Abstract
[Purpose] The current study aimed to validate the exercise habits and perception of physical exercise among residents of an island in the Western Pacific Region, where the high prevalence of noncommunicable diseases is a serious health issue. [Participants and Methods] Semi-structured interviews were conducted with one doctor, three nurses, and six patients from a noncommunicable disease clinic on one island of the Kingdom of Tonga. The questions focused on the patients’ exercise habits and perception of physical exercise. Their comments were structured using the KJ method. [Results] Structuring of the comments revealed that the exercise habits of the island residents had three unique features: variations in thinking and behavior toward exercise, variations in the amount of daily exercise, and the presence of key persons in the community who affect their exercise habits. [Conclusion] Exercise programs suitable for countries in the Western Pacific Region that consider environmental and cultural factors should be developed and disseminated in the future.
Keywords: Noncommunicable diseases, Physical exercise, The Western Pacific Region
INTRODUCTION
To date, the incidence of noncommunicable diseases (NCDs), including obesity, diabetes, and heart disease, is high. Hence, NCDs are considered a serious and globally relevant issue1). Previously, these health concerns were unique to developed nations. However, they are now common among developing countries. NCDs cause more than 15 million premature deaths annually worldwide, with 77% of cases observed in low- and middle-income countries1). The Western Pacific Region has a dense concentration of countries with high rates of obesity and diabetes2, 3). The Polynesian country of Tonga is one example. That is, 87% of its population is overweight, and 69% of females are obese4). Thus, NCDs in this region should be urgently controlled.
The behavioral risk factors of NCDs include smoking, physical inactivity, alcohol use, and unhealthy diet5). The World Health Organization (WHO) has proposed several action plans for reducing the behavioral risk factors of NCDs, including efforts to promote physical activity to address physical inactivity5). Regular physical activity is useful in preventing and managing NCDs6). Physical activity refers to all movements of a person, and it commonly includes walking, cycling, sports, and active recreation or games6). The associations between the type and amount of physical activity and health are not yet completely understood. Nevertheless, it has been shown that regular physical activity contributes to the primary and secondary prevention of several chronic illnesses and that it is associated with a lower rate of premature death7).
The WHO’s most recent action plan on the promotion of physical activity emphasizes the importance of Sustainable Development Goals (SDGs)8, 9). It states that creating an active society is an effective method to continuously promote physical activity on a global scale8). To create an active society, it is necessary to educate community members about the benefits of physical activity and how to perform it. This can increase the understanding of and encourage positive attitudes toward physical activity, and provide free access to enjoyable and affordable, socially and culturally appropriate experiences of physical activity8). The plan is proposed as a foundation for health promotion in all countries, including both developed and developing nations. However, it does not mention which specific activities should be performed in different parts of the world.
Among the SDGs, the WHO sets the target 3.4 to reduce the rate of premature mortality from NCDs by one-third through prevention and treatment and to promote mental health and well-being by 203010). NCDs are chronic illnesses, and their onset is closely related to lifestyle. Thus, their prevention and treatment are long-term processes that are rooted in the nation’s unique culture and peoples’ lifestyle. If the people of a country or region must abstain from behaviors that are risk factors of NCDs and sustain a healthy lifestyle in the long-term, health interventions should be amenable to them. The unique culture and lifestyles of a people in a specific region is indispensable in achieving SDGs in each country.
The Western Pacific Region is an area in which the growing prevalence of NCDs is a cause of concern, and people in this region should be encouraged to perform physical activity. However, the acquisition of exercise habits among the residents is inhibited by challenges in performing exercise outside during the day in the tropical climate and the custom of walking outdoors barefoot. To promote physical activity in the Western Pacific Region, it is important to obtain information about local environmental and cultural factors, particularly the citizens’ attitudes toward physical activity and their exercise habits. The current study aimed to validate the exercise habits and perception of physical exercise among residents of an island in the Western Pacific Region where the high prevalence of NCDs is considered a serious problem.
