- Email: [email protected]
Elicitation interview study to identify salient beliefs about exercise participation in adults with cystic fibrosis
Journal Pre-proof Elicitation interview study to identify salient beliefs about exercise participation in adults with cystic fibrosis Tiffany J. Dwyer, Barbara N. Griffin, Peter T.P. Bye, Jennifer A. Alison
PII:
S0031-9406(19)30106-3
DOI:
https://doi.org/10.1016/j.physio.2019.10.004
Reference:
PHYST 1146
To appear in:
Physiotherapy
Please cite this article as: Dwyer TJ, Griffin BN, Bye PTP, Alison JA, Elicitation interview study to identify salient beliefs about exercise participation in adults with cystic fibrosis, Physiotherapy (2019), doi: https://doi.org/10.1016/j.physio.2019.10.004
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Elicitation interview study to identify salient beliefs about exercise participation in adults with cystic fibrosis
Author names and affiliations PhD
[email protected]
Barbara N Griffinc
PhD
[email protected]
Peter TP Byeb,d
PhD
[email protected]
Jennifer A Alisona,e
PhD
[email protected]
a
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Tiffany J Dwyera,b
Discipline of Physiotherapy, Faculty of Health Sciences, University of Sydney, Sydney,
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Australia
Department of Respiratory Medicine, Royal Prince Alfred Hospital, Sydney, Australia
c
Department of Psychology, Faculty of Human Sciences, Macquarie University, Australia
d
Central Clinical School, Sydney Medical School, University of Sydney, Sydney, Australia
e
Sydney Local Health District, Sydney, Australia
Name
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Corresponding author
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b
Dr Tiffany J Dwyer
Discipline of Physiotherapy
Institution
The University of Sydney
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Department
Address
PO Box 170, Lidcombe NSW 1825, Australia
Tel
+61 2 9351 9312
Fax
+61 2 9351 9601
Email
[email protected]
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Objectives: Conduct an elicitation study, using the Theory of Planned Behaviour framework, to identify salient beliefs about exercise participation in adults with cystic fibrosis (CF). Specifically, identify attitudes on advantages and disadvantages of exercise (behavioural beliefs); individuals and groups who apply social pressure to exercise (normative beliefs); and perceived control over facilitators and barriers to exercise (control beliefs) for adults with CF. Design: Qualitative interviews using open-ended, structured questions.
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Setting: Adult CF clinic in a large Australian hospital. Participants: Sixteen adults with CF, three relatives/friends of adults with CF and six CF clinic staff.
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Results: The most common positive attitudes about exercise were to keep fit and healthy (68%) and feel better and happier (60%), and negative attitude was to feel breathless (36%). Social
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pressure to exercise mainly came from parents/family (72%) and friends (52%), and 60% of
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participants reported that no-one discourages exercise. Having someone to exercise with (44%) and be encouraged (36%) were the most common facilitators of perceived control to exercise,
barriers.
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whereas being unwell (96%) and not having sufficient time (56%) were the most common
Conclusions: Attitudes, social pressure and perceived control to exercise for adults with CF were similar to beliefs previously reported by the general population and some patient groups.
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A number of CF-specific exercise beliefs, mainly related to pulmonary function, were also reported. These findings can help develop questionnaires for larger groups of adults with CF, interpret relationships between exercise beliefs and participation, and inform clinicians to target interventions to increase exercise participation.
Contribution of the paper
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This is the first study to apply a theoretical model, using the Theory of Planned
Behaviour, to identify beliefs that might influence exercise participation for adults with CF.
Positive attitudes about exercise (that it will keep adults with CF fit and healthy and feel
better and happier), social pressure to exercise (supported by parents, family and friends) and perceived control to exercise (have someone to exercise with and be encouraged) were similar to beliefs previously reported by the general population and some patient groups. A number of CF-specific exercise beliefs, mainly related to pulmonary function, were also reported. Identification of the behavioural, normative and control beliefs about exercise
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participation for adults with CF in this study can help develop questionnaires for larger groups of adults with CF, interpret relationships between exercise beliefs and participation, and inform
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clinicians to target interventions to increase exercise participation.
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Keywords: cystic fibrosis; exercise; physical activity; Theory of Planned Behaviour; elicitation
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Introduction and Purpose
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study;
Cystic fibrosis (CF) is a complex disease and most therapy is required daily with individuals spending approximately 1.5 hours per day on medication and airway clearance regimens, including pancreatic enzyme replacement, inhaled and oral antibiotics, inhaled mucoactive
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medications, and airway clearance techniques.[1] Exercise training programmes improve exercise capacity and may also improve lung function and quality of life,[2] thus people with CF are encouraged to exercise in addition to other treatments[3-6].
Despite the well-recognised physical and psychological benefits from exercise, participation is often below recommended levels, with self-reported adherence to exercise ranging from 21-
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57% for adults with CF.[7-12] A systematic review investigating interventions to promote physical activity for people with CF concluded that intensive, supervised exercise training programmes does not increase physical activity.[13] Longer term studies, however, with counselling and behavioural change strategies did increase physical activity when measured one to three years after the intervention.[13] In order to promote exercise participation through behavioural change strategies, it is first necessary to examine foundations or determinants of behaviour. In other words, we must first understand decision-making processes for adults with
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CF on whether or not to participate in exercise. To the authors’ knowledge no published study has applied a theoretical model to identify factors influencing exercise participation for people
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with respiratory diseases.
There are many conceptual frameworks that have successfully explained people’s exercise
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behaviour (e.g. self-efficacy theory, health belief model). The Theory of Planned Behaviour is
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one of the most comprehensive and validated models in the exercise domain, confirmed by systematic reviews and meta-analyses.[14-16] This theory proposes that exercise participation can be predicted from the intention to exercise and surrounding control factors (Figure 1).[17,
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18] The strength of exercise intention is related to the attitude toward exercise (behavioural beliefs), social pressure to exercise (normative beliefs) and perceived control over the ability to exercise (control beliefs). A significant benefit of the Theory of Planned Behaviour is it also
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identifies intervention targets and has been successfully used by health care professionals to increase exercise participation (e.g. [19, 20]).
The first step in conducting research into exercise participation, using the Theory of Planned Behaviour framework, is to conduct an elicitation study, to identify specific behavioural, normative and control beliefs of the population in question.[21-24] Elicitation studies have
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three benefits: informing researchers of appropriate questions for the second step, which examines how beliefs relate to actual behaviour; and after completing the second step, interpreting relationships between beliefs and behaviour; and informing clinicians how best to tailor interventions to focus on specific beliefs to encourage or discourage the behaviour. Exercise beliefs vary between populations[25] and to our knowledge, no published study has conducted an elicitation study on exercise beliefs for people with respiratory diseases. Qualitative studies on exercise participation in CF populations identified facilitators (knowing
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the health benefits of exercise, enjoyment, and sense of mastery/accomplishment) and barriers (time-consuming, disease burden, pulmonary limitations and low self-efficacy)[12, 26-29]. Those studies, however, either involved adolescents[26, 27, 29] or did not include all belief
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components of the Theory of Planned Behaviour[12, 28], so the results are insufficient to satisfy
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all components of an elicitation study on exercise participation for adults with CF.
