Journal of Physical Activity and Health, 2014, 11, 1276  -1283 http://dx.doi.org/10.1123/jpah.2012-0386 © 2014 Human Kinetics, Inc.

Official Journal of ISPAH www.JPAH-Journal.com ORIGINAL RESEARCH

The Perceived Role and Influencers of Physical Activity Among Pregnant Women From Low Socioeconomic Status Communities in South Africa Moise Muzigaba, Tracy L. Kolbe-Alexander, and Fiona Wong Background: Facility-based and context-specific interventions to promote physical activity (PA) among pregnant women from economically underprivileged communities remain sparse and undocumented in South Africa. This study aimed to generate information about pregnant women’s views and experiences of PA during pregnancy, which will later be used to inform the development of a PA-based intervention targeting this group. Methods: Qualitative methods were used and framed on the Theory of Planned Behavior (TPB). Five focus group discussions were conducted at a Community Health Centre in Cape Town, each comprising a stratified random sample of between 8 and 6 pregnant women living in eight low socioeconomic status communities close to the facility. The participants included primi- and multigravida black and mixed racial ancestry women at different stages of pregnancy. Data were analyzed using a Framework approach. Results: PA was considered important for self and the baby for most participants. However, they reported a number of barriers for translating intentions into action including the lack of supportive environment, fear of hurting oneself and the growing baby, lack of time due to work and family responsibilities, and not knowing which and how much PA is safe to do. Some of the incentives to engage in PA included establishing community-based group exercise clubs, initiating antenatal PA education and PA sessions during antenatal visits. Conclusion: Based on our findings the need for an intervention to promote PA in pregnancy is evident. Such an intervention should, however, aim at addressing barriers reported in this study, particularly those related to the behavioral context. Keywords: determinants, pregnancy, poor communities A body mass index (BMI) of more than 25 has been associated with increased risk for noncommunicable disease, morbidity and mortality1 and more than half (56%) of South African women are either overweight or obese.2 Obesity during pregnancy is associated with pregnancy-induced hypertension, gestational diabetes, macrosomia, and preterm labor, among other adverse pregnancy outcomes.3 Excessive weight gain during pregnancy has also been reported as the strongest predictor for sustained weight retention one year after birth.4–6 Therefore, gestational weight gain and control is important as excessive weight gain which could adversely affect both the mother and baby’s health.7 Recent developments in public health practice in South Africa have led to the prioritization of pregnancy as an area of interventions to prevent obesity.8 Physical activity has been shown to play a role in controlling weight gain during pregnancy, and is therefore often recommended to women who were physically active before becoming pregnant. Women who were inactive before pregnancy can also increase their daily levels of physical activity, particularly in the second trimester, under the guidance of their physician.9 Indeed,

the health and fitness benefits of physical activity during pregnancy have been well documented10 and include a reduction in the risk of preeclampsia,11–13 the treatment or prevention of gestational diabetes,12,14 and improved plasma lipid and insulin response.15,16 Furthermore mental health benefits including increased vigor, reduced fatigue, reduced stress and anxiety, decreased symptoms of depression and improved self-concept are also well established.17 However, many women stop being physically active during pregnancy.10 Therefore the aim of this research study was to conduct a needs-assessment to determine the perceptions of physical activity during and after pregnancy among pregnant women residing in eight low socioeconomic status communities and who attended antenatal services at a Community Health Centre in Cape Town. The information obtained will be applied in the development of an intervention program which will complement the Antenatal Education and Birth Preparedness Program (AEBPP) currently being delivered in some healthcare facilities in South Africa. The study sought to provide answers to the following questions:

Muzigaba ([email protected]) is with the School of Public Health, University of the Western Cape, Cape Town, Western Cape Province, South Africa; the Research Associate, Durban University of Technology, Durban, South Africa; and the Nelson R. Mandela School of Medicine, School of Clinical Medicine, University of KwaZulu-Natal, Durban, South Africa. Kolbe-Alexander is with the UCT/MRC Research Unit for Exercise Science and Sports Medicine, University of Cape Town, Cape Town, Western Cape, South Africa. Wong is with the Dept of Monitoring and Evaluation, Matrix Public Health Consultants, Inc., Toronto, Ontario, Canada.

