physical activity and stages of change in fifth and sixth graders

Physical Activity and Stages of Change in Fifth and Sixth Graders Julie Walton, Sharon Hoerr, Linda Heine, Stacey Frost, Danielle Roisen, Melissa Berkimer

ABSTRACT The Stage of Change (SC) paradigm was adapted to assess readiness to be or stay physically active amongfifh and sixth graders. Students completed a four-item SC survey, the Past Year Leisure Time Physical Activity Questionnaire, and the Modifiable Physical Activity Questionnaire for Adolescents. Precontemplation, contemplation, and preparation stages were grouped as “pre- action” (PRE), and action and maintenance as ‘‘post-action” (AX) stages. Nearly 40% of all students were in PRE, compared to 60% of students in AX stages. Twenty-two percent of all students were in the sedentary precontemplation or contemplation stages. Significantly more boys were in maintenance than girls, and more girls than boys were in contemplation. Students averaged 14-21 hourdweek of television, video, or computer work, and 1.6 hours/week of physical activity outside of school. Interventions may be targeted at a specific SC to enable a child to move forward along the SC continuum toward an active lifestyle. (J Sch Health. 1999;69(7):285-289)

ack of regular physical activity constitutes a major risk L factor for cardiovascular disease.l Cardiovascular disease and stroke cause nearly one-half of all deaths, and they are significant contributors to disability.2 Many cardiovascular risk behaviors track from childhood into adul tho~d,~ ,~ and inactive children and youth are more likely to become inactive adult^.^ Encouraging children into a sustainable active lifestyle should influence adult levels of heart disease and stroke in the future.

Prevailing beliefs suggest children are too sedentary. Observed increases in adiposity of children supports this concern.6 Physical activity rates decline as children age, and boys are typically more active than girls across all age

Efforts to increase childhood physical activity have included additional hours of physical education, physical education homework, intramural opportunities, structured recess times, walking clubs, fitness clubs, and lunchtime and after-school programs.

The Stage of Change paradigm has been applied in a variety of adult health behavior modification applications.lO.” As a specific health behavior develops over time, adults progress through five stages: precontemplation (PRECON), contemplation (CONT), preparation (PREP), action (ACT), and maintenance (MAINT). Researchers have used the Stage of Change model to examine readiness to become and stay physically active in adults,12 but little evidence is available to describe the application of Stage of Change paradigms to physical activity in children.

The purposes of this study were sixfold: 1) to adapt the Stage of Change paradigm to fifth and sixth graders to assess perceptions regarding readiness to be/stay physically active; 2) to compare self-reports of physical activity scores to attitudes about physical activity in conjunction with the stages of readiness for activity; 3) to investigate whether the interval between fifth and sixth grade is a pivotal point in the observed decline in physical activity in children, girls in

Julie Walton, PhD, Exercise Physiologist, Certified Exercise Specialist, Spectrum Health HeartReach Program, MC 148, 100 Michigan St.. NE, Grand Rapids, MI 49503; or [email protected]>; Sharon Hoerr, RD, PhD, Dept. of Food Science and Human Nutrition, Michigan State University, East Lansing, MI 48825; Linda Heine, RN, HeartReach Program Supervisor, Spectrum Health HeartReach Program, MC 148, 100 Michigan St., NE, Grand Rapids, MI 49503; Stacey Frost, Danielle Roisen, and Melissa Berkimer, Dietetic Students, Dept. of Food Science and Human Nutrition, College of Human Ecology, Michigan State University, East Lansing, MI 48824. This article was submitted March 16, 1999 and revised and accepted for publication June 15, 1999.

particular; 4) to explore how SC information might help health educators develop targeted physical activity interventions; 5 ) to identify activities that fifth- and sixth-grade children enjoy and are already doing, and 6 ) to connect hospital and university research and evaluation staff and resources with the needs of the education community. This work originated out of a partnership between a fifth- and sixth-grade school and the hospital, after focus groups comprised of teachers, students, parents, community members, and hospital staff identified a desire for after- school classes in physical activity, nutrition, and personal safety. The university helped address data management needs that neither the school nor hospital could provide.