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The aim of this elicitation study was to identify attitudes about advantages and disadvantages of exercise (behavioural beliefs); individuals and groups who apply social pressure to exercise (normative beliefs); and perceived control over facilitators and barriers to exercise (control
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beliefs) for adults with CF. For this elicitation study, we decided to interview adults with CF, friends and relatives of adults with CF and adult CF clinic staff, to gather a broad view of beliefs
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about exercise participation for adults with CF.
Methods
Participants
Adults with CF, relatives and friends of adults with CF, and staff involved in CF care were recruited from the CF Clinic at Royal Prince Alfred Hospital, Sydney, Australia. Potential participants were approached during a routine visit to the multidisciplinary CF Clinic. Patients
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with CF were excluded if they had received a lung transplant, as it was assumed their exercise beliefs would not represent the majority of adults with CF, particularly for facilitators and barriers of pulmonary function to exercise participation. Research procedures were approved by the Sydney South West Area Health Service Ethics Committee (RPAH Zone) (Protocol X060188) and participants provided written informed consent prior to data collection.
Study design
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Participants were interviewed by one researcher (TJD), a Physiotherapist who had worked in the CF Clinic for two years, in a quiet room, away from the clinic area. The qualitative interviews included a series of open-ended, structured questions, aimed at eliciting salient
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beliefs about exercise participation for adults with CF. Notes were taken during the interviews and the main ideas were summarised by the interviewer at the completion of the interview, to
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confirm and clarify responses with the interviewee. We aimed to recruit at least 25 people, the
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recommended number of participants for an elicitation study,[23] or until idea saturation occurred[24] (i.e. subsequent interviews obtained only redundant information as no new beliefs about exercise were identified). Clinical data (height, weight and lung function) for the
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participants with CF were obtained from CF Clinic records on the day of the interview. After the interview, adults with CF were asked about their current exercise participation.
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Interview questions
The open-ended questions were based on elicitation study guidelines.[21, 22] Participants with CF were asked to answer according to their own beliefs and experiences about exercise. Relatives and friends of adults with CF were asked to answer according to their beliefs and experiences about their friend or relative with CF exercising. CF Clinic staff were asked to answer according to their beliefs and experiences about adults with CF exercising.
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In order to determine their behavioural beliefs, that may guide someone with CF to exercise or not, participants were asked about their attitudinal considerations: What do you think are the advantages/disadvantages for you/your friend or relative with CF/adults with CF to exercise? Additional prompts were: How do you think exercise would help/might have negative side effects?; What else do you associate with exercising?
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In order to determine their normative beliefs about who are the significant or relevant individuals that may create social pressure or influence someone with CF to exercise or not, participants were asked: Which individuals or groups would approve/disapprove of you/your
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friend or relative with CF/adults with CF to exercise? Additional prompts were: What other
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individuals or groups come to mind when you think about exercising?
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In order to determine their control beliefs about factors that may facilitate or impede someone with CF to exercise or not, participants were asked: What factors or circumstances would enable/make it difficult for you/your friend or relative with CF/adults with CF to exercise or
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make it more or less likely that you/they would exercise? Additional prompts were: What other issues come to mind when you think about difficulties to exercise?; Are there any differences in
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exercising when well compared to when unwell?
Data analysis
The responses from each question of the interviews were collated by one researcher (TJD). Content analysis was independently performed by two researchers (BNG and TJD), arranging responses into common themes and listing in order of frequency. There was 100% content validity agreement between the researchers.
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Results Sixteen adults with CF, three relatives or friends of adults with CF and six CF Clinic staff participated in the study. The participants with CF were representative of the whole CF Clinic in terms of age, sex and lung function (Table 1). There was a range of employment: seven participants were working; one was looking for work; one was a full-time homemaker and carer of children; two were students; and five were pensioners. Five described their job (or lifestyle
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if not employed) as active and 11 as sedentary. The average reported exercise participation was 4.3 ± 2.7 times per week totaling 185 ± 148 minutes. One participant reported never exercising and seven reported meeting exercise participation guidelines (≥150 minutes of moderate to
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strenuous physical activity per week)[30].
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Of the relatives or friends of adults with CF, there was one mother, one husband and one friend.
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Relatives and friends of adults with CF did not provide any additional beliefs not already identified by adults with CF or CF Clinic staff, so recruitment of these participants was halted after three had been interviewed. Of the CF Clinic staff, there was one respiratory physician,
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one nurse, two physiotherapists and two social workers. Their average clinical experience in CF care was 9 ± 4 years (range 3-15). No new ideas or beliefs were identified after interviewing 25 people, so recruitment was stopped as idea saturation had occurred, the standard practice for
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elicitation studies.[24]
Attitude and Behavioural Beliefs about Exercise Advantages to exercise participation For the whole cohort, 23 different advantages for exercise were reported (Supplementary Data Table 1). The most identified themes about physical benefits or advantages of exercise for
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someone with CF were to: keep fit and healthy (68%); improve lung function and decrease breathlessness (56%) and decrease cough and clear the lungs (44%). The most reported themes about psychological benefits or advantages of exercise for someone with CF were to: feel better and happier (60%); feel stronger and have more energy (28%); improve body image (24%) and be fun or social (20%). Also, 16% of participants stated an advantage of exercise was to reduce the time required for airway clearance techniques. Disadvantages to exercise participation
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For the whole cohort, 24 different disadvantages for exercise were reported (Supplementary Data Table 2). The most elicited themes about negative physical side effects or disadvantages of exercise for someone with CF were to: feel breathless (36%); cause injury (24%) and cough
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(16%). The most frequently mentioned themes about negative psychological side effects or disadvantages of exercise for someone with CF were to: feel tired or reduce energy (16%); not
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enjoy exercise (16%); feel embarrassed to exercise in public (12%) and feel frustration when
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unable to keep up with others (12%). Also, 24% of participants commented that a disadvantage of exercise was to be time-consuming.
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Social Pressure and Normative Beliefs about Exercise Significant others who approve of exercise participation For the whole cohort, 16 different groups of people who positively influence exercise
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participation were reported (Supplementary Data Table 3). The most cited people or groups who approve of someone with CF exercising were: parents and family (72%); friends (52%); doctors in the CF Clinic (44%); staff of the CF Clinic and hospital (36%) and physiotherapists in the CF Clinic (32%). Also, 28% of participants responded “everyone” approves of exercise.
Significant others who disapprove of exercise participation
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For the whole cohort, nine different groups of people who negatively influence exercise participation were reported (Supplementary Data Table 4). The most frequent response, however, was “no-one” disapproves of someone with CF exercising (60%). Some participants also listed over-protective or misinformed parents and friends (20%) to disapprove of exercise.
