Perceived exercise barriers enablers and benefits among exercising and nonexercising adults with arthritisResults from a qualitative study.код для вставкиСкачать
Arthritis & Rheumatism (Arthritis Care & Research) Vol. 55, No. 4, August 15, 2006, pp 616 – 627 DOI 10.1002/art.22098 © 2006, American College of Rheumatology ORIGINAL ARTICLE Perceived Exercise Barriers, Enablers, and Beneﬁts Among Exercising and Nonexercising Adults With Arthritis: Results From a Qualitative Study SARA WILCOX,1 CHERYL DER ANANIAN,1 JILL ABBOTT,2 JOELLEN VRAZEL,1 CORNELIA RAMSEY,1 PATRICIA A. SHARPE,1 AND TERESA BRADY3 Objective. Rates of participation in regular exercise are lower among individuals with arthritis than those without arthritis. This study examined perceived exercise barriers, beneﬁts, and enablers in exercising and nonexercising adults with arthritis. Methods. Twelve focus groups were conducted with 68 adults with arthritis. Groups were segmented by exercise status, socioeconomic status, and race. Focus group discussions were transcribed verbatim and coded. NVivo software was used to extract themes for exercisers and nonexercisers. Results. A wide range of physical, psychological, social, and environmental factors were perceived to inﬂuence exercise. Some of these factors were similar to those in general adult samples, whereas others were unique to individuals with chronic disease. Symptoms of arthritis were barriers to exercise, yet improvements in these outcomes were also seen as potential beneﬁts of and motivations for exercise. Exercisers had experienced these beneﬁts and were more likely to have adapted their exercise to accommodate the disease, whereas nonexercisers desired these beneﬁts and were more likely to have stopped exercising since developing arthritis. Health care providers’ advice to exercise and the availability of arthritis-speciﬁc programs were identiﬁed as needs. Conclusion. This study has implications for how to market exercise to individuals with arthritis and how communities and health care professionals can facilitate the uptake of exercise. These implications are discussed. KEY WORDS. Arthritis; Exercise; Barriers; Beneﬁts. INTRODUCTION Arthritis, the leading cause of disability in the United States, has a negative impact on health-related quality of life (1). In total, the treatment of arthritis, its complications, and resulting disability cost the United States an The views expressed in this report are not the ofﬁcial views of the Centers for Disease Control and Prevention or the Association of Schools of Public Health. Supported by a grant from the US Centers for Disease Control and Prevention and the Association of Schools of Public Health (project S2109-22/22). 1 Sara Wilcox, PhD, Cheryl Der Ananian, PhD, JoEllen Vrazel, PhD, Cornelia Ramsey, PhD, MSPH, Patricia A. Sharpe, PhD: University of South Carolina, Columbia; 2Jill Abbott, DrPH: The Ohio State University Comprehensive Cancer Center, Columbus; 3Teresa Brady, PhD: US Centers for Disease Control and Prevention, Atlanta, Georgia. Address correspondence to Sara Wilcox, PhD, Department of Exercise Science, Arnold School of Public Health, University of South Carolina, 1300 Wheat Street (Blatt), Columbia, SC 29208. E-mail: firstname.lastname@example.org. Submitted for publication June 14, 2005; accepted in revised form November 3, 2005. 616 estimated $86 billion per year (1997 US dollars), and this number is expected to increase as the US population ages (2). The National Arthritis Action Plan (3) and Healthy People 2010 (4) underscore the importance of exercise among persons with arthritis. Exercise is a critical component of disease management (5–7). In randomized clinical trials, exercise (aerobic and resistance training) has been shown to reduce pain; delay disability; improve physical function, postural sway, quality of life, aerobic capacity, and muscle strength; and reduce the risk of other chronic conditions among individuals with arthritis (8 –17). Despite the well-documented beneﬁts of exercise for arthritis management, rates of inactivity are higher in persons with arthritis than in those without (18). Although much research has focused on the correlates of exercise among adults in general (19), few studies have focused on unique factors for individuals with arthritis (20). Understanding these factors among exercisers and nonexercisers may help researchers and practitioners develop programs, tailor recruitment and retention strategies, and implement health communication messages more effectively. There- Exercise and Arthritis 617 Figure 1. Recruitment of participants. The boxes at the bottom of the ﬁgure indicate the segmentation of focus groups that were completed. Two groups were conducted for each population subgroup. The numbers in parentheses indicate the number of persons. Ex ⫽ exercise; FG ⫽ focus group; PI ⫽ private investigator; SES ⫽ socioeconomic status. fore, the major goal of this project was to understand the barriers, enablers, and motivations for exercise, as well as the perceived beneﬁts and outcomes of exercise most meaningful to persons with arthritis. Special attention was given to factors that differentiated exercisers from nonexercisers. MATERIALS AND METHODS Participants. This study was approved by the University of South Carolina Institutional Review Board. Participants responded to advertisements in local newspapers, on local radio stations whose target audience is African Americans, and in ﬂyers posted throughout community establishments. Recruitment was ongoing from May 2003 through March 2004. Participants expressing an interest in the study were screened via telephone after providing oral consent. Eligible participants were ages ⱖ18 years with any type of diagnosed arthritis and were classiﬁed as either exercisers or nonexercisers. All but one participant resided in Lexington or Richland County (i.e., greater metro area of Columbia, SC). Groups were segmented by exercise status, socioeconomic status (operationalized as education less than or equal to high school versus greater than high school), and race/ethnicity (Figure 1). Two focus groups were conducted for each group. Segmentation creates homogeneity along participant characteristics that are potentially related to the topic of interest and helps participants feel comfortable and willing to talk openly (21). Procedures. Eleven experts in exercise and/or arthritis convened via teleconference and provided input on factors that inﬂuence exercise, personally meaningful outcomes among persons with arthritis, types of questions to ask participants, how to segment groups, and how to recruit