- Email: [email protected]
ethnic groups
Articles
Quantitative Study of Correlates of Physical Activity in Women from Diverse Racial/Ethnic Groups Women’s Cardiovascular Health Network Project Introduction and Methodology Amy A. Eyler, PhD, Dyann Matson-Koffman, PhD, Deborah Rohm Young, PhD, Sara Wilcox, PhD, JoEllen Wilbur, PhD, Janice L. Thompson, PhD, Bonnie K. Sanderson, PhD, Kelly R. Evenson, PhD Background: Physical activity is an important aspect of cardiovascular disease prevention. However, data show a high prevalence of physical inactivity among women and ethnic minority and low-income populations. The purpose of this introduction is to describe the Women’s Cardiovascular Health Network Project and implementation of the Women and Physical Activity Survey. The goal of the survey was to identify personal, social environmental, and physical environmental factors that are associated with physical activity status among diverse groups of women. Methods:
Seven universities were funded to study factors that influence physical activity among African-American, Native American, Latina, and white women residing in rural, suburban, and urban living environments. An ecologic model was used to design a quantitative questionnaire that was implemented by telephone or face-to-face interviews in seven sites across the United States.
Results:
The survey was completed by a total 4122 women, with group totals ranging from 300 to 1000. Results from each site are presented in individual articles in this issue. A summary of results that compare and contrast the groups is presented in an additional report.
Conclusion:
This study provides important information on the assessment of physical activity among women. Results can be used to help improve assessments and to develop more effective policies and interventions for unique groups of women. (Am J Prev Med 2003;25(3Si):5–14) © 2003 American Journal of Preventive Medicine
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large body of research has established that regular physical activity reduces the risk of premature death and disability from a variety of health conditions and cardiovascular disease in particular.1 Despite the known benefits of a physically active From the Prevention Research Center, School of Public Health, Saint Louis University (Eyler), St. Louis, Missouri; Cardiovascular Health Branch, Division of Adult and Community Health, National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention (Matson-Koffman), Atlanta, Georgia; Department of Kinesiology, University of Maryland (Young), College Park, Maryland; Department of Exercise Science, Norman J. Arnold School of Public Health, University of South Carolina (Wilcox), Columbia, South Carolina; Department of Public Health, Mental Health, and Administrative Nursing, College of Nursing, University of Illinois at Chicago (Wilbur), Chicago, Illinois; Department of Pediatrics, Center for Health Promotion and Disease Prevention, University of New Mexico Health Sciences Center (Thompson), Albuquerque, New Mexico; University of Alabama (Sanderson), Birmingham, Alabama; Department of Epidemiology, School of Public Health, University of North Carolina–Chapel Hill (Evenson), Chapel Hill, North Carolina Address correspondence and reprint requests to: Amy A. Eyler, PhD, Prevention Research Center, School of Public Health, Saint Louis University, 3545 Lafayette Avenue, St. Louis MO 63104. E-mail: [email protected].
lifestyle, more than one quarter of the U.S. population remains completely inactive during leisure time, and U.S. trends in activity showed little improvement from 1990 through 1998.2 Also, population-wide surveillance data show a high prevalence of physical inactivity for leisure time, particularly among women and ethnic minority and low-income populations.3 According to the 1997–1998 National Health Interview Survey, approximately 41% of women were physically inactive.4 Among racial/ethnic groups, 55% of African-American women and 57% of Hispanic women were inactive. The national prevalence of physical inactivity for Native American and Asian/Pacific Islander women are unknown.5 Living environment could promote or limit physical activity behavior. National data show that rural women in minority groups are more likely to be completely sedentary than urban women in minority groups.6,7 Lack of sidewalks and limited access to places where women can be physically active are often reported as barriers to physical activity in rural residents.8,9 Findings of two national studies indicated that urban resi-
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Table 1. Research site, population characteristics, and method of delivery University
n
Race/ethnicity
Environment
Mean age (years)
Method
University of Illinois–Chicago University of Illinois–Chicago University of Maryland–College Park University of Maryland–College Park University of South Carolina University of Alabama–Birmingham University of North Carolina–Chapel Hill University of New Mexico Saint Louis University
399 300 234 300 917 567 671 350 1000
African American Latina African American Latina African American African American Latina Native American White
Urban Urban Urban Urban Mixed Rural Mixed Mixed Rural
33.7 32.3 36.8 31.9 35.6 37.5 31.8 31.9 39.2
Interview Interview Interview Interview Telephone Telephone Interview Interview Telephone
dence was not associated with physical activity,10,11 but results from focus groups suggested that high crime and personal safety issues were common barriers to physical activity in urban women.12,13 Much of the past research to identify factors that influence physical activity focused on interpersonal or psychosocial variables.14 However, it could be that an ecologic approach is necessary for a more comprehensive understanding of physical activity behavior.5 An ecologic model, such as the one proposed by McLeroy et al.15 recognized that the numerous factors that influence physical activity include the social environment, community norms, and empowerment for affecting environmental and policy changes. Accordingly, these models can aid in understanding the correlates of physical activity in minority women because they recognize societal, organizational, and other external constraints placed on women that could limit their participation. Previous research that identified physical activity correlates showed that personal, interpersonal, social environmental, physical environmental, and policy level factors all influenced physical activity level.5 Personal factors, (e.g., self-efficacy or attitudes toward exercise) and interpersonal factors (e.g., social environment, level of social support) have been shown to be significant characteristics associated with physical activity.5 Community factors (e.g., sense of community and knowing people in the community who exercise) are another layer of influence on physical activity behavior. Policy issues (e.g., flexible work schedules) can also affect physical activity levels.5 An additional category of factors that could play an integral role in physical activity is the physical environment (e.g., presence of sidewalks or hills). Alone or in combination, these levels of factors can enhance or suppress a woman’s decision to become physically active.
Methods In 1999, the Centers for Disease Control and Prevention (CDC) funded seven universities to design and implement the Women’s Cardiovascular Health Network Project through the Prevention Research Centers (Table 1). The Robert
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Wood Johnson Foundation provided additional funding. The objective of this 3-year, multisite project was to identify factors, particularly policy and environmental factors, that are important in influencing physical activity among women in ethnic minority groups and low-income women aged 20 to 50 years. The populations studied are depicted in Table 1. The original populations were chosen in conjunction with the proposals written at the request of the funding agency. Urban Latina women were not represented in the original study but were added with additional funding from The Robert Wood Johnson Foundation. To achieve the objective of this project, an underlying goal was to develop a survey that can be used to effectively assess correlates of physical activity among diverse groups of women. Because of the inherent uniqueness of each group, our intention was not to pool the data but to look at the usability of the instrument in determining physical activity correlates in each group. Individual group data have more practical use than pooled data, because interventions most often target specific groups or subgroups of the population. Data from this study can be used to inform and tailor interventions to these groups. Our project began with a thorough literature search using the ecologic model as a theoretical base to identify knowledge gaps for the correlates of physical activity in the subgroups of interest.5 Subsequently, core questions were created for a qualitative (focus group) study that would help identify social, policy, and environmental factors as potential barriers or enablers of physical activity. Forty-two focus groups were conducted, and results were published in a monograph.12 Findings from the focus group study were used to develop a quantitative survey (Appendix 1).
Women and Physical Activity Survey The factors included in the survey were found to be associated with physical activity in our literature review, the qualitative analysis of the focus groups, or both. When possible, intact, psychometrically tested scales were used. However, some components (e.g., social issues) were developed specifically for this survey because no suitable, validated instrument was available. The reliability analyses from each of the ethnic/minority groups are described elsewhere in this supplement.16 The core components of the Women and Physical Activity Survey, their source, and an explanation of the contents are presented here.
