Application of the Transtheoretical Model

to Physical Activity and Exercise Behaviors

in African-American Adolescents
Erika R. Shaver, MPH, RDN
Kellye C. McGlumphy, BS
Amaanat K. Gill, BS
Rebecca E. Hasson, PhD, FACSM

Objectives: In this study, we examined the inter-relationships between Transtheoretical Model

(TTM) constructs (stages of change, self-efficacy, decisional balance, processes of change) and
determined the utility of TTM to predict physical activity in African-American youth. Methods: A
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community-based sample of 109 African-American youth (62% girls, age: 14.8 ± 0.2 years) were
included in this analysis. TTM constructs were assessed using the Patient-Centered Assessment
and Counseling for Exercise questionnaire. Moderate-to-vigorous physical activity (MVPA) and
Copyright (c) PNG Publications. All rights reserved.

total physical activity (TPA) were measured objectively using accelerometry. Results: Higher self-
efficacy was observed at higher stages of change in both boys and girls (p = .02). Despite higher
MVPA (p < .001) and TPA (p < .001) in boys, there were no sex differences in TTM constructs (p >
.05). Stages of change predicted MVPA in girls, with those in the maintenance stage reporting
significantly more MVPA compared to those in precontemplation/contemplation (p = .03) and
preparation stages (p = .04). Cons predicted higher TPA in boys only (p = .02). Conclusions: These
findings suggest specific TTM constructs relate to physical activity in African-American youth
and the importance of these constructs may differ by sex.

Key words: adolescents; adolescent health; health disparities; exercise; exercise psychology; Transtheoretical Model
Am J Health Behav.™ 2019;43(1):119-132
DOI: https://doi.org/10.5993/AJHB.43.1.10

R
acial/ethnic disparities in physical activity
participation have been well documented,
particularly among African Americans.1,2
Forty-one percent of African-American adolescents
meet the daily recommendation of 60 minutes of
physical activity compared to 50% in Whites.2
Previous research also confirms a gender disparity
in physical activity participation among African-
American adolescents, with 29% of African-Amer-
ican girls meeting the daily recommendation of 60
minutes of physical activity compared to 53% in
African-American boys.2 Lifelong physical activity
habits are established at a young age.3 Hence, it is
important to identify contributing factors to the
increase in inactivity observed in African-American
pediatric populations, girls in particular, to inform
intervention strategies designed to increase physical
activity participation in this ethnic minority group.
Hasson et al4 reviewed several racial/ethnic dis-
parities in access to social and environmental sup-
ports for physical activity, which in part, contribute
to the lower physical activity participation reported
in African-American adolescents. Compared to
Whites, African-American youth are less likely to
have physical activity equipment at home, more
likely to have access to electronic-media devices,
and more likely to attend schools with insufficient
physical activity programming. African-American
parents tend to provide less social support for their
children to be physically active and they themselves

Erika R. Shaver, Graduate Research Assistant, Childhood Disparities Research Laboratory. Kellye C. McGlumphy, Undergraduate Research Assistant,
Childhood Disparities Research Laboratory. Amaanat K. Gill, Undergraduate Research Assistant, Childhood Disparities Research Laboratory. Re-
becca E. Hasson, Associate Professor. All authors from the School of Kinesiology, University of Michigan, Ann Arbor, MI.
Correspondence Dr Hasson; hassonr@umich.edu

Am J Health Behav.™ 2019;43(1):119-132 119

 Application of the Transtheoretical Model to Physical Activity and Exercise Behaviors in African-American Adolescents
are less physically active compared to white parents,
leading to less role-modeling support available for
their children. African-American youth also lack
safe places to exercise in their neighborhoods. For
example, 70% of African-American neighbor-
hoods do not have recreational facilities, and parks
in these communities are more likely to be viewed
as dangerous places that can be taken over easily
for undesirable activities (ie, gang activity).5,6 Inter-
views with 18 African-American mothers further
revealed that perception of safety, especially the
threat of violence, decreased the amount of daily
outdoor physical activity in which their daugh-
ters participated.7 Taken together, these findings
suggest that the lack of social and environmental
support for physical activity represent important
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barriers to physical activity participation among
African-American boys and girls.
An understudied factor that may contribute to
Copyright (c) PNG Publications. All rights reserved.
ethnic disparities in physical activity is an indi-
vidual’s willingness to change their behavior. Pro-
chaska’s stages of change are one construct of the
Transtheoretical Model (TTM) that measure an in-
dividual’s readiness to change their physical activity
behaviors. There are 5 stages of change – precon-
templation, contemplation, preparation, action, and
maintenance.8 An individual in precontemplation
does not exercise and does not plan to start exercis-
ing within the next 6 months.9 Individuals may be
in this stage because they are uniformed or under-
informed about the consequences of inactivity; or,
they may have become discouraged in their ability
to become more physically active due to multiple
failed attempts.9 Someone in contemplation does
not exercise but plans to start within 6 months.9
These individuals are more aware of the benefits of
increasing their physical activity but also remain
acutely aware of the barriers to activity.10 A person
in preparation plans to start exercising within one
month and has taken initial steps towards this goal.9
These individuals have taken some significant ac-
tion in the past year, such as joining a sports team,
routinely using exercise videos, or taking evening
walks with their family. An individual in the ac-
tion stage has been exercising regularly for less than
6 months.9 Finally, individuals in the maintenance
stage have been exercising for 6 or more months.9
These individuals are less tempted to relapse into
inactivity and are increasingly confident that they
can continue to engage in regular exercise.9 Thus,
120
individuals in different stages of change may require
different interventions to increase or maintain their
physical activity levels. Given the multiple social
and environmental barriers to physical activity ex-
perienced by African-American youth, it is plau-
sible that this group may be less ready to change its
physical activity behavior.
Self-efficacy, decisional balance, and processes of
change are other constructs of TTM that are related
to stages of change and potentially subsequent phys-
ical activity behavior. Self-efficacy describes an indi-
vidual’s level of confidence to participate regularly
in physical activity.9,11 Individuals in a higher stage
of change report greater self-efficacy compared to
those in lower stages.9,12 Decisional balance is the
consideration of pros compared to the cons (or
the benefits compared to the costs) of adopting a
physically active lifestyle.9,11 Individuals in a higher
stage of change typically report more pros related to
engaging in regular exercise compared to those in
lower stages.9 Finally, processes of change includes af-
fective, behavioral, cognitive, and evaluative strate-
gies that an individual may use to increase physical
activity behavior.11,13 Social liberation, for example,
involves an individual increasing their awareness
of social opportunities to be physically active.11,13
An individual may use this process to identify a
walking group or exercise class that is available in
the community. Helping relationships, on the other
hand, is a process that involves trusting, accepting,
and using the support of others during a behavioral
change.11,13 An individual may use this process by
asking friends and family to join them in the walk-
ing group or exercise class they previously identi-
fied. Previous research suggests that individuals in a
higher stage of change use more processes of change
compared to those in lower stages.9,12 It is unclear
whether the interrelationships between stages of
change, self-efficacy, decisional balance, and pro-
cesses of change contribute to lower physical activ-
ity participation in African-American youth.
TTM in relation to physical activity has been
studied mostly among white, middle-class, adult
female populations,9 with few studies examin-
ing the utility of this model in African-American
populations. In a multi-ethnic cohort of 184 col-
lege students ages 18 and 19 years, Lee et al14 noted
that physical activity participation was significantly
greater in the maintenance phase compared to all

