General and Arthritis-Specific Barriers to Moderate Physical Activity in Women With Arthritis

Women's Health Issues 21-1 (2011) 57e63

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Original article

General and Arthritis-Specific Barriers to Moderate Physical Activity in Women With Arthritis Danielle R. Brittain, PhD a,*, Nancy C. Gyurcsik, PhD b, Mary McElroy, PhD c, Sara A. Hillard, MS c a

Department of Health and Exercise Science, University of Oklahoma, Norman, Oklahoma College of Kinesiology, University of Saskatchewan, Saskatoon, Saskatchewan, Canada c Department of Kinesiology, Kansas State University, Manhattan, Kansas 6650 b

Article history: Received 3 February 2010; Received in revised form 23 July 2010; Accepted 26 July 2010

a b s t r a c t Background: Most women with arthritis are insufficiently active, despite the health benefits derived from participation in moderate physical activity (MPA). Understanding perceived barriers that make it difficult for women with arthritis to be active is needed to inform interventions. Barriers are often assessed through investigator-provided lists, containing mainly general, personal, and situational barriers, common across populations (e.g., lack of time). However, identifying an encompassing range of problematic barriers that challenge women’s activity participation is needed. Such barriers may be general and arthritis specific (e.g., pain). Problematic barriers may be best identified through assessment of whether individuals actually experience these barriers (i.e., are present) and, for present barriers, their extent of limitation on activity. Thus, the primary study purpose was to examine whether the presence of general and arthritisspecific barrier categories and the limitation of these overall categories were significant predictors of participation in MPA among women with arthritis (n ¼ 248). Methods: On-line measures of barriers and MPA were completed. Findings: A multiple regression model predicting activity was significant (r2adjusted ¼ .22; p < .01). Both arthritis-specific and general barrier limitation were the strongest predictors of activity. Arthritis-specific personal barriers were reported as being present most often (e.g., pain). Conclusion: Interventions should identify problematic barriers, taking into account the extent to which both general and disease-specific barriers limit activity, and then target their alleviation through the use of coping strategies as a way to improve activity adherence and health among women with arthritis. Copyright Ó 2011 by the Jacobs Institute of Women’s Health. Published by Elsevier Inc.

Introduction Arthritis affects nearly one in five adults and results in negative health outcomes, such as increased pain and decreased activities of daily living and health-related quality of life (Centers for Disease Control and Prevention [CDC], 2008; Helmick et al., 2008). Negative health outcomes can be improved through regular participation in moderate physical activity (MPA; i.e., 150 min/week; Conn, Hafdahl, Minor, & Nielsen, 2008; Minor, Strenstrom, Klepper, Hurley, & Ettinger, 2003; U.S. Department of Health and Human Services, 2008). Unfortunately, up to 80% of individuals with arthritis are insufficiently active, a problem more pronounced among women (Abell, Hootman, Zack, Moriarty, & Helmick, 2005; * Correspondence to: Danielle R. Brittain, PhD, Department of Health and Exercise Science, 1401 Asp Avenue, University of Oklahoma, Norman, Oklahoma 73019. Phone: (405)325-9028; fax: (405)325-0594. E-mail address: [email protected] (D.R. Brittain).

Hootman, Macera, Ham, Helmick, & Sniezek, 2003; Shih, Hootman, Kruger, & Helmick, 2006; Theis, Helmick, & Hootman, 2007). Thus, identifying reliable correlates of women’s MPA, such as perceived barriers, is needed (Eyler, 2003; Marks & Allegrante, 2005; Shih et al., 2006; Wilcox, Der Ananian, Sharpe, Robbins, & Brady, 2005). Barriers can be personal and situational as well as general and population-specific impediments that hinder or completely deter participation in MPA (Bandura, 2004; Brawley, Martin, & Gyurcsik, 1998; Jackson, 1988). General barriers are common across populations, such as being too tired or unmotivated (personal) or a lack of social support (situational; Brittain, Gyurcsik, & McElroy, 2008; Gyurcsik, Spink, Bray, Chad, & Kwan, 2006). Other barriers are specific to a population, such as pain (personal) and the lack of arthritis-specific exercise programs in communities (situational; Brawley, Culos-Reed, Angove, & Hoffman-Goetz, 2002; Brittain et al., 2008; Gyurcsik et al., 2006; Wilcox et al., 2006). Because a multitude of general and population-specific, personal, and situational barriers may exist,