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Physical activity assessment. The physical activity assessment was based on questions used in the 2001 Behavioral Risk Factor Surveillance System (BRFSS) survey.17 The questions assessed frequency and duration of moderate and vigorous physical activity performed in a usual week. Brief definitions of “moderate” and “vigorous” were stated before the questions were asked. Social issues scale. The social issues scale measured social perceptions that could be relevant to physical activity status. This scale was adapted from a scale used in the U.S. Women’s Determinants Survey.6 Some questions (e.g., health problems question) were added to the scale on the basis of information gained in the focus groups. The five questions on social issues begin with the phrase “When I see a woman exercising. . .” and cover factors such as feeling guilty about not exercising, wanting to exercise too, potential health problems, selfishness, and “showing-off.” One question (wanting to exercise too) was reverse coded, the responses were numerically added to calculate a total score, and the factor was used in the logistic regression analyses as an independent variable. Each question provided for a four-tiered response that ranged from strongly agree to strongly disagree. To compute a total score, the numbers for the responses were added. The higher the score, the more positive was the evaluation about women who exercised. The mean of the scale for each population was computed by dividing the total score by the number of questions. Social roles scale. This scale was adapted from the Women’s Role Strain Survey of Lengacher18 and was tailored to assess the strain of multiple social roles and the relationship to being physically active. The nine questions began with the phrase “If you wanted to exercise . . . .” The questions address factors that might “get in the way” of exercising. These factors include household tasks, childcare, eldercare, work, feeling guilty about taking time for self, husband/partner support, and other people’s thoughts about exercise. Each question provided for a four-tiered response that ranged from strongly agree to strongly disagree. A number was assigned for each response, and the numbers were added to compute a total score. The higher the score, the less social role strain the women reported. To obtain the mean social roles score, the total score was divided by the number of questions, taking into account a skip pattern of the response to marital status and the employment question. Sense of community scale. The sense of community scale was adapted from a sense of community perception scale.19 Questions about neighborhood issues included the following topics: Is the neighborhood a good place to live? Can neighbors be counted on if someone is threatened or injured? Can neighbors be counted on if someone is destructive to property? and Can law enforcement be counted on if needed? Each question had a four-tiered response that ranged from strongly agree to strongly disagree. The numeric responses to the questions were added, then divided by 4 to compute the mean. Physical environment scale. This scale was developed by Ainsworth et al.20 as an assessment of the physical environment, including perceptions of the community environment. This scale was used to obtain information on traffic volume,
presence of sidewalks and sidewalk conditions, street lighting at night, problems with unattended dogs, and safety from crime. The questions had varying scales of responses. The questions on street lighting, dogs, and crime were recoded by grouping responses into fewer categories for analyses. Other questions. In addition to these scales, the survey included questions that assessed socio-demographic characteristics, general health, self-efficacy, religious and community involvement, access to physical activity facilities, and suggestions for interventions. The survey was tested (n⫽70) before implementation. After analysis of pilot responses, no major changes were made to the survey after pilot testing.1
Terminology Physical activity is defined as bodily movement produced by the contraction of skeletal muscle that increases energy expenditure above the basal level.1 In contrast, exercise is defined as physical activity that is planned, structured, repetitive, and purposive in the sense that improvement or maintenance of one or more components of physical fitness is the objective.21 From our qualitative studies, we found that women confused the terms physical activity and exercise. Moderate physical activity was often equated with a general “busyness.”12 Therefore, the term exercise was used for many of the survey questions to convey the concept of intentional physical activity.
Data Collection Methods of delivery for this survey varied by site and are described in detail in each of the articles in this supplement. At three sites, the survey was conducted by telephone with the use of a modified form of random digit dialing within the selected population. Because the populations studied at several sites were difficult to reach by telephone, surveys were administered by face-to-face interview. Staff members at sites studying Latina women administered the survey in Spanish, unless the woman answering the survey preferred to respond in English. Data were collected in 2001–2002. Detailed descriptions of sample selections and data collection methodology are presented in each of the articles included in this supplement.
Data Analysis Analysis was guided by research questions that were determined at the beginning of the study that reflected the multilevel, ecologic model as it applies to physical activity behavior. The research questions were as follows: ● ● ●
What personal factors influence physical activity in women? What is the nature and extent of social influence on physical activity in women? Does the physical environment influence physical activity in women?
To answer these questions, the main dependent variable in this study was physical activity status. With the use of recommendations developed by CDC and the American College of Sports Medicine,22 we divided the samples into three categories: meets recommendations (women who were moderately
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active for 30 minutes 5 to 7 days a week or vigorously active 20 minutes 3 to 7 days a week), insufficiently active (women who did some physical activity but not enough to meet recommendations), and inactive (women who did not participate in any moderate or vigorous physical activities for at least 10 minutes at a time in a usual week). We conducted two analyses. First, the women who met recommendations were compared with the women who were inactive plus the women who were insufficiently active. By this comparison, we were able to identify differences between women who met recommendations and women who did not meet the recommendations. This information could be useful in planning baseline physical activity programs geared toward inactive women. Second, we compared the women who met recommendations plus the women who were insufficiently active with women who were inactive. Grouping those women who did any activity (not just those who met recommendations) can give us more insight on potential factors that could distinguish physically active versus physically inactive. With the use of physical activity status as the dependent variable, we computed unadjusted odds ratios (ORs) and 95% confidence intervals (CIs) for variables to answer each of the research questions. Analyses were redone, controlling for important potential confounders relevant to each population under study. Because of the population differences, adjusting for the same factors across groups was not a practical aspect of analysis. For example, acculturation was an influential factor among Latina women but would not have been an adjustable factor for other groups. Each group adjusted for factors relevant to their own population. The variables used to determine correlation of personal factors with physical activity status were age, education, income, employment, marital status, number of children aged 17 years or younger living at home, general health status, and self-efficacy. For the research question on social influence, the independent variables included knowing people who exercise, seeing people exercising in the neighborhood, belonging to community groups, and attending religious services. Also, social roles, social issues, and sense of community were independent variables, and the mean scores were used in comparisons. For the research question on physical environment, the independent variables were traffic, the presence of sidewalks, street lighting at night, unattended dogs, safety, places within walking distance, and access to places to exercise. Additionally, open-ended questions about why women did not exercise or did not exercise more and about potential changes in the community or workplace that would facilitate more exercise were analyzed by frequency of response.
Limitations Several limitations of this study warrant discussion. First, this survey relied on self-reported information. Although observation and/or biomechanical measurement might be more accurate in measuring physical activity, it is costly and methodologically difficult for large studies. We addressed this potential bias by using one of the most valid and reliable lifestyle physical activity assessments available for the general population.17 Additionally, physical activity is a multifaceted and complex behavior. Differences in perception could 8
have contributed to variance in responses. For example, not having sidewalks may not be seen as a barrier to someone who is a dedicated walker but would be perceived as a barrier to others. Second, even though this was a study of minority women, we did not include Asian women. This exclusion was due to parameters of the funding agency and might be considered a limitation of the study. In addition, because this study was cross-sectional, temporality of results cannot be implied. Despite the limitations, this is one of the most comprehensive studies on physical activity among diverse populations of women, and it significantly contributes to the literature on the topic.
Conclusions Although research on physical activity is expanding, some population groups are still not well represented in studies. This study adds to the literature on Latinas and Native American women and will provide good information on assessment of correlates for women in general. By determining correlates important in the decision of women to be physically active, more effective interventions can be planned and implemented in these population groups.
References 1. United States Department of Health and Human Services. Physical activity and health: a report of the Surgeon General. Atlanta GA: U.S. Department of Health and Human Services, Center for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion, 1996. 2. Centers for Disease Control and Prevention. Physical activity trends— United States, 1990 –1998. MMWR Morb Mortal Wkly Rep 2001;50:166 –9. 3. Centers for Disease Control and Prevention. Monthly estimates of leisuretime physical activity—United States, 1994. MMWR Morb Mortal Wkly Rep 1997;46:393–7. 4. Schoenborn C, Barnes P. Leisure-time physical activity among adults: United States, 1997–98. Adv Data Vital Health Stat 2002;325:1–23. 5. Eyler A, Wilcox S, Matson-Koffman D, et al. Correlates of physical activity among women from diverse racial/ethnic groups: a review. J Womens Health Gend Based Med 2002;11:239 –53. 6. Brownson R, Eyler A, King A, Brown D, Shyu Y, Sallis J. Patterns and correlates of physical activity among U.S. women 40 years and older. Am J Public Health 2000;90:264 –70. 7. Wilcox S, Castro C, King A, Housemann R, Brownson R. Determinants of leisure time physical activity in rural compared with urban older and ethnically diverse women in the United States. J Epidemiol Community Health 2000;54:667–72. 8. Eyler A, Vest J. Environmental and policy factors related to physical activity in rural white women. Women Health 2002;36:111–22. 9. Brownson R, Schmid T, King A, et al. Support for policy interventions to increase physical activity in rural Missouri. Am J Health Promot 1997;12: 263–6. 10. Duelberg S. Preventive health behavior among black and white women in urban and rural areas. Soc Sci Med 1992;34:191–8. 11. King A, Castro C, Wilcox S, Eyler A, Sallis J, Brownson R. Personal and environmental factors associated with physical inactivity among different racial/ethnic groups of U.S. middle- and older-aged women. Health Psychol 2000;19:354 –64.
