R e s e a r c h A r t i c l e B a r r ie r s t o a n d E x p e c t a t io n s o f P e r f o r m in g P h y s i c a l A c t i v it y in F e m a l e S u b j e c t s w it h T y p e 2 D i a b e t e s . A B S T R A C T : The aims o f the study were to establish in a cohort o f fem ale patients with Type Diabetes the knowledge and perceptions o f exercise, personal and environmental barriers to doing exercise and the outcome expectations o f p e r­ form ing physical activity. The sample consisted o f 28 patients between the ages o f 48 and 70 (mean =60.2, SD = 6.6) years and 11 ethnic groups, attending the M amelodi Hospital Diabetic Outpatient Clinic. The duration o f the disease ranged fro m I to 22 years and 82% o f the patients were using oral hypoglycaemic agents. Demographic and qualitative data were captured by means o f fo cu s group interviews. Demographic data were summ arized with descriptive statistics. Qualitative data were analysed by means o f well- described principles o f qualitative data analyses. A percent agreement was perform ed and data were re-coded until the inter-rater reliability was 85%. A ll 28 subjects reported that they saw doing household chores and walking as ways o f exercising. Sixty one percent o f the subjects indicated relief from arthritis as a benefit o f exercise. The main environmental barrier was the absence o f a convenient venue (61%). Tiredness (36%) and arthritis (36%) were the main personal barriers to doing exercise. A ll subjects indicated a better quality o f life and improvement o f functional capabilities as outcome expectations o f taking part in an exercise program. Subjects had positive attitudes towards exercise, wanted to have control in the program and also expressed the need f o r social support. KEY WORDS: TYPE 2 D IABETES MELLITUS, PERCEPTIO N OF EXERCISE, PERSONAL BARRIERS, EN VIRO N­ MENTAL BARRIERS, OUTCOM E EXPECTATIONS. VAN ROOIJEN AJ, MSc Physiotherapy (UOFS)’; RHEEDER P, M .M ed (Internal Medicine) (UP)2; EALES CJ, PhD (Wits)3; MOLATOLI HM , MPhysT Education (UP)4. 1 D e p a rtm e n t o f Ph y sio th erap y , U n iversity o f th e W itw a te rs r a n d . Study le a d e r, C lin ical E p id em io lo g y U n it, U n iv e rs ity o f P re to ria . C o -stu d y lead e r, D e p a rtm e n t o f P h y sio th erap y , W its M e d ic a l School. D e p a rtm e n t o f P h y sio therapy, U n iversity o f P reto ria. INTRODUCTION Increasing trends in the prevalence o f diabetes and in the societal costs of the com plications o f diabetes have focused attention on improving the quality o f diabetes care (Songer 1995; King et al 1998). According to the World Health O rganisation’s (W HO) concept o f reha­ bilitation, subjects should be encouraged to becom e increasingly self-responsible for their own active and productive life and thus for improving their own quality o f life (WHO 1964). In a report by Eales and Stewart (2001), the following hypothesis was put forward: “... fo r subjects with chronic diseases to be con­ sidered successfully rehabilitated, they should accept responsibility f o r their own rehabilitation. ” They defined self­ respon sib ility as the moral duty o f the patient to successfully execute the required health behaviour for improved health. Physical activity is recommended as part o f the m anagem ent regim en for subjects with Type 2 Diabetes M ellitus (Type 2 DM). The positive effects of regular physical activity on the prevention and control o f Type 2 DM, hyperlipi- daemia, insulin resistance, obesity and its overall im pact on cardiovascular disease are reasons to stimulate subjects to perform regular exercise (Ligtenberg et al 1995). In addition sensible exercise can improve functional status, longevity and quality o f life (Leon et al 1987). However, it is known that long-term adherence to regular physical activity program for the elderly Type 2 DM patient is generally poor and that w ith­ out supervision, com p lian ce is low (Ligtenberg et al 1997). Hays et al (1999) reported that fac­ tors which may influence the initiation and maintenance o f exercise programs of Type 2 DM, are personal characteris­ tics o f the patient (personality, cognitive- and environmental factors) and environ­ mental influences (social, cultural and econom ic factors). Cognitive factors include knowledge, thoughts, attitudes and skills. In a study on the know ledge of, attitudes towards Type 2 DM and the level of physical activity o f urban black fem ale subjects, low educational levels, poor diabetes C O RRESPO ND ENCE TO: AJ Van Rooijen D epartm ent o f Physiotherapy University o f Pretoria P O Box 667, Pretoria 0001 Tel: (012) 354-2018 Fax: (012) 354-1226 Email: tvrooije@ m edic.up.ac.za SA J o u r n a l o f P h y s io t h e r a p y 2002 V o l 58 No 1 3 R ep ro du ce d by S ab in et G at ew ay u nd er li ce nc e gr an te d by th e P ub lis he r (d at ed 2 01 3. ) mailto:tvrooije@medic.up.ac.za knowledge, low levels o f physical acti­ vity and class I obesity status were reported (Van Rooijen et al 2001). Tolerant cultural attitudes towards obesity w ithin the black com m unity may have contributed to this finding. T he prevalence o f obesity may con­ tribute to discom fort which could lead to low long-term adherence to regular physical activity programs. Swift et al (1995) reported that dis­ com fort during exercise has been related to decreased participation in exercise in Type 2 DM subjects. Barriers to the assumption o f self­ responsibility are lack o f knowledge, lack o f sufficient interest in what is preventable and a culture o f stressing individual rights w hich progressively erodes the idea o f individual respon­ sibility (Eales and Stewart 2001). Behavioural change in Type 2 DM subjects will depend on patients’ beliefs regarding the outcom e o f performing certain behaviours and the importance he/she attaches to the outcome. Little is known about the health beliefs and o ut­ com e expectations regarding physical activity, with specific reference to the culture of urban black female subjects with Type 2 DM. Environmental barriers to physical activity in this sample are also unknown. The aims o f this study were to esta­ blish participants’ knowledge and percep­ tions o f exercise, the kind o f exercises they wanted to do, the personal and environmental barriers to doing exercise and the outcom e expectations o f per­ form ing physical activity in this sample o f subjects. (See Figure 1) METHOD Ethical clearance was obtained from the Ethics com m ittee o f the Pretoria Academ ic Hospital) N um ber 1 16/99). T he superintendent and matron o f the M am elodi Hospital also consented to the study. Subjects The convenience, purposive sam ple con­ sisted o f a subset o f a larger study that had been conducted one year prior to this study (Van Rooijen et al 2001). Twenty-eight black women with Type 2 DM, between the ages o f 48 and 70, who participated in the previous study, were contacted by telephone. All the women were attending the Hospital Diabetic O utpatient Clinic in M amelodi. Subjects from the sam e gender and so cio ­ econom ic background w ere used to ensure h o m ogeneity o f the group (C ote-A rsenault and M orrison-B eedy 1999). The only exclusion criterion was disinterest in doing exercise. Four to ten subjects were recruited for each focus group to avoid no shows, an unproduc­ tive discussion o f too small a group o f subjects or the danger that sm aller dis­ cussions may start in a group that was too large (M aillet NA et al 1996). Subjects w ere com pensated for their transport costs and were served refresh­ ments and received a small gift after the focus group. The data capturing com m enced on 22 M arch 2001 and was com pleted on 10 April 2001. Setting Focus groups were held in a relaxed, inform al setting at the M am elodi Day Hospital. This hospital was accessible, convenient, non-threatening and accept­ able to the participants. As a result it allowed for and encouraged open dis­ cussion. Seating facilities were adequate ensuring maximum opportunity for eye contact with both the facilitator and other group members. Two audiotape recorders were placed centrally to ensure good quality recording. Instrumentation D em o g rap h ic and qualitativ e data were captured. The phenom enological approach by means o f focus group inter- Figure 1: Factors infuencing the initiation and maintenance o f physical activity in black wom en w ith Type 2 Diabetes Mellitus. CONCEPTUAL FRAMEWORK 4 SA J o u r n a l o f P h y s io t h e r a p y 2002 V o l 58 No 1 R ep ro du ce d by S ab in et G at ew ay u nd er li ce nc e gr an te d by th e P ub lis he r (d at ed 2 01 3. ) views was used to provide an under­ standing o f the social and behavioural attitudes of individuals (M aillet et al 1996). Structured questions were used, with open questions by the facilitator around a topic when indicated. The focus group technique was a cost-effective method to obtain in-depth information from a hom ogeneous group that may be useful in developing intervention program s for risk reduction o f chronic diseases (Quatromoni et al 1994). It was also an effective method o f obtaining data from subjects with a low educational level (Betts et al 1996). An exploratory approach was followed to understand the needs, language and beliefs o f the sam ple and to gain insight into the health beliefs and outcom e expectations regarding physical activity (Cote- Arsenault and M orrison-Beedy 1999). The open response form at of the focus group provided an opportunity to obtain large and rich amounts o f data in partici­ pan ts’ own words. However, generalisa­ tion o f the results is difficult, because small numbers o f subjects were inter­ viewed and were not random ly selected. A skilled and expert group facilitator, who was know ledgeable about Type 2 DM and familiar with group dynamics was selected and trained. She also trans­ lated the questions into Tswana. A field- w orker was trained to take detailed field notes and record behavioural data. The research team met beforehand to prepare the venue, test the equipm ent and to clarify each m em ber’s role. The focus groups were conducted in Tswana. The first question was sim ple and neutral to allow the participants to feel com fortable and the get to know a little bit about the other participants around the table and to estab lish rapport. Questions were addressed to the group as a whole, taking care not to single out individual participants. The questions logically progressed from the general to the specific and were asked in four main categories: (See Table 1) Process The subjects reported at 09:00 on the day o f their appointm ent to the research venue. Each subject was welcomed and introduced to the research team. Informed consent was obtained from each patient after the aims, procedures and possible benefits o f the study were explained to them. Subjects had the o p p o rtunity to ask questions before the consent form was signed. Each sub­ je c t received a signed copy o f her own consent form. The participating subjects were given nam etags to provide a basis for building greater rapport between the facilitator and the participants. It also enabled the facili­ tator to direct questions at a group m em ­ ber by name and achieve sim ultaneous eye contact. In this way greater identity