a representative sample. As a result of these calls and a review of the literature (20), 2 moderator’s guides were developed, 1 for exercisers and 1 for nonexercisers. The moderator’s guides were pilot tested to determine how well the questions were understood by participants and captured participants’ experiences with exercise. At the conclusion of each pilot group, participants provided feedback on the questions. Because signiﬁcant changes were made to the moderator’s guide for exercisers, participants from this pilot group were not included in any analyses. Minimal changes were made to the moderator’s guide for nonexercisers. Focus groups were moderated by 3 white women with masters degrees who had training and experience conducting focus groups and indepth interviews (10 groups were moderated by 1 person). All focus groups were audio recorded and transcribed verbatim, and transcripts were reviewed for accuracy. All individuals directly involved in coding and analysis attended 3 training sessions. All read the 12 focus group transcripts and generated a list of themes that were then organized into a code book with deﬁnitions. Two of 5 coders were randomly assigned to code each of the 12 focus groups, ensuring that coding pairs differed across the focus groups. Each person independently coded the transcript, and the pair met to review all codes and come to a 618 consensus. Consensus codes for all focus groups were entered into NVivo (QSR International, Doncaster, Victoria, Australia). Throughout the coding process, new codes and their deﬁnitions were discussed, added as needed, and shared with all coders, and previously coded transcripts were recoded to reﬂect these changes. The focus group (rather than individual participants) was the unit of analysis. In focus groups, participants often express agreement with one another by nodding and shaking their heads, thus an analysis of simple frequency counts of themes is not a good indicator of the importance of a theme. Results are reported according to how many groups of exercisers and nonexercisers expressed the theme. One limitation of focus groups is that some members may not feel comfortable expressing contradictory views. To minimize this potential, we recruited homogeneous groups to prevent acquiescence to opinions of individuals with higher status, and the moderators were trained to prompt individuals who did not respond to questions or who did not nod in agreement. Additional measures. Sociodemographics and background information. Participants reported their age, sex, race, educational attainment, income, and employment status. Participants also reported their arthritis type (based on a physician’s diagnosis) and duration (years). Physical activity. A modiﬁed version of the 2001 Behavioral Risk Factor Surveillance System physical activity module was administered during the telephone screening (22). The questions were modiﬁed to obtain information on structured exercise only. Participants reported the type, frequency, and duration of their moderate-intensity, vigorous, and strengthening structured activities. Participants were classiﬁed into 1 of 2 groups. Exercisers participated in moderate activities on at least 3 days per week for ⱖ30 minutes per day, vigorous activities on at least 3 days per week for ⱖ20 minutes per day, or strength training on at least 3 days per week for ⱖ20 minutes per day. Participating in exercise at this level has been shown to yield health beneﬁts in individuals with arthritis. Nonexercisers were those who exercised (any amount) on 0 or 1 day per week, or who exercised for ⱕ10 minutes on 2 days per week. Those who did not fall into one of these 2 groups were ineligible. RESULTS Characteristics of participants. The ﬂow of participants through the recruitment process is shown in Figure 1. Of the 75 participants who took part in a focus group (including the 7 who took part in the pilot group of exercisers), the most common recruitment sources were newspaper advertisements (n ⫽ 26) and ﬁtness and community-based wellness facilities (n ⫽ 14). Characteristics of the 68 focus group participants retained in the analyses are shown in Table 1. Focus group ﬁndings: barriers to exercise. Participants discussed barriers to exercise as well as factors that made Wilcox et al exercise more difﬁcult. Themes and illustrative quotations for barriers are listed in Tables 2 and 3. Physical barriers. Pain. Pain was described as a barrier to exercise in all focus groups and was the single most discussed topic. Pain was described in 3 ways: the occurrence of pain prevented a person from exercising, experiencing pain during exercise made a person not want to exercise, and pain experienced after exercise decreased a person’s willingness to participate in future exercise. Although similar themes emerged for exercisers and nonexercisers, exercisers were more likely to make adaptations to their exercise (e.g., modify type or intensity, take a respite during arthritis ﬂares) and work through pain to attain beneﬁts, whereas nonexercisers were more likely to give up exercise altogether. Fatigue. Exercisers and nonexercisers described fatigue as being a barrier to exercise or making exercise more difﬁcult. Although both groups were willing to modify their activities in response to fatigue, nonexercisers more often decreased frequency, whereas exercisers were more likely to adjust other aspects of their exercise, such as intensity. Participants attributed their fatigue to a variety of factors, including medication, insomnia, and depression. Mobility. Most commonly, exercisers and nonexercisers described impaired mobility as a major challenge to exercise. Nonexercisers also discussed decreased mobility after engaging in exercise. Comorbid conditions. Comorbid conditions were described as barriers to exercise more often among exercisers than nonexercisers. These conditions ranged from musculoskeletal to cardiovascular ailments. Nonexercisers and exercisers experienced similar comorbidities; however, only nonexercisers described asthma (2 groups). Psychological barriers. Attitudes and beliefs. Lack of time, motivation, and enjoyment of exercise and the sentiment that “I should but I don’t” were cited by exercisers and nonexercisers alike. Whereas nonexercisers described these factors as barriers to exercise, exercisers described them as factors that made exercise more difﬁcult. Exercisers were also more likely than nonexercisers to talk about how other life activities took priority over exercise, making it difﬁcult to ﬁt in exercise. Nonexercisers were much more likely than exercisers to describe their belief that they were physically unable to exercise and unskilled to exercise. Fear. Among nonexercisers, participants’ fear of water and fear of experiencing pain were barriers. The fear of water prevented them from participating in water aerobics, an exercise they believed to be safe and effective for individuals with arthritis. Perceived negative outcomes. This theme emerged as a barrier for both exercisers and nonexercisers. Almost all of the comments were based on actual experiences. The general consensus was that individuals were going to “pay for it” afterwards, although the outcomes mentioned were varied and sometimes nonspeciﬁc. For some, the potential negative outcomes were accepted as part of the exercise Exercise and Arthritis 619 Table 1. Sociodemographic and physical activity–related characteristics of the sample by exercise status* Characteristic Type of arthritis (selfreported as physician diagnosed), no.