Southern Women’s Responseto a Walking Intervention

Mary A. Nies, Ph.D., R.N., F.A.A.N., FAAHB,

Catherine E. Reisenberg, M.S.N., C.S., F.N.P.,

Heather L. Chruscial, M.A., and

Kay Artibee, M.Ed., R.N.

Abstract The need to change the sedentary habits of manyAmerican adults is well recognized. Middle-aged women are animportant target group for increased physical activity because of

certain health risks such as osteoporosis. In the current study, 31women between the ages of 30 and 60 from high- and low-incomegroups (high-income >$50,000; low-income <$50,000 per year)took part in a physical activity intervention. The goal was to

increase walking activity to a minimum of 90 min per week. Eachwoman received 16 telephone calls over a 6-month period inwhich she was asked to reflect upon the benefits of walking, goal

setting, restructuring plans, social support, exercise efficacy,relapse prevention, and maintenance. Content analysis revealed anumber of themes emerging from intervention conversations.

There were differences between races in walking location andwalking partners. Furthermore, there were differences betweenincome groups in beliefs about the benefits of walking and social

support. Overall, the intervention appeared to provide a basis forwomen to develop a walking routine. The women were able toreflect upon their walking routine and attempts to begin awalkingroutine and to identify how each component of the intervention

affected their individual daily routine.

Key words: women, physical activity, intervention, qualitative.

Healthy People 2010 states that moderate physicalactivity should occur at least five times a week for30 min per day to optimize health (U.S. Department ofHealth and Human Services, 2000). Moderate activitiesshould be at least equivalent to a brisk walk. Despite thisinformation, many women continue to have inactivelifestyles. Forty-percent of adults aged 18 and older in thenation are completely sedentary in their leisure time (U.S.Department of Health and Human Services, 2000).Furthermore, most adults do not have occupations thatprovide sufficient physical activity to produce healthbenefits (U.S. Department of Health and Human Servi-ces, 2000). The need to change the sedentary habits of theadult U.S. population is well recognized. Physical inac-tivity has been linked to premature cardiovasculardisease, obesity, diabetes, orthopedic problems, andemotional distress (NIH Consensus Statement, 1995;U.S. Department of Health and Human Services, 2000).

Middle-aged women are an important target group fora physical activity intervention for a number of reasons.Regular exercise may help to prevent osteoporosis, aleading cause of disability in older women (Chien, Wu,Hsu, Yang, & Lai, 2000; Marcus, 2001). According toHealthy People 2010, physical activity that promotesstrength and flexibility may protect against disability andenhance functional independence (U.S. Department ofHealth and Human Services, 2000). According to Christ-mas and Andersen (2000), sedentary people who improvetheir physical fitness improve longevity and are less likelyto develop or die of cardiovascular disease than thosewho remain sedentary. Physical activity may amelioratedisease, reduce depression, and delay decline as peopleage (Bassey, 2000; Christmas & Andersen, 2000). Recent

Mary A. Nies is Associate Dean For Research; Professor; Director,

Center For Health Research; Director, Doctoral and Postdoctoral

Programs, Wayne State University, 5557 Cass Avenue, Detroit, Michigan.

Catherine E. Reisenberg, is a Doctoral Student, Vanderbilt University,

Nashville, Tennessee. Heather L. Chruscial is a Doctoral Candidate,

Wayne State University, Detroit, Michigan. Kay Artibee is a Research

Assistant, Vanderbilt University, Nashville, Tennessee.

Address correspondence to Mary A. Nies, Ph.D., R.N., F.A.A.N.,

FAAHB, Wayne State University, 5557 Cass Avenue, Detroit, MI.

E-mail: m.nies@wayne.edu

Public Health Nursing Vol. 20 No. 2, pp. 146–152

0737-1209/03/$15.00

� Blackwell Publishing, Inc.

