteria and 0 if they did not. The “60-min”
variable was cross-tabulated with participants in both the
action and maintenance stages.
We repeated the assessment of misclassification on the
stage of readiness to be physically active in a similar way.
Level of agreement was calculated using the BRFSS items
and “regular” was defined as accumulating 30 min of phys-
ical activity on 5 or more days of the week. A categorical
variable (150 min) was created to describe who did (coded
1) and did not (coded 0) meet the criteria. Responses were
deemed inconsistent if women in action and maintenance
stages did not report sufficient activity to meet the criterion
of 150 min or, conversely, if precontemplators and contem-
plators reported more than 150 min of total activity during
the previous 2-wk period.
RESULTS
Data were collected from a total of 2912 U.S. women
aged 40 yr and over. The response rate (87.3%) was calcu-
lated according to the method of the council of American
Survey Research Organizations and was based on the ratio
of completed interviews to the sum of completed interviews
plus refused interviews and a standard fraction of telephone
numbers that were working but were either unanswered or
busy after multiple attempts. The sample included 745 black
(26%), 738 American Indians/Alaskan Natives (25%), 660
Hispanics (23%), and 769 whites (26%). The mean age was
lower for both Hispanic and American Indian/Alaskan Na-
tive women (mean age 54 yr in both groups) compared with
women in the white and black groups (mean age 57 yr in
both groups; P ⬍ 0.0001)). White women were more likely
to have completed a college education compared with
women in the other race/ethnic groups (␹2 ⫽182.5, P ⬍
0.0001). Fewer Hispanic women were current smokers (␹2
⫽ 41.4, P ⬍ 0.0001), and black women and American
Indian/Alaskan Native women were more likely to be over-
1150 Official Journal of the American College of Sports Medicine
weight (defined as BMI ⬎ 27.3) compared with their coun-
terparts (␹2 ⫽ 138.8, P ⬍ 0.0001).
Table 1 presents the distribution of women across the
stages of exercise by race/ethnicity. Just under half of the
total sample reported that they were currently undertaking
regular exercise and had been doing so for the past 6 months
(49%; maintenance stage). Twenty-four percent of women
overall indicated that they were doing no regular exercise
and that they did not intend to do more (precontemplation),
and 16.4% reported being currently sedentary but intended
to do more exercise in the next 6 months (contemplation
stage). Few women were categorized in the stages of prep-
aration and action (4.7% and 6.3%, respectively). Women in
precontemplation were compared with all other stages, and
this revealed that significantly fewer Hispanic women were
in the precontemplation stage (19%) compared with white,
black, and American Indian/Alaskan Native American
women (23%, 24%, and 28%, respectively). Similarly, con-
templators, and then maintainers, were compared with
women in all other stages, and these results indicated that
Hispanic women were significantly less likely to be in the
contemplation stage (P ⬍ 0.02) and American Indian/Alas-
kan Native American women were less likely to be in
maintenance (P ⬍ 0.0001) than their counterparts (see Table
1).
Table 2 shows younger women (40 – 69 yr) were signif-
icantly more likely to be in the maintenance stage and older
women (70⫹) were more likely to be in the precontempla-
tion stage (P ⬍ 0.0001). Women with lower levels of
education were significantly more likely to be in the early
stages of change (precontemplation), whereas those women
who had completed college or postgraduate training were
more likely to be in maintenance (P ⬍ 0.0001, Table 2).
Women who were overweight (defined as BMI ⬎ 27.3) or
who were current smokers were significantly more likely to
be in precontemplation compared with women who had a
BMI ⬍ 27.3 (P ⬍ 0.03) or women who had never smoked
or who were ex-smokers (P ⬍ 0.05; see Table 2).
Age, education, smoking, and BMI vary across race/
ethnicity and are known to be closely related to participation
in regular exercise. Table 3 reports the unadjusted OR and
http://www.acsm-msse.org
TABLE 2. Description of women in each stage of exercise by age, education, body mass index (BMI), smoking behavior, and consumption of fruit and vegetables.
PC C Prep Action Main
Row %
Age (yr)a N ⫽ 618 N ⫽ 429 N ⫽ 124 N ⫽ 165 N ⫽ 1284
40–49 21.7 18.3 4.8 7.0 48.2
50–59 19.3 19.1 5.2 7.1 49.3
60–69 23.0 11.9 4.9 5.8 54.4
70⫹ 36.6 12.8 3.5 3.8 43.4
Educationb N ⫽ 618 N ⫽ 429 N ⫽ 124 N ⫽ 163 N ⫽ 1282
⬍High school 31.6 15.7 6.0 4.9 41.7
High school 24.7 17.9 4.9 6.7 45.8
Tech college 18.4 15.7 3.4 5.8 56.7
College grad 18.6 16.7 3.4 7.2 54.1
Postgrad 14.0 14.0 5.6 8.9 57.5
5 F/V per Dayc N ⫽ 584 N ⫽ 412 N ⫽ 119 N ⫽ 160 N ⫽ 1247
No 23.2 17.5 4.9 5.6 48.8
Yes 23.0 13.6 4.2 8.2 50.9
BMId N ⫽ 592 N ⫽ 417 N ⫽ 117 N ⫽ 160 N ⫽ 1250
BMI ⬍ 27.3 21.3 13.5 4.6 5.4 55.2
BMI ⬎ 27.3 25.7 19.9 4.6 7.4 42.4
Smoking statuse N ⫽ 618 N ⫽ 429 N ⫽ 124 N ⫽ 165 N ⫽ 1282
Current 26.0 20.0 5.9 5.7 42.4
Ever smoked 23.5 14.7 4.3 6.7 50.9
Never smoked 22.8 15.8 4.5 6.4 50.5
5 F/V per day ⫽ eats 5 serves of fruit and veg per day computed from self-reported average serves of fruit and veg per day in the last month.
a
␹2 ⫽ 64.1, df ⫽ 12, P ⬍ 0.0001.
␹ ⫽ 71.1, df ⫽ 16, P ⬍ 0.0001.
b 2