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identifying problematic barriers that deter women with arthritis from participating in MPA is needed. With this understanding, interventions can be developed to alleviate such barriers as a way to improve MPA adherence and health among women with arthritis. In quantitative research examining the relationship between barriers and activity among people with arthritis, barriers have been primarily assessed through investigator-provided lists (e.g., Der Ananian, Wilcox, Saunders, Watkins, & Evans, 2006; Gecht, Connell, Sinacore, & Prohaska, 1996; Kang, Estwing Ferrans, Kim, Kim, & Lee, 2007; see Wilcox et al. [2005] for a review). Typically, such measures require responses to the entire list of mainly general barriers, with no or only a limited number of arthritis-specific barriers being assessed. Two issues arise with this measurement approach. First, by providing a list in which individuals must respond to all barriers, both relevant and irrelevant barriers are assessed, thereby making it difficult to identify problematic barriers (Brawley et al., 1998; Gyurcsik et al., 2009). Second, “one-size-fits-all” lists of barriers do not adequately assess arthritis-specific barriers, which qualitative research has found to be salient among samples with arthritis. For example, focus groups have reported arthritis-specific barriers, such as pain and joint stiffness (personal), as well as a lack of tailored activity programs in the community for those with arthritis-related limitations (situational; Der Ananian et al., 2006; Gyurcsik et al., 2009; Hendry, Williams, Markland, Wilkinson, & Maddison, 2006; Wilcox et al., 2006). An improved measurement approach would include respondents identifying barriers present in their lives, and then indicating the extent to which each barrier limits their participation in MPA (Brawley et al., 1998). Both the frequency in which different barriers are present and the extent to which the barriers limit activity participation may vary among individuals with arthritis (Gyurcsik et al., 2009). This measurement approach is advantageous because individuals respond only to barriers that are relevant, rather than being forced to respond to an entire list of investigator-provided barriers, some of which may be irrelevant (Brawley et al., 1998). In the case of barriers that are present, subsequent assessment of limitation indicates the strength of each barrier in preventing activity. Expectations are that the more limiting the barrier, the lower the participation in activity (Bandura, 1986). Prior research in healthy adult populations has generally demonstrated that for barriers that were present in people’s lives, as limitation increased, MPA declined (Bloomquist, Gyurcsik, Brawley, Spink, & Bray, 2008; Brittain et al., 2008; Gyurcsik, Bray, & Brittain, 2004). Only one study to date has used the recommended barriers assessment approach among women with arthritis. Using an openended elicitation approach for women to first identify up to three barriers, Gyurcsik et al. (2009) found that arthritis-specific barriers (e.g., pain, stiffness) were more frequently reported than general barriers. Further, the average limitation across the elicited barriers had a negative association with MPA participation, whereas barrier presence was not a significant predictor. One conclusion was that the mere presence of barriers was not important in predicting activity. Rather, the extent to which barriers posed challenges to activity among women with arthritis was a deterrent, as captured by high limitation. A second conclusion was that arthritis-specific barriers pose great challenges to MPA and should be assessed in future research. Of note, however, examining whether general and arthritis-specific barriers, on their own, predicted activity was not done because this was not their study purpose. Better understanding of whether the presence and/or extent of limitation of general and/or arthritis-specific barriers are

associated with activity is needed. One or both categories of barriers may pose difficulties to being active. From an intervention perspective, better understanding which category(ies) is predictive of activity is important because strategies to alleviate arthritis-specific barriers may differ from strategies to alleviate general barriers (Gyurcsik et al., 2009). Further, advancing our understanding of whether the presence of barriers and/or their limitation are associated with activity may provide information to help interventionists to identify problematic barriers. For example, if barrier limitation is found to be a reliable predictor of activity, then future barrier measures should assess limitation to identify problematic barriers. The primary purpose of the study was to examine whether the presence of general and arthritis-specific barrier categories and the limitation of these overall categories were significant predictors of participation in MPA among women with arthritis. A secondary purpose was to describe the presence of general and arthritis-specific barriers (personal and situational) reported by the study sample and, for those barriers that were present, their perceived limitation. No study hypotheses were advanced owing to the preliminary nature of the present study. Method Participant Recruitment and Procedures After study approval by the university’s institutional review board, women with self-reported doctor-diagnosed arthritis were recruited to participate in an on-line survey. Participants were recruited via e-mails to arthritis-specific web-based chat groups and organizations, who were asked to post a study announcement. The announcement included the study purposes, participant inclusion criteria, the link to the on-line survey, and encouragement for individuals to forward the link to others. The survey began with informed consent information and, for those providing consent, participant inclusion criteria were outlined. The criteria included being a woman, aged 18 years or older, residing in the United States, and having self-reported doctor-diagnosed arthritis, which is a credible measure of disease presence (Helmick et al., 2008). A total of 344 individuals expressed interest in the study, but 96 did not satisfy participant inclusion criteria. Study participants (n ¼ 248) completed a 25-minute on-line survey, which was available for 5 months. The survey assessed demographics, MPA, and general and arthritis-specific barrier presence and limitation. Measures Demographics General demographic information that was collected included age, income (coded as 1e9 for data analyses), race, and selfreported height and weight. Arthritis-specific demographic information included years since being doctor-diagnosed with arthritis, limitations in daily activities owing to arthritis (i.e., yes, no, or do not know), and arthritis-related pain (i.e., 0 [no pain in a typical week] to 10 [severe pain in a typical week]; Gyurcsik et al., 2009; Hadjistavropoulos et al., 2007). MPA Because MPA was a focus of the study, a control definition was provided to serve as a reference for participants’ responses to the primary study measures. MPA was defined as “Organized sports participation, as well as activities like brisk walking, swimming, cycling, and yard work. Moderate activities cause small increases