and cohesiveness between the group m embers was developed (Richter 2001). A short dem ographic questionnaire was com pleted consisting of age, ethnic group, em ploym ent status, duration of disease and use o f medication. The facilitator w elcom ed the partici­ pants and introduced herself and the fieldworker. Subjects were asked to introduce them selves as an icebreaker. The facili­ tator explained the purpose o f and the course o f the focus group discussion. The importance of each participant’s contribution was stressed. The rules for the group discussion were given and the role o f the fieldw orker was explained. T he use o f the two audio tape recorders was explained and subjects were assured that the recordings would only be listened to or looked at by the research er and that the p articipants would stay anonymous. A definition o f physical activity and exercise was given. The research questions were then put forward and participants were asked to participate in the discussion. The facili­ tator addressed questions to the group as a w hole and no subject was singled out. Asking inquisitive questions, using sum m aries and reflection, w ithout inter­ fering with the dialogue o f the interview, facilitated active participation o f all group members. T he field w o rk er docum ented the order in which subjects spoke to aid Table 1: Questions used fo r discussion during the focus groups in English and Tswana. Knowledge and perceptions / Kitso Do you w ant to do exercise? A o b la t la g o ik w e tlis a ? W h a t do you perceive exercise to be? G o y a k a w e n a , o a k a n y a g o r e g o ik w e tlis a k e e n g ? W h y do you think it is important to exercise? O a k a n y a g o r e b o tlh o k w a b a g o ik w e tlis a k e e n g ? Logistical / DiHhomamiso W h a t sort of exercise do you w ant to do? K e m o k g w a o fe o b a t la n g g o ik w e tlis a k a o n e ? Do you w ant to exercise on you own or in a group? A o b a t la g o ik w e tlis a o le n g m o n g k g o ts a le b a th o b a b a n g ? W h a t is the best time o f day for you to exercise and where do you w ant to exercise? K e n a k o e fe v a le ts a ts i e e g o s ia m e ts e n g g o ik w e tlis a ? W here do you want to exercise? O b a t la g o ik w e tlis a fe lo g o fe ? Environmental and personal barriers / Dikgoreletsi W hat w ill keep you from exercising? K e e n g se s e k a g o th ib e la n g g o ik w e tlis a ? W h a t would make you leave an exercise program? K e e n g se s e k a d ir a n g g o re o tlo g e le g o ik w e tlis a ? W hat would make you stay in an exercise program? K e e n g se s e k a d ir a n g g o r e o k g o th a lle g o ik w e tlis a ? Expected outcomes / DiHamorago How do you think you can benefit from doing exercise? O a k a n y a g o r e d it la m o r a g o tse m o s o la tsa g o ik w e tlis a m o g o w e n a e k a b a e n g ? How do you want to feel if you exercise? M a ik u t lo a g a g o , o b a t la a b a jw a n g m o r a g o g a g o ik w e tlis a ? SA J o u r n a l o f P h y s io t h e r a p y 2002 V o l 58 No 1 5 R ep ro du ce d by S ab in et G at ew ay u nd er li ce nc e gr an te d by th e P ub lis he r (d at ed 2 01 3. ) Table 2: Demographic data. Demographics N % Ethnic group North Solho 5 18 Ndebele 4 14 Zulu 5 18 Mopaedi 3 11 Tswana 5 18 Tsonga 2 7 Other 4 14 Employment Full day work 1 4 status Part-time work 1 4 Unemployed 26 92 Pension Yes 14 50 N o 14 50 Duration of 1-4 8 29 disease (years) 5-7 7 25 8-10 4 14 11-13 4 14 17-19 2 7 20-22 3 11 Medication Insulin injections Tablets 5 23 18 82 voice recognition o f the recording. N on­ verbal behaviour such as eye contact, posture, gestures between group m em ­ bers was also documented. After the focus group, subjects were thanked and acknowledged for the useful information. Teas and eats were served. Debriefing with the research team was done to discuss im portant information during the post-group discussions. Focus groups with participants were conducted until a clear pattern emerged and subsequent focus groups repeated information (M cDougall 1999). Possible sources of bias M ultiple focus groups w ere held to decrease threats to external validity. Training o f the facilitator in the manner o f questioning, reduced bias in data collection. A ggressive and dom inant subjects were prevented from taking over the discussion. STATISTICAL AND DATA ANALYSIS Dem ographic data were entered into a file on the Statistics - program on the computer, screened for missing values. Data were analysed using Statistics ® software. D ata were sum m arised with descriptive statistics: mean, SD, median, range, frequency and percentage. Transcripts were made from the audio tape recordings in Tswana. A trained multilingual nurse translated the tran­ scriptions and field notes into English. Transcripts were read through several times by the researcher to get a sense o f com m on themes that were relevant to the research question (Strauss and Corbin 1990). Line-by-line analysis was done to generate categories. Notes were made, throughout the reading on general them es in the transcripts. This enabled the researcher to become more fully aware o f the participants’ frames o f reference. Open coding was done by reading through the transcripts again and by m aking as many headings as necessary to describe all aspects o f the content. Grouping them together into broader categories reduced the numbers of cate­ gories. R epetitious and very sim ilar headings were rem oved to com pile a final list o f categories. Asking an independent qualitative researcher to generate categories w ith­ out seeing the researcher’s list enhanced the validity o f the categorising