1. What are pregnant women’s beliefs/perceptions and attitudes vis-à-vis physical activity during and after pregnancy? 2. Do pregnant women agree that physical activity is good for them and their babies? If so, what are the barriers in translating intention to action? If not, what are they missing? 3. How does the individual’s behavioral context play a role? 4. Does it have to be what professionals think is appropriate for them? (What do pregnant women think would work for them given prevailing day to day conditions?)

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Promoting PA in Pregnancy in Resource-Poor Settings   1277

Methods

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Underlying Theory This study was framed on the Theory of Planned Behavior (TPB).18 The theory assumes that to predict an individual’s intention to participate in a particular behavior, it is important to establish their attitude toward the behavior. In addition, the influence of societal norms on their choices and decision making and their perceived behavioral control should be assessed.18 We sought to examine these predictors so as to establish a hypothetical pathway linking pregnant women’s attitudes, beliefs, norms and perceptions to their intentions to be physically active during pregnancy. Our assumptions for the proposed intervention (which is not reported here) are that by changing these “predictors” the participants will be more likely to perceive the benefits of physical activity and thus intention to include daily physical activity will increase, leading to a change in PA behavior. Figure 1 depicts our hypothetical model of behavioral pathways, based on the TPB, to being physically active during (and after) pregnancy.

Study Design This is a qualitative exploratory research study. It was conducted during the first wave of a facility-based implementation research project called the Expectant Parent Project (EPP) which aims to promote PA among pregnant women. The EPP was approved by the Human Research Ethics Committee of the Health Sciences Faculty at the University of Cape Town (HREC REF 477/2011). Approval to conduct the project at the research site (REF: RP 146/2011) was also obtained from the Directorate of Impact Assessment within the Western Cape Department of Health, South Africa.

Study Setting The study was conducted in the Maternal and Obstetric Unit (MOU) at Vanguard Community Health Centre, located in the Western Cape Province of South Africa. The MOU at the center operates five days per week, has a 24-hour labor ward, and on average admits about 100 antenatal bookings per week.19 The center serves 8 different communities (Bonteheuwel, Crossroads, Langa, Milnerton, Dunoon, Table

Figure 1 — Theoretical model of physical activity during and after pregnancy based on the Theory of Planned Behavior.20

1278  Muzigaba, Kolbe-Alexander, and Wong

View, Maitland, and Kensington) which have high unemployment rates. Residents of these communities are generally characterized by low income households, having low educational attainment, and if employed, are in relatively unskilled occupations.20

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Study Participants Participants in study were pregnant women attending antenatal services at the MOU at Vanguard Community Health Centre. These participants were from anyone of the eight communities described above. The researchers visited the MOU on five different days over a period of two months for data collection. On the day of data collection, all pregnant women present in the MOU were stratified by race and each stratum was subjected to simple random sampling. During random selection, all participants in each stratum were assigned a unique number (eg, ranging between 1 and 20). A random number table was then used to select consecutive 2-digit numbers starting from the upper left number. The random number that matched a participant’s number was added to the list of selected participants. This procedure was followed on five different visits and in each case, selection stopped when at least 3 participants in each stratum had been added to the list. Stratification was performed to ensure that pregnant women from all racial groups are adequately represented in the sample. Random selection allowed the researchers to obtain mixed samples of primi- and multigravida women as well as women at different age groups and stages of pregnancy. These criteria allowed some diversity in the sample and hence an array of women’s views and experiences was obtained.

