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Record:1
Examinationofthetranstheoreticalmodelandexercisein3
populations.(includesabstract)RodgersWMCourneya
KSBayduzaALAmericanJournalofHealthBehavior,
Jan/Feb200125(1):3341.9p.(JournalArticleresearch,
tables/charts)ISSN:10873244PMID:11289727
Database: CINAHLPluswithFullText
ExaminationoftheTranstheoreticalModelandExercisein3Populations
Objective:Toexaminedifferencesintheprocessesofchangeandselfefficacyforexerciseacrossthe
stagesofchangein3populationstodetermineitssuitabilityforuseindiversegroups.Methods:Cross
sectionalsurveydesignwithpopulationasabetweensubjectsvariable:highschoolstudents
(n[equals]168),universityundergraduatestudents[n[equals]215],andemployedadults[n[equals]63].
Results:ANOVAsrevealedmaineffectsofstage[p[lessthan].0001)andpopulation[p[lessthan].001)in
processuseandselfefficacybutnopopulationbystageinteraction.Conclusions.Theconsistencyof
patternsoftheTTMvariablessupportsitspotentialforeffectiveinterventionindiversepopulations.

AmJHealthBehav200125(1]:3341

Ithasbeenwellestablishedthatasedentarylifestyleisdetrimentaltohealth.TheUSsurgeongeneral
recentlyindicatedthatlackofphysicalactivityincreasestheriskofcoronaryheartdisease,various
cancers,andallcausemorbidityandmortality.[1]Ithasbeenequallywellestablished,however,that
adherencetophysicalactivityispoor.[2]Infact,theUSsurgeongeneralhasreportedthatupto60%of
Americansareinsufficientlyactiveand25%arenotactiveatall,indicatingthattheproblemofexercise
adherenceispervasive,andtheresultanthealthriskissignificant.Thus,thediscoveryofeffectivemeans
ofinterventiontoimproveexerciseadherencehasbecomeacentralfocusofpsychologyasitrelatesto
exercise.

Onemodelthathasachievedwidespreadattentionfromresearchersandpractitionersregardingavariety
ofhealthrelatedbehaviors,includingexercise,hasbeenthetranstheoreticalmodel(TTM).[3]Thecentral
constructofTTMisthestagesofchange.Thestageconstructwasdevelopedtoreflectthetemporal
dimensionofhealthbehaviorchange.[4]Thatis,stageshighlightthedynamicnatureofhealthbehavior
changeandattemptstodemarcate"when"meaningful(ie,clinicallysignificant)healthbehaviorchange
hasoccurred.FivestagesofchangehavebeenproposedwithintheTTM.

Inthefirststage,precontemplation,thepersonisnotengagedintheappropriatehealthbehaviorandhas
nointentiontochangeintheforeseeablefuture.Inthecontemplationstage,thepersonhasformedan
intentiontochangeinthenearfuturebutstillhasnotattemptedthebehaviorchange.Thethirdstage,
preparation,isreachedwhenthepersonintendstotakeactionintheimmediatefuture,hasadetailed
planfortakingaction,andmayhavetakensomesmallstepstowardbehaviorchange.Theactionstageis
achievedwhenbehaviorhasbeenchangedtothetargetlevelthatisrecommendedforthatbehavior(eg,
exercising3timesperweekfor30minutesatmoderatetovigorousintensity).Oncethislevelofbehavior
hasbeenmaintainedfor6months,thepersonentersthemaintenancestage,whichmaylastaslongas5
years.

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TheTTMalsoincludesprocessesofchangetoexplain"how"peoplechangetheirhealthbehaviors.[5]
Theprocessesofchangehavebeenhypothesizedtodistinguishbetweenstages,andtorepresent2
broadcategoriesofactivitiesthatpeopleuseinordertomovefromstagetostage:cognitive(covert
processes)andbehavioral(overtprocesses).[3]Thereare10proposedprocessesofchange:
consciousnessraising,dramaticrelief,selfreevaluation,environmentalreevaluation,selfliberation,social
liberation,counterconditioning,stimuluscontrol,contingencymanagement,andhelpingrelationships.[4]
ProchaskaandVelicer[5]havenotedthattheprocessesaretheleaststudiedaspectoftheTTM.