other stages. In another cohort of 223 African-
American college women, average age 21 years,
perceived barriers were higher and self-efficacy was
lower for those in the precontemplation stage. Per-
ceived benefits, however, were not significantly dif-
ferent across stages.15
Only a handful of studies have examined the re-
lationships between TTM constructs and physical
activity among children and adolescents, and re-
sults have been mixed. In a cohort of elementary
school children, stages of change was not signifi-
cantly related to 8 measures of physical activity,
including aerobic endurance, push-ups, and sit-
ups.9,16 Similarly, in a cross-sectional study in 127
seventh-grade students, 40 of whom were African
Americans, stages of change was not a significant
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predictor of moderate-to-vigorous physical activity
(MVPA).17 In contrast, Lee et al14 reported that lei-
sure-time physical activity was greater in individu-
Copyright (c) PNG Publications. All rights reserved.
als in the action and maintenance stages compared
to those in the precontemplation, contemplation,
and preparation stages in a sample of 819 Cana-
dian adolescents, ages 13-19 years. Another study
within this cohort of Canadian adolescents found
that self-efficacy and pros increased while cons de-
creased among children who were categorized in
higher stages of change.13 Moreover, individuals
utilized each process of change more frequently in
the action stage compared to earlier stages.13 These
results are similar to those of De Bourdeauduij et
al,18 who in a population of 5931 Flemish adoles-
cents ages 12-18 years, found that pros and cons
varied significantly across stages of change. Self-
efficacy was also greater in those in the prepara-
tion stage compared to those in the contemplation
stage. Of interest, 33% of girls were in pre-action
stages (precontemplation and contemplation) and
were not regularly active, compared to only 18%
of the boys, pointing to a potential gender dispar-
ity in girls’ willingness to change their physical
activity behavior.18 Given the dramatic drop in
physical activity participation during the period of
adolescence, with the greatest declines observed in
African-American youth,1,2 clarifying the interrela-
tionships of TTM constructs and physical activity
in this ethnic minority group is needed to better
promote physical activity in this population.
To date, most research has focused on the rela-
tionship between physical activity and stages of
Am J Health Behav.™ 2019;43(1):119-132
Shaver et al
change, or between stages of change and other
TTM constructs. No researchers have explored all
4 TTM constructs – stages of change, decisional
balance, processes of change, and self-efficacy – in
relation to physical activity in African-American
youth using objective measures. TTM tailored
interventions have resulted in greater change in
short-term physical activity compared to non-tai-
lored interventions.19 Yet, most interventions are
developed for individuals in the action phase.9 Giv-
en the lower levels of physical activity participation
among African-American youth and the mixed
evidence of TTM constructs in relation to physical
activity among pediatric populations,13,17 the pur-
pose of this study was 2-fold. Our primary pur-
pose was to examine the interrelationships between
TTM constructs and examine the utility of TTM
to predict moderate-to-vigorous physical activity
(MVPA) and total physical activity (TPA) among
African-American youth. Our secondary purpose
was to examine potential gender differences in the
relationships between TTM constructs and physi-
cal activity. We hypothesized that pros, self-efficacy,
and processes of change would increase with each
stage, and that cons would decrease with each
stage. We also hypothesized that stages of change,
pros, self-efficacy, and processes of change would
predict significantly more minutes of MVPA and
TPA, and cons would predict significantly fewer
minutes of physical activity. Additionally, we hy-
pothesized that African-American girls would clas-
sify themselves in a lower stage of change compared
to African-American boys, and that African-Amer-
ican girls would have significantly fewer pros and
processes of change, lower self-efficacy, and greater
cons compared to African-American boys.
METHODS
Sample Population, Recruitment, and
Procedure
Children and adolescents in Washtenaw Coun-
ty, Michigan were recruited to participate in the
Health & Culture Project. The Health & Cul-
ture Project was a nutrition and physical activity
education program that examined the associations
between social, cultural, and psychological factors
related to physical activity, diet, and obesity risk
in African-American adolescents. A total of 273
youth, ages 11-18 years, enrolled in the Health
DOI: https://doi.org/10.5993/AJHB.43.1.10 121
 Application of the Transtheoretical Model to Physical Activity and Exercise Behaviors in African-American Adolescents
& Culture Project from middle schools (N = 85),
high schools (N = 31), afterschool programs (N =
46), community centers (N = 30), and the general
community in Washtenaw County, Michigan (N =
81) via flyers and word-of-mouth. Data collection
occurred at the Childhood Disparities Research
Laboratory or off-site in school classrooms, after-
school programs, or community centers.
A subset of participants (109 African-American
adolescents, 68 girls and 41 boys) who completed
questionnaires assessing physical activity beliefs
and behaviors and had valid accelerometer data
were included in this cross-sectional analysis. Of
the 134 African-American individuals not included
from this analysis, 62 were boys and 72 were girls.
Those who were excluded did not significantly dif-
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fer from those who were included in body mass
index (BMI) (25.5 ± 0.6 vs. 24.7 ± 0.6; p = .43)
or BMI percentile (76.0 ± 2.6 vs. 72.5 ± 2.4; p =
Copyright (c) PNG Publications. All rights reserved.
.30). Those who were excluded were significantly
younger (14.3 ± 0.2 years old) compared to those
who were included (14.8 ± 0.2 years old; p = .03).
Measurements
Independent variables. We assessed stages of
change, processes of change, self-efficacy, and de-
cisional balance using the Patient-Centered As-
sessment and Counseling for Exercise (PACE)
questionnaire packet.20 Processes of change, self-
efficacy, and decisional balance have been validated
in a multiethnic adolescent population20 and ver-
sions of stages of change questionnaire have been
validated among adolescents.18 We describe each
survey below. For all questionnaires, physical ac-
tivity was defined as “any activity that increases
your heart rate and makes you get out of breath
some of the time.” Sports, running, brisk walk-
ing, rollerblading, biking, skateboarding, dancing,
swimming, soccer, basketball, football, and surfing
were examples of physical activity provided on the
survey.
Stages of change. This questionnaire included a
2-part question that measures participants’ readi-
ness to change their physical activity behaviors.
Participants first were asked: “In a typical week,
how many days do you do physical activity for 60
minutes or more?” If they answered less than 5 days
per week, they were asked if they do not intend
to start in the next 6 months (precontemplation),
122
if they intend to start in the next 6 months (con-
templation), or if they intend to start in the next
30 days (preparation). If they answered 5 days or
more, they were asked how many months they have
exercised for 5 days or more [less than 6 months
(action) or 6 months or more (maintenance)].
Processes of change. The processes of change
questionnaire reflected the thoughts, activities, and
feelings people may experience during a physical
activity behavior change. Participants responded
to 15 statements such as “I look for information
about physical activities or sports” and “I keep
track of how much physical activity I do” using a
5-point Likert-type scale, ranging from 1 (never) to
5 (many times). The score was an average of the 15
responses.20 This measure demonstrated high reli-
ability in the present analysis (Cronbach α=0.91).
Self-efficacy. Six items assessed the participant’s
confidence in overcoming barriers to being physi-
cally active. We asked participants how sure they
were that they could do physical activity in certain
situations, such as “when you feel sad or stressed”
or “when your family and friends want you to do
something else.” Each statement was associated
with a 5-point Likert-type scale ranging from 1
(I’m sure I can’t) to 5 (I’m sure I can). This survey
was scored by averaging the responses.20 This mea-
sure demonstrated high reliability in the present
analysis (Cronbach α=0.79).
Decisional balance. Decisional balance consists
of “pros” and “cons” of change that convey cog-
nitive and motivational aspects of decision mak-
ing. Each participant was asked: “How important
is each statement to you when deciding whether
or not to do physical activity?” They were provid-
ed 5 statements of physical activity pros, such as
“physical activity would help me stay fit,” and 5
physical activity cons, such as “I would feel em-
barrassed if people saw me doing physical activ-
ity.” Each statement was associated with a 5-point
Likert-type scale ranging from 1 (not important)
to 5 (extremely important). A pros score and cons
score were created by averaging the appropriate
questions.20 This measure demonstrated high reli-
ability in the present analysis (Pros: Cronbach α =
.77; Cons: Cronbach α = .71).
Dependent variable. MVPA and TPA were mea-
sured using GT3X ActiLife accelerometers. We
asked participants to wear the device snugly on their
 Shaver et al

