Qualitative Exploration of Family Influences on Physical Activity in Hispanic Families

Abstract

Background:

Limited information exists on how the family unit aids or impedes physical activity (PA) engagement within Hispanic populations. This qualitative study explored family-level influences on PA in dyads of adult Hispanic family members (eg, parent–adult child, siblings, spouses).

Methods:

In-person interviews and brief surveys were conducted together with 20 dyads lasting 1.5 hours each. Two researchers coded and analyzed text using thematic analysis in NVivo (version 11.0). They resolved discrepancies through consensus and used matrix coding analysis to examine themes by participants’ demographics.

Results:

The participants were mainly women (70%), from Mexico (61.5%), and they reported low levels of acculturation (87.5%). Themed facilitators for PA included “verbal encouragement,” “help with responsibilities,” “exercising with someone,” and “exercising to appease children.” Themed challenges included “lack of support,” “challenges posed by children,” “sedentary behaviors,” and “competing responsibilities.” Women more so than men described family-level challenges and facilitators, and dyads where both study partners were physically active provided more positive partner interaction descriptions for PA support than other dyads.

Conclusions:

This study suggests that leveraging family support may be an important approach to promote and sustain PA, and that family-focused interventions should integrate communication-building strategies to facilitate family members’ ability to solicit support from each other.

The US Hispanic population is the largest and among the fastest-growing racial/ethnic minority groups in the United States, representing 18% of the population.^1,2 Hispanic populations face disproportionately higher rates of chronic conditions, such as obesity and diabetes, compared with non-Hispanic Whites; 47% of Hispanics are obese compared with 38% of non-Hispanic Whites,³ and 16% of Hispanics have diabetes compared with 9% of non-Hispanic Whites.⁴ Healthy behaviors, such as physical activity (PA), can lower the risk of diabetes and other obesity-related chronic diseases^5-7; yet, only 17% of Hispanic Americans meet national PA guidelines for weekly aerobic and strength-conditioning activities compared with 23.5% of non-Hispanic Whites.⁸

Studies suggest that close family ties and shared living environments can result in similar health behaviors.^9-11 Within Hispanic cultures, familism is a cultural value that prioritizes care for one’s family and centers the needs of the family over the individual. In this sense, the family may significantly influence behavior change, including its adoption and maintenance.^9,12,13 For example, sustained engagement in PA is more likely if one’s family also shares similar beliefs, attitudes, and behaviors toward PA.¹⁴ Thus, it is important for health promotion and disease prevention interventions among Hispanic populations to incorporate family-level health behavior change strategies. Prior research has examined barriers and facilitators of PA in Hispanic populations, revealing individual-level challenges, such as lack of time and resources, fatigue, lack of motivation, and perceived poor health. At the family level, the absence of support and conflicting household responsibilities were reported as common barriers to PA.^15-25 Conversely, PA facilitators have included modeling of PA by family and peers, social support for PA, access to resources and information on PA, and time to schedule PA.^{16,17,19,20,26-28}

While some studies mention the role of the family environment, including the behaviors and attitudes of other family members on individuals’ PA habits, the examination of family and dyad-specific influences on PA attitudes and engagement as a primary focus has not been thoroughly explored. Furthermore, while some of these studies engage Hispanic participants in their study, most do not enroll exclusively Hispanic populations—a limitation which may overlook cultural implications relevant to health promotion and intervention-delivery efforts in this population. Reducing PA disparities among Hispanic populations requires an in-depth exploration of facilitators and barriers within the household context to understand how that environment can be intervened upon to better support healthy PA behaviors. Thus, this study conducted simultaneous in-depth interviews with Hispanic family dyads living in the same household to uniquely explore the factors that impact PA engagement. An understanding of these factors can improve the design of interventions and programs that target the root of PA behaviors specific to this underserved and underresearched population.

Methods

For the purpose of this paper, the ethnicity “Hispanic” referred to individuals of Spanish heritage (Cuban, Mexican, Puerto-Rican, South or Central American, and Spain), regardless of race.²⁹ This definition framed our conversation on PA disparities in this population throughout this paper.

Study Design and Data Collection

We conducted in-person qualitative interviews with 20 adult Hispanic family dyads (n = 40 individuals) between June and November 2016 to explore perceived household and family influences on PA habits. These interviews were conducted to inform the design of a family-focused intervention to increase PA and healthy eating in dyads of adult Hispanic family members. Social cognitive theory,^30,31 which emphasizes the dynamic interactions between individuals, their behavior, and the environment, was used to guide this study. We focused specifically on the social environment and sought information regarding both sources of influence on PA within the household as well as ways in which study partners could support one another to address potential barriers to PA engagement.