146

studies suggest that even light to moderate physicalactivity is associated with decreased risk of coronaryheart disease in women (Lee, Rexrode, Cook, Manson, &Buring, 2001). At least 1 hour of walking per weekpredicted lower risk (Lee et al., 2001).

Given the numerous physical and mental benefits ofregular physical activity, it is important to examine whatfactors contribute to a person’s sedentary behaviors.Many factors may contribute to lack of activity found inthe U.S. population and in women specifically. Manyexternal factors in women’s lives have been self-reported asreasons for not engaging in regular physical activity. Workconflicts, lack of energy, lack of time, caregiving duties,lack of access to convenient facilities, undesirable envi-ronments, and lack of social support are all reportedbarriers to physical activity in women (King et al. 2000;Nies, Vollman, & Cook, 1999; U.S. Department of Healthand Human Services, 2000; Wilcox, Castro, King,Housemann, & Brownson, 2000). In general, determinantsof physical activity in adults include self-efficacy, socialsupport, fewer perceived barriers and greater perceivedbenefits, and exercise enjoyment (Sallis & Owen, 1999).

In addition to the mentioned barriers, which maydecrease physical activity, characteristics such as raceand socioeconomic status (SES) may also play a role.African Americans are more likely than EuropeanAmericans to be physically inactive (Crespo, Smit,Andersen, Carter-Pokras, & Ainsworth, 2000; U.S.Department of Health and Human Services, 2000).According to Crespo et al. (2000), this difference existsacross education level, family income, and marital status.African Americans are also more likely to be overweight,putting them at increased risk for many diseases such ashigh blood pressure and coronary heart disease (U.S.Department of Health and Human Services, 2000).Coronary heart disease death rates for African Americanwomen remain 34% higher than rates for white women(Mosca et al., 1997).

SES has also been related to physical activity in pastresearch. People from lower social classes are less likely toengage in regular physical activity (Crespo, Ainsworth,Keteyian, Heath, & Smit, 1999; U.S. Department ofHealth and Human Services, 2000). Higher SES groupsare also more likely to engage in vigorous physicalactivity (Wardle & Griffith, 2001). Differences in socialand cultural expectations, time, economic resources,social support, and low self-efficacy in exercise may beimportant factors in explaining these differences (Crespoet al., 1999). In addition, depression has been associatedwith low income and lack of exercise activity (Allgoewer,Wardle, & Steptoe, 2001; Ritsher, Warner, Johnson,Dohrenwend, & Bruce, 2001; Turner, Lloyd, & Roszell,1999).

With these potential barriers and risk factors associatedwith sedentary behavior in mind, an intervention wasdesigned to increase the physical activity of AfricanAmerican and European American women from high andlow socioeconomic classes. One of the most frequentlyidentified determinants of physical activity is an indivi-dual’s perception of personal capabilities, or self-efficacy(Bandura, 1986). One feature of self-efficacy is that anindividual’s efficacy expectations can be increased topromote beneficial changes in health behavior (Bandura,1984). Positive self-efficacy is associated with a perceptionthat personal ability and skill are adequate to successfullyperform an activity (Bandura, 1984).

However, increased efficacy alone may not be enoughto increase physical activity. A number of interventionstudies have successfully employed other behavioral, orcognitive-behavioral, methods to influence physical activ-ity participation (Krummel, Koffman, Bronner, Davis,Greenlund, Tessaro, Upson, & Wilbur, 2001). Research-ers using strategies such as relapse prevention, restructur-ing plans, and goal setting have found encouraging results(Krummel et al., 2001). Social support is also importantin exercise adherence. Enhancing social support may bean important aspect of interventions aimed at increasingphysical activity in a population of sedentary women ofvarious racial backgrounds (Eyler et al., 1999).

In an effort to increase the physical activity of AfricanAmerican and European American women, an interven-tion was implemented. The counseling intervention designwas based on past literature and theoretical considera-tions. The intervention strategies included helping theparticipant know about the benefits of physical activity,increasing physical activity self-efficacy, goal setting,restructuring plans, dealing with relapse prevention, andincreasing social support.