METHODS Subjects comprised all 518 students in the only fifth-

and sixth-grade building of a predominantly middle class, urban-suburban school district in western Michigan. Before implementing an after-school intervention, affirmative parental consent and returned surveys were obtained for 409 students (78.9%) in fall 1997. Following approval from both the hospital and school district, surveys were sent home in lieu of homework on a school night (Thursday), and returned to the homeroom teacher the following day. Surveys, which took students approximately 30 minutes to complete, were coded to assure confidentiality of results. Homeroom teachers distributed a Five-Day Physical Activity log upon receipt of completed surveys. Activity logs were kept by students the following Sunday through Thursday. Fifty-five percent of students returned a Five- Day Physical Activity Log.

Students’ readiness for regular physical activity was assessed by four questions from the original paradigm of Prochaska et al,lO.”.” adapted to a “yes” or “no” format (Table 1). The typical six-month time span for maintenance in adults was modified to two months to accommodate a child’s more limited ability to recall. “Exercise” was defined as “at least 30 minutes of exercise or physical activity that does not include the exercise you get in physical education class.”

Past year physical activity was assessed with the Past Year Leisure Time Physical Activity Questionnaire (PYPAQ) developed by Aaron et al.I4 The instrument uses a checklist of activities for each of the past 12 months, and asks students to estimate the amount of time spent in each activity, both in days per week and in minutes per day.

Journal of School Health September 1999, Vol. 69, No. 7 285

Time spent in each activity was calculated and reported as hourslweeklactivity. The PYPAQ was validated in adolescents, comparing the PYPAQ to four, 7-day activity recalls (r = 0.55-0.67 in boys and 0.73-0.83 in girls).14

Fourteen-day physical activity recall was assessed using the Modifiable Activity Questionnaire for Ad01escents.l~ Students checked the number of days per week they participated in vigorous and moderate physical activity for at least 20 minutes per session. The questionnaire also addressed hours of television watching and computer and video game participation per week, as well as the number of competitive sporting activities in which a student participated during the past year.

Three sets of matched survey questions were written for this study regarding attitude toward physical activity, exercise, and physical education (PE). Items used a five-point Likert scale (strongly disagree, disagree, no opinion, agree, strongly agree).

Following university approval for secondary data analysis, dietetic student research assistants analyzed the data using the Statistical Package for the Social Sciences (SPSS for Windows, Ver 7). If a student could be categorized into two consecutive Stage of Change stages simultaneously, data were re-examined and a paradigm devised for classify- ing students into one stage only. For classification in "post- action" stages (AX), students also had to respond positively to the statement, "getting regular exercise is important to me as a way of life for lifetime health." This method was applied to address the staging dimension concept of intention to be active to avoid any arbitrary assignment to a particular stage.I6 Pearson correlation coefficients (p <.05) were applied to determine the association between Stage of Change and logged activity data. Sets of matched physical activity attitude questions were analyzed by multiple regression.

Table 1 Stages of Change Classification

for Physical Activity in Fifth and Sixth Graders"

"Exercise" is at least 30 minutes of total exercise or physical activity every day, not including what you do in physical education class.

1.

2.

I have been exercising almost every day for more than two months Yes No I didn't used to get much exercise, but in the last two months, I have been exercising almost every day. Yes No I do not exercise every day right now, but I plan to begin exercising almost every day some time in the next month. Yes No I do not exercise every day right now, but I plan to begin exercising almost every day some time in the next two months. Yes No

3.

4.