Table 1
Sex Differences in Demographics, Physical Activity, and TTM Constructs
Boys Girls
Variable N Frequency (%) Mean (SE) N Frequency (%) Mean (SE) p-value
Age (years) 41 - 14.8 (0.3) 68 - 14.9 (0.2) .70
BMI Percentile 41 - 67.6 (4.2) 68 - 75.4 (3.2) .14
MVPA 41 - 22.9 (2.7) 68 - 8.3 (1.3) < .001*
TPA 41 - 135.8 (7.7) 68 - 101.0 (4.6) < .001*
Days per week achieving
41 4.4 (0.2) 68 3.4 (0.2) .06
PA recommendation
0 0 0.0 - 6 8.8 - -
1 1 2.4 - 10 14.7 - -
2 3 7.3 - 10 14.7 - -
3 5 12.2 - 7 10.3 - -
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4 12 29.3 - 12 17.6 - -
5 10 24.4 - 9 13.2 - -
6 or 7 10 24.4 - 14 20.6 - -
Copyright (c) PNG Publications. All rights reserved.

Stage of Change 41 3.5 (0.2) 68 3.1 (0.2) .47

Precontemplation/
13 31.7 27 39.7
Contemplation
Preparation 8 19.5 - 18 26.5 - -
Action 7 17.1 - 7 10.3 - -
Maintenance 13 31.7 - 16 23.5 - -
Processes of Change 41 3.0 (0.1) 68 2.9 (0.1) .56
Self-efficacy 41 3.6 (0.1) 68 3.3 (0.1) .09
Pros 41 3.7 (0.1) 68 3.8 (0.1) .71
Cons 41 1.8 (0.1) 68 1.7 (0.1) .65

*p < .05

Note.
Mean and standard error are shown for age, BMI, BMI percentile, MVPA, TPA, Processes of change, self-efficacy, pros,
and cons. The frequency of stage of change and days per week achieving physical activity recommendations is also
reported. BMI, body mass index; MVPA, moderate-to-vigorous physical activity; TPA, total physical activity; PA,
physical activity. Physical activity recommendation is defined as achieving 60 minutes of mostly MVPA.

right hip using an adjustable belt. At home, they
were advised to remove the accelerometers during
bathing, water-based activities, contact sports, and
while they slept. We also asked them to complete a
non-wear and sleep diary. The devices were initial-
ized to collect raw data at a frequency of 30 Hz.
Raw accelerometer data were then downloaded and
integrated into 60s epochs using ActiLife software,
version 6.11.8. A wear time of ≥600 minute/day
for ≥4 days was used as the criteria for a valid wear
time data.12 Sleep time was manually entered and
marked as non-wear time. Consecutive periods of
zero counts for ≥60 minutes were also defined as
non-wear time, allowing for 1-2 minutes of counts
between 0 and 100.21 Non-wear times were exclud-
ed from the analyses. We used Puyau cut-points,22
commonly used in adolescent populations,23,24 to
derive activity intensities (ie, light and MVPA).
TPA was calculated by averaging the total minutes
of light and MVPA.
Covariates. Given the negative associations of
weight status25 and age26,27 with physical activity
participation in youth, these variables were also in-
cluded in the regression models.

Am J Health Behav.™ 2019;43(1):119-132 DOI: https://doi.org/10.5993/AJHB.43.1.10 123

 Application of the Transtheoretical Model to Physical Activity and Exercise Behaviors in African-American Adolescents
Body mass index. We calculated BMI and BMI
percentiles using guidelines from the US Centers
for Disease Control and Prevention.28,29 Height was
measured to the nearest 0.1 cm using a ShorrBoard®
(Weigh and Measure, LLC., Olney, MD). Body
weight (kg) was measured to the nearest 0.1 kg us-
ing an electronic scale (Doran Scales, Inc., Batavia,
IL). Height and weight were measured using stan-
dardized procedures.30
Demographic information. Information about
sex and age was self-reported by the participant.
Data Analysis
Analyses were conducted using SPSS Version
24. We used t-tests to assess gender differences in
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demographic characteristics, processes of change,
self-efficacy, pros, cons, MVPA, and TPA. We used
Pearson’s chi-square tests to assess gender differ-
Copyright (c) PNG Publications. All rights reserved.
ences in stages of change and number of times per
week participants achieved 60 minutes of physical
activity. Univariate analysis of variance (ANOVA)
was used to identify significant differences in pro-
cesses of change, self-efficacy, pros, and cons across
the stages of change. Tukey post hoc analyses were
completed for ANOVAs that demonstrated a sig-
nificant result. Two linear regression models were
run to examine the relationship between the inde-
pendent variables (stages of change, processes of
change, self-efficacy, pros, cons) and the dependent
variables (MVPA and TPA) in African-American
girls and boys, with BMI, sex, and age as covari-
ates. “Female” and “maintenance” (the final stage
of change) served as the reference variables for sex
and stages of change, respectively. Because only 5
participants categorized themselves in the “precon-
templation” phase, precontemplation and contem-
plation stages were combined into one stage for the
regression analysis. Two additional regression mod-
els for MVPA and TPA were run with sex interac-
tion terms included for all independent variables
(stages of change, processes of change, self-efficacy,
pros, and cons). The a priori statistical significance
for all analyses was set at p < .05.
RESULTS
In the present analysis of 109 youth participants,
62.4% were girls and 26.6% were classified as obese
with an average age of 14.8 years. The participants’
average TPA was 114 minutes each day, 14 minutes
124
of which were MVPA. The stages of change among
participants was distributed as follows: 40 subjects
(36.7%) were in precontemplation/contemplation
stages, 26 (23.9%) were in the preparation stage, 14
(12.8 %) were in the action stage, and 29 (26.6%)
were in the maintenance stage.
Table 1 shows sex differences in demographics,
physical activity, and TTM constructs. Girls had
significantly fewer minutes of MVPA (8.3 ± 1.3 vs.
22.9 ± 2.7; p < .001) and TPA (101.0 ± 4.6 vs.
135.8 ± 7.7; p < .001) per day compared to boys.
There were no significant differences in age, BMI
percentile, days per week achieving physical activ-
ity recommendations between boys and girls (all ps
> .05). There were also no significant differences in
stages of change, processes of change, self-efficacy,
pros, or cons between African-American girls and
boys (all ps > .05).
Table 2 presents differences in processes of
change, self-efficacy, pros, and cons by stage of
change. Self-efficacy was significantly different
across stages of change (p = .02) with higher self-
efficacy observed among those in the maintenance
stage compared to precontemplation/contempla-
tion stages. Self-efficacy did not significantly differ
between any other stages (all ps > .05). There were
also no significant differences between the stages of
change and processes of change (p = .39), pros (p =
.57), or cons (p = .26).
Table 3 presents the relationship between TTM
constructs and MVPA. Those in the precontempla-
tion/contemplation stages engaged in 8 fewer min-
utes of MVPA per day compared to those in the
maintenance stage (p = .03), and those in the prepa-
ration stage, engaged in 9 fewer minutes of MVPA
per day compared to those in the maintenance stage
(p = .02). Sex was a statistically significant predictor
of MVPA with boys participating in more MVPA
compared to girls (p < .001). There was no signifi-
cant difference in MVPA between the action and
maintenance phases (p > .05). MVPA was not sig-
nificantly associated with processes of change, pros,
cons, self-efficacy, age, or BMI (all ps > .05).
Table 4 presents the sex-stratified model of the
relationship between MVPA and TTM constructs.
Girls in both the precontemplation/contemplation
phases as well as the preparation phase were pre-
dicted to participate in 10 fewer minutes of MVPA
compared to girls in the maintenance phase (p =
 Shaver et al

