Vol.3, No.1, 118-127 (2013) Open Journal of Preventive Medicine
http://dx.doi.org/10.4236/ojpm.2013.31015
Stage of readiness for planned activity reveals heart
failure patients at higher risk
Tracie R. Parish1*, Maria Kosma2, Michael A. Welsch2
1Department of Kinesiology and Health Studies, Southeastern Louisiana University, Hammond, USA;
*Corresponding Author:
2Department of Kinesiology, Louisiana State University, Baton Rouge, USA
Received 5 November 2012; revised 6 December 2012; accepted 14 December 2012
ABSTRACT
Few individuals with chronic heart failure (CHF)
engage in regular physical act ivity. PURPOSE: 1)
To examine stage of readiness for planned
physical activity; 2) To compare estimated self-
reported daily physical activity and exercise
tolerance/capacity by stage of readiness; and 3)
To determine the association between stages of
readiness for planned physical activity, self-
reported daily physical activity and exercise
tolerance, in CHF patients. METHODS: One-
hundred eleven CHF patients (Age: 53 ± 14 yrs;
New York Heart Association class II/III) partici-
pated. Each participant’s stage of readiness for
planned physical activity was assessed. Pa-
tients completed a self-reported daily physical
activity questionnaire, and performed a six-
minute walk test. RESULTS: Average left ven-
tricular ejection fraction (LVEF) was 30.12% ±
10.72%. Twelve patients were in Precontempla-
tion (PC), 29 in Contemplation (C), 30 in Prepa-
ration (PR), 20 in Action (A), and 20 in Mainte-
nance (M). There were no differences in age and
LVEF between stages. Those classified in A/M
performed more minutes in activities > 3 METs.
Average 6MWD was 349 ± 118 meters, with sig-
nificant differences between stages (PC, C < PR
< A < M; p < 0.01). Thirty-four of 71 patients in
preaction scored < 300 m eter s v ersus only 3 an d
5 of 40 from A/M. CONCLUSION: The majority of
CHF patients are in pre-action stages of readi-
ness for adoption of planned physical activity.
Patients in pre-action are engaged in less daily
activity and have lower exercise tolerance/ca-
pacity than those in A/M. Lower exercise toler-
ance/capacity suggests these patients are more
fragile and at greater risk for complications and
early mortality. Greater emphasis should be
placed on strategies to move patients toward
A/M.
Keywords: Chronic Heart Failure; Transtheoretical
Model; Daily Activity; Exercise Tolerance
1. INTRODUCTION
Chronic heart failure (CHF) remains a significant
health problem in the United States, with frequent hospi-
talizations, widespread functional impairment, and a high
mortality rate. Recent studies have shown the significant
value of the use of a multidisciplinary approach in the
management of the heart failure patient. These programs
emphasize the importance of close monitoring and pa-
tient education [1,2]. Despite positive outcomes from
these programs, including fewer readmissions and hos-
pital days, decreased medical costs, and improved func-
tional status and quality of life, patient participation and
adherence remain suboptimal [2,3].
A major component of the management of the CHF
patient is planned physical activity. Such programs have
shown great promise as studies have revealed significant
improvements in functional ability and quality of life and
a reduction in healthcare costs and mortality in patients
engaged in exercise programs [2,4]. Consequently, cur-
rent recommendations on the management of CHF pa-
tients strongly emphasize an active lifestyle, and if pos-
sible, participation in a moderate planned physical activ-
ity regimen [5-7]. Despite the benefits of physical activ-
ity for CHF patients, research indicates few individuals
with this condition actually engage in regular physical
activity [8,9]. Numerous studies have revealed that tradi-
tional methods of promoting physical activity have been
only marginally successful in CHF patients, citing failure
to adhere to recommendations as a predominant factor
[10,11].
Literature suggests it is unrealistic to expect patients to
make changes they are not prepared to make and little
attention has focused on assessing the motivation and
readiness of CHF patients to make necessary behavioral
changes [8]. Application of behavioral theories, such as
the Transtheoretical model (TTM) of behavior change

T. R. Parish et al. / Open Journal of Preventive Medicine 3 (2013) 118-127 119
may be useful in designing effective intervention pro-
grams for patients with heart failure [6,12,13]. These
approaches could be used to guide strategies that go be-
yond traditional patient educational approaches [14]. For
example, with the appropriate activities to meet the pa-
tient’s stage of readiness for change, healthcare providers
may facilitate a patient’s movement along the continuum
of change to alter lifestyle behaviors, such as physical
activity, that can result in improved outcomes [13,15,16].
