Participation in Physical Activity by Persons Living with HIV Disease

JANAC Vol. 14, No. 5, September/October 2003 10.1177/1055329003255284 Clingerman / Participation in Physical Activity

Participation in Physical Activity by Persons Living With HIV Disease Evelyn M. Clingerman, RN, DNSc

Physical activity (PA) may offer substantial health benefits for persons with HIV disease. The purpose of this study is to describe and explore physical activity behaviors in a sample of persons living with HIV disease. This descriptive correlational study surveyed 78 persons (n = 70 men; n = 8 women) from two outpatient settings. Results showed somewhat fewer of the participants met Healthy People 2010 PA recommendations than persons in the general population. Walking was the preferred PA. Average functional social support was significantly correlated with (a) weekly frequency of performing moderate 30-minute PA (r = .38, p < .01) and (b) HIV-RNA (viral load) values (r = –.37, p < .05). Significant correlations were also found between scores on general health status self-reported CD4+ cell counts (.33, p < .05) and HIV-RNA (.39, p < .05) values. Total friend functional social support was significantly (.32, p < .01) correlated with weekly frequency of moderate or vigorous PA. Key words: HIV disease, physical activity, social support, health promotion

Although more than 20 million persons have died as a result of infection with HIV, more than 40 million people worldwide live with HIV infection (Henry J. Kaiser Family Foundation, 2002). Primarily as a result of improvements in antiretroviral therapy and subsequently fewer opportunistic infections, there is an increased prevalence of persons living with HIV disease (PLWHD). The Centers for Disease Control and Prevention (CDC, 2002) estimates that between 850,000 and 900,000 Americans are living with HIV or acquired immunodeficiency syndrome (AIDS).

Many HIV seropositive Americans can expect to live full and productive lives for decades (Gifford & Sengupta, 1999). Persons infected with HIV, as others who have chronic and debilitating illnesses, experience a disease course that is variable in acuity, length, and disability (Corbin & Strauss, 1992; Strauss et al., 1984). HIV disease can deprive an individual of his or her physical and psychological resources, such as mobility, muscular strength, joint flexibility, endurance, and energy (LaPerriere, Klimas, Major, & Perry, 1997; Shepard, 1997a). Physical activity may facilitate coping with illness-related stress and improve aerobic capacity and cardiopulmonary and immune function for PLWHD (Calabrese & LaPerriere, 1993; Chesney & Folkman, 1994). Empirical findings show that PLWHD value and utilize exercise as a form of self-care or health promotion (Barroso, 1995; Kendall, 1992; Standish et al., 2001). Furthermore, the scientific literature provides evidence of exercise interventions with this population (Baigis et al., 2002; LaPerriere et al., 1991; LaPerriere, Klimas, Fletcher, et al., 1997; Mustafa et al., 1999; Nixon, O’Brien, Glazier, & Tynan, 2002; Roubenoff et al., 1999). Yet little is known about current health-promoting physical activity behaviors of PLWHD. Type, frequency, and duration of physical activity behaviors for this population are missing from the empirical literature. The purpose of this study is to describe and explore physical activity behaviors in a sample of PLWHD. The following research questions were posed: Evelyn M. Clingerman, RN, DNSc, is a post-doctoral fellow at the University of Texas at Austin.

JOURNAL OF THE ASSOCIATION OF NURSES IN AIDS CARE, Vol. 14, No. 5, September/October 2003, 59-70 DOI: 10.1177/1055329003255284 Copyright © 2003 Association of Nurses in AIDS Care

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• • •

What types of physical activity behaviors are performed by PLWHD? What is the frequency and duration of specific physical activity behaviors for PLWHD? What demographic and social factors are associated with participation in physical activity behaviors for PLWHD?