Table 2
Differences in Processes of Change, Self-efficacy, Pros, and Cons across the Stages of Change
Precontemplation/
Stage of Change Preparation Action Maintenance F(3,105) p-value
Contemplation
Mean (SE) Mean (SE) Mean (SE) Mean (SE)
Processes of Change 2.8 (0.1) 3.0 (0.1) 3.0 (0.3) 3.2 (0.2) 1.0 .39
Pros 3.6 (0.2) 3.9 (0.2) 3.7 (0.3) 3.9 (0.2) 0.7 57
Cons 1.9 (0.1) 1.5 (0.1) 1.7 (0.1) 1.7 (0.2) 1.3 .26
Self-efficacy 3.2 (0.1) 3.4 (0.1) 3.4 (0.3) 3.8 (0.2) 3.4 .02*

* p < .05

Note.
Mean, standard errors, F values, degrees of freedom, and p-values are shown for processes of change, self-efficacy, pros,
and cons.
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.03 and p = .04, respectively). This statistically sig- efficacy, or BMI (all ps > .05). Sex was a predic-
nificant relationship was not present in boys. There tor of TPA with boys participating in more TPA
Copyright (c) PNG Publications. All rights reserved.

were no significant relationships between MVPA
and processes of change, pros, cons, or self-efficacy
in girls or boys (all ps > .05).
Table 5 presents the relationship between TTM
constructs and TPA. There were no statistically sig-
nificant relationships between TPA and any stages
of change, processes of change, pros, cons, self-
compared to girls (p = .001). Additionally, age was
a significant predictor of TPA with a one-year in-
crease in age predicting 7 fewer minutes of total
physical activity per day (p = .002).
Table 6 presents the sex-stratified model of the re-
lationship between TPA and the TTM constructs.
A one-unit increase in cons predicted 21 additional

Table 3
Predicted MVPA based on TTM Constructs among African-American Adolescents (N = 109)
MVPA β-Coefficient Standard Error p-value 95% Confidence Interval
Stages of Change
Precontemplation/
Contemplation -7.7 3.5 .03* -14.6 -0.9
Preparation -8.6 3.7 .02* -16.0 -1.2
Action -2.5 4.4 .57 -11.3 6.2
Processes of Change -0.7 2.4 .78 -5.4 4.1
Pros 0.6 1.9 .74 -3.1 4.3
Cons 2.2 1.9 .25 -1.6 6.0
Self-efficacy -0.5 1.8 .76 -4.2 3.1
Sex 12.3 2.8 < .001* 6.7 17.9
Age -0.3 0.8 .73 -1.8 1.3
BMI (kg/m2) -0.4 0.2 .06 -0.8 0.0

* p < .05

Note.
Unstandardized beta coefficients and standard errors are shown. Maintenance and being female were the reference
variables.

Am J Health Behav.™ 2019;43(1):119-132 DOI: https://doi.org/10.5993/AJHB.43.1.10 125

 Application of the Transtheoretical Model to Physical Activity and Exercise Behaviors in African-American Adolescents

Table 4
Predictors of MVPA Stratified by Sex
MVPA β-Coefficient Standard Error p-value 95% Confidence Interval
Stages of Change
Precontemplation/
Contemplation
Boys -7.0 5.9 .24 -18.8 4.8
Girls -10.0 4.5 .03* -18.9 -1.1
Boys vs Girls 2.9 7.4 .69 -11.8 17.7
Preparation
Boys -7.8 6.2 .22 -20.2 4.6
Girls -10.0 4.8 .04* -19.6 -0.3
Boys vs Girls 2.1 7.9 .78 -13.5 17.8
Action
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Boys -0.7 6.6 .92 -13.8 12.4

Girls -7.6 6.5 .24 -20.5 5.3
Boys vs Girls 6.9 9.3 .46 -11.5 25.3
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Processes of Change
Boys -7.4 5.4 .18 -18.2 3.4
Girls 1.7 2.8 .54 -3.8 7.2
Boys vs Girls -9.1 6.1 .14 -21.2 3.0
Pros
Boys 4.2 3.5 .24 -2.8 11.2
Girls -0.5 2.3 .84 -5.1 4.1
Boys vs Girls 4.7 4.2 .27 -3.7 13.0
Cons
Boys 5.3 3.1 .10 -0.9 11.5
Girls 0.3 2.5 .92 -4.8 5.3
Boys vs Girls 5.0 4.0 .21 -2.9 12.9
Self-efficacy
Boys 2.3 3.3 .50 -4.3 8.8
Girls -2.5 2.3 .29 -7.0 2.1
Boys vs Girls 4.7 4.0 .25 -3.3 12.7

* p < .05

Note.
Unstandardized beta coefficients and standard errors are shown; maintenance was the reference variable for
stages of change.