Importantly, patients’ perceptions of his/her stage of
readiness might not always match their actual behavior
[8]. Therefore, assessment of daily physical activity or
exercise tolerance should be included to compare results
of such assessments with the individual’s stage of readi-
ness. One of the better predictors of a patient’s functional
ability, exercise tolerance and physical activity behavior
is the maximum distance an individual can walk on a
6-min walk test [17-21]. The 6-min walk test is a useful,
simple, noninvasive alternative for assessing physical
activity in CHF patients [19,20] and provides prognostic
information [19,21,22] about the patient and is sensitive
to interventions such as exercise training. There currently
are no studies that have examined the TTM constructs
for physical activity behavior to an actual measure of
daily activity and exercise tolerance in CHF patients.
Such data could potentially provide a better understand-
ing of the links between the TTM constructs and the pa-
tient’s physical activity behavior.
The specific aims of this study were: 1) To examine
stage of readiness for planned physical activity; 2) To
compare estimated self-reported daily physical activity
and exercise tolerance/capacity by stage of readiness and
3) To determine the association between the stages of
readiness for planned physical activity, self-reported
daily physical activity and exercise tolerance, in patients
with CHF. It was hypothesized the majority of patients
would be in the pre-action stage of readiness; and that
daily physical activity and six minute walking distance
would be higher in those classified in the action and
maintenance stages of readiness for planned physical
activity.
2. METHODS
2.1. Participants
Patients with a diagnosis of heart failure were re-
cruited from the Baton Rouge, LA and Jackson, MS ar-
eas. Participants had to be at least 18 years of age, and be
on stable and optimal pharmacotherapy for their heart
failure condition as determined by their physician. In
addition, participants had to have the ability to read and
write English. Participants were not excluded on the ba-
sis of gender, race, and/or etiology of heart failure. Ex-
clusion criteria included individuals with acute medical
conditions related or independent of the primary diagno-
sis (e.g. congestive heart failure requiring hospitalization,
unstable angina, active infections etc.). Prior to participa-
tion, each individual was required to complete an in-
formed consent approved by the area Institutional Re-
view Board.
2.2. Study Design
The study was a cross-sectional design aimed the stage
of change for physical activity in individuals with CHF.
Upon arrival to a scheduled Cardiology appointment,
each participant was asked at check-in if they wanted to
participate. If willing, they were given the informed con-
sent approved by the area Institutional Review Board.
Subsequently, the individual was given a folder contain-
ing all questionnaires to be completed for the study, in-
cluding stage of change, and the Daily Activity in Heart
Failure Questionnaire (DAIHFQ) [23,24]. Additionally,
each participant underwent a six minute walk (6MWD)
test and a review of medical history and demographics.
2.3. Experimental Methods
Stage of Change: Each participant’s stage of change
for physical activity adoption was assessed by the Stages
of Change for Physical Activity Questionnaire, using the
algorithm recommended by Reed and colleagues [25].
Specifically, participants were asked to indicate their
present levels of physical activity behavior. Regular
physical activity or exercise was defined as “any planned
physical activity of moderate intensity (e.g., brisk walk-
ing, cycling, jogging, swimming, aerobics, etc.) aimed at
improving/maintaining your health. The activity does not
have to be painful to be effective but should be done at a
level that increases your breathing rate and causes you to
break a sweat. For activity to be regular it must add up to
a total of 30 or more minutes per day, and be done at
least 5 days per week. For example, you could take a 30
minute walk or take 3 ten minute walks each day.” Par-
ticipants were asked to indicate whether they engage in
planned regular physical activity, according to the above
definition, by marking one out of five statements, each of
which reflects one of the five stages: precontemplation:
“I do NOT plan to start regular physical activity in the
next 6 months ”; contemplation (C): “I am planning to
start regular physical activity in the next six months”;
preparation (P): Not regularly, but I engage in such ac-
tivities occasionally and plan to start on a regular basis
within the next month; action (A): “I have been physi-
cally active for LESS than six months”; and, mainte-
nance (M): I have been physically active for MORE than
six months”. This staging measure is recommended as
the most accurate estimate for adults [25,26], and the
construct validity and test-retest reliability of this meth-

T. R. Parish et al. / Open Journal of Preventive Medicine 3 (2013) 118-127
120
odology has received strong support in previous research
[26].