PARTICIPANTS AND METHODS
This study was conducted on one of the islands of Tonga (hereafter referred to as Island A). The Kingdom of Tonga, located in Polynesia, is an archipelago comprising 176 islands, and it has a population of approximately 105,000. Most of the country’s citizens work in agriculture, and many pursue seasonal employment abroad11). Island A, where this study was conducted, has a population of roughly 5,000, and its primary industries are agriculture, forestry, and tourism.
The study included one doctor (female) and three nurses (female) who were involved in the prevention and treatment of NCDs at the clinic on the island and six adult patients (one male, five females) who had been at the clinic. We conducted an individual interview in English with each participant using a semi-structured format at the island’s clinic. Table 1 shows the interview guide. The participants provided a written informed consent. Then, the participants’ comments were recorded using a voice recorder and transcribed.
Table 1. Interview guide for medical professionals and patients at a clinic in Island A.
| Participants | Items | Questions |
| Medical | Exercise habits of the people in Island A | 1. What type of exercise do they usually like to do? |
| professionals | 2. Do they exercise regularly? | |
| Types of exercise and music that are likely to be preferred and accepted by the people of Island A | 1. Are there any popular exercises and music among them? | |
| 2. What type of exercise and music do you think attract them? | ||
| Points that must be considered when promoting and establishing exercise habits among the people of Island A | 1. Could you give us any advice on delivering regular exercise and make it a habit? | |
| Own exercise program if there is any | 1. Could you tell us about the participants of your exercise program, the number of participants, place, time, and frequency? | |
| 2. Could you tell us the purpose and efficacy of your exercise program? | ||
| 3. Could you tell us the contents of your exercise program, such as postures and physical movements in the exercise and the time required for each program? | ||
| 4. What do you think is the issue or problem when carrying out or providing instructions regarding the exercise program? | ||
| Opinion on exercise and exercise habits | 1. What type of exercise do you usually like to do? | |
| 2. Do you exercise regularly? | ||
| 3. What do you think about regular exercise to maintain good health? | ||
| Patients | Opinion on exercise and exercise habits | 1. What type of exercise do you usually like to do? |
| 2. Do you exercise regularly? | ||
| 3. Do you think regular exercise can maintain good health? | ||
| Types of exercise and music that are likely to be preferred and accepted by the people of Island A | 1. Are there any popular exercises and music among them? | |
| 2. What type of exercise and music do you think attract them? | ||
| Points that should be considered when promoting and establishing exercise habits among the ‛Euan people | 1. Could you give us any advice on delivering regular exercise and make it a habit? | |
| Own exercise program if there is any | 1. Could you tell us about the participants of your exercise program, the number of participants, place, time, and frequency? | |
| 2. Could you tell us the purpose and efficacy of your exercise program? | ||
| 3. Could you tell us the contents of your exercise program, such as postures and physical movements in the exercise, the time required for each program? | ||
| 4. What do you think is the issue or problem when carrying out or providing instructions regarding the exercise program? |
Comments were then structured using the KJ method, which is also known as an Affinity Diagram. The KJ method is a qualitative research method developed in Japan. Using this method, each participant comment made during the interview process is written on a label (label making), and the labels are then grouped based on content similarity. The groups generated were then provided with a one-sentence label directly expressing the group’s unique characteristics and core meaning. Thereafter, they were organized into higher-order groups based on content similarity, and the labeling process was repeated. If the group organization was completed, the overall structure of the collection of groups was made into a chart on a single sheet of paper and described as a “story” in a written explanation. The first author completed the formal training in the KJ method before its implementation. In this study, based on the technique of previous studies12, 13) that adopted the KJ method, we cautiously selected some comments collected during the interviews to be used for grouping. The first round of chart-making and written explanation was conducted by the first author alone. The contents were then reviewed by a nurse who was involved in education and research and who practiced in the field of international nursing, and a physical therapist who lived in developing countries and engaged in international cooperation. We repeatedly revised the contents to ensure the study’s reliability.
This study was approved by the research ethics committee of Tohoku Fukushi University (RS190106, RS220105).
RESULTS
Based on the interviews, we created 103 labels for comments from the doctor and nurses and 105 labels for comments from the patients. Based on the technique used in previous studies12, 13), we cautiously narrowed these down to 40 labels for comments from the doctor and nurses and 40 labels for comments from the patients.