Perceived Control and Control Beliefs about Exercise Facilitators of exercise participation
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For the whole cohort, 35 different facilitators for exercise were reported (Supplementary Data Table 5). The most expressed themes about internal facilitators or promoters for someone with CF to exercise were to: enjoy exercise and have a varied exercise programme (24%); be
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knowledgeable about benefits of exercise (24%) and be motivated (20%). The most identified themes about external facilitators or promoters of exercise were to: have someone to exercise
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with (44%); be encouraged (36%); have easy access to transport or easy to get to the place
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where they exercise (28%); be structured exercise or organised by someone else (20%) and have time available to exercise (20%).
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Barriers to exercise participation
For the whole cohort, 36 different barriers to exercise were reported (Supplementary Data Table 6). The most recorded themes about internal barriers or impediments for someone with CF to
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exercise were to: be unwell (96%); have poor motivation (52%); have poor lung function or be too breathless (48%) and not be in a routine to exercise (28%). The most repeated themes about external barriers or impediments for someone with CF to exercise were to: have insufficient time available (56%); insufficient finance (32%); be difficult to get to the place where they exercise or poor transport options (28%) and bad weather (20%).
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Discussion The primary purpose of this study was to establish the social and cognitive foundations forming a CF adult’s decision to exercise, specifically their attitude, social pressure and perceived control to exercise. This is the first elicitation study examining beliefs underpinning exercise participation for adults with CF. The results of these interviews can be used to construct questionnaires to examine and quantify determinants of exercise intention and participation in larger populations of adults with CF. They also help clinicians interpret relationships between
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exercise beliefs and participation and tailor interventions to address specific beliefs to increase exercise participation.
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The most common favourable behavioural beliefs or attitudes toward exercise, reported by 88% of adults with CF in this qualitative study, concerned improvements in physical and
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psychological health. This theme was identified in 100% of the elicitation studies reported in a
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systematic review covering exercise in healthy and patient populations[25] and listed as the most compelling reason to participate in physical activity by all the CF adolescents when asked about facilitators to exercise[29]. Sixty-nine percent of adults with CF in this current elicitation
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study reported CF-specific advantages to pulmonary function with exercise, namely improvements in lung function, reductions in breathlessness and cough. Thirty-eight percent of adults with CF, however, also identified that breathlessness and cough induced during exercise
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was a disadvantage. These same pulmonary issues were reported in studies examining adherence to exercise for CF adolescents[26, 27, 29] and adults[12].
In our study, the three most common groups reported to influence exercise participation were: parents and family (cited by 69% of adults with CF); health professionals (69%); and friends (50%). This is similar to the systematic review of elicitation studies into exercise participation
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for healthy and patient populations.[25] Interestingly, only two[26, 27] of the five previous studies examining facilitators and barriers to exercise participation for people with CF identified the role of family in encouraging or discouraging physical activity. Those two studies involved the youngest participants and clearly outlined the importance of parental support and positive role modelling. Perhaps parental influence on their child’s exercise participation decreases as the child approaches adolescence. In the only previous study that exclusively involved adults with CF, 58% of participants reported the recommendation to exercise by medical staff aided
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adherence, a similar percentage to this current study.[12]
Convenience was the most common facilitating factor identified to aid exercise participation,
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reported by 81% of adults with CF in this study and appearing in 47% of the elicitation studies in a systematic review of exercise participation in healthy and patient populations.[25] Social
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support and encouragement to exercise was listed by 63% of adults with CF, compared to only
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29% of studies in the systematic review[25] and in only two[26, 27] of the five previous qualitative studies in patients with CF.
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Being unwell was reported by all adults with CF in this study as a barrier to exercise participation. Health issues were identified in all the elicitation studies of the systematic review of exercise participation in healthy and patient populations[25] and by 60% of adults with CF
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in a previous study as barriers to exercise[12]. Poor pulmonary function and breathlessness were thought to be additional barriers to exercise for 63% of adults with CF in this study, and also encountered by 23% of adults with CF in another study.[12] Inconvenience was the second most frequent barrier to exercise, listed by 75% of adults with CF in this study and 68% of adults with CF in an earlier study.[12] Interestingly, only half the studies on adolescents with CF reported inconvenience or insufficient time acting as barriers to exercise.[26, 27] This may
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reflect the greater time demands on adults with CF, compared to their younger peers, due to additional pressures of work and family commitments.
On the whole, responses were similar for adults with CF, their relatives and friends and CF Clinic staff. Staff listed a few more specific advantages, disadvantages, facilitators and barriers to exercise participation not identified by patients or their relatives and friends (advantages such as improvements in bone density; disadvantages such as excessive weight loss; facilitators such
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as belonging to a clinic that promotes exercise; and barriers such as infection control precautions). Only 33% of staff, however, compared to 50% of adults with CF, acknowledged the role of friends to influence exercise participation or social aspects and having someone to
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exercise with to promote exercise participation. As well, only one staff member identified the importance of encouragement to facilitate exercise participation and the importance of self-
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motivation to exercise (compared to 50% and 25% of adults with CF, respectively). One clinical
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implication of these findings may be that staff involved in CF care should take account of the importance of family and friends and the encouragement they provide when attempting to
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increase exercise participation of their patients.
There are some limitations to this study. Firstly, all participants were interviewed by a physiotherapist, who worked in the CF clinic. This may have created bias, where participants
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felt they should report more positive beliefs about exercise. Half the beliefs reported in each category, however, were negative or perceived disadvantages to exercise. Another limitation is that elicitation studies only provide content analysis of different beliefs, so without detailed indepth qualitative interviews, it cannot be confirmed which reported beliefs are the true determinants of behaviour. One strength of our study, however, was to increase breadth of responses or beliefs by interviewing adults with CF, friends and relatives and CF clinic staff.
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Conclusion The attitudes, social pressure and perceived control to exercise identified in this study are similar to those reported by healthy populations and other patient groups.[25] Many participants in this qualitative study, however, also reported additional beliefs that were CF-specific, namely extra advantages, disadvantages, facilitators and barriers to exercise related to pulmonary function. Future research, using questionnaires developed from the main themes identified in
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this study, in wider samples of adults with CF, will be able to quantitatively examine the strength of the associations between exercise beliefs, intention and participation. Those studies will provide empirical evidence to establish frameworks targeting increased exercise
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participation for adults with CF.
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Ethical approval: Sydney South West Area Health Service Ethics Committee (RPAH Zone)
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(Protocol X06-0188)
Funding: This research did not receive any specific grant from funding agencies in the public,
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commercial, or not-for-profit sectors.
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Conflict of interest: None of the authors has a conflict of interest to disclose.
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References
6. 7. 8.
9. 10.
11. 12.
13.
14. 15.
Jo
16.
ro of
5.
-p
4.
re
3.
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2.