† Osteoarthritis Rheumatoid arthritis Fibromyalgia Gout Other (includes those not sure of type) Years with arthritis, no. (mean ⫾ SD) Age, no. (mean ⫾ SD years) Education, no. (mean ⫾ SD years) Sex‡ Female Male Marital status§ Married Widowed Divorced or separated Not married Living with partner Race or ethnicity§ White Black/African American Hispanic American Indian Not speciﬁed Occupational status§ Employed Full time Part time Retired Unemployed Homemaker Student Income 0–$29,999 $30,000–$59,999 ⱖ$60,000 Minutes of physical activity per week, mean ⫾ SD Total minutes¶ Strength minutes¶ Moderate minutes¶ Vigorous minutes‡ Percentage meeting the physical activity recommendations† Strength Moderate Vigorous Exercisers (N ⴝ 36) Nonexercisers (N ⴝ 32) 36 31 16 (44.4) 14 (38.9) 6 (16.7) 1 (2.8) 8 (22.2) 16 (51.6) 8 (25.8) 11 (35.5) 2 (6.4) 6 (19.4) 31 (12.50 ⫾ 10.71) 28 (12.57 ⫾ 8.24) 36 (58.8 ⫾ 15.0) 36 (13.6 ⫾ 3.0) 32 (56.9 ⫾ 10.6) 32 (13.1 ⫾ 2.2) 36 27 (75.0) 9 (25.0) 36 13 (36.1) 8 (22.2) 7 (19.5) 6 (16.7) 2 (5.6) 36 23 (63.9) 13 (36.1) 0 (0) 0 (0) 0 (0) 36 32 30 (93.8) 2 (6.2) 30 16 (53.3) 4 (13.3) 7 (23.3) 2 (6.7) 1 (3.3) 32 15 (46.9) 13 (40.6) 1 (3.1) 1 (3.1) 2 (6.3) 31 11 (30.5) 3 (8.3) 13 (36.1) 6 (16.7) 2 (5.6) 1 (2.8) 31 13 (42.0) 9 (29.0) 9 (29.0) 36 5 (16.1) 3 (9.7) 13 (41.9) 6 (19.3) 2 (6.5) 2 (6.5) 25 16 (64.0) 6 (24.0) 3 (12.0) 32 230.6 ⫾ 124.7 54.9 ⫾ 66.1 146.1 ⫾ 89.9 33.6 ⫾ 70.4 9.22 ⫾ 20.2 0.8 ⫾ 3.2 5.8 ⫾ 13.9 2.8 ⫾ 15.9 12 (33.3) 29 (83.0) 6 (16.7) – – – * Values are the number (percentage) unless otherwise indicated. † Categories are not mutually exclusive; therefore, the percentages can add up to greater than 100%. ‡ Groups differ signiﬁcantly (P ⬍ 0.05). § Due to the small sample size in some cells, differences between groups were examined for the percentage of participants who were white versus nonwhite, employed versus not employed, and married or partnered versus neither married nor partnered. No signiﬁcant differences were found. ¶ Groups differ signiﬁcantly (P ⬍ 0.001). Illustrative quotations 3 “When you have a ﬂare-up and your joints become swollen and inﬂamed . . . then you really can’t exercise.” 6 “I would love to be able to walk much of the mall . . . but I can walk a little while and sit down on one of those benches and rest and let the worst of the pain calm down, and I can walk a little bit more to another bench, and I make it that way.” 5 “I do love to dance . . . and I will do my best to hang in there with everybody else, knowing the consequences the next day . . . You know you are going to hurt.” 5 “I have ﬁbromyalgia, and my problem more than pain, I mean, I have pain, but to me, the problem is more fatigue, and I used to ride bikes and do more vigorous exercise, and once I got ﬁbromyalgia, I just have to push myself to make myself exercise.” n Exercisers Lack of positive outcomes Perceived outcomes Negative outcomes Fear I’m not skilled enough I physically can’t Not a priority Lack of enjoyment I should but I don’t Psychological/behavioral Attitudes and beliefs Lack of time Comorbid conditions Illustrative quotations 5 “My house is always in front of me like a mountain to climb, and I do what I can and then I got to sit down again . . . After a while, sometimes you just give up, and you go to bed, and I’m supposed to be exercising.” 5 “The reason I have not made an attempt to go into an exercise class because, well, I hurt so bad.” 5 “[Arthritis] is what made it so painful now to do the same thing I use to do, but I was on an exercise program to strengthen my muscles and joints because the orthopedic told me to do it, and then now when I do it, it’s like you are straining your muscles, and you hurt more.” 6 “Well, exercise for me deﬁnitely causes the pain.” n Nonexercisers 5 “Cause I ﬁnd . . . that if I really do go out, I like to walk at least 3 6 “If I want to . . . if I feel like I really want to do something . . . to have fun with miles. If I . . . sometimes if I do 3 miles, I’m going to pay for it, so I exercising, I do it, and I suffer the consequences later.” have to back off. I can’t do as much, and I have to get that in my head.” 0 4 “I have been swimming and aerobics, but none of that helped me at all. Nothing. Not a thing. I still have that pain.” 5 “I don’t have the time to really walk every day and that’s what I 3 “If I had the time and were able to do those exercises, they would help.” would like to do, and that’s one of the barriers for me is the time.” 3 “I probably would not go if it were left up to me, but now I know it’s 4 “ . . . I don’t know what’s in my mind that’s keeping me from it. One doctor told me, good for me.” he says, ‘It may mean your life if you exercise.’ Now, you think that would be enough motivation. I’m still not doing it. It bugs me that I’m such a failure at that.” 3 “The doctor has just ordered me into an exercise class, and I’m, you 3 “I hate exercise. I just hate it. It’s the most boring thing in the world to go to a club know, ﬁghting and kicking it all the way . . . I got to tell you, for the and pick up little weights, and I’ve done it, and it just bored me to last 10 years of my life, I would do pretty much anything rather tears . . . boredom . . . even tried the treadmill in front of the TV. It’s a waste of than exercise.” time. You don’t accomplish anything.” 4 “You have to take time. I have to be able to go down there and do 2 “And here I am at home by myself and when I do start feeling better, you know, I this if I didn’t have to stay home and cook, but you know, it’s just think I’m maybe I need to exercise. . . . You know, I’ll procrastinate for, I mean, I’ll time consuming, and it just takes away from being at home . . . By even cook which I don’t do. I’ll even do that before I’ll exercise.” the end of the day, I’ve had enough. . . .” 