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12. Eyler A, Wilcox S, Matson-Koffman D, et al. Environmental, cultural, and policy factors related to physical activity in a diverse sample of women: the Women’s Cardiovascular Health Network Project. Women Health 2002;36: 123–38. 13. Eyler A, Baker E, Cromer L, King A, Brownson R, Donatelle R. Physical activity and minority women: a qualitative study. Health Educ Behavior 1998;25:640 –52. 14. Sallis J, Bauman A, Pratt M. Environmental and policy interventions to promote physical activity. Am J Prev Med 1998;15:379 –97. 15. McLeroy K, Bibeau D, Steckler A, Glanz K. An ecological perspective on health promotion programs. Health Educ Q 1988;15:351–77. 16. Evenson K, Eyler A, Wilcox S, Thompson JL, Burke J. Test–retest reliability of a questionnaire on physical activity and its correlates among women from diverse racial and ethnic groups. Am J Prev Med 2003;25(suppl):15–22. 17. Centers for Disease Control and Prevention. Behavioral Risk Factor Surveil
18. 19.
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lance System. Available at: www.cdc.gov/brfss. Accessed on December 1, 2002. Lengacher C. A reliability and validity study of the Women’s Role Strain Inventory. J Nurs Meas 1997;5:139 –50. Parker E, Lichtenstein R, Chulz A, et al. Disentangling measures of individual perceptions of community social dynamics: results of a community survey. Health Educ Behav 2001;28:462–86. Ainsworth B, Bassett D, Strath S, et al. Comparison of three methods of measuring time spent in physical activity. Med Sci Sports Exerc 2002;32: s457–64. Caspersen CJ, Powell KE, Christenson GM. Physical activity, exercise, and physical fitness: definitions and distinctions for health-related research. Public Health Rep 1985;100:126 –31. Pate R, Pratt M, Blair S, et al. Physical activity and public health. A recommendation from the Centers for Disease Control and Prevention and the American College of Sports Medicine. JAMA 1995;273:402–7.
Appendix 1 Women and Physical Activity Survey Screening Questions 1.1) What is your age? ___ Enter age in years 777. Don’t know/Not sure 999. Refused What is your race? Would you say: 1.2) Which one or more of the following would you say is your race? Read: 1. White 2. Black or African American 3. Asian 4. Native Hawaiian or Other Pacific Islander 5. American Indian, Alaska Native: Tribe or 6. Other Do not read: 7. don’t know 9. refused 1.3) Are you Hispanic or Latino? 1. Yes 0. No Do not read: 777. Don’t know/not sure 999. Refused
Physical Environment 2.1) In general, would you say the motorized traffic where you live is . . . Read: 1. Heavy 2. Moderate 3. Light 777. Don’t know/not sure 999. Refused 2.2) Does your immediate neighborhood have any sidewalks? Do not read: 1. Yes 0. No SKIP To 2.4
777. Don’t Know/Not Sure 999. Refused SKIP To 2.4 2.3) For walking where you live, would you say your sidewalks are Read: 1. Very well maintained 2. Somewhat maintained 3. Not very well maintained 4. Not at all maintained Do not read: 777. Don’t know/not sure 999. Refused 2.4) For walking at night, would you describe the street lighting where you live as Emphasize street lighting. Read: 1. Very good 2. Good 3. Fair 4. Poor 5. Very poor 666. No lighting Do not read: 777. Don’t know/not sure 999. Refused 2.5) For walking where you live, would you say that unattended dogs are . . . Read: 1. A big problem 2. Somewhat of a problem 3. Not very much of a problem 4. Not a problem at all Do not read: 777. Don’t know/not sure 999. Refused 2.6) How safe from crime is it where you live? Would you say . . . Read: 1. Extremely safe 2. Somewhat safe 3. Slightly safe 4. Not at all safe
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Do not read: 777. Don’t know/not sure 999. Refused 2.7) In you community, are there businesses or places where you need to go such as stores or churches, where you can walk instead of driving? Do not read: 1. Yes 0. No . . . . . . . . . skip to #2.10 777. Don’t Know/Not Sure . . . skip to #2.10 999. Refused . . . skip to #2.10 2.8) Do you consider it safe to walk there? Do not read: 1. Yes 0. No 777. Don’t Know/Not Sure . . . skip to #2.10 999. Refused . . . skip to #2.10 2.9) Do you walk there? Read: 1. Always 2. Sometimes 3. Never Do not read: 777. Don’t know/Not Sure 999. Refused 2.10) In your community are there places you could go to exercise if you wanted to? Do not read: 1. Yes 0. No . . . skip to #2.12 777. Don’t Know/Not Sure . . . skip to #2.12 999. Refused . . . skip to #2.12 2.11) Are they indoor, outdoor or both? Do not read: 1. Both 2. Indoor 3. Outdoor 4. Neither 777. don’t know/not sure 999. refused 2.12) What things about your community or neighborhood keeps you from exercising more? (Mark all responses) Do not read: 1. Not enough sidewalks 2. Not enough bike lanes 3. Not enough recreational facilities 4. Not enough physical activity programs 5. High crime 6. No street lights 7. Unattended dogs 8. Too many hills 9. Bad weather 10. Heavy traffic 11. Four air from cars 12. Poor scenery 13. Rural environment or remote area 14. Gang violence 15. Verbal abuse from persons on street 16. Mentally ill or homeless people on street 17. Random gunshots 18. Speeding drivers 19. Nothing or no reason
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20. Other reason 777. Don’t Know/Not Sure 999. Refused
Sense of Community Please indicate if you agree with the following four statements on a scale of strongly agree, agree, disagree, or strongly disagree. 3.1) Your neighborhood is a good place for you and your family to live. Read: 1. Strongly Agree 2. Agree 3. Disagree 4. Strongly Disagree Do not read: 777. Don’t know/not sure 999. Refused 3.2) Your neighbors can be counted on to help if someone is physically threatened or injured. Read: 1. Strongly Agree 2. Agree 3. Disagree 4. Strongly Disagree Do not Read: 777. Don’t know/not sure 999. Refused 3.3) Your neighbors can be counted on to help if someone is destructive to property in your neighborhood. Read: 1. Strongly Agree 2. Agree 3. Disagree 4. Strongly Disagree Do not Read: 777. Don’t know/not sure 999. Refused 3.4) Law enforcement can be counted on if there is trouble in the neighborhood. Read: 1. Strongly Agree 2. Agree 3. Disagree 4. Strongly Disagree Do not Read: 777. Don’t know/not sure 999. Refused 3.5) Do you attend any neighborhood, community, or social group meetings such as block watches, parent teacher associations, etc? Do not read: 1. Yes 0. No 777. Don’t know/not sure 999. Refused 3.6) Do you attend any religious services or functions? Do not read: 1. Yes 0. No
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777. Don’t know/not sure 999. Refused If answered no to both #3.5 and #3.6 go to #4.1 3.7) Do you spend time in these organizations talking about topics like smoking, eating, or exercise? Do not read: 1. Yes 0. No SKIP TO 4.1 777. Don’t Know/Not Sure SKIP TO 4.1 999. Refused SKIP TO 4.1 3.8) Have you made any changes in your health behaviors as a result of comments made or programs held through these organizations? Do not read: 1. Yes 0. No 777. Don’t know/not sure 999. Refused
Employment, Marital Status and Children 4.1) Which of the following best describes you: Read: 1. Employed for wages full-time 2. Employed for wages part-time 3. Self-employed 4. Out of work for more than 1 year 5. Out of work for less than 1 year 6. Homemaker 7. Student 8. Retired 9. Disabled and unable to work Do not read: 777. Don’t know/not sure 999. Refused 4.2) Which of these best describes you? Read: 1. Married 2. A member of an unmarried couple 3. Divorced 4. Widowed 5. Separated 6. Never been married Do not read: 777. Don’t know/Not sure 999. Refused 4.3) How many children live in your household who are . . . Read: 1. Less than 5 years old 2. 5 through 12 years old 3. 13 through 17 years old Do not read: 777. Don’t know/not sure 999. Refused
Physical Activity Ask if answered 1, 2 or 3 to question 4 . . . , if none of those responses go to question 5.2 5.1 When you are at work, which of the following best describes what you do? Would you say
