College students' understanding of moderate physical activity: a qualitative study.

Abstract: The purpose of this study was to examine college students' understanding of physical activity and the moderate physical activity recommendation. Thirty students attended focus groups and responded to questions about physical activity. Data were analyzed using NUD*IST software and a two-step data coding process. Results indicated that students understood the definition of physical activity but were confused about the frequency, duration, and accumulation components of the moderate physical activity recommendation. Messages that clarify the specific components of the current public health moderate physical activity recommendation may be needed in the college student population.

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Physical activity is "any bodily movement produced by skeletal muscles that results in energy expenditure" (Casperson, Powell, & Christenson, 1985, p. 126). In 1995, the Centers for Disease Control and Prevention and the American College of Sports Medicine released a joint recommendation regarding the amount of physical activity (PA) needed for health benefits (Pate et al., 1995). The recommendation states that adults should accumulate 30 minutes or more of moderate intensity physical activity on most, preferably all, days of the week (Pate et al., 1995). The three main components of the recommendation are frequency, intensity, and duration. "Most, preferably all, days of the week" has been interpreted by researchers to be at least five days a week (Jones et al., 1998). Moderate intensity physical activity (MPA) is defined as an intensity that is 3-6 times the energy expended at rest, or approximately equal to expending 200 calories in PA per day (Pate et al., 1995). Some examples of MPA include brisk walking (3-4 miles per hour), home repair, and house cleaning (Pate et al., 1995). The duration component of the recommendation has two aspects. First, in order to obtain health benefits, MPA must be performed for a minimum of 30 minutes per day. Second, the 30 minutes of MPA can be accumulated in bouts of at least 10 minutes (Murphy, Nevill, Nevill, Biddle, & Hardman, 2002) throughout the day.

The majority of Americans are not meeting the current public health MPA recommendation stated above. Epidemiological data indicate that only 15% of US adults accumulate at least 30 minutes of MPA on at least 5 days each week, and 40% are completely sedentary during their leisure-time (US Department of Health and Human Services [USDHHS], 2000). Further, the most rapid decrease in physical activity occurs in late adolescence and early adulthood (Stephens, Jacobs, & White, 1985). In total, 42.9% of college-age individuals do not engage in adequate amounts of PA to receive health benefits (Centers for Disease Control and Prevention [CDC], 1997).

According to social cognitive theory, knowledge about a health behavior and the benefits it offers increases self-efficacy (i.e., a person's confidence in his or her ability to perform the behavior), and self-efficacy is the main determinant of whether the person will perform the behavior (Bandura, 1997; Baranowski, Perry, & Parcel, 2002). Therefore, knowledge of PA and the associated health benefits of PA provide the foundation for an individual to become more physically active (Kahn et al., 2002).

Results from a large epidemiological study indicated that a substantial proportion of college students are not active enough to accrue health benefits (CDC, 1997). It is unclear whether college students understand the definition of PA, the health benefits it offers, and the current public health MPA recommendation. Therefore, the purpose of this study was to qualitatively examine college students' understanding of PA. Given that the current public health recommendation calls for MPA, emphasis was placed on the students' awareness of the benefits and components of MPA.

METHOD

PARTICIPANTS

Full-time college students between 18 and 30 years of age were recruited from a large university in the south central U.S. upon approval from the university's Institutional Review Board. Researchers recruited students by announcing the opportunity to participate in the study in large, general-education classes, placing flyers in high-traffic areas around campus, posting advertisements in the campus newspaper and the student website and through direct contact with students at recruiting tables in the student union. Interested students were instructed to call or email the researchers. Students who called were screened during the initial telephone call to determine their eligibility. Those who responded by email were sent an email containing the screening questions and asked to send their responses back to the researchers. Students were excluded from the study if they reported during the screening process that they had previously completed, or were currently enrolled in, any health or exercise science classes in which they may have learned about PA and the MPA recommendation. Eligible participants were contacted either by phone or e-mail, and given a specific time to attend a focus group in a centrally located area on campus with other participants of the same gender.

Each focus group was limited to six participants to increase each individual's contribution to the group's ideas (Krueger, 1998a; Morgan, 1998). When similar themes were found to be voiced by participants across focus groups (i.e., theoretical saturation was reached) recruitment of students into new focus groups ceased (Creswell, 1998).