The participants were recruited by bilingual research staff and trained community health workers from community sites (eg, community-based organizations, health fairs, food fairs) in predominantly Hispanic neighborhoods across Houston, TX. All family dyads, except for one, were interviewed in Spanish by trained bicultural and bilingual research staff. One staff member conducted the interview using a structured interview guide (Table 1), while a second staff member took notes. Both members of the dyad were interviewed together and were asked each question; however, no one was required to answer any question. In-depth interviews took place at community sites, and each session lasted approximately 1.5 hours. All interviews were audio-recorded.

Table 1.

Interview Guide

In-depth physical activity questions with Hispanic dyads
Let’s talk about PA. Physical activity is any body movement that works your muscles and requires more energy than resting. Walking, running, dancing, swimming, yoga, and gardening are a few examples of PA.
1. In a typical week, what kind of PA do you usually do?
Where do you do it?
How long do you do it?
Who do you do it with?
(If not previously mentioned, probe for PA in different domains.) What about around your home?
What about at your work? What about getting to places?
How long have you been doing this? How did you get started?
2. What are things that others in your family do to be physically active?
3. What makes it hard to be physically active? What gets in the way?
4. In what ways does your family discourage you to be more active?
5. If you wanted to be more physically active, how would you go about doing that?
What would help you to be more active?
What would NOT help you be more active?
What can (partner) do to help?
(Partner), what do you think you could do to help (participant) be more active?
What might make it hard to be more active?

Eligibility Criteria and Consent

Interested individuals were screened for eligibility and invited to participate if they self-reported Hispanic ethnicity, were between the ages of 18 and 65 years, spoke English or Spanish, and had a working telephone number. Participants were required to enroll with an eligible adult family member (ie, blood relation or through marriage/partner) living in the same household. Pregnant women were ineligible. Prior to the data collection, study procedures were approved by and were followed in accordance with The University of Texas MD Anderson Cancer Center’s institutional review board and ethics review committee. The participants were required to provide informed consent to participate in the study, and they completed a brief survey that assessed demographics, acculturation,^12,32,33 self-reported height, and weight.

As part of the broader study, PA was measured using the modified version of the Godin Leisure Time Exercise Questionnaire.³⁴ From self-reported PA estimates, we assessed whether each participant met or failed to meet the national recommendations for weekly PA (150 min of moderate-intensity PA per week or equivalent vigorous-intensity PA).³⁵ Following this, we further determined whether study partners were (1) concordant active, such that both partners met the leisure PA guidelines; (2) concordant inactive, such that neither partner met the leisure PA guidelines; and (3) discordant, such that one partner in the dyad met the leisure PA guidelines, while the other partner failed to meet the guidelines. The participants each received a $40 gift card and small incentive items for their participation.

Data Management and Analysis

The data management team coded and analyzed the interview transcripts using qualitative thematic analysis in NVivo.^36,37 Audio recordings were transcribed verbatim and were translated into English by a professional outside vendor for the interviews originally conducted in Spanish. A bilingual research staff verified transcripts against the original audio files to ensure accuracy. J.C.J. then imported the transcripts into NVivo 11 for data management. In NVivo, J.C.J. formatted each document for compatibility, including the assignment of headers to differentiate between interviewees’ and participants’ text. J.C.J. then proceeded to develop a codebook of a priori codes, which were informed by the interview guide and existing literature in this field. From December 2018 to April 2019, J.C.J. read and coded transcripts using the initially developed coding scheme. Using the codebook developed by J.C.J., N.I.H. coded 40% of the transcripts that were selected at random. During this round of coding, the 2 coders met 6 times to discuss the codebook and to modify and/or discuss the generation of new codes that were better suited for capturing text data. During these sessions, the coding team discussed and resolved differences where necessary. Once this was achieved, the coding team discussed how codes were related. These codes were grouped together and subsumed under distinct themes. In the hierarchy of organization, themes were then grouped together and convened under distinct categories. As a last step, the coding team used NVivo’s matrix coding feature to cross-tabulate codes by participants’ demographic variables to explore similarities and differences in themes across subgroups, such as gender (male vs female), dyad type (spouse/partner vs parent–child vs siblings), and dyad concordance in meeting PA guidelines.