Background A contemporary perspective of health subsumes more than the absence of disease. This attitude toward health directs nurses and other health care professionals to focus on health promotion for people who live with chronic conditions. Coinciding with this perspective is an increasing prevalence of persons diagnosed with HIV disease. Thus, nurses are expanding the focus of care, from one that has been primarily acute and episodic to the maintenance of optimal wellness within the context of a chronic illness. Regular physical activity is a health promotion behavior that facilitates coping in chronic conditions (Gavin, Rejeski, & Norris, 1996; Morgan & Goldston, 1987; Pender, Murdaugh, & Parsons, 2002). Benefits associated with physical activity for the general population are clear (American College of Sports Medicine, 1998; Nieman, 1998; U.S. Department of Health and Human Services [USDHHS], 1996), and expectations of the type and amount of physical activity for healthy populations are identified in Healthy People 2010 national and state health care objectives (CDC & Center for Chronic Disease and Health Promotion [CCDHP] 2000; USDHHS, 2000). Healthy People 2010 classifies individuals as participating in regular moderate physical activity if they admit to participating in moderate activities five or more times per week for at least 30 minutes, or three or more times per week for at least 20 minutes for vigorous activity. The Behavioral Risk Factor Surveillance Survey (BRFSS) provides important data for tracking the health of our nation’s citizens.

(Holzemer, 2002). Early in the disease process, individuals may appear physically asymptomatic yet may experience psychosocial symptoms such as sadness, stress, anxiety, and fear. As the disease progresses in severity and symptoms increase, individuals face multiple lifestyle changes and eventual debilitation. Developing and maintaining a healthy lifestyle is important for persons infected with HIV. Physical inactivity places all people, including PLWHD, at higher risk for other acute and chronic conditions. Physical inactivity can prevent PLWHD from achieving their highest level of wellness. Physical activity behaviors may play an important and protective role for HIV-infected people over their lifetime. Focus group findings from 27 HIV-positive men (n = 19) and women (n = 8) in the rural South reflected unanimous agreement that participants valued exercise as an important self-care activity (Gaskins & Lyons, 2002). In spite of valuing physical activity, most persons admitted they did not engage in any type of organized exercise but did identify walking as the most common type of physical activity. Similar findings were reported from a survey of 1,675 HIVpositive men (n = 1,319) and women (n = 356), which showed that aerobic exercise was one of the most (63%) frequent activities (Standish et al., 2001). Barroso and Powell-Cope’s (2000) metasynthesis documented that persons living with HIV disease utilized physical activity as a self-care behavior, and found that it encouraged a commitment to stay healthy. Earlier, Barroso (1995) found that mild exercise was a theme of self-care for long-term survivors of HIV. The most common form of exercise identified was walking. Prior findings also showed that long-term HIV survivors who participated in physical fitness or exercise programs were able to adapt to illness-related changes (Solomon, Temoshok, O’Leary, & Zich, 1987). Further empirical evidence shows that PLWHD value and use physical activity as a strategy in health promotion throughout their disease process (Gaskins & Brown, 1992; Hall, 1994; Kendall, 1992). Physical Activity

Persons With HIV Disease An infection with HIV can proceed from an asymptomatic stage to the most severe stage of AIDS

Physical activity has been incorporated into disease treatment regimens for PLWHD. One program teaches that physical activity can decrease fatigue; improve

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muscular strength; increase flexibility, energy, and endurance; and improve a sense of well-being (Gifford, Lorig, Laurent, & Gonzales, 1997; Gifford & Sengupta, 1999). Furthermore, empirical evidence suggests that participation in interventions of moderate physical activity may provide specific health benefits such as cardiopulmonary fitness; improved immune, joint, and muscle function; and positive metabolic changes for PLWHD (Arey & Beal, 2002; LaPerriere, Klimas, Fletcher, et al., 1997; Perna et al., 1997; Smith et al., 2001). Exercise may actually slow the progression of an AIDS-related illness and may be effective in the prevention of complications such as malnutrition, AIDS wasting, and cardiovascular and lipid abnormalities, associated with HIV disease (Macallan, 1999; Mustafa et al., 1999; Terry, Sprinz, & Riberio, 1999). A recent Cochrane review summarized results of randomized controlled trials of aerobic exercise intervention studies for HIV-positive persons 18 years of age or older (Nixon et al., 2002). This report determined that aerobic exercise, at least 20 minutes three times a week for at least 4 weeks appeared to be safe and offered possible improvements in cardiopulmonary fitness and psychological well-being for adults living with this disease. Progressive resistance exercise, or muscle strengthening, offers a unique benefit by improving muscle mass in persons with HIV disease (Roubenoff, Suri, Raymond, Fauntleroy, & Gorback, 1997; Roubenoff & Wilson, 2001; Spence, Galantino, Mossberg, & Zimmerman, 1990). The preservation of lean body mass for individuals who experience lipodystrophy syndrome associated with highly active antiretroviral therapy may be particularly helpful (Brown & Batterham, 2001; Martinez, Garcia-Viejo, Blanch, & Gatell, 2001). Although exercise has psychological benefits that attenuate stress for people managing HIV disease (LaPerriere et al., 1990; LaPerriere et al., 1991; Stringer, Berezovskaya, O’Brien, Beck, & Casaburi, 1998), individuals may or may not participate in regular physical activity. Turk and Rudy (1991) suggested that patients appraise their symptoms, based on their self-knowledge, and make decisions regarding issues such as pain, symptom severity, health beliefs, and perceptions. Additionally, self-reported health status is thought to be a significant predictor of adherence to