Thirty students participated in the study. A total of 16 women age 19.3 [+ or -] 1.0 years and 14 men age 21.6 [+ or -] 3.4 years participated in eight focus groups: four female groups and four male groups. Groups consisted of three to six participants each. The majority of students (86.6%) identified as white, and most (56.6%) were freshmen or sophomores.

INSTRUMENT DEVELOPMENT

The researchers designed structured focus group questions (Morgan, 1998; see Table 1). Questions about MPA examined the students' understanding of the frequency, intensity, and duration of MPA necessary for health benefits to be realized, as well as the health benefits students would expect from participating in MPA. Focus group questions were designed to be succinct, conversational, and open-ended. The questions built in sequence with an opening, introductory, transition, key, and ending questions as recommended by Krueger (1998a).

PROCEDURES

Focus groups were conducted in a comfortable, quiet conference room. As each participant entered the room, the student was greeted by a facilitator of the same gender. Participants then completed an informed consent form and a brief demographic questionnaire (Krueger, 1998b). When these forms were completed, pizza and beverages were provided as incentives to participate and to help provide an informal setting (Krueger, 1998b; Morgan, 1998). Next, the facilitator began the focus group discussion. Students in a focus group answered, in turn, identical questions with the exception of probing questions that were asked for clarification purposes. A second facilitator took written notes about nonverbal communication expressed during the group and asked additional probing questions. Each focus group lasted approximately 1 to 1.5 hours. After all participants answered all questions, they were thanked and the group concluded.

DATA ANALYSIS

Each focus group was recorded using a digital audio recorder. Researchers transcribed the recordings verbatim and checked against the second facilitator's written notes for accuracy. Each transcript was then analyzed using the qualitative data analysis program QSR NUD*ISTO version N6 (NUD*IST, 2002).

DATA CODING

A two-step process was used to code the data. Throughout the coding process, data collected from the female students were grouped separately from those collected from the male students. For the first step, open coding was used. One study investigator grouped data that were similar in theme together into a category and assigned a label that captured its theme. A second investigator then reviewed the categories and labels which had been created. Any suggested changes in either the composition of the categories or the labels were discussed with the other investigator. When agreement between the investigators in the composition and label of each category was reached, the next step in the coding process was taken. For this step, axial coding was conducted, which consists of relating categories to the central phenomena of interest (Strauss & Corbin, 1998). This step involved relating the categories, created during open coding to definitions of PA, to the health benefits of PA, and to the frequency, intensity, and duration of MPA necessary for health benefits. As part of this step, relationships among categories were assessed, and similar categories were combined.

RESULTS

DEFINING PHYSICAL ACTIVITY

Most students were able to correctly define PA. Participants understood that PA includes "movements that require energy" and some type of "physical exertion."

Female: ... doing something physical. Walking, playing basketball ... anything, taking a walk around the block, or walking your dog, or something that exerts physical energy.

Male: Physical activity to me means actually getting off your rear end and walking around, running, lifting weights, or doing something where your body is actively moving.

Interestingly, male students overwhelmingly associated physical activity with physical labor.

Male: ... whether walking is your form of physical activity ... or lifting something in your workplace.

Male: Physical activity might just be like, uh, doing stuff at work like moving boxes, stuff like that.

PERCEIVED HEALTH BENEFITS OF PHYSICAL ACTIVITY

Overall, participants had similar perceptions regarding the health benefits of PA. Some of the health benefits discussed by both genders included weight management (e.g., burning calories), an increase in mental health (e.g., less risk of depression and increased self-confidence), a longer life, and a better quality of life. More males than females reported that regular PA provides mental health benefits. Other benefits reported by males included a reduction in heart disease and an increase in longevity. Females' most common responses were that PA leads to a decrease in fat and an increase in the number of calories burned.

Female: I say the benefits would be better health, like a more fit body, losing weight, or whatever goal you're setting for yourself.

Male: I would say that physical activity is good for you. It just doesn't help you physically, but it also helps you mentally. It works your brain and gets you processing information, working out problems while you are at work and all that.