D.R. Brittain et al. / Women's Health Issues 21-1 (2011) 57e63

in breathing or heart rate. You should be able to carry on a conversation when doing moderate activities” (American College of Sports Medicine, 2009; CDC, 2003). After reading the control definition, participants reported if they performed moderate activity for at least 10 minutes in a typical week (yes/ no). If answered as “yes,” participants reported the number of days they performed moderate activity in a typical week and the total number of minutes spent doing their moderate activity per day. A total activity score was calculated for each participant by multiplying the total days of MPA by the total number of minutes per day (CDC, 2003). General and arthritis-specific barriers A 41-item list assessed the presence and extent of limitation of general and arthritis-specific barriers. The list was derived from previous barriers research with samples diagnosed with arthritis as well as research on barriers to activity among other adult samples (Bloomquist, Hillard, Gyurcsik, Hacker, & Morales, 2004; Brittain, Baillargeon, McElroy, Aaron, & Gyurcsik, 2006; Der Ananian et al., 2006; Hendry et al., 2006; Gyurcsik et al., 2009). As explained, one shortcoming of previous investigatorprovided barrier measures has been the inclusion of mainly general barriers and forcing responses to all barrier items. The present measure addressed these shortcomings by including a broad range of general and arthritis-specific barriers derived from previous research. Further, the current measure allowed participants to identify only those barriers that they were relevant to them (i.e., experienced). To further identify problematic barriers, participants could report up to three additional barriers in an open-ended fashion on the measure. Because of the low number of additional barriers reported by the participants (n ¼ 5), these barriers were excluded from the analyses. A total of 25 general barriers (6 personal; 19 situational) and 16 arthritis-specific barriers (5 personal; 11 situational) were assessed. Similar to prior research, participants were first provided with a control definition of barriers (Brittain et al., 2006). Barriers were defined as preventing or hindering one from being physically active. Participants then indicated whether each barrier was present/experienced in a typical week. Participants then reported the extent to which each present barrier limited their activity participation in a typical week on a 1 (doesn’t limit me) to 10 (fully limits me) scale (Brittain et al., 2006; Gyurcsik et al., 2009). In line with prior research that used a similar measure (Brittain et al., 2006), general barrier presence and limitation as well as arthritis-specific barrier presence and limitation scores were calculated for each participant. For general barrier presence, the total number of barriers a participant reported as being present was divided by the total number of possible general barriers (i.e., 25). This score represented the proportion of general barriers that were present for each participant. To calculate general barrier limitation, general barrier limitation scores reported by a participant were summed and divided by the total number of general barriers she reported. This score represented the average limitation for each participant and ranged from 1 (doesn’t limit me) to 10 (fully limits me). The same process was repeated when calculating arthritis-specific barrier presence and limitation scores for each participant. Statistical Analyses Missing data were minimal (i.e., <5%) and randomly distributed in the barrier limitation and MPA measures. Thus, recommendations by Tabachnick and Fidell (1997) were followed.

59

Missing data on an entire measure (i.e., MPA) were replaced with the sample mean. Missing data in barrier limitation were replaced with the participant’s mean response on the measure. Data were then screened for outliers and normality. The MPA data included five outliers and were non-normally distributed. Recommendations by Tabachnick and Fidell (2007) were followed to address these issues. Outliers were changed to 1 unit higher than the next highest value in the MPA data. Then, the MPA data were transformed, using a square root procedure. The transformed variable was entered in the regression analysis. However, because the results were the same whether the transformed or raw data were used, the original mean MPA score is presented in the results section to best aid in interpretation for the reader. The means and standard deviations of a) general barrier presence and limitation, b) arthritis-specific barrier presence and limitation, and c) MPA were calculated. To address the primary study purpose, a hierarchical multiple regression analysis, involving three steps, to predict MPA was conducted. Assumptions regarding linearity, homoscedasticity, and normality were first checked and found to be satisfied, so the regression analysis proceeded. The initial two steps controlled for potential demographic covariates found to be associated with MPA in past research (Fontaine & Haaz, 2006; Sallis & Owen, 1999; Wilcox et al., 2005). On step 1, the general demographic variables of age, income, and body mass index were entered. On step 2, the arthritis-specific demographic variables of pain owing to arthritis and arthritisrelated activity limitation were entered. Step 3 included general and arthritis-specific barrier presence and limitation variables. To address the secondary purpose, the presence and limitation of each barrier item was determined. To calculate the presence of each barrier, the total number of participants reporting each barrier was determined. The limitation of each barrier was calculated as the average score reported by the participants for that barrier item. Results Participants Participants were 248 mostly White (n ¼ 226), married (n ¼ 147) women aged 18 to 83 years (Mage ¼ 48.92  12.89), who reported being doctor-diagnosed arthritis in the last 1 to 10 years (n ¼ 144). The majority of the participants were also employed full-time (n ¼ 120), had a median income of $50,000 to $59,999 per year, and attended some college/technical school (n ¼ 73) or were college graduates (n ¼ 85). Nearly all participants reported limitations in their overall activities owing to arthritis (n ¼ 218) and a moderate level of arthritis-related pain in a typical week (Mpain ¼ 5.61  1.88). Participants were overweight with a mean body mass index of 29.47  8.16 kg/m2 (Table 1). Descriptives of the Primary Study Variables Participants reported the presence of nearly eight general barriers in a typical week (Mgeneral presence ¼ 7.67  4.62), which were slightly more than moderately limiting to their MPA (Mgeneral limitation ¼ 6.21  2.35). Participants also reported experiencing about five arthritis-specific barriers in a typical week (Marthritis-specific presence ¼ 5.15  3.71) that were slightly more than moderately limiting to their activity (Marthritis-specific limitation ¼ 5.75  2.96). Participants MPA was 76.89 minutes per week (SD ¼ 80.16).

