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Clinical
Factors influencing exercises in Chinese people with type 2 diabetes W. He1
MS, Y.
Zhang2
RN, BN
& F. Zhao1
MS
1 Lecturer, School of Nursing, Nantong University, Nantong, Jiangsu, China, 2 Registered Nurse with Bachelor’s Degree, and currently an undergraduate student, School of Nursing, Australian Catholic University, Brisbane, Queensland, Australia
HE W., ZHANG Y. & ZHAO F. (2013) Factors influencing exercises in Chinese people with type 2 diabetes. International Nursing Review 60, 494–500 Aims: The purpose of this article is to explore factors influencing adherence to exercise in Chinese people with type 2 diabetes (T2D). The findings can be used to explain exercise behaviours and develop interventions to improve the level of adherence to exercise. Methods: A qualitative approach was used in this study. Data were collected at Nantong City, China. A purposive sampling scheme was used to recruit people with T2D for in-depth semi-structured interviews. Potential patients chosen from the case records in one teaching hospital were screened by telephone for eligibility. Inclusion criteria for recruiting participants were: diagnosis with T2D for at least 6 months; a treatment plan that recommends exercises; and ⱖ20 years of age. Exclusion criteria included: type 1 diabetes; severe complications of T2D; and cognitive impairment. Each interview was audio-recorded. Recruitment efforts were suspended when the data reached saturation. Thematic analysis was employed to identify themes influencing factors from collected data. Results: Seventeen participants were recruited for interviews when data reached saturation. Six themes were identified after thematic analysis: ‘beliefs about disease’, ‘health communication’, ‘feasibility of regimen’, ‘conducting skills’, ‘environmental support’ and ‘perceived benefits’. Conclusion: The influencing factors should be comprehensively considered when explaining behaviour relating to exercises or designing health-promotional and health-educational interventions to improve the level of adherence to exercise. This study suggests that health professionals need to pay attention to the patient preferences during health communication to design a feasible exercise regimen in a collaborative way. Non-adherence to exercise cannot be attributed to patients only. Patients should be supported, not blamed. Limitation: The recruitment of participants from one city might limit the generalizations of the findings to larger areas of China and other ethnic groups. Gender differences related to factors influencing exercises need further consideration. Keywords: Adherence, China, Diabetes, Exercise
Introduction The number of people living with diabetes worldwide is expected to rise from 366 million in 2011 to 552 million by 2030 Correspondence address: Ms Fangfang Zhao, School of Nursing, Nantong University, No. 19 Qixiu Road, Chongchuan District, Nantong City, Jiangsu Province 226001, China; Tel: +86-513-85051868; Fax: +86-513-85051868; E-mail: [email protected].
© 2013 International Council of Nurses
if immediate action is not taken (International Diabetes Federation 2011). The international collaborative study of cardiovascular disease in Asia (InterASIA) (n = 15 236) reported that the prevalence of T2D (35–74 years of age) was 5.49% in China (Hu et al. 2008, 2009). A systematic review that selected 22 studies conducted between 1997 and 2008 with sample sizes ranging from 1058 to 769 792 participants found that the prevalence of type 2 diabetes (T2D) in adults increased from 2.6 to
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9.7% in China over the past decade (Chinese Diabetes Society 2011; Li et al. 2012). The increasing prevalence calls for an effective regimen of self-management to treat T2D. One of the key health behaviours for self-management of T2D is exercise. The China Guidelines for T2D recommends a regimen of more than 150 min of exercise per week for treating T2D (Chinese Diabetes Society 2011). The level of adherence to exercise, however, is unsatisfactory in Chinese people with T2D. Zheng et al. (2007) conducted a cross-sectional survey (n = 349) and pointed out that only 54.1% of the surveyed Chinese people with T2D followed exercise regimens. In a similar study (Gu et al. 2011), 301 participants with T2D self-reported the level of adherence to exercise. A score from 1 to 4 points represented a very poor to a very good degree of adherence, respectively, with an average score of 2.6 points among participants, indicating a low level of adherence (Gu et al. 2011). In an effort to improve the level of adherence to exercise in people with T2D, it became necessary to determine the factors influencing adherence to better health promotion and health education. We conducted a study with the following objectives: (1) to describe the exercising experiences of people with T2D, and (2) to explore factors influencing adherence to exercise in people with T2D.
Methods This study employed a qualitative approach in exploring adherence to exercise in Chinese people with T2D as conceptualized and grounded in personal experience. Setting and participants
The study took place in a health education room in one teaching hospital at Nantong City, China. Nantong City is located at the estuary of the Yangtze River in the east of Jiangsu Province, with a population totalling 7.6 million covering an area of 8000 km2 (Nantong Government 2012). According to the most recent survey in Nantong City, the T2D prevalence (ⱖ20 years of age) was 6.13% (236/3849) in 2006 (Huang et al. 2006). The average score of adherence to exercise was only 6.06 (full score was 16) in Nantong people with T2D (Gu et al. 2006). The teaching hospital was selected because it is a third-grade class-A (top grade and class) hospital with 2002 beds and over 130 million patient attendances per year. Inclusion criteria for recruiting participants were: diagnosis with T2D for at least 6 months; a treatment plan that recommends exercise; and ⱖ20 years of age. Exclusion criteria included: type 1 diabetes; severe complications of T2D; and cognitive impairment.