Results

As shown in Table 2, the participants had a mean age of 39 years (SD = 12.9), and the majority were female (70%), born in Mexico (61.5%), and married or living with a partner (65%) and did not graduate high school (60%). The vast majority (88%) were of low acculturation. Only 40% of the participants met PA recommendations of 150 minutes of moderate or 75 minutes of vigorous PA per week. As shown in Table 3, the most frequently reported dyad relationships were parent-adult child (50%), followed by spousal/partner dyads (40%). Household size ranged from 2 to 11 people, with an average of 5 household members. In addition, 5 dyads were concordant active, 9 dyads were concordant inactive, and 6 dyads were discordant.

Table 2.

Characteristics of Individual Participants (n = 40)

Variables
Gender
Male	12 (30.0)
Female	28 (70.0)
Birth country, n (%)
United States	6 (12.8)
Mexico	24 (61.5)
Other (South America and Central America)	10 (25.6)
Insurance,a n (%)
Yes	16 (47.1)
No	18 (52.9)
Education,b n (%)
Less than high school	24 (63.1)
High school diploma or GED	3 (7.9)
More than high school	11 (29.0)
Marital status, n (%)
Married/partners	26 (65.0)
Never married/separated/divorced	14 (35.0)
Annual household income,c n (%)
<$19,999	13 (39.4)
$20,000–$49,999	20 (60.6)
BMI categories, kg/m2,d n (%)
Normal	8 (25.8)
Overweight	8 (25.8)
Obese (classes I, II, and III)	15 (48.4)
Met PA recommendations, n (%)	16 (40.0)

Abbreviations: BMI, body mass index; GED, general equivalency diploma; PA, physical activity. Note: Number of missing values:

^an = 6.

^bn = 2.

^cn = 7.

^dn = 9.

Table 3.

Characteristics of Each Study Dyad (20 Dyads Represented)

Dyad type		Gender	Age, y	Household (n) and <18 in home (n)	Birth country	Acculturation	Met PA guidelines	PA concordance
1	Spouse	Female	27	5 (3)	Mexico	Low	No	Concordant inactive
	Spouse	Male	32		United States	Low	No
2	Mother	Female	42	6 (3)	Mexico	Low	Yes	Discordant
	Son	Male	19		Mexico	Low	No
3	In-law	Female	42	5 (2)	Central America	Low	Yes	Concordant active
	In-law	Male	53		Central America	Low	Yes
4	Spouse	Female	54	2 (0)	Mexico	Low	No	Concordant inactive
	Spouse	Male	56		Mexico	Low	No
5	Spouse	Female	28	5 (3)	Mexico	Low	Yes	Concordant active
	Spouse	Male	29		Mexico	Low	Yes
6	Partner	Male	43	5 (3)	Central America	Low	No	Concordant inactive
	Partner	Female	56		Central America	Low	No
7	Mother	Female	62	6 (0)	Mexico	Low	Yes	Discordant
	Son	Male	20		United States	High	No
8	Mother	Female	38	4 (1)	Central America	Low	Yes	Concordant active
	Daughter	Female	22		Central America	Low	Yes
9	Spouse	Female	44	4 (2)	Mexico	Low	No	Concordant inactive
	Spouse	Male	65		Mexico	Low	No
10	Mother	Female	39	4 (1)	Central America	Low	No	Concordant inactive
	Daughter	Female	18		Central America	Low	No
11	Spouse	Female	45	2 (0)	Mexico	Low	No	Concordant inactive
	Spouse	Male	49		South America	Low	No
12	Sibling	Female	40	11 (7+)	Mexico	Low	Yes	Concordant active
	Sibling	Female	43		Mexico	Low	Yes
13	Mother	Female	44	5 (2)	Mexico	Low	Yes	Concordant active
	Daughter	Female	19		United States	High	Yes
14	Spouse	Female	38	5 (3)	Mexico	Low	Yes	Discordant
	Spouse	Male	46		Mexico	Low	No
15	Son	Male	30	4 (0)	United States	High	No	Discordant
	Mother	Female	55		Mexico	Low	Yes
16	Spouse	Female	35	6 (4)	South America	Low	No	Discordant
	Spouse	Male	36		Mexico	Low	Yes
17	Mother	Female	50	4 (1)	United States	High	No	Concordant inactive
	Daughter	Female	20		United States	High	No
18	Daughter	Female	25	5 (0)	Mexico	Low	Yes	Discordant
	Mother	Female	45		Mexico	Low	No
19	Daughter	Female	25	5 (1)	Mexico	Low	No	Concordant inactive
	Mother	Female	53		Mexico	Low	No
20	Daughter	Female	29	7 (3)	Mexico	Low	No	Concordant inactive
	Mother	Female	48		Mexico	Low	No

Abbreviation: PA, physical activity. Note: Acculturation was measured into high/low using the Bidimensional Acculturation Scale for Hispanics. Concordance active—2 partners meeting PA guidelines; concordant inactive—neither partner met PA guidelines; discordant—one partner met PA guidelines, while the other did not. Meeting national PA guidelines—150 minutes of moderate-intensity PA per week or equivalent vigorous-intensity PA.

