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Physical Activity Barriers and Program Preferences Among Indigent Internal Medicine Patients with Arthritis (CE)
The study purpose was to determine, among indigent arthritis patients, physical activity barriers, program preference frequencies and demographic associations. A structured interview of 223 indigent, internal medicine clinic patients with self-reported arthritis was administered in a cross-sectional study design. The two most frequently reported barriers included bad health (52%) and pain (51%). The majority preferred to exercise alone (54%), close to home (76%), and in the early morning/evening (83%). The preferred method of receiving exercise information was by video or audio tape. Frequency of reported barriers was significantly associated with age, ethnicity, and gender; specific program preferences were significantly associated with age and gender only. Exercise programs for indigent patients with arthritis should be home-based with flexible scheduling. Educational material should include both video and audio tape formats. Future interventions should consider barriers related to poor health and pain while remaining responsive to age, gender, and ethnic differences. Nurses can play a pivotal role in such interventions.
Exercise reduces pain (Ettinger et al., 1997; Fransen, McConnell, & Bell, 2003; Kovar et al., 1992; O’Reilly, Muir, & Doherty, 1999; Petrella, 2000; Rejeski, Ettinger, Martin, & Morgan, 1998; Smidt et al., 2005) and disability (Ettinger et al.; Rejeski et al.; O’Reilly et al.; Penninx et al., 2001; Roddy, Zhang, & Doherty, 2005) among patients with arthritis, which is the major cause of disability in the United States (Centers for Disease Control and Prevention, 2001, 2006). Patients with arthritis are less active (Hirata et al., 2006; Hootman, Marcera, Ham, Helmick, & Sniezek, 2003; Shih, Hootman, Kruger, & Helmick, 2006) and enhancing physical activity requires providers to understand the barriers and program preferences reported by this population. Only two studies have evaluated such barriers, and none has evaluated program preferences (Fontaine & Haaz, 2006; Neuberger, Kasal, Smith, Hassanein, & Deviney, 1994). Such information is needed to facilitate the efforts of rehabilitation health professionals to enhance the activity level of patients with arthritis. The study aims were to determine (1) physical activity barriers and program preferences among indigent internal medicine clinic patients with arthritis and (2) the influence of gender, age, and ethnicity on barriers and program preferences.
Materials and Methods
Adult patients in an academic internal medicine clinic participated in a cross-sectional study. Non-English speaking, acutely ill, demented, or psychotic patients were excluded. Overall response rate was 393 out of 444 (88.5%). Of these, 223 had a self-reported diagnosis of arthritis; results from these 223 patients are reported.
A pilot-tested structured interview was administered by trained research staff. The study was approved by the local institutional review board and informed consent was obtained prior to data collection. Patients were asked how often 18 barriers interfered with exercise (5-point Likert-type scale, 1 = never to 5 = very often). Program preferences measurement utilized yes/no and multiple choice questions. Body mass index (BMI) was calculated from self-reported height and weight.
Chi-square and Fisher’s exact test were used to test gender and ethnicity differences for barriers and program preferences; age differences were examined with independent t tests and ANOVA. Spearman’s correlation was used to test the association between age and each barrier. Likert scale items were dichotomized (infrequent = 1, 2, 3; frequent = 4, 5) for descriptive analyses. All Likert-scale categories were used for Spearman’s correlations.
The majority of patients were Caucasian women with fewer than 12 years of education and annual income of under $20,000 (see Table 1). Patients were older (mean = 53 ± 9.1) and obese (mean BMI = 32 ± 7.7); the majority (78%) perceived their health as fair or poor. Payer status information was available on 125 (56%) of participants. Seventy-five (60%) were self-pay, with 46 (37%) being Medicaid/Medicare and 4 (3%) being other.
The most frequently reported barriers included bad health, pain, discouragement, fear of injury, and lack of discipline, lack of interest, lack of equipment, and lack of time (Figure 1). Barriers that interfered with exercise in fewer than 10% of respondents included cost, lack of enjoyment, weather, knowledge, lack of company, lack of facilities, lack of transportation, embarrassment, lack of skill, and lack of family support.