Selfefficacyanddecisionalbalance[ie,prosandcons)havebeenintegratedintotheTTMostensiblyto
clarifythecognitivechangesthataccompanyhealthbehaviorchange(ie,tounderstand"why"people
change).SelfefficacyhasbeenoneofthemoststudiedaspectsoftheTTMandisdefinedasone's
situationalspecificselfconfidence.[3,7]Selfefficacyhasalsobeendemonstratedtoshowgood
distinctionsamongthestages,withindividualsinlaterstagesexhibitinghigherselfefficacythandothose
inearlierstages.[8]

Approximately40studieshaveexaminedtheTTMintheexercisedomain.[9,12]Thevastmajorityof
thesestudieshavebeencrosssectionalalthoughstudiesemployinglongitudinalandinterventiondesigns
arebeginningtoemerge.[1315]ThesestudieshaveexaminedtheTTMacrossawiderangeof
populationsincludingdifferentworksitegroups(eg,medical,industrial,retail,government),agegroups
(eg,preadolescents,adolescents,olderadults),placesofresidence(eg,rural,urban),medicalconditions
(eg,cardiacpatients),andcountries(eg,UnitedStates,Canada,Britain,Australia).

ReviewersoftheTTM'sapplicabilityintheexercisedomainhavegenerallyconcludedthatithasbeen
supportedacrossallpopulationsthathavebeenstudied.[912]Whatisimpliedinthisconclusionisthat
thepatternofchangesinTTMvariablesacrossthestagesofexercisechangeissimilaracross
populations.Thisconclusionisimportantbecauseitsuggeststhatthetheoreticalprinciplesunderlying
stagematchedexerciseinterventionsarethesameregardlessofthepopulationofinterest.Unfortunately,
thisconclusionshouldnotbemadebasedonsinglepopulationstudiesregardlessofthenumberof
studiesavailable.Thebestthatcanbeconcludedfromsuchstudiesisthatthepatternsofchangesacross
thestagesappeartobesimilaracrosspopulations.Totestthisissuerequiresdirectcomparisonsofthe
patternsofchangesamongmultiplepopulationsinasinglestudy.Inthepresentstudy,weaddressedthis
issuebyexaminingthepatternofTTMchangesacross3distinctpopulations:highschoolstudents,
universityundergraduatestudents,andemployedadults.Usinga5(stage)x3(population)factorial
designwehypothesized(1)amaineffectforstagethatisconsistentwiththeTTManditsresearchon
singlepopulations,(2)thepossibilityofamaineffectforpopulationthatsimplyindicatesthatthereare
consistentdifferencesamongpopulationsinthelevelofTTMvariables,andmostimportantly(3)no
stagebypopulationinteractionthat,iffound,wouldindicatethatthepatternofchangesacrossthestages
wasdifferentamongthepopulationsand,hence,thatTTMfindingsandunderlyingstagematched
principlesarenotgeneralizableacrosspopulationsintheexercisedomain.