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Table 1 Participant Demographics Variables

Table 2 Prediction of Moderate Physical Activity n (%)

Age (yrs) 18e29 21 (8) 30e49 96 (39) 50e69 110 (44) 70 10 (4) Race White 226 (91) African American 7 (3) Other minority 5 (2) Income ($US) 9,999 14 (6) 10,000e19,999 12 (5) 20,000e29,999 17 (7) 30,000e39,999 28 (11) 40,000e49,999 32 (13) 50,000e59,999 21 (9) 60,000e69,999 19 (8) 70,000e79,999 19 (8) 80,000 71 (29) Marital status Married 147 (59) Single 47 (19) Divorced 29 (12) Other 20 (8) Education Some high school 21 (8) High school graduate 83 (33) Some college/technical college 61 (25) College graduate 20 (8) Graduate/professional degree 62 (25) Employment status Full time 127 (51) Part time 48 (19) Retired 18 (7) Homemaker 17 (7) Student 6 (2) Other 30 (12) No response 2 (1) BMI (kg/m2) Years since being doctor-diagnosed with arthritis 1 21 (8) 1e5 83 (33) 6e10 61 (25) 11e15 20 (8) 16e20 21 (8) 20 41 (17) Arthritis-related pain in a typical week Limitations in daily activities owing to arthritis Yes 218 (88) No 27 (11) Do not know 3 (1)

M (SD)

Predictor

r2 Adjusted

48.92 (12.89)

Step 1 BMI Age Income Step 2 BMI Age Income Pain due to arthritis Arthritis-related activity limitation Step 3 BMI Age Income Pain due to arthritis Arthritis-related activity limitation General barrier presence General barrier limitation Arthritis-specific barrier presence Arthritis-specific barrier limitation

0.10**

D r2

bstandardized 0.29** 0.04 0.11

0.11**

0.02 0.28** 0.05 0.09 0.09 0.06

0.22**

0.12** 0.20** 0.07 0.05 0.02 0.03 0.10 0.24** 0.18* 0.21*

Abbreviation: BMI, body mass index. * p < .05. ** p < .01.

General and arthritis-specific barrier limitation variables had the strongest associations with activity (see standardized b; Table 2). Presence and Limitation of Each Barrier

29.47 (8.16)

5.61 (1.88)

Abbreviation: BMI, body mass index. Note: “No response” comprises the remainder of percentages that do not add up to 100.

General and Arthritis-Specific Barriers Predicting MPA Table 2 illustrates the results from the hierarchical multiple regression analysis predicting MPA. In step 1, the overall model containing the general demographic predictors was significant [F(3,244) ¼ 10.30; p < .001]. In step 2, the arthritis-specific demographic variables did not contribute additional unique variance to the model [F(5,242) ¼ 7.17; p < .001; r2change ¼ 0.02; p > .05]. In step 3, general and arthritis-specific barrier presence and limitation variables contributed an additional 12% of variance (p < .01) to the overall model [F(9,238) ¼ 8.60; p < .01]. General barrier limitation as well as arthritis-specific barrier presence and limitation were significant predictors in the overall model.

Table 3 contains the 41 general and arthritis-specific personal and situational barriers examined in the study. All barriers were reported as being present. Similar to previous barriers research with other populations, barriers reported as being present by at least 30% of the sample were of focus (Brittain et al., 2008; Spink et al., 2006). Four of the five arthritis-specific personal barriers (80%) and three of the 11 (27%) arthritis-specific situational barriers were reported by 30% or more of the participants (Table 3). Four of the six general personal barriers (67%) and 10 of the 19 (53%) general situational barriers were reported at least 30% of the sample (Table 3). In regard to limitation, all 41 barriers were reported as moderately limiting or more to participation in MPA. Arthritis-specific personal barriers reported as being present most often included: I don’t exercise because of the pain from my arthritis (n ¼ 174), I don’t exercise because my arthritis limits what my body can do (n ¼ 157), and arthritis makes my body and joints too stiff to exercise (n ¼ 149). The arthritis-specific situational barriers of the local fitness facility doesn’t offer arthritisspecific programs (n ¼ 84) and exercise instructors don’t tell me how to do the exercise differently when my arthritis flares up (n ¼ 81) were reported most frequently. Participants also frequently reported the presence of the personal barriers of the temperature outside keeps me from exercising (n ¼ 144) and I can’t find a time to exercise that fits with my schedule (n ¼ 127), and the general situational barrier of working long hours makes me tired so I don’t feel like exercising (n ¼ 139). Discussion The present study examined whether the presence of general and arthritis-specific barriers and their limitations were significant predictors of MPA in women with arthritis. The limitation of arthritis-specific and general barriers were the strongest

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Table 3 Presence and Limitation of General and Arthritis-Specific Barriers Barriers: Total Sample (n ¼ 248)

Mlimit (SD)