1 4 “I did aerobics, and I loved it, but I can’t do aerobics. I can’t do step because I can’t step up and step back because of my feet and my knees. I can’t run. I can’t stoop. I can’t squat. I can’t get down on the ﬂoor. If I get on the ﬂoor, I can’t get up.” 1 4 “Everybody else is good, so I don’t want to be around them, you know, and I’m a hermit.” 0 3 “I’ve been told to try water aerobics, but I’m not a water person. I’m terriﬁed of water, so that doesn’t work with me.” 3 “Now I can’t walk that far because my knee will not allow me to walk, and I mean I can’t keep up with my husband.” 3 “ . . . and I don’t get the exercise like I would like to because, when I walk a certain distance, I get to where I can’t hardly go . . . and if it gets real severe, I usually end up in the bed.” 5 “But exercise he wanted me to do . . . he said it would make it worse 3 “Well, should I go and try the aquatics and get exercise, or should I go out and try to because I had psoriasis on my knees and my feet and legs . . . they walk again? But I have asthma, so I don’t want to go out in this heat and walk. So, would crack and was real sore, and he said the exercise that he it’s like a catch-22. Where do you go?” would want me to do would make it worse.” Impaired mobility Impediment to exercise 3 “When it ﬂares up . . . I can’t turn over in the bed. I can’t get out to walk. I’m like a 90-year old person that really can’t walk.” Result of exercise 1 Fatigue After exercise During exercise Physical Pain Before exercise Key themes and subcategories Table 2. Summary of physical and psychological barriers to exercise among exercisers and nonexercisers with arthritis (n ⴝ 6 focus groups each) 620 Wilcox et al n Illustrative quotations n Illustrative quotations Nonexercisers 2 “My husband, he knows what I go through, what I’ve had done to me and he’ll 3 “ . . . I don’t have anybody that cares what I do. I mean, I live say, ‘you ain’t got no business doing that. You know, you know how you by myself, and I would imagine if I had a man or if I had a are, you know.’ So he doesn’t encourage me, because he doesn’t want the child or something that said, ‘Come on, go, Mom’ . . . You aftermath of it. But my daughter is truly my cheerleader.” know, my bird doesn’t care what I do . . . Nobody really cares, so why should I . . . You know, I don’t have anybody saying, ‘Go, gal, go.’ ” Lack of acknowledgment of arthritis 1 2 “When I do walk with my husband, he’s about 3 steps ahead of me, and he keeps getting farther and farther ahead of me, and he doesn’t understand why I can’t keep up with him. That’s why I am just glad that he’s got the ladies in the neighborhood he can walk with. Now, I don’t have to go out and try to walk.” Doctor did not mention exercise 3 “They never mentioned it. The ﬁrst thing they say is, ‘We do a blood test. Oh, 3 “My doctor never told me nothing about it because I be you’ve got rheumatoid arthritis. Here, take this.’ Okay, that makes me sick. fussing with him all the time about me. I can’t walk, and ‘Okay, take this.’ That gave me a rash. ‘Okay, take this.’ That gives me the he ain’t never tell me nothing about what to do or no place hives. ‘Okay, take 2 of these.’ Oh, that’s making me swell. ‘Well, take a shot to go, you know what I mean . . . nothing like that.” of this.’” Doctor did not refer to programs 0 3 “I will say this . . . there is very little being passed around that’ll tell you, ‘You can go here, or you can go there.’ It’s sort of a word-of-mouth thing.” Doctor did not give exercise 2 “He gave me a pamphlet that had movement in it. Stretching exercise and sit- 0 instruction ups and rolling in a ball and doing all that to stretch your back out, and he didn’t really show me how to do any. He just give me this piece of paper and said, ‘Here.’ ” No one to exercise with 3 “I think if I had somebody to exercise with . . . sometimes when I do want to 5 “If I had someone, you know, a partner that I was doing it go, I don’t have enough motivation . . . like if I want to walk . . . Sometimes I with, that motivates me more to walk and exercise . . . ” don’t have anybody to do anything with. That gets in the way.” Competing role responsibilities 2 “If you’re working and have a family, it’s really extra, extra hard and then if 4 “[Exercising] exhausts me. I mean, it was bad enough . . . I do you’re hurting besides, I can imagine it’s even more difﬁcult.” the laundry and taking care of the kids and cooking and working and every . . . I’d be da’goned if I was gonna go, you know, jog for a mile, you know. No, no, no. Not for me.” Environmental Programs or facilities: lack of arthritis- 5 “There are some of the other health clubs and spas and so forth that do water 6 “I don’t know nothing like that around here. I haven’t heard. speciﬁc facilities aerobics, but they don’t key to arthritis or ﬁbromyalgia or joint replacement If it is, I haven’t heard about it, you know. It might be, but I like they do there, and it’s not working out well with them because I had haven’t heard about it.” one friend . . . there was a place . . . that was a little closer to her house, and she tried them, and she could not do the exercises there. They were not keyed toward a person who had joint problems or anything like that, and you just couldn’t do them without damaging yourself.” Environmental conditions 5 “[Rain] messes up your knees. It messes up your back. You don’t feel like 4 “But I have asthma so I don’t want to go out in this heat and getting up and doing anything really.” walk. So it’s like a catch-22. Where do you go?” Cost 2 “The other one was at the Y and number one the Y is just too darned 3 “Every place I’ve checked, even at churches, you know, I expensive anymore.” cannot afford it being on disability.” Transportation 0 3 “Well, I didn’t have transportation for a while either.” Social Lack of support Lack of encouragement for exercise Key themes and subcategories Exercisers Table 3. Summary of social and environmental barriers to exercise among exercisers and nonexercisers with arthritis (n ⴝ 6 focus groups each) Exercise and Arthritis 621 622 Wilcox et al experience. Both exercisers and nonexercisers concurred that negative outcomes generally resulted from pushing beyond one’s limits. Nonexercisers expressed the theme that exercise might not be “worth it” if it did not help their symptoms. Participants questioned the need for exercise when it did not seem to positively affect their arthritis symptoms. come and sometimes described being uninsured or underinsured, often due to