Read: 1. Mostly sitting or standing 2. Mostly walking e. Mostly heavy labor or physically demanding work Do not read: 777. Don’t know/not sure 999. Refused We are interested in two types of physical activity—vigorous and moderate. Vigorous activities cause large increases in breathing or heart rate while moderate activities cause small increases in breathing or heart rate. Now, thinking about the moderate physical activities that you do [if employed, insert: while not working,] . . . 5.2) In a usual week, do you do moderate activities for at least 10 minutes at a time, such as brisk walking, bicycling, vacuuming, gardening, or anything else that causes some increase in breathing or heart rate? Do not read: 1. Yes 0. No . . . skip to #5.5 777. Don’t know/not sure . . . skip to #5.5 999. Refused . . . skip to #5.5 5.3) How many days per week do you do moderate activities for at least 10 minutes at a time? Do not read: Days per week 777. Don’t know/not sure 999. Refused 5.4) On days when you do moderate activities for at least 10 minutes at a time, how much total time do you spend doing these activities? Do not read: : Hours and minutes 777. Don’t Know/Not sure 999. Refused Now, thinking about the vigorous activities you do [if employed, insert: while not working,] . . . 5.5) In a usual week, do you do vigorous activities for at least 10 minutes at a time, such as running, aerobics, heavy yard work, or anything else that causes large increases in breathing or heart rate? Do not read: 1. Yes 0. No . . . skip to #6.1 777. Don’t know/not sure . . . skip to #6.1 999. Refused . . . . . . skip to #6.1 5.6) How many days per week do you do these vigorous activities? Do not read: Days per week 777. Don’t Know/Not sure 999. Refused 5.7) On days when you do vigorous activities for at least 10 minutes at a time, how much total time do you spend doing these activities? Do not read: : Hours and minutes 777. Don’t Know/Not sure 999. Refused
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Social Issues 6.1) How many people in your neighborhood exercise? Would you say . . . Read: 1. A lot exercise 2. Some exercise 3. Few exercise 4. None at all exercise Do not read: 777. Don’t know/not sure 999. Refused 6.2) Do you know people who exercise? Do not read: 1. Yes 0. No . . . skip to #6.4 777. Don’t know/not sure . . . skip to #6.4 999. Refused . . . skip to #6.4 6.3) Why do you think they exercise? (may respond with more than one answer) Mark all responses. Do not read: 1. health 2. feel better 3. weight 4. mental benefits 5. health care provider advice 6. sleep better 7. look better 8. social reasons 9. Other 777. don’t know 999. Refused Please indicate if you agree with the following statements on a scale of strongly agree, agree, disagree, or strongly disagree. 6.4) When I see women exercising, it makes me feel guilty. Would you say that you . . . Read: 1. Strongly agree 2. Agree 3. Disagree 4. Strongly disagree Do not read: 777. Don’t know/not sure 999. Refused 6.5) When I see women exercising I want to exercise, too. Would you say that you . . . Read: 1. Strongly agree 2. Agree 3. Disagree 4. Strongly disagree Do not read: 777. Don’t know/not sure 999. Refused 6.6) When I see a woman exercising, I think she probably has a health problem like diabetes or high blood pressure. Would you say that you . . . Read: 1. Strongly agree 2. Agree 3. Disagree 4. Strongly disagree
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Do not read: 777. Don’t know/not sure 999. Refused 6.7) When I see a woman exercising, I think she is selfish. Would you say that you . . . Read: 1. Strongly agree 2. Agree 3. Disagree 4. Strongly disagree Do not read: 777. Don’t know/not sure 999. Refused 6.8) When I see a woman exercising, I think she is showing off. Would you say that you . . . Read: 1. Strongly agree 2. Agree 3. Disagree 4. Strongly disagree Do not read: 777. Don’t know/not sure 999. Refused
Social Roles 7.1) If you wanted to exercise, household tasks like cooking and cleaning would get in the way. Would you say that you . . . Read: 1. Strongly agree 2. Agree 3. Disagree 4. Strongly disagree Do not read: 777. Don’t know/not sure 999. Refused 7.2) If you wanted to exercise, childcare responsibilities would get in the way. Would you say that you . . . Read: 1. Strongly agree 2. Agree 3. Disagree 4. Strongly disagree Do not read: 777. Don’t know/not sure 999. Refused 7.3) If you wanted to exercise, elder care responsibilities would get in the way. Would you say that you Read: 1. Strongly agree 2. Agree 3. Disagree 4. Strongly disagree Do not read: 777. Don’t know/not sure 999. Refused Ask if answered 1, 2 or 3 to #4.1, if not go to #7.5 7.4) If you wanted to exercise, work would get in the way. Would you say that you . . . Read: 1. Strongly agree
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2. Agree 3. Disagree 4. Strongly disagree Do not read: 777. Don’t know/not sure 999. Refused 7.5) If you wanted to exercise, feeling guilty for taking time for yourself would get in the way. Would you say that you . . . Read: 1. Strongly agree 2. Agree 3. Disagree 4. Strongly disagree Do not read: 777. Don’t Know/Not Sure 999. Refused Ask if answered 1 or 2 to #4.2, if not go to #7.7 7.6) If you wanted to exercise, what your partner or husband might think about you would get in the way. Would you say that you . . . Read: 1. Strongly agree 2. Agree 3. Disagree 4. Strongly disagree Do not read: 777. Don’t know/not sure 999. Refused 7.7) If you wanted to exercise, what other people might think about you would get in the way. Would you say that you . . . Read: 1. Strongly agree 2. Agree 3. Disagree 4. Strongly disagree Do not read: 777. Don’t know/not sure 999. Refused 7.8) If you wanted to exercise, community obligations or activities would get in the way. Would you say that you . . . Read: 1. Strongly agree 2. Agree 3. Disagree 4. Strongly disagree Do not read: 777. Don’t know/not sure 999. Refused 7.9) If you wanted to exercise, you would need to put more effort into organizing your time. Would you say that you . . . Read: 1. Strongly agree 2. Agree 3. Disagree 4. Strongly disagree Do not read: 777. Don’t know/not sure 999. Refused
Motivation and Self-Efficacy 8.1) What is the main personal reason you do not exercise more? (mark only one) Do not read: 1. don’t have enough time 2. too tired or don’t have the energy 3. ill or otherwise physically unable 4. don’t enjoy being active 5. don’t have anyone to be active with 6. afraid of injury 7. it is too expensive 8. already get enough exercise 9. self-motivation or will power 10. no personal reason 11. other 777. Don’t Know/Not Sure 999. refused 8.2) What one thing would it take to get you to exercise more? (mark only one) Do not read: 1. more time 2. money 3. access 4. support from family 5. support from a friend 6. childcare 7. doctor’s advice 8. transportation 9. facilities 10. self-motivation or will-power 11. no personal reason 12. already get enough exercise 13. other 777. Don’t Know/Not Sure 999. refused 8.3) How confident are you that you could exercise more. Would you say that are are: Read: 1. Very confident 2. Somewhat confident 3. Not at all confident Do not read: 777. Don’t Know/Not Sure 999. Refused
Suggested Interventions 9.1) What in your community could be done or changed that would be most helpful in increasing the exercise levels of women? Ask if answered 1, 2, or 3 to 4.1, if not go to question 10.1 9.2) What in your workplace could be done or changed that would be most helpful in increasing the exercise levels of women in your community?
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Demographics and General Health 10.1) Would you say that in general your health is: Read: 1. Excellent 2. Very Good 3. Good 4. Fair 5. Poor Do not read: 777. Don’t know/not sure 999. Refused 10.2) What is your zip code? Do not read: _____ 777. Don’t know/not sure 999. Refused 10.3) Is your annual household income from all sources . . . Read: 4. a. Less than $25,000 If “no,” ask e; if “yes,” ask b ($20,000 to less than $25,000) 3. b. Less than $20,000 If “no,” code a; if “yes,” ask c ($15,000 to less than $20,000) 2. c. Less than $15,000 If “no,” code b; if “yes,” ask d ($10,000 to less than $15,000) 1. d. Less than $10,000 If “no,” code c 5. e. Less than $35,000 If “no,” ask f ($25,000 to less than $35,000)
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6. f. Less than $50,000 If “no,” ask g ($35,000 to less than $50,000) 7. g. Less than $75,000 If “no,” code h ($50,000 to $75,000) 8. h. $75,000 or more Do not read: 777. Don’t know/not sure 999. Refused 10.4) What is the highest grade or year of school you completed? Do not read: 1. Eighth grade or less 2. Some high school 3. High school or GED certificate 4. Some technical school 5. Some college 6. College graduate 7. Post grad or professional degree 777. Don’t know/Not sure 999. Refused
Closing Statement That’s my last question. Everyone’s answers will be combined to give us information about health practices of people. Thank you very much for your time and cooperation.