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Data collection
In-depth semi-structured one-to-one interviews were conducted to explore the factors influencing the level of adherence to exercise in Chinese people with T2D. A list of questions and topics that were addressed during the interviews had been prepared as an interview guide before the interviews (Table 1). Purposive sampling was employed in this study. Potential participants were chosen from case records in the hospital and were screened by telephone for eligibility based on inclusion and exclusion criteria. A necessary and brief explanation of the purpose of this study and the process of data collection was also done telephonically when obtaining permission from the participants. A written agreement for recruitment was obtained from each participant before interviews on the day appointed. Each interview took 1–1.5 h and was audio-recorded. The length of interview was adjusted in accordance with participants’ wishes and topic requirements (Holloway & Wheeler 2010). Sampling was stopped when the data collected reached saturation, which indicates the point at which a sense of closure is attained because new data yield redundant information (Polit & Beck 2012). Interviews were then transcribed and participants were asked to review the transcripts for accuracy and completeness. In this study, of all the participants invited, three declined via the telephone recruitment. Recruitment efforts were suspended when 17 participants were successfully enrolled and when the data reached saturation. Data analysis
Thematic analysis was used to analyse the data collected. Each interview was transcribed verbatim prior to commencing thematic analysis. During the process of analysis, analytical memos or notes containing ideas and thoughts about the data as well as the reasons for grouping them in a particular way were written. The phases of thematic analysis include: (1) familiarizing with data, (2) generating initial codes, (3) searching themes, (4) reviewing themes, (5) defining and naming themes, and (6) producing the report (Braun & Clarke 2006). Lincoln & Guba (1985) developed four criteria (credibility, dependability, confirmability and transferability) to judge the
Table 1 Interview guiding questions 1. Do you do exercises regularly? If yes, could you tell me how? If no, could you tell me why? 2. Could you please tell me what factors do you think influencing (facilitate/impede) your doing exercises? 3. Could you please tell me how you understand the role of exercises to your health?
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merits of qualitative research. Credibility and dependability in this study were conducted through the use of audit trail and member checking. The audit trail was conducted by the researchers and an independent auditor. The independent auditor was a nursing expert not involved directly in the research, but familiar with the qualitative research enquiry. The process of audit in this study followed five phases proposed by Erwin and colleagues (Erwin et al. 2005). Auditability also facilitated achieving confirmability. A member checking was made with the participants as described earlier to seek clarification from them. During the early stage of the research process, participants were invited to review their transcript and give further comments to make additional contributions or strengthen accuracy. During the analysis stage, participants were invited to review categories and themes developed by researchers. The member checking sought to determine the authenticity of the analysis. Transferability was addressed by describing the settings that enable the readers to evaluate the context of this study. Ethical consideration
The ethical issues of the study concerned ensuring individual confidentiality and autonomy of the participants. Participants were informed of the purpose and research design of this study. Informed consent was obtained from all participants.
Results Table 2 lists the demographic characteristics of participants recruited (n = 17) based on the data obtained during eligibility screening. As shown, the mean age of participants overall was 58 years, ranging from 39 to 77 years of age, and the mean duration of T2D was 10 years, ranging from 5 to 17 years. Through the interviews, participants were able to reflect on their perceptions on the factors influencing exercise. The core themes used by the participants to describe their perceptions on the influencing factors were characterized by: ‘beliefs about disease’, ‘health communication’, ‘feasibility of regimen’, ‘conducting skills’, ‘environmental support’ and ‘perceived benefits’. The following sections describe each of these interrelated themes and provide relevant quotations. Theme 1: beliefs about disease
The beliefs about disease that participants held greatly influenced the level of adherence to exercise. The message of T2D forming participants’ beliefs could be derived from the neurological system (e.g. hearing and vision) and their own past experiences. Patients with accurate and sufficient beliefs about T2D were more likely to be willingly and actively engaged in exercise. At first, I was too busy to find time for exercises. Then, he (my doctor) told me that healthy lifestyle is equally
Table 2 Demographic data of participants No.
Age, years
Gender
Profession
Education
Duration of T2D, years
Employment status
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17
76 74 55 55 49 58 43 55 39 61 65 67 75 40 55 54 70
Female Female Male Female Male Male Male Female Male Male Male Male Female Female Male Male Male
Medical doctor Company clerk Government officer Company clerk Government officer Government officer Engineer Accountant Company clerk Farmer Teacher Draftsman Nurse Company clerk Administrator Worker Veteran
Bachelor’s degree Secondary program Special course education* Special course education Special course education Secondary program Special course education Secondary program Special course education High school Special course education Bachelor’s degree Secondary program Bachelor’s degree Primary school High school High school
5 17 14 7 5 12 9 7 13 5 14 14 2 8 12 18 8
Retired Retired Employed Retired Employed Employed Employed Employed Employed Employed Employed Retired Retired Employed Employed Retired Retired
*A non-degree program higher than a secondary program. T2D, type 2 diabetes.
© 2013 International Council of Nurses
Influencing factors of exercises in T2D
important as medication. . . . I think what he says is correct. He is a medical expert after all. (Participant 3) I know doing exercises is good for health. . . . During a period when I worked on a project, I have not played badminton for about half a year. My blood glucose level was not wellcontrolled as before. . . . Now, I realise the importance of exercises . . . (Participant 7) Some beliefs about T2D from participants’ important referents (e.g. family members, close friends, colleagues, etc.) influenced the complementation of exercises. My job requires building up relationship with clients for running business. You know, Chinese culture . . . My director contributes much of his spare time to such social activity for relationship, and he sets us an example. . . . I cannot find time for doing sports. (Participant 9) Theme 2: health communication
The level of adherence to exercise was influenced by communication between the participants and health professionals. Participants tended to follow the experienced health professionals’ regimens in big hospitals. The more respect health professionals showed to participants, the more likely it was that participants would follow the proposed advice (exercises). He (my doctor) is a medical expert. . . . He is familiar with my case. . . . He is quite patient and has a caring heart. . . . His advices are convincing and easy to follow. (Participant 3) I prefer expert consultation service in big hospitals. . . . I trust their clinical experience. . . . The experts can tell me what exercises suit me best instead of just suggesting me to do exercises. (Participant 15) Ignoring participants’ preferences during health communication would make exercise regimens unmanageable. When I visit a doctor, I do not have the chance to talk about my own situation. . . . The doctor is always very busy and the consultation normally takes five minutes even less. . . . I just listen to the doctor’s advices. Everyone talks about the importance of exercises. But I still do not know how to do exercises after I visit the doctor. . . . Persistence in exercises is easy to say but hard to do. (Participant 16) Theme 3: feasibility of regimen
The participants were more likely to exercise when the regimen was feasible. Walking was the most popular exercise the participants endorsed because it could be easily integrated into participants’ daily lives.