Sawicki, G.S., D.E. Sellers, and W.M. Robinson, High treatment burden in adults with cystic fibrosis: challenges to disease self-management. Journal of Cystic Fibrosis, 2009. 8(2): p. 91-96. Radtke, T., et al., Physical exercise training for cystic fibrosis. Cochrane Database of Systematic Reviews, 2017(11): p. CD002768. Association of Chartered Physiotherapists in Cystic Fibrosis, Standards of care and good clinical practice for the physiotherapy management of cystic fibrosis. Third edition. 2017, UK Cystic Fibrosis Trust: London. Button, B.M., et al., Physiotherapy for cystic fibrosis in Australia and New Zealand: A clinical practice guideline. Respirology, 2016. 21(4): p. 656-667. Flume, P.A., et al., Cystic fibrosis pulmonary guidelines: airway clearance therapies. Respiratory Care, 2009. 54(4): p. 522-537. Smyth, A.R., et al., European Cystic Fibrosis Society Standards of Care: Best Practice guidelines. Journal of Cystic Fibrosis, 2014. 13( Suppl 1): p. S23-S42. Abbott, J., et al., Treatment compliance in adults with cystic fibrosis. Thorax, 1994. 49(2): p. 115-120. Dalcin, P.d.T.R., et al., [Adherence to treatment in patients with cystic fibrosis]. Jornal Brasileiro De Pneumologia: Publicacao Oficial Da Sociedade Brasileira De Pneumologia E Tisilogia, 2007. 33(6): p. 663-670. Gumery, L., et al., Physiotherapy and nebuliser use in a Birmingham adult cystic fibrosis unit. Physiotherapy, 1998. 84(3): p. 127-132. Myers, L.B., An exploratory study investigating factors associated with adherence to chest physiotherapy and exercise in adults with cystic fibrosis. Journal of cystic fibrosis, 2009. 8(6): p. 425-427. Shepherd, S.L., et al., A comparative study of the psychosocial assets of adults with cystic fibrosis and their healthy peers. Chest, 1990. 97(6): p. 1310-1316. White, D., K. Stiller, and N. Haensel, Adherence of adult cystic fibrosis patients with airway clearance and exercise regimens. Journal of Cystic Fibrosis, 2007. 6(3): p. 163170. Cox, N.S., J.A. Alison, and A.E. Holland, Interventions for promoting physical activity in people with cystic fibrosis. Cochrane Database of Systematic Reviews, 2013(12): p. CD009448. Armitage, C.J. and M. Conner, Efficacy of the Theory of Planned Behaviour: a metaanalytic review. British Journal of Social Psychology, 2001. 40(Pt 4): p. 471-499. Downs, D.S. and H.A. Hausenblas, The Theories of Reasoned Action and Planned Behavior applied to exercise: A meta-analytic update. Journal of Physical Activity and Health, 2005. 2(1): p. 76-97. McEachan, R.R.C., et al., Prospective prediction of health-related behaviours with the Theory of Planned Behaviour: a meta-analysis. Health Psychology Review, 2011. 5(2): p. 97-144. Ajzen, I., Attitudes, personality, and behavior. 1988, Chicago: Dorsey. Ajzen, I., The theory of planned behavior. Organizational behavior and human decision processes, 1991. 50: p. 179-211. Aaron, S.D., et al., Combination antibiotic susceptibility testing to treat exacerbations of cystic fibrosis associated with multiresistant bacteria: a randomised, double-blind, controlled clinical trial. Lancet, 2005. 366(9484): p. 463-471. Jemmott, J.B.I., et al., Cognitive-behavioural health-promotion intervention increases fruit and vegetable consumption and physical activity among South African
ur na
1.
17. 18. 19.
20.
Beliefs about exercise participation in CF
28/10/2019 Page 15 of 18
25.
26.
27.
28. 29.
30.
Jo
ur na
31.
ro of
24.
-p
23.
re
22.
lP
21.
adolescents: a cluster-randomised controlled trial. Psychology & Health, 2011. 26(2): p. 167-185. Ajzen, I. Construction of a standard questionnaire for the theory of planned behavior. [web site] 2006 [cited 14/9/2018; Available from: http://wwwunix.oit.umass.edu/~aizen/pdf/tpb.measurement.pdf. Ajzen, I. and M. Fishbein, Understanding attitudes and predicting social behavior. 1980, Englewood Cliffs, NJ: Prentice Hall. Francis, J.J., et al. Constructing questionnaires based on the Theory of Planned Behaviour: A manual for health services researchers. 2004 [cited 14/9/2018; Available from: http://openaccess.city.ac.uk/id/eprint/1735. Montano, D.E. and D. Kasprzyk, Theory of reasoned action, theory of planned behaviour, and the integrated behavioural model, in Health behaviour: Theory, research and practice, K. Glanz, B.K. Rimer, and K. Wiswanath, Editors. 2014, John Wiley & Sons: San Francisco. p. 95-124. Downs, D.S. and H.A. Hausenblas, Elicitation studies and the theory of planned behavior: a systematic review of exercise beliefs. Psychology of Sport & Exercise, 2005. 6: p. 1-31. Moola, F.J., G.E. Faulkner, and J.E. Schneiderman, "No time to play": perceptions toward physical activity in youth with cystic fibrosis. Adapted Physical Activity Quarterly, 2012. 29(1): p. 44-62. Moola, F.J., et al., Developing physical activity interventions for youth with cystic fibrosis and congenital heart disease: Learning from their parents. Psychology of Sport and Exercise, 2011. 12(6): p. 599-608. Street, R., et al., Experiences of physical activity: A phenomenological study of individuals with cystic fibrosis. Journal of Health Psychology, 2016. 21(2): p. 261-270. Swisher, A.K. and M. Erickson, Perceptions of physical activity in a group of adolescents with cystic fibrosis. Cardiopulmonary Physical Therapy Journal, 2009. 19(4): p. 107-113. World Health Organisation. Global Recommendations on Physical Activity for Health. 2010 [cited 14/9/2018; Available from: https://apps.who.int/iris/handle/10665/44399. Quanjer, P.H., et al., Multi-ethnic reference values for spirometry for the 3-95-yr age range: the global lung function 2012 equations. European Respiratory Journal, 2012. 40(6): p. 1324-1343.
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Figure captions Figure 1: Model of Ajzen’s Theory of Planned Behaviour, adapted for exercise participation in people with lung disease.