␹ ⫽ 11.7, df ⫽ 4, P ⬍ 0.02.
c 2

␹ ⫽ 46.05, df ⫽ 8, P ⬍ 0.03.
d 2

␹ ⫽ 15.4, df ⫽ 8, P ⬍ 0.05.
e 2

the adjusted odds controlling for these covariates. There
were no significant racial/ethnic differences between pre-
contemplators and contemplators in the unadjusted or ad-
justed models. However, relative to the other ethnic groups,
black women were more likely to be in the sedentary stages
(precontemplation or contemplation) compared with the
later active stages (preparation, action, or maintenance (ad-
justed OR 0.53, CI 0.31– 0.91) following adjustment for the
covariates.
As well as assessing stage of readiness to exercise, we
assessed readiness to undertake physical activities of mod-
erate intensity as recommended in the recent Surgeon Gen-
eral’s Report on Physical Activity and Health (48) (Table 4).
Almost 80% of all women identified with the maintenance
stage of physical activity. Less than 10% reported to be in
the precontemplation stage, and few women fell into the
middle stages of contemplation, preparation, or action. Sim-
ilar to the results focusing on exercise stage of change
American Indian/Alaskan Native women were less likely to
be in maintenance stage compared with their counterparts (P
⬍ 0.007).
Table 5 summarizes the analyses conducted to assess the
level of agreement between subjects’ self-reported level of
participation in exercise (BRFSS items) and their classifi-
cation on the stages of exercise and physical activity. Al-
most one fifth of women (19%; N ⫽ 117) classified as in the
sedentary stages of precontemplation or contemplation (N ⫽
618) responded positively (“Yes”) to the question “In the
past 2 weeks have you done any exercises, sports, or phys-
ically active hobbies?” Meanwhile, 5% (N ⫽ 85) of those in
the active stages of preparation, action, or maintenance (N ⫽
1573) responded negatively (“No”) to the previously stated
question. Frequency (number of times) and duration (num-
ber of minutes) data were used to calculate whether indi-
viduals in the action and maintenance stages reported suf-
ficient activity to meet the stated criterion for regular
exercise (namely 60 min). The results revealed 20% (N ⫽
332) did not report sufficient levels of participation.