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I usually walk for an hour after dinner. . . . I am old and cannot do any sports. When my doctor suggested me to do exercises, I thought of walking. . . . It has been my habit. (Participant 17) When patients built up some exercise activities, which then became habits, exercises would be easily maintained. Participants seldom felt tired of engaging in activity-oriented exercises and always did them with great enthusiasm. I have more leisure time after retirement. So I begin to learn to dance at citizen square. Many people dance there and I will not feel shy. I do not feel tired at all after dancing for an hour after dinner. (Participant 4) Theme 4: conducting skills
The participants with sufficient skills to engage in exercises demonstrated a good level of adherence. Skills at engaging in exercises could be obtained from their own experience, health professionals or people around them. I am always very busy with my work, and cannot afford enough time for exercises. But I think out a way. I usually get off the bus one stop prior to my destination, and then choose to walk home after work. I think it suits me because it will not take up too much of my time. (Participant 6) I can always see a group of people do some exercises with the equipment provided by the community. I learn to do some physical activities from them. Now, I am able to do exercises with all the equipment. (Participant 11) Some participants did not adhere to exercise because they lacked the skills of doing exercises, despite willingness to exercise. I once tried to play table tennis. But when I went to the venue, no one was willing to play with me because I am just a beginner. . . . My son helped me to apply for a swimming training class. I learn swimming from a coach. Now I always take my grandson and swim in swimming pool in summer. (Participant 10) Theme 5: environmental support
Environmental factors, including natural environment and social support, either facilitate or constrain the implementation of exercises. Natural environment refers to weather condition that influences the complementation of exercises. I can go swimming when it rains because the swimming pool is an indoor pool. But I cannot go swimming when it gets
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cold. In cold days, walking is possibly the only option. . . . Weather is an important factor. (Participant 10) Social support includes the assistance from other people, organizations and government departments. The lack of exercise equipment might constrain patients’ motivation to exercise. I have made some diabetic friends in my community. We do morning exercises in one fitness place in community every day except rainy days. . . . We often meet and exchange experience of our exercise habits and encourage each other. I feel quite confident with people solving the same problem as me. . . . I do not feel lonely. (Participant 12) When I visit my brother at countryside, I cannot find any exercise equipment there. . . . I cannot always just do walking there because it is boring. . . . I think the community support is very important. (Participant 11) Theme 6: perceived benefits
The benefits participants sensed served as a positive motivation for adherence to exercise. Perceived benefits can be expressed in a better physical sensation and the improvement of clinical indicators. Sometimes, I feel quite uncomfortable, and do not have the right mood to do anything. But I cannot help dancing once I hear the dancing music. Then, I leave behind all the stress and feel quite good. I will not feel tired at all while dancing. (Participant 4) I believe exercises help modify blood glucose. . . . Sometimes, I measured my blood glucose after walking for half an hour after dinner. Two-hour post-prandial blood glucose level always ranges between 7 and 8 mmol/l. Hyper glucose level does not happen. (Participant 13)
Discussion The findings of this study are hoped to expand and deepen the understanding of the experiences of maintaining exercises in Chinese people with T2D. As we have shown, six themes were identified as factors influencing the implementation of exercises in Chinese people with T2D. Participants expressed concerns about the influencing factors that cannot be determined or can only be partially determined by them. Before discussing the results further, a caveat is necessary. The results must be interpreted with regard to the study context and sample. This study employed Chinese participants. As a result, there is a danger that the results would be regarded as being specific to Chinese population. In reality, some experiences may be shared by other ethnic groups. Consistent with the research
© 2013 International Council of Nurses
findings in the qualitative approach with participants from UK (Lawton et al. 2006), Finland (Korkiakangas et al. 2011), Canada (Casey et al. 2010) and Australia (Wycherley et al. 2012), perceived physical, psychological, and therapeutical benefits and environmental support are considered as crucial motivators for people with T2D to exercise. We would not wish the findings of this study to be ghettoized, especially if this leads to their being perceived as a Chinese issue. It should also be noted that taking the appearance of similarity between other studies and this study at face value is inappropriate (Lawton et al. 2006). Health communication is a unique theme identified in this study. Some studies have been conducted to explore the association between health communication and health behaviour. A meta-analysis of 127 studies pointed out that communication in health care was highly correlated with patients’ adherence (Zolnierek & Dimatteo 2009). Some reviews drew a similar summary about the positive association between health communication and adherence to health behaviour (Jin et al. 2008; Roter & Hall 2009). In this study, participants mentioned the importance of health professionals, clinical settings, communication styles and their preferences during health communication related to exercises. Large hospitals play a dominant role in Chinese healthcare system as the majority of highly qualified health professionals are employed in and the most advanced medical facilities are available at these hospitals. Participants expected more experienced health professionals and better healthcare services in larger hospitals. Conformity to the authority of health professionals is the psychology default for most patients because health professionals are expected to be equipped with sufficient expertise (Cong 2004). Patients tend to behave as passive recipients because they rely on health professionals due to either deep trust or helplessness (Cong 2004). However, some participants recruited in this study stated that patients and health professionals should be collaborative during health communication. Their own opinions on how to exercise need to be considered. As a result, non-adherence to exercise recommendations cannot be attributed to patients only. Patients tend to adhere to a feasible exercise regimen and seek to gain skills on how to maintain it. The complexity of an exercise regimen will surely constrain the adherence to exercise. An effective way to design a feasible exercise regimen is to integrate exercise into daily activity or encourage patients to build up their exercise activities. Consistent with previous studies (Casey et al. 2010; Lawton et al. 2006), walking is the most popular exercise because it is easy to do. Surprisingly, even such simple exercise as walking needs strategies to adhere to when the participants were too busy to find time. Without developing exercise skills, an exercise regimen is meaningless and unfeasible. So,