METHODS

ParticipantsandProcedure

Werecruited3distinctpopulationstomaximizediversity:highschoolstudents,universitystudents,and
employedadults.Thehighschoolstudentswererecruitedfrom2communityhighschools.Permission
wasobtainedfromtheschoolboardand,subsequently,theprincipalsoftwolargehighschoolstoconduct
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thestudy.Teachersofhealthandphysicaleducationclassesallottedclasstimeforthecompletionof
questionnairesunderexamconditions(ie,notalkingorwanderingeyes)duringclasstime.Studentswere
providedwithenvelopesinwhichtheysealedtheircompletedquestionnaires,andtheydepositedtheir
responsesinaboxprovidedbytheresearcher.Allofthestudentsintheclassesreturnedquestionnaires.
Ifthestudentschosenottoparticipate,theyreturnedthequestionnaireblank.Of192questionnaires
returned,168werecompleteandusable(88%).Theseparticipantsincluded93malesand71females
withameanageof16.58years(SD[equals]2.43).Theywereingrades10to12.Theuniversity
undergraduatestudentswererecruitedfromarequiredfirstyearundergraduatecourseandcompleted
thequestionnairesduringclasstime.Thesamplewas229whowereattendingtheclassthatday,with
215(94%)providingcompletedatasets(63males,151femalesmeanage[equals]21.40years,
SD[equals]4.02).Aconveniencesampleofemployedadultswasrecruitedfromalocalmunicipallevel
governmentofficeandalargetelecommunicationsfirm.Managerswerecontacted,andthoseagreeingto
participatedistributedquestionnairestotheiremployees.Employeesinterestedinthestudycompletedthe
questionnairesintheirworkenvironments,sealedtheminanenvelope,andreturnedthemtoabox
providedforthispurpose.Iftheychosenottocompletethequestionnaires,theywerereturnedblank.Of
77returnedquestionnaires,63(82%)werecompletedandusable.Thefinalsampleincluded18males
and44femaleswithameanageof34.64years(sd[equals]9.46).Becauseofthesamplingprocedures
used(directcontactwithconveniencesamples),thereturnratesarequitehigh.

Measures

Stageofchangewasassessedusinganalgorithmthatusedadefinitionofvigorousphysicalactivity
followedby4statementsmyesornoresponseformat.[16]Thedefinitionwas"Vigorousphysicalactivity
orexerciseincludeshardactivitiessuchasjogging,aerobics,swimming,andbiking.Forvigorousactivity
toberegular,itmustbeatleast20minuteseachtime,andbedoneatleast3daysperweek."The4
statementswere(1)Icurrentlyparticipateinvigorousphysicalactivity(2)Iintendtoincreasemy
participationinvigorousphysicalactivityinthenext6months(3)Icurrentlyengageinregularvigorous
physicalactivity(4)Ihavebeenparticipatinginvigorousphysicalactivityregularlyforthepast6months.
Participantsrespondedyesornotoeachofthesequestions.Thestageswerecalculatedasfollows:

Precontemplationl[equals]no,2[equals]no,3[equals]no,4[equals]no

Contemplationl[equals]no,2[equals]yes,3[equals]no,4[equals]no

Preparationl[equals]yes,2[equals]yes/no,3[equals]no,4[equals]no

Actionl[equals]yes,2[equals]yes/no,3[equals]yes,4[equals]no

Maintenancel[equals]yes,2[equals]yes/no,3[equals]yes,4[equals]yes

ProcessesofchangewereassessedbytheProcessesofChangeQuestionnaire(PCQ)developedand
validatedspecificallyfortheexercisedomainbyMarcus,Rossi,Selby,Niaura,andAbrams.[17]ThePCQ
contains39itemsthatmeasurethe10processesofchange.Individualswereaskedtorecallthepast
monthandtoratethefrequencyofoccurrenceofeachitemona5pointscalefrom1(never)to5
(repeatedly).Internalconsistenciesforthepresentstudyarereportedforeachprocessforeach
populationintheorder:highschool,undergraduates,adults.TheCronbach'salphaswere:consciousness
raising([alpha][equals].84,.78,.81),dramaticrelief([alpha][equals].89,.88,.89),environmental
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reevaluation([alpha][equals].83,.71,.79),selfreevaluation([alpha][equals].83,.67,.79),social
liberation([alpha][equals].66,.48,.53),counterconditioning([alpha].78,.77,.89),helpingrelationships
[[alpha].83,.77,.76),contingencymanagement([alpha][equals].78,.56,.82),selfliberation[[alpha]
[equals].71,.56,.77),andstimuluscontrol([alpha][equals].79,.61,.74).