Stage Response

1. Precontemplation (PRECON) No to all questions 2. Contemplation (CONT) Yes to #4, No to remainder 3. Preparation (PREP) Yes to #3, No to remainder 4. Action (ACT) Yes to #2, No to remainder 5. Maintenance (MAINT) Yes to #1, No to remainder

RESULTS Table 2 contains the distribution of subjects by grade and

gender for Stage of Change for physical activity/exercise. No significant differences occurred by grade. Grouping precontemplation, contemplation, and preparation as "pre-action" (PRE) stages, and action and maintenance as "post-action'' (AX) stages categorized 40% of students in PRE and 60% of students in AX stages. Significantly more boys than girls were in MAINT (57.9% of boys vs. 39.5% of girls, p<.05), and significantly more girls than boys were in PREP (21.5% of girls vs. 10.3% of boys, p<.05). Gender differences for PRECON, CON, and ACT were nonsignificant.

Among students reporting less than 30 minutes of exer- ciselday on the daily exercise log, 76% also reported being in PREAX stages of exercise (p<.05). Of students recording 2 30 minutes of daily exercise, 67% also reported being in AX stages (p<.05). Twenty-two percent of all students were totally sedentary (PRECON or CONT).

Hours of television, computer, and video game activities per day are reported in Table 3 (mean = 2-3 hourdday, k 1). Students participated in at least 20 minutes of hard exercise an average of five to seven of the past 14 days. They also reported engaging in at least 20 minutes of light exercise on five of the past 14 days. Thus, the total number of activity sessions lasting at least 20 minutes, irrespective of intensity, was 10-12 of 14 days (a minimum three to four hours of activity every two weeks). The most popular activities by frequency of participation were bicycling, in-line skating, basketball, and swimming (Table 4).

When asked if they preferred exercising to sitting and doing nothing, most agreed they would rather exercise. Conversely, most students slightly disagreed when asked if they would be glad to skip exercise for a few days. Students agreed that regular exercise is an important factor in devel- oping lifetime health. Attitudes toward PE are presented in Table 5, in which significantly more fifth graders favored increases in physical education than did sixth graders (70.2% of fifth graders vs. 52.3% of sixth graders).

Table 2 Stages of Change

for Physical Activity by Grade and Gender"

"Pre-Action" (PRE) "Post-Action'' (AX)

PRECON CONT PREP ACTION MAINT

5th grade 11.9 12.9 11.9 13.4 50.0 (n = 194)

(n = 215)

(n = 195)

(n = 214)

(n = 409)

a percentage of students in each stage. * differences between boys and girls are significantly

different Pe.001, ANOVA.

6th grade 9.3 10.2 19.1 13.0 48.4

Girl 10.8 12.8 21.5* 15.4 39.5"

BOY 10.3 10.3 11.2" 11.2 57.9"

Total 10.5 11.5 15.6 13.2 49.1

286 Journal of School Health September 1999, Vol. 69, No. 7

DISCUSSION To our best knowledge, this is the first reported use of an

age-adjusted Stage of Change paradigm for describing physical activity behavior of fifth- and sixth-grade children. The sedentary (PRECON and CONT) students in this study (23.6% of girls and 20.6% of boys), in findings supported by the physical activity logs, can be labeled as the most “at- risk” group for low physical activity. They had not been physically active for at least two months (one of which was during summer vacation), and had no immediate plans to begin exercising on their own any time soon. For various reasons, those in PRECON and CONT were not interested in being regularly active.” As a result, they need to be continually exposed to enjoyable physical activity alterna- tives, and messages about the advantages of being regularly active.

Significantly more boys were in MAINT than girls. This finding concurs with other studies in which boys were more active than girls.” However, no significant differences occurred in the number of girls and boys in ACT. As a rule, children are more physically active than adults. However, as children age, levels of physical activity decline. A precipitous drop off in physical activity occurs around age 14. In girls, the decline may begin earlier.I9 A study of fifth graders at recess demonstrated the tendency for girls to choose less active pursuits during recess. While boys played basketball and tag, girls preferred talking, walking and four square.8 Because this study included one summer and one autumn month, this result may indicate girls are seasonally active, and less likely to habitually be in MAINT, whereas boys are more active on a year-round basis. The likelihood of seasonal variations needs investigation.