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a 3-month exercise intervention (Pavone, Burnett, LaPerriere, & Perna, 1998). Important markers associated with health status for PLWHD include laboratory values. Holzemer (2002) reported that PLWHD generally know their most recently determined CD4+ cell counts and viral load values. Further evidence substantiated a correlation (r = .93) between self-report laboratory values and actual laboratory values in this population (Standish et al., 2001). Although published guidelines exist for safe aerobic exercise, assessment of specific physical activity behaviors for PLWHD remains undocumented. Social Support Social support is a key element that influences health and health promotion (Badura, 1991; Cohen, 1988; Gottlieb, 1985; Kasl & Cobb, 1966). Kahn (1979) conceptualized social support as an expression of affect, affirmation, and aid through personal networks. Given the potential for accompanying body image changes and social isolation, studies that examine the benefits associated with social support are particularly salient for persons with HIV disease (Martinez et al., 2001; Meadows, le Marechal, & Catalan, 1998). Empirical evidence has shown that there is a relationship between receiving emotional support and the ability to garner assistance or aid, for individuals managing their HIV disease (Adelman, 1989; Folkman, Chesney, & Christopher-Richard, 1994). More important, relationships between social support and positive health practices have been observed in the literature (Jeffery et al., 2000; McNicholas, 2002). Courneya and McAuley (1995) found that social support correlated with behavioral control, which led to exercise adherence (n = 62) in a structured exercise program. Similar findings were reported in a study of elderly women who exercised (O’Brien Cousins, 1995). More recently, Collins et al. (2001) determined that persons substantially changed their health-promoting behaviors following an HIV diagnosis. Social support networks, especially significant others, can be important in providing emotional, psychological support and assistance. Support from family and friends has been found to influence participation in physical activity in other populations (Sternfeld, Ainsworth, & Quesenberry, 1999). Cohen (1988)

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suggested providers of social support offer health promotion advice and encourage performance of health promotion activities. In spite of potential health benefits associated with physical activity and the need to facilitate optimal wellness while living with a chronic condition, few investigations have examined factors that facilitate or hinder physical activity for this population. Given theoretical and empirical linkages between physical activity and social support, and the need for increased knowledge development, an investigation exploring possible relationships is warranted.

Method Design Recruitment This descriptive, correlational study obtained a convenience sample of men (n = 70) and women (n = 8), recruited from two settings: (a) an infectious disease clinic (n = 68) and (b) a community service organization for HIV-positive individuals (n = 10). Data were collected during normally scheduled clinic and agency hours. Inclusion criteria were (a) 18 years of age or older, (b) self-disclosed infection with HIV, (c) no hospitalizations within the previous 4-week period, and (d) able to read and/or understand English. Participants resided in an urban area of the northern Great Lakes region of the United States. Participants identified their HIV status to the investigator, who acquired verbal confirmation by staff members in the respective settings.

Procedure Data Collection The Human Subjects Committee from the university and from the hospital associated with the Infectious Disease Clinic approved this study. Informed written consent was obtained from all study participants prior to enrollment. A staff member of the clinic or a member of the community health service agency setting identified prospective participants and introduced them to the investigator.