Qualitative Results

Text exploration showed that many participants described participation in leisure activities, much of which were done with other members of the same household; this included walking around the neighborhood or to a nearby park, going to the gym, taking children to ride their bikes, swimming, and dancing. One significant observation was that, compared with women, men were more likely to describe challenges and facilitators to PA that were outside the scope of family influences. For example, job responsibilities presented itself as a significant barrier to leisure PA participation, but simultaneously, was a means to being active throughout the day. One male participant (spouse) described it as such:

Well, the exercise and all that I do it at work because I have to go from one place to the other. What I try to do when I come home is to relax—I mean, you are exhausted because even though people say they come home and they still want to go to the gym—well, maybe it’s the ones who are seated all day long, because right now I do like all the jobs. And then they tell me, “Let’s go for a walk,” so I say no. What I want is to rest my feet because my job is hard; I don’t have time to go for a run, for a walk or to make exercise.

Prominent family-level themes related to challenges and facilitators to PA are described below. Representative quotes for these themes are discussed in Table 4. In Table 5, we present responses for dyad-specific influences on PA to explore whether certain dyad-specific dynamics were more encouraging for PA engagement. Within these dyads, we examined responses within the context of gender differences, dyad relationship type (spouses vs parent–child), and dyad concordance/discordance pairs.

Table 4.

Representative Quotes for Factors Influencing PA

Themes	Quotes	Dyad type
Challenges to PA (category)
Lack of support	Q1: “Motivation helps people a lot. But sometimes when I’m getting ready to go for a walk, I talk with my sister-in-law and she discourages me in that moment. She asks me why I walk; she says it’s crazy. I feel that she is not a support for me. I tell her, ‘Let’s go for a walk’ but she says ‘Oh, no.’”	Mother, parent–child dyad
	Q2: Mother: “I used to walk. When I was pregnant with her. I had lost a lot of weight just by walking a mile every day. Now we say we’re going to walk, but then something always comes up.” Daughter: “I really want to do it, but I feel like she wouldn’t do it with me. I’m serious. I just feel like you [mom] wouldn’t do it with me. ”	Parent–child dyad interaction
	Q3: “When I come home from work, he tells me to rest. He tells me not to go for a walk and I say no. He even went to the doctor’s practice to ask if I could walk in the park under the sun. The doctor told him that I could do everything; that I didn’t have any limit, and it was very good for my health, to help recover more. And then he calmed down because the doctor answered all his questions.”	Mother, parent–child dyad
Challenges posed by children	Q4: “They tell me ‘let’s go to the park.’ At first, I don’t want to go, but they tell me, ‘let’s play.’ They try to exercise with me, ‘mom, teach me how to play and I’ll play with you.’ But they discourage me when they start fighting. The children have that thing; they motivate me and discourage me.”	Wife, spousal dyad
	Q5: “The children make me not want to do physical activity because they say, ‘Oh, why do you do that; why do you dance?’ When I did Zumba, once I fell, I hurt my knee. Now they say, ‘Are you going to go to dance again and fall again?’ They make me not want to do it.”	Sister, sibling dyad
Sedentary lifestyle	Q6: Daughter: “I think whenever I’m working it’s better because it makes me get up and do something. Because whenever we are at home, we don’t get up usually.” Mother: “We watch a lot of TV. We binge watch.” Daughter: “Yeah. We don’t get up for anything because we watch Netflix.” Mother: “We could spend the whole day watching. If I didn’t have to get up and cook or do something, we would just watch. I agree with what she says because if the rest of us are sitting there watching TV, you don’t feel like getting up if you don’t have somebody telling you, ‘Come on. Let’s go take a walk around the park or whatever,’ You’re less likely to do it. So that plays a big part for us.”	Parent–child dyad interaction
	Q7: “We always have the same routine. We come home; we sit down; we sleep and we get up again. We work; we come home; we sleep—I mean, we’re always doing the same thing and not doing something different.”	Mother, parent–child dyad
Competing responsibilities (individual and family)	Q8: “The kids are very energetic, so sometimes I already feel tired at night; so I say no, I don’t want to do it today. That’s the most difficult thing—that sometimes I feel really tired and I don’t feel like doing it [PA]. I think that when they [children] are a bit older, I’ll have more time, because if I’m exercising, they might want something, or the baby might cry and then I have to stop and take care of them.”	Wife, spousal dyad
	Q9: Mother: “It would help if someone encouraged me to go to walk, but they are always busy with their own business.” Son: “I want to take her out walking—but, I think the hard thing about it is finding the time. ” Mother: “We could improve our communication so that we can find time. We are both busy, and sometimes he tells me, but he forgets about it or I do.”	Parent–child dyad interaction
Facilitators to PA (category)
Verbal encouragement	Q10: “My husband would encourage us to go, especially if he sees to the point where I’m losing weight. He’d say, ‘you look good, keep doing it.’”	Mother, parent–child dyad
Instrumental support—someone to exercise with	Q11: Sister: “When I first started to go to the Zumba classes it was because she [sister] brought me here. I was going through a very depressing stage because I was left unemployed and all that, and she said, ‘Why are you [staying] there? Come with me, let’s go to Zumba.’ I didn’t want to, but then I liked it and I kept coming.” Sister 2: “I’m like her happy pill, because she has her 2 kids with some problems, and she gets depressed a lot. I’m like her medicine; I’m like ‘let’s go there. Let’s take the kids to the park.’ I’m her motivation.”	Sibling dyad interaction
Instrumental support: help with responsibilities	Q12: “He could support me by doing things together, and he can help me do whatever I’m doing. At home he can help me do the dishes or clean the bathroom or the rooms.”	Wife, spousal dyad
	Q13: “I believe that taking turns with responsibilities during the time that they are asleep would help. That’s when I could do more PA.”	Wife, spousal dyad
Exercising to appease children	Q14: “What motivates me to keep doing activity? It is 2 things, because of my illness and for my children to be thin. And also because they get bored because they are inside the house. So my children motivate me to distract them. That’s what motivates me to exercise.”	Husband, spousal dyad
	Q15: “My daughter asks me, ‘Mom, are we going to do exercises?’ or ‘Mom, aren’t we going to do this activity today?’ She asks these questions, and she reminds me of that [exercise]. So I tell her, ‘Oh now, we’ll do this,’ and we do it.”	Wife, spousal dyad
	Q16: “I forget that I’m tired there. In other words, I love them so much. They are my kids and I’m telling you, I try to do whatever they say even though I am really tired.”	Mother, parent–child dyad