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Quantitative Study of Correlates of Physical Activity in Women from Diverse Racial/Ethnic Groups Women’s Cardiovascular Health Network Project Introduction and Methodology Amy A. Eyler, PhD, Dyann Matson-Koffman, PhD, Deborah Rohm Young, PhD, Sara Wilcox, PhD, JoEllen Wilbur, PhD, Janice L. Thompson, PhD, Bonnie K. Sanderson, PhD, Kelly R. Evenson, PhD Background: Physical activity is an important aspect of cardiovascular disease prevention. However, data show a high prevalence of physical inactivity among women and ethnic minority and low-income populations. The purpose of this introduction is to describe the Women’s Cardiovascular Health Network Project and implementation of the Women and Physical Activity Survey. The goal of the survey was to identify personal, social environmental, and physical environmental factors that are associated with physical activity status among diverse groups of women. Methods:
Seven universities were funded to study factors that influence physical activity among African-American, Native American, Latina, and white women residing in rural, suburban, and urban living environments. An ecologic model was used to design a quantitative questionnaire that was implemented by telephone or face-to-face interviews in seven sites across the United States.
Results:
The survey was completed by a total 4122 women, with group totals ranging from 300 to 1000. Results from each site are presented in individual articles in this issue. A summary of results that compare and contrast the groups is presented in an additional report.
Conclusion:
This study provides important information on the assessment of physical activity among women. Results can be used to help improve assessments and to develop more effective policies and interventions for unique groups of women. (Am J Prev Med 2003;25(3Si):5–14) © 2003 American Journal of Preventive Medicine
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large body of research has established that regular physical activity reduces the risk of premature death and disability from a variety of health conditions and cardiovascular disease in particular.1 Despite the known benefits of a physically active From the Prevention Research Center, School of Public Health, Saint Louis University (Eyler), St. Louis, Missouri; Cardiovascular Health Branch, Division of Adult and Community Health, National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention (Matson-Koffman), Atlanta, Georgia; Department of Kinesiology, University of Maryland (Young), College Park, Maryland; Department of Exercise Science, Norman J. Arnold School of Public Health, University of South Carolina (Wilcox), Columbia, South Carolina; Department of Public Health, Mental Health, and Administrative Nursing, College of Nursing, University of Illinois at Chicago (Wilbur), Chicago, Illinois; Department of Pediatrics, Center for Health Promotion and Disease Prevention, University of New Mexico Health Sciences Center (Thompson), Albuquerque, New Mexico; University of Alabama (Sanderson), Birmingham, Alabama; Department of Epidemiology, School of Public Health, University of North Carolina–Chapel Hill (Evenson), Chapel Hill, North Carolina Address correspondence and reprint requests to: Amy A. Eyler, PhD, Prevention Research Center, School of Public Health, Saint Louis University, 3545 Lafayette Avenue, St. Louis MO 63104. E-mail: [email protected].
lifestyle, more than one quarter of the U.S. population remains completely inactive during leisure time, and U.S. trends in activity showed little improvement from 1990 through 1998.2 Also, population-wide surveillance data show a high prevalence of physical inactivity for leisure time, particularly among women and ethnic minority and low-income populations.3 According to the 1997–1998 National Health Interview Survey, approximately 41% of women were physically inactive.4 Among racial/ethnic groups, 55% of African-American women and 57% of Hispanic women were inactive. The national prevalence of physical inactivity for Native American and Asian/Pacific Islander women are unknown.5 Living environment could promote or limit physical activity behavior. National data show that rural women in minority groups are more likely to be completely sedentary than urban women in minority groups.6,7 Lack of sidewalks and limited access to places where women can be physically active are often reported as barriers to physical activity in rural residents.8,9 Findings of two national studies indicated that urban resi-
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0749-3797/03/$–see front matter doi:10.1016/S0749-3797(03)00159-4
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Table 1. Research site, population characteristics, and method of delivery University
n
Race/ethnicity
Environment
Mean age (years)
Method
University of Illinois–Chicago University of Illinois–Chicago University of Maryland–College Park University of Maryland–College Park University of South Carolina University of Alabama–Birmingham University of North Carolina–Chapel Hill University of New Mexico Saint Louis University
399 300 234 300 917 567 671 350 1000
African American Latina African American Latina African American African American Latina Native American White
Urban Urban Urban Urban Mixed Rural Mixed Mixed Rural
33.7 32.3 36.8 31.9 35.6 37.5 31.8 31.9 39.2
Interview Interview Interview Interview Telephone Telephone Interview Interview Telephone
dence was not associated with physical activity,10,11 but results from focus groups suggested that high crime and personal safety issues were common barriers to physical activity in urban women.12,13 Much of the past research to identify factors that influence physical activity focused on interpersonal or psychosocial variables.14 However, it could be that an ecologic approach is necessary for a more comprehensive understanding of physical activity behavior.5 An ecologic model, such as the one proposed by McLeroy et al.15 recognized that the numerous factors that influence physical activity include the social environment, community norms, and empowerment for affecting environmental and policy changes. Accordingly, these models can aid in understanding the correlates of physical activity in minority women because they recognize societal, organizational, and other external constraints placed on women that could limit their participation. Previous research that identified physical activity correlates showed that personal, interpersonal, social environmental, physical environmental, and policy level factors all influenced physical activity level.5 Personal factors, (e.g., self-efficacy or attitudes toward exercise) and interpersonal factors (e.g., social environment, level of social support) have been shown to be significant characteristics associated with physical activity.5 Community factors (e.g., sense of community and knowing people in the community who exercise) are another layer of influence on physical activity behavior. Policy issues (e.g., flexible work schedules) can also affect physical activity levels.5 An additional category of factors that could play an integral role in physical activity is the physical environment (e.g., presence of sidewalks or hills). Alone or in combination, these levels of factors can enhance or suppress a woman’s decision to become physically active.
Methods In 1999, the Centers for Disease Control and Prevention (CDC) funded seven universities to design and implement the Women’s Cardiovascular Health Network Project through the Prevention Research Centers (Table 1). The Robert
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Wood Johnson Foundation provided additional funding. The objective of this 3-year, multisite project was to identify factors, particularly policy and environmental factors, that are important in influencing physical activity among women in ethnic minority groups and low-income women aged 20 to 50 years. The populations studied are depicted in Table 1. The original populations were chosen in conjunction with the proposals written at the request of the funding agency. Urban Latina women were not represented in the original study but were added with additional funding from The Robert Wood Johnson Foundation. To achieve the objective of this project, an underlying goal was to develop a survey that can be used to effectively assess correlates of physical activity among diverse groups of women. Because of the inherent uniqueness of each group, our intention was not to pool the data but to look at the usability of the instrument in determining physical activity correlates in each group. Individual group data have more practical use than pooled data, because interventions most often target specific groups or subgroups of the population. Data from this study can be used to inform and tailor interventions to these groups. Our project began with a thorough literature search using the ecologic model as a theoretical base to identify knowledge gaps for the correlates of physical activity in the subgroups of interest.5 Subsequently, core questions were created for a qualitative (focus group) study that would help identify social, policy, and environmental factors as potential barriers or enablers of physical activity. Forty-two focus groups were conducted, and results were published in a monograph.12 Findings from the focus group study were used to develop a quantitative survey (Appendix 1).
Women and Physical Activity Survey The factors included in the survey were found to be associated with physical activity in our literature review, the qualitative analysis of the focus groups, or both. When possible, intact, psychometrically tested scales were used. However, some components (e.g., social issues) were developed specifically for this survey because no suitable, validated instrument was available. The reliability analyses from each of the ethnic/minority groups are described elsewhere in this supplement.16 The core components of the Women and Physical Activity Survey, their source, and an explanation of the contents are presented here.