Actual control
Normative beliefs: Social pressure to exercise
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Behavioural beliefs: Attitude toward exercise
Exercise intention
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Control beliefs: Perceived control to exercise
Exercise participation
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Table 1. Participant characteristics Characteristic
Participants with CF (n=16)
Adult CF clinic patients (n=109)
Mean (SD)
Range
Mean (SD)
Range
Age, yr
27 (6)
19 – 37
28 (9)
17 – 62
Sex, % female
50
BMI, kg/m2
22.2 (3.5)
18.6 – 33.1
22.6 (3.3)
15.1 – 33.5
FEV1, predicted %
53 (23)
16 – 101
62 (23)
15 – 107
FVC, predicted %
75 (21)
25 – 99
82 (20)
25 – 122
FEV1/FVC, ratio
0.59 (0.14)
0.28 – 0.88
0.63 (0.14)
0.24 – 0.91
44
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Mean, standard deviation (SD) and range of characteristics for the 16 participants with CF and all patients of the Adult CF clinic. Forced expiratory volume in 1 second (FEV1) and forced vital capacity (FVC) expressed as percentage of predicted normal.[31]
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PII:
S0031-9406(19)30106-3
DOI:
https://doi.org/10.1016/j.physio.2019.10.004
Reference:
PHYST 1146
To appear in:
Physiotherapy
Please cite this article as: Dwyer TJ, Griffin BN, Bye PTP, Alison JA, Elicitation interview study to identify salient beliefs about exercise participation in adults with cystic fibrosis, Physiotherapy (2019), doi: https://doi.org/10.1016/j.physio.2019.10.004
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Elicitation interview study to identify salient beliefs about exercise participation in adults with cystic fibrosis
Author names and affiliations PhD
[email protected]
Barbara N Griffinc
PhD
[email protected]
Peter TP Byeb,d
PhD
[email protected]
Jennifer A Alisona,e
PhD
[email protected]
a
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Tiffany J Dwyera,b
Discipline of Physiotherapy, Faculty of Health Sciences, University of Sydney, Sydney,
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Australia
Department of Respiratory Medicine, Royal Prince Alfred Hospital, Sydney, Australia
c
Department of Psychology, Faculty of Human Sciences, Macquarie University, Australia
d
Central Clinical School, Sydney Medical School, University of Sydney, Sydney, Australia
e
Sydney Local Health District, Sydney, Australia
Name
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Corresponding author
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b
Dr Tiffany J Dwyer
Discipline of Physiotherapy
Institution
The University of Sydney
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Department
Address
PO Box 170, Lidcombe NSW 1825, Australia
Tel
+61 2 9351 9312
Fax
+61 2 9351 9601
[email protected]
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Objectives: Conduct an elicitation study, using the Theory of Planned Behaviour framework, to identify salient beliefs about exercise participation in adults with cystic fibrosis (CF). Specifically, identify attitudes on advantages and disadvantages of exercise (behavioural beliefs); individuals and groups who apply social pressure to exercise (normative beliefs); and perceived control over facilitators and barriers to exercise (control beliefs) for adults with CF. Design: Qualitative interviews using open-ended, structured questions.
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Setting: Adult CF clinic in a large Australian hospital. Participants: Sixteen adults with CF, three relatives/friends of adults with CF and six CF clinic staff.
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Results: The most common positive attitudes about exercise were to keep fit and healthy (68%) and feel better and happier (60%), and negative attitude was to feel breathless (36%). Social
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pressure to exercise mainly came from parents/family (72%) and friends (52%), and 60% of
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participants reported that no-one discourages exercise. Having someone to exercise with (44%) and be encouraged (36%) were the most common facilitators of perceived control to exercise,
barriers.
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whereas being unwell (96%) and not having sufficient time (56%) were the most common
Conclusions: Attitudes, social pressure and perceived control to exercise for adults with CF were similar to beliefs previously reported by the general population and some patient groups.
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A number of CF-specific exercise beliefs, mainly related to pulmonary function, were also reported. These findings can help develop questionnaires for larger groups of adults with CF, interpret relationships between exercise beliefs and participation, and inform clinicians to target interventions to increase exercise participation.
Contribution of the paper
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This is the first study to apply a theoretical model, using the Theory of Planned
Behaviour, to identify beliefs that might influence exercise participation for adults with CF.
Positive attitudes about exercise (that it will keep adults with CF fit and healthy and feel
better and happier), social pressure to exercise (supported by parents, family and friends) and perceived control to exercise (have someone to exercise with and be encouraged) were similar to beliefs previously reported by the general population and some patient groups. A number of CF-specific exercise beliefs, mainly related to pulmonary function, were also reported. Identification of the behavioural, normative and control beliefs about exercise
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participation for adults with CF in this study can help develop questionnaires for larger groups of adults with CF, interpret relationships between exercise beliefs and participation, and inform
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clinicians to target interventions to increase exercise participation.
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Keywords: cystic fibrosis; exercise; physical activity; Theory of Planned Behaviour; elicitation
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Introduction and Purpose
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study;
Cystic fibrosis (CF) is a complex disease and most therapy is required daily with individuals spending approximately 1.5 hours per day on medication and airway clearance regimens, including pancreatic enzyme replacement, inhaled and oral antibiotics, inhaled mucoactive
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medications, and airway clearance techniques.[1] Exercise training programmes improve exercise capacity and may also improve lung function and quality of life,[2] thus people with CF are encouraged to exercise in addition to other treatments[3-6].
Despite the well-recognised physical and psychological benefits from exercise, participation is often below recommended levels, with self-reported adherence to exercise ranging from 21-
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57% for adults with CF.[7-12] A systematic review investigating interventions to promote physical activity for people with CF concluded that intensive, supervised exercise training programmes does not increase physical activity.[13] Longer term studies, however, with counselling and behavioural change strategies did increase physical activity when measured one to three years after the intervention.[13] In order to promote exercise participation through behavioural change strategies, it is first necessary to examine foundations or determinants of behaviour. In other words, we must first understand decision-making processes for adults with
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CF on whether or not to participate in exercise. To the authors’ knowledge no published study has applied a theoretical model to identify factors influencing exercise participation for people
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with respiratory diseases.
There are many conceptual frameworks that have successfully explained people’s exercise
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behaviour (e.g. self-efficacy theory, health belief model). The Theory of Planned Behaviour is
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one of the most comprehensive and validated models in the exercise domain, confirmed by systematic reviews and meta-analyses.[14-16] This theory proposes that exercise participation can be predicted from the intention to exercise and surrounding control factors (Figure 1).[17,
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18] The strength of exercise intention is related to the attitude toward exercise (behavioural beliefs), social pressure to exercise (normative beliefs) and perceived control over the ability to exercise (control beliefs). A significant benefit of the Theory of Planned Behaviour is it also
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identifies intervention targets and has been successfully used by health care professionals to increase exercise participation (e.g. [19, 20]).
The first step in conducting research into exercise participation, using the Theory of Planned Behaviour framework, is to conduct an elicitation study, to identify specific behavioural, normative and control beliefs of the population in question.[21-24] Elicitation studies have
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three benefits: informing researchers of appropriate questions for the second step, which examines how beliefs relate to actual behaviour; and after completing the second step, interpreting relationships between beliefs and behaviour; and informing clinicians how best to tailor interventions to focus on specific beliefs to encourage or discourage the behaviour. Exercise beliefs vary between populations[25] and to our knowledge, no published study has conducted an elicitation study on exercise beliefs for people with respiratory diseases. Qualitative studies on exercise participation in CF populations identified facilitators (knowing
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the health benefits of exercise, enjoyment, and sense of mastery/accomplishment) and barriers (time-consuming, disease burden, pulmonary limitations and low self-efficacy)[12, 26-29]. Those studies, however, either involved adolescents[26, 27, 29] or did not include all belief
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components of the Theory of Planned Behaviour[12, 28], so the results are insufficient to satisfy
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all components of an elicitation study on exercise participation for adults with CF.