Discouragement interfered with exercise more in women than men (19% versus 7%, p = .039). When compared with African American patients, Caucasians more frequently reported lack of discipline (32% versus 9%, p < .001), time (16% versus 7%, p = .036), and fear of injury (17% versus 7%, p = .027). Age was negatively correlated with embarrassment (r = –0.24, p < .001), lack of time (r = –0.16, p = .015), discouragement (r = –0.20, p = .004), lack of equipment (r = –0.15, p = .022), transportation (r = –0.19, p = .004), pain (r = –0.18, p = .009), and fear of injury (r = –0.18, p = .007).
Exercising alone was preferred (54%) and 29% wished to exercise with a family member (Table 2). Only 24% preferred to exercise away from home, and 83% preferred to exercise in the early morning/evening. Almost half of respondents (43%) preferred to receive exercise information via videotape or audiotape with 29% preferring written materials or information from another source (class or friend). The four most popular group exercise components included good music, fun exercises, convenient scheduling, and an enthusiastic leader.
More women than men preferred good music (75% versus 57%, p = 0.01), fun exercises (89% versus 76%, p = .012), mats/carpets (82% versus 62%, p = .004), and videotaped leader (45% versus 28%, p = .029). No ethnic differences existed in program preferences. Patients preferring exercise in early morning were older than those preferring early evening (mean age 55 versus 50, p = .001). Older patients also preferred exercising outdoors near their home (mean age = 55) compared with those preferring their home or another site (mean age = 51; p = .017 and 0.047, respectively). Younger patients preferred fun exercises and convenient scheduling (mean age 52 versus 57 for both; p = .003 and .005, respectively).
Bad health and pain were major barriers to exercise among indigent internal medicine patients with arthritis. The majority preferred to exercise alone or with a family member, close to home, and in the early morning/evening. The preferred method for information dissemination was video or audio tape. Preferred group exercise components included good music, fun exercises, convenient scheduling, and an enthusiastic leader. Several barriers were significantly associated with age, ethnicity, and gender, and specific program preferences were associated with age and gender only.
Neuberger (1994) studied 100 primarily Caucasian adult outpatients (non-indigent, mean age = 53) with rheumatoid or osteoarthritis, able to undergo bicycle ergometer testing. Major barriers included “exercise was tiring” (57%), “exercise was hard work” (40%), lack of time (33%), inaccessibility to exercise facilities (27%), inconvenient facility schedules (25%), and lack of encouragement by family/friends (25%). Unlike our study, pain and age did not influence barriers, possibly because Neuberger studied a healthier subject population. Consistent with our results, Fontaine (2006) reported that joint pain and poor health were associated with reduced levels of physical activity. Ethnicity and gender differences were not examined in either study, and no prior study has evaluated program preferences in patients with arthritis.
Ethnicity influences studied by Masse and Anderson (2003) found that African American women in the lower income group perceived more barriers to physical activity than African American women in the higher income group. A similar difference was not seen for Hispanic women. Differences in specific barriers were not examined. Dergance and colleagues (2003) surveyed elderly Mexican American and European Americans with or without arthritis about physical activity barriers. Mexican Americans reported lack of time as a barrier, and, similar to our findings, European Americans reported lack of discipline. Unlike our results, no ethnic differences existed in fear of injury. Prevalent barriers were similar to those reported by our participants with the exception of pain, which may be due to differences in the study population (i.e., community dwelling rather than clinic based).
Although the use of self-reported diagnosis of arthritis (as opposed to physician and/or radiographic diagnosis) is a possible study limitation, the measure is most likely to have identified patients with clinically symptomatic arthritis (and hence clinically significant disease). Sampling for our study was clinic based (not population based), possibly reducing the generalizability of our study results and explaining the frequent reporting of bad health as a barrier. Study strengths include an adequate sample size for evaluating age, gender, and ethnic differences. Also, our study is unique in its focus on an indigent population with minority representation and its examination of specific physical activity barriers and program preferences among arthritis patients.
Future exercise interventions for indigent patients with arthritis should be home based (especially for older patients) with flexible