method. It also reduced researcher bias. Lists were com pared, discussed and adjust­ ments were made. The degree to w hich the chosen categories covered all aspects of the interviews were evaluated and adjusted. Each transcript was then worked through with the list o f categories and sub-head- ings and coded accordingly. Ten percent of the data was given to an independent researcher for a reliability check at the researcher’s coding scheme. A percent agreem ent was perform ed between the indep en d en t re se a rc h e rs’ and the researcher’s codes. The use o f the codes that were unclear was identified. Decision rules were created to clarify the use of the codes that were unclear. Another small subset was then re-coded until the inter-rater reliability was 85%. This process ensured that the researcher’s codes and categories were understand­ able, exhaustive, mutually exclusive and independent. Each coded section of the interview was then cut out o f the tran­ script and all items o f each code were grouped. The cut out sections was pasted onto sheets, headed-up with the appropriate headings and sub-headings. All sections were filed together for direct reference when writing up the findings. Copies o f the com plete interview s and the audio tape recordings were kept in a safe place. TRUSTWORTHINESS OF THE DATA Credibility o f the data was obtained by the fact that the researcher did not faci­ litate the focus groups. In this way the researcher could not have influenced the subjects with her knowledge in the field (reflexivity). F ield notes w ere kept throughout the research process. The re se a rc h er d iscu ssed the research process and findings with an impartial co lleag u e w ho has exp erien ce with qualitative research (triangulation). T he transferability o f the data was im proved by providing a dense descrip­ tion of the background inform ation on the subjects. The description of the exact methods of data gathering, analysis and interpretation contributed to the auditability o f the study. A colleague, who was not involved in any other aspects o f the study, but who is fam iliar with the process of category generation was asked to read through two tran­ scripts and to identify a category system. 6 SA J o u r n a l o f P h y s io t h e r a p y 2002 V o l 58 No 1 R ep ro du ce d by S ab in et G at ew ay u nd er li ce nc e gr an te d by th e P ub lis he r (d at ed 2 01 3. ) Table 3: Summary o f identified benefits o f exercise. Identified Benefit N Frequency o f response Percentage % W eight loss 28 9 32 Better circulation 28 6 21 Helps for Arthritis 28 17 61 Body stays healthy 28 6 21 Relief of constipation 28 1 4 Improved sleeping 28 1 4 Improve blood sugar 28 10 36 Feel better 28 7 25 Relaxes them 28 5 18 It was then discussed with and com ­ pared to the researcher’s category system ( confirmability). RESULTS T he results are presented in the follow ­ ing order: Dem ographic, focus groups and inte­ grated results. Demographical data T he dem ographics o f this sam ple by ethnicity, em ploym ent status, receiving p en sio n , du ratio n o f d iab etes and type o f m edicine used are provided in Table 2. The mean age o f the sample group was 60,18 years (6.55). Ages ranged from 48 to 70 years, with a median of 60.5. Other ethnic groups included single C oloured, M opele, M osw azi, and M otebele subjects. All o f the mentioned ethnic groups could understand and speak Tswana. Focus group data The subjects were relaxed during the focus groups. They laughed easily and used a lot o f hand signs and body m ove­ m ents during talking. Three subjects got up and dem onstrated how they would do certain household tasks. T he follow ing categories w ere derived from the data: • Perception o f exercise • Personal barriers • Environmental barriers and logistical arrangements • O utcom e expectations o f an exercise program • A dherence to an exercise programme Perception o f exercise All 28 subjects reported that they were doing household chores and that they saw that as a way o f exercising. Household chores consisted o f doing laundry, going to the shops, cooking, washing, gardening, cleaning the home, carrying a baby on the back. Walking as a way o f exercising was m entioned 40 times during the 5 focus groups, how ever the intensity of w alk­ ing ranged from walking far distances to w alking as a possible way to exercise. “1 always walk distances and I do household chores and that way I exercise ” “ To me exercise means going to the garden to water my crops and harvest and then go home. When I arrive home, I clean the yard and then I sit down. In the afternoons I take a walk around my yard. ” Subjects also expressed the following benefits o f exercise: (See Table 3) T he follow ing statem ent by one o f the subjects stressed the psychological benefit o f exercise: “Som etim es when you wake up, you are not fe e lin g well, som etim es you meditate about your problems, but when you exercise, you d o n ’t concentrate on those things and you become happy and you believe that everything will be fin e. ” Personal barriers Subjects expressed psychological and p hysiological barriers to exercise. Psychological barriers were stress-related, not feeling well and forgetfulness. “When you arrive home an you fe e l bad and you meditate on other things in life and your sugar level goes up.... ” “I am m editating a lot about my problem s and you know diabetes makes you forgetful ” “ I am always on and o ff and I c a n ’t be active ” Several subjects also m entioned that their bodies were “already sick with diabetes Two subjects also felt that they had lost too m uch weight and 2 subjects indi­ cated that they were too lazy to exercise. “ / know that we are supposed to exercise, its ju s t that we are so lazy to exercise” Subjects also indicated that they did not know what other exercises to do apart from walking and doing household chores and that they were not used to make choices regarding health care for them ­ selves. O ne subject was o f the opinion that people would think that she is insane if she exercised. Two other subjects indicated that they did not want to lift their legs in lying, did not like running around and that they did not want to wear gym clothes. One subject felt that diabetes patients were not treated well at the Diabetes clinic and had to wait a long time to see the doctor, only not to be informed about their illness. 