The women in the intervention group were instructedto increase their walking gradually to at least 90 min perweek. Field notes were taken on intervention log sheetsfor qualitative analysis to better understand the effect andmeaning of the physical activity intervention for thewomen. The purpose of this qualitative study was toinvestigate how the women responded to the physicalactivity counseling intervention.

METHOD

Participants

The sample consisted of 31 women from the metropolitanarea of a southern state between the ages of 30 and60 (M ¼ 42.5, SD ¼ 7.2): three high-income AfricanAmericans (Hi/AA), 12 high-income European Ameri-cans (Hi/EA), nine low-income African Americans(Lo/AA), and seven low-income European Americans

Nies et al.: Women’s Responses 147

(Lo/EA). High income was defined as a yearly householdincome of more than $50,000 and low income was definedas less than $50,000 per year. The women were consideredphysically sedentary, or mostly inactive, at the beginningof the study. They engaged in physical exerciseinfrequently or not at all. Women who had a physicalcondition that walking might aggravate (e.g., uncon-trolled blood pressure, dizziness, or joint problems) werenot included in the study. The sample was recruited usingflyers placed in the community. There was randomassignment to an intervention, attention control, orcontrol group. Because the interest of the researcherswas to examine responses to the intervention, only thosewomen assigned to an intervention group were includedin this paper. Participants were paid $30 to participate inthe study for 1 year.

Procedure

This study was part of a larger study. The focus of thelarger study was to implement a walking interventionaimed at increasing physical activity of low- and high-income African American and European Americanwomen. The focus of the current study was to examinehow the women (qualitatively) responded to the physicalactivity intervention based upon race and SES.

The procedure for implementing the intervention wasas follows. A research assistant made telephone calls tointervention participants for 24 weeks, taking field notesimmediately as participants responded to the interventiontelephone counseling.

The research assistant called the women in the inter-vention group 16 times over 24 weeks. She assessed theirphysical activity levels and helped them determine how tofit adequate walking activity into their week. Participantsreceived calls once a week for the first 8 weeks and thenevery other week for the remaining 16 weeks. Thewalking goals for the participants gradually increaseduntil they reached a minimum of 90 min of walking perweek.

The research assistant was trained to follow theintervention script and guide the women in problemsolving. The 31 women received calls from the sameresearch assistant throughout the study. The telephonecalls were designed to be brief (£15 min), and theparticipants were not encouraged to elaborate on theirresponses, but time was taken to ensure that the womenwere able to respond to the question with an answer thatbest illustrated their experience.

Data Analysis

The study used a qualitative, descriptive design. Verbatimtranscripts from intervention telephone calls for eachwoman were compiled and verified. Content analysis was

used to identify recurrent themes within each of theintervention components, using the individual as the unitof analysis. A brief document memo was created for eachsubject to summarize her intervention experience and wasused for future comparisons (case to case). QSR NUD-IST software (1997) was used to organize the themes fromthe brief document. Initial themes were identified andverified during weekly meetings between the primaryinvestigator and the research assistant. Codes werefurther refined with coding of transcripts by an expertin health promotion. They were then compared until100% agreement by consensus was made on coding foreach line of transcript. The final thematic categories andcodes were presented to 30% of the participants. Allparticipants agreed with the categories and did notidentify any discrepancies.

RESULTS

Several themes emerged within each component of theframework: benefits, goal setting, restructuring, socialsupport, exercise efficacy, relapse prevention, and main-tenance. In addition, income and race appeared to havesome effect on how the women interacted with many ofthe aforementioned components.