Selfefficacywasassessedusing5itemson5pointratingscalesrangingfrom1[equals]notatall
confidentto5[equals]extremelyconfident.Theinstructionswere"pleaseindicatebycheckingthe
responsethatmostaccuratelyreflectshowconfidentyouarethatyoucouldexerciseineachofthe
followingsituations"followedby"whenIamtired,""whenIaminabadmood,""whenIfeelIdon'thave
time,""whenIamonvacation,"and"whenitisrainingorsnowing."[8]Cronbach'salphaforthisscale
washighschool,.77undergraduates,.82adults.76.

RESULTS

DistributionofindividualsacrossstagesbypopulationispresentedinTable1.Themeansandstandard
deviationsforeachconstructacrossthestagesofchangearepresentedseparatelyforeachpopulationin
Tables2(cognitiveprocesses),3(behavioralprocesses),and4(selfefficacy).Totestourhypotheses,we
conductedANOVAsforeachofthe10processesandforselfefficacy.ApplyingaBonferronicorrection
factor,theacceptableprobabilitylevelfordeterminationofsignificancewasp[lessthan].004.These
resultsarepresentedinTables2,3,and4.Theresultsindicatedsignificantunivariatemaineffectsof
stageforall10processesofchangeandselfefficacyandsignificantunivariatemaineffectsofpopulation
for8ofthe10processesofchangeandselfefficacy(Tables2to4).Therewerenostagexpopulation
interactionsthatachievedstatisticalsignificanceatp[lessthan].004.

:Distributionofpeopleperstageperpopulation

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:Descriptionstatisticsforcognitiveprocesses

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:Descriptionstatisticsforbehavioralprocesses

:Meansandstandarddeviationforselfefficacy

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StudentNewmanKeulsposthoctestswereperformedtodeterminethespecificdifferencesforstageand
populationmaineffects.TheposthocresultsforstagearepresentedinTable5.Ingeneral,the
precontemplatorsusedalltheprocessessignificantlylessthantheothergroupsdid,andtherewere
increases,particularlyofthebehavioralprocesses,withprogressionthroughthestages.Theposthoc
resultsforgrouparealsopresentedinTable5.Theorderofthegroupswithrespecttoreporteduseof
theprocesseswasconsistentwiththeadultsreportingthelowestandtheundergraduatesreportingthe
highestfrequency.Anysignificantdifferenceswereduetotheadults'beingsignificantlylowerthanthe
other2groupsortheundergraduates'beingsignificantlyhigher.

:Posthoctestsforstageandpopulation

DISCUSSION

ThepurposeofthepresentstudywastodirectlycomparepatternsofchangesinTTMvariablesacross
thestagesin3populations:highschoolstudents,universityundergraduatestudents,andemployed
adults.TheresultsindicatedsignificantdifferencesinTTMvariablesacrossthestagesandamong
populationsbutnosignificantstagebypopulationinteraction.Eachoftheseresultsisdiscussedinturn
followedbyfuturedirections,practicalimplications,andlimitationsofthestudy.

Thepatternsofchangesacrossthestagesaresimilartothosefoundbypreviousresearchersusingadult
populations,suchasthosereportedbyMarcusandSimkin[11]intheirreviewoftheTTMandexercise.
Thepresentstudyshoweddistinctdifferencesbetweenstagesintheuseoftheprocesses,withaclear
indicationofincreaseduseofprocessesassociatedwithadvancingstage.Althoughtherearefewer
studiesexaminingadolescents,similarresultstothepresentstudywerereportedbyNiggandCourneya[
18]andWyse,Mercer,Ashford,BuxtonandGleeson.[19]Wyseetal,[19]however,examinedyoung
adultsbetweentheagesof16and21,whichwouldbesimilartothepresentadolescentand
undergraduategroupscombined.