Physical Activity Questionnaire: Garet et al. pub-
lished a detailed self-administered questionnaire of daily
energy expenditure dealing with 7 dimensions of every-
day life to better reflect habitual activities in patients
with heart failure [23,24]. To validate this questionnaire
the investigators [23,24] measured actual VO2peaks and
found it to be a valid and reliable reflection of physical
activity status. The original questionnaire was in French;
therefore, in the present study a translation of the French
questionnaire was used. The translation was made with
help of the original investigators of the questionnaire
with some modifications for appropriate physical activity
choices for the US population. The questionnaire con-
siders seven main areas including sleeping and rest-
ing, basic everyday activities (e.g. eating and washing),
housework activities, leisure time physical activities,
physical activity in salaried or voluntary work, moving
about, and miscellaneous activities. Subsequently, activi-
ties could be classified in terms of intensity, i.e. activities
below 3 METs, between 3 and 5 METs, and above 5
METs, as well as duration (minutes performed) [23].
Three response models were applied depending on the
item. For example, participants reported information per-
taining to time spent on each activity, quantifying the
number of times the activity is done per week or day, and
reported whether help or interruption was needed sys-
tematically, sometimes, or never during an activity [23].
Detailed scoring instructions are provided elsewhere
[24].
Six-Minute Walk Test: Exercise intolerance is de-
fined as the reduced ability to perform activities that in-
volve dynamic movement of large skeletal muscles be-
cause of dyspnea or fatigue [17]. Exercise tolerance was
measured as the maximum walking distance achieved on
a 6-min-walk test [17]. The six-minute walk test is rec-
ommended as a useful, simple, noninvasive alternative
for assessing physical activity in patients with heart fail-
ure. The test was performed in a corridor and participants
were instructed to walk as far as possible in 6 minutes,
avoiding chest pain, marked dyspnea, or other symptoms
[27]. To standardize the protocol, the participants were
not coached during the test, but made aware of time re-
maining to completion. The use of the six-minute walk
test has received a lot of attention recently, due to its
relative ease of administration. The test is also thought to
reflect a realistic effort as performed in daily life, and
appears highly acceptable to patients. Furthermore, sev-
eral studies have reported the prognostic significance of
the 6-minute walk test in patients with heart failure
[18,20].
Estimated Exercise Capacity: Estimated VO2peak
was calculated from the 6-minute walking distance, us-
ing a regression equation [21]. The equation: VO2peak =
0.03 × 6-minute walking distance (meters) + 3.98 (r2 =
0.42 vs. actual VO2peak measures) has been validated
against actual VO2peak measures and is based on the fact
that the 6-minute walking distance is a significant pre-
dictor of VO2 peak [21].
2.4. Statistical Analysis
The Statistical Package for the Social Sciences (IBM,
SPSS Statistics 20, Armonk, NY) was used for all data
analyses. Descriptive statistics were performed to pro-
vide demographic characteristics of the study partici-
pants. To compare self-reported daily physical activity
and exercise tolerance/capacity by stage of readiness a
univariate general linear model was used. In addition, to
determine the association between the stage of readiness
for planned physical activity, self-reported daily physical
activity and exercise tolerance simple correlation coeffi-
cients and a multivariate general linear model were used.
3. RESULTS
3.1. Patient Characteristics
Patient characteristics are presented in Tables 1 and 2.
A total of 111 patients were studied. 81 participants were
men, and 30 women. The mean age for the total group
was 53 ± 14 (years), the average left ventricular ejection
fraction (LVEF) for the group was 30.12 ± 10.72%. Eti-
ology of heart failure included: ischemic heart disease
(19%), non-ischemic cardiomyopathy (8%), hypertensive
heart disease (19%), viral induced heart failure (3%),
idiopathic cardiomyopathies (43%), and congenital heart
failure (8%). The duration of heart failure averaged
nearly 7 years, ranging from 6 months to 35 years. All
patients were classified as New York Heart Association
(NYHA) Class II (60%) and III (40%). Thirty-five per-
cent of the patients were married, 35% were sepa-
rated/divorced or widowed, and the remaining 30% were
single or engaged. Sixty-six percent of the participants
were Caucasian, 32% were African-American, and 2%
Hispanic.