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The aim of this elicitation study was to identify attitudes about advantages and disadvantages of exercise (behavioural beliefs); individuals and groups who apply social pressure to exercise (normative beliefs); and perceived control over facilitators and barriers to exercise (control
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beliefs) for adults with CF. For this elicitation study, we decided to interview adults with CF, friends and relatives of adults with CF and adult CF clinic staff, to gather a broad view of beliefs
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about exercise participation for adults with CF.
Methods
Participants
Adults with CF, relatives and friends of adults with CF, and staff involved in CF care were recruited from the CF Clinic at Royal Prince Alfred Hospital, Sydney, Australia. Potential participants were approached during a routine visit to the multidisciplinary CF Clinic. Patients
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with CF were excluded if they had received a lung transplant, as it was assumed their exercise beliefs would not represent the majority of adults with CF, particularly for facilitators and barriers of pulmonary function to exercise participation. Research procedures were approved by the Sydney South West Area Health Service Ethics Committee (RPAH Zone) (Protocol X060188) and participants provided written informed consent prior to data collection.
Study design
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Participants were interviewed by one researcher (TJD), a Physiotherapist who had worked in the CF Clinic for two years, in a quiet room, away from the clinic area. The qualitative interviews included a series of open-ended, structured questions, aimed at eliciting salient
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beliefs about exercise participation for adults with CF. Notes were taken during the interviews and the main ideas were summarised by the interviewer at the completion of the interview, to
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confirm and clarify responses with the interviewee. We aimed to recruit at least 25 people, the
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recommended number of participants for an elicitation study,[23] or until idea saturation occurred[24] (i.e. subsequent interviews obtained only redundant information as no new beliefs about exercise were identified). Clinical data (height, weight and lung function) for the
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participants with CF were obtained from CF Clinic records on the day of the interview. After the interview, adults with CF were asked about their current exercise participation.
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Interview questions
The open-ended questions were based on elicitation study guidelines.[21, 22] Participants with CF were asked to answer according to their own beliefs and experiences about exercise. Relatives and friends of adults with CF were asked to answer according to their beliefs and experiences about their friend or relative with CF exercising. CF Clinic staff were asked to answer according to their beliefs and experiences about adults with CF exercising.
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In order to determine their behavioural beliefs, that may guide someone with CF to exercise or not, participants were asked about their attitudinal considerations: What do you think are the advantages/disadvantages for you/your friend or relative with CF/adults with CF to exercise? Additional prompts were: How do you think exercise would help/might have negative side effects?; What else do you associate with exercising?
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In order to determine their normative beliefs about who are the significant or relevant individuals that may create social pressure or influence someone with CF to exercise or not, participants were asked: Which individuals or groups would approve/disapprove of you/your
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friend or relative with CF/adults with CF to exercise? Additional prompts were: What other
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individuals or groups come to mind when you think about exercising?
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In order to determine their control beliefs about factors that may facilitate or impede someone with CF to exercise or not, participants were asked: What factors or circumstances would enable/make it difficult for you/your friend or relative with CF/adults with CF to exercise or
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make it more or less likely that you/they would exercise? Additional prompts were: What other issues come to mind when you think about difficulties to exercise?; Are there any differences in
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exercising when well compared to when unwell?
Data analysis
The responses from each question of the interviews were collated by one researcher (TJD). Content analysis was independently performed by two researchers (BNG and TJD), arranging responses into common themes and listing in order of frequency. There was 100% content validity agreement between the researchers.
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Results Sixteen adults with CF, three relatives or friends of adults with CF and six CF Clinic staff participated in the study. The participants with CF were representative of the whole CF Clinic in terms of age, sex and lung function (Table 1). There was a range of employment: seven participants were working; one was looking for work; one was a full-time homemaker and carer of children; two were students; and five were pensioners. Five described their job (or lifestyle
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if not employed) as active and 11 as sedentary. The average reported exercise participation was 4.3 ± 2.7 times per week totaling 185 ± 148 minutes. One participant reported never exercising and seven reported meeting exercise participation guidelines (≥150 minutes of moderate to
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strenuous physical activity per week)[30].
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Of the relatives or friends of adults with CF, there was one mother, one husband and one friend.
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Relatives and friends of adults with CF did not provide any additional beliefs not already identified by adults with CF or CF Clinic staff, so recruitment of these participants was halted after three had been interviewed. Of the CF Clinic staff, there was one respiratory physician,
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one nurse, two physiotherapists and two social workers. Their average clinical experience in CF care was 9 ± 4 years (range 3-15). No new ideas or beliefs were identified after interviewing 25 people, so recruitment was stopped as idea saturation had occurred, the standard practice for
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elicitation studies.[24]
Attitude and Behavioural Beliefs about Exercise Advantages to exercise participation For the whole cohort, 23 different advantages for exercise were reported (Supplementary Data Table 1). The most identified themes about physical benefits or advantages of exercise for
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someone with CF were to: keep fit and healthy (68%); improve lung function and decrease breathlessness (56%) and decrease cough and clear the lungs (44%). The most reported themes about psychological benefits or advantages of exercise for someone with CF were to: feel better and happier (60%); feel stronger and have more energy (28%); improve body image (24%) and be fun or social (20%). Also, 16% of participants stated an advantage of exercise was to reduce the time required for airway clearance techniques. Disadvantages to exercise participation
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For the whole cohort, 24 different disadvantages for exercise were reported (Supplementary Data Table 2). The most elicited themes about negative physical side effects or disadvantages of exercise for someone with CF were to: feel breathless (36%); cause injury (24%) and cough
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(16%). The most frequently mentioned themes about negative psychological side effects or disadvantages of exercise for someone with CF were to: feel tired or reduce energy (16%); not
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enjoy exercise (16%); feel embarrassed to exercise in public (12%) and feel frustration when
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unable to keep up with others (12%). Also, 24% of participants commented that a disadvantage of exercise was to be time-consuming.
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Social Pressure and Normative Beliefs about Exercise Significant others who approve of exercise participation For the whole cohort, 16 different groups of people who positively influence exercise
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participation were reported (Supplementary Data Table 3). The most cited people or groups who approve of someone with CF exercising were: parents and family (72%); friends (52%); doctors in the CF Clinic (44%); staff of the CF Clinic and hospital (36%) and physiotherapists in the CF Clinic (32%). Also, 28% of participants responded “everyone” approves of exercise.
Significant others who disapprove of exercise participation
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For the whole cohort, nine different groups of people who negatively influence exercise participation were reported (Supplementary Data Table 4). The most frequent response, however, was “no-one” disapproves of someone with CF exercising (60%). Some participants also listed over-protective or misinformed parents and friends (20%) to disapprove of exercise.