Themaineffectforpopulationshowedthattheundergraduatesreportedusingalltheprocessesmore
thandidthehighschoolstudentsandtheadultsthelatterreportedusingalltheprocessestheleast.The
presentmethodologydoesnotpermitafirmexplanationforthisfinding,butonepossibilityisthatthe

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universityundergraduateshadgreaterexposuretoexerciserelatedinformation.Itcouldalsobethat
universitystudentshavethemost"flexible"lifestyle,andthereforefewerconstraints(ie,fewerfamily
commitments,especiallychildrenlessrigidworkschedule).Anaturalextensionofthisrelativelackof
constraint,aswellasbeingstudentsofalargeuniversity,couldbegreaterresourcebase.Forexample,
theymaybeabletouse"helpingrelationships"frommorepeopleandfromdifferentpeopleforexercise
thanforacademicwork.Incontrast,adultsinsecurejobstendtoalsohavesecuresocialnetworksthat
canberestrictiveinandofthemselves.MannellandKleiber[19]havepointedoutthatduring
midadulthood,peopleexhibitanarrowingofactivitiesduetophysicalconstraintsandsocialconstraints
(suchascaregiving,work),andthatthispersistsuntilretirement.Thedistributionofadultsacrossthe
stageswasdifferentfromthatofthehighschoolstudentsanduniversitystudentsinthepresentstudy.
Thereweredisproportionatelymoreadultsintheearlierstagesanddisproportionatelyfewerinthelater
stagesasshownbythepercentagesonTable1.Itispossiblethatifthepercentageofparticipantsper
groupperstagehadbeenheldconstant,thepatternofdifferencesmightchange.Itisalsopossible,
however,thatthedistributionofthesepopulationsacrossstagesisakeydifferencebetweenthegroups
thatneedsfurtherattention.

Anothernotablefindingwasthelackofsensitivityofcognitiveprocessescomparedtothebehavioral
processesfordistinguishingbetweenstagesofexercisebehavior.Asdemonstratedbytheposthoctests,
thecognitiveprocessesseemonlytodistinguishprecontemplatorsfromtheotherstages,whereasthe
behavioralprocessesseemtobemoresensitivetoexercisebehaviorchange.Althoughonlyexercisewas
assessedinthecurrentstudy,itappearsthatthecognitiveprocessesmightbelesssensitivetoexercise
thanothertypesofhealthbehavior(eg,smoking[4]).Onefactortoconsideristhenatureofexercise,
whichisdiscreteandoflowfrequencycomparedtootherbehaviorslikesmoking,whichareperformed
multipletimesdailyandofteninassociationwithotherbehaviors(suchaswork,eating,orcoffeedrinking)
probablymakingthemmoreinsidious.Suchbehaviorsmayrequiremorecognitivevigilance,therefore
renderingthemmoresensitivetocognitiveprocesses.

Thekeyfindingofthepresentstudywasthefailuretofindastagebypopulationinteractionevenusing
themoreliberalstrategyofmultipleunivariatetests.Thisfindingofferssupportforthecontentionof
ProchaskaandVelicer[3]thattheprinciplesofthemodelapplytodiversepopulations.Thatis,thepattern
ofchangeamongTTMvariablesacrossthestagesisthesameregardlessofthepopulationexamined.
Themaindiscriminatingfactorexaminedinthepresentstudy,however,wasage(ie,highschoolstudents,
universityundergraduatestudents,employedadults).Itisconceivablethatotherpopulationcharacteristics
suchashealthstatusmaybemoreimportantthanageandmayresultinstagebypopulationinteractions.
Forexample,itispossiblethatindividualsoflimitedmobilitywouldneedmoresocialsupport(helping
relationships).Thus,futurestudiesareneededthatsimultaneouslycomparesuchgroupsofindividuals.