Figure 1 shows the chart made to depict the exercise habits of citizens from the perspective of the doctor and nurses, and the written explanation is as follows.
Fig. 1.
Exercise habits of residents from the perspective of medical professionals in Island A.
The doctors and nurses of Island A were engaged in community-based medical care for the residents of the whole island from the standpoint of medical professionals. Although they focused on preventing and treating patients with NCDs in the clinic, they are aware that they should reach out to communities across the island. As medical professionals, they want to become healthier themselves and act as role models who promote healthy lifestyle habits to the island’s residents.
Exercise habits on the island are affected by its natural, physical, and human environment. Spaces, facilities, and equipment that could allow citizens to play sports are present across the island. However, the need to prevent daytime heat limits outdoor exercise in the early morning and just before sunset. In the local community, the residents’ decisions and behaviors are influenced by church leaders and government officials. Therefore, it is essential to coordinate with the local community if one affects exercise habits. Exercising with other members of the community is also useful in promoting exercise habits among island inhabitants.
Each of the island’s residents has a different disposition and lifestyle, and they prefer to act freely based on their own judgments. They do not like to be bound by rules and regulations, and they personally want to participate in exercise programs or health education. The island’s citizens enjoy dance and music. However, the style differs according to gender and generation. Some citizens play sports and participate in exercise programs, whereas others do not. Those who work in agriculture are in a position similar to those who exercise daily.
Figure 2 depicts the chart made to depict the citizens’ exercise habits from the perspective of the citizens of Island A themselves, and the written explanation is as follows.
Fig. 2.
Exercise habits of residents from the perspective of residents in Island A.
Some of the residents of Island A have exercise habits, and others do not. Further, some residents exercise naturally in their everyday lifestyle or work. Residents who regularly engage in sports, dance, or other physical activities believe in the benefits of exercise on their health. However, several residents were not interested in physical activity and do not exercise. Meanwhile, some were interested in physical activity. However, they still do not exercise.
Although most citizens prefer specific types of music and exercise, their preferences vary. Numerous island residents enjoy dancing to music with a high tempo. Nevertheless, each person has different taste in music genre and exercise style.
Local leaders, community activities, and residents’ own awareness and knowledge of exercise play a role in their exercise habits. Local leaders, such as sports coaches, medical professionals, and government officials, and local community activities, including church activities, affect the exercise habits of residents. The exercise habits of citizens can be effectively expanded by explaining the significance of exercise and how to successfully implement it.
DISCUSSION
Some residents exercised regularly, whereas others did not. Furthermore, some were interested in exercise but did not actually perform any activity. It is important to consider each resident’s attitude toward exercise when disseminating exercise habits. The interview results showed that the residents were more likely to decide and act freely without being bound by rules. Therefore, unilateral proposals for them to exercise do not lead to their acquisition of exercise habits. The attitude of each resident toward exercise should be respected. The positive effects of physical exercise on health conditions in Western societies have been validated, and the WHO has promoted routine physical exercise worldwide. However, health has various definitions in developing countries, including several non-Western societies, according to cultural beliefs, traditional practices, and social relationships that differ from those of Western societies14). Therefore, it is important to consider cultural adaptation (i.e., regional beliefs and values) in promoting health initiatives that involve physical activity in developing countries15). Hence, it is essential to investigate how residents in each country define their health status and perceptions on how physical exercise affects their health status at the first stage of promoting physical exercise in developing countries, which was the goal of this study. Furthermore, in Island A, where this research survey was conducted, residents have varying attitudes toward exercise, and their habits related to exercise were also likely to differ. Hence, there is a need to respect the beliefs and values of individual residents in addition to those generally shared by the residents in the region. The survey confirmed the presence of music and dances that are enjoyed by several residents in Island A. For example, developing exercises that are inspired by melodies, rhythms, and body movements contained in them may be effective in promoting physical exercise among the residents. However, residents have diverse beliefs and values. Therefore, the physical exercise program that should be popularized in Island A and, possibly, in the Western Pacific Region must comprise both a general program targeting numerous residents and a collection of diverse special programs targeting specific groups of residents and tailored to their individual health conditions, exercising habits, tastes, and preferences.