Perceived Control and Control Beliefs about Exercise Facilitators of exercise participation
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For the whole cohort, 35 different facilitators for exercise were reported (Supplementary Data Table 5). The most expressed themes about internal facilitators or promoters for someone with CF to exercise were to: enjoy exercise and have a varied exercise programme (24%); be
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knowledgeable about benefits of exercise (24%) and be motivated (20%). The most identified themes about external facilitators or promoters of exercise were to: have someone to exercise
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with (44%); be encouraged (36%); have easy access to transport or easy to get to the place
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where they exercise (28%); be structured exercise or organised by someone else (20%) and have time available to exercise (20%).
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Barriers to exercise participation
For the whole cohort, 36 different barriers to exercise were reported (Supplementary Data Table 6). The most recorded themes about internal barriers or impediments for someone with CF to
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exercise were to: be unwell (96%); have poor motivation (52%); have poor lung function or be too breathless (48%) and not be in a routine to exercise (28%). The most repeated themes about external barriers or impediments for someone with CF to exercise were to: have insufficient time available (56%); insufficient finance (32%); be difficult to get to the place where they exercise or poor transport options (28%) and bad weather (20%).
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Discussion The primary purpose of this study was to establish the social and cognitive foundations forming a CF adult’s decision to exercise, specifically their attitude, social pressure and perceived control to exercise. This is the first elicitation study examining beliefs underpinning exercise participation for adults with CF. The results of these interviews can be used to construct questionnaires to examine and quantify determinants of exercise intention and participation in larger populations of adults with CF. They also help clinicians interpret relationships between
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exercise beliefs and participation and tailor interventions to address specific beliefs to increase exercise participation.
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The most common favourable behavioural beliefs or attitudes toward exercise, reported by 88% of adults with CF in this qualitative study, concerned improvements in physical and
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psychological health. This theme was identified in 100% of the elicitation studies reported in a
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systematic review covering exercise in healthy and patient populations[25] and listed as the most compelling reason to participate in physical activity by all the CF adolescents when asked about facilitators to exercise[29]. Sixty-nine percent of adults with CF in this current elicitation
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study reported CF-specific advantages to pulmonary function with exercise, namely improvements in lung function, reductions in breathlessness and cough. Thirty-eight percent of adults with CF, however, also identified that breathlessness and cough induced during exercise
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was a disadvantage. These same pulmonary issues were reported in studies examining adherence to exercise for CF adolescents[26, 27, 29] and adults[12].
In our study, the three most common groups reported to influence exercise participation were: parents and family (cited by 69% of adults with CF); health professionals (69%); and friends (50%). This is similar to the systematic review of elicitation studies into exercise participation
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for healthy and patient populations.[25] Interestingly, only two[26, 27] of the five previous studies examining facilitators and barriers to exercise participation for people with CF identified the role of family in encouraging or discouraging physical activity. Those two studies involved the youngest participants and clearly outlined the importance of parental support and positive role modelling. Perhaps parental influence on their child’s exercise participation decreases as the child approaches adolescence. In the only previous study that exclusively involved adults with CF, 58% of participants reported the recommendation to exercise by medical staff aided
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adherence, a similar percentage to this current study.[12]
Convenience was the most common facilitating factor identified to aid exercise participation,
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reported by 81% of adults with CF in this study and appearing in 47% of the elicitation studies in a systematic review of exercise participation in healthy and patient populations.[25] Social
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support and encouragement to exercise was listed by 63% of adults with CF, compared to only
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29% of studies in the systematic review[25] and in only two[26, 27] of the five previous qualitative studies in patients with CF.
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Being unwell was reported by all adults with CF in this study as a barrier to exercise participation. Health issues were identified in all the elicitation studies of the systematic review of exercise participation in healthy and patient populations[25] and by 60% of adults with CF
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in a previous study as barriers to exercise[12]. Poor pulmonary function and breathlessness were thought to be additional barriers to exercise for 63% of adults with CF in this study, and also encountered by 23% of adults with CF in another study.[12] Inconvenience was the second most frequent barrier to exercise, listed by 75% of adults with CF in this study and 68% of adults with CF in an earlier study.[12] Interestingly, only half the studies on adolescents with CF reported inconvenience or insufficient time acting as barriers to exercise.[26, 27] This may
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reflect the greater time demands on adults with CF, compared to their younger peers, due to additional pressures of work and family commitments.
On the whole, responses were similar for adults with CF, their relatives and friends and CF Clinic staff. Staff listed a few more specific advantages, disadvantages, facilitators and barriers to exercise participation not identified by patients or their relatives and friends (advantages such as improvements in bone density; disadvantages such as excessive weight loss; facilitators such
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as belonging to a clinic that promotes exercise; and barriers such as infection control precautions). Only 33% of staff, however, compared to 50% of adults with CF, acknowledged the role of friends to influence exercise participation or social aspects and having someone to
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exercise with to promote exercise participation. As well, only one staff member identified the importance of encouragement to facilitate exercise participation and the importance of self-
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motivation to exercise (compared to 50% and 25% of adults with CF, respectively). One clinical
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implication of these findings may be that staff involved in CF care should take account of the importance of family and friends and the encouragement they provide when attempting to
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increase exercise participation of their patients.
There are some limitations to this study. Firstly, all participants were interviewed by a physiotherapist, who worked in the CF clinic. This may have created bias, where participants
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felt they should report more positive beliefs about exercise. Half the beliefs reported in each category, however, were negative or perceived disadvantages to exercise. Another limitation is that elicitation studies only provide content analysis of different beliefs, so without detailed indepth qualitative interviews, it cannot be confirmed which reported beliefs are the true determinants of behaviour. One strength of our study, however, was to increase breadth of responses or beliefs by interviewing adults with CF, friends and relatives and CF clinic staff.
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Conclusion The attitudes, social pressure and perceived control to exercise identified in this study are similar to those reported by healthy populations and other patient groups.[25] Many participants in this qualitative study, however, also reported additional beliefs that were CF-specific, namely extra advantages, disadvantages, facilitators and barriers to exercise related to pulmonary function. Future research, using questionnaires developed from the main themes identified in
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this study, in wider samples of adults with CF, will be able to quantitatively examine the strength of the associations between exercise beliefs, intention and participation. Those studies will provide empirical evidence to establish frameworks targeting increased exercise
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participation for adults with CF.
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Ethical approval: Sydney South West Area Health Service Ethics Committee (RPAH Zone)
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(Protocol X06-0188)
Funding: This research did not receive any specific grant from funding agencies in the public,
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commercial, or not-for-profit sectors.
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Conflict of interest: None of the authors has a conflict of interest to disclose.
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References
6. 7. 8.
9. 10.
11. 12.
13.
14. 15.
Jo
16.
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5.
-p
4.
re
3.
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2.