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Physical activity assessment. The physical activity assessment was based on questions used in the 2001 Behavioral Risk Factor Surveillance System (BRFSS) survey.17 The questions assessed frequency and duration of moderate and vigorous physical activity performed in a usual week. Brief definitions of “moderate” and “vigorous” were stated before the questions were asked. Social issues scale. The social issues scale measured social perceptions that could be relevant to physical activity status. This scale was adapted from a scale used in the U.S. Women’s Determinants Survey.6 Some questions (e.g., health problems question) were added to the scale on the basis of information gained in the focus groups. The five questions on social issues begin with the phrase “When I see a woman exercising. . .” and cover factors such as feeling guilty about not exercising, wanting to exercise too, potential health problems, selfishness, and “showing-off.” One question (wanting to exercise too) was reverse coded, the responses were numerically added to calculate a total score, and the factor was used in the logistic regression analyses as an independent variable. Each question provided for a four-tiered response that ranged from strongly agree to strongly disagree. To compute a total score, the numbers for the responses were added. The higher the score, the more positive was the evaluation about women who exercised. The mean of the scale for each population was computed by dividing the total score by the number of questions. Social roles scale. This scale was adapted from the Women’s Role Strain Survey of Lengacher18 and was tailored to assess the strain of multiple social roles and the relationship to being physically active. The nine questions began with the phrase “If you wanted to exercise . . . .” The questions address factors that might “get in the way” of exercising. These factors include household tasks, childcare, eldercare, work, feeling guilty about taking time for self, husband/partner support, and other people’s thoughts about exercise. Each question provided for a four-tiered response that ranged from strongly agree to strongly disagree. A number was assigned for each response, and the numbers were added to compute a total score. The higher the score, the less social role strain the women reported. To obtain the mean social roles score, the total score was divided by the number of questions, taking into account a skip pattern of the response to marital status and the employment question. Sense of community scale. The sense of community scale was adapted from a sense of community perception scale.19 Questions about neighborhood issues included the following topics: Is the neighborhood a good place to live? Can neighbors be counted on if someone is threatened or injured? Can neighbors be counted on if someone is destructive to property? and Can law enforcement be counted on if needed? Each question had a four-tiered response that ranged from strongly agree to strongly disagree. The numeric responses to the questions were added, then divided by 4 to compute the mean. Physical environment scale. This scale was developed by Ainsworth et al.20 as an assessment of the physical environment, including perceptions of the community environment. This scale was used to obtain information on traffic volume,
presence of sidewalks and sidewalk conditions, street lighting at night, problems with unattended dogs, and safety from crime. The questions had varying scales of responses. The questions on street lighting, dogs, and crime were recoded by grouping responses into fewer categories for analyses. Other questions. In addition to these scales, the survey included questions that assessed socio-demographic characteristics, general health, self-efficacy, religious and community involvement, access to physical activity facilities, and suggestions for interventions. The survey was tested (n⫽70) before implementation. After analysis of pilot responses, no major changes were made to the survey after pilot testing.1
Terminology Physical activity is defined as bodily movement produced by the contraction of skeletal muscle that increases energy expenditure above the basal level.1 In contrast, exercise is defined as physical activity that is planned, structured, repetitive, and purposive in the sense that improvement or maintenance of one or more components of physical fitness is the objective.21 From our qualitative studies, we found that women confused the terms physical activity and exercise. Moderate physical activity was often equated with a general “busyness.”12 Therefore, the term exercise was used for many of the survey questions to convey the concept of intentional physical activity.
Data Collection Methods of delivery for this survey varied by site and are described in detail in each of the articles in this supplement. At three sites, the survey was conducted by telephone with the use of a modified form of random digit dialing within the selected population. Because the populations studied at several sites were difficult to reach by telephone, surveys were administered by face-to-face interview. Staff members at sites studying Latina women administered the survey in Spanish, unless the woman answering the survey preferred to respond in English. Data were collected in 2001–2002. Detailed descriptions of sample selections and data collection methodology are presented in each of the articles included in this supplement.
Data Analysis Analysis was guided by research questions that were determined at the beginning of the study that reflected the multilevel, ecologic model as it applies to physical activity behavior. The research questions were as follows: ● ● ●
What personal factors influence physical activity in women? What is the nature and extent of social influence on physical activity in women? Does the physical environment influence physical activity in women?
To answer these questions, the main dependent variable in this study was physical activity status. With the use of recommendations developed by CDC and the American College of Sports Medicine,22 we divided the samples into three categories: meets recommendations (women who were moderately
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active for 30 minutes 5 to 7 days a week or vigorously active 20 minutes 3 to 7 days a week), insufficiently active (women who did some physical activity but not enough to meet recommendations), and inactive (women who did not participate in any moderate or vigorous physical activities for at least 10 minutes at a time in a usual week). We conducted two analyses. First, the women who met recommendations were compared with the women who were inactive plus the women who were insufficiently active. By this comparison, we were able to identify differences between women who met recommendations and women who did not meet the recommendations. This information could be useful in planning baseline physical activity programs geared toward inactive women. Second, we compared the women who met recommendations plus the women who were insufficiently active with women who were inactive. Grouping those women who did any activity (not just those who met recommendations) can give us more insight on potential factors that could distinguish physically active versus physically inactive. With the use of physical activity status as the dependent variable, we computed unadjusted odds ratios (ORs) and 95% confidence intervals (CIs) for variables to answer each of the research questions. Analyses were redone, controlling for important potential confounders relevant to each population under study. Because of the population differences, adjusting for the same factors across groups was not a practical aspect of analysis. For example, acculturation was an influential factor among Latina women but would not have been an adjustable factor for other groups. Each group adjusted for factors relevant to their own population. The variables used to determine correlation of personal factors with physical activity status were age, education, income, employment, marital status, number of children aged 17 years or younger living at home, general health status, and self-efficacy. For the research question on social influence, the independent variables included knowing people who exercise, seeing people exercising in the neighborhood, belonging to community groups, and attending religious services. Also, social roles, social issues, and sense of community were independent variables, and the mean scores were used in comparisons. For the research question on physical environment, the independent variables were traffic, the presence of sidewalks, street lighting at night, unattended dogs, safety, places within walking distance, and access to places to exercise. Additionally, open-ended questions about why women did not exercise or did not exercise more and about potential changes in the community or workplace that would facilitate more exercise were analyzed by frequency of response.
Limitations Several limitations of this study warrant discussion. First, this survey relied on self-reported information. Although observation and/or biomechanical measurement might be more accurate in measuring physical activity, it is costly and methodologically difficult for large studies. We addressed this potential bias by using one of the most valid and reliable lifestyle physical activity assessments available for the general population.17 Additionally, physical activity is a multifaceted and complex behavior. Differences in perception could 8
have contributed to variance in responses. For example, not having sidewalks may not be seen as a barrier to someone who is a dedicated walker but would be perceived as a barrier to others. Second, even though this was a study of minority women, we did not include Asian women. This exclusion was due to parameters of the funding agency and might be considered a limitation of the study. In addition, because this study was cross-sectional, temporality of results cannot be implied. Despite the limitations, this is one of the most comprehensive studies on physical activity among diverse populations of women, and it significantly contributes to the literature on the topic.
Conclusions Although research on physical activity is expanding, some population groups are still not well represented in studies. This study adds to the literature on Latinas and Native American women and will provide good information on assessment of correlates for women in general. By determining correlates important in the decision of women to be physically active, more effective interventions can be planned and implemented in these population groups.
References 1. United States Department of Health and Human Services. Physical activity and health: a report of the Surgeon General. Atlanta GA: U.S. Department of Health and Human Services, Center for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion, 1996. 2. Centers for Disease Control and Prevention. Physical activity trends— United States, 1990 –1998. MMWR Morb Mortal Wkly Rep 2001;50:166 –9. 3. Centers for Disease Control and Prevention. Monthly estimates of leisuretime physical activity—United States, 1994. MMWR Morb Mortal Wkly Rep 1997;46:393–7. 4. Schoenborn C, Barnes P. Leisure-time physical activity among adults: United States, 1997–98. Adv Data Vital Health Stat 2002;325:1–23. 5. Eyler A, Wilcox S, Matson-Koffman D, et al. Correlates of physical activity among women from diverse racial/ethnic groups: a review. J Womens Health Gend Based Med 2002;11:239 –53. 6. Brownson R, Eyler A, King A, Brown D, Shyu Y, Sallis J. Patterns and correlates of physical activity among U.S. women 40 years and older. Am J Public Health 2000;90:264 –70. 7. Wilcox S, Castro C, King A, Housemann R, Brownson R. Determinants of leisure time physical activity in rural compared with urban older and ethnically diverse women in the United States. J Epidemiol Community Health 2000;54:667–72. 8. Eyler A, Vest J. Environmental and policy factors related to physical activity in rural white women. Women Health 2002;36:111–22. 9. Brownson R, Schmid T, King A, et al. Support for policy interventions to increase physical activity in rural Missouri. Am J Health Promot 1997;12: 263–6. 10. Duelberg S. Preventive health behavior among black and white women in urban and rural areas. Soc Sci Med 1992;34:191–8. 11. King A, Castro C, Wilcox S, Eyler A, Sallis J, Brownson R. Personal and environmental factors associated with physical inactivity among different racial/ethnic groups of U.S. middle- and older-aged women. Health Psychol 2000;19:354 –64.