COMPONENTS OF MODERATE PHYSICAL ACTIVITY

Frequency. Male and female students disagreed about the frequency of MPA needed to obtain health benefits. The most common response among females was that MPA should be performed "everyday." However, some women said that MPA performed as little as three days per week still offers health benefits.

Female: I think doing something like everyday, whether it be walk up a flight of stairs, or like run, or walk, or something. It doesn't have to be a huge deal ... as long as you do something a little bit, you know, like physically active you're helping yourself.

Males demonstrated strikingly less concordance in their responses. There was no clear majority of male responses indicating how many days are needed to attain health benefits. Responses ranged from 3 to 7 days per week.

Male: I'd say at least 3 times a week, but probably not more that 6.

Male: I would say 5 days a week for health benefits. Five days in a row, then 2 days off.

Intensity. Females said that MPA is an "average" intensity or "within their abilities" and that MPA is evident by an increased heart rate, increased respiration, sweating, and a slight muscle burn. Conversely, males said that MPA is slightly higher in intensity than an average activity. Like the females, males associated MPA with a slight increase in heart rate and respiration. However, males said that MPA produces no physical strain such as a muscle burn. Although the males' responses differed slightly from those of the females, both males and females seemed to understand the intensity of MPA described in the MPA recommendation.

Female: ... Moderate activity is doing something that is within your capabilities, but it doesn't stress you whereas strenuous, or something more than moderate, would be something that you would have to push yourself to do.

Male: Moderate is anything that is not very strenuous or stressful, but just something higher than normal physical activity.

Duration. There was little agreement between males and females about the duration of MPA needed to attain health benefits. While the majority of females correctly identified 30 minutes of MPA as the minimum time required for health benefits, a few females commented that less than 30 minutes of MPA would suffice. Most males believed that to receive health benefits, an individual must do MPA for a minimum of one hour.

Female: I think maybe 30 minutes. It's ... long enough to raise your heart rate--that's what they taught us in gym class.

Male: I think that most people, pretty much everybody, needs like an hour. So, a minimum of an hour.

Students did not understand that the accumulation of MPA throughout the day leads to health benefits. All females reported that accumulated MPA imparts fewer health benefits than if activity is performed in one prolonged session. Most males agreed with the females that the benefits of accrued MPA are limited. A few males even responded that accrued MPA does not provide any health benefits at all.

Female: You'll still get health benefits if you split it up, but you will get much more benefits if you do it [MPA] all together because you'll keep your heart rate up and it'll stay there.

Male: I think that you need to do it [MPA] for 20 minutes together, or more, to get any good.

DISCUSSION

The purpose of this study was to investigate college students' awareness of the definition and health benefits of PA and the components of the current public health MPA recommendation. A major finding was that the college students in this study understood the definition of PA. However, they expressed considerable confusion regarding the components of the MPA recommendation, specifically frequency and duration. As evidenced by their responses, most students correctly understood that physical activity is any bodily movement that results in energy expenditure (Casperson, et al., 1985). Further, students in this study understood some of the health benefits associated with PA.

Scientific evidence (Murphy et al., 2002; Pate et al., 1995; USDHHS, 1996, 2000) suggests that health benefits, such as decreases in numerous chronic diseases (i.e., cardiovascular disease, cancers, type 2 diabetes), reduced blood pressure, and reduced blood lipids are health benefits associated with PA. Students in this study tended to focus on the immediate benefits of PA (e.g., weight management) instead of the long-term benefits (e.g., reduction in chronic disease risk). This is not surprising given that the students were young adults who may perceive that they are invulnerable to chronic disease.

Students were somewhat confused about the frequency of MPA necessary to obtain health benefits. While the majority of females knew that MPA should be performed everyday, or at least most days a week (Jones et al., 1998), a few thought only three days were needed. The males in this study were unable to discern the frequency of MPA needed for health benefits, with responses ranging from 3 to 7 days a week. The current physical fitness recommendation for maintaining or improving cardio-respiratory endurance states a minimum frequency of 3 days per week (Pollock et al., 1998). The males may be more familiar with the suggested frequency of the physical fitness recommendation than the frequency required in the current public health MPA recommendation.