Data Collection All the data were collected from March to April 2012. A topic guide was developed based on the theoretical framework depicted in Figure 1. The guide was then used to conduct one pilot and five actual focus group discussions (FGD) with study participants. In the 5 actual FGDs, 3 groups comprised 7 participants each, 1 group comprised 8 participants, and the other group comprised 6 participants. In total, there were 35 pregnant women who were invited to participate in the study, but only 34 completed the interviews. One woman stated that she was not interested in participating further and thus was excluded from the study. An interviewer-administered questionnaire was also used to gather information about each participant’s demographic, medical and pregnancy profiles as well as current PA levels. Physical activity levels were assessed in terms of minutes spent doing the equivalent of moderate intensity exercises per week.21 The interviewer asked participants to indicate which types of PA they were involved in during pregnancy, and the frequency with which the exercises were done. Based on this information, the interviewer subjectively estimated the intensity of PA as light, moderate or vigorous, and using a 3-item scale (physically active: ≥ 150 min/week; not physically active: < 150 min/week and not reported), whether the participant could be classified as being physically active or not. The information on the intensity and frequency was then recorded on the questionnaire. Standardized questionnaires such as the International Physical Activity Questionnaire and Pregnancy Physical Activity Questionnaire, among others, were not used in this study as this was not the main focus of the current investigation. The authors only sought to draw out a rough estimate of the physical activity profile among study participants. Participants signed informed consent forms before participating in the study. Focus groups consisted of between 8 and 6 pregnant

women selected as per the criteria explained earlier. All FGDs took place in a private room at the MOU and were recorded using a digital audio-recorder. Field notes were also compiled by a research assistant throughout the study period. Discussions lasted between 70 to 100 minutes and participants were allowed to express their views using a language of their preference. However, the English language dominated the discussion as most participants could understand English. A flexible and responsive approach22 was used to achieve a detailed exploration of pregnant women’s views and experiences about PA during pregnancy. Questions were posed in such a way that they do not make respondents uncomfortable to interact, as is often the case with FGDs. Participants were also reassured that the discussion was not meant to test their knowledge but rather to share experiences with each other.

Data Analysis The recorded data were first transcribed in the original language used by study participants. Where responses were in a language other than English, translation to English was done after transcriptions were completed. All five steps of a deductive framework analysis technique (Familiarization, identification of thematic framework, indexing, charting, as well as mapping and interpretation)23 were then applied. Data were interpreted against the underlying assumptions of the hypothetical framework in Figure 1. To maximize validity, standard operating procedures were developed for data collection and analysis. The topic guide was first piloted and refined before it was used during four subsequent FGDs. The pilot data are not included in the data analysis. Furthermore, only one trained FGD moderator was used to facilitate all the discussions. During analysis, all three researchers read two of the interview transcripts and agreed on the suitable coding framework. Respondent validation (cross-checking interim findings) was also conducted by means of reflection to ensure that information reported by participants had been accurately understood.23 To ensure the reliability of the coding framework, a peer reviewing process involving 2 members of the research team was conducted. Quantitative data were subjected to descriptive statistics using SPSS version 8.0 for windows.

Results Participants’ Demographic and Medical Profile The mean age of study participants was 25.6 years (SD ± 5.2) and the ages ranged from 17 years old to 36 years old. Participants in the study presented a wide range of demographic and maternal characteristics (Table 1). Approximately 60% and 39% of them were black and of mixed ancestry, respectively. Very few participants were in their first trimester (17%) and about half were in their second trimesters. Unemployment was high (59%) and 44% did not complete high school (Grade 12). None of the participants had 3 or more biological children at the time of the study. Majority were either Gravida-1 or 2 (35% and 44% respectively). About 44% reported that they were not currently physically active. Of the 56% who reported doing some PA, 44% reported participating in light PA and 12% moderate PA. About 88% reported that they were not diagnosed with diabetes, hypertension, asthma, depression and musculoskeletal pain. These findings are summarized in Table 1.