Benefits

The women identified what they liked about the walkingand described their walking experience. Almost all of the31 participants identified physical and psychological well-being as benefits of their walking routine. Psychologicalwell-being was defined using phrases that pertained todecreasing stress, relaxing, and improving overall sense ofwell-being. One Hi/AA woman stated that the walkingwas ‘‘relaxing.’’ Similarly, a Lo/AA woman said that herwalking ‘‘has improved my mood, decreased stress.’’Other women commented on appreciating the time alone,‘‘getting out by myself, clearing my thoughts’’ (Hi/EA).

Physical well-being was defined by participant com-ments that indicated that the walking benefited theirphysical health, for example, ‘‘I feel less tired, toning upmy body’’ (Lo/AA). Some of the women had otherphysical ailments or conditions and noted that thewalking appeared to aid in the improvement of theircondition. ‘‘This is really good for me. Good for myhealth. It’s real important to keep my health up especiallybecause of breast cancer’’ (Hi/EA).

Many women gained a sense of accomplishmentbecause of their walking. For example ‘‘felt good becauseI did something’’ (Hi/AA), and, in the words of a Lo/EAparticipant, ‘‘I know that I am doing what I am supposedto do.’’ Slight differences were found between all high-income and all low-income women who identified

148 Public Health Nursing Volume 20 Number 2 March/April 2003

accomplishments as a benefit. The high-income womenreported the benefit of accomplishment more frequentlythan the low-income women during the intervention calls.

Many women felt that a benefit of walking was toexperience some element of nature. The women notedthat ‘‘being outside was nice’’ (Hi/AA), or ‘‘refreshing tobe outside’’ (Hi/EA), or that it was ‘‘beautiful, being inthe sun, enjoying the environment’’ (Lo/EA). Almost allEuropean American women (low- and high-income)noted nature connection as a benefit, whereas only halfof all African American women mentioned this benefit.

The theme of companionship was similar acrossgroups. Companionship was defined by comments thatsuggested that walking enabled the participant to spendtime with friends, family, or pets. For example, one Lo/AA woman said that she enjoyed the walking because shewas ‘‘able to be with a friend.’’

Goal Setting

The women were guided to set goals about the days andlocation they planned to walk. Walking goals were madearound a certain time of day (e.g., in the morning) or atarget number of days (e.g., 3 weekdays). Conversely,some women set a walking goal for a specific day(s) of theweek. For example, one Lo/AA woman stated that shewould walk Monday through Friday for 15 min at 10:00a.m. and 2:00 p.m. No differences appeared to exist inplanning day and time to walk based upon income orrace. The participants who were unsure of their walkingplan were usually ill or had other life stressors. Mostwomen who planned to walk every day had a successful,consistent walking program. A few women who struggledto begin a walking routine also mentioned walking everyday. Perhaps making a goal of walking every day helpedthe women who seldom walked feel as if they wereimproving their odds of walking at least 1 day.

Malls, neighborhoods, parks, and workplace consis-tently emerged as locations the women planned to walk.Other community sites included schools, tracks, andgyms. European American participants reported a plan towalk in parks more frequently than African Americanwomen did. African Americans reported more plans towalk at their workplace, malls, or other communitylocations. All groups identified neighborhoods as apossible walking location, but Lo/AA women identifiedit most infrequently.

The actual locations the women walked were consistentwith their plans. Malls, neighborhood, parks, gyms, andworkplace were all used. Most women used more than onelocation. All groups used workplace most frequently. Useof neighborhoods, parks, and malls varied between races.European American women identified neighborhoods andparks as used more often than African American women

did. In contrast, about half of all African Americansreported using malls, versus about one fourth of EuropeanAmericans. European American women were most con-sistent reporters of walking more than 90 min per week.However, almost all women reported walking at least90 min at some point in the intervention. The majority ofwomen reported walking three to four times per week.