minutes of TPA among boys only (p = .02). Ad-
ditionally, the relationship between cons and TPA
differed by sex, with a positive relationship in boys
and an inverse relationship among girls (p = .02).
There were no statistically significant associations
between TPA and any stages of change, processes
of change, pros, or self-efficacy among girls or boys
(all ps > .05).
DISCUSSION
Given the lower physical activity levels among
African-American adolescents, we sought to ex-

126
 Shaver et al

Table 5
Predicted TPA based on TTM Constructs among African-American Adolescents (N = 109)
TPA β-Coefficient Standard Error p-value 95% Confidence Interval

Stages of Change
Precontemplation/
-5.6 10.2 .59 -25.9 14.7
Contemplation
Preparation -19.5 11.1 .08 -41.6 2.5
Action 14.8 13.1 .26 -11.2 40.7
Processes of Change -0.1 7.1 .99 -14.2 14.0
Pros -3.1 5.5 .58 -14.0 7.9
Cons 6.5 5.7 .26 -4.8 17.8
Self-efficacy 5.3 5.4 .33 -5.4 16.0
Sex 27.7 8.3 .001* 11.2 44.2
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Age -7.1 2.3 .002* -11.7 -2.6

BMI (kg/m )2
-0.3 0.6 .58 -1.6 0.9

* p < .05
Copyright (c) PNG Publications. All rights reserved.

Note
Unstandardized beta coefficients and standard errors are shown. Maintenance and being female were the reference
variables.

plore the interrelationships between the TTM
constructs and examine the model’s utility in pre-
dicting MVPA and TPA using objective measures
of physical activity. Higher levels of self-efficacy
were observed at higher stages of change (ie, main-
tenance) but we found no statistically significant
relationships among processes of change, decision-
al balance, and stages of change. Despite statisti-
cally significant sex differences in MVPA and TPA,
there were no sex differences in TTM constructs.
Stages of change, or one’s willingness to change
their behavior, significantly predicted MVPA, par-
ticularly among the girls. Interestingly, cons, or the
costs associated with engaging in regular exercise,
predicted higher TPA in boys only. No other TTM
constructs were associated with MVPA or TPA in
the entire sample or among the sex-stratified mod-
els. These findings suggest that only certain TTM
constructs (stages of change and cons) significantly
relate to physical activity participation among Afri-
can-American youth, and the importance of these
constructs may differ by sex.
The current sample of African-American ado-
lescents only averaged 14 minutes of MVPA and
114 minutes of TPA each day. Data from the Na-
tional Health and Nutrition Examination Survey
(NHANES), a national multi-ethnic sample of
adolescents ages 12-19 years,31 reported similar lev-
els of MVPA, with youth achieving 15 minutes of
MVPA each day. Our findings also revealed that
African-American girls reported significantly low-
er levels of MVPA (8 minutes) compared to their
male counterparts (23 minutes). These findings are
again similar to NHANES which reported an av-
erage of 9 minutes of MVPA per day in African-
American girls compared to 23 MVPA minutes per
day in African-American boys.31 These results are
considerably lower than those reported by Belcher
et al26 (girls and boys averaged 47 and 74 MVPA
minutes per day, respectively), and that of Baskin
et al32 (girls and boys averaged 29 and 54 MVPA
minutes per day, respectively). This discrepancy is
likely due to the different cut points used across
these studies (Freedson cut points vs Puyua cut
points). We chose Puyua cut points for the present
analysis as Freedson cut points may overestimate
exercise intensity by misclassifying light physical
activity as MVPA.24
In the present study, the higher the individual’s
score on the stages of change questionnaire, the

Am J Health Behav.™ 2019;43(1):119-132 DOI: https://doi.org/10.5993/AJHB.43.1.10 127

 Application of the Transtheoretical Model to Physical Activity and Exercise Behaviors in African-American Adolescents

Table 6
Predictors of TPA Stratified by Sex
TPA β-Coefficient Standard Error p-value 95% Confidence Interval
Stages of Change
Precontemplation/
Contemplation
Boys 0.3 17.0 .99 -33.5 34.0
Girls -14.7 12.8 .25 -40.1 10.7
Boys vs Girls 14.9 21.3 .48 -27.3 57.2
Preparation
Boys -25.6 17.8 .16 -60.1 9.9
Girls -22.4 13.9 .11 -49.9 5.1
Boys vs Girls -3.2 22.5 .89 -48.0 41.6
Action
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Boys 29.3 18.8 .12 -8.1 66.7

Girls -4.6 18.5 .81 -41.4 32.2
Copyright (c) PNG Publications. All rights reserved.

Boys vs Girls 33.9 26.5 .20 -18.8 86.6

Processes of Change
Boys 0.9 15.5 .96 -30.0 31.8
Girls 2.9 7.9 .72 -12.8 18.6
Boys vs Girls -2.0 17.4 .91 -36.6 32.6
Pros
Boys 0.8 10.1 .94 -19.3 20.9
Girls -5.0 6.6 .45 -18.1 8.2
Boys vs Girls 5.8 12.1 .64 -18.2 29.7
Cons
Boys 21.3 9.0 .02* 3.5 39.1
Girls -5.9 7.3 .42 -20.4 8.5
Boys vs Girls 27.2 11.4 .02* 4.6 49.9
Self-Efficacy
Boys 7.7 9.5 .42 -11.2 26.5
Girls 0.4 6.6 .96 -12.7 13.5
Boys vs Girls 7.3 11.5 .53 -15.6 30.2

* p < .05

Note.
Unstandardized beta coefficients and standard errors are shown. Maintenance was the reference variable for
stages of change.