Influencing factors of exercises in T2D
when an exercise regimen is delivered, relevant information or suggestions on developing skills should be delivered to people with T2D at the same time. Previous qualitative researchers identified the needs to provide supervision/support/guidance in exercises to make the regimen feasible (Casey et al. 2010; Korkiakangas et al. 2011; Lawton et al. 2006; Wycherley et al. 2012). It should be noted that a feasible regimen can only be made when considering patients’ preferences during a collaborative health communication. A rough prescription from health professionals, such as ‘you need to exercise’, should be abandoned. A detailed and feasible regimen including ‘what to do and how to do it’ should be proposed after sufficiently considering patients’ preferences. Implications for nursing practice and further research
This study suggests that influencing factors should be comprehensively considered when explaining the maintenance of exercises or designing health-promotion and health-educational interventions to improve the level of adherence to exercise. Some factors are patient related (e.g. belief about disease), while some require collaboration between patients, health professionals and health system (e.g. health communication, feasibility of regimen and environmental support). As a result, non-adherence to exercise cannot be solely attributed to patient-driven problems. A comprehensive consideration of influencing factors is needed when developing interventions for promoting adherence to exercise. For example, a person with T2D cannot be simply blamed if his non-adherence to exercise results from insufficient skill or unfeasible regimens. It is important for health professionals to work together with T2D patients to design feasible regimens after considering the patients’ preferences and the influencing factors to assure adherence to exercise. Further work should develop and validate scales that can be used to evaluate the influencing factors identified in this study. Confirmatory factor analysis can be used to test the model containing the influencing factors and the maintenance of exercises. Health-promotional and health-educational interventions can be designed to improve the level of adherence to exercise in this group. Measures should include the improvement of exercise motivators and reduction of barriers to exercise after comprehensively considering the influencing factors. Limitations
This study has limitations. First, the recruitment of participants in one city might limit the generalizations of the findings to larger areas of China. Further qualitative studies might be conducted to develop a stratified purposive sampling to promote generalization. The principle is that the participants’ answers in
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the different strata can be close to the whole population’s (Teddlie & Tashakkori 2009). Second, limitations of generalizing the findings to other ethnic groups cannot be excluded. Further studies are needed to confirm the influencing factors in other ethnic groups. Third, gender differences related to factors influencing exercises need further consideration.
Conclusion This study has identified six interrelated themes as factors influencing exercises in Chinese people with T2D. They are ‘beliefs about disease’, ‘health communication’, ‘feasibility of regimen’, ‘conducting skills’, ‘environmental support’ and ‘perceived benefits’. These themes provide guidance for explaining exercise behaviours and developing interventions for improving the level of adherence to exercise in Chinese people with T2D. Specifically, this study suggests that health professionals need to pay attention to the patients’ preferences during health communication to develop feasible exercise regimens with patients in a collaborative way. Non-adherence to exercise cannot be attributed to patients only, and patients should be supported, not blamed.
Declaration of competing interest No conflict of interest has been declared by the authors.
Author contributions W. He and F. Zhao: Study conception/design. W. He and Y. Zhang: Data collection/analysis. W. He and Y. Zhang: Drafting of manuscript. W. He and Y. Zhang: Critical revisions for important intellectual content. W. He: Supervision. W. He and F. Zhao: Statistical expertise. W. He: Administrative/technical/ material support.
References Braun, V. & Clarke, V. (2006) Using thematic analysis in psychology. Qualitative Research in Psychology, 3 (2), 77–101. Casey, D., De Civita, M. & Dasgupta, K. (2010) Understanding physical activity facilitators and barriers during and following a supervised exercise programme in type 2 diabetes: a qualitative study. Diabetic Medicine: A Journal of the British Diabetic Association, 27 (1), 79–84. Chinese Diabetes Society (2011) China Guideline for Type 2 Diabetes. Peking University Medical Press, Beijing. Cong, Y. (2004) Doctor-family-patient relationship: the Chinese paradigm of informed consent. The Journal of Medicine and Philosophy, 29 (2), 149–178. Erwin, E.H., Meyer, A. & McClain, N. (2005) Use of an audit in violence prevention research. Qualitative Health Research, 15 (5), 707–718. Gu, J., Gong, Y. & Lv, B. (2011) Survey of the compliance to medical advice among elder patients with diabetes in communities. Chinese General Practice, 14 (9B), 3007–3008.
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Gu, Y., et al. (2006) Investigation on the comprehensive treatment of people with type 2 diabetes in Nantong. Medical Journal of Communications, 20 (5), 619–620. Holloway, I. & Wheeler, S. (2010) Chapter 6. Interviewing. In Qualitative Research in Nursing and Healthcare, 3rd edn (Holloway, I. & Wheeler, S., eds). Wiley Blackwell, Chichester, West Sussex, pp. 87–106. Hu, D., et al. (2008) Increasing prevalence and low awareness, treatment and control of diabetes mellitus among Chinese adults: the InterASIA study. Diabetes Research And Clinical Practice, 81 (2), 250–257. Hu, D., et al. (2009) Prevalence and risk factors for type 2 diabetes mellitus in the Chinese adult population: the InterASIA Study. Diabetes Research And Clinical Practice, 84 (3), 288–295. Huang, J., Wu, G., Chen, D. & Li, G. (2006) Investigation and analysis on the epidemiology of Diabetes in Nantong City. Medical Journal of Communications, 20 (4), 469–472. International Diabetes Federation (2011) IDF Diabetes Atlas. Available at: http://www.idf.org/diabetesatlas/news/fifth-edition-release (accessed 1 May 2013). Jin, J., Sklar, G.E., Min Sen Oh, V. & Chuen Li, S. (2008) Factors affecting therapeutic compliance: a review from the patient’s perspective. Therapeutics and Clinical Risk Management, 4 (1), 269–286. Korkiakangas, E.E., et al. (2011) Motivators and barriers to exercise among adults with a high risk of type 2 diabetes – a qualitative study. Scandinavian Journal of Caring Sciences, 25 (1), 62–69. Lawton, J., et al. (2006) ‘I can’t do any serious exercise’: barriers to physical activity amongst people of Pakistani and Indian origin with type 2 diabetes. Health Education Research, 21 (1), 43–54.
