In their own voices: definitions and interpretations of physical activity

Women’s Health Issues 13 (2003) 194 –199

IN THEIR OWN VOICES: DEFINITIONS AND INTERPRETATIONS OF PHYSICAL ACTIVITY Catrine Tudor-Locke, PhDa*, Karla A. Henderson, PhDb, Sara Wilcox, PhDd, Rhonda S. Cooper, MSc, J. Larry Durstine, PhDd, and Barbara E. Ainsworth, PhDc,d,e b

a Department of Exercise and Wellness, Arizona State University, Mesa, Arizona Department of Recreation and Leisure Studies, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina c Prevention Research Center, School of Public Health, University of South Carolina, Columbia, South Carolina d Departments of Exercise Science and e Epidemiology and Biostatistics, University of South Carolina, Columbia, South Carolina

Received 17 December 2002; received in revised form 25 March 2003; accepted 22 April 2003

Terms such as physical activity, exercise, and leisure are perceived and interpreted differently by people differing in gender, class, and sociocultural factors. We accessed multiple diverse data sources (including qualitative data recently collected in research and evaluation studies) to explore African-American and American Indian women’s (age 40⫹) definitions, meanings, and interpretations of “physical activity”. These women reported that physical activity is typically considered to be structured “exercise” and not incidental activities of daily life. The term “leisure” was interpreted from a cultural perspective as being lazy. These women also had difficulty understanding the meaning of “intensity” (e.g., “moderate”, “vigorous”). Researchers must acknowledge and understand inconsistencies that arise and how these might influence design of, and responses to, self-report assessment of physical activity. Keywords: Exercise, Leisure, Ethnicity

Introduction Accurate assessment of physical activity behaviors is important to: 1) monitor status of an important healthrelated behavior; 2) determine trends and appropriately allocate resources; and 3) evaluate program/ policy effectiveness. Researchers have struggled with quantifying physical activity trends using self-reported data (Pratt, Macera & Blanton, 1999) obtained from self- or interviewer-administered questionnaires and logs or diaries. Despite well-known limitations and biases associated with self-report (Sallis & Saelens, 2000), such assessment approaches will likely continue because they offer a low-cost alternative to collecting data on large samples. It is imperative, then, that researchers appreciate the limitations of these approaches and promote construction of better instruments that yield more valid and reliable data. A major * Correspondence to: Catrine Tudor-Locke, PhD, Department of Exercise and Wellness, Arizona State University, 7001 E. Williams Field Road, Mesa, AZ 85212. E-mail: [email protected]. Copyright © 2003 by the Jacobs Institute of Women’s Health. Published by Elsevier Inc.

challenge facing researchers is how to accurately assess physical activity in women, particularly in older (40⫹) and ethnically diverse women (Airhihenbuwa, Kumanyka, Agurs & Lowe, 1995; Eyler, Baker, Cromer, King, Brownson & Donatelle, 1998; Masse et al., 1998; Pate et al., 1995; Warnecke et al., 1997). Terms such as “physical activity”, “exercise”, “leisure”, and “recreation” are poorly understood or interpreted differently even among people socialized within mainstream white culture. Little consensus, or understanding, exists even between researchers regarding the most appropriate way to describe intensity modifiers (e.g., “moderate”, “vigorous”, “strenuous”) on physical activity questionnaires (Ainsworth et al., 2000; LaMonte & Ainsworth, 2001; Masse et al., 1998). These misunderstandings and inconsistencies are further compounded when culture and language translations are considered. The purpose of this conceptual paper is to 1) review definitions, meanings, and interpretations of physical activity, associated terms, and intensity modifiers from a range of perspectives (e.g., dictionary, re1049-3867/03 $-See front matter. doi:10.1016/S1049-3867(03)00038-0

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Table 1. Summary of data sources from the Cultural Activity Participation Study (CAPS) used to examine physical activity (PA) and associated concepts Data Source