3.2. Stage of Change Classification
The majority of participants reported being in the
preparation stage of change (n = 41, 27.7%), followed by
contemplation (n = 33, 22.3%), maintenance (n = 29,
19.6%), action (n = 23, 15.5%), and precontemplation (n
= 22, 14.9%). In regards to the stage of change classifi-
cation, no significant differences were noted for age,
LVEF and heart failure duration. Furthermore, no dif-
ferences in the stage classifications for race, employment
status, income level, education level, heart failure diag-

T. R. Parish et al. / Open Journal of Preventive Medicine 3 (2013) 118-127 121
Table 1. Descriptive statistics (age, height, weight, BMI).
Age (yrs) Height (m) Weight (kg) BMI (kg/m2)
Stage of Change
Mean SD Mean SD Mean SD Mean SD
Precontemplation 53 12 1.74 0.10 96.10 40.66 31.30 10.87
Contemplation 54 17 1.72 0.08 87.39 28.08 29.18 7.42
Preparation 53 12 1.75 0.10 105.29 31.82 34.11 10.10
Action 56 9 1.76 0.07 93.69 14.15 30.20 4.91
Maintenance 50 16 1.76 0.09 91.84 13.98 29.91 5.14
Total 53 14 1.74 0.09 94.31 26.36 30.82 7.73
Table 2. Descriptive statistics (hemodynamics).
LVEF (%) HR (bts/min) SBP (mmHg) DBP (mmHg)
Stage of Change
Mean SD Mean SD Mean SD Mean SD
Precontemplation 33.38 13.06 73 13 130 22.91 73 14.93
Contemplation 29.55 12.79 75 20 115 26.99 71 18.99
Preparation 27.29 8.99 77 14 117 18.50 68 10.17
Action 31.37 7.55 72 12 110 15.90 70 6.85
Maintenance 31.35 11.22 75 11 121 8.51 69 6.69
Total 30.12 10.72 75 13 118 19.59 70 12.09
nosis, number of co-morbidities and medications were
observed. Therefore, these demographic variables were
not treated as moderators in subsequent analyses.
3.3. Daily Physical Activity and Stage of
Readiness
Table 3 presents the estimated minutes of rest and
various intensities of physical activity per day for the
heart failure patients per stage of readiness. The means
and standard deviations for minutes spent in the different
categories of activity indicate the majority of time indi-
viduals performed light activity (1 - 3 METs: 855 ± 269
min/day) followed by moderate activity (3 - 5 METs:
128 ± 99 minutes), and higher activity (>5 METs: 15 ±
19 min/day).
On the basis of a multivariate general linear model
with the categories of activity as the dependent measures
and stages of change as the fixed factor, a significant
main effect was found (p = 0.0005). No differences were
noted between the stage of change classification for rest
and those activities considered between 1 - 3 METs. In
contrast, patients classified in the Action and Mainte-
nance stages of readiness performed significant more
minutes in physical activities above 3 METs (p = 0.003)
compared to those in the precontemplation/contempla-
tion/preparation stages of readiness (see Figure 1).
3.4. Six Minute Walk Distance and Stage of
Readiness
As indicated in Table 4, the average walking distance
for the entire group was 349 ± 118 meters. The walking
distance appears to increase dependent on the stage of
change category. Indeed, the univariate general linear
model analyses with the 6 minute walk distance as the
dependent measure and stages of change as the fixed
factor, revealed a significant main effect (p = 0.0001).
Post hoc examination, using a Tukey test, indicates the
following differences: The 6-minute walk distance for
individuals in precontemplation, contemplation and prepa-
ration stages appear to be similar, whereas the 6-minute
walk distance for the action and maintenance groups are
significantly higher. Finally, there does not appear to be
a significant difference between the action and mainte-
nance groups. These findings suggest the 6-minute walk
distance is capable of distinguishing the action and mainte-
nance stages from the previous stages of readiness and is
in support of the stated hypothesis.
3.5. Estimated Exercise Capacity and Stage
of Readiness
Means and standard deviations for the estimated
VO2peak are presented in Table 4. Consistent with the

T. R. Parish et al. / Open Journal of Preventive Medicine 3 (2013) 118-127
122
Figure 1. Estimated VO2peak per stage of readiness. *p < 0.05 vs. precontemplation, contemplation, and preparation.
analysis for the 6-minute walk distance there was a sig-
nificant main effect for stage of change category (p =
0.0004), and significant differences in the means for es-
timated VO2peak between the Action and Maintenance
categories vs. the remaining three categories. Importantly,
the average estimated VO2peak for the Action and
Maintenance groups is above the prognostic relevant 14
ml/kg/min threshold (as indicated by the dashed line on
Figure 2).