Restructuring Plans

The women were asked to identify how they thought theycould improve their walking program throughout theintervention. Restructuring plans consisted of plans thatcompletely revised some portion of the woman’s walkingroutine. Location changes often were made to counteractinclement weather, ‘‘I do not foresee any problems, I planto walk in the mall to avoid bad weather’’ (Hi/AA). Forother women, changing their walking location was basedupon convenience, ‘‘I need a place to walk that is not outof the way, a place more convenient’’ (Hi/EA). Thewomen made similar concrete changes about times anddays of walking, ‘‘I would like to get up in the morning, Ijust need to get started’’ (Lo/EA); ‘‘I will try to walk thisweekend.’’ Changes in attitude strategies were mentaladjustments that women perceived would improve thewalking program. For example, one Lo/AA womanstated that, ‘‘I tell myself that I can do it and make abetter effort.’’ A Hi/AA woman said that she needed to‘‘stop being so lazy, feel motivated.’’ Collectively, changestrategies were used in the early weeks of the interventionand appeared to be ‘‘core’’ restructuring strategies. Thesewere then followed by enhancement or preparationstrategies that fine-tuned the walking routine. Forinstance, women would bring shoes or workout clothesto facilitate their walking, ‘‘I brought my workout clothesto work’’ (Hi/EA); ‘‘I plan to bring tennis shoes and walkafter work’’ (Lo/AA). Lo/AA was the predominate groupusing this strategy. All Lo/AA women were preparing towalk at their place of work. Perhaps their work environ-ment was the safest and the most feasible. When Lo/AAwomen used preparation, the strategy was implementedearly in intervention, before Week 8.

Many women felt that adding new shoes, a Walkman,or a treadmill would improve their walking routine. Low-income women mentioned adding equipment both earlyand late in the program; high-income women noted thisstrategy late in the intervention.

Several women identified adding a partner as a meansto improve their walking routine, ‘‘possibly better if I hada partner’’ (Hi/AA). All but one of the high-incomeparticipants mentioned adding a partner as an enhance-ment strategy. The low-income women did not identifywanting to add a partner as frequently as the high-incomewomen, but, of the two low-income groups, Lo/AA

Nies et al.: Women’s Responses 149

identified adding a partner more frequently than Lo/EA.One member of the Lo/AA group mentioned adding apartner almost every week. She had several psychosocialproblems, including depression, and a suicide attempt byher son, which might have explained her need for socialsupport. Perhaps her need for a walking partner reflectedher overall need for support.

As the women worked through the intervention, theywanted walking to be more a part of their routine. Theyfelt as if developing a routine would improve theirprogram. For example, one Hi/EA woman said, ‘‘I needto find a way to make it part of my routine.’’ High-incomewomen identified the routine strategy more frequentlythan low-income women.

The women who did establish a walking routine oftencited increasing their walking time as a means torestructure, ‘‘squeeze in a little more time’’ (Lo/AA).Overall, the women who identified increasing walking asan enhancement strategy did so late in the intervention,after Week 20, suggesting that a walking routine mightneed to be well established before the strategy is used.

Social Support

The support plan category identifies persons with whomthe woman could identify as a potential walking partner.Walking companions were support persons who partici-pated in the walking activity with the woman. Manywomen stated that they, themselves, were their main formof support. Other women identified husbands, boyfriends,and partners. Almost all women identified nonfamilialsupporters including coworkers, friends, and neighbors.Family support was frequently identified and was definedas children, siblings, parents, and extended familymembers.

By the end of the intervention, high-income womenidentified family most frequently as the predominant formof verbal support. Low-income women most often identi-fied nonfamilial support. The second-most frequentlyidentified form of verbal support identified by Hi/AA,Lo/AA, and Lo/EA women was self. In fact, many womengained a sense of pride from supporting themselves, ‘‘I liketo go by myself. I want to motivate myself’’ (Lo/AA); ‘‘Ienjoy walking by myself, not interested in a partner’’; ‘‘Icannot think of anybody who is as committed or as inter-ested as me’’ (Hi/AA). The Hi/EA identified significantothers as their second-greatest source of verbal support.