Number of Participants

Characteristics of Women

Individual in-depth interviews to examine PA involvement and meanings

56 women

Individual in-depth interviews to examine PA involvement and meanings Focus groups to ascertain perceptions of survey questions and design and other issues Focus groups to ascertain perceptions of survey questions and design and other issues Focus groups to evaluate outcomes of lifestyle physical activity program Focus groups to evaluate outcomes of lifestyle physical activity program Focus groups to evaluate outcomes of lifestyle physical activity program Expert panel convened to explore issues related to physical activity among minority women

26 women

Ages 40–86 years 30 African-American 26 American Indian Ages 40–80 years 26 American Indian All American Indian over 40 years old All African-American over 40 years old All African-American over 40 years old All American Indian over 40 years old All American Indian over 40 years old Half male 20% AfricanAmerican and American Indian

searcher-defined, and the self-reported perspectives of African-American and American Indian women aged 40⫹); and 2) make recommendations for improved measurement of physical activity for diverse groups.

Methods and Data Sources Several data sources (Table 1) were used in addressing the issues surrounding definitions and meanings. The methods used to obtain initial data came from in-depth interviews and focus groups. AfricanAmerican women from the capitol city in South Carolina and the surrounding area, and American Indian women from the Pueblos of New Mexico, the Navajo Nation in New Mexico, and the Leech Lake Reservation in Minnesota participated in the interviews. The women interviewed were a subset of the women who were involved with the Cross-Cultural Activity Participation Study (CAPS) (Ainsworth, Irwin, Addy, Whitt & Stolarczyk, 1999). Briefly, CAPS was a 5-year community study (funded through the Women’s Health Initiative of the National Institutes of Health), aimed at developing and validating a physical activity survey capable of accurately assessing moderate activity patterns among minority women over 40 years of age. Participants were recruited through newspaper ads, church contacts, senior citizen centers, and health providers. Usually the in-depth interviews took 45 to 75 min; a convenient private place determined by the interviewee was scheduled. Tape-recorded interviews were transcribed verbatim (except for five interviews in the Navajo language that were translated into English by the interviewer before transcription). Each of the focus groups lasted about 75 min.

3 Focus groups (15 women) 3 Focus groups (12 women) 2 Focus groups (11 women) 4 Focus groups (16 women) 2 Focus groups (10 women) 5 Discussion groups (50 participants)

Individuals were not randomly selected but represented either a variety of a South Carolina community’s constituencies or American Indian women from Minnesota and New Mexico, including individuals who were physically active as well as inactive. Several of the focus groups included women who had been participants in a lifestyle outcomes program. A semistructured interview guide approach was used to collect data for each of the studies described in Table 1. This approach allowed interviewers and focus group leaders the freedom to probe and to ask questions in whatever order seemed appropriate. The questions were designed to encourage people to talk about their lives and how they perceived and described the relative importance of physical activity. Specific questions were asked in the interviews and in the focus groups related to perceptions of physical activity, perceived motivations and constraints, community involvement, and attitudes about physical activity. Specific questions were not asked about meanings and definitions, but these ideas emerged as the participants talked. Data analyses were conducted for both the interviews and the focus groups using a modified constant comparison technique and an interpretive paradigm (Henderson, 1991). We uncovered some of the patterns from examining literature sources (obtained by referring to contemporary textbooks and also from an online search of PubMed) as well as from analysis of the interviews and the focus groups. This interpretive approach assumes that human beings are conscious, feeling, thinking, and reflective subjects, and that people impute meanings about what is happening to them and how they interact with others. Traditional quantitative meth-

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Table 2. A comparison of dictionary, researcher, and participant definitions of physical activity, associated terms, and intensity modifiers Term Physical activity

Physical Activity

Exercise

Leisure

Random House Webster’s College Dictionary Does not exist as a defined phrase

Of or pertaining to the body Engaged in action or activity; characterized by energetic work, motion, etc. Bodily or mental exertion, especially for the sake of training or improvement; something done or performed as a means of practice or training Time free from the demands of work or duty; free or occupied; with free or unrestricted time; without haste or pressure; slowly