Promoting PA in Pregnancy in Resource-Poor Settings   1279

Table 1 Selected Medical and Demographic Characteristics of Study Participants Variable

“. . . having lots of intercourse is good exercise for your pregnancy.” (Age 20, race MA, G1)

n

(%)

 Black

21

(61.7)

 White

0

(0.0)

  Mixed ancestry

13

(38.2)

 Indian

0

(0.00)

6

(17.6)

Race

Stage of pregnancy   First trimester   Second trimester

17

(50.0)

  Third trimester

11

(32.3)

12

(35.2)

  Part-time employment

2

(5.90)

 Unemployed

20

(58.8)

  Gravida 1

12

(35.0)

  Gravida 2

15

(44.0)

  Gravida 3

7

(20.6)

 Yes

4

(11.7)

 No

30

(88.2)

 Yes

19

(55.9)

 No

15

(44.0)

  Not reported

0

(0.00)

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Employment status   Full-time employment

Parity

Has at least one chronic condition

Physically active (self-reported)

Focus Group Discussions A number of analytical typologies emerged during analysis. These represented a wide range of participants’ views and experiences. Findings of this study are presented according to these typologies. Verbatim quotes from study participants are also included along with the age, race (“B” for black and “MA” for mixed racial ancestry) and Gravida status (represented by “G”) of the concerned participant. Behavioral Beliefs and Attitudes.  It appeared that all participants

were generally aware of, and recognized the importance of being healthy during pregnancy. Lifestyle behaviors associated with a healthy pregnancy included PA in addition to good nutrition, safe sex and avoidance of alcohol and tobacco products. “It is important to be healthy during pregnancy for the sake of the development of your child. Everything you take in the child does too.” (Age 32, race B, G3)

“. . . Well for me I think exercise helps the child to be active too . . . .” (Age 21, race B, G1) Several perceived advantages of PA were also reported by the majority of study participants. Some indicated that they may be aware of some benefits around PA, however most of these respondents seemed to be unsure of the recommendations for exercise during pregnancy. “You won’t gain too much weight if you exercise and just to have benefits for the baby and the mother . . . .” (Age 26, race B, G2) “I think exercise will keep you younger after pregnancy and also will help you stay strong . . . . For example walking is good to keep baby and mommy healthy. (Age 36, race B, G3) “. . . for example it is easier to give birth when you exercise during pregnancy . . . .” (Age 28, race MA, G2) Beliefs and attitudes about the disadvantages of being physically active during pregnancy were mainly centered on the fear of hurting oneself or/and the unborn baby. Most women believed that it is “dangerous” to perform PA while pregnant. “May be if you run a lot you can make the baby sore or if you change direction all of a sudden or you run into something you can hurt your baby.” (Age 31, race B, G2) “I think exercise causes back pain and bleeding . . . . I have also been told that the baby will come early if you exercise during pregnancy.” (Age 22, Race MA, G1) Control Beliefs/Perceived Behavioral Control.  Study participants indicated a number of individual-level and contextual/ situational barriers to being physically active during pregnancy. At the level of an individual, physical pain, large body size due to pregnancy and lack of energy were the most frequently cited barriers to engaging in PA during pregnancy.

“It is difficult to do exercise if you have a big tummy and swollen feet stop me from exercising . . . . I am really scared of pain.” (Age 25, race MA, G1) “Tiredness doesn’t put you in the mood for exercising. You always feel like sleeping.” (Age 36, race B, G3). “. . . bending down is really difficult when you are pregnant.” (Age 24, race B, G1) With regards to environmental barriers, the unavailability of PAbased facilities at community level and the lack of time to exercise due to family and work responsibilities were the major impediments to being physically active during pregnancy.

“Drinking alcohol causes alcohol-syndrome and it is very important to live healthy . . . .” (Age 24, Race B, G1)

“I will speak for myself . . . . Time is really not on my side, I start work at 11h am and finish at 7h30 in the evening and I only have two days off during the week so there is little time to do exercise. Taking care of my husband and children also takes up much of my time.” (Age 34, race MA, G2)

Few participants also had interesting beliefs about the meaning of being physically active in pregnancy.