more likely they were to engage in moderate-to-
vigorous physical activity. African-American youth
in the maintenance stage were predicted to partici-
pate in 8 additional minutes of MVPA compared
to youth in the precontemplation and contempla-
tion stages and 9 additional minutes of MVPA
compared to youth in the preparation stage. Data
from the PACE questionnaire also revealed that
boys and girls in the precontemplation/contem-
plation and preparation stages reported achieving
60 minutes of physical activity an average of 2 and
3 days per week, respectively, compared to 6 days

128

for those in the maintenance stage. These findings
are consistent with research previously conducted
in Belgian and Canadian adolescents. De Bour-
deauduij et al18 noted that Belgian adolescents in
precontemplation reported achieving the recom-
mended amount of moderate physical activity (60
minutes) and/or vigorous activity (20 minutes) 2
days per week compared to adolescents in mainte-
nance, who achieved 6 days per week. Among Ca-
nadian youth, those in precontemplation achieved
one day of moderate activity compared to 4 days
for those in the action and maintenance stages.14
The statistically significant relationship between
stages of change and moderate-to-vigorous physi-
cal activity observed in the present analysis was
primarily driven by the girls, with greater MVPA
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participation predicted in girls at higher stages of
change (ie, maintenance). One possible reason for
the non-significant findings in boys may relate to
Copyright (c) PNG Publications. All rights reserved.
other environmental and psychosocial factors play-
ing a larger role in African-American boys’ physical
activity participation. Trost et al33 demonstrated in
a sample of 198 predominately African-American
sixth-grade students that participation in commu-
nity-based physical activity organizations and social
norms regarding physical activity (eg, what par-
ents, friends and classmates think about physical
activity) explained 13% of the variance in moder-
ate physical activity and 12% of the variance in vig-
orous physical activity participation in boys. These
factors were not significant predictors in girls.33
Moreover, McGlumphy et al34 observed in a sam-
ple of 139 African-American adolescents, perceived
stress predicted lower MVPA in African-American
boys, whereas no significant relationships between
perceived stress and MVPA was present in girls.34
Taken together, these results suggest that social and
environmental factors may be stronger predictors
of MVPA in African-American boys than their
willingness to change their physical activity behav-
ior. Continued investigation of the determinants of
physical activity participation in this sex group is
warranted.
The lack of association between TPA and stages
of change in the present study is inconsistent with
findings from De Bourdeaudhuij et al18 who re-
ported that TPA significantly differed across each
stage of change except between the preparation and
action stages in a sample of 5931 Flemish adoles-
Am J Health Behav.™ 2019;43(1):119-132
Shaver et al
cents. This discrepancy in study findings may re-
late to the definition of physical activity employed
in the present study. Physical activity was defined
as “any activity that increases your heart rate and
makes you get out of breath some of the time” and
examples of sporting activities were included. As
such, adolescents may have answered this ques-
tion in the context of MVPA rather than TPA.
How De Bourdeaudhuij et al18 classified physical
activity was not clarified in their publication. More
importantly, the measurement of physical activity
differed between studies (accelerometry vs self-re-
port), which could also account for the differences
in study findings. Additional research is needed to
improve understanding of how the conceptualiza-
tion and measurement of physical activity relates
to the utility of TTM to predict physical activity in
African-American youth.
Contrary to our hypothesis, cons, or the costs
of being regularly physically active was associated
with greater TPA in African-American boys only
and when cons was measured in relationship to
stages of change, there was no significant differ-
ence in cons across the stages. Both findings were
surprising, as other studies have indicated an in-
verse association between cons and physical activity
stages of change. For example, Nigg et al13 found
that cons decreased among children who self-cate-
gorized into higher stages. One explanation for our
finding is that whereas the costs associated with
regular exercise may exist for African-American
boys, they may be less aware of these barriers when
choosing to engage in activity. It is also possible that
African-American boys have other social and envi-
ronmental resources to overcome these barriers. As
such, decisional balance may not accurately predict
physical activity participation in African-American
boys. Additional research is needed to gain better
understanding of why cons are associated with in-
creased TPA in African-American boys.
Another surprising finding was the lack of a
statistically significant association between physi-
cal activity and processes of change as well as be-
tween process of change and stages of change. Nigg