Recreation

Refreshment, as by means of agreeable exercise; a means of enjoyable relaxation

Moderate

Kept or keeping within reasonable limits; not extreme, excessive, or intense; of medium quantity, extent, or amount

Vigorous

Full or characterized by vigor; strong or active; robust; energetic; forceful

Strenuous

Characterized by or calling for vigorous exertion; intensely active, energetic

Definitions From the Literature

Summary of Participants’ Voices

Any bodily movement produced by skeletal muscles that results in energy expenditure (Caspersen, 1985)

Ranged from structured exercise for the purposes of improving oneself to the demands of daily work and home life

A subcategory of physical activity defined as planned, structured movement undertaken to improve or maintain one or more aspects of physical fitness (Caspersen, 1985) Time when all obligations (i.e., chores) have been done and the individual has time to enjoy and participate in an activity of choice (Bammel & BurrusBammel, 1996) Enjoyable activity done during one’s free time (Henderson, Bialeschki, Shaw & Freysinger, 1996) Any activity performed at 3–6 METs, or 4–7 kcal/min, examples: Brisk walking (3–4 miles/hour), raking leaves (Ainsworth et al., 2000; U.S. Department of Health and Human Services, 1996) Any activity performed at ⬎6 METs or ⬎7 kcal/min, examples: jogging, lap swimming, jumping rope (Ainsworth et al., 2000; U.S. Department of Health and Human Services, 1996) Not operationalized

Pushing oneself, performed solo, often requiring going to a gym or other facility

Relaxation, free from obligation

Social time

Movement associated with enjoyment

Moving fast, working up a sweat, pushing oneself.

Synonymous with vigorous; Stressed, drained, difficult

Note: METs (metabolic equivalents) are multiples of the rate of oxygen consumption at rest, or 1 MET, or about 3.5 mL/min/kg.

ods often have been unable to uncover the complex nature of women’s attitudes and practices, especially for marginalized groups (Allison, 1988). These qualitative approaches also facilitated understanding and identifying a range of patterns of behavior. Specific to this paper, examples were extracted from the transcripts to illustrate a range of perceptions about physical activity. The data were used as a secondary analysis to describe the reality of the understandings of these terms as compared with literature sources. These analyses were exploratory and descriptive and served as a means to illustrate some of the problems with inconsistent interpretations of terms. The data provided examples and were not presented in this paper’s context as a systematic summary of the original research and evaluation studies conducted.

Definitions and Meanings Clarifying terms is an essential aspect of scholarly study. Consistent and operational definitions are not enough, however. Meanings attributed to terms are also critical to understanding how people make sense of their lives and talk about what they do. Howe and Rancourt (1990) explained that meanings are defined as a relationship between an individual and his or her environment. If some groups experience their environment differently than mainstream white culture, meanings may vary and definitional consistency is difficult. Much of the research that is done (e.g., studies using self-reported behavior reduced to numeric data for statistical analyses) assumes that all respondents should hold similar definitions and at-