Support for walking plans was similar across groups.Support of friends was most often cited as part of thewalking plan for all racial and income groups. Inaddition, almost all women planned to walk by them-selves at some point during the intervention, but not allwomen desired to walk by themselves, as evidenced by therestructuring strategy of adding a partner.

A difference in support plans was found betweenincome groups. The high-income women appeared toplan to walk with a significant other and pets more oftenthan low-income participants.

All women most frequently identified a walking com-panion as nonfamilial support. Walking alone wassecond-most identified. The women who did not reportwalking alone had regular walking partners. Immediatefamily was the third-most commonly identified walkingpartner. For all groups, family walking partners weremost often other women, that is, mothers, daughters, andnieces. The European American women stated that familymembers were walking companions more frequently thanany other group. In addition, European American womenfrequently walked with their dogs, whereas no AfricanAmerican women walked or planned to walk with pets.

Exercise Efficacy

The women were questioned about how they felt aboutthemselves and their efforts to walk as a means to probeinto the status of their self-efficacy. Some of the positivemessages that the women gave themselves included, ‘‘Iknow I can do it. I believe in myself’’ (Lo/AA); ‘‘I remindmyself that the more I walk the more I want to walk. Itbecomes part of routine.’’ (Hi/AA); ‘‘I feel better afterwalking. I will become strong’’ (Lo/EA). All of the partic-ipants experienced positive feelings about their walking,but not all women experienced these feelings every week.

Relapse Prevention

The women were asked to identify what they could do toprevent a relapse in their walking program if for somereason they began to miss a couple of days of walking.Persistence in attitude meant that the women wouldresume walking as soon as possible and mentally wouldhold themselves accountable. Most comments were sim-ilar to this Hi/EA’s, ‘‘Not beat up on myself and start assoon as possible’’ or this Lo/EA’s, ‘‘Well, I missed somechances that I could have gone walking, but I can gowalking next week.’’ Restructuring strategies were used.They were change attitude and time, ‘‘better attitude andplan to go at a specific time’’ (Hi/AA), and enhancepreparation, ‘‘get motivated, buck up, bring tennis shoesto work’’ (Lo/AA). Social support strategies were oftenused in combination with other relapse prevention strat-egies. For example, one Hi/EA woman planned to ‘‘buildself-motivators and use support, husband.’’ Identifyingbenefits was most often used as an exclusive strategy,‘‘Remind myself how it [walking] is both mentally andphysically good for me’’ (Lo/AA); ‘‘try to remind myselfof benefits’’ (Hi/EA). No differences or trends were foundbetween the groups.

150 Public Health Nursing Volume 20 Number 2 March/April 2003

Maintenance

No trends appeared based on race and income whenmaintenance strategies were analyzed. The maintenanceof the women’s walking program was similar to relapseprevention. Routine was identified as a means to maintainwalking because of an established, predictable, and stableroutine. For example, one Hi/EA woman said that shewould maintain her walking routine because she learnedto ‘‘incorporate it into my day, like brushing my teeth.This is what I do in the mornings.’’ To demonstrate howroutine the walking had become, two Lo/AA women alsoused the analogy of a walking routine being like brushingteeth. Most women who maintained walking because ofan established routine had comments that resonated withone of the Hi/EA participants, ‘‘Walking is really routine,part of my life.

DISCUSSION

The women identified several benefits of walking as theybegan their new routines. They were an increased sense ofphysical and psychological well-being, a sense of accom-plishment, a connection to nature, and gains in compan-ionship. These may be benefits the women were unawareof before the intervention. The women were also encour-aged to set goals for themselves with regard to theirwalking routine. They talked about days and times forwalking and plans for location. Also discussed wererestructuring plans, or how they could improve theirwalking programs. They were also able to reflect onchanges they could make and ways they could enhancetheir walking success. The social support that theyreceived from others and the support they gave tothemselves was considered. Many women planned andincorporated companions into their walking routines.Some used the time to walk a family pet. Throughintervention, women were encouraged to build theirexercise self-efficacy by using positive affirmations andself-praise. Many women were able to use positive self-talk to motivate and to remind themselves of the benefitsof their new walking routine. Lastly, reflection on relapseprevention and maintenance of walking routines wasdiscussed. Women set up a plan of what they could doif they began to miss walking opportunities. Womenspoke of restructuring attitude, being persistent, gainingsocial support, and reminding themselves of benefits.According to the women, an important part of main-taining their walking was to make walking part of theirlife routine.