Abbreviation: PA, physical activity.

Table 5.

Quotes for Partner Influences on Physical Activity

Group comparisons	Quotes	Dyad type
Men vs women	Q1: Mother: “Well, she could start doing it with me so I would feel more motivated. If you have company there, you want to do it.” Interviewer: “What do you think about that.” Daughter: “Well, yes. We have to have somebody push you, because the 2 of us, we spoil each other a lot.” Mother: “Yes, you have to feel that you have somebody there supporting you, somebody who is also in the same situation that you are, because when you are alone sometimes you become discouraged.”	Woman, parent–child dyad interaction
	Q2: “I don’t walk very well and so the more exercises I do the better. She supports me, that’s why she goes to walk with me, because she is afraid that I’m going to fall. We go for a walk every day, and during the afternoon there at home.”	Man, spousal dyad
Parent–child vs spousal/partner relationships	Q3: “She would just have to encourage me, like say ‘Nobody’s looking at you.’ And like she has said before, ‘if you want to go walking, we’ll go; we’ll do this or we’ll do that together.’ It would be a big thing for her to just say it.”	Mother, parent–child dyad
	Q4: “He says that I have to lose weight; that I have to exercise. And I tell him that well, he has to love me the way I am.”	Wife, spousal dyad
Concordant active vs concordant inactive dyads	Q5: “I like going to the park to explore, because if I exercise at home, it’s not the same thing. When I go to the park, I’m more relaxed. She [study partner] always supports me in what I decide to do. Sometimes I get off work and I tell them [study partner and younger daughter] ‘get ready because we are leaving to exercise.’ The children help me to keep going; motivation helps people a lot.”	Mother, concordant active dyad
	Q6: “We can keep a family calendar, around the house where everybody can keep it updated, so we can do activities. Like just write down a day or ask my sister or my dad when they have time. My dad doesn’t work on Sundays, so maybe he would like to go out walking. We can all pick that Sunday and go.”	Son, concordant inactive dyad

Themes Related to PA Challenges

Lack of Support.

Lack of support for PA was a common theme that was mostly discussed by women from parent–adult child dyads. Two subthemes within lack of support were observed: absence of emotional support and absence of instrumental assistance from family members in the home. For emotional support, participants described how those close to them did not provide emotional encouragement for PA and that the absence of such support was demotivating to exercise efforts (Q1 in Table 4). In addition, the participants expressed how the absence of instrumental support was a challenge to being active. One mother–daughter dialog reflected the challenges faced when one partner did not support the other (Q2). The participants also described how the unsupportive behaviors and attitudes of family members negatively impacted their PA behavior. Particularly, one woman who was a cancer survivor described disagreements she had with her husband, who was concerned about her levels of PA following cancer treatment. His opposition abated only after her physician addressed his concerns (Q3).

