STRATEGIES FOR PHYSICAL ACTIVITY MAINTENANCE IN AFRICAN AMERICAN WOMEN

Abstract

Objective

To examine whether African American women who were exercise maintainers reported the same barriers to and benefits from exercise as currently inactive women and to describe maintainers’ strategies for exercise maintenance.

Methods

Semi-structured qualitative interviews

Results

Ten women were classified as exercise maintainers and 9 as relapsers. Both groups reported similar benefits from and barriers to exercise. Maintainers reported strategies they used to sustain their exercise programs: wanting to act as a role model, seeking out social support, and setting goals.

Conclusions

Programs that address barriers to exercise may not be successful unless coupled with facilitators that promote maintenance.

Introduction

Regular physical activity is associated with a decreased risk of developing chronic diseases, such as diabetes, heart disease, and colon and breast cancer.¹ Additionally, low physical activity is an important determinant of metabolic syndrome, which has risen in prevalence in recent years, especially due to increases in hypertension, waist circumference, and hypertriglyceridemia in women.² Despite the known benefits from exercise, in the United States only 28% of women report engaging in leisure-time physical activity.³ African American women often participate in less leisure-time physical activity than other women – over 32% report no leisure-time activity compared to 23% of White women.³ Also, a national sample of women 40 years and older estimated that African American women participated in lower levels of overall physical activity than White, Hispanic and Native American women (66.5% compared to 71.7%, 76.8% and 74.0%, respectively).⁴

For many individuals, maintaining participation in a physical activity program can be difficult. Relapse back to inactivity is very common; intervention programs often show a large rate of attrition and low levels of maintenance over time, and little is known about real-world exercise program adherence.⁵ Since African American women have high prevalence of chronic disease and obesity,⁶ finding strategies to promote physical activity maintenance in this population is very important from a public health standpoint.

Other authors note many barriers cited by African American women to engaging in physical activity. These include feelings about physical appearance during exercise and the hassle of personal care after exercise,^7–9 family responsibilities and caregiving,^8–10 time constraints,^8–10 economic constraints,^7,8 major life changes or trauma,⁸ and problems with weather and environment.⁸ However, little research has specifically examined African American women who are successful in maintaining a physical activity regimen. Understanding the strategies these women use for maintenance may provide vital information to inform interventions for non-exercisers. Therefore, we explored the benefits and barriers to exercise maintenance perceived by physical activity maintainers and physical activity relapsers in a sample of African American women in the South Side of Chicago, Illinois. To focus on women who may have had additional motivation to engage in physical activity, we specifically interviewed women who were “at risk” for diabetes who reported a family history of the disease, high body mass index (BMI), impaired glucose tolerance and/or a history of gestational diabetes. Additionally, we elicited information on the strategies used by physical activity maintainers to sustain their physical activity levels.

Methods

Sample

We conducted audio taped, semi-structured interviews in 2003 with 19 African American women at risk for diabetes who had either participated in continuous exercise in the past but were no longer active (relapsers) or who were currently maintaining physical activity (maintainers). Flyers advertising the study were placed at a local YMCA on Chicago’s South Side. Interested women were asked to call the telephone number designated on the flyer, and were then screened over the telephone for eligibility by the project manager. A few women were referred to the study by friends.

Women were eligible if they had at least one diabetes risk factor and if they met study criteria for being currently physically active or physically active in the past. When potential participants called the project manager, they were first asked about their diabetes risk factors, defined as having at least one of the following: a BMI ≥25 kg/m² (calculated by obtaining participants’ self-reported height and weight), a history of gestational diabetes, a first-degree relative with diabetes, or impaired glucose tolerance. Current or past physical activity maintenance was based on the Centers for Disease Control and Prevention’s (CDC) definition of exercise maintenance (engaging in physical activity for at least 30 minutes on 5 or more days of the week over the past 6 months);¹¹ similar definitions of maintenance are often used in intervention studies.⁵ Specifically, respondents were asked over the telephone if they engaged in at least 30 minutes of exercise on 5 or more days of the week over the past 6 months, or whether they were adherent to this level of activity in the past. For women who responded affirmatively, as validation, they were then asked to describe the activities they did weekly, the time spent participating in these activities and how many months/years they were active (e.g., aerobics class three times a week for 30 minutes and walking briskly two days for 30 minutes for the past two years). If the type and level of activity met the CDC’s criteria, an interview was scheduled by the project manager. Additionally, interview participants were again asked about their physical activity level during the interview as further confirmation of their exercise status.