disability. Transportation. Among nonexercisers, lack of transportation to facilities or programs was a barrier. It was unclear whether the respondents did not have access to transportation or were not capable of driving because of their arthritis. Social barriers. Lack of support. Not having support from family, friends, and health care providers was expressed in different ways. Some exercisers and nonexercisers stated that although their signiﬁcant others did not discourage them from exercise, no one really encouraged them to do so. Other participants, more commonly nonexercisers, expressed the notion that signiﬁcant others did not acknowledge their physical limitations and were not sympathetic to their struggles. Exercisers and nonexercisers also described their health care providers’ emphasis on medication and failure to mention exercise. Whereas nonexercisers said that their physicians did not refer them to helpful exercise programs, exercisers were more likely to discuss how their physicians did not instruct them on how to exercise properly. No one to exercise with. Although both groups described how the lack of an exercise partner was a barrier, this theme was more common among nonexercisers. Without exercise partners, frequency of exercise decreased. For both groups, ideal exercise partners were those who preferred similar exercise schedules and who lived close by. Nonexercisers also desired exercise partners with similar abilities. Competing role responsibilities. Feelings of responsibility to one’s family emerged as a barrier to exercise, especially among nonexercisers. Nonexercisers reported less energy as a result of their competing roles, whereas exercisers described how they were left with less time to engage in exercise. Focus group ﬁndings: exercise beneﬁts and enablers. Participants discussed the advantages and beneﬁts that may result or have resulted from exercise, identiﬁed the single outcome that made or would make exercise worth doing, and described what would motivate them or make it easier for them to start or continue an exercise program. The themes and illustrative quotations are listed in Tables 4 and 5. Environmental barriers. Lack of programs or facilities. In almost all groups, the lack of exercise programs or facilities speciﬁcally for persons with arthritis emerged as a barrier. Although participants acknowledged nearby ﬁtness clubs, there were few programs or facilities that met their speciﬁc needs. Some participants were aware of facilities and programs but said they were too far away to attend regularly. Others described a lack of qualiﬁed instructors, particularly those who understood physical limitations. Environmental conditions. Weather, including hot and cold weather and rain, was the most common environmental barrier cited by exercisers and nonexercisers. Both cold weather and damp, rainy weather were barriers in part because they aggravated symptoms of arthritis. Other environmental conditions that impeded exercise included congested parking, concrete surfaces, presence of dogs, and lack of sidewalks. Cost. Cost of programs emerged as a barrier to exercise among both groups, but cost seemed to be especially prohibitive among nonexercisers who lived on a limited in- Physical beneﬁts and enablers. Symptom management. In all groups, participants described how exercise could reduce pain. Although some participants quickly noted that exercise did not stop pain, many stated that it decreased the severity and intensity of pain enough to make it more manageable. Those who exercised were generally more positive because they had experienced pain reduction and other beneﬁts. In contrast, nonexercisers expressed more doubt that exercise would reduce their pain. Approximately half of the responses from nonexercisers resulted from being asked to identify the one outcome that would make exercise worth doing or would motivate them to start exercising. Reduced stiffness was described similar to pain reduction among exercisers and nonexercisers, although it was more commonly cited by exercisers. Exercisers also cited increased energy more often than nonexercisers. Fewer groups described improved sleep, the prevention of disease progression, and decreased use of medications as beneﬁts. Mobility and function. Participants in all groups stated that exercise gave them the ability to move and function, not necessarily at a normal level, but at least at a level that allowed them to function in life and conduct everyday activities. Mobility was a critical outcome for enabling them to cope with arthritis. Exercisers repeatedly expressed the theme of “use it or lose it.” There was an important distinction between groups. Nonexercisers described wanting to return to the life they had before arthritis when they were able to function normally, whereas exercisers discussed how exercise enabled them to live a more normal life. Many exercisers added that if they did not move, they would “lock up,” “freeze up,” or “shut down.” Several participants stated that they would be “crippled” if they did not exercise. Nonexercisers often used phrases such as “this is what I hear,” “I don’t know but maybe,” or “this is what I understand” to describe the mobility and function beneﬁts or desired outcomes. Strength and ﬂexibility. Increased strength was viewed as an important component to improving mobility and functioning by exercisers and nonexercisers alike. Several nonexercisers noted that building muscles around a joint or strengthening muscles would enhance mobility. Increased ﬂexibility was a similar theme. In general, both 5 3 Behavioral enablers 5 Weight loss Enjoyment 4 Strength and ﬂexibility 6 4 Activities of daily living Emotional 6 Mobility and function 5 3 Increased energy Attitudes and beliefs 6 Reduced stiffness 6 6 Physical Symptom management Reduced pain Psychological/behavioral Independence n Key themes and subcategories “ . . . and to me it’s just come down to it’s got to be a personal goal. So I’ve been setting time limits, as you stated [name], in my daily planner about when to make it a priority, when I can put it in, trying to work my life around it.” “ . . . because before I started doing this [exercise] my doctor was trying to schedule me in a nursing home and I said, I said I would not go . . . .after about 3 weeks I could begin to see the difference. And now 2 years later I’m feeling just great compared to what I was.” “ . . . through exercise and, I mean, the medication too, but I have a whole different outlook on having ﬁbromyalgia. Like 2 years ago I was like ‘I don’t know how I’m going to live the rest of my life doing this. . . . I don’t know how I’m gonna ever have the life I used to have before.’ And now I’m not 100% but I’m making progress getting back to where I was before. I know I’m never gonna be the same person as before but I think I can get pretty close now.” “Makes you feel good when you get through with it. Makes you more energetic or . . . your state of mind. It makes you feel like you’ve done something good for yourself.” “I like everything about exercise.” “ . . . if I lose weight maybe I’ll feel better, maybe I won’t hurt so much . . . ” “To bend down to pick green beans or something my legs were just . . . there’s no strength there and there’s a big tremendous difference with the weight machines. So I go 3 times a week for about an hour each time and it just keeps the muscles from deteriorating.” “It’s beginning to feel better. Not hurting as bad as you did and being able to do things that you couldn’t do before. I’m still limited but man it’s so different now. And that’s why I go religiously . . . ” “It’s just that if I don’t keep exercising, then every morning I’m stiffer longer in the morning than if I don’t exercise . . . I think pretty soon I’d just be sitting in a chair not able to go.” “ . . . the more I pushed myself to do something like step class, I couldn’t believe how much energy I had. And when I sleep now I don’t usually wake up. I sleep through the night and I can get 9 hours and be a lot more functional.” “The exercise that I do, I push myself to do it. Because I know that if I didn’t do something that I will eventually be crippled. I’ve been to the point to where I, you know, was either had to be in a wheel chair, had to use a walker, or, you know, just you couldn’t do nothing. You couldn’t make a ﬁst. You couldn’t walk or anything.” “My biggest motivation I think is that I want to be able to continue to do things myself. When I ﬁrst came down with my arthritis there were so many things I couldn’t do. Like a zipper or do a button . . . .and the more I exercise and stay mobile the more I can do for myself.” Illustrative quotations Exercisers 1 5 6 4 3 4 4 3 6 1 4 6 n “ . . . if I feel like I really want to do something that’s, you know, to have fun with exercising, I do it and I suffer the consequences later.” “Yeah it did make me feel better but it makes me feel better but yet it bothers me. It hurts me.” “I think I’ve done something. So it gives me a mental boost, and then when my wife comes home, I say, ‘Hey, I rode the bike today, I did some exercise today.’ . . . It’s nothing to someone else, but to me to be able to take that one pound weight and do it like barbells and to ride that bike for 10 minutes, it just really makes me feel like I did something.” “But I thought gosh if I don’t do something. I don’t want to be . . . I don’t want to be disabled.” “But I did ﬁnd that my orthopedic told me to exercise as far as doing leg lifts and things and that would to build the muscles up around my knees and once I built the muscles up around my knees, that would help me not to be in such pain or be able to walk and be more mobile.” “I would like to get back in the life that I used to have, to be able to get out and do things with my children that I used to do and go places I used to go and not worry about hurting later. Everyday things. . . . I’d like to get out one day and just clean my whole house. It’s just totally impossible. . . .” “I think that exercise that strengthens your body . . . like with arthritis and with age you start losing your posture, and I think if you could do exercises maybe like weightbearing exercises that you do with weights and things that would strengthen some of the parts of your body that would help you hold your body . . . .” “If I lost weight my arthritis wouldn’t be as bad.” “And so with the movement it relieves some of the stiffness.” “Stop the pain. If I could get some of the results I used to get before the pain, that would make me keep going.” Illustrative quotations Nonexercisers Table 4. Summary of perceived physical and psychological beneﬁts and enablers of exercise among exercisers and nonexercisers with arthritis (n ⴝ 6 focus groups each) Exercise and Arthritis 623 3 4 3 Programs for people with arthritis Low cost Availability of equipment 5 5 Someone to exercise with Environmental Water exercise 6 4 Social Enjoyment of exercising with others Encouragement n Key themes and subcategories “ . . . I did hear something about there is a heated pool over at Harbison and they have water workouts for people with arthritis but I don’t know if that’s still going on or not.” “ . . . with arthritis, and yes, you can go to regular classes, but I think you really need instructors who are going to understand not so much the exercise, but the limitations what we have and that is what’s missing.” “ . . . The yoga once a week is $15 a month and you’ve got to join [name] for $35, and I think it’s the biggest bargain around.” “So I bought me one of those walkers, where I can walk in the house. So I do that often.” “It helps me mentally. It helps me physically. It . . . I meet a lot of different people at the gym and it’s amazing how quick you can form a relationship with people that you have never met before. And it’s a great way to share time with other friends. You can get them to come to the gym with you.” “My daughter is my cheerleader. She has always encouraged me. Cause sometimes she’ll call and she, more than anyone can tell when I’m having a bad day. She’ll say ‘Ma, you might need to just get up and go for a little walk. Just go out in the yard Ma.’ You know, just whatever, she’s my cheerleader.” “I probably wouldn’t go but my husband goes so I go with him. I would probably be very bad about exercising if I weren’t going like that.” Illustrative quotations Exercisers 3 2 4 6 6 6 5 n “And so now it’s (the bike) on the back porch and it faces the woods and so I sit up there and I ride it and I have a little timer that I found and I set it for 15 minutes, then I walk for 10 minutes. I’ve been doing that like I say a month or so now.” “That’s why a water class and something like that where you’ve got an instructor. Somebody there that can lead you and give you 10 exercises for your particular body.” “ I think it’s like several of them said, ﬁnding a place to go to do the exercise and having instructors there that know your limitations to what you can do and what you can’t do and how it’s going to affect your joints in the certain exercises that you do.” “Yeah. And it’s 3 times a week and it’s $30 for 3 times a week which is really good.” “Words don’t mean as much as go. You know let’s go, let’s do it together.” “I get a lot