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Li, H., et al. (2012) Diabetes prevalence and determinants in adults in China mainland from 2000 to 2010: a systematic review. Diabetes Research and Clinical Practice, 98 (2), 226–235. Lincoln, Y.S. & Guba, E.G. (1985) Naturalistic Inquiry. Sage Publications, Beverly Hills, CA. Nantong Government (2012) Introduction to Nantong. Available at: http:// www.nantong.gov.cn/col/col22/index.html (accessed 25 December 2012). Polit, D.F. & Beck, C.T. (2012) Glossary. In Nursing Research: Generating and Assessing Evidence for Nursing Practice, 9th edn (Polit, D.F. & Beck, C.T., eds). Wolters Kluwer and Lippincott Williams & Wilkins, Philadelphia, PA, pp. 719–746. Roter, D.L. & Hall, J.A. (2009) Communication and adherence: moving from prediction to understanding. Medical Care, 47 (8), 823–825. Teddlie, C. & Tashakkori, A. (2009) Chapter 8. Sampling strategies for mixed methods research. In Foundations of Mixed Methods Research: Integrating Quantitative and Qualitative Approaches in the Social and Behavioral Sciences, 1st edn (Teddlie, C. & Tashakkori, A., eds). Sage Publications, Inc., Thousand Oaks, CA, pp. 168–196. Wycherley, T.P., et al. (2012) Self-reported facilitators of, and impediments to maintenance of healthy lifestyle behaviours following a supervised research-based lifestyle intervention programme in patients with type 2 diabetes. Diabetic Medicine, 29 (5), 632–639. Zheng, S., et al. (2007) The compliance of setting up health life behavior style of T2DM patients. Chinese General Practice, 10 (23), 1980–1981. Zolnierek, K.B.H. & Dimatteo, M.R. (2009) Physician communication and patient adherence to treatment: a meta-analysis. Medical Care, 47 (8), 826–834.
Clinical
Factors influencing exercises in Chinese people with type 2 diabetes W. He1
MS, Y.
Zhang2
RN, BN
& F. Zhao1
MS
1 Lecturer, School of Nursing, Nantong University, Nantong, Jiangsu, China, 2 Registered Nurse with Bachelor’s Degree, and currently an undergraduate student, School of Nursing, Australian Catholic University, Brisbane, Queensland, Australia
HE W., ZHANG Y. & ZHAO F. (2013) Factors influencing exercises in Chinese people with type 2 diabetes. International Nursing Review 60, 494–500 Aims: The purpose of this article is to explore factors influencing adherence to exercise in Chinese people with type 2 diabetes (T2D). The findings can be used to explain exercise behaviours and develop interventions to improve the level of adherence to exercise. Methods: A qualitative approach was used in this study. Data were collected at Nantong City, China. A purposive sampling scheme was used to recruit people with T2D for in-depth semi-structured interviews. Potential patients chosen from the case records in one teaching hospital were screened by telephone for eligibility. Inclusion criteria for recruiting participants were: diagnosis with T2D for at least 6 months; a treatment plan that recommends exercises; and ⱖ20 years of age. Exclusion criteria included: type 1 diabetes; severe complications of T2D; and cognitive impairment. Each interview was audio-recorded. Recruitment efforts were suspended when the data reached saturation. Thematic analysis was employed to identify themes influencing factors from collected data. Results: Seventeen participants were recruited for interviews when data reached saturation. Six themes were identified after thematic analysis: ‘beliefs about disease’, ‘health communication’, ‘feasibility of regimen’, ‘conducting skills’, ‘environmental support’ and ‘perceived benefits’. Conclusion: The influencing factors should be comprehensively considered when explaining behaviour relating to exercises or designing health-promotional and health-educational interventions to improve the level of adherence to exercise. This study suggests that health professionals need to pay attention to the patient preferences during health communication to design a feasible exercise regimen in a collaborative way. Non-adherence to exercise cannot be attributed to patients only. Patients should be supported, not blamed. Limitation: The recruitment of participants from one city might limit the generalizations of the findings to larger areas of China and other ethnic groups. Gender differences related to factors influencing exercises need further consideration. Keywords: Adherence, China, Diabetes, Exercise
Introduction The number of people living with diabetes worldwide is expected to rise from 366 million in 2011 to 552 million by 2030 Correspondence address: Ms Fangfang Zhao, School of Nursing, Nantong University, No. 19 Qixiu Road, Chongchuan District, Nantong City, Jiangsu Province 226001, China; Tel: +86-513-85051868; Fax: +86-513-85051868; E-mail: [email protected].