With regards to the duration of MPA necessary for health benefits, most females correctly identified 30 minutes as the minimum threshold for health benefits while most males overestimated the necessary duration by 100% (60 minutes). When questioned about the accumulation of MPA, both males and females incorrectly responded that the benefits of accumulated MPA would be fewer, or of lesser quality, than those of MPA accomplished during one prolonged bout of activity. Comments such as these suggest that these students are unaware that the current MPA recommendation (Pate et al., 1995) allows for the accumulation of PA and that recent research has demonstrated that accumulating PA throughout the day offers similar health benefits to activity performed in one bout (Murphy et al., 2002).

Our findings should be interpreted with caution. Although the students in this study are from a large university, they represent only a small sample from a much larger population of students nationwide. Results are not generalizable to the wider population. Despite these limitations, our findings do give insight into potential issues for future research. They suggest that the MPA recommendation may not be reaching college students. Our findings support those of Morrow and Blair (1999) and Morrow, Jackson, Bazzarre, Milne, and Blair (1999) who reported that only 32% of Americans and 16% of those in the college age range (18-25 years) had heard of the MPA recommendation. These two studies used quantitative methods to ascertain if certain populations had heard of the MPA recommendation. While still examining the MPA concept, our qualitative study allows for more meaningful inquiry of how well college students understand the components of MPA, not merely if they are familiar with the recommendation. Our results indicate that these students did not understand the MPA recommendation. Consequently, more effort should be made to teach college students about the MPA recommendation.

This endeavor can be accomplished through student health centers at universities, through health classes that can incorporate the MPA recommendation into physical activity learning modules, through media campaigns aimed at college-aged students, and through environmental changes in college campuses. Possible interventions could include walking trails and increased sidewalks around and throughout college campuses and utilizing closed campuses to vehicular traffic so that students must walk or ride a bicycle from place to place around campus. Additional interventions could encourage contests between university organizations such as walking campaigns or competitions that emphasize the accumulation of PA over traditional fitness-oriented programs.

The results of these qualitative findings can be used to develop surveys designed to evaluate college students understanding of PA and the current public health MPA recommendation. In addition, research that examines the apparent gender differences found in this study regarding students' understanding of MPA is warranted to explain the underlying factors that may contribute to these differences. Future research that assesses the association between students' PA behavior and their understanding of specific PA recommendations should be undertaken in an effort to explain the declining PA rates in this population. These findings provide qualitative insight concerning college students' understanding of PA and the components of the current public health MPA recommendation. Students understood the definition of PA; however, they were confused about some of the components of MPA necessary for obtaining health benefits, such as frequency, duration, and accumulation.

Acknowledgements: This work was completed while the first author was a doctoral student in the Department of Health and Exercise Science at the University of Oklahoma, Norman, OK.

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CHES AREAS

Responsibility I--Assessing Individual and Community Needs for Health Education

Competency A: Obtain health related data about social and cultural environments, growth and development factors, needs, and interests.

Competency D: Determine factors that influence learning and development.

Responsibility IV--Evaluating Effectiveness of Health Education Programs Competency C: Interpret results of program evaluation.

Competency D: Infer implications from findings for future program planning.

Timothy K. Behrens, PhD, CHES is an Assistant Professor in the Department of Health Promotion and Education at the University of Utah. Mary K. Dinger, PhD, CHES and Kristiann C. Heesch, DrPH, MPH are Assistant Professors in the Department of Health and Exercise Science at the University of Oklahoma. Susan B. Sisson, PhD is a Measurement Coordinator for Project ACT in the Department of Psychology at the University of South Carolina. Address all correspondence to Timothy K. Behrens, PhD, CHES, Department of Health Promotion and Education, University of Utah, 1901 E, South Campus Drive, Annex 2130-D, Salt Lake City, UT 84112; PHONE: [phone]; FAX: [phone]; E-MAIL: [e-mail].

Table 1. Summary of Focus Group Questions

1. What do you think of when you hear the term "physical activity"?
2. What are the health benefits of physical activity?
3. What does the term moderate physical activity mean to you?
4. How often do you need to be physically active in order to attain
   the health benefits associated with moderate physical activity?
5. How hard do you need to be working for your activity to be
   considered moderate?
6. How long do you need to be physically active in order to get the
   benefits associated with moderate physical activity discussed
   earlier?
7. Does moderate activity need to be done all at once, or can it be
   done in blocks of time? Please explain.