Barrier Presence

General personal 1. The temperature outside keeps me from exercising. 2. I can’t find a time to exercise that fits with my schedule. 3. When I exercise around other people, I’m worried about how my body looks. 4. I don’t feel like I am athletic enough to be a part of an exercise group. 5. I don’t like changing into and out of exercise clothes. 6. I have an injury or health issue (not arthritis) that stops me from exercising General situational 1. Working long hours makes me tired so I don’t feel like exercising. 2. My health insurance doesn’t cover exercise costs (e.g. memberships, programs) 3. I have a hard time scheduling an exercise time with another person. 4. I don’t have time to exercise because I spend so much time at work. 5. When I go to a place to exercise, other people exercising there make me feel uncomfortable. 6. I don’t exercise because it costs too much for memberships/participation. 7. It’s hard for me to find someone with similar skills to exercise with. 8. It takes too much time to get to and from an exercise facility. 9. There are no free exercise facilities where I can go to in the community where I live. 10. My workplace doesn’t have a place to exercise. 11. There are no streetlights in my neighborhood so it is hard for me to exercise at night. 12. Being on a fixed income (Social Security) makes it difficult for me to afford to exercise (e.g. memberships, programs). 13. My friends don’t exercise. 14. My spouse/partner doesn’t exercise 15. It is unsafe in my neighborhood to exercise. 16. I have to take care of children/grandchildren so I don’t have time to exercise. 17. There are no public parks/trails that I can use for exercise in the community where I live. 18. My spouse/partner isn’t supportive of me exercising. 19. My friends aren’t supportive of me exercising. Arthritis-specific personal 1. I don’t exercise because of the pain from my arthritis. 2. I don’t exercise because my arthritis limits what my body can do. 3. Arthritis makes my body and joints too stiff to exercise. 4. Having arthritis makes me feel down in the dumps so I don’t exercise. 5. I don’t exercise because I’m afraid I might fall due to my arthritis. Arthritis-specific situational 1. The local fitness facility doesn’t offer arthritis-specific programs. 2. Exercise class instructors don’t tell me how to do the exercises differently when my arthritis flares up. 3. There aren’t any exercise programs for people with arthritis in the community where I live. 4. Exercise class instructors don’t consider the pain I have from my arthritis when teaching the class. 5. Exercise class instructors don’t consider how arthritis limits my body when teaching the class. 6. Exercise class instructors don’t consider the stiffness I have from my arthritis when teaching the class. 7. I don’t know others who exercise and also have arthritis. 8. My local/state policy makers don’t make laws to make it easy for people with arthritis to exercise. 9. The sidewalks where I want to exercise are in bad shape making it hard for me to exercise when my arthritis flares up. 10. My friends don’t want me to exercise because I have arthritis. 11. My spouse/partner doesn’t want me to exercise because I have arthritis.

n

%

144 127 100 97 60 53

58.1 51.2 40.3 39.1 24.2 21.4

7.08 7.06 7.09 6.62 6.35 6.96

(2.00) (2.04) (2.09) (2.18) (2.24) (2.35)

139 113 102 102 99 94 94 89 84 81 66 42

56.0 45.6 41.1 41.1 39.9 37.9 37.9 35.9 33.9 32.7 26.6 16.9

7.57 7.35 6.37 7.42 6.95 7.79 6.77 7.02 7.56 6.37 7.36 7.86

(2.09) (2.83) (2.18) (2.04) (2.04) (2.33) (2.07) (1.89) (2.80) (2.79) (2.55) (2.73)

40 39 37 36 29 23 12

16.1 15.7 14.9 14.5 11.7 9.3 4.8

6.80 6.41 6.95 6.72 7.21 5.83 5.83

(1.99) (2.63) (2.83) (2.24) (2.70) (2.29) (2.59)

174 157 149 113 51

70.2 63.3 60.1 45.6 20.6

7.28 7.18 6.89 6.64 6.75

(1.89) (1.98) (2.17) (2.28) (2.50)

84 81 78 73 72 71 60 51 47

33.9 32.7 31.5 29.4 29.0 28.6 24.2 20.6 19.0

7.27 7.30 7.59 7.14 7.10 7.10 6.78 7.75 7.19

(2.50) (2.49) (2.37) (2.37) (2.46) (2.49) (2.59) (2.24) (2.46)

10 7

4.0 2.8

6.40 (3.03) 6.86 (2.85)

Note: Barrier limitation ranged from 1 (doesn’t limit me) to 10 (fully limits me).

predictors of activity. As the limitation of these barriers increased, MPA had an associated decrease among the sample. Study findings about the predictive association between the limitation of population-specific and general barriers and activity are similar to barriers research with other adult samples (Brawley et al., 2002; Brittain et al., 2006; Brittain et al., 2008; Gyurcsik et al., 2006) as well as the only study to examine limitation among a sample with arthritis (Gyurcsik et al., 2009). The present study extends Gyurcsik et al.’s (2009) findings by demonstrating that both categories of barriers may be problematic to women with arthritis. The arthritis-specific findings in our study would not have been observed if a measure containing only general barriers was used. From an intervention perspective, not considering problematic arthritis-specific barriers would make it difficult to facilitate an increase in MPA. Taken together, evidence is mounting to support Brawley et al.’s (1998) suggestion that the presence of barriers may not be

the best indicant of their impact on activity. Although the presence of arthritis barriers was a significant predictor in the present study, and are more commonly cited than general barriers among those with arthritis (Gyurcsik et al., 2009), the standardized b values in the regression revealed that limitation was more strongly associated with activity. Thus, although the presence of barriers may be associated with activity, the extent to which experienced barriers limit activity may serve as the better indicant of the strength of problematic barriers. Experienced barriers may be limiting because individuals do not know how to effectively cope with barriers and/or they do not have adequate confidence to regularly use coping strategies when barriers arise (Bandura, 1986; Baumeister, Heatherton, & Tice, 1994; Gyurcsik et al., 2009). Future research should examine these propositions to better inform the design of effective interventions to help women with arthritis overcome problematic barriers.