© 2013 International Council of Nurses
if immediate action is not taken (International Diabetes Federation 2011). The international collaborative study of cardiovascular disease in Asia (InterASIA) (n = 15 236) reported that the prevalence of T2D (35–74 years of age) was 5.49% in China (Hu et al. 2008, 2009). A systematic review that selected 22 studies conducted between 1997 and 2008 with sample sizes ranging from 1058 to 769 792 participants found that the prevalence of type 2 diabetes (T2D) in adults increased from 2.6 to
494
Influencing factors of exercises in T2D
9.7% in China over the past decade (Chinese Diabetes Society 2011; Li et al. 2012). The increasing prevalence calls for an effective regimen of self-management to treat T2D. One of the key health behaviours for self-management of T2D is exercise. The China Guidelines for T2D recommends a regimen of more than 150 min of exercise per week for treating T2D (Chinese Diabetes Society 2011). The level of adherence to exercise, however, is unsatisfactory in Chinese people with T2D. Zheng et al. (2007) conducted a cross-sectional survey (n = 349) and pointed out that only 54.1% of the surveyed Chinese people with T2D followed exercise regimens. In a similar study (Gu et al. 2011), 301 participants with T2D self-reported the level of adherence to exercise. A score from 1 to 4 points represented a very poor to a very good degree of adherence, respectively, with an average score of 2.6 points among participants, indicating a low level of adherence (Gu et al. 2011). In an effort to improve the level of adherence to exercise in people with T2D, it became necessary to determine the factors influencing adherence to better health promotion and health education. We conducted a study with the following objectives: (1) to describe the exercising experiences of people with T2D, and (2) to explore factors influencing adherence to exercise in people with T2D.
Methods This study employed a qualitative approach in exploring adherence to exercise in Chinese people with T2D as conceptualized and grounded in personal experience. Setting and participants
The study took place in a health education room in one teaching hospital at Nantong City, China. Nantong City is located at the estuary of the Yangtze River in the east of Jiangsu Province, with a population totalling 7.6 million covering an area of 8000 km2 (Nantong Government 2012). According to the most recent survey in Nantong City, the T2D prevalence (ⱖ20 years of age) was 6.13% (236/3849) in 2006 (Huang et al. 2006). The average score of adherence to exercise was only 6.06 (full score was 16) in Nantong people with T2D (Gu et al. 2006). The teaching hospital was selected because it is a third-grade class-A (top grade and class) hospital with 2002 beds and over 130 million patient attendances per year. Inclusion criteria for recruiting participants were: diagnosis with T2D for at least 6 months; a treatment plan that recommends exercise; and ⱖ20 years of age. Exclusion criteria included: type 1 diabetes; severe complications of T2D; and cognitive impairment.
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Data collection
In-depth semi-structured one-to-one interviews were conducted to explore the factors influencing the level of adherence to exercise in Chinese people with T2D. A list of questions and topics that were addressed during the interviews had been prepared as an interview guide before the interviews (Table 1). Purposive sampling was employed in this study. Potential participants were chosen from case records in the hospital and were screened by telephone for eligibility based on inclusion and exclusion criteria. A necessary and brief explanation of the purpose of this study and the process of data collection was also done telephonically when obtaining permission from the participants. A written agreement for recruitment was obtained from each participant before interviews on the day appointed. Each interview took 1–1.5 h and was audio-recorded. The length of interview was adjusted in accordance with participants’ wishes and topic requirements (Holloway & Wheeler 2010). Sampling was stopped when the data collected reached saturation, which indicates the point at which a sense of closure is attained because new data yield redundant information (Polit & Beck 2012). Interviews were then transcribed and participants were asked to review the transcripts for accuracy and completeness. In this study, of all the participants invited, three declined via the telephone recruitment. Recruitment efforts were suspended when 17 participants were successfully enrolled and when the data reached saturation. Data analysis
Thematic analysis was used to analyse the data collected. Each interview was transcribed verbatim prior to commencing thematic analysis. During the process of analysis, analytical memos or notes containing ideas and thoughts about the data as well as the reasons for grouping them in a particular way were written. The phases of thematic analysis include: (1) familiarizing with data, (2) generating initial codes, (3) searching themes, (4) reviewing themes, (5) defining and naming themes, and (6) producing the report (Braun & Clarke 2006). Lincoln & Guba (1985) developed four criteria (credibility, dependability, confirmability and transferability) to judge the
Table 1 Interview guiding questions 1. Do you do exercises regularly? If yes, could you tell me how? If no, could you tell me why? 2. Could you please tell me what factors do you think influencing (facilitate/impede) your doing exercises? 3. Could you please tell me how you understand the role of exercises to your health?
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merits of qualitative research. Credibility and dependability in this study were conducted through the use of audit trail and member checking. The audit trail was conducted by the researchers and an independent auditor. The independent auditor was a nursing expert not involved directly in the research, but familiar with the qualitative research enquiry. The process of audit in this study followed five phases proposed by Erwin and colleagues (Erwin et al. 2005). Auditability also facilitated achieving confirmability. A member checking was made with the participants as described earlier to seek clarification from them. During the early stage of the research process, participants were invited to review their transcript and give further comments to make additional contributions or strengthen accuracy. During the analysis stage, participants were invited to review categories and themes developed by researchers. The member checking sought to determine the authenticity of the analysis. Transferability was addressed by describing the settings that enable the readers to evaluate the context of this study. Ethical consideration
The ethical issues of the study concerned ensuring individual confidentiality and autonomy of the participants. Participants were informed of the purpose and research design of this study. Informed consent was obtained from all participants.
Results Table 2 lists the demographic characteristics of participants recruited (n = 17) based on the data obtained during eligibility screening. As shown, the mean age of participants overall was 58 years, ranging from 39 to 77 years of age, and the mean duration of T2D was 10 years, ranging from 5 to 17 years. Through the interviews, participants were able to reflect on their perceptions on the factors influencing exercise. The core themes used by the participants to describe their perceptions on the influencing factors were characterized by: ‘beliefs about disease’, ‘health communication’, ‘feasibility of regimen’, ‘conducting skills’, ‘environmental support’ and ‘perceived benefits’. The following sections describe each of these interrelated themes and provide relevant quotations. Theme 1: beliefs about disease
The beliefs about disease that participants held greatly influenced the level of adherence to exercise. The message of T2D forming participants’ beliefs could be derived from the neurological system (e.g. hearing and vision) and their own past experiences. Patients with accurate and sufficient beliefs about T2D were more likely to be willingly and actively engaged in exercise. At first, I was too busy to find time for exercises. Then, he (my doctor) told me that healthy lifestyle is equally
Table 2 Demographic data of participants No.