and Coureya13 previously reported a significantly
greater use of each process of change in 819 high
school students classified in the higher stages of
change compared to lower stages of change. The
emphasis on each individual process of change in
DOI: https://doi.org/10.5993/AJHB.43.1.10 129
 Application of the Transtheoretical Model to Physical Activity and Exercise Behaviors in African-American Adolescents
Nigg and Coureya’s analysis rather than evaluating
the construct as a whole may account for the dif-
ferences in study findings. It is also possible that
African-American adolescents use different pro-
cesses of change to increase their physical activ-
ity participation given the lower physical activity
resources available to this ethnic group. As such,
this construct may not be suitable for use in this
ethnic group. Further research is needed to better
understand whether African-American youth use
culturally-specific strategies to change their behav-
ior and whether or not these strategies are related
to their willingness to change their physical activity
behavior.
Finally, self-efficacy was not a statistically signifi-
cant predictor of physical activity in the present
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analysis. This was unexpected, as other studies have
identified self-efficacy as a significant predictor of
physical activity in multi-ethnic populations. For
Copyright (c) PNG Publications. All rights reserved.
example, the Eating and Activity in Teens study
found that a one-unit increase in self-efficacy pre-
dicted an additional 42 and 36 minutes of MVPA
in boys and girls, respectively, in a multi-ethnic
sample of 2793 students in grades 6-12.35 Indi-
viduals in the precontemplation/contemplation
stage however, reported significantly lower levels of
self-efficacy compared to those in the maintenance
stage, which is consistent among other adolescent
populations. Nigg and Courneya,13 reported that
self-efficacy was significantly lower in those in
the precontemplation and contemplation stages
compared to those in the maintenance stage. This
suggests that although self-efficacy significantly in-
creases at higher stages of change, this construct
may not be directly related to physical activity par-
ticipation in African-American youth. Neverthe-
less, interventionists should continue to target both
self-efficacy and stages of change to increase MVPA
in African-American youth.
Taken together, these findings suggest inter-
ventions designed to increase MVPA in African-
American pediatric populations may need to be
tailored to an individual’s willingness to change.
Indeed, previous research has demonstrated that
TTM-based interventions are effective in im-
proving short-term physical activity participation
in adults.36 To our knowledge, only one study to
date has used a TTM-tailored approach to increase
physical activity in youth. Frenn et al37 conducted
130
a computer-based nutrition and physical activity
intervention in 103 diverse seventh graders and
MVPA increased by 22 minutes in the intervention
group compared to a 46 minute decrease among
controls. Among the African-American students,
MVPA increased by approximately 10 minutes
in the intervention group. This intervention used
8 computer-based sessions that integrated both
Health Promotion Model and TTM constructs.
Each session provided 2-to-3-minute videos de-
signed to enhance consciousness raising and self-re-
evaluation, 2 processes of change that are important
in the precontemplation and contemplation stages.
For example, consciousness raising involves seeking
and learning new information about physical ac-
tivity behavior. For one session, this intervention
incorporated consciousness-raising by educating
persons on their involvement in choosing activities
that are accessible and possible to perform safely.37
The results of this study indicated that MVPA in-
creased for individuals in contemplation and prep-
aration phases.37
In the present study we did not observe a statisti-
cally significant association among decisional bal-
ance, stages of change, and MVPA. Rather, our
findings suggest tailoring interventions to individu-
als’ stages of change and self-efficacy may be more
beneficial for increasing MVPA in African-Ameri-
can youth. An intervention tailored to individuals
in the contemplation and preparation stage may be
particularly important for African-American ado-
lescents, as the greatest percentage of youth in the
current analysis (37%) classified themselves in the
precontemplation/contemplation stage. Thirty-five
of these 40 individuals were in the contemplation
stage. Approximately 24% of youth classified them-
selves in the preparation stage. Computer-based in-
terventions in particular, can be provided in schools,
community centers and public libraries where indi-
viduals can have equal-access to this intervention.
The strengths of this study included the use of
accelerometers for objective measurement of physi-
cal activity and validated questionnaires to assess
TTM. The limitations included a cross-sectional
design that relied on self-reported questionnaire
data. Additionally, activity log compliance associ-
ated with accelerometry was low, which may have
contributed to under-reporting of vigorous activity
associated with contact sports (particularly among