“Sometimes the other children make me very tired but there is no other choice but to look after them.” (Age 20, race B, G1)

“. . . To me it means no smoking, no drinking, safe sex, and exercise.” (Age 19, race MA, G1)

1280  Muzigaba, Kolbe-Alexander, and Wong

“There are no facilities to exercise in my community . . . . There is nothing other than sex, lots of it . . . .” (Age 22, race MA, G1)

“I think if you can dedicate yourself to exercise then you can do it.” (Age 18, race MA, G1)

Some women also associated PA with better financial position and overall wellbeing and happiness. There was a general perception that exercising requires having access to a gymnasium.

“About time management and other responsibilities at home, I can share these with my husband.” (Age 31, race B, G3)

“The problem is the facilities as to where to get that [PA], and at this moment it is only when you go to Virgin Active [a local prestigious and commercial gymnasium] that you see some section with pregnant women doing exercise, . . . so it all comes down to having money.” (Age 27, race MA, G1)

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“It’s all about happiness. Like a nice job, nice house, nice husband or boyfriend.” (Age 20, MA, G1) Few of the women also expressed safety in the neighborhood as a major concern. “Maybe if there was a way of doing exercise together it may be safe for us. It is not safe out there for walking.” (Age 26, race B, G1) Almost all the study participants indicated that forming groups of pregnant women who exercise together, or establishing a fitness center in their respective communities would incentivize their participation in PA during, and possibly be maintained after pregnancy.

“In terms of confidence I think for me it’s about what you want: if you want to be healthy you will do exercise. If you think about the benefits of doing what you want then you will do it . . . . I don’t want fat rolls [used locally to denote postpartum abdominal obesity].” (Age 32, race MA, G2) Other incentives for being physically active during pregnancy included the desire to stay in shape, as well as general health and wellbeing. Normative Beliefs/Subjective Norms.  All study participants generally felt that the midwife or a medical doctor was responsible for providing medically based permission to participate in PA while pregnant. They often stated that this was important before they could start any PA program to ensure that they were safe enough to protect themselves and the baby.

“If the doctor says I can exercise then I will exercise . . . . I think it is good to know that you are safe before you do anything.”. (Age 36, race B, G3)

“I have never heard of pregnancy exercise before. If there was I would go.” (Age 18, race B, G1)

Some participants were encouraged by members of their families to have sufficient rest which militated against efforts to do any form of PA.

“. . . so that’s why I am saying that if maybe there is a club for pregnant women to exercise, like a venue indoors, then maybe I will go there.” (Age 19, race B, G1)

“Sometimes people at home tell you that you need to rest you know . . . . And you spend a lot of time sleeping with no exercise.” (Age 19, race B, G1)

“. . . for example walking on the beach in a group would be lovely. Or may be a club for pregnant ladies, we need that . . .” (Age 22, race MA, G2)

The fact that almost all the study participants reported not being aware of what types of PA they should be doing, and how much is required, could be a proxy indication that PA was not part and parcel of the antenatal education and birth preparedness program at the study site. In fact, some participants reported that they had never received advice from any health care professional at the facility about PA and its importance.

Furthermore, all study participants voiced that the existence of a PA education program for pregnant women at antenatal service centers in their communities would facilitate their participation in physical activity. Participants consistently requested that information related to PA during pregnancy be made available to them. “I think if there could a booklet, this booklet that shows you at a certain stage these are the exercises that you can do that might help you during your pregnancy or may be even after giving birth as well to stay healthy. I think that would be good.” (Age 32, race MA, G2) Furthermore, the existence of a PA sessions at the antenatal facilities was regarded by many participants as important. “When we come to the clinic you should arrange for an exercise session.” (Age 24, race B, G2) “. . . Like if there is like a club here and there are more pregnant women doing it we would be motivated.” (Age 25, race B, G1) A number of study participants cited self-motivation, selfconfidence and family support as important factors which would determine their control over being physically active in pregnancy. “My little one is helping to be active because we play a lot and walk around sometimes.” (Age 29, race MA, G2)