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tach comparable meanings to terms. For comparative purposes, dictionary and research definitions, and CAPS participants’ reported meanings of physical activity, associated terms, and intensity modifiers are assembled in Table 2. Physical activity and related terms The African-American and American Indian women in the CAPS studies were asked in varying ways to describe physical activity and associated terms as well as discuss their meanings. The perceptions ranged from a specific focus on strenuous exercise to a broader understanding of the “busy-ness” of daily life. Physical activity connotations were frequently associated with structured exercise and the perception of being “in really good shape” and/or in good health. For example, one woman defined physical activity as, “Taking time out to do some exercise for your own self-being.” Another woman described how physical activity lowered her blood sugar and stated, “You know, by walking beyond where you’re comfortable, you know kind of pushing yourself.” Other ideas included “moving around, movement,” “physical activity means a lot of work, you know, like walking, running, exercise,” and “physical activity means that you run every day, you exercise your body, and be active.” Many of these meanings focused on physical activity as regular, intentional, and beyond the typical movement of daily living. Daily activities that might provide cardiovascular benefits were mentioned by some of the women. One woman defined physical activity as “stair climbing.” She stated that she lived in an upstairs apartment and stated, “I can’t tell you how many times I’m up and down the stairs.” Another woman illustrated being physically active as “running around chasing after kids.” An American Indian woman said physical activity was “doing something that exerts energy and that can be from weeding garden to cleaning the house to, oh yeah, having sex, golfing, walking, shopping, that kind of stuff.” Similarly, another woman said, “I think working around the house is just as good as going to the gym and working out for an hour. I’d rather do stuff like that and it has to be done [housework, yard work], it fits into my life, it’s pertinent, you know, I can’t not do it.” An African-American woman said, “I was always active and everything and I love to walk. . .I never was what they would call into this exercising bit cause I walked.” Many women felt they have no leisure time outside home and family responsibilities, and therefore, little leisure-time physical activity. Most of the women in the CAPS studies saw recreation as having an activity component, but leisure was generally defined as relaxation: “leisure is relaxing and recreation is social.” For example, some of the descriptions given of leisure included the following: “having some time to sit and

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relax,” “sightseeing,” “when I don’t have no one else bothering me,” “having time to oneself,” “just doing nothing,” and “doing very little activity.” Overall the meanings associated with physical activity related to either a narrow idea of structured exercise, or a broader perspective related to incidental movement. Exercise was more likely to be negatively perceived, and that seemed to create resistance from some women about its value in their lives. On the other hand, physical activity when perceived as movement, and sometimes being busy, did not always reflect moderate to vigorous intensity physical activities more commonly associated with health benefits (U.S. Department of Health and Human Services, 1996). The notion of “leisure-time physical activity” had little consistent meaning to these women, and several did not believe that such an idea could exist in their lives. Intensity modifiers Focus group results suggested that participants interpret the terms “moderate”, “strenuous”, and “vigorously” differently from what researchers had intended, despite definitions provided to standardize the meanings. In general, “strenuous” was understood more consistently than “vigorous.” In addition, “vigorous” was poorly understood when physiologic cues were omitted from the questionnaire. One woman defined vigorous as, “If I’m sweating, then I feel it’s vigorous.” Strenuous implied stress for some of the women, indicating that term was interpreted outside the parameters of physical activity. Another woman indicated that being busy and vigorous were the same in her mind and did not necessarily involve physical activity. When asked if they could develop consensus about the definitions, focus group participants agreed that vigorous and strenuous intensity were synonymous if the activity involved moving fast, working up a sweat, and pushing oneself. The interpretations of moderate intensity physical activity were varied and more difficult to understand. The term “less vigorous” (to reflect moderate intensity) was least well understood and not recommended by focus group members. This definition of moderate also seemed to relate to a person’s sense of subjectivity and intrinsic motivation. For example, one woman indicated that if she enjoyed something she viewed it differently than if she did not. Enjoyment was often associated with something that was “moderate.” Another woman indicated that if she felt “drained” at the end of the day, then it was a strenuous day, and not moderate. Age and fitness level also seemed to have implications for the definitions of activity among these focus group members. For example, one focus group discussed how for an older person strenuous might be perceived differently than for a younger person. Doing an activity could be strenuous or moderate de-

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pending on how hard one worked. The pace of the activity often determined how participants defined an activity. Vacuuming, for example, was vigorous if performed at a faster pace. Language was another dimension explaining why definitions of physical activity, associated terms, and intensity modifiers might be varied among different cultural groups. In the CAPS study (Henderson, Ainsworth, Stolarzcyk, Hootman & Levin, 1999), interviewers asked Navajo and Pueblo women about their physical activity and in several cases, the interviews were conducted in the Navajo language. The translator said that the word for physical activity in Navajo was basically translated as “stretching” but it meant more than that. Stretching included stretching, walking, running, and any type of physical movement. One woman defined stretching as “what the body does when it’s physically moving.” When several of the women spoke of stretching, they were referring to more than what might be connoted with that word when translated back to English. Therefore, in considering the cultural dimensions of physical activity definitions, perceptions, and measurement, the issue of translations as well as other differential interpretations must be considered.