After the interview, the participants were grouped as either maintainers (currently adherent to the CDC’s definition of exercise maintenance) or relapsers (women whose previous exercise experience matched the CDC’s guideline, but who had either stopped exercising entirely or had only intermittently exercised for the past 6 months). One woman, after being interviewed, was determined not to meet the criteria for being either a maintainer or relapser; her interview was excluded from the final sample. Additionally, due to specific circumstances for one interviewee, we allowed flexibility for a slight exercise relapse after a recent family member’s death since she was typically physically active. Thirty women were interested in participating; 19 women were eligible and completed the interview. Interviews ceased when theme saturation occurred.

Interview domains

Each interview lasted approximately one hour and was conducted by one of two investigators (LE and AK). The interviewer taped each interview and an outside source transcribed the interviews. The interview guide was developed based on a review of the exercise barriers and facilitators literature, and was initially pilot tested on two women from the participating YMCA and revised for clarification. We asked open-ended questions about participants’ experiences with exercise, including what types of exercise they did in the past and their current activity levels. Open-ended questions were asked about barriers to exercise maintenance. As follow-up we asked more specific barrier questions that were identified from the literature including time constraints, weather, injuries, lack of motivation and energy, assisting family members who are ill, transportation issues, and work commitments. Questions on benefits from exercise included health benefits and weight loss related to exercise. No debriefing techniques were used, but we asked follow-up probes and questions to clarify and explore participants’ comments further. Participants provided self-reported age, height and weight information both at screening and at the interview.

Data analysis

Participant demographics were compared between maintainers and relapsers using two-sided t-tests and chi-square methods with exact testing. We analyzed the transcripts by employing an iterative process of textual analysis based on Grounded Theory, which is a method that allows themes to be inductively generated from the data.¹² Specifically, using Grounded Theory methods we approached the interview analyses with no theoretical framework; instead, we identified themes as they emerged throughout the analysis. First, LE and ACK independently reviewed interview transcripts. Each reviewer separately transferred interview responses to working spreadsheets and categorized quotes in the transcripts based on emerging topics they identified from their independent reading of the interviews. Then, LE and ACK then met to develop consensus on emerging topics and establish inter-rater reliability on interview coding after 5 transcripts. This continued until all 19 interviews were reviewed and responses were entered into the spreadsheets. Next, LE and ACK reviewed the responses to identify major themes that emerged from the interviews. Although a coding manual was not developed, the reviewers worked together to agree on how codes were assigned for consistency. Finally, to ensure the validity of our findings, an independent reviewer, JAW, systematically reviewed 50% of the transcripts (equally relapsers and maintainers) to assess the consistency and reliability of the analysis. Discrepancies in coding were minimal and were resolved by JAW with the input of ACK.

Results

Participant demographics

Participants included African American women who were residents of the South Side of Chicago during the spring of 2003; this area of Chicago is predominately African American and of lower socioeconomic status. We classified 10 women as maintainers and 9 women as relapsers. Approximately half in both groups reported periods of consistent physical activity over several years, whereas the remaining participants reported shorter periods of maintenance of approximately 1 year increments. All relapsers were currently inactive. The participants were between the ages of 27–77 years; mean age in years was similar between groups (40.6 years for maintainers and 40.8 years for relapsers, p=0.98) (Table 1). Maintainers had a slightly lower average BMI, although not significantly (33.4 vs. 35.7 kg/m², p=0.49). Diabetes risk factors were similar among groups, and no women reported a history of gestational diabetes or impaired glucose tolerance. Of the relapsers, 67% were employed compared to 40% of the maintainers (p=0.02). Maintainers were also less likely to be married (20% vs 56%, p=0.02). However, the number of women with children in each group did not differ significantly.

Table 1.

Characteristics of Physical Activity Maintainers and Relapsers

	Maintainers N=10	Relapsers N=9	p-value
Age, years (sd)	40.6(14.6)	40.8(10.1)	0.98
Body mass index, kg/m2 (sd)	33.4(9.1)	35.7(3.9)	0.49
Report of diabetes risk factors, N(%)a
First degree relative	8(80)	8(89)	0.24
High body mass indexb	6(60)	5(56)
Employed, N(%)	4(40)	6(67)	0.06
Married, N(%)	2(20)	5(56)	0.02
Number with children, N(%)	7(70)	7(78)	0.48

^aPercent reporting each diabetes risk factor. Many participants had more than one risk factor; therefore, percents sum to greater than 100%.

^bDefined as a body mass index ≥25 kg/m².

Maintainers and relapsers describe similar benefits from exercise

Overall, maintainers (M) and relapsers (R) cited very similar perceived benefits of exercise. A majority of both groups stated that physical activity improved their appearance and helped them lose weight. Most of the women interviewed were overweight and wanted to lose weight. Comments from both groups included things such as: “[Exercise] always makes me feel better and I know it makes me look better, even if I don’t lose all the weight” (M1). Relapsers also had beneficial experiences with physical activity: “[Exercise] worked. It helped [my weight] a lot” (R1). The women generally felt as though physical activity was necessary for achieving their weight goals above and beyond changing their diets.