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Findings that addressed our secondary purpose illustrated that participants most frequently reported the presence of arthritisspecific personal barriers, including pain, stiffness, and arthritis limiting what one’s body can do. These barriers were slightly more than moderately limiting to the women’s MPA participation. Although reported by fewer participants, the arthritis-specific situational barriers that were most present included the lack of tailored physical activity programs and, if such programs were offered, the lack of instructor knowledge on issues related to arthritis and performance of activity. A number of the general and arthritis-specific barriers experienced by the sample have been reported in prior focus group research with adults who have arthritis (Der Ananian et al., 2006; Hendry et al., 2006; Wilcox et al., 2006). However, pain is typically the only arthritis-specific barrier that is assessed on quantitative measures (Bajwa & Rogers, 2007). Results of the present study illustrated that the women experienced a range of relevant arthritis-specific barriers that posed difficulties to their activity. Thus, future quantitative assessments of barriers should include a range of arthritis-specific barriers, in additional to general barriers Strengths and Limitations As mentioned, quantitative assessments have typically required samples with arthritis to respond to investigator-provided lists of mainly general barriers. Study strengths included assessing both general and arthritis-specific barriers, including their presence and extent of limitation, and examination of their independent relationships with MPA. Despite addressing some shortcomings of previous barrier measures, the present study had some weaknesses. The cross-sectional design did not permit any conclusions about cause and effect relationships between barriers and activity. The demographics of the study sample, such as being mainly White, middle class women, limits the generalizability of the findings. Possible biases may have also been introduced by the participant recruitment methods (web-based, snowballing technique). Finally, although a standard self-report measure of MPA was used (American College of Sports Medicine, 2009; CDC, 2003), an objective measure may have provided a more accurate assessment. Future Directions All barriers in the present study were reported as being present, suggesting that women with arthritis experience a broad array of barriers. Thus, a list of barriers, including both general and arthritis specific, may not be sufficient to always capture relevant barriers in all women with arthritis. In the future, one strategy to still capture personally relevant, arthritis-specific, and/or general barriers, and to reduce subject burden (i.e., versus assessing a long list of barriers) would be to have individuals report their barriers in an open-ended fashion. Then, individuals also could report the actual frequency with which each listed barrier occurs and its limitation (Brawley et al.,1998). Doing so would provide interventionists with a better idea of the most frequent and problematic barriers. For example, certain barriers may have high limitations but are not experienced frequently across women with arthritis. Thus, to increase the effectiveness of an intervention across all participants, interventionists should target frequently occurring and limiting barriers. Further, identifying strategies that regularly active women with arthritis use to overcome their barriers can guide future interventions to help other women diagnosed with arthritis, who

struggle in being active, learn and practice the use of such strategies (Bandura, 2004). Clinical Practice Application Enhancing MPA adherence is important so women with arthritis can better manage their arthritis and realize health improvements. Existing physical activity programs offered through organizations, such as the Arthritis Foundation (e.g., Arthritis Foundation Exercise Program and Self-Help Course) and the CDC (e.g., Chronic Disease Self-Management Program; Active Living Everyday), are effective in improving health and overcoming select barriers (Boutaugh, 2003; Rejeski, Brawley, & Jung, 2008). However, the present research suggests participants in PA programming should also identify their own relevant barriersdparticularly those that are limitingdand learn strategies to cope through interactions with program participants and leaders (cf. Baumeister & Vohs, 2003; Rejeski et al., 2008; Meichenbaum & Turk, 1987). These interactions should first focus on women identifying limiting arthritis-specific and general, personal, and situational barriers. Leaders should then focus on helping women to identify and communicate potential cognitive (e.g., thinking about arthritisrelated outcomes arising from activity, including reduced pain) and behavioral (e.g., modifying activity when in pain; schedule activity) coping strategies (cf. Brawley, Rejeski, & Lutes, 2007; Der Ananian et al., 2006; Gyurcsik et al., 2009). As women practice effectively using coping strategies when barriers arise, their confidence to continue to use the strategies when needed should increase, thus positively impacting their MPA adherence (Bandura, 1997). Coping must be discussed across multiple sessions, as women face new barriers and/or need further ideas for coping strategies (Meichenbaum & Turk,1987). As the women become practiced and efficacious in their use of effective strategies, the need for these interactions will reduce and only be required when new barriers arise that severely limit activity participation. Conclusion Promoting regular MPA among women with arthritis will help them to better manage their arthritis and improve their health. The present study provided information that the limitation of arthritis-specific and general barriers may be important to assess when identifying problematic barriers. Thus, limiting perceived barriers may be one factor to target in interventions. References Abell, J. E., Hootman, J. M., Zack, M. M., Moriarty, D., & Helmick, C. G. (2005). Physical activity and health related quality of life among people with arthritis. Journal of Epidemiology and Community Health, 59, 380e385. American College of Sports Medicine. (2009). Physical activity and public health guidelines. Available: http://www.acsm.org. Accessed April 22, 2009. Bajwa, H. A., & Rogers, L. Q. (2007). Physical activity barriers and program preferences among indigent internal medicine patients with arthritis. Rehabilitation Nursing, 32, 31e40. Bandura, A. (1986). Social foundations of thought and action: A social cognitive theory. Englewood Cliffs, NJ: Prentice Hall. Bandura, A. (1997). Self-efficacy. The exercise of control. New York: W.H. Freeman and Company. Bandura, A. (2004). Health promotion by social cognitive means. Health Education and Behavior, 31, 143e164. Baumeister, R. F., Heatherton, T. F., & Tice, D. M. (1994). Losing control. How and why people fail at self-regulation. San Diego: Academic Press. Baumeister, R. F., & Vohs, K. D. (2003). Self-regulation and the executive function of the self. In M. R. Leary, & J. P. Tangney (Eds.), Handbook of self and identity (pp. 197e217). New York: Guilford Press. Bloomquist, C. D., Gyurcsik, N. C., Brawley, L. R., Spink, K. S., & Bray, S. R. (2008). The road to exercise is filled with good intentions: Why don’t my proximal