3.6. Association between Six Minute Walk
Test and Daily Physical Activity
Simple correlation coefficients revealed significant
associations between the 6-minute walk test and self-
reported amount of minutes spent at rest (r = −0.27, p =
0.02), performing activities between 3 and 5 METs (r =
0.52, p = 0.0009), and activities over 5 METs (r = 0.56, p
= 0.0001). A significant association was also seen be-
tween total minutes of daily physical activity and the
6-minute walk test (r = 0.32, p = 0.005).
4. DISCUSSION
4.1. Patients Characteristics
Review of the available literature reveals very few
studies have attempted to examine the readiness for be-
havioral changes in CHF patients [8,16]. Consequently,
it is difficult to compare the patient characteristics in the
present study to other studies. Perhaps the only study of
comparison is by Sneed and Paul [14]. In this study a
mail survey was sent to patients with heart failure [14].
Respondents were asked to select the stage of readiness
for change in six lifestyle behaviors important in man-
agement of the heart failure syndrome. Unfortunately,
Sneed and Paul [8] did not examine the full TTM model
among individuals with heart failure. Despite that, it is
interesting to note the patient population in that study
was remarkably similar to the present study [8].
Considering the present study also examined the asso-
ciation of the stage of change construct for physical ac-
tivity with self-reported daily physical activity, and an
actual measures of exercise tolerance (six minute walk
test), a second comparison study is offered by Garet et al.
[23]. These investigators assessed the reproducibility,
sensitivity, and concurrent validity of self-reported daily
energy expenditure in a population of stable CHF pa-
tients. Their population consisted of 105 Caucasian par-
ticipants (Age: 55.8 ± 12.4 yr, range 31 - 80 years).
Mean LVEF was nearly exactly as reported in the present
study (LVEF: 30.12% ± 10.72%).

T. R. Parish et al. / Open Journal of Preventive Medicine 3 (2013) 118-127 123
Table 3. Minutes of rest and various intensities of physical activity per day.
Variable Stage of Change Mean Std. Deviation n
Precontemplation
Contemplation
Preparation
Action
Maintenance
613
604
531
573
551
108
111
137
126
192
14
23
24
15
15
Rest
Total 572 137 91
Precontemplation
Contemplation
Preparation
Action
Maintenance
820
995
1030†
1133†
1041†
224
223
339
341
393
14
23
24
15
15
Total Activity (min)
Total 1008 315 91
Precontemplation
Contemplation
Preparation
Action
Maintenance
684
879
907
927
824
230
201
277
312
299
14
23
24
15
15
Minutes up to 3 METs
Total 855 269 91
Precontemplation
Contemplation
Preparation
Action
Maintenance
73
107
111
186
180
86
61
101
86
121
14
23
24
15
15
Minutes between 3 to 5 METs
Total 128 99 91
Precontemplation
Contemplation
Preparation
Action
Maintenance
2
8
13
20
37
7
13
14
14
27
14
23
24
15
15
Minutes above 5 METs
Total 15 19 91
p < 0.05 compared to precontemplation/contemplation/preparation; †p < 0.1 compared to precontemplation/contemplation.
Table 4. Descriptive statistics: exercise tolerance (six minute
walking distance (meters)) and estimated VO2peak.
6 MWD Estimated VO2
peak n
Stage of Change
Mean SD Mean SD
Precontemplation
Contemplation
Preparation
Action
Maintenance
297
276
323
401
472
137
108
80
87
73
12.90
12.24
13.66
16.01
18.15
4.11
3.22
2.40
2.60
2.20
12
29
30
20
20
Total 349 118 14.44 3.54111
p < 0.05 vs. precontemplation, contemplation, and preparation.
In summary, the present population characteristics
appear to be similar to published studies, and based on
the available guidelines for the management of heart
failure, it would appear that the participants in this study
would be excellent candidates for heart failure interven-
tion programs including exercise training [6,9].