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12. Eyler A, Wilcox S, Matson-Koffman D, et al. Environmental, cultural, and policy factors related to physical activity in a diverse sample of women: the Women’s Cardiovascular Health Network Project. Women Health 2002;36: 123–38. 13. Eyler A, Baker E, Cromer L, King A, Brownson R, Donatelle R. Physical activity and minority women: a qualitative study. Health Educ Behavior 1998;25:640 –52. 14. Sallis J, Bauman A, Pratt M. Environmental and policy interventions to promote physical activity. Am J Prev Med 1998;15:379 –97. 15. McLeroy K, Bibeau D, Steckler A, Glanz K. An ecological perspective on health promotion programs. Health Educ Q 1988;15:351–77. 16. Evenson K, Eyler A, Wilcox S, Thompson JL, Burke J. Test–retest reliability of a questionnaire on physical activity and its correlates among women from diverse racial and ethnic groups. Am J Prev Med 2003;25(suppl):15–22. 17. Centers for Disease Control and Prevention. Behavioral Risk Factor Surveil
18. 19.
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lance System. Available at: www.cdc.gov/brfss. Accessed on December 1, 2002. Lengacher C. A reliability and validity study of the Women’s Role Strain Inventory. J Nurs Meas 1997;5:139 –50. Parker E, Lichtenstein R, Chulz A, et al. Disentangling measures of individual perceptions of community social dynamics: results of a community survey. Health Educ Behav 2001;28:462–86. Ainsworth B, Bassett D, Strath S, et al. Comparison of three methods of measuring time spent in physical activity. Med Sci Sports Exerc 2002;32: s457–64. Caspersen CJ, Powell KE, Christenson GM. Physical activity, exercise, and physical fitness: definitions and distinctions for health-related research. Public Health Rep 1985;100:126 –31. Pate R, Pratt M, Blair S, et al. Physical activity and public health. A recommendation from the Centers for Disease Control and Prevention and the American College of Sports Medicine. JAMA 1995;273:402–7.
Appendix 1 Women and Physical Activity Survey Screening Questions 1.1) What is your age? ___ Enter age in years 777. Don’t know/Not sure 999. Refused What is your race? Would you say: 1.2) Which one or more of the following would you say is your race? Read: 1. White 2. Black or African American 3. Asian 4. Native Hawaiian or Other Pacific Islander 5. American Indian, Alaska Native: Tribe or 6. Other Do not read: 7. don’t know 9. refused 1.3) Are you Hispanic or Latino? 1. Yes 0. No Do not read: 777. Don’t know/not sure 999. Refused
Physical Environment 2.1) In general, would you say the motorized traffic where you live is . . . Read: 1. Heavy 2. Moderate 3. Light 777. Don’t know/not sure 999. Refused 2.2) Does your immediate neighborhood have any sidewalks? Do not read: 1. Yes 0. No SKIP To 2.4
777. Don’t Know/Not Sure 999. Refused SKIP To 2.4 2.3) For walking where you live, would you say your sidewalks are Read: 1. Very well maintained 2. Somewhat maintained 3. Not very well maintained 4. Not at all maintained Do not read: 777. Don’t know/not sure 999. Refused 2.4) For walking at night, would you describe the street lighting where you live as Emphasize street lighting. Read: 1. Very good 2. Good 3. Fair 4. Poor 5. Very poor 666. No lighting Do not read: 777. Don’t know/not sure 999. Refused 2.5) For walking where you live, would you say that unattended dogs are . . . Read: 1. A big problem 2. Somewhat of a problem 3. Not very much of a problem 4. Not a problem at all Do not read: 777. Don’t know/not sure 999. Refused 2.6) How safe from crime is it where you live? Would you say . . . Read: 1. Extremely safe 2. Somewhat safe 3. Slightly safe 4. Not at all safe
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Do not read: 777. Don’t know/not sure 999. Refused 2.7) In you community, are there businesses or places where you need to go such as stores or churches, where you can walk instead of driving? Do not read: 1. Yes 0. No . . . . . . . . . skip to #2.10 777. Don’t Know/Not Sure . . . skip to #2.10 999. Refused . . . skip to #2.10 2.8) Do you consider it safe to walk there? Do not read: 1. Yes 0. No 777. Don’t Know/Not Sure . . . skip to #2.10 999. Refused . . . skip to #2.10 2.9) Do you walk there? Read: 1. Always 2. Sometimes 3. Never Do not read: 777. Don’t know/Not Sure 999. Refused 2.10) In your community are there places you could go to exercise if you wanted to? Do not read: 1. Yes 0. No . . . skip to #2.12 777. Don’t Know/Not Sure . . . skip to #2.12 999. Refused . . . skip to #2.12 2.11) Are they indoor, outdoor or both? Do not read: 1. Both 2. Indoor 3. Outdoor 4. Neither 777. don’t know/not sure 999. refused 2.12) What things about your community or neighborhood keeps you from exercising more? (Mark all responses) Do not read: 1. Not enough sidewalks 2. Not enough bike lanes 3. Not enough recreational facilities 4. Not enough physical activity programs 5. High crime 6. No street lights 7. Unattended dogs 8. Too many hills 9. Bad weather 10. Heavy traffic 11. Four air from cars 12. Poor scenery 13. Rural environment or remote area 14. Gang violence 15. Verbal abuse from persons on street 16. Mentally ill or homeless people on street 17. Random gunshots 18. Speeding drivers 19. Nothing or no reason
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20. Other reason 777. Don’t Know/Not Sure 999. Refused
Sense of Community Please indicate if you agree with the following four statements on a scale of strongly agree, agree, disagree, or strongly disagree. 3.1) Your neighborhood is a good place for you and your family to live. Read: 1. Strongly Agree 2. Agree 3. Disagree 4. Strongly Disagree Do not read: 777. Don’t know/not sure 999. Refused 3.2) Your neighbors can be counted on to help if someone is physically threatened or injured. Read: 1. Strongly Agree 2. Agree 3. Disagree 4. Strongly Disagree Do not Read: 777. Don’t know/not sure 999. Refused 3.3) Your neighbors can be counted on to help if someone is destructive to property in your neighborhood. Read: 1. Strongly Agree 2. Agree 3. Disagree 4. Strongly Disagree Do not Read: 777. Don’t know/not sure 999. Refused 3.4) Law enforcement can be counted on if there is trouble in the neighborhood. Read: 1. Strongly Agree 2. Agree 3. Disagree 4. Strongly Disagree Do not Read: 777. Don’t know/not sure 999. Refused 3.5) Do you attend any neighborhood, community, or social group meetings such as block watches, parent teacher associations, etc? Do not read: 1. Yes 0. No 777. Don’t know/not sure 999. Refused 3.6) Do you attend any religious services or functions? Do not read: 1. Yes 0. No
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777. Don’t know/not sure 999. Refused If answered no to both #3.5 and #3.6 go to #4.1 3.7) Do you spend time in these organizations talking about topics like smoking, eating, or exercise? Do not read: 1. Yes 0. No SKIP TO 4.1 777. Don’t Know/Not Sure SKIP TO 4.1 999. Refused SKIP TO 4.1 3.8) Have you made any changes in your health behaviors as a result of comments made or programs held through these organizations? Do not read: 1. Yes 0. No 777. Don’t know/not sure 999. Refused
Employment, Marital Status and Children 4.1) Which of the following best describes you: Read: 1. Employed for wages full-time 2. Employed for wages part-time 3. Self-employed 4. Out of work for more than 1 year 5. Out of work for less than 1 year 6. Homemaker 7. Student 8. Retired 9. Disabled and unable to work Do not read: 777. Don’t know/not sure 999. Refused 4.2) Which of these best describes you? Read: 1. Married 2. A member of an unmarried couple 3. Divorced 4. Widowed 5. Separated 6. Never been married Do not read: 777. Don’t know/Not sure 999. Refused 4.3) How many children live in your household who are . . . Read: 1. Less than 5 years old 2. 5 through 12 years old 3. 13 through 17 years old Do not read: 777. Don’t know/not sure 999. Refused
Physical Activity Ask if answered 1, 2 or 3 to question 4 . . . , if none of those responses go to question 5.2 5.1 When you are at work, which of the following best describes what you do? Would you say