Implications for Questionnaire Design The development of future assessment tools must take into account the evolving nature of the field of study as well as subjective perceptions that may exist. Both scientific and human elements ought to be considered. Issues relevant to gender, race, and class must also continue to be explored no matter how difficult they are to ascertain. Although the perfect instrument is yet to be developed, some ideas seem important to consider. Culturally relevant and gender-specific wording seem to be important. Women’s lives are most often punctuated with gender roles of caregiving, and these roles clearly impact the way that women live their lives. The physical activity constructs queried should represent activities performed by women in their daily lives and at least include items about house care, lawn/garden care, family caregiving, nonoccupational walking, transportation, dance/sport, conditioning, leisure/inactivity, occupation, and volunteer activities. In addition, discrimination and stereotypes also likely influence activities in both implicit and explicit ways. Gender and race issues are often hard to articulate, but these difficulties do not mean that we can abdicate the responsibilities for developing valid measurement instruments. The examples used to illustrate physical activity dimensions should relate to a range of possible activities and be carefully selected in

consultation with the unique population to be studied by way of preliminary focus groups. Unguided, the interpretations will be much too broad and may be tied to nonphysical activity concepts such as enjoyment or stress. It is also important to note to participants that measurement instruments such as these are designed to look at physical body movement activity and not the stresses of daily life. The potential utility of an interviewer-administered questionnaire is implicated. Connotations of terms such as “physical activity” and “leisure”, both positive and negative, must also be taken into account. Giving definitions of terms such as “strenuous” is important. For example, researchers might use a variety of examples (again informed by focus groups with the target population) that represent the intended intensity level. Therefore, it is important to plan to explain such terms before administration of any questionnaire to an individual. Once again, an interviewer-administered questionnaire would best facilitate this recommendation and permit subsequent clarification to the respondent, if needed, during instrument completion. Questionnaires must also be as short as possible while capturing important physical activity constructs since participants revealed that they did not take the time to read a lot of words. Balancing demands to guide respondents with appropriate terms, definitions, and examples while still keeping the self-report instrument short is, to say the least, a challenge. Despite these challenges, self-report is a pragmatic approach to assessing physical activity in populations. We cannot throw this approach out. Neither can researchers ignore the responsibility of trying to be as clear as possible in designing questionnaires to collect valid and reliable data. Regardless of the instrument developed, however, the importance of pretesting with culturally specific populations must be emphasized.

Conclusions This study was undertaken to highlight some of the issues surrounding comprehension for middle-aged minority women in an attempt to shed light on important implications for improving the assessment of physical activity. Researchers must acknowledge and understand inconsistencies that arise and how these might influence design of, and responses to, selfreport assessment of physical activity. Even specific definitions can sometimes be misinterpreted if researchers do not listen to the “voices” of the women whom they study. A number of implications discussed include using familiar terms and example activities informed by the target population designing

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brief instruments, and consistently pretesting instruments. Acknowledgments Support for this paper was provided by NIH-CDC SIP #W22-U48/CCU409664-03, awarded to Dr. Ainsworth. We thank the many interviewers and data collection staff involved in CAPS for their efforts in the series of studies referred to in this paper. This paper was presented to the Australian and New Zealand Association of Leisure Studies Conference in July 2001.