4.2. Stage of Readiness
Classification according to the TTM for stage of
change reveals the majority of participants in this study
were in the preparation stage of change (n = 41, 27.7%),
followed by contemplation (n = 33, 22.3%), maintenance
(n = 29, 19.6%), action (n = 23, 15.5%), and precontem-
plation (n = 22, 14.9%). These findings are somewhat
similar to a previous study which examined the predic-
tors of exercise adherence and the validity of the Stages

T. R. Parish et al. / Open Journal of Preventive Medicine 3 (2013) 118-127
124
model among older adults (n = 349) with a cardiac diag-
nosis (not heart failure) after discharge from a cardiac
rehabilitation inpatient program [16]. In that study, 16%
of the patients were in precontemplation, 16% in con-
templation, 22% in preparation, and 23% in both the ac-
tion and maintenance stage [16]. In yet another study, the
theorized associations of the TTM of behavior change
constructs were examined along with exercise barriers,
by stage of change for exercise behavior among indi-
viduals with physical disabilities [28]. In that study the
majority of participants reported being in the mainte-
nance stage of change (53.7%), followed by precontem-
plation (18.9%), action (11.8%), contemplation (9.0%),
and preparation (6.5%) [28]. One possible explanation
for the greater number of individuals classified in the
maintenance stage in the comparison study [28] is the
passive recruitment method used by those authors, which
tends to over-represent individuals with an interest in
the subject matter. Other than differences in recruiting
strategies, it is difficult to reconcile the differences
among studies, given the vast differences in terms of
populations, geographical location, and overall subject
number. However, it is important to appreciate that in the
current study 65% of patients were in the pre-action
stages of readiness to engage in a treatment strategy
known to be critical in the management of their disease.
In fact, the present data fall in line with the study by
Sneed & Paul [8] who reported only 38% of patients
with heart failure exercised regularly.
4.3. Daily Physical Activity and Stage of
Readiness
Perhaps not surprising the amount of time spent in ac-
tivities >5 METs in these patients is very low. This is
not dissimilar from previous work from the Louisiana
Healthy Aging Study [29]. In that study, a strong age-
related decline in levels of moderate intensity physical
activity, and an increase in time spent in light intensity
activity with increasing age, suggests higher intensity
activities are being avoided or replaced by lower inten-
sity activities. It is important to consider that decreased
physical activity, in the elderly, is responsible for 46% of
the decrease in total energy expenditure [30], and that a
decline in daily physical activity predicts frailty and health-
related disability [31].
The reason(s) for the low levels of moderate and
higher intensity physical activity among the patients
cannot be discerned from the present data but most likely
include psychological and physiological factors. Previ-
ous studies report in independently living older adults a
lack of interest in physical activity participation, and
joint pain as possible deterrents [32]. Given the cardinal
symptoms of CHF patients include chronic fatigue,
shortness of breath and exercise intolerance it is under-
standable higher MET activities are to a large extent
avoided.
Uniquely, these data suggest that individuals in the ac-
tion and maintenance stages perform a greater amount of
physical activity, especially at higher intensities, com-
pared to those in the early stages of readiness (precon-
templation, contemplation). Perhaps this indeed provides
validation of the TTM constructs for physical activity for
the CHF patients, or recognition of those patients to in-
clude physical activity in the management of their condi-
tion.
4.4. Six Minute Walk Distance and Stage of
Readiness
A unique contribution of these data are the findings
that the 6-minute walking distance is capable of distin-
guishing individuals in the action and maintenance stages
from the early stages of readiness (precontemplation,
contemplation). The 6-minute walk test carries important
prognostic information. The total group average for the
maximum walking distance (349 ± 118 meters) in this
study appears to be quite typical for patients with heart
failure, with a NYHA Class II and III. For example,
Opasich et al. reported a maximum walking distance of
396 ± 92 meters in 315 chronic heart failure patients (age:
53 ± 9 years, NYHA class: II (182), III (133)) [22].
Perhaps more importantly, based on the literature in-
dicating that a maximum walking distance less than 300
meters is associated with an increased likelihood of early
mortality [19,20,22]; the results of the present study
suggest many of the patients are at elevated risk for
complications [33]. In fact, 36% of all the participants in
this study scored below the 300 meter threshold. Inter-
estingly, patients who scored below 300 m on the
6-minute walk test were not different from the patients
scoring above 300 m, in terms of age, BMI, LVEF, rest-
ing blood pressure and heart rate. In addition, no differ-
ences were noted for race, employment status and in-
come, etiology, and length of heart failure, co morbid-
ities, or number of medications. One interesting observa-
tion in the present study is that a greater percentage of
women scored below the 300 meter threshold. Given the
evidence that the distance of <300 m also identifies
women at high risk of death [19], this requires further
examination and focus from a clinical perspective. A
further important observation is that the average age for
the women in this study was significantly lower than the
men, yet their average maximum walking distance was
much lower as well.