the boys). Finally, the generalizability of this study
may be limited to African-American youth residing
in southeast Michigan. Despite these limitations,
we demonstrated that those in the precontempla-
tion/contemplation stages reported less self-efficacy
compared to those in the maintenance stage, iden-
tified stages of change as a significant predictor of
MVPA in African-American girls, and observed a
positive relationship between decisional balance
and TPA in African-American boys.
African-American girls and boys are achieving
less than half of the physical activity recommen-
dations, with girls accumulating significantly fewer
minutes of MVPA and TPA compared to boys. We
identified stages of change as a statistically signifi-
cant predictor of MVPA in African-American girls,
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which suggests that one’s readiness to change their
behavior may be an important factor to consider
when designing physical activity interventions for
Copyright (c) PNG Publications. All rights reserved.
this group. Furthermore, self-efficacy was signifi-
cantly lower for those in precontemplation/con-
templation stages compared to the maintenance
stage. Taken together, these results highlight the
utility of these TTM constructs and intervention-
ists should consider using the constructs to tailor
physical activity interventions for African-Ameri-
can youth. It is important to note that processes of
change were not associated with physical activity
in this analysis and decisional balance produced a
paradoxical relationship with physical activity. As
such, these TTM constructs may not be suitable
for use in this population but additional research
is warranted given the cross-sectional nature of this
analysis. It is also important to note that for Af-
rican-American youth, categorizing oneself in the
maintenance stage only predicted 8 to 9 additional
minutes of MVPA compared to contemplation/
precontemplation and preparation stages, which
is approximately 15% of the daily physical activ-
ity recommendations. These findings confirm that
factors contributing to physical activity behavior in
this group are multi-dimensional. Previous litera-
ture has emphasized the role of peer support,35 psy-
chological stress,34 neighborhood safety,7 and access
to community programming33 in shaping physi-
cal activity behaviors in African-American youth.
Hence, interventionists should consider tailoring
their interventions to address adolescents’ readiness
to change their behavior and help them overcome
social and environmental barriers to physical activ-
Am J Health Behav.™ 2019;43(1):119-132
Shaver et al
ity. Future research also should continue to exam-
ine TTM in concert with social and environmental
factors to better understand what role these factors
may play in shaping African-American adoles-
cents’ willingness to change their physical activity
behavior.
Human Subjects Statement
This study was reviewed and approved by the
University of Michigan Institutional Review Board.
This study is registered at www.clinicaltrials.gov
(No. NCT02938663). Participants and their par-
ent (if youth was under 18 years of age) signed an
informed consent document before participating.
Conflict of Interest Statement
The authors have nothing to disclose.
Acknowledgements
We thank the Health & Culture Project team
and Michigan Consulting for Statistics, Comput-
ing and Analytics Research. We are also grateful for
our study participants and their families for their
involvement. The results of this study are presented
clearly, honestly, and without fabrication, falsifica-
tion, or inappropriate data manipulation. A poster
of preliminary results was presented at the 2016
Obesity Week conference in New Orleans, Loui-
siana. This work was supported by the University
of Michigan Office of Research and the University
of Michigan School of Public Health Momentum
Center.
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