TABLE 3. Adjusted and unadjusted logistic regression comparing stage of exercise by race/ethnicity.
Unadjusted Adjusted
OR CI OR CI
Race/Ethnicitya Precontemplation compared with contemplation
White 1.00 1.00
Black 1.26 0.89–1.78 1.02 0.60–1.75
AI/ANc 1.14 0.81–1.60 1.19 0.70–2.00
Hispanic 1.29 0.86–1.87 0.90 0.52–1.56
Race/Ethnicityb Sedentary (precontemplation and contemplation combined) compared with active (preparation, action and
maintenance combined)
White 1.00 1.00
Black 0.76 0.61–0.94 0.53 0.31–0.91
AI/ANc 0.66 0.53–0.82 0.68 0.40–1.14
Hispanic 1.08 0.86–1.36 0.74 0.40–1.35
Adjusting for the following demographic and health variables that changed the OR (relative change of ⫾10%) when entered individually:
a
Age, education, BMI, smoking, fruit and vegetable consumption (‘5-a-day’) and race ⫻ BMI
b
Education, race ⫻ BMI and race ⫻ smoking
c
American Indian/Alaskan Native.

STAGE OF READINESS TO EXERCISE Medicine & Science in Sports & Exercise姞 1151
TABLE 4. Distribution of women across the stages of physical activitya by race/ethnicity.
Column % White Black AI/ANAb Hispanic Total
(Row %) (N ⴝ 714) (N ⴝ 687) (N ⴝ 690) (N ⴝ 619) (N ⴝ 2710)
Precontemplators 8.7 9.3 11.4 7.3 9.2
(N ⫽ 250) (24.8) (25.6) (31.6) (18.0) (100)
Contemplators 4.8 4.9 5.6 3.6 4.8
(N ⫽ 129) (27.1) (26.4) (30.2) (16.3) (100)
Preparation 3.6 5.2 3.9 5.0 4.4
(N ⫽ 120) (21.7) (30.0) (22.5) (25.8) (100)
Action 2.2 1.7 3.6 1.5 2.3
(N ⫽ 62) (25.8) (19.4) (40.3) (14.5) (100)
Maintenancec 80.7 78.7 75.4 82.7 79.3
(N ⫽ 2149) (26.8) (25.2) (24.2) (23.9) (100)
100 100 100 100
a
Regular physical activity defined as walking briskly, vacuuming, digging in the garden, general housework, or any other physical activity with similar exertion, accumulating 30 min
or more on 5 or more days of the week.
Repeated Chi square analyses compared each stage with all other stages combined.
b
American Indian/Alaskan Native.
␹ ⫽ 11.5, df ⫽ 3, P ⬍ 0.009.
c 2

Data on participation in leisure time exercise and other
physical activities (e.g., vacuuming, gardening, lifting) were
used to assess consistency with the stage of readiness for
physical activity. The results showed that 7% of women in
precontemplation or contemplation reported levels of phys-
ical activity which exceeded the criterion of “at least 150
min per week,” whereas approximately 10% of women in
action or maintenance reported physical activity of less than
150 min. The criterion of 150 min reflects the recent rec-
ommendation of 30 min of moderate activity on most days
of the week, where most is interpreted as 5 or more days
(48).
DISCUSSION
This study appears to be the first to report data on stage
of readiness to exercise from a nationally representative
sample of women aged 40 yr and above across four racial
groups—white, black, American Indian/Alaskan Native
American, and Hispanic. Our study is enhanced by the large,
representative national sample and the inclusion of previ-
ously used questionnaire items.
Stage of readiness to exercise. Almost half of the
women in this sample were categorized as being in the
maintenance stage of readiness to exercise. That is, they
reported undertaking regular exercise during the past 6
months where regular was defined as “3 ⫻ week for at least
20 min” and exercise was specified as “activities including
power walking, jogging, aerobic dancing, biking, rowing,
weight lifting....” This result is considerably higher than we
anticipated and is not consistent with data on participation in
these types of activities obtained in previous population
surveys (48). Although both the 1992 BRFSS and 1992
NHIS defined “regular, sustained physical activity” as 5 or
more times per week for 30 min or more per occasion, those
data revealed that less than one quarter of American women
reported this level of activity and this percentage decreased
with age. Even fewer women (⬍16%) reported participation
in more vigorous types of exercise (48).
There are no other published national data on stage of
readiness to exercise to directly compare our findings. How-
ever, a national telephone survey of 2000 men and women
(18 yr and older), undertaken after the publication of the
U.S. Surgeon General’s report on physical activity, found
11% of women (134/1216) reported doing regular (ⱖ5
times a week) moderate exercise for longer than the last 6
months (maintenance to moderate exercise) (31). Another
5% of women had been doing regular vigorous exercise (⬎3
times per week) for more than 6 months (maintenance to
vigorous exercise) (31). Combining both moderate and vig-
orous exercise suggests that only 16% of this sample of
mostly white (73%) respondents were in the maintenance
stage, which is considerable lower than our findings.