1 “Som etim es you come in very tired and the doctor do not tell you any­ thing.... ” Physiological barriers to exercise are presented in Table 4. Table 4: Summary o f physiological barriers to exercise. Identified Physiological b a rrier N Frequency o f response Percentage % Tiredness 28 10 36 Arthritis 28 10 36 Foot problems 28 6 21 Sore body 28 4 14 Respiratory problems 28 3 11 Other illnesses 28 2 7 SA J o u r n a l o f P h y s io t h e r a p y 2002 V o l 58 No 1 7 R ep ro du ce d by S ab in et G at ew ay u nd er li ce nc e gr an te d by th e P ub lis he r (d at ed 2 01 3. ) Table 5: Adherence to an exercise program . Positive influences Negative influences • A program suitable for their physical abilities • G ood working relationship • G roup support • O nly diabetes patients • Agreement with program • Patience of presenters o f program • Improvement in health • Visitors • Illness • "N o t feeling well" • Social responsibilities • Household chores • Cost o f transport • Family affairs • Difficulties at home • Tiredness • Laziness E nvironm ental barriers and logistical arrangem ents T he lack o f a convenient venue to do exercise in was the main environm ental barrier. Sixty-one percent o f the subjects staying in different areas o f the M amelodi com m unity indicated that the M amelodi Day H ospital was too far to travel to on a regular basis. The subjects w anted a venue for d iabetics only, because they felt that there would not be harm ony if other people jo in e d the group. The venue would have to be easily accessible due to the cost o f trans­ port. They did not want to do exercises on Thursdays, because it was the day when they go to church. The majority o f the subjects also felt that the exercise classes should not be on a clinic day, due to the long w aiting periods at the clinic. One subject m entioned that the com ­ munity members were impatient with the older people walking slowly. O utcom e expectations Subjects had the follow ing outcom e expectations from an exercise program: • Better health “When you wake up, you should not fe e l tired and heavy; your body m ust be flexib le ” • Improved quality o f life “ We want to have a good life, there is nothing that can conquer a good life ” • Education “A part fro m exercises, we need some advises one how to handle the illness and how to deal with problem s like stress ” • W eight loss “ It will help me reduce my appetite, because people with diabetes eat a lo t” • Stress relieve “ I want to fe e l relaxed and p ea ce­ fu l....n o w after we have exercised we will be laughing and we will fe e l very good afterwards ” • Better control o f the H b A lc “ I will remember that my sugar level is high ” • Group support “ A dvises that we can give each other, as we m eet and c h a t” • Fun “ A ttending exercises to be fu n , so that we alw ays want to come back again next Tuesday and that you will be looking fo rw a rd to that d a y ” A dherence to the program The subjects were o f the opinion that the follow ing factors w ould influence their adherence to an exercise program : (See Table 5) Subjects felt that they w ere com ­ pelled to try the exercises if they were serious about their health. “We w o n ’t stop as soon as we have started, it is not possible, we fo llo w what we have been told...but i f you are disre­ spectful you will not come to exercise ” DISCUSSION Taking the time to listen to patients’ views about health care and how they experience it is instrum ental to d evel­ oping program s that are acceptable to the com m unities. Satisfactory health care involves not merely im provem ent from bodily symptoms, but the social and psychological reintegration o f the patient and the com m unity (Hammond- Took 1989). Q ualitativ e research m ethodology was used to improve the understanding o f p a tie n ts’ p erception o f exercise, personal and environm ental barriers to doing exercise and outcom e expectations o f an exercise program. The sample consisted o f mainly older fem ale Type 2 Diabetes M ellitus patients, attending the M am elodi Diabetes Clinic. The sample group consisted o f 11 ethnic groups o f whom 92% were unemployed. The duration o f the disease ranged from 1 to 22 years and 82% o f the patients were using oral hypoglycem ic agents. All 28 subjects reported doing household chores and walking as ways to exercising. The most im portant findings o f this study were that the participants knew the physiological and psychological bene­ fits o f exercise and that they should take responsibility to exercise if they were serious about their health. E nvironm ental barriers and logistical arrangem ents The lack o f a convenient venue to do exercise in was the main environmental barrier m entioned by the majority o f the subjects. The ideal self-m anagem ent intervention must be relatively low cost and cost-effective and a large percentage o f the relev an t pop u