Read: 1. Mostly sitting or standing 2. Mostly walking e. Mostly heavy labor or physically demanding work Do not read: 777. Don’t know/not sure 999. Refused We are interested in two types of physical activity—vigorous and moderate. Vigorous activities cause large increases in breathing or heart rate while moderate activities cause small increases in breathing or heart rate. Now, thinking about the moderate physical activities that you do [if employed, insert: while not working,] . . . 5.2) In a usual week, do you do moderate activities for at least 10 minutes at a time, such as brisk walking, bicycling, vacuuming, gardening, or anything else that causes some increase in breathing or heart rate? Do not read: 1. Yes 0. No . . . skip to #5.5 777. Don’t know/not sure . . . skip to #5.5 999. Refused . . . skip to #5.5 5.3) How many days per week do you do moderate activities for at least 10 minutes at a time? Do not read: Days per week 777. Don’t know/not sure 999. Refused 5.4) On days when you do moderate activities for at least 10 minutes at a time, how much total time do you spend doing these activities? Do not read: : Hours and minutes 777. Don’t Know/Not sure 999. Refused Now, thinking about the vigorous activities you do [if employed, insert: while not working,] . . . 5.5) In a usual week, do you do vigorous activities for at least 10 minutes at a time, such as running, aerobics, heavy yard work, or anything else that causes large increases in breathing or heart rate? Do not read: 1. Yes 0. No . . . skip to #6.1 777. Don’t know/not sure . . . skip to #6.1 999. Refused . . . . . . skip to #6.1 5.6) How many days per week do you do these vigorous activities? Do not read: Days per week 777. Don’t Know/Not sure 999. Refused 5.7) On days when you do vigorous activities for at least 10 minutes at a time, how much total time do you spend doing these activities? Do not read: : Hours and minutes 777. Don’t Know/Not sure 999. Refused
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Social Issues 6.1) How many people in your neighborhood exercise? Would you say . . . Read: 1. A lot exercise 2. Some exercise 3. Few exercise 4. None at all exercise Do not read: 777. Don’t know/not sure 999. Refused 6.2) Do you know people who exercise? Do not read: 1. Yes 0. No . . . skip to #6.4 777. Don’t know/not sure . . . skip to #6.4 999. Refused . . . skip to #6.4 6.3) Why do you think they exercise? (may respond with more than one answer) Mark all responses. Do not read: 1. health 2. feel better 3. weight 4. mental benefits 5. health care provider advice 6. sleep better 7. look better 8. social reasons 9. Other 777. don’t know 999. Refused Please indicate if you agree with the following statements on a scale of strongly agree, agree, disagree, or strongly disagree. 6.4) When I see women exercising, it makes me feel guilty. Would you say that you . . . Read: 1. Strongly agree 2. Agree 3. Disagree 4. Strongly disagree Do not read: 777. Don’t know/not sure 999. Refused 6.5) When I see women exercising I want to exercise, too. Would you say that you . . . Read: 1. Strongly agree 2. Agree 3. Disagree 4. Strongly disagree Do not read: 777. Don’t know/not sure 999. Refused 6.6) When I see a woman exercising, I think she probably has a health problem like diabetes or high blood pressure. Would you say that you . . . Read: 1. Strongly agree 2. Agree 3. Disagree 4. Strongly disagree
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Do not read: 777. Don’t know/not sure 999. Refused 6.7) When I see a woman exercising, I think she is selfish. Would you say that you . . . Read: 1. Strongly agree 2. Agree 3. Disagree 4. Strongly disagree Do not read: 777. Don’t know/not sure 999. Refused 6.8) When I see a woman exercising, I think she is showing off. Would you say that you . . . Read: 1. Strongly agree 2. Agree 3. Disagree 4. Strongly disagree Do not read: 777. Don’t know/not sure 999. Refused
Social Roles 7.1) If you wanted to exercise, household tasks like cooking and cleaning would get in the way. Would you say that you . . . Read: 1. Strongly agree 2. Agree 3. Disagree 4. Strongly disagree Do not read: 777. Don’t know/not sure 999. Refused 7.2) If you wanted to exercise, childcare responsibilities would get in the way. Would you say that you . . . Read: 1. Strongly agree 2. Agree 3. Disagree 4. Strongly disagree Do not read: 777. Don’t know/not sure 999. Refused 7.3) If you wanted to exercise, elder care responsibilities would get in the way. Would you say that you Read: 1. Strongly agree 2. Agree 3. Disagree 4. Strongly disagree Do not read: 777. Don’t know/not sure 999. Refused Ask if answered 1, 2 or 3 to #4.1, if not go to #7.5 7.4) If you wanted to exercise, work would get in the way. Would you say that you . . . Read: 1. Strongly agree
American Journal of Preventive Medicine, Volume 25, Number 3Si
2. Agree 3. Disagree 4. Strongly disagree Do not read: 777. Don’t know/not sure 999. Refused 7.5) If you wanted to exercise, feeling guilty for taking time for yourself would get in the way. Would you say that you . . . Read: 1. Strongly agree 2. Agree 3. Disagree 4. Strongly disagree Do not read: 777. Don’t Know/Not Sure 999. Refused Ask if answered 1 or 2 to #4.2, if not go to #7.7 7.6) If you wanted to exercise, what your partner or husband might think about you would get in the way. Would you say that you . . . Read: 1. Strongly agree 2. Agree 3. Disagree 4. Strongly disagree Do not read: 777. Don’t know/not sure 999. Refused 7.7) If you wanted to exercise, what other people might think about you would get in the way. Would you say that you . . . Read: 1. Strongly agree 2. Agree 3. Disagree 4. Strongly disagree Do not read: 777. Don’t know/not sure 999. Refused 7.8) If you wanted to exercise, community obligations or activities would get in the way. Would you say that you . . . Read: 1. Strongly agree 2. Agree 3. Disagree 4. Strongly disagree Do not read: 777. Don’t know/not sure 999. Refused 7.9) If you wanted to exercise, you would need to put more effort into organizing your time. Would you say that you . . . Read: 1. Strongly agree 2. Agree 3. Disagree 4. Strongly disagree Do not read: 777. Don’t know/not sure 999. Refused
Motivation and Self-Efficacy 8.1) What is the main personal reason you do not exercise more? (mark only one) Do not read: 1. don’t have enough time 2. too tired or don’t have the energy 3. ill or otherwise physically unable 4. don’t enjoy being active 5. don’t have anyone to be active with 6. afraid of injury 7. it is too expensive 8. already get enough exercise 9. self-motivation or will power 10. no personal reason 11. other 777. Don’t Know/Not Sure 999. refused 8.2) What one thing would it take to get you to exercise more? (mark only one) Do not read: 1. more time 2. money 3. access 4. support from family 5. support from a friend 6. childcare 7. doctor’s advice 8. transportation 9. facilities 10. self-motivation or will-power 11. no personal reason 12. already get enough exercise 13. other 777. Don’t Know/Not Sure 999. refused 8.3) How confident are you that you could exercise more. Would you say that are are: Read: 1. Very confident 2. Somewhat confident 3. Not at all confident Do not read: 777. Don’t Know/Not Sure 999. Refused
Suggested Interventions 9.1) What in your community could be done or changed that would be most helpful in increasing the exercise levels of women? Ask if answered 1, 2, or 3 to 4.1, if not go to question 10.1 9.2) What in your workplace could be done or changed that would be most helpful in increasing the exercise levels of women in your community?
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Demographics and General Health 10.1) Would you say that in general your health is: Read: 1. Excellent 2. Very Good 3. Good 4. Fair 5. Poor Do not read: 777. Don’t know/not sure 999. Refused 10.2) What is your zip code? Do not read: _____ 777. Don’t know/not sure 999. Refused 10.3) Is your annual household income from all sources . . . Read: 4. a. Less than $25,000 If “no,” ask e; if “yes,” ask b ($20,000 to less than $25,000) 3. b. Less than $20,000 If “no,” code a; if “yes,” ask c ($15,000 to less than $20,000) 2. c. Less than $15,000 If “no,” code b; if “yes,” ask d ($10,000 to less than $15,000) 1. d. Less than $10,000 If “no,” code c 5. e. Less than $35,000 If “no,” ask f ($25,000 to less than $35,000)
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6. f. Less than $50,000 If “no,” ask g ($35,000 to less than $50,000) 7. g. Less than $75,000 If “no,” code h ($50,000 to $75,000) 8. h. $75,000 or more Do not read: 777. Don’t know/not sure 999. Refused 10.4) What is the highest grade or year of school you completed? Do not read: 1. Eighth grade or less 2. Some high school 3. High school or GED certificate 4. Some technical school 5. Some college 6. College graduate 7. Post grad or professional degree 777. Don’t know/Not sure 999. Refused
Closing Statement That’s my last question. Everyone’s answers will be combined to give us information about health practices of people. Thank you very much for your time and cooperation.
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