Significantly more girls than boys were in PREP. More

Table 3 Percentage of Students WatchinglPlaying TV,

Computer and Video Games Outside of School

Hours Per Day 5th grade 6th grade All of Participation n=188 n =221 n = 409

0 1.6 1.4 1.5 < 1 34.0 25.2 29.3 2-3 45.5 50.0 47.9 4-5 10.5 14.9 12.8 26 6.8 8.1 7.5

Table 4 Favorite Extracurricular Physical

Activities in Fifth- and Sixth-Grade Students

Mean Hours/ % of Activity Week Students

Biking 2.10 77.0 In-line skating 1.40 57.9 Basketball 1.40 55.4 Swimming 2.10 47.5 Yard work 0.80 42.9

Type of Activity

individual individual tearnlindividual individual/team individual

inactive girls than boys were thinking about becoming active. Targeting students in PREP provides a natural progression for physical educators and health educators. Preparers use skill-building to increase confidence in the decision to change.” These individuals are most open to acquiring the skills for being regularly active, skills often taught in school health and physical education.

Individuals who do not feel competent in activities that require physical skill tend to be the most inactive.20,” The skill gap between boys and girls begins to grow in late preadolescence. Finding more girls than boys in PREP indi- cates the need for physical educators, in particular, to be increasingly sensitive to the need for skill development in girls. In theory, moving students forward along the skill continuum also should influence a move from PRE to AX stages. Presently, these students have daily physical education every other week. Significantly more fifth graders wished for increased PE opportunities than sixth graders, suggesting that the fifth-grade year may be a pivotal point in a student’s perception of the importance of PE.

Because PE and health education are where the skills for lifetime physical activity are learned, it makes sense that more time in these classes can lead to increased physical competence, as well as the conceptual ability to make the decision to change, thereby improving lifetime physical activity maintenance. In addition, PE programs may need to focus earlier on the needs of girls in learning enjoyable lifetime physical activity skills to prevent their earlier declines in physical activity, as well as steer them toward increasing levels of ACT and MAINT.

One study” of adults indicated no gender differences for the PREP stage. Many adults look to universal exercise options such as walking when contemplating initiation of a physical activity program. Consequently, adults in PREP may believe they have adequate skills in place to begin exercising, whereas a preadolescent girl, often given a menu of sports in which to participate, does not.

No significant differences occurred in extracurricular activity levels between fifth and sixth graders. This finding would indicate that the interval between fifth and sixth grade is not a pivotal point in the observed decline of inten- tional physical activity in children, despite a simultaneous drop in attitudes toward PE. Perhaps, the attitude change provides a first signal that required activity is becoming less accepted by preadolescents. Taylor et a122 reported that

Table 5 Respondents’ Attitude

Toward Physical Education by Grade

Statement: I wish we could have physical education more often.

Strongly Agree Strongly Disagree + Agree No Opinion + Disagree

5th grade

6th grade n = 191 70.2% 14.1 % 13.6%

n= 222 52.3% 22.5% 24.3%


children frequently forced to exercise may develop negative attitudes toward physical activity that last into adulthood.

Students averaged two to three hours per day of television, video, and computer gamedwork (14-21 hours per week). This finding computes to a 9: 1 ratio of sedentary to physical activity pursuits in this population. The increasingly popular Internet may influence this ratio upward as these children age. Hofferth et a123 reported 14 hourdweek of television-only in children under age 13 in 1997.

According to the Modifiable Activity Questionnaire for Adolescents, students engaged in 20-minute sessions of vigorous exercise five to seven days of every two weeks (2.5-3.5 days per week), excluding physical education classes. This finding computes to a minimum of 0.8 to 1.2 hours of vigorous activity per week. In addition, students engaged in moderate activity 2.5 days per week (0.8 hours moderate activity per week). In total, students were active for a minimum of 1.6 hours per week. The results of Craig et a12’ demonstrated that Massachusetts fifth graders participated in vigorous activity between 7.2 and 9.5 hours per week. The large discrepancy is difficult to explain, particu- larly because this study included fair-weather months, whereas the Craig et a1 study was conducted in winter months. Perhaps western Michigan children are simply less active.