of general support in that area. Nobody pushes me to exercise hard, but everybody supports me to do whatever I can to exercise.” “Yeah, I think like the others said I think it’s being with other people when you exercise in a group, it’s more like a social thing for you to get to be with other people. And the fact that it gives you more energy. You feel healthier.” Illustrative quotations Nonexercisers Table 5. Summary of perceived social and environmental beneﬁts and enablers of exercise among exercisers and nonexercisers with arthritis (n ⴝ 6 focus groups each) 624 Wilcox et al Exercise and Arthritis exercisers and nonexercisers talked about needing to be “more ﬂexible” and described the importance of staying “limber” and “loose.” Exercisers said that an activity such as swimming “limbers you up,” and yoga “increases your ﬂexibility.” Several comments related to ﬂexibility also related to the beneﬁt of reduced stiffness described earlier. Weight loss. Exercisers and nonexercisers described exercise as a way to “keep the weight down” or noted that it was beneﬁcial to managing the weight that they had gained over the years. Exercisers perceived that losing weight would make them feel better or noted that weight loss had actually helped with their arthritis. Nonexercisers said that they wanted weight loss results from exercise and that it would help them be more motivated to exercise. Other less common themes. Exercisers described improvements in comorbid conditions or their symptoms. Several said that they began exercising because of heart conditions, but that it also had a positive impact on their arthritis. Diabetes and osteoporosis were also raised as comorbid conditions that prompted them to exercise. Finally, in 2 groups, exercisers described how regular exercise decreased the amount of medication needed to manage the symptoms of arthritis. Psychological beneﬁts and enablers. Independence. Independence was a theme for exercisers and nonexercisers, although it was cited more often by exercisers. Exercisers reported compelling reasons as to why they were motivated to exercise regularly, including avoiding becoming “an invalid” or having to be in a wheelchair, fear of having to go into a nursing home, and, most importantly, being able to remain “self-sufﬁcient.” Attitudes and beliefs. Exercisers and nonexercisers described how exercise improved their attitudes and beliefs. Exercisers noted improvements in self-conﬁdence and an overall improved attitude toward their disease. Nonexercisers, in contrast, liked the feeling of being able to accomplish something, no matter how small. Whereas exercisers described participating in sufﬁcient exercise to attain beneﬁts, nonexercisers struggled to be active but felt that even the simplest of efforts were “a really big deal.” Emotional beneﬁts. All groups described the emotional beneﬁts of exercise. Exercisers reported that it made them “feel better” or “feel good” during and after the activity. In addition to feeling good, many exercisers described the link between exercise and both “stress relief” and relaxation, and said that exercise helped them to forget about their pain. Although many nonexercisers also reported that exercise made them “feel good,” there was a distinct difference in how some viewed this beneﬁt. Some nonexercisers implied that the emotional beneﬁt might not outweigh the pain that exercise caused. Most nonexercisers who described emotional beneﬁts from exercise referred to exercise experiences before rather than after arthritis. Enjoyment. In groups of both exercisers and nonexercisers, participants described liking exercise or having fun while exercising, including exercising in a group, with a signiﬁcant other, or by themselves. Among nonexercisers, the theme of enjoyment surfaced primarily from discussions about their exercise before arthritis. Although some 625 still described enjoying exercise, they often “paid for it later” with pain or fatigue. Behavioral enablers. Exercisers expressed speciﬁc behavioral enablers for exercise, whereas no clear themes emerged for nonexercisers. Exercisers stated that they were internally motivated to exercise and underscored the importance of self-regulatory skills, including making exercise a priority, scheduling exercise, and setting goals. Social beneﬁts and enablers. Exercisers and nonexercisers described the enjoyment of exercising with others and the positive social interaction of being around others who exercise. Exercisers mentioned that being in or around groups of exercisers was a positive social outcome. Social beneﬁts among nonexercisers were typically described in relation to their exercise experiences before arthritis. Nonexercisers described the social beneﬁts of exercise and thought it was a motivating factor. Exercisers and nonexercisers identiﬁed similar social enablers, including having important others (e.g., friends, family, health care providers) encourage them to exercise and having someone to exercise with. Exercisers often said that they had someone to exercise with, whereas nonexercisers said that they did not have this type of support but desired it. Likewise, nonexercisers expressed the need to receive external cues or reminders from important others for exercise. Having an exercise group of similar others was viewed as important for nonexercisers because of the emotional support it provided. Environmental enablers. Both exercisers and nonexercisers stated that a water-based exercise program would make it easier for them to exercise. They also described the need for programs and instructors who understood issues related to arthritis and exercise. Exercisers were more likely than nonexercisers to say that low-cost programs enabled them to exercise. Finally, having exercise equipment such as a treadmill or a stationary bicycle within one’s immediate physical environment (i.e., a person’s home or a relative’s home) was perceived as making exercise more likely among exercisers and nonexercisers. DISCUSSION By recruiting a relatively large sample of individuals with arthritis, measuring exercise participation, and conducting stratiﬁed recruitment to ensure a diverse sample of exercisers and nonexercisers, our qualitative study extends what is known about the perceived barriers, beneﬁts, and enablers of exercise among persons with arthritis. Relatively few studies have examined these issues, and even fewer have been speciﬁcally designed with this purpose in mind (20). Furthermore, only 3 studies (all with small samples) have used a qualitative approach (23–25), one of which measured physical activity and stratiﬁed on the basis