Possible race and income differences were found inbenefits, goal setting, restructuring, and social support.Income differences appear to be most apparent in mattersthat involve equipment, status, and social support. The

low-income women potentially could not afford thematerial goods that were accessible to high-incomewomen, which resulted in different goals and plans. Forinstance, the low-income participants reported the desireto add new equipment to enhance their walking routinemore often than high-income women did. The low-income group did not identify accomplishment as abenefit of walking as frequently as the high-income group.The discrepancy in accomplishment may be due to overallfeelings of accomplishment. The high-income women mayfeel overall more ‘‘accomplished’’ in their lives. Perhapslow-income women do not feel as accomplished ingeneral. The high-income women also reported moreverbal support from family members and planned to walkwith family members more often than the low-incomewomen.

Racial differences were most apparent with regard toenvironmental issues. The European American womenwere more likely to walk outdoors in a park or theirneighborhood. The European American group was morelikely to report a connection to nature as a benefit ofwalking. The African American women reported usingmalls more often than European American women.European American women were also more likely towalk with a family member or a pet. Perhaps differencesin family structure and lifestyle are responsible for thesedifferences in walking experience.

IMPLICATIONS OF THE STUDY

The women in the study were able to integrate walkingroutines into their daily lives. Given the importance ofphysical exercise for optimal health, identifying ways tomotivate sedentary women to become active is crucial.Counseling interventions, focused on the benefits ofwalking, goal setting, restructuring walking plans, socialsupport, exercise efficacy, relapse prevention, andmaintenance may be useful tools for establishingwalking routines. Furthermore, these counseling inter-ventions also revealed possible differences in experiencebased on racial and income level groups. The plans andpractices of incorporating walking into daily routinemay vary and should be considered by health careprofessionals when promoting a physical activity rout-ine. Although using qualitative content analysis canallow examination of themes from data such astelephone calls or written transcripts, it does havelimitations. For this study specifically, making judg-ments regarding group differences can only be tentative.The researchers noted trends that existed with differentincome levels and different racial groups. It will beimportant for future research to examine those differ-ences further.

Nies et al.: Women’s Responses 151

ACKNOWLEDGMENTS

Preparation of this manuscript was supported by NIHNINR Grant NR03999.

REFERENCES

Allgoewer, A., Wardle, J., & Steptoe, A. (2001). Depressive

symptoms, social support, and personal health behaviors inyoung men and women. Health Psychology, 20(3), 223–227.

Bandura, A. (1984). Self-efficacy mechanism in human agency.

American Psychologist, 122–147.Bandura, A. (1986). Social foundations of thought and action: A

social cognitive theory. Englewood Cliffs, NJ: Prentice Hall.Bassey, E. J. (2000). The benefits of exercise for the health of

older people. Reviews in Clinical Gerontology, 10(1), 17–31.Chien, M. Y., Wu, Y. T., Hsu, A. T., Yang, R. S., & Lai, J. S.

(2000). Efficacy of a 24-week aerobic exercise program for

osteopenic postmenopausal women. Calcified Tissue Inter-national, 67(6), 443–448.

Christmas, C., & Andersen, R. A. (2000). Exercise and older

patients: Guidelines for the clinician. Journal of the AmericanGeriatrics Society, 48(3), 318–324.