latio n m ust be willing and able to participate (Norris S L e t al 2001). U tilization o f com m unity resources is im portant in this aspect. In this way the issues o f social support and spirituality in patients’ self-care will be addressed, but it would also serve as a means to educate patients, their fam ilies and the com m unity about im proving diabetes m anagem ent (Sam uel-Hodge et al 2000). O lder adults with diabetes are often incorrectly stereotyped as being slow and unm otivated in m anaging their dia­ betes as one o f the subjects in the current study had pointed out (M ooradian AD et al 1999). D iabetic com plications often interfere with sleep and increase the risks o f falls. Fear o f falling will force patients to reduce their mobility. It is therefore crucial that the functional capa­ bilities as well as the gait and balance o f patients should be assessed. An exercise program may develop stronger muscles and bones and reduce the risks o f falls and fractures. In this way the sense o f well-being and agility may be improved. Perception o f exercise In this study the perception o f exercise by the sam ple corresponded well with 8 SA J o u r n a l o f P h y s io t h e r a p y 2002 V o l 58 No 1 R ep ro du ce d by S ab in et G at ew ay u nd er li ce nc e gr an te d by th e P ub lis he r (d at ed 2 01 3. ) the types o f physical activity for older people as docum ented by the World Health Organization, with all 28 subjects reporting that they were doing household chores nam ely gardening, housew ork and walking (WHO 1999). Kriska (2000) also stated that housew ork and family care taking appear to take a substantial portion o f the total energy expenditure o f an average day. However, it was shown in a previous study in a similar sample o f Type 2 Diabetes patients in M amelodi that the more active subjects were doing household and leisure time activities, but not on a regular basis (Van Rooijen et al 2001). Although exercise does not need to be strenuous or prolonged it should at least include 30 minutes o f daily leisure activities such as walking or gardening, which are readily attainable by this sample group (W annamethee S 2001, Blair SN and Jackson AS 2001). Personal barriers Personal barriers are patients’ percep­ tions o f their illness, including disease- related beliefs, emotions, knowledge and experiences. Subjects expressed lack o f knowledge, as well as psychological and physiological barriers to exercise. These findings correlate with a recent study by Sam uel-Hodge (2000) and associates, on the influences on day-to-day self­ m anagem ent of Type 2 Diabetes among African-Am erican women. Being tired can be attributed to m ultiple causes including general life stress, physical exertion and diabetes. Diabetes-related tiredness may be caused by the psycho­ logical impact o f the disease on the patient in terms o f fear and worry about the disease. Patients aptly expressed this in the following way: “I am meditating a lot about my pro b lem s” and “I am already sick with d ia b etes”. The physio­ logical barriers can be attributed to a sedentary lifestyle and com plications of Type 2 Diabetes, such as hypertension and m acro-vascular disease (Songer 1995). The lack o f diabetes know ledge also contributes to the health-related stress: “Som etim es you come in very tired and the doctor do not tell you anything. ” Subjects also indicated that they did not know what other exercises to do apart from w alking and doing household chores and that they were not used to make choices regarding health care for themselves. In a recent focus group study on A frican-A m erican W om en’s Exercise Barriers the follow ing was stated: “We as Black women have not been taught about exercise, where this is like a luxury thing. I was not taught the value o f exercising or eating right until I got to be an adult... ” (Crosson et al 2000). An effective diabetes m anage­ ment program may address these barriers. It should respect an individual’s habits, routines and lifestyle and incorporate social support (Norris SL et al 2001). Outcom e expectations o f an exercise program Two m ajor expectations cam e to the fore in the responses o f the subjects: Im provem ent o f fu n ction al capabilities: • Physical: “When you wake up, you should not fe e l tired and heavy; your body must be fle x ib le ” and “it will help me reduce my appetite, because people with diabetes eat a lot ” • Cognitive: “A part fro m exercises, we need some advises one how to handle the illness and how to deal with p ro ­ blems like stress ” and “I will remem­ ber that my sugar level is h ig h ” • Social: “A dvises that we can give each other, as we meet and c h a t” and “Attending exercises to be fun, so that we always want to come back again next Tuesday and that you will be looking fo rw a rd to that day ” Im provem ent o f well-being: • Perception o f health: “I want to fe e l relaxed and p e a c e fu l... now after we have exercised we will be laughing and we will fe e l very good afterwards ” • E m otional function: “We want to have a good life, there is nothing that can conquer a good life ”. A dults who feel good about their em otion al functioning may exercise and be more active (Spirduso W W and Cronin DL, 2001). Adherence to an exercise program R esearchers have been unable to conclu­ sively distinguish strong characteristics o f exercise ad h eren ce and exercise non-adherence (K erner MS et al 2001, O ldridge et al 1990). The follow ing categories could how ever be identified: • A ttitude towards exercise • Support by significant other persons • Perception of control • M otivation T he responses o f the