“I have never heard of pregnancy exercise lessons ever since I have been coming to this hospital. If there was I would go . . . .” (Age 32, race B, G2)

Discussion This study examined the views and experiences of pregnant women from low socioeconomic status communities in Cape Town about being physically active during pregnancy. The use of the TPB enabled us to frame the study to capture common attitudes, beliefs, barriers and enablers of being physically active within the context of the target population.

Main Findings and Their Implications for a Possible Intervention The most encouraging finding in this research study is that pregnant women were interested in participating in PA during pregnancy and requested more information and a possible intervention program. It was evident that the participants were aware of the benefits of being physically active during pregnancy, even though the level of

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Promoting PA in Pregnancy in Resource-Poor Settings   1281

knowledge varied among them. However, although most participants were aware of, and generally endorsed the importance of PA in pregnancy, they were unsure of the types of PA that are recommended and deemed safe for pregnancy. Furthermore, some women did, in fact, report concerns about safety for self and the unborn baby. Therefore, a PA education and promotion program would be opportune in this context, especially considering the fact that women in this phase are more receptive to behavioral change interventions compared with other phases of their live.24 These interventions might play a role in addressing some of the gaps in participants’ behavioral beliefs and attitudes and to a certain degree some normative beliefs toward PA. Another important finding was that the women reported that they did not receive PA related advice and information from the healthcare providers at the clinic. These findings are consistent with those reported in previous research.7,25 For example, a study by Weir et al7 showed that pregnant women generally felt that their midwife had provided minimal or no active advice to encourage them to be physically active during pregnancy. The perceived lack of routine advice from health care workers on PA during pregnancy could translate into women’s lack of confidence in the accuracy of the knowledge they have about the benefits of PA during pregnancy. Thus, empowering women attending the clinics with relevant knowledge might not only reassure them of the role of PA in health and pregnancy, but could also be another way to get them to convey this message to their communities and families.26 Similar pathways to health promotion at community level have been previously reported.26 Some researchers argue that, investments in women’s empowerment, better access to health care, and generation and utilization of relevant new knowledge, would have great positive effects on health and quality of life for the entire community including women, men, and children26 The women who participated in our study also expressed interest in PA clubs or antenatal PA classes as this would facilitate access to safe and regular PA. Combining PA education and demonstration classes at antenatal facilities may help alleviate some personal and contextual issues which prevent pregnant women from adopting and having control of appropriate PA behavior.27 For example, Hegaard et al argue that concerns for safety for self and that of the baby as well as lack of motivation would be more effectively addressed through this approach.27 A typical intervention for this setting could also entail empowering facility-based health care providers (health promoters, physiotherapists, midwives, nurses, etc) with resources and tools such as instructions DVDs, brochures and posters, to educate women about the benefits and guidelines for physical activity during (and after) pregnancy. In addition, these healthcare workers could be trained to lead exercise sessions at the healthcare facility, or be provided with the resources to source possible external service providers who might be willing to deliver their program at the clinic. Instruction DVDs and information brochures have been used before to promote physical activity among pregnant women in clinical settings.28–31 These techniques are more effective when combined with other approaches such as encouraging pregnant women to set goals for themselves,32,33 promoting self-monitoring34 and providing pregnant women with rewards or other various forms of incentives.35 The involvement of partners and/or doulas in pregnant women’s efforts to be physically active may also be of great value. This argument is well supported by the literature which recognizes the need to expand the intervention beyond pregnant women to include other key players such as the partner36 as well as other family members and social networks.37,38