of this measure (23). Physical, psychological, social, and environmental barriers, beneﬁts, and enablers were identiﬁed in this study, consistent with social cognitive theory (26) and social ecological models (27,28). While some inﬂuences were 626 similar to those reported in other general populations (19), others appeared unique to individuals with a chronic disease. Consistent with other studies (25,29), symptoms of arthritis, including pain, stiffness, fatigue, and mobility problems, were perceived as barriers to exercise. Yet improvements in these outcomes were also seen as potential beneﬁts of and motivations for exercise. The role of exercise in promoting independence was a salient and highly motivating beneﬁt, especially among exercisers. Exercisers had experience achieving many beneﬁts, whereas nonexercisers described these potential beneﬁts as outcomes that would motivate them to exercise. Nonexercisers expressed some doubt that they would beneﬁt from exercise and thought that increased pain, even if temporary, may not be worth the beneﬁts. A number of our ﬁndings have direct implications for how to market exercise to individuals with arthritis and how communities and clinicians can facilitate participation in exercise. First, individuals with arthritis value the information provided by health care providers (24,25). Receiving such information has been shown to predict higher levels of physical activity among adults with rheumatoid arthritis (30). The perceived lack of advice, instruction, and referrals was cited in our study as a barrier. Providers may feel ill prepared to prescribe exercise (24) and may need additional assistance to make exercise recommendations and speciﬁc referrals. In addition, results from research trials take time to inﬂuence practice (31), and the lack of advice, instruction, and referrals may reﬂect this lag in evidence-based practice. Second, wider availability and awareness of arthritisspeciﬁc programs is needed for individuals with arthritis and health care providers. The lack of arthritis-speciﬁc programs and knowledgeable instructors was identiﬁed as a major barrier, especially among nonexercisers. Considering the prevalence of arthritis, community programs and facilities should be encouraged to expand their programming to individuals with arthritis and to publicize such programs. Program characteristics that build self-efﬁcacy, facilitate social support, encourage individuals to work at their own pace, and are led by quality instructors are particularly important (29). Third, exercisers and nonexercisers identiﬁed similar barriers to exercise. What differentiated these groups was that exercisers were less likely to allow these barriers to prevent exercise and often modiﬁed their exercise to accommodate physical limitations. Nonexercisers were more likely to have given up exercise altogether or to have greatly reduced its frequency when faced with arthritisspeciﬁc barriers. Print and other forms of messages might be more effective if they emphasize ways in which individuals with arthritis can modify exercise to accommodate their disease. Fourth, most exercisers and nonexercisers alike were aware of the beneﬁts of exercise, yet nonexercisers were not engaging in it. These ﬁndings indicate that knowledgebased approaches alone are unlikely to affect behavior (19,32), and techniques to increase self-efﬁcacy (33), problem-focused coping, and self-regulatory skills are important for changing behavior. Fifth, pain relief and improved mobility from exercise Wilcox et al were the major motivators for exercisers and nonexercisers. However, pain was the primary reason why nonexercisers had quit an exercise program. Pain is consistently associated with lower rates of exercise across arthritis types, despite the fact that a substantial number of controlled, randomized trials of exercise in persons with arthritis have reported reductions in pain (11,34,35). In one intervention study (36), improvements in pain predicted subsequent exercise participation, suggesting that this outcome may be critical to exercise adherence. Recruitment and program messages might need to explain to persons with arthritis that pain may increase during and immediately after exercise, but that overall pain management can be enhanced. Many exercisers voiced this message. Interventions might also need to include pain management strategies. Finally, in addition to traditional outcome measures, personally meaningful outcomes for individuals with arthritis (e.g., pain reduction, increased mobility, decreased stiffness, independence) should be emphasized in intervention materials and assessed in research and practice settings. These outcomes are what matter most to the individuals with arthritis and are likely to predict subsequent adherence. As is common in qualitative research, a purposive sample of participants was recruited. Key stratiﬁcation factors expected to affect the discussion were used to structure the composition of groups and to create homogeneous groups. To increase the generalizability of ﬁndings, we used a variety of recruitment strategies to reach the entire community. Nonetheless, participants who volunteer in such a study may differ from those who do not volunteer along potentially important variables such as disease severity, attitudes about health and exercise, and sociodemographics. Furthermore, local communities vary widely in the availability of resources and programs for individuals with arthritis, and our ﬁndings may not be as applicable in communities with more such resources or in rural areas with substantially fewer resources. To limit the number of groups conducted, groups were not segmented by age or disease type. Also, we recruited a small number of men, particularly those who were nonexercisers. It is likely that barriers, attitudes, and beliefs differ by age (or generation), sex, and disease type. Therefore, we are not able to make sex-, age-, and disease-speciﬁc conclusions. Finally, not all potentially pertinent characteristics of participants were measured (e.g., personality traits). Despite potential limitations, our ﬁndings provide useful information for understanding the experiences with and beliefs about exercise among persons with arthritis and informing recruitment and intervention strategies. ACKNOWLEDGMENTS We would like to thank Carol Rheaume for her assistance in pilot testing the moderator’s guide and Billy Oglesby for providing qualitative training and consultation. We also gratefully acknowledge each of the individuals who took part in our focus groups. 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