D.R. Brittain et al. / Women's Health Issues 21-1 (2011) 57e63 exercise intentions match my actions? Journal of Applied Biobehavioral Research, 13, 102e118. Bloomquist, C. D., Hillard, S., Gyurcsik, N. C., Hacker, T., & Morales, R. (2004). An investigation of barriers to physical activity among women with arthritis using an ecological approach. Journal of Sport and Exercise Psychology, 26(S37). Boutaugh, M. L. (2003). Arthritis Foundation community-based physical activity programs: Effectiveness and implementation issues. Arthritis Care and Research, 49, 463e470. Brawley, L. R., Culos-Reed, S. N., Angove, J., & Hoffman-Goetz, L. (2002). Understanding the barriers to physical activity for cancer patients: Review and recommendations. Journal of Psychosocial Oncology, 20, 1e22. Brawley, L. R., Martin, K. A., & Gyurcsik, N. C. (1998). Problems in assessing perceived barriers to exercise: Confusing obstacles with attributions and excuses. In J. Duda (Ed.), Advances in sport and exercise psychology measurement (pp. 337e350). Morgantown, WV: Fitness Information Technology. Brawley, L. R., Rejeski, W. J., & Lutes, L. (2007). A group-mediated cognitivebehavioral intervention for increasing adherence to physical activity in older adults. Journal of Applied Biobehavioral Research, 5, 47e65. Brittain, D. R., Gyurcsik, N. C., & McElroy, M. (2008). Perceived barriers to physical activity among adult lesbians. Women in Sport and Physical Activity, 17, 68e79. Brittain, D. R., Baillargeon, T., McElroy, M., Aaron, D., & Gyurcsik, N. C. (2006). Barriers to moderate physical activity in adult lesbians. Women and Health, 43, 75e92. Centers for Disease Control and Prevention (CDC). (2003). Prevalence of physical activity, including lifestyle activities among adults, US 2000e2001. Morbidity and Mortality Weekly Report, 53, 764e769. Centers for Disease Control and Prevention (CDC). (2008). Notice to readers: Arthritis is awareness monthdMay 2008. Morbidity and Mortality Weekly Report, 57, 498e499. Conn, V. S., Hafdahl, A. R., Minor, M. A., & Nielsen, P. J. (2008). Physical activity interventions among adults with arthritis: Meta-analysis of outcomes. Seminars in Arthritis and Rheumatism, 37, 307e316. Der Ananian, C., Wilcox, S., Saunders, R., Watkins, K., & Evans, A. (2006). Factors that influence exercise among adults with arthritis in three activity levels. Preventing Chronic Disease, 3, 1e16. Eyler, A. A. (2003). Correlates of physical activity: Who’s active and who’s not? Arthritis Care and Research, 49, 136e140. Fontaine, K. R., & Haaz, S. (2006). Risk factors for lack of recent exercise in adults with self-reported, professionally diagnosed arthritis. Journal of Clinical Rheumatology, 12, 66e69. Gecht, M. R., Connell, K. J., Sinacore, J. M., & Prohaska, T. R. (1996). A survey of exercise beliefs and exercise habits among people with arthritis. Arthritis Care and Research, 9, 82e88. Gyurcsik, N. C., Brawley, L. R., Spink, K. S., Brittain, D. R., Fuller, D. L., & Chad, K. (2009). Physical activity in women with arthritis: Examining perceived barriers and selfregulatory efficacy to cope. Arthritis & Rheumatism, 61, 1087e1094. Gyurcsik, N. C., Bray, S. R., & Brittain, D. R. (2004). Coping with barriers to vigorous physical activity during transition to university. Family and Community Health, 27, 130e142. Gyurcsik, N. C., Spink, K. S., Bray, S. R., Chad, K., & Kwan, M. (2006). An ecologically based examination of barriers to physical activity in students from grade seven through the first year of university. Journal of Adolescent Health, 38, 704e711. Hadjistavropoulos, T., Herr, K., Turk, D. C., Fine, P. G., Dworkin, R. H., Helme, R., et al. (2007). An interdisciplinary expert consensus statement on assessment of pain in older adults. Clinical Journal of Pain, 23, S1eS43. Helmick, C. G., Felson, D. T., Lawrence, R. C., Gabriel, S., Hirsch, R., Kwoh, C. K., et al. (2008). Estimates of the prevalence of arthritis and other rheumatic conditions in the United States. Arthritis Care and Research, 58, 15e25. Hendry, M., Williams, N. H., Markland, D., Wilkinson, C., & Maddison, P. (2006). Why should we exercise when our knees hurt? A qualitative study of primary care patients and osteoarthritis of the knee. Family Practice, 23, 558e567. Hootman, J. M., Macera, C. A., Ham, S. A., Helmick, C. G., & Sniezek, J. E. (2003). Physical activity levels among the general US adult population and in adults with and without arthritis. Arthritis Care and Research, 49, 129e135.