References Ainsworth, B. E., Haskell, W. L., & Whitt, M. C., et al. (2000). Compendium of physical activities: An update of activity codes and MET intensities. Medicine and Science in Sports and Exercise, 32 (Suppl. 9), S498 –S504. Ainsworth, B. E., Irwin, M. L., Addy, C. L., Whitt, M. C., & Stolarczyk, L. M. (1999). Moderate physical activity patterns of minority women: The Cross-Cultural Activity Participation Study. Journal of Women’s Health & Gender-Based Medicine, 8, 805– 813. Airhihenbuwa, C. O., Kumanyika, S., Agurs, T. D., & Lowe, A. (1995). Perceptions and beliefs about exercise, rest, and health among African-Americans. American Journal of Health Promotion, 9, 426 – 429. Allison, M. T. (1988). Breaking boundaries: Future directions in cross-cultural research. Leisure Sciences, 10, 247–259. Bammel, G., & Burrus-Bammel, L. L. (1996). Leisure and human behavior (3rd ed.). Dubuque, IA: Times Mirror Higher Education. Caspersen, C. J. (1989). Physical activity epidemiology: Concepts, methods, and applications to exercise science. Exercise and Sports Science Reviews, 17, 423– 473. Eyler, A. A., Baker, E., Cromer, L., King, A. C., Brownson, R. C., & Donatelle, R. J. (1998). Physical activity and minority women: A qualitative study. Health Education & Behavior, 25, 640 – 652. Henderson, K. A. (1991). Dimensions of choice: A qualitative approach to research in recreation, parks, and leisure. College Park, PA: Venture Publishing. Henderson, K. A., Ainsworth, B. E., Stolarzcyk, L. M., Hootman, J. M., & Levin, S. (1999). Notes on linking qualitative and quantitative data: The Cross-Cultural Physical Activity Participation Study. Leisure Sciences, 21, 247–255. Henderson, K. A., Bialeschki, M. D., Shaw, S. M., & Freysinger, V. J. (1996). Both gains and gaps. State College, PA: Venture Publishing. Howe, C. A., & Rancourt, A. M. (1990). The importance of definitions of selected concepts for leisure inquiry. Leisure Sciences, 12, 395– 406. LaMonte, M. J., & Ainsworth, B. E. (2001). Quantifiying energy expenditure and physical activity in the context of dose-response.

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Medicine and Science in Sports and Exercise, 33 (6 Suppl.), S370 – S378. Masse, L. C., Ainsworth, B. E., & Tortolero, S., et al. (1998). Measuring physical activity in midlife, older and minority women: Issues from an expert panel. Journal of Women’s Health, 7, 57– 67. Pate, R. R., Pratt, M., & Blair, S. N., et al. (1995). Physical activity and public health: A recommendation from the Centers for Disease Control and Prevention and the American College of Sports Medicine. JAMA, 273, 402– 407. Pratt, M., Macera, C. A., & Blanton, C. (1999). Levels of physical activity and inactivity in children and adults in the United States: Current evidence and research issues. Medicine and Science in Sports and Exercise, 31 (11 Suppl.), S526 –S533. Sallis, J. F., & Saelens, B. E. (2000). Assessment of physical activity by self-report: Status, limitations, and future directions. Research Quarterly for Exercise and Sport, 71, 1–14. U.S. Department of Health and Human Services. (1996). Physical activity and health: A report of the Surgeon General. Atlanta, GA: U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Promotion. Warnecke, R. B., Johnson, T. P., & Chavez, N., et al. (1997). Improving question wording in surveys of culturally diverse populations. Annals of Epidemiology, 7, 342.

Author Descriptions Dr. Tudor-Locke’s research includes physical activity assessment and developing and evaluating programs designed to increase physical activity in typically sedentary populations. Dr. Henderson’s areas of research within the field of recreation and leisure studies have included gender, diversity, physical activity, and interpretive approaches to research. Dr. Wilcox’s research is focused on understanding factors that influence physical activity in older adults, women, and persons of color, and on developing and evaluating interventions to increase physical activity in these populations. Ms. Cooper’s research interests include physical activity, cardiovascular disease risk factors, and associated outcomes. Dr. Durstine is a clinical exercise physiologist with an interest in chronic diseases and disabilities. Dr. Ainsworth is a Professor of Epidemiology and Exercise Science with research interests in physical activity and public health.