Some residents, such as those engaged in agriculture, have already performed sufficient exercise in their daily lives. It may be inappropriate to recommend additional sports and other practices to such residents. By contrast, it is necessary to disseminate exercise habits to residents who do not have the opportunity to exercise in their daily lives. Approximately 60% of Tonga’s population is engaged in agriculture, and most agricultural products are for subsistence and own production11). In Island A, which was the field of research in this study, several residents were engaged in agriculture and forestry. We must cautiously adjust the amount of additional daily exercise required for each resident based on the diversity of living environment and working conditions of individuals, which is needed to tailor exercise programs for individual beliefs and values, as mentioned above. Further, the tropical climate in the Western Pacific Region also affect the dissemination of the exercise habits of residents. Outdoor exercise should be conducted in the early morning and just before sunset to prevent daytime heat. Furthermore, it is important to adopt an educational and informational approach in the process of promoting physical exercise8). Such approaches should aim to increase awareness about the positive effects of exercise on health. In addition, the approaches should help in maintaining the amount of exercise in residents who already have a sufficient amount of exercise on a daily basis and in starting and continuing exercise in residents who are not doing so. In the physical exercise program that must be promoted in Island A and, possibly, in the Western Pacific Region, implementing an educational and informational approach to physical exercise in several places may be required in addition to the popularization of sports and exercise. Encouraging physical exercise via school health while lifestyles are formed at school age may be effective in promoting physical exercise.
This survey elucidated the standpoint and attitude of medical professionals in Island A. Medical professionals play a primary role in preventing and treating NCDs at clinics and outreaching physical exercise programs to communities. Moreover, this survey suggested the importance of cooperation between medical professionals and key personnel, such as government officials and church officials, who have a close relationship with the residents on a daily basis, to spread exercise habits among residents. Reports on implementing physical activity promotion programs in developing countries have advocated the importance of establishing partnerships with governmental and non-governmental organizations and private groups and leveraging these relationships16). The WHO’s Global Action Plan on Physical Activity calls for the creation of an active society to sustainably implement the promotion of physical activity on a global scale, which requires community engagement (i.e., diverse members of the community who should be actively involved)8). Through this research, we were able to identify community members and key persons with a particularly strong influence on the promotion of physical activity in Island A. For residents to maintain a healthy lifestyle and refrain from behaviors that are risk factors for noncommunicable diseases in the long-term, we intend to establish partnerships with these key persons and work together to promote physical activity. The number of allied health workers who provide support for promoting physical activity, including physical therapists, is growing gradually17). The techniques and findings of community rehabilitation that we have accumulated across Western societies may be used in disseminating exercise habits in the Western Pacific Region, including Island A. We are required to help residents in such areas to acquire exercise habits and prevent NCDs via technical cooperation and volunteer activities.
A survey conducted on one island in the Western Pacific Region revealed the exercise habits of the residents and the factors affecting these habits. Results showed that the attitude toward exercise and lifestyles differed in each resident. For them to acquire exercise habits, it is necessary to implement individualized interventions and to cooperate with key personnel who are deeply involved with the residents in their daily life in the community. This study performed an interview survey on a limited number of participants on one island in the Western Pacific Region. Therefore, in the future, it will be necessary to conduct surveys on more sites and participants to obtain more generalized findings.
Conference presentation
Part of this research result was presented at the 7th Asia-Pacific Occupational Therapy Congress 202118).
Funding
This study was funded by Grant-in-Aid for Challenging Exploratory Research, Japan (16K15983).
Conflict of interest
There are no conflicts of interest to declare.
Acknowledgments
The authors thank Dr. Selvaia Taunaholo, medical professionals, and patients at an NCD Clinic in The Kingdom of Tonga for their cooperation in the research. The authors also thank Kana Sakuma (a Japan Overseas Cooperation Volunteer, 2015–2017) and Tomomi Sakai (a Japan Overseas Cooperation Volunteer, 2017–2019) for their assistance in the research.
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