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Jackson, E. L. (1988). Leisure constraints: A survey of past research. Leisure Sciences, 10, 203e215. Kang, H. S., Estwing Ferrans, C., Kim, M. J., Kim, J. I., & Lee, E. (2007). Aquatic exercise in older Korean women with arthritis. Identifying barriers to and facilitators of long-term adherence. Journal of Gerontological Nursing, 33, 49e56. Marks, R., & Allegrante, J. P. (2005). Chronic osteoarthritis and adherence to exercise: A review of literature. Journal of Aging and Physical Activity, 13, 434e460. Meichenbaum, D., & Turk, D. C. (1987). Facilitating treatment adherence: A practitioner’s guide. New York: Plenum Press. Minor, M., Stenstrom, C. H., Klepper, S. E., Hurley, M., & Ettinger, W. H. (2003). Work group recommendations: 2002 exercise and physical activity conference, St. Louis. Missouri. Arthritis Care and Research, 49, 453e454. Rejeski, W. J., Brawley, L. R., & Jung, M. E. (2008). Self-management of behavior in geriatric medicine. In J. B. Halter, J. G. Ouslander, M. E. Tinetti, S. Studenski, K. P. High, & S. Asthana (Eds.), Hazzard’s geriatric medicine and gerontology (pp. 325e341). New York: McGraw-Hill Medical. Sallis, J. F., & Owen, J. (1999). Physical activity and behavioral medicine. Thousand Oaks, CA: Sage. Shih, M., Hootman, J. M., Kruger, J., & Helmick, C. G. (2006). Physical activity in men and women with arthritis. National Health Interview Survey, 2002. American Journal of Preventive Medicine, 30, 385e393. Spink, K. S., Shields, C. A., Chad, K., Odnokon, P., Muhajarine, N., & Humbert, L. (2006). Correlates of structured and unstructured activity among sufficiently active youth: A new approach to understanding youth and adolescents’ level of physical activity. Pediatric Exercise Science, 26, 203e215. Tabachnik, B. G., & Fidell, L. S. (2007). Using multivariate statistics. Boston: Pearson Education Inc. Theis, K. A., Helmick, C. G., & Hootman, J. M. (2007). Arthritis burden and impact are greater among U.S. women than men: Intervention opportunities. Journal of Women’s Health, 16, 441e453. U.S. Department of Health and Human Services. (2008). Physical activity guidelines for Americans (ODPHP Publication No. U0036). Available: http:// www.health.gov/PAGuidelines/pdf/paguide.pdf. Accessed April 22, 2009. Wilcox, S., Der Ananian, C., Abbott, J., Vrazel, J., Ramsey, C., Sharpe, P. A., et al. (2006). Perceived exercise barriers, enablers, and benefits among exercising and nonexercising adults with arthritis: Results from a qualitative study. Arthritis Care and Research, 55, 616e627. Wilcox, S., Der Ananian, C., Sharpe, P. A., Robbins, J., & Brady, T. (2005). Correlates of physical activity in persons with arthritis: Review and recommendations. Journal of Physical Activity and Health, 2, 230e252.

Author Descriptions Danielle R. Brittain, PhD, is an Assistant Professor at the University of Oklahoma. She conducts research on theory-based, psychosocial factors of regular physical activity participation as a strategy for health promotion among healthy samples and those with various types of chronic disease.

Nancy C. Gyurcsik, PhD, is an Associate Professor in the College of Kinesiology at the University of Saskatchewan. Her research focus is on health promotion and arthritis management through physical activity adherence. Psychosocial factors important to adherence are of primary interest.

Mary McElroy, PhD, is a professor of Kinesiology and Public Health at Kansas State University. She has written several books and numerous journal articles on gender, race/ethnicity, and social class relating to participation in physical activity and sport.

Sara A. Hillard, MSc, was a Masters student in the Department of Kinesiology at Kansas State University at the time of this research. Her research focus was on barriers to physical activity among women with arthritis.