In regards to the stated hypothesis, it was predicted
that the maximum walking distance would distinguish
the action and maintenance stages from the precontem-
plation and contemplation stages of readiness. Indeed the

T. R. Parish et al. / Open Journal of Preventive Medicine 3 (2013) 118-127 125
gest that the majority of patients with heart failure in the
early stages of readiness are below the 14 ml/kg/min
threshold, a powerful prognostic indicator of an in-
creased likelihood of death or hospitalization within 3
months to a year [21,33].
action and maintenance stages were different from the
precontemplation and contemplation stages of readiness.
Closer observation of these data reveal that the majority
of patients in the action and maintenance stages were in
fact above the 300meter, compared to the majority of
patients in the early stages (i.e., precontemplation, con-
templation) who were below this clinically important
cut-off. More specifically, 51% of patients in the pre-
contemplation stages were below the 300 meter, com-
pared to only 7.5% in the action/maintenance stages.
These data suggest many of CHF patients who are in the
pre-action stages of readiness for physical activity are at
elevated risk for complications.
4.6. Association between Six Minute Walk
Test and Daily Physical Activity
Recognizing that the questionnaire was translated and
slightly modified, the data did allow further comparison
to the functional scores. The findings revealed significant
associations between the 6-minute walk test and the
self-reported amount of minutes spent at rest (r = −0.27,
p = 0.02), performing activities between 3 and 5 METs (r
= 0.52, p = 0.0009), activities over 5 METs (r = 0.56, p =
0.0001). Moreover, a significant association was appar-
ent between the total minutes of physical activity per-
formed throughout the day, and the 6-minute walk test (r
= 0.32, p = 0.005). This is the first study to report these
associations using a submaximal performance test. In
comparison to previous work [23] the reported associa-
tions are somewhat lower. The discrepancy may in part
be a consequence of the questionnaire modifications, or
4.5. Estimated Exercise Capacity and Stage
of Readiness
Using the 6-minute walking distance to estimate
VO2peak reveals that a greater majority of those indi-
viduals above 14 ml/kg/min are in the action and main-
tenance categories (see Figure 2). More specifically,
71% of patients in the precontemplation stages were be-
low the 14 ml/kg/min threshold compared to only 7.5%
in the Action/Maintenance stages. Again these data sug-
Figure 2. Estimated minutes of physical activity between 3 and 5 METs according to stage of readiness. *p < 0.05 vs. precontempla-
tion, contemplation, and preparation.
OPEN A CCESS

T. R. Parish et al. / Open Journal of Preventive Medicine 3 (2013) 118-127
126
the fact that the 6-minute walk test was used. Irrespective
of those possibilities, the findings are intriguing and
suggest the questionnaire is able to differentiate between
patients who score high or low on the 6-minute walk test.
Interestingly, the patients in the present study had lower
estimated VO2peak values, than their French counter-
parts. In addition, the patients in this study performed
fewer activities above 5 METs and had slightly lower
overall energy expenditures over the course of the day. It
is difficult to reconcile these differences as the US pa-
tients were similar in terms of age, gender, LVEF,
NYHA class, and etiology of disease. However, there are
apparent differences in terms of weight and BMI, with
the American cohort heavier (American Cohort: 95.28 ±
26.43; French Cohort: 74.80 ± 15.00) and with a greater
average BMI (American Cohort: 31.68 ± 8.53; French
Cohort: 25.08 ± 4.00).
These data suggest that those in the early stages are
clinically more fragile, are less involved in daily physical
activities and are women. The importance of this infor-
mation obviously lies in the fact that specific strategies
need to be developed to move patients in these pre-action
stages toward the Action stage.
In conclusion, data from this study indicate that the
majority of CHF patients are in the pre-action stages of
readiness for adoption of planned physical activity. In
addition, CHF patients in pre-action stages of readiness
are engaged in less self-reported daily activity compared
and have significant lower exercise tolerance/capacity
than those in the action and maintenance stages. The fact
that a significantly higher number of CHF patients in pre-
action stages scored < 300 meters on the six-minute walk
test and have an estimated VO2peak of <14 ml/kg/min,
indicates these patients are clinically more fragile and at
greater risk for complications and early mortality. These
data suggest greater clinical emphasis should be placed
on strategies to move patients toward the action and
maintenance stages of readiness.
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