subjects in the present study have shown that the same categ o ries w ill also influence their adherence to exercise. Subjects had a p o sitiv e attitu d e tow ards exercise, because they had a good perception o f exercise and knew what the benefits o f exercise were. The need for support by significant other persons was expressed by their need for good w orking relation­ ships, patience by the presenters o f the exercise program and group support. The respondents wanted to have control in the program by stating that it should be suitable for their physical abilities, that they should agree with the program and that it should be for diabetic patients only. The negative influences on adher­ en ce to exercise m entioned by the subjects may be an indication o f poor motivation to do exercise. For a diabetes self-m anagem ent program to succeed, patients must adhere to it and be com ­ pliant with behaviour changes. However, the decision not to com ply with such a program may be quite reasonable, par­ ticularly if the program does not meet patient expectations, is inconvenient or conflicts with other priorities, such as social responsibilities, household chores and family affairs. O ldridge and Spencer (1985) have shown that the lack o f support from the spouse and inconvenience was associated with the highest risk for dropout from an exercise program. CONCLUSION It can be concluded from the results of this qualitative study that the subjects had a good perception o f exercise, knew the benefits o f exercise and wanted to have a higher quality o f life by means o f feeling better and function better on a daily basis. H ow ever personal and envi­ ronm ental barriers may contribute to a risk for dropout from an exercise pro­ gram if they are not addressed. Patient beliefs, attitudes and behaviours are influenced by cultural and socio-eco­ nomic factors and are important. The relationship o f culture to health beliefs, attitudes and behaviour is especially SA J o u r n a l o f P h y s io t h e r a p y 2002 V o l 58 No 1 9 R ep ro du ce d by S ab in et G at ew ay u nd er li ce nc e gr an te d by th e P ub lis he r (d at ed 2 01 3. ) Figure 2: Factors infuencing the initiation and maintenance of physical activity in black w om en w ith Type 2 Diabetes Mellitus. REVISED CONCEPTUAL FRAMEWORK important in the treatm ent o f diabetes, which usually includes changing patterns o f eating, physical activity and other culturally em bedded behaviours. If a diabetes exercise program is to be effec­ tive, it must be sensitive and relevant to the culture o f the people expected to carry it out, be convenient and involve spouses and family members. It is clear from the results that a coor­ dinated team approach is needed to address these outcom e expectations. C lark et al (2001) also endorses such an approach in a recent publication on changing the way diabetes is treated. The conceptual fram ew ork is there­ fore revised to the following: ACKNOWLEDGMENTS The South African Society o f Physio­ therapy’s Research Fund funded this ongoing research on the physical activity o f urban black female patients with Type 2 Diabetes. REFERENCES B etts N M , B aranow ski T, H o e rr SL 1996 R e co m m en d a tio n s fo r p lanning and reporting focus group research. Journal o f N utrition E d u cation 28: 279-281 B lair SN , Jackson AS 2001 P hysical fitness and activity as se parate heart disease risk factors: a m eta-analysis. M edicine and Science in S p o rts and M e dicine 33:754-761 B urnard P 1991 A m ethod o f a n alysing in te r­ v iew tra n s c rip ts in q u a lita tiv e re se a rc h . N ursing E ducation T oday 11: 4 6 1-466 B utchart A 1997 The Bantu Clinic: a genealogy o f the A frican p a tient as o b jec t and effecl o f S outh A frican C linical M edicine, 1930-1990. C ultural M e dicine P sychiatry 21(4): 405-47 C lark C M , Fradkin JE, H iss R G , L orenz RA, V inicor F, W arren-Boulton E 2001 T he National D iabetes E ducation Program , changing the way diab etes is treated. D iab etes C are 24(4) 617 C o te-A rsen a u lt D, M o rrison-B eedy D 1999 Practical advice fo r p lanning and conduction fo cu s groups. N ursing R esearch 48:280-283 C rosson P, Zhu W, T im m G 2 000 A frican A m erican W om en’s E xercise B arriers: a focus gro u p study. R esearch Q u a rterly fo r E xercise and S port 71(1): p A -100 D ep artm en t o f H ealth 1997 P olicy G u idelines on the prevention o f physical inactivity in o ld er persons at prim ary level - D raft 1 E a le s C J, S te w a rt AV 2001 H e alth and re s p o n s ib ility se lf-e ffic a c y , s e lf-c a re and self-responsibility. S outh A frican Journal o f P h y sio th e rap y 57: 20-25 F itzgerald JT, G ruppen L D , A n derson RM , Funnell M M , S cott SJ, G ru n b e rg er G , A m an L C 2000 T he In flu en c e o f T reatm ent m odality and E th nicity on A ttitudes in Type 2 D iabetes. D iabetes C are 23(3): 313 G la sg o w R E , S try c k er L A , H am pson SE, R u g g iero 1997 P ersonal m odel beliefs and social-environm ental bairiers related to diabetes self-m anagem ent. D iabetes C are 20: 556-561 H am m ond-T ook D 1989 R ituals and M e d i­ cines: In d ig en o u s H ealing in South A frica. A D D o n k e r Publisher, Johannesburg: 17-163 H ays LM , C lark D O 1999 C o rre la te s o f p hy­ sical activity in a sam ple o f o ld er adults with T ype 2 D iabetes. D iabetes C are 22: 706-712 K ern er M S, G rossm an A H 2001 Scale c o n ­ s tru c tio n fo r m e a s u rin g a ttitu d e , b e lie fs , p e rception o f c o ntrol and intention to exercise. Jo u rn a l o f S p o rts M e d icin e and P hysical F itness 41: 124-131 K im chi J, P o lo v k a