Age, years
Gender
Profession
Education
Duration of T2D, years
Employment status
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17
76 74 55 55 49 58 43 55 39 61 65 67 75 40 55 54 70
Female Female Male Female Male Male Male Female Male Male Male Male Female Female Male Male Male
Medical doctor Company clerk Government officer Company clerk Government officer Government officer Engineer Accountant Company clerk Farmer Teacher Draftsman Nurse Company clerk Administrator Worker Veteran
Bachelor’s degree Secondary program Special course education* Special course education Special course education Secondary program Special course education Secondary program Special course education High school Special course education Bachelor’s degree Secondary program Bachelor’s degree Primary school High school High school
5 17 14 7 5 12 9 7 13 5 14 14 2 8 12 18 8
Retired Retired Employed Retired Employed Employed Employed Employed Employed Employed Employed Retired Retired Employed Employed Retired Retired
*A non-degree program higher than a secondary program. T2D, type 2 diabetes.
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important as medication. . . . I think what he says is correct. He is a medical expert after all. (Participant 3) I know doing exercises is good for health. . . . During a period when I worked on a project, I have not played badminton for about half a year. My blood glucose level was not wellcontrolled as before. . . . Now, I realise the importance of exercises . . . (Participant 7) Some beliefs about T2D from participants’ important referents (e.g. family members, close friends, colleagues, etc.) influenced the complementation of exercises. My job requires building up relationship with clients for running business. You know, Chinese culture . . . My director contributes much of his spare time to such social activity for relationship, and he sets us an example. . . . I cannot find time for doing sports. (Participant 9) Theme 2: health communication
The level of adherence to exercise was influenced by communication between the participants and health professionals. Participants tended to follow the experienced health professionals’ regimens in big hospitals. The more respect health professionals showed to participants, the more likely it was that participants would follow the proposed advice (exercises). He (my doctor) is a medical expert. . . . He is familiar with my case. . . . He is quite patient and has a caring heart. . . . His advices are convincing and easy to follow. (Participant 3) I prefer expert consultation service in big hospitals. . . . I trust their clinical experience. . . . The experts can tell me what exercises suit me best instead of just suggesting me to do exercises. (Participant 15) Ignoring participants’ preferences during health communication would make exercise regimens unmanageable. When I visit a doctor, I do not have the chance to talk about my own situation. . . . The doctor is always very busy and the consultation normally takes five minutes even less. . . . I just listen to the doctor’s advices. Everyone talks about the importance of exercises. But I still do not know how to do exercises after I visit the doctor. . . . Persistence in exercises is easy to say but hard to do. (Participant 16) Theme 3: feasibility of regimen
The participants were more likely to exercise when the regimen was feasible. Walking was the most popular exercise the participants endorsed because it could be easily integrated into participants’ daily lives.
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I usually walk for an hour after dinner. . . . I am old and cannot do any sports. When my doctor suggested me to do exercises, I thought of walking. . . . It has been my habit. (Participant 17) When patients built up some exercise activities, which then became habits, exercises would be easily maintained. Participants seldom felt tired of engaging in activity-oriented exercises and always did them with great enthusiasm. I have more leisure time after retirement. So I begin to learn to dance at citizen square. Many people dance there and I will not feel shy. I do not feel tired at all after dancing for an hour after dinner. (Participant 4) Theme 4: conducting skills
The participants with sufficient skills to engage in exercises demonstrated a good level of adherence. Skills at engaging in exercises could be obtained from their own experience, health professionals or people around them. I am always very busy with my work, and cannot afford enough time for exercises. But I think out a way. I usually get off the bus one stop prior to my destination, and then choose to walk home after work. I think it suits me because it will not take up too much of my time. (Participant 6) I can always see a group of people do some exercises with the equipment provided by the community. I learn to do some physical activities from them. Now, I am able to do exercises with all the equipment. (Participant 11) Some participants did not adhere to exercise because they lacked the skills of doing exercises, despite willingness to exercise. I once tried to play table tennis. But when I went to the venue, no one was willing to play with me because I am just a beginner. . . . My son helped me to apply for a swimming training class. I learn swimming from a coach. Now I always take my grandson and swim in swimming pool in summer. (Participant 10) Theme 5: environmental support
Environmental factors, including natural environment and social support, either facilitate or constrain the implementation of exercises. Natural environment refers to weather condition that influences the complementation of exercises. I can go swimming when it rains because the swimming pool is an indoor pool. But I cannot go swimming when it gets
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cold. In cold days, walking is possibly the only option. . . . Weather is an important factor. (Participant 10) Social support includes the assistance from other people, organizations and government departments. The lack of exercise equipment might constrain patients’ motivation to exercise. I have made some diabetic friends in my community. We do morning exercises in one fitness place in community every day except rainy days. . . . We often meet and exchange experience of our exercise habits and encourage each other. I feel quite confident with people solving the same problem as me. . . . I do not feel lonely. (Participant 12) When I visit my brother at countryside, I cannot find any exercise equipment there. . . . I cannot always just do walking there because it is boring. . . . I think the community support is very important. (Participant 11) Theme 6: perceived benefits
The benefits participants sensed served as a positive motivation for adherence to exercise. Perceived benefits can be expressed in a better physical sensation and the improvement of clinical indicators. Sometimes, I feel quite uncomfortable, and do not have the right mood to do anything. But I cannot help dancing once I hear the dancing music. Then, I leave behind all the stress and feel quite good. I will not feel tired at all while dancing. (Participant 4) I believe exercises help modify blood glucose. . . . Sometimes, I measured my blood glucose after walking for half an hour after dinner. Two-hour post-prandial blood glucose level always ranges between 7 and 8 mmol/l. Hyper glucose level does not happen. (Participant 13)
Discussion The findings of this study are hoped to expand and deepen the understanding of the experiences of maintaining exercises in Chinese people with T2D. As we have shown, six themes were identified as factors influencing the implementation of exercises in Chinese people with T2D. Participants expressed concerns about the influencing factors that cannot be determined or can only be partially determined by them. Before discussing the results further, a caveat is necessary. The results must be interpreted with regard to the study context and sample. This study employed Chinese participants. As a result, there is a danger that the results would be regarded as being specific to Chinese population. In reality, some experiences may be shared by other ethnic groups. Consistent with the research