Instruments Personal Profile Form (PPF). The PPF is a researcher-developed instrument used to collect demographic and health-related information. It required less than 5 minutes to complete. Physical Activity Questionnaire (PAQ). The PAQ is composed of questions from Module 11 (physical activity) of the BRFSS, administered by the CDC (2002) and state departments of community or public health. The BRFSS, a random-digit-dialed telephone survey, is used to collect surveillance data with noninstitutionalized persons aged 18 years or older (Caspersen, 1997; Macera & Pratt, 2000). Module 11 questions have been used to capture progress toward meeting national health care objectives associated with Healthy People 2010 (USDHHS, 2000). This instrument assesses leisure time and occupationally related physical activity and includes walking and moderate, vigorous, and strengthening physical activity behaviors and elicits frequency (days per week) and duration (minutes per week) information. The investigator reformatted the 11 questions from Module 11 to eliminate “telephone surveyor cues” and instructions and to enhance appearance of the form for this study. A representative of CDC’s Physical Activity Division reviewed the PAQ for the intact nature and integrity of the questions. Reported reliability of Module 11 questions, Cronbach’s alpha, ranged from .50 to .84 in previous reports (Ainsworth et al., 1999; Jones et al., 1999). Internal consistency of the PAQ for this sample was coefficient alpha .73. The PAQ was used to operationalize Healthy People 2010 recommendations for physical activity behaviors with respect to type, frequency, and duration of walking and moderate, vigorous, and muscle-strengthening physical activities. Moderate activities were identified on the PAQ, as on Module 11 of the BRFSS, as activities such as brisk walking, bicycling, vacuuming, gardening or any activity that causes some increase in breathing or heart rate. Similarly, vigorous physical activity was described as running, aerobics, heavy yard work, or anything else that causes large increases in breathing or heart rate. Additional questions in the

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PAQ addressed occupationally related physical activity and sedentary activity (hours of television viewing). The Norbeck Social Support Survey (NSSQ). The 9item NSSQ is based on Kahn’s (1979) conceptualization of social support (Norbeck, 1995). The NSSQ measures multiple aspects of social support including affect, aid, and social networks. Network properties such as frequency of contact, amount of functional support, and support categories are computed. A search of multiple research databases show 309 NSSQ citations (Gigliotti, 2002). Adequate reliability and validity have been previously established in the literature (Fogel, 2001; Norbeck, 1981; Norbeck & Anderson, 1989; Norbeck, Lindsey, & Carrieri, 1981, 1983; Pedro, 2001). Cronbach’s alpha for the current sample was 0.95. The Medical Outcomes Study-HIV (MOS-HIV). The MOS-HIV (Wu, Revicki, Jacobson, & Malitz, 1997) is a 35-item disease-specific questionnaire that has been used to measure quality of life in this population. The MOS-HIV also includes an overall health status scale. This investigation measured health status using the overall health status scale, which is composed of five test items, scored 1 to 5. The total health status score is obtained after recoding three items and summing the items. Possible scores range from 5 to 25, with greater scores indicating better perceived health status. Raw scores are then transformed to a 0 to 100 scale. Reliability and validity of the MOS-HIV have been established in previous investigations, and it has been used extensively in studies for PLWHD (Baigis et al., 2002; Burgess, Dayer, Catalan, Hawkins, & Gazzard, 1993; Lubeck & Fries, 1992; Paton et al., 2002; Wachtel et al., 1992; Wu et al., 2002; Wu et al., 1991). Internal consistency for this sample was a Cronbach’s alpha of .84 for the five items.

Results Sociodemographic Characteristics Participants ranged in age from 23 to 70 years (M = 40.4, SD = 8.33). Most (59%) of the participants were