Challenges Posed by Children.

Another challenge-related theme to PA was the issue of children in the household interfering with participants’ PA. Responses for this theme were only expressed by women participants. The respondents explained the challenges they faced when trying to engage children in leisure activities in or outside the home. The PA engagement was often met with a lack of enthusiasm, sibling disagreements about the activities they wanted to do, or shifting temperamental attitudes (Q4 and Q5).

Sedentary Lifestyle Impedes PA.

Another challenge was the sedentary lifestyles in participants’ households. This topic was discussed by women participants from parent–child dyads who were also concordant inactive dyads. The participants described unhealthy norms in the home, such as excessive television watching and children playing video games for long periods of time. Extended time in these sedentary activities left the participants lacking motivation to engage in PA, particularly when no one else in the household was trying to be active. We were able to capture this challenge to PA across an interaction between mother and daughter (Q6) and in a mother’s description of this theme as a challenge to PA (Q7).

Competing Responsibilities.

Finally, competing responsibilities was another observed theme. This theme was reported across all dyad relationships and concordant and discordant dyads. However, only women mentioned this barrier, describing that household duties and attending to family members often got in the way of their PA. These responsibilities often centered around chores, preparing meals for the family, and attending to children’s needs, such as caring for a newborn, taking children to appointments, going to school and sporting activities, and assisting children with their homework. Attending to these responsibilities often left women too tired or with too little time to integrate PA into their daily routines (Q8). In addition to an individual’s competing responsibilities, the participants also reported how family members’ busy schedules compounded those challenges, particularly for individuals who sought to exercise with a family member. With other family members consumed with their own responsibilities, some participants felt it was difficult to find time to be active with another family member (Q9).

Themes Related to PA Facilitators

Verbal Encouragement.

Verbal encouragement was a facilitating theme frequently mentioned by women from parent–child and spousal dyads and concordant inactive dyads. The respondents stated that PA was more likely when they received words of support to be active (Q10).

Instrumental Support: Someone to Exercise With.

The respondents further described the benefits of having an adult family member as an exercise partner and how their presence was motivating and helped to resolve initial doubts about exercise. Like verbal encouragement, this theme applied primarily to concordant inactive dyads and women (Q11).

Instrumental Support: Help With Responsibilities.

Another instrumental supportive theme was help with responsibilities. In particular, women from parent–child and spousal dyad groups expressed that engaging in exercise would be easier to achieve if family members helped with responsibilities around the home. Examples included help picking up children from school and extracurricular events, help caring for a senior parent or newborn, and help with chores. Within this theme, female partners specifically described how their partners’ help to balance responsibilities would help them achieve more PA (Q12 and Q13).

Exercising to Appease Children.

Finally, the participants described that the desire to make children happy and healthy and to spend time with them encouraged them to be active. This theme was shared by both parent–child and spousal dyads. This was one of the few facilitators in which men described how the family impacted their PA behavior. An example quote was by a father who described that he exercised because it was beneficial for his and his children’s health (Q14). The participants explained that exercising would have been unlikely were it not for kids in the household asking them to take part in outdoor activities, with one attendee describing how her younger daughter was a motivating force in getting her to exercise (Q15). Finally, the participants additionally expressed that the desire to see their children happy and active overrode potential barriers, such as fatigue (Q16).

Partner Influences on PA by Gender, Dyad Relationship, and Dyad Concordance/Discordance

In Table 5, we also explored participants’ perceptions regarding specifically how their study partner (in comparison with broader family influences) could provide support for them to be physically active. This approach was particularly important to help identify and understand underlying group dynamics within dyad focused studies. We explored differences in dyad-specific responses by various groups, including gender, dyad relationship (spouses vs parent–child), and dyad concordance/discordance. Within these dyads, most women indicated that exercising together and help with responsibilities were ways in which their study partners could best offer support for PA. The women described wanting their partners to go on walks with them more often, start doing exercises with them, accompany them to classes, go dancing together, and balance caring for the family so the women could exercise (Q1 in Table 5). Conversely, compared with women’s descriptive examples of partner support, men’s responses were often succinct and less detailed. Still, some men also described that they too wanted their partners to show support by engaging in activities with them, and one husband was able to describe in detail how his wife offered her support (Q2).