Because the women in our study identified other health behaviors such as a healthy diet which is important for a healthy pregnancy, the PA intervention should be complemented with nutrition education and counseling.39 Interestingly, sociocultural beliefs and attitudes toward body image did not emerge in our study as one of the barriers to engaging in PA during pregnancy. A number of studies conducted in similar settings have shown that many black women prefer being overweight, and equate thinness with having HIV/AIDS.40,41 Another study conducted in a predominantly black township in South Africa also revealed that a large body size was perceived to reflect affluence and happiness.42 A possible explanation for this may be that the pregnant women’s concerns for their health during pregnancy as well as that of their unborn baby outweigh sociocultural beliefs and attitudes they hold toward their body size. This could results in their willingness to be physically active during pregnancy, as was reported in this study. However, this supposition needs to be substantiated in future research to ascertain the potential role that sociocultural dynamics might play in promoting or undermining the intervention proposed here. Furthermore, there may be value in investigating whether such sociocultural beliefs and attitudes manifest differently during and after the pregnancy period.

Strengths of the Study Design The selection process of study participants involved a stratified random sampling technique which provided a good representation of pregnant women at facility level, in relation to age, level of pregnancy, level of education, employment status, and parity. Also worth noting is the fact that, generally, the participants’ background characteristics reflected those commonly reported in other relatively poor communities in South Africa. Therefore, it may not be surprising that the knowledge, attitudes and experiences around PA in pregnancy which were elicited from the participants reflect those of pregnant women in similar settings in South Africa.

Strengths of the Study as a Basis for Informing Future Interventions The literature shows that in order for a physical activity intervention for pregnant women to be successful, the intervention should be informed by formative research conducted within the target population.38,43 Our study findings hold the promise of generating a well informed intervention which reflects the need of the target population as well as the context within which they live. Furthermore, the use of behavioral theories (such as the Theory of Planned behavior used in this study, Social Cognitive Theory, Social Ecological Model, Transtheoretical Model and The Life course Framework) is strongly recommended to inform the design of behavioral PA interventions for pregnant women.44 Recent evidence also shows that there is a gap in PA interventions in underprivileged groups of pregnant women.44 This study could be a step further in the direction of closing this evidence gap, particularly in South Africa where, to our knowledge, little to no science-based interventions exist to promote PA in pregnancy.

Limitations of the Study Design Interviews were moderated in English, which all study participants could understand but few could not adequately speak. Fortunately, this limitation was apparent during the pilot interview and a female

1282  Muzigaba, Kolbe-Alexander, and Wong

translator was brought in to help translate for about 5% of participants who could not express themselves fully in English. Although there were few occasions wherein translation was required, we suspect that this may have interfered with the original message from the 5% of participants who could not speak English, particularly with regards to semantics. The person who facilitated the interviews was, however, a female health professional and a trained interviewer who understood the context well and strived to not appear as an expert at the start of each interviews.

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Conclusion The participants in this study presented a multifaceted behavioral context which impacts on their control over being PA during pregnancy. As far as is known, this constitutes new knowledge within the South African context. It was apparent that their views and opinions about what affects them in their day to day lives should be taken into account when developing a physical activity intervention designed to benefit them. There is a need to design a PA intervention for pregnant women that is context-specific and sensitive toward individual experiences and circumstance in the study communities. Acknowledgments The authors would like thank the World Heart Federation (WHF) for providing seed funding toward the EPP. Our thanks also go to Dr. Vash Mungal-Singh, Mrs. Lucy Gericke, Mrs. Erika Ketterer, and other HSFSA staff who supported this investigation. We also express our gratitude to all the Heart and Stroke Foundation South Africa’s (HSFSA) partners, including the Hatter Institute of Cardiology Research—University of Cape Town, Western Cape Department of Health—Health Promotion Unit, and Matrix Public Health Consultants Inc. Canada. Lastly, but not least, special thanks go to Alice Grainger-Gasser and her team at the WHF for their invaluable support.

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