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African American, single (57.7%), and diagnosed (67.9%) in midlife (M = 32.5, SD = 9.19), and acquired HIV through sexual contact (68%). The majority (79.2%) of the participants completed at least high school, but a few (14.3%) earned less than a high school education. Approximately one quarter (n = 20, 25.6%) of the participants earned less than $10,000 annually, and slightly more than half (n = 45, 57.7%) earned less than $21,000 annually. Although many participants were unemployed (38.5%), approximately one quarter (26.9%) of the participants were employed more than 40 hours per week, and 16.7% were employed full time. Some participants (n = 13, 16.7%) identified that they were employed more than 40 hours per week. More (n = 47, 60.3%) participants reported knowing CD4+ cell counts than HIV-RNA values (n = 38, 48.7%). Mean reported CD4+ cell count was 386.2/ mm3 (SD = 321.7) and ranged from 2 to 1,200. Of those who reported CD4+ cell counts, 42.2% reported values less than 200. Self-reported mean HIV-RNA values were 32,108.2 (SD = 73,236) and ranged from undetectable to 300,000, with 23% of the participants reporting undetectable levels. Mean body mass index, based on self-reported height and weights, was computed as 24.2kg/m2. Physical Activity Behaviors Nearly one third (30.8%) of the participants in this sample identified that their occupationally related physical activity included mostly sitting or standing, whereas 15.4% identified working in occupations that involved walking and 15.4% in occupations that included heavy labor or physically demanding work. The majority (86%) of the participants identified walking at least 10 minutes at work or anytime during their usual day. Many of the participants identified that they engaged in a physical activity, although they did not perform the activity with the frequency or duration to meet Healthy People 2010 recommendations. For example, 67 persons identified that they may have performed some walking, whereas 42 individuals identified walking for at least 30 minutes at a time, and at least 5 days per week. The most common form of physical activity identified by the participants was

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Table 1. Healthy People 2010 Recommendations Physical Activity Walking (only) 30 minutes 5 days/week Walking and moderate physical activity Walking and vigorous physical activity Walking and moderate and vigorous physical activity Total walking recommendations Muscle strengthening 3 days per week Moderate (only) physical activity 5 days/ week at least 30 minutes Moderate physical activity and walking Moderate physical activity and vigorous physical activity Moderate, vigorous, and walking physical activity Total moderate recommendations Vigorous (only) physical activity 3 days/ week at least 20 minutes Vigorous physical activity and walking Vigorous physical activity and moderate physical activity Vigorous, moderate, and walking physical activity Total vigorous recommendations

n

Table 2. Frequency of Physical Activities (Percentage)

20 10 4 8 42 38

(53.8) (48.7)

Type of Physical Activity

Days/Week Performing Activities (Mode)

Participants (N)

Walking Strengthening Moderate physical activity Vigorous physical activity

5 3 3 3

23 16 15 7

3 10 1 8 22

(28.2)

2 4 1 8 15

(19.2)

walking. This was followed by muscle strengthening recommendations, then moderate, and finally vigorous activity. Although 57 participants identified performing moderate physical activities, only 22 (28.2% of the total sample) participants met Healthy People 2010 recommendations for moderate physical activity. Considerably fewer (n = 19) participants participated in vigorous physical activity behaviors, whereas 15 participants (19.2% of the total sample) reported meeting Healthy People 2010 recommendations for vigorous physical activity. Some persons may have met recommendations or engaged in more than one physical activity (Table 1). For example, the prevalence (53.8%) of persons who met the walking recommendation also included individuals who identified meeting both walking and moderate recommendations (n = 10), or walking and vigorous recommendations (n = 4). Although many participants engaged in at least one type of regular physical activity, 20 of the participants (25.6%) did not walk for more than 10 minutes at a time, nor did they perform moderate, vigorous, or strengthening physical activity. Thirty-one of the

participants (39.7%) did not meet any of the Healthy People 2010 recommendations. Frequency of physical activity was measured by number of days per week that participants engaged in the activity (Table 2). Frequency of walking was identified more often than the other physical activity behaviors. Duration of walking ranged from 30 to 1,800 minutes per week. Correlates of Physical Activity Although most demographic characteristics were not significant in this study, annual income was significantly correlated with (a) scores on overall health status (r = .50, p < .01), (b) weekly duration of vigorous physical activity (r = .49, p < .05), and (c) inversely (r = –.39) but significantly (p < .05) correlated with selfreported HIV-RNA values (Table 3). Additional significant relationships were found between the amount of average functional social support and (a) weekly frequency of moderate 30-minute physical activity (r = .38, p < .01), (b) weekly frequency of moderate or vigorous 30-minute physical activity (r = .29, p < .01), and (c) HIV-RNA (viral load) values (r = –.37, p < .05). Weekly duration (minutes) of vigorous physical activity was significantly (r = .46, p < .05) correlated with scores on general health status as well as income. Significant correlations were also found between scores on general health status and self-reported CD4+ (.33, p < .05) and HIV-RNA (–.39, p < .05) cell counts, as well as income, and frequency of vigorous physical activity. Sedentary activity, captured as television viewing (hours/week), demonstrated a significant (p < .05) inverse correlation (r = –.24) with frequency of moderate or vigorous 30-minute physical activity and approached an inverse significance (r = –22, p = .06) with respect to general health status.