Compared with spousal/partner dyads, parent–child and sibling dyads gave more descriptive and positive examples of how their study partner could help them be more active. These dyads often expressed that their partner could support them by exercising with them or by offering encouragement to initiate or continue PA engagement. In Q3, Table 5, a mother described how her daughter could support her by offering to be active with her. In contrast, we noted that responses from spousal/partner dyads regarding partner support were less descriptive, dismissive in tone, and discourteous in some examples (Q4).

In addition, we also examined partner support through the context of discordant and concordant active/inactive dyad pairs. Compared with dyads who were concordant active, concordant inactive dyads were more likely to describe family-level obstacles to PA engagement. The responses of concordant active dyads regarding partner support for PA also were mostly positive versus the responses of concordant inactive and discordant dyads. Also concordant active dyads were more likely to speak of the PA behaviors that they were presently doing with their partners, rather than the PA behaviors that they wished they could be doing together. In one example (Q5), an interviewee in a concordant active dyad described how she loved going to the park to exercise and further expounded on how her partner specifically encouraged her to exercise. Conversely, concordant inactive and discordant dyads were more likely to describe ways that their study partners could help them be more active in the future. These types of dyads proposed joint activities, such as taking walks together, having a partner initiate PA, or carefully planning activities that were amenable to family members’ schedules; one such example is described in detail (Q6).

Discussion

The purpose of this qualitative research was to explore family-level influences on PA among Hispanic adult family dyads living in the same household, with a particular focus on the interpersonal and contextual challenges and facilitators that impacted PA engagement. There were multiple unique elements to this study, such as the observation of PA engagement themes across family dyads who were interviewed simultaneously within the same space, the conduct of interviews with a majority immigrant study population wherein most participants reported low levels of acculturation, and the ability to examine family-level influences on PA engagement within the context of type of dyadic relationship, concordant/discordant PA partners, and gender. While various populations may relate to the findings of this study, the transferability of our findings applies largely to Hispanic families of similar demographic makeup. To that end, the contributions made within this paper will inform and equip behavioral scientists with the knowledge necessary to build on this research through hypothesis testing questions that advance learnings and optimal health for this population. The results suggest that within this population, the family environment played a key role in shaping individuals’ PA behavior, particularly among women. Moreover, women described how the actions, attitudes, and behaviors of other family members, including both adults and children, had an impact on their own motivation and PA engagement.

First, competing responsibilities, challenges posed by children, lack of support, and sedentary lifestyles were principal challenges to PA engagement and were primarily reported by women. Our finding that family-level challenges and facilitators to PA were more prevalent among women is consistent with previous qualitative studies conducted in Hispanic populations.^16,19,28,38 In particular, competing responsibilities as a barrier to PA aligns with current research.^16,19,28,38 In these studies, women described how time spent cooking, cleaning, and caring for household members left little time to exercise.^28,39 This family-level delineation of tasks along gender lines is common; research has shown that expectations are placed on Hispanic women to assume traditional gender roles in caring for their families, while men were less likely to describe household responsibilities as a barrier to PA engagement.¹⁸ Given that the prioritization of the family’s needs left Hispanic women with little energy or time to focus on their own interests,³⁹ future interventions should underscore communication-building strategies so that women are better positioned to request assistance from their partners or other family members to achieve PA.

In this study, children were a predominant theme across dyads’ narratives. For example, PA engagement was often impeded or aided by the behaviors and attitudes of participants’ young children. Women described how they included children in family-level leisure activities, such as walking around the neighborhood, going to the park, and dancing at home. The parents also described engaging in PA at the request of their young children. This facilitator, which has not been significantly explored across past studies, suggests that the presence of children in the household can enrich a participant’s PA habits. The participants mentioned not wanting to disappoint their children and thus took part in activities even while tired or not in the mood to engage in leisure PA. On the other hand, parents described how their young children’ s indifference to PA or their mercurial temperaments could make it difficult to be active. Again, women more often than men reported children’s behaviors as having an influence on their own PA engagement. Given the important focus that parents in this study placed on meeting the needs of children, health promotion efforts should emphasize the broader family context in behavioral interventions and consider the ways in which having young children in the home may act as both a barrier and a facilitator to PA engagement. Furthermore, where competing responsibilities and time constraints make it difficult for parents to secure time to engage in PA, researchers should be encouraged to think innovatively about how policy-driven programs (eg, early head start, childcare assistance programs) and interventions can weigh positively on healthy behavior adoption. Future efficacy and effectiveness intervention studies should examine the impact of these strategies to better understand their contributions to health promotion efforts.