There was also consensus that exercise could help prevent health problems. Many women had family members or friends affected by chronic illnesses and wanted to avoid such diseases. Some women described exercise specifically for diabetes prevention, “I [exercise] for obvious health reasons because I know that I'm at risk of diabetes, having it in my family” (M2) and “I don't want to get diabetes…It's like everybody in my family [has it]…Then with it being on both sides [of my family], it's kinda scary” (R2). Additionally, some women noted that the weight loss from exercise was important for maintaining their health in general. One maintainer said, “I don't want [my weight] to get out of proportion and go any further and start going into health problems” (M3). Also, the maintainers in particular described getting a general feeling of well-being from physical activity, where one gets “More self-esteem…[Exercise is] like eating a cookie. You eat one, you...want to keep on eating” (M4) and “I think it’s probably the most important thing I can do. I think it also helps me emotionally just by, you know, helping the endorphins kick in. Good stress reducer too” (M5).

Maintainers and relapsers describe similar barriers to exercise maintenance

Both maintainers and relapsers described similar barriers to physical activity maintenance. Often cited was the barrier of work commitments. Both maintainers and relapsers described working long hours or having to travel for work. Comments included “By the time I get home [from work] I'm so exhausted and I have every intention of walking or doing something and it's just not happening” (R3) and “When I do have jobs…I can't exercise and then it feels like the job's taken over my life” (M1). Many women also stated that exercise would be much easier to do if their jobs had gyms on location or were more supportive about incorporating exercise into the workday.

Poor weather was also a barrier to exercise maintenance. Both maintainers and relapsers indicated that they were less physically active in the winter when they could not take advantage of Chicago’s parks and lakefront. Relapsers described situations such as “I used to run on…the lake...Like every day in the summertime. But it was only in the summer (R2)” and “Sometimes I will use weather as an excuse...not to exercise. I have a stationary bike…I do have options to work out at home. The weather should not be a factor” (R4). Maintainers also described weather as a barrier: “[It’s] so cold and damp and rainy, that when I got home from work [normally I’d] change into my work out clothes and run to the Y...I’m going, ‘when I get in that house, I'm not leaving back out.’ Just too icky” (M2) and “I enjoy walking but I cut back [in the winter because it is] slippery and of course, very cold. I don't walk as often and as far as I usually want to walk” (M4). For both maintainers and relapsers, even a gym membership did not always provide motivation to exercise if the weather was bad enough.

Less mentioned by maintainers and relapsers were family-related barriers and cost barriers. Although few of the women described family-related barriers, those who did often had very significant family events that they felt prevented them from exercising. Some of the women noted that exhaustion or stress from caring for sick or elderly family members disrupted their exercise programs. One woman described feeling fatigued from visiting her diabetic mother every day and her sick father every weekend. Another had difficulty working out when she “had a death in my family, one of my favorite uncles. I like went into a depression. So I didn’t come [to the YMCA] for 3 months” (M3). Related to costs of gym memberships, often the women enjoyed exercising at the YMCA, but felt that membership costs were prohibitive. Examples included, “I did like the Y overall, but because of cost that was the reason why I cancelled my membership for about a year” (M6), and “The biggest challenge [for me to work out consistently] would be a cost factor” (R5). Also, the desire to have a personal trainer was seen as too costly, “Most of the personal trainers [at the YMCA] you have to pay and I don't have money to pay” (R6).

Maintainers’ specific facilitators for exercise maintenance

Although maintainers and relapsers described similar benefits from and barriers to exercise, maintainers often spoke about using specific facilitators to continue exercise that were not a part of the relapsers’ lifestyles. The facilitators described by the maintainers included:

Being a positive influence for family members

Maintainers often spoke about wanting to be a role model for their children or other family members. One maintainer stated, “Probably my daughter is a big influence on [my exercise]...I want to basically bridge the family curse [of being overweight]...And not let it continue on with her and let her see that I am active and maybe that'll motivate her” (M6). Another said about her niece, “I'm kind of changing her old view [to reflect that] women can lift weights and still be feminine” (M2). Additionally, many maintainers mentioned actively attempting to get their family members to engage in exercise through participating in classes or activities together.

Establishing Social Support

Maintainers actively sought out the help of others when exercising. One woman participated in a program at the YMCA: “[The trainer] goes through my log and he sees the dates I signed in. And let’s say I miss two sessions, then I’ll get a phone call. And that motivates me since I don’t want him to have to call me like that” (M1) Other maintainers also saw exercising with a friend, family members, training groups, personal trainer, or going to a fitness class as providing support to continue exercise. For example, one woman who previously worked out at home joined the YMCA because, “I just couldn't get into it [without] that camaraderie” (M7).