B, S tevenson JS 1991 T riangulation: operational definitions. N ursing R esearch 40: 364-366 K reftin g L 1991 R ig o r in qualitativ e research: the a s s e s s m e n t o f tru s tw o rth in e s s . T he A m erican Journal o f O c cu pational T herapy 45: 2 1 4-222 L eon A S , C o n n e tt J, Jacobs D R , R auram aa R 1987 L e isu re -tim e p h y sic al activ ity levels and risk o f c o ro n ary heart dise ase and death. Journal o f the A m erican M edical A ssociation 258: 2388-2395 K ing H , A u b e rt RE, H erm an W H 1998 G lobal burden o f diab e tes, 1995-2025: p revalence, num erical estim a te s and projections. D iabetes C are 25: 26-35 K riska A 2000 E thnic and cultural issues in a sse ssin g physical activity R esearch Q uarterly fo r E x erc ise and S port 71: 47-59 L ig ten b erg PC , H o e k stra JB L , Bol E, Z onder- land M L, E rk elen s D W 1997 E ffects o f ph y ­ sical train in g on m etabolic c o ntrol in elderly T ype 2 D iab etes M e llitus patients. C linical S cience 93: 127-135 10 SA J o u r n a l o f P h y s io t h e r a p y 2002 V o l 58 No 1 R ep ro du ce d by S ab in et G at ew ay u nd er li ce nc e gr an te d by th e P ub lis he r (d at ed 2 01 3. ) L ig te n b erg PC, H oekstra JB L , Z on d erlan d M L , E rkelens D W 1995 Physical activity and D ia b e te s M e llitu s. E u ro p e a n Jo u rn a l o f Internal M edicine 6: 95-108 M a ille t N A , M elkus G D , S p ollett G 1996 U sin g focus groups to chara cte riz e the health b eliefs and practices o f b lack w om en with N on-insulin-dependent D iabetes. The D iabetes E d u ca to r 22: 39-46 M cD ougall P 1999 F ocus groups: an overview o f their use as a research m ethod. C om m unity Pra c tio n er 72: 48-49 M o o rad ian A D , M cL aughlin S, B oyer CC, W inter J 1999 D iabetes care fo r o ld er adults. D iab etes Spectrum 12(2): 70 N orris SL, Englegau M M , N arayan K M V 2001 E ffectiv en ess o f self-m a n ag e m en t training in T ype 2 D iabetes. D iab etes C are 24(3): 561 O ldridge N B, S treiner D L 1990 T h e health b e lie f m o d e l: p re d ic tin g c o m p lia n c e and d ropout in cardiac rehabilitation. M e dicine and S cience in Sports and E xercise 22(5): 678-683 O ld rid g e N B, Spencer J 1985 E xercise habits and perceptions before and after grad u atin g or d ropout from supervised cardiac exercise rehabilitation. Journal o f C ardiac Rehabilitation 5: 313-319 Q uatrom oni PA, M ilb au e r M , P o sn er B M , C a rb alleira NP, B runt M , C h ipkin SR 1994 U se o f focus g ro u p s to e x p lo re n u trition p ra c tic e s a n d h e a lth b e lie fs o f u rban C a ribbean L atin o s w ith d iabetes. D iabetes C are 17: 869-873 R ichter M S 2001 T h e use o f focus groups in the de v elo p m en t o f standards fo r perinatal education. U n p ublished paper: 1-23 S a m uel-H odge C D , K ey serlin g T C , H eaden SW, Jackson, EJ, Skelly A H , A m m erm an A S, Ingram AF, E lasy TA 200 0 Influences on d a y -to -d a y se lf-m a n a g e m e n t o f T ype 2 D iabetes am ong A frican-A m erican w om en. D iabetes C are 23(7): 928-933 S k e lle y A H , M a rsh a ll JR , H a u g h e y BP, D avis PJ, D unfo rd R G 1995 S elf-efficacy and c o nfidence in o utcom es as dete rm in a n ts o f s e lf-c a re p ra c tic e s in In n e r-C ity , A fric a n A m erican w om en w ith N on-insulin-dependent d iabetes. T he D iab etes E d u ca to r 21(1): 38-46 S onger TJ 1995 E p idem iology o f Type II D iabetes. P harm aco E conom ics 8: 1-11 S p ird o so W W , C ro n in D L 2001 E x erc ise d o se -resp o n se effects on quality o f life and in d ependent living in o ld er adults. M e dicine and S cience in Sports and M e dicine 33(6) Suppl: S 598-S 608 Strauss A, C orbin J 19 90 B asics o f Q u a litative R esearch. Sage Publications, N e w bury Park, CA : 57-73 S w ift C S , A rm s tro n g JE , B e e rm a n K A , C a m pbell R K , P ond-S m ith D 1995 A ttitudes and beliefs a b o u t e xercise a m o n g persons with N on-insulin-dependent D iabetes. D iabetes E d u ca to r 21:5 3 3 -5 4 0 Van R ooijen AJ, R h e ed e r P, E ales C J, B ecker P. B lac k fe m a le p atien ts w ith T ype 2 D iabetes M ellitus: K n ow ledge, A ttitudes and Physical A ctivity. SA Journal o f P h y siotherapy 2001 Vol 57(3): 20-27 W annam ethee SG , S haper A G 2001 P hysical a ctiv ity in the p re vention o f c ard io v ascu la r d ise a s e : an e p id e m io lo g ic a l p e rsp e c tiv e . [R eview ] Sports M e dicine 31: 101-114. W esta w a y M S , V iljo e n E, R h e e d e r P, M asem ola T 1998 D e term ining health status and quality o f life fo r D iabetes M e llitu s urban black patients and well persons; a p ilot study. D raft R eport: 1-26. W orld H ealth O rganization 1964 R e h ab ili­ tation o f patients w ith c ard io v ascu la r diseases: rep o rt o f a W H O E x p ert C om m ittee. G eneva. W orld H ealth O rganization 1999 A g eing and P hysical activity: G eneva. New Millennium Time to think of a change? Quality Locums are looking fo r quality personnel in all grades and specialities fo r w o rk in the UK. E ligibility fo r a visa or w o rk permit would be an advantage, but even if you are not eligible w e w ould still like to hear from you as w e may be able to help. Quality Locums are the largest independent M edical, Care and Education A gency in the UK and w e have branches in South A frica and Australia. W e need M edical Staff of all specialities, Social W orkers and Teachers urgently to fill full and part time positions throughout Great Britain and Ireland. W e are experts at helping you to take advantage of the o pportunities in the UK. 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