When the Modifiable Questionnaire data are compared to the Five-Day Physical Activity Logs, the value of 1.6 hours of activity per week is not unrealistic. Perhaps the lower participation rate in the Massachusetts students signals a higher degree of self-selection of active students. Because of the higher survey response rate for this study, it likely includes less-active children. A limitation of this study is that it did not survey students regarding discontinuous bouts of activity. Children typically choose to exercise in spurts of activity, rather than in the more adult-like pattern of 20 continuous minutes/se~sion.~

These students demonstrated an adult-like physical activity profile in terms of hours of activity per week outside of school hours. This finding could reflect a limitation of using the Modifiable Activity Questionnaire for Adolescents in a preadolescent population. Yet, it is possible that the evolution of physical childhood play into more adult-like patterns of exercise and activity occurs earlier than fifth grade. The low rates of physical activity outside of school do not agree with the attitude responses of most students that they would like to have more physical education, or that they would prefer to exercise than “sit around and do nothing.” As with many adults, it is likely that the students believe in the “goodness” of being physically active, yet do not bear that out with action. Perhaps children this age still “play” after school, yet do not record this as physical activity or exercise.

S a l l i ~ ~ ~ noted that “kids love play, whereas adults hate exercise.” It might be beneficial to investigate student perceptions of play, physical activity, and exercise, as well as perceived barriers to activity, and the point in time where discontinuous bouts of “play” are abandoned in favor of structured, continuous, adult-like exercise. In addition, play, as perceived by children, likely incorporates sedentary pursuits such as computer or video games as well as physical activities.

Another explanation may lie in the changing profile of children’s use of free time. Hofferth et alZ3 demonstrated a

significant decrease in the time children spend in unstructured outdoor play. This result was attributed to increases in school day length, as well as more structured activities such as team sports. Not surprisingly, students in this study reported participation in an average of two extracumcular competitive team or individual sports in the past 12 months. Despite this participation, actual minutes of activity/week remained low over the 12-month span. Interestingly, students preferred unstructured, self-directed physical activity outside of school. Four of the five most popular physical activities were individualized in nature, not requir- ing any formalized organization or team pursuit (Table 4).

CONCLUSION Collaboration among the school, hospital, and university

was a strength of the study. Close work with the school district in designing the study resulted in a high response rate from parents and students. In addition, the project exposed undergraduate students to data management and presentation techniques while allowing the hospital- community coalition to gain access to university faculty and student resources.

Adapting the Stage of Change model to describe the readiness to be and stay physically active in fifth- and sixth- grade children can yield significant insight into physical activity patterns, enabling educators to target specific interventions toward children in PRE vs. AX Stage of Change. In this study, boys were more active than girls, and attitudes toward physical activity were generally positive. Just asking children to become more physically active will result in a high degree of failure, because they have no intention of making changes in the near future. Encouraging them to be more active should specifically aim to raise consciousness regarding the importance of being regularly active. It takes repeated consciousness-raising to nudge an individual into PREP. Simply providing opportunities to be active, such as recess, intramurals, open gym, and team sports, is not enough for these ambivalent students. Nevertheless, hours of surveyed sedentary pursuits were nine times higher than physical activities regardless of age, with 22% of students totally sedentary outside of school.

In theory, if educators could move students along the skill continuum, they also should be able to influence a move from PRE to AX stages of readiness to be active. Students demonstrated an adult-like physical activity profile in terms of hours of activity per week, and the type of activity pursued. This Stage of Change information is important to understanding the evolution of childhood play into adult patterns of physical activity. Because risk for disease is tracked from adolescence into adulthood, it is imperative that educators identify and address risky sedentary behavior as early as possible.

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physical activity and stages of change in fifth and sixth graders

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