Goal Setting/Rewards

Maintainers mentioned different methods of goal setting and reward strategies they used to motivate themselves. Comments included “I do a punishment-reward system. If I do three days [at the gym] then I get to reward myself. If I don't do my three days during the week, then I have to come on the weekends. I don't want to come up here on the weekends” (M8) and “To make it more interesting, I think I have to set goals for myself or set higher goals too. You know, it's very exciting when I can increase [the] weight [on the weight machine]” (M2). Others spoke about treating themselves to a purse or some other desired good if they met their exercise goals or keeping a calendar where they crossed off the days they were physically active.

Discussion

This study suggests that African American women, regardless of current physical activity level, may agree on the benefits from exercise, although this must be confirmed with a larger sample. Weight and appearance improvement was the most often cited benefit by both maintainers and relapsers. Participants also perceived exercise as a way to stave off future health problems. Most women in our study had a relative affected by diabetes or other chronic disease and saw exercise as a way to prevent the onset of future disease, suggesting that these women generally understand the health benefits from exercise. Exercise maintenance barriers were similar to earlier studies^8–10 and were consistent among maintainers and relapsers. Poor weather and work commitments were commonly mentioned as impediments. Most of the women worked long hours, and for those who were unemployed, other obligations affected their ability to be physically active. Some women in both groups experienced major family-related barriers (e.g. assisting sick family members) that cut down on their physical activity time. Finally, gym membership cost and the cost of personal trainers were noted as prohibitive.

The similar barriers experienced by both maintainers and relapsers imply that addressing barriers to exercise in interventions may not be enough to give relapsers the ability to continue with a physical activity program. Also, the similarity of the perceived benefits from exercise maintenance stated by both groups (e.g., improvements in weight/appearance) reveals that relapsers have similar motivations to exercise as maintainers, but that these benefits alone may not be enough to induce or sustain exercise over time. One solution may be encouraging and supporting the adoption and sustainability of the facilitators used by maintainers in this study (being a positive influence for family members, having social support, and goal setting/rewards) to provide the resources relapsers need to stay physically active.

Other research has found that facilitators similar to those mentioned by our exercise maintainers – especially for social support – are important to promoting exercise.^{5,7,8,13–17} Since many persons who initiate exercise eventually quit, our study demonstrates that these supports may need to be maintained over time, rather than the limited time frame often associated with most programs. Interventions must find ways to make these facilitators more permanent for participants. For example, the desire of our relapsers to be a good role model for family members and to have exercise social support demonstrates that an intervention promoting a family physical activity plan over time could be successful.

Also, future research should explore whether there are differences in magnitude of barriers to exercise maintenance between maintainers and relapsers. Although our maintainers and relapsers described similar work, weather, family and cost-related barriers, there may be differences in the nature of these barriers that were not elucidated in our interviews that could provide guidance for future interventions. Also, although not seen in our analysis, if maintainers have a higher level of reported exercise benefits than relapsers, this may tip them in the direction of physical activity maintenance, and it may be important to focus more attention on promoting benefits to relapsers. Finally, future interventions must address physical activity maintenance in culturally appropriate ways since perception of overweight differs among ethnic and sex groups.^18,19 In our study, women mentioned weight loss as important, but also were concerned with improving their health by exercising. Since many public health messages about physical activity tout weight loss as motivation over health benefits, more appropriate communication may be necessary to support sustainable physical activity.

Our study has several limitations. Our sample size is small because we intentionally stopped interviews when theme saturation occurred. Confirmation of the relative importance of each theme in a larger sample would be useful. Also, all of our participants were urban, Midwestern African American women affiliated with a local YMCA who had at least one diabetes-related risk factor. We purposely focused on women who were currently physically active or had engaged in regular exercise in the past; therefore, our findings regarding exercise maintenance may not be generalizable to other populations, but do provide unique information since exercise maintenance is little explored. Our participants also had a very wide age range (27–77 years); there may be differences in age-related barriers and facilitators that were not elicited by our limited sample size. Furthermore, this study has some inherent biases due to the fact that participants were self-selected and self-reported their diabetes risk factors, exercise status and anthropometric data. However, by obtaining exercise information at two points, we increased the accuracy of this measure. Although under-report of BMI is possible, a recent study found generally accurate height and weight report by African American women, although like many populations, there was some under-report bias.²⁰ Finally, more detailed information on exercise history, types of activity, and socioeconomic status would also help to inform subsequent studies.

Despite these limitations, this study provides an important initial step in understanding how to promote exercise maintenance in higher risk women. African American women in our study were aware of the benefits of physical activity, and many had found strategies that worked to maintain physical activity. Our findings suggest that creating positive social supports for sedentary women, encouraging them to participate in exercise with their families and friends, and finding ways to assist them with goal-setting strategies may be the most beneficial ways to promote long-term physical activity.