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findings in the qualitative approach with participants from UK (Lawton et al. 2006), Finland (Korkiakangas et al. 2011), Canada (Casey et al. 2010) and Australia (Wycherley et al. 2012), perceived physical, psychological, and therapeutical benefits and environmental support are considered as crucial motivators for people with T2D to exercise. We would not wish the findings of this study to be ghettoized, especially if this leads to their being perceived as a Chinese issue. It should also be noted that taking the appearance of similarity between other studies and this study at face value is inappropriate (Lawton et al. 2006). Health communication is a unique theme identified in this study. Some studies have been conducted to explore the association between health communication and health behaviour. A meta-analysis of 127 studies pointed out that communication in health care was highly correlated with patients’ adherence (Zolnierek & Dimatteo 2009). Some reviews drew a similar summary about the positive association between health communication and adherence to health behaviour (Jin et al. 2008; Roter & Hall 2009). In this study, participants mentioned the importance of health professionals, clinical settings, communication styles and their preferences during health communication related to exercises. Large hospitals play a dominant role in Chinese healthcare system as the majority of highly qualified health professionals are employed in and the most advanced medical facilities are available at these hospitals. Participants expected more experienced health professionals and better healthcare services in larger hospitals. Conformity to the authority of health professionals is the psychology default for most patients because health professionals are expected to be equipped with sufficient expertise (Cong 2004). Patients tend to behave as passive recipients because they rely on health professionals due to either deep trust or helplessness (Cong 2004). However, some participants recruited in this study stated that patients and health professionals should be collaborative during health communication. Their own opinions on how to exercise need to be considered. As a result, non-adherence to exercise recommendations cannot be attributed to patients only. Patients tend to adhere to a feasible exercise regimen and seek to gain skills on how to maintain it. The complexity of an exercise regimen will surely constrain the adherence to exercise. An effective way to design a feasible exercise regimen is to integrate exercise into daily activity or encourage patients to build up their exercise activities. Consistent with previous studies (Casey et al. 2010; Lawton et al. 2006), walking is the most popular exercise because it is easy to do. Surprisingly, even such simple exercise as walking needs strategies to adhere to when the participants were too busy to find time. Without developing exercise skills, an exercise regimen is meaningless and unfeasible. So,
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when an exercise regimen is delivered, relevant information or suggestions on developing skills should be delivered to people with T2D at the same time. Previous qualitative researchers identified the needs to provide supervision/support/guidance in exercises to make the regimen feasible (Casey et al. 2010; Korkiakangas et al. 2011; Lawton et al. 2006; Wycherley et al. 2012). It should be noted that a feasible regimen can only be made when considering patients’ preferences during a collaborative health communication. A rough prescription from health professionals, such as ‘you need to exercise’, should be abandoned. A detailed and feasible regimen including ‘what to do and how to do it’ should be proposed after sufficiently considering patients’ preferences. Implications for nursing practice and further research
This study suggests that influencing factors should be comprehensively considered when explaining the maintenance of exercises or designing health-promotion and health-educational interventions to improve the level of adherence to exercise. Some factors are patient related (e.g. belief about disease), while some require collaboration between patients, health professionals and health system (e.g. health communication, feasibility of regimen and environmental support). As a result, non-adherence to exercise cannot be solely attributed to patient-driven problems. A comprehensive consideration of influencing factors is needed when developing interventions for promoting adherence to exercise. For example, a person with T2D cannot be simply blamed if his non-adherence to exercise results from insufficient skill or unfeasible regimens. It is important for health professionals to work together with T2D patients to design feasible regimens after considering the patients’ preferences and the influencing factors to assure adherence to exercise. Further work should develop and validate scales that can be used to evaluate the influencing factors identified in this study. Confirmatory factor analysis can be used to test the model containing the influencing factors and the maintenance of exercises. Health-promotional and health-educational interventions can be designed to improve the level of adherence to exercise in this group. Measures should include the improvement of exercise motivators and reduction of barriers to exercise after comprehensively considering the influencing factors. Limitations
This study has limitations. First, the recruitment of participants in one city might limit the generalizations of the findings to larger areas of China. Further qualitative studies might be conducted to develop a stratified purposive sampling to promote generalization. The principle is that the participants’ answers in
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the different strata can be close to the whole population’s (Teddlie & Tashakkori 2009). Second, limitations of generalizing the findings to other ethnic groups cannot be excluded. Further studies are needed to confirm the influencing factors in other ethnic groups. Third, gender differences related to factors influencing exercises need further consideration.
Conclusion This study has identified six interrelated themes as factors influencing exercises in Chinese people with T2D. They are ‘beliefs about disease’, ‘health communication’, ‘feasibility of regimen’, ‘conducting skills’, ‘environmental support’ and ‘perceived benefits’. These themes provide guidance for explaining exercise behaviours and developing interventions for improving the level of adherence to exercise in Chinese people with T2D. Specifically, this study suggests that health professionals need to pay attention to the patients’ preferences during health communication to develop feasible exercise regimens with patients in a collaborative way. Non-adherence to exercise cannot be attributed to patients only, and patients should be supported, not blamed.
Declaration of competing interest No conflict of interest has been declared by the authors.
Author contributions W. He and F. Zhao: Study conception/design. W. He and Y. Zhang: Data collection/analysis. W. He and Y. Zhang: Drafting of manuscript. W. He and Y. Zhang: Critical revisions for important intellectual content. W. He: Supervision. W. He and F. Zhao: Statistical expertise. W. He: Administrative/technical/ material support.
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