In addition, this study delved deeply into the presence of support, or the lack thereof, as a significant influence on PA engagement. Many participants expressed how the presence of support—whether verbal or instrumental—was a predominant driver for PA engagement. Conversely, not being encouraged by family members or having a partner to exercise with were major challenges to PA. We also found that lack of support was also closely linked to another challenge: sedentary lifestyles. The “sedentary lifestyle” was largely noted in concordant inactive dyads who described that PA engagement would be more likely if they had a partner who motivated them or exercised with them. Indeed, the idea of social support as a facilitator to PA initiation and maintenance is supported by numerous studies which underscore supportive relationships as being advantageous for sustained healthy behavior change.^9,17,40-42 For example, in Kouvonen et al,⁴³ individuals who received high levels of emotional support from a study partner who met PA guidelines were likely to still be engaged in adequate PA up to 5 years later. It is also important to note that most of our study participants reported low levels of acculturation. Research shows that individuals who report low acculturation often rely on and lean into their families and other cultural safety nets for social support.⁴⁴ Tying back to the familism concept frequently observed within this population, it is vital that research efforts within this population intervene at social support levers to ensure that persons are getting the help needed to sustain long-term healthy PA behavior change. For example, the integration of support-building strategies specifically within this population may encourage individuals who are not meeting PA guidelines to actively seek support (whether instrumental or emotional) from persons within their family and household unit.

A novel aspect to this study was the ability to explore dyads’ feedback on how their partners could support their involvement in PA. Our observations that women sought instrumental and emotional support from their partners fell in line with prior research. For example, Thornton et al⁴⁵ showed that women were most likely to seek out these types of support and that partners/spouses and female relatives were the primary sources of such support. On the other hand, the men in our study were less expressive about the ways that their study partners could help them be more active. It is possible that women and men had varying comfort levels in articulating the need for PA support. It is also reasonable to consider that because men felt they were active at work, they did not see the need to be additionally active or seek support in increasing PA output. Furthermore, we observed differences across dyad relationships regarding how study partners discussed supporting one another, with nonspousal dyads offering more positive and supportive examples compared with spousal dyads. These findings may suggest that communication may be an important component of family-based approaches and that interventions need to integrate communication strategies on how to ask and provide support within the family context to overcome challenges to facilitate healthy PA habits.

It is important to note the study’s limitations. First, the qualitative design limits the ability to extrapolate findings to a broader population; thus, caution must be exercised when interpreting the study’s findings. Nevertheless, the participants who participated in this in-depth exploration of facilitators and motivators to PA offered important insights on the many ways in which the home environment influences PA behaviors. Second, fewer men than women participated in this study. As such, we may not have been able to fully capture the range of responses around PA behaviors and PA challenges and facilitators that Hispanic men may encounter. Third, the measurement approaches used in this study did not comprehensively capture other sources of PA, including domestic, job-related, and commute activity. The Godin Questionnaire, which was used to determine those who met PA guidelines, accounts for engagement in leisure PA. In addition, though the purpose of these interviews was to inform a broader intervention on how to increase PA engagement, it would have been impactful to explicitly explore potential factors that impact PA engagement in other domains. In the absence of doing so, we may have overlooked possible responses on how to overcome certain barriers to PA, including time constraints and competing responsibilities. Finally, these interviews were conducted with both respondents in the room. Although this allowed us to observe dyadic interactions, it is also possible that the participants may not have shared all their opinions due to their partner also being present.

Despite these limitations, this study had many strengths. The study design was novel in that we explored family influences on PA behaviors within a dyadic context. Unique to this study was our ability to also explore possible differences in responses to themes across various subgroups within the study’s sample (eg, concordant active vs inactive, relationship type, and men vs women). In doing so, we were able to explore PA behaviors, family-level challenges and facilitators to PA, and partner support for PA within this underserved population in ways that were not thoroughly examined across past qualitative studies. We were also able to uniquely observe conversations between partners. We found that participants’ PA-related attitudes and behaviors influenced each other’s behavior and that observing and understanding these interpersonal dynamics significantly informs and advances behavioral research on dyadic study populations and the wider field of health promotion.

Conclusion

This study highlighted family-level challenges and facilitators to PA in this sample of adult Hispanic family dyads. Lack of support, competing responsibilities, sedentary norms within the household, and challenges posed by children were described as significant obstacles to PA. However, encouragement, instrumental support, and exercising to appease children played a salient role in promoting PA. Interventions conducted in Hispanic populations may be best served by targeting the family unit, integrating family-centric activities, and emphasizing the importance of social support and family communication to further leverage these important relationships to foster healthy behavior change.