Crespo, C. J., Ainsworth, B. E., Keteyian, S. J., Heath, G. W., &

Smit, E. (1999). Prevalence of physical inactivity and itsrelation to social class in U.S. adults: Results from the ThirdNational Health and Nutrition Examination Survey, 1988–94. Medicine and Science in Sports and Exercise, 31(12),

1821–1827.Crespo, C. J., Smit, E., Andersen, R. E., Carter-Pokras, O., &

Ainsworth, B. E. (2000). Race/ethnicity, social class and their

relation to physical inactivity during leisure time: Resultsfrom the Third National Health and Nutrition ExaminationSurvey (1988–94). American. Journal of Preventive Medicine,

18(1), 46–53.Eyler, A. A., Brownson, R. C., Donatelle, R. J., King, A. C.,

Brown, D., & Sallis, J. F. (1999). Physical activity, socialsupport and middle- and older-aged minority women:

Results from a U.S. survey. Social Science and Medicine,49(6), 781–789.

King, A. C., Castro, C., Wilcox, S., Eyler, A. A., Sallis, J. F., &

Brownson, R. C. (2000). Personal and environmental factorsassociated with physical inactivity among different racial-ethnic groups of U.S. middle-aged and older-aged women.

Health Psychology, 19(4), 354–364.Krummel, D. A., Koffman, D. M., Bronner, Y., Davis, J.,

Greenlund, K., Tessaro, I., . Upson, D., & Wilbur, J. (2001).

Cardiovascular health interventions in women: What works?

Journal of Women’s Health and Gender-Based Medicine,10(2), 117–136.

Lee, I., Rexrode, K. M., Cook, N. R., Manson, J. E., & Buring,J. E. (2001). Physical activity and coronary heart disease in

women: Is ‘no pain, no gain’ passe? Journal of the AmericanMedical Association, 285, 1447–1454.

Marcus, R. (2001). Role of exercise in preventing and treating

osteoporosis. Rheumatic Diseases Clinics of North America,27(1), 131–141.

Mosca, L., Manson, J. E., Sutherland, S. E., Langer, R. D.,

Manolio, T., & Barrett-Connor, E. (1997). Cardiovasculardisease in women: A statement for healthcare professionalsfrom the. American Heart Association Writing Group, 96(7),

2468–2482.Nies, M. A., Vollman, M., & Cook, T. (1999). African American

women’s experiences with physical activity in their daily lives.Public Health Nursing, 16(1), 23–31.

NIH Consensus Statement (1995). Physical activity and car-diovascular health, 1–13. National Institutes of Health Con-sensus Development Conference on Physical Activity and

Cardiovascular Health, Bethesda, MD.QSR NUD-IST. (1997). London, UK: Scolari, Sage Publication

Ltd.

Ritsher, J. E. B.,Warner, V., Johnson, J.G., &Dohrenwend, B. P.(2001). Inter-generational longitudinal study of social classand depression: A test of social causation and social selectionmodels. British Journal of Psychiatry, 178(Suppl. 40), S84–

S90.Sallis, J. F., & Owen, N. (1999). Determinants of physical

activity. In J. F. Sallis, & N. Owens (Eds.). Physical activity

and behavioral medicine (pp. 110–134). Thousand Oaks, CA:Sage.

Turner, R. J., Lloyd, D. A., & Roszell, P. (1999). Personal

resources and the social distribution of depression. AmericanJournal of Community Psychology, 27(5), 643–672.

U.S. Department of Health and Human Services (2000). Healthy

People 2010 (PHS Publication no. 91–50213). Washington,DC: U.S. Government Printing Office.

Wardle, J., & Griffith, J. (2001). Socioeconomic status andweight control practices in British adults. Journal of Epide-

miology and Community Health, 55(3), 185–190.Wilcox, S., Castro, C., King, A. C., Housemann, R., &

Brownson, R. C. (2000). Determinants of leisure time phy-

sical activity in rural compared with urban older and ethni-cally diverse women in the United States. Journal ofEpidemiology and Community Health, 54(9), 667–672.

152 Public Health Nursing Volume 20 Number 2 March/April 2003