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Table 3. Relationships Among Physical Activity, Health Status, Average Functional Support, and Self-Reported Laboratory Markers

1 2 3 4 5 6 7 8 9 10

1

2

3

—

.85** —

.05 .19 —

4 .38** .23 .01 —

5

6

7

–.06 .90 –.22 –.19 —

.39** .24 .18 .79** –.24* —

.39 .25 .46* .13 –.15 .32 —

8 .06 .18 .50** .03 –.15 –.01 .49* —

9

10

.13 .13 .33* –.16 .06 .21 .15 .09 —

–.37* –.40* –.39* –.01 .08 –.20 –.32 –.33* –.45** —

NOTE: 1 = Average functional support. 2 = Total functional support from friends. 3 = Overall health status. 4 = Weekly frequency of moderate 30 minutes of physical activity. 5 = Weekly duration of sedentary activity (television watching). 6 = Weekly frequency of moderate or vigorous 30 minutes of physical activity. 7 = Weekly vigorous physical activity duration. 8 = Annual income. 9 = CD4+ cell counts. 10 = viral load counts. *p < .05. **p <.01.

Discussion As a group, the participants in this study were more active than may have been expected. For example, 53% reported walking at least 30 minutes 5 days per week. Participants (n = 21) in this study reflected national data (26.9%) with respect to the number who did not participate in any leisure-time physical activity (CDC & CCDHP, 2002a; National Center for Health Statistics, 2001). Furthermore, findings showed that participants predominately favored walking as a form of physical activity over moderate, strengthening and vigorous activity, and performed walking with a greater frequency than other activities (Table 2). This is consistent with others who have found walking to be the most favorable form of physical activity (Barroso, 1995; Brooks, 1988; Gaskins & Lyons, 2002; Siegel, Brackbill, & Heath, 1995; Solomon et al., 1987). In this study, a slightly smaller percentage (28.2%) of the participants identified meeting moderate physical activity recommendations than national figures (30%) (CDC & CCDHP, 2002b). Curiously, a greater percentage (19.2%) of the participants in this sample identified meeting vigorous physical activity recommendations than the percentage (14%) in national data. A sizeable number of individuals in the current study also reported meeting muscle-strengthening recommendations. Findings associated with muscle strengthening and vigorous physical activity may have

reflected a strong masculine bias in the sampling of this study. National data reveal a more equitable gender distribution. Additionally, the current sample included a majority of participants who were employed, and whose health status may have afforded them an opportunity to include health promotion activities into their daily living. Others have found income positively related to performance of physical activity (Nies & Kershaw, 2002). The relationship between health status, frequency of vigorous physical activity, and laboratory markers was notable, indicating that participants that viewed a more favorable health status reported more frequent participation in vigorous forms of physical activity and identified higher levels of CD4+ cell counts and lower HIV-RNA values. Previous research identified measures of physical health as a predictor of adherence to physical exercise in a sample of 34 seropositive men and women (Pavone et al., 1998). These findings demonstrated a preference for walking, as well as a greater frequency of walking versus other types of physical activity. Walking may be predictive of participation in other types of healthpromoting physical activity for this population. Larger sample sizes using a longitudinal design could lead to more powerful insights. The scientific community has supported both aerobic and progressive resistance exercise in this population (Carr, 2000; Martinez et al., 2001; Nixon et al., 2002; Roubenoff & Wilson, 2001).

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These results also identified muscle strengthening as an important type of physical activity. Moderate lifestyle activity can enhance health in select populations (Blair & Connelly, 1996; Shepard, 1997b). Studies comparing structured and unstructured interventions for persons living with chronic HIV disease are worthy of research consideration.