Sawicki, G.S., D.E. Sellers, and W.M. Robinson, High treatment burden in adults with cystic fibrosis: challenges to disease self-management. Journal of Cystic Fibrosis, 2009. 8(2): p. 91-96. Radtke, T., et al., Physical exercise training for cystic fibrosis. Cochrane Database of Systematic Reviews, 2017(11): p. CD002768. Association of Chartered Physiotherapists in Cystic Fibrosis, Standards of care and good clinical practice for the physiotherapy management of cystic fibrosis. Third edition. 2017, UK Cystic Fibrosis Trust: London. Button, B.M., et al., Physiotherapy for cystic fibrosis in Australia and New Zealand: A clinical practice guideline. Respirology, 2016. 21(4): p. 656-667. Flume, P.A., et al., Cystic fibrosis pulmonary guidelines: airway clearance therapies. Respiratory Care, 2009. 54(4): p. 522-537. Smyth, A.R., et al., European Cystic Fibrosis Society Standards of Care: Best Practice guidelines. Journal of Cystic Fibrosis, 2014. 13( Suppl 1): p. S23-S42. Abbott, J., et al., Treatment compliance in adults with cystic fibrosis. Thorax, 1994. 49(2): p. 115-120. Dalcin, P.d.T.R., et al., [Adherence to treatment in patients with cystic fibrosis]. Jornal Brasileiro De Pneumologia: Publicacao Oficial Da Sociedade Brasileira De Pneumologia E Tisilogia, 2007. 33(6): p. 663-670. Gumery, L., et al., Physiotherapy and nebuliser use in a Birmingham adult cystic fibrosis unit. Physiotherapy, 1998. 84(3): p. 127-132. Myers, L.B., An exploratory study investigating factors associated with adherence to chest physiotherapy and exercise in adults with cystic fibrosis. Journal of cystic fibrosis, 2009. 8(6): p. 425-427. Shepherd, S.L., et al., A comparative study of the psychosocial assets of adults with cystic fibrosis and their healthy peers. Chest, 1990. 97(6): p. 1310-1316. White, D., K. Stiller, and N. Haensel, Adherence of adult cystic fibrosis patients with airway clearance and exercise regimens. Journal of Cystic Fibrosis, 2007. 6(3): p. 163170. Cox, N.S., J.A. Alison, and A.E. Holland, Interventions for promoting physical activity in people with cystic fibrosis. Cochrane Database of Systematic Reviews, 2013(12): p. CD009448. Armitage, C.J. and M. Conner, Efficacy of the Theory of Planned Behaviour: a metaanalytic review. British Journal of Social Psychology, 2001. 40(Pt 4): p. 471-499. Downs, D.S. and H.A. Hausenblas, The Theories of Reasoned Action and Planned Behavior applied to exercise: A meta-analytic update. Journal of Physical Activity and Health, 2005. 2(1): p. 76-97. McEachan, R.R.C., et al., Prospective prediction of health-related behaviours with the Theory of Planned Behaviour: a meta-analysis. Health Psychology Review, 2011. 5(2): p. 97-144. Ajzen, I., Attitudes, personality, and behavior. 1988, Chicago: Dorsey. Ajzen, I., The theory of planned behavior. Organizational behavior and human decision processes, 1991. 50: p. 179-211. Aaron, S.D., et al., Combination antibiotic susceptibility testing to treat exacerbations of cystic fibrosis associated with multiresistant bacteria: a randomised, double-blind, controlled clinical trial. Lancet, 2005. 366(9484): p. 463-471. Jemmott, J.B.I., et al., Cognitive-behavioural health-promotion intervention increases fruit and vegetable consumption and physical activity among South African
ur na
1.
17. 18. 19.
20.
Beliefs about exercise participation in CF
28/10/2019 Page 15 of 18
25.
26.
27.
28. 29.
30.
Jo
ur na
31.
ro of
24.
-p
23.
re
22.
lP
21.
adolescents: a cluster-randomised controlled trial. Psychology & Health, 2011. 26(2): p. 167-185. Ajzen, I. Construction of a standard questionnaire for the theory of planned behavior. [web site] 2006 [cited 14/9/2018; Available from: http://wwwunix.oit.umass.edu/~aizen/pdf/tpb.measurement.pdf. Ajzen, I. and M. Fishbein, Understanding attitudes and predicting social behavior. 1980, Englewood Cliffs, NJ: Prentice Hall. Francis, J.J., et al. Constructing questionnaires based on the Theory of Planned Behaviour: A manual for health services researchers. 2004 [cited 14/9/2018; Available from: http://openaccess.city.ac.uk/id/eprint/1735. Montano, D.E. and D. Kasprzyk, Theory of reasoned action, theory of planned behaviour, and the integrated behavioural model, in Health behaviour: Theory, research and practice, K. Glanz, B.K. Rimer, and K. Wiswanath, Editors. 2014, John Wiley & Sons: San Francisco. p. 95-124. Downs, D.S. and H.A. Hausenblas, Elicitation studies and the theory of planned behavior: a systematic review of exercise beliefs. Psychology of Sport & Exercise, 2005. 6: p. 1-31. Moola, F.J., G.E. Faulkner, and J.E. Schneiderman, "No time to play": perceptions toward physical activity in youth with cystic fibrosis. Adapted Physical Activity Quarterly, 2012. 29(1): p. 44-62. Moola, F.J., et al., Developing physical activity interventions for youth with cystic fibrosis and congenital heart disease: Learning from their parents. Psychology of Sport and Exercise, 2011. 12(6): p. 599-608. Street, R., et al., Experiences of physical activity: A phenomenological study of individuals with cystic fibrosis. Journal of Health Psychology, 2016. 21(2): p. 261-270. Swisher, A.K. and M. Erickson, Perceptions of physical activity in a group of adolescents with cystic fibrosis. Cardiopulmonary Physical Therapy Journal, 2009. 19(4): p. 107-113. World Health Organisation. Global Recommendations on Physical Activity for Health. 2010 [cited 14/9/2018; Available from: https://apps.who.int/iris/handle/10665/44399. Quanjer, P.H., et al., Multi-ethnic reference values for spirometry for the 3-95-yr age range: the global lung function 2012 equations. European Respiratory Journal, 2012. 40(6): p. 1324-1343.
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Figure captions Figure 1: Model of Ajzen’s Theory of Planned Behaviour, adapted for exercise participation in people with lung disease.
Actual control
Normative beliefs: Social pressure to exercise
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Behavioural beliefs: Attitude toward exercise
Exercise intention
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Control beliefs: Perceived control to exercise
Exercise participation
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Table 1. Participant characteristics Characteristic
Participants with CF (n=16)
Adult CF clinic patients (n=109)
Mean (SD)
Range
Mean (SD)
Range
Age, yr
27 (6)
19 – 37
28 (9)
17 – 62
Sex, % female
50
BMI, kg/m2
22.2 (3.5)
18.6 – 33.1
22.6 (3.3)
15.1 – 33.5
FEV1, predicted %
53 (23)
16 – 101
62 (23)
15 – 107
FVC, predicted %
75 (21)
25 – 99
82 (20)
25 – 122
FEV1/FVC, ratio
0.59 (0.14)
0.28 – 0.88
0.63 (0.14)
0.24 – 0.91
44
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Mean, standard deviation (SD) and range of characteristics for the 16 participants with CF and all patients of the Adult CF clinic. Forced expiratory volume in 1 second (FEV1) and forced vital capacity (FVC) expressed as percentage of predicted normal.[31]
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