Ifthepresentedresultsarereplicatedacrossotherdiversepopulations,thereareimportantpractical
implicationsthatfollow.First,itappearsthatgeneric,massmediacampaignswouldbeexpectedtobe
effectiveacrosshealthypopulationsintermsofprovidingstageappropriateimpetusforchange.Thus,
costeffectivepopulationbasedcampaigns,giventheyhaveappropriatecontent,canbeexpectedtobe
aseffectiveascampaignsproducedfordifferentpopulations.Thespecificinterventiontechniques,
however,wouldlikelyhavetobepopulationspecific.Forexample,informationthatmightresultin
consciousnessraisingforanadolescentwouldprobablybedifferentfromthatforanemployedadult.
Similarly,whatmightbeaneffectivereinforcerforauniversitystudentwouldlikelybedifferentfromwhat
mightbeaneffectivereinforcerforanemployedadult.
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Thepresentstudyhasimportantlimitationsthatneedtobetakenintoaccountwheninterpretingthedata
andplanningfutureresearch.Onelimitationisthecrosssectionaldesignandtheselfreportnatureofthe
data.Certainly,prospectivestudiesareneededtoexaminehoweachofthe3groupsmightprogressfrom
stagetostage.Replicationinlargersamplesthanthoseusedinthepresentstudyisalsowarranted.It
shouldbenoted,however,thatthemostrestrictedgroupinthisstudy,employedadults,isprobablythe
moststudiedgroupinthegeneralliterature.Thesamplesizesarebetterforthehighschoolstudentsand
undergraduateshowever,thesetooneedtobeexpanded.Finally,thisstudyalsoneglectedtoaddress
theentireTTMbytheomissionoftheprosandcons.Becausethefocusofthisstudywastocontrastthe
utilityofTTMconstructsin3populations,itwasimportanttomaintainconsistentmeasuresinall3.Pilot
workprecedingthisstudyindicatedthattheprosandconsassessmentwasnotbeingwellreceivedbythe
highschoolstudentsduetowordinganditemcontent.Therefore,ratherthanmakechangestotheitems
thatmightresultinotherpopulationorvalidityproblems,wedecidedtoomitassessmentoftheprosand
cons.Itremainsunknown,therefore,howthese3populationscomparewithrespecttodecisional
balance.

Insummary,thepresentstudyofferssupportforthegeneralizabilityofTTMfindingsintheexercise
domainacrosspopulations.Takeninconsiderationofotherresearchaddressingtheeffectivenessof
mediated(ie,massmedia)healthpromotioncampaigns,itisevidentthatbroadspectrum,stagematched,
populationbasedcampaignstoincreaseexercisebehaviorarelikelytobeeffectiveacrossavarietyof
healthypopulations.Keepinginmindthatthemajorityofthepopulationcanbedescribedashealthy,[20]
thepotentialhealthinfluenceofsuchcampaignsisconsiderable.Thisstudysupportstheideathatthe
TTM,particularlyselfefficacyandtheprocessesofchange,performsconsistentlyacrosshighschool
students,universityundergraduatestudents,andemployedadults,suggestingthattheunderlying
principlesofchangearesimilaracrosspopulations.

ACKNOWLEDGMENTS

ThisresearchwassupportedbyaUniversityofAlbertaSocialSciencesResearchOperatingGrant
awardedtoDr.Rodgers.Dr.Courneya'sresearchprogramissupportedbytheNationalCancerInstitute
ofCanada(NCIC)withfundsfromtheCanadianCancerSociety(CCS)andtheCCS/NCIC
SociobehavioralCancerResearchNetwork.

WendyM.Rodgers,PhD,AssociateProfessorKerryS.Courneya,PhD,ProfessorAngelaL.Bayduza,
MA,Instructor,FacultyofPhysicalEducationandRecreation,UniversityofAlberta,Edmonton,Alberta,
Canada.

AddresscorrespondencetoDr.Rodgers,PhysicalEducationandRecreation,UniversityofAlberta,
Edmonton,Alberta,CanadaT6G2H9.Email:wrodgers@per.ualberta.ca

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~~~~~~~~
ByWendyM.RodgersKerryS.CourneyaandAngelaL.Bayduza

Thisarticleiscopyrighted.Allrightsreserved.
Source:AmericanJournalofHealthBehavior

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