Nursing Implications Developing and maintaining a healthy lifestyle for PLWHD is important and can influence both the quality and quantity of life. The findings in this study with respect to the relationship between income and general health status are not unlike previous research (Clark, Grembowski, & Durham, 1995). Contextual factors associated with low-income levels have been associated with higher rates of psychological distress, ineffective coping strategies, and the likelihood of fewer social supportive resources (Weiss & Lonnquist, 2003; Wilkinson, 1992). One can postulate that low-income persons in this sample also perceived their general health status as low. Given the increased numbers of individuals living longer with HIV disease, increased incidence of HIV among economically disenfranchised groups, and nursing’s commitment to health promotion, it is crucial that nurse researchers incorporate poverty and marginality into their research. Changing welfare eligibility criteria may find clients challenged to access benefits. Although there is empirical evidence showing that social support is important in health promotion (Courneya & McAuley, 1995; O’Brien Cousins, 1995; Oman & Duncan, 1995), there has been little scientific evidence supporting a strong relationship between specific physical activity behaviors and social support for people living with chronic HIV disease. In this study, significant relationships were found between participants’ average functional support and the frequency with which they participated in moderate or vigorous physical activity for 30-minute bouts. Studying nontraditional methods of accessing and using social support structures and networks may shed light on participation in physical activity with this population. Investigations and intervention programs that focus on individual responsibilities and overlook

social support networks could miss significant determinants of physical activity. Aerobic physical activity is considered safe for 20 minutes three times per week (Nixon et al., 2002). In light of recommendations and health-related benefits, nurses and other health care providers, particularly those in community and home care settings, should assess the type, frequency, and duration of physical activities, as well as social support resources. It is important for clinicians to teach PLWHD to incorporate physical activity behaviors associated with established guidelines into lifestyle health promotion. Researchers who focus on developing relational ties with communities of patients and clinicians can work toward empowering individuals and communities.

Limitations of the Study These results are encouraging, yet it is important to recognize a number of limitations. Data collected were self-reported and include measurement error. It may have been difficult for participants to recall all information with accuracy. A proxy measure of illness stage was collected from self-reported laboratory markers. This makes it difficult to offer specific illness-related generalizations. Persons living with HIV disease, as others with chronic or debilitating conditions, may have different health perceptions based on stage of illness as well as daily variations related to symptom presentation (Turk & Rudy, 1991). Stages of illness verification and/or laboratory test results are required to address these questions. Pharmacological treatment regimens, although not included in this investigation, could add additional insights. This study was limited to participants who attended a clinic and a community service organization, where counseling was more readily accessible. Future studies may benefit from identifying physical activity information provided by health care practitioners. This study did not attempt to identify intensity of physical activity behaviors. Calculating intensity adds more in-depth knowledge of health-related outcomes. Still, the Surgeon General’s report recognizes a continuum of intensity and duration for physical activity and suggests that sedentary persons begin with short

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durations of a moderate-intensity activity, such as walking (USDHHS, 1996). Additionally, physical activity behaviors may have been influenced as a result of winter months in a northern Midwest location. Longitudinal investigations are necessary to identify the presence of seasonal differences. It is also worth noting that the results of this study are limited to the sample of predominately male participants. Future studies are needed before generalizing results to include women. Given that women account for an estimated 30% of new HIV infections, and in light of the National Revitalization Act of 1993 regarding the inclusion of women in clinical research, future investigations must be attuned to exploring genderspecific differences (Denton, Hajdukowski-Ahmed, O’Connor, & Zeytinogulu, 1999; Henry J. Kaiser Family Foundation, 2002; National Institutes of Health & Office of Extramural Research, 2001). Previous research has historically focused on the efficacy of exercise interventions in controlled settings. Moderate intensity aerobic exercise is considered safe within the guidelines outlined for PLWHD (Nixon et al., 2002). One study examined the effect of a home-based exercise intervention (Baigis et al., 2002). The future role of nursing research must also be broadened to include distinct contextual disparities that exist for persons living in low-income settings. Research on physical activity and determining factors will contribute to further knowledge with respect to health promotion for an increasing population of people who are living with HIV disease.

Acknowledgments The author wishes to acknowledge the valuable contributions by Dr. Lynn Rew, EdD, RNC, HNC, FAAN, for her careful review of the manuscript, and the Cain Center for Nursing Research at The University of Texas School of Nursing for providing resources needed in manuscript preparation. The author is grateful to the generous participants in this study for contributing their time and personal efforts in this investigation.

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