TABLE 5. Congruence between response to items on physical activity and self-report stage of exercise and stage of physical activity.
Stages That Indicate No Activity Stages That Indicate at Least Some Exercise
Precontemplation Contemplation Preparation Action Maintenance
Stage of readiness for exercise
Response to BRFSS items indicated some exercise Yes 18.9%
No 5.4%
Response to BRFSS items indicated meeting ‘60 min’ Yes 1.0%
No 20.1%
Stage of readiness for physical activity
Response to BRFSS items indicated meeting ‘150 min’ Yes 7.1%
No 9.5%
Shaded cells indicate % misclassification/inconsistent responses between criteria.

1152 Official Journal of the American College of Sports Medicine http://www.acsm-msse.org

 It is possible that the proportion of women in maintenance
stage in our survey is inflated. This may be due to the
question format or response scale. However, we used the
five statements that have been most commonly used in other
studies (41) and the original Yes/No response scale and
algorithm for classification. Furthermore, the question pro-
vided a clear definition of the type of exercise and the term
“regular,” both of which were found to be important in a
recent review of stages questions and response formats (41).
It is more likely that these specifications would have de-
creased rather than inflated the number of women who
reported being in maintenance. Much of the work in this
area has focused on younger women, and it is possible, due
to a lack of understanding or difficulties in recall, that older
adults may overreport their general activity levels. A ten-
dency toward more optimistic reporting has been noted in at
least one study of older women (51).
It may be that women in this survey perceived the term
“exercise” to be a broader concept than was specified and
therefore considered other activities that they regularly un-
dertake in their answer to this question. Subsequent focus
group research with women from different race/ethnic back-
grounds has found that the term exercise may be interpreted
differently and that some women perceive activities, such as
traditional dancing and cooking for festivals, as exercise and
they feel that these sorts of tasks should be included in any
assessment of their level of physical activity (18,32). It has
been previously suggested that most survey instruments to
date are not sensitive to racial/ethnic differences, and they
are therefore likely to misrepresent the actual physical ac-
tivity patterns of women from minority background (46).
Our 1-yr sampling frame helped to diminish the possibil-
ity of inflation of results stemming from data collection
during a season more favorable to participation in physical
activity, but there may be some misclassification of women
between the stages of preparation, action, and maintenance
due to the complexity of the question. Across all race/
ethnicity groups, very few women were classified in the
former two stages. Some women may have forgotten the
criteria for “regular” in their response to the third statement
“I currently exercise regularly” (Yes/No), and a positive
response would exclude them from the preparation stage.
The fourth statement asked women to consider whether they
had been exercising regularly for a “period of 6 months.”
Again a positive response excluded them from the action
stage, although some may have had difficulty recalling
accurately their pattern of activity across this relatively long
time period. Recalling activity while remembering defini-
tions (type, duration, intensity) and considering time frames
may be too complex. It is also possible that the sequence of
the stage questions after the BRFSS items influenced the
responses by sensitizing women to their level of participa-
tion, causing some inflation.
Comparison of any data on participation in exercise is
particularly difficult due to the variation in the question
format, examples of exercise, response format, sampling
frame, and analyses. There has been greatest consistency
when estimates of the prevalence of inactivity have been
STAGE OF READINESS TO EXERCISE
compared (5). Our survey found 40% of women were in
sedentary stages (precontemplation 23.6% and contempla-
tion 16.4%). This is higher than NHIS, NHANES, and
BRFSS, which reported 27%, 27%, and 31% of women
(aged 18 yr or more), respectively, undertaking no leisure-
time physical activity (48). Although these national surveys
do show the proportion of women doing no activity in-
creased for older women, there still remains a discrepancy
between our data on stage of readiness and previously
reported data on exercise from national surveys. Although
one would expect less difficulty in reporting no activity, as
opposed to some activity, this remains a possibility. Alter-
natively, the higher level of inactivity in the study could
stem from the greater inclusion of ethnic minorities some of
which (e.g., older American Indian women) have been un-
derrepresented in previous national surveys in this area.
Determinants of stage of readiness to exercise.
The differences between the stages of exercise and age,
education, BMI, and smoking status are consistent with
previous studies (8). Younger women were more likely to be
in later stages of action and maintenance. Conversely, over-
weight women were more likely to be in precontemplation.
We were particularly interested to see if there were any
differences between the race/ethnic groups on stage of readi-
ness to exercise. The results from the adjusted and unad-
justed logistic regression show how important it is to control
for several demographic and health variables in these anal-
yses. In the initial analyses between precontemplators and
contemplators, and between sedentary and active women,
the sociodemographic and health variables substantially
changed the odds ratios and were therefore kept in the
regression models. Although we expected the apparent dif-
ferences among race would have been accounted for by the
differences in sociodemographic and health characteristics,
after adjustment the racial differences by stage increased in
some cases. Specifically, although black women were less
likely to be in the later active stages compared with white
women in both the crude and adjusted models, the OR
changed from 0.76 (CI 0.61– 0.94) to 0.53 (CI 0.31– 0.91)
after controlling for BMI, education, and smoking. The
importance of these covariates is also seen when the appar-
ent difference observed between American Indian/Alaskan
Native women and white women (unadjusted OR 0.66 CI
0.53– 0.82) was not significant in the adjusted model (OR
0.68 CI 0.40 –1.14). These data show that racial differences
should not be assessed without taking into consideration the
sociodemographic and health characteristics that may con-
found relationships.
There are few data on participation in physical activity by
black women, but our results are consistent with the findings
from population surveys which show blacks are less likely
to undertake regular, sustained physical activity relative to
whites (BRFSS, whites 20%, blacks 13%; NHANES, whites
22%, blacks 18%) (48).
Stage of readiness to be physically active. In ad-
dition to assessing stage of exercise, we assessed stage of
readiness to be physically active by using a modified
stage question with definitions of “physical activity” and
Medicine & Science in Sports & Exercise姞 1153
“regular” consistent with the recommendations that all
American adults should accumulate at least 30 min of mod-
erate intensity physical activity on most, if not all, days of
the week (48). The results reveal that about 80% of all
women felt they met these criteria, and their responses to the
four statements classified them into the maintenance stage.
Although no other national survey has collected data on this
question, we suggest that this finding is artificially high.
The inflation may be due to the complexity of the ques-
tion, which requires the respondent to consider at least four
factors, namely: 1) a broad category of physical activities
that are different to both the focus on “exercise” of previous
questions in the survey and that contrasts with commonly
held perceptions that only vigorous activities and sports are
“exercise” (14); 2) whether they accumulated more than 30
min of these types of activities (which included an example
of housework); 3) whether they did this on 5 or more days
of the week; and 4) consider whether they had done this for
a period of more than 6 months. Furthermore, it is likely that
the inclusion of housework as an example inflated the re-
sults and that these data therefore do not represent a true
reflection of the level of participation in physical activities
that would be considered of sufficient intensity (at least 3
METs) to be potentially beneficial to health. To date, few
data exist on which aspects of housework and gardening are
of sufficient intensity to benefit health and the reliability of
items measuring them. Moreover, there are no data with
which to compare the reliability of responses to this stage
item on these types of activities (5).
A similar question on stage of readiness to be physically
active was developed and used in a small comparative study
undertaken by Richards-Reed et al. (41). In their sample of
314 male and female adults (18 –91 yr), two thirds of re-
spondents (62%) were classified as maintainers. Richards-
Reed et al. used similar definitions for “physical activity”
and “regular” compared with ours, but different examples:
“one 30-min walk, jog, bike, or swim” or “10 min of digging
and 5 min of climbing stairs.” The findings from both
studies suggest that when a more general definition of
physical activity is used, which includes examples of house-
work, gardening, and/or other activities undertaken around
the home, the majority of respondents will identify with the
later stages of action and maintenance. However, whether
these data are valid, and reliable measures of the true level
of participation in moderate-intensity physical activities that
can benefit aspects of our physical and mental health re-
mains to be established. Further research is required to
elucidate these factors and, indeed, how this question is
interpreted by different subpopulations (women, race/eth-
nicity, older adults). Our own test-retest results only showed
fair reliability for this stage item and thus further psycho-
metric development would be desirable.
Congruence between self-report stage of exer-
cise and physically activity and self-report level of
participation in specific physical activities and ex-
ercise. Finally, we were interested in the consistency of
responses to two different, but clearly related, measures of
participation in exercise. Our results revealed disagreement
1154 Official Journal of the American College of Sports Medicine
scores of 19% (precontemplators/contemplators) and 5%
(preparation/action/maintenance) between answers to the
stage of exercise question and the BRFSS items on partic-
ipation in exercise during the previous 2 wk. Although the
latter items attempts to measure behavior in a specified time,
the question on stage only records an individuals’ general
appraisal of their pattern of exercise over the past 6 months
and their intentions over the next 6 months. The measure of
stage may be useful, but data from this study highlight that
it should not be misinterpreted and used as a measure of
current level of exercise.
Our results also show that it is possible for individuals in
action and maintenance (20%) to report insufficient vigor-
ous exercise to reach the criterion (60 min) set for these
stages. Similarly, the modified stage question addressing
physical activity or “lifestyle” (17) activity also produced
misclassification. We found 7% of precontemplators and
contemplators reported sufficient activity to reach the 150-
min threshold and that 10% of those in later stages did not.
At least one other intervention study has reported misclas-
sification of a similar order of magnitude (6). Although this
magnitude of error (range 5–20%) may be acceptable in
population-based estimates, these findings are particularly
important for practitioners who not only use the model of
stages of change as a guiding framework for the develop-
ment and matching of interventions but also as a measure in
their evaluation. Measurement error of this magnitude is
likely to obscure any intervention effect.
In addition to the above misclassification, we observed
that 10% (N ⫽ 292) of women surveyed were not included
in the analysis due to their responses not meeting the stage
algorithms, however, there were no significant differences
between women who were and those who were not staged
on age, education, or race/ethnicity (data not shown). Closer
inspection of these cases revealed that some respondents
gave contradictory responses within the stage question (e.g.,
a negative response to “I currently exercise” and a positive
response to “I currently exercise regularly” and vice versa).
It is possible that our results are unique to the combination
of this sample population and survey method (telephone)
and differences between question and response format have
been previously reported (41). However, these responses
provide further evidence of potential difficulties in respond-
ing to stage questions that involve consideration of multiple
factors (time frame, type of activity, duration).
We believe there is a need for further testing of the
reliability and validity of measuring instruments for the
stage of exercise and stage of physical activity and across a
wider range of populations (in terms of race/ethnicity, age,
and gender). Such research should lead to consensus with a
recommended format(s) and response scale available for
dissemination. The application of the principles of the stages
of change theory and the modification of the measurement
methods to the accumulation of physical activities of mod-
erate intensity (which may include housework and other
tasks that are not traditionally perceived as exercise) should
be avoided until considerably more conceptual and psycho-
metric development has occurred.
http://www.acsm-msse.org
CONCLUSION
In summary, we found 49% of women across four race/
ethnic groups were classified into the maintenance stage of
readiness to exercise; however, there were significant dif-
ferences between the minority groups. Specifically, black
women were more likely to be in the precontemplation or
contemplation stages even after controlling for important
sociodemographic and health variables (age, education,
BMI, and smoking). There is, however, some concern about
the distribution of this population of women across the
stages of readiness to exercise, and further research should
be done to verify our findings. The analysis of a modified
stage question developed to assess readiness to be physical
active may have provided inflated results, possibly due to
the complexity of the question. Further psychometric devel-
opment of such a scale is encouraged. Finally, the compar-
isons of data on exercise with data on stages of change
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young adults. Health Educ. Res. 10:365–377, 1995.

APPENDIX 1. Algorithm for stage of readiness.a

Stagea PC C Prep Action Main
Stage of readiness to exercise
1. I currently exercise No No Yes Yes Yes
2. I intend to exercise in the next 6 months No Yes Yes Yes Yes
3. I currently exercise regularly No No No Yes Yes
4. I have exercised regularly for the past 6 months No No No No Yes
5. I have exercised regularly in the past for a period of at least 3 months — — — — —
Stage of readiness to be physically active
1. I am currently physically active No No Yes Yes Yes
2. I intend to become physically active in the next 6 months No Yes Yes Yes Yes
3. I currently engage in regular physical activity No No No Yes Yes
4. I have been physically active regularly in the past for a period of at least 3 months No No No No Yes
5. I have been physically active regularly in the past for a period of at least 3 months — — — — —
a
PC, precontemplation; C, contemplation; Prep, preparation; Action, action; Main, maintenance.

1156 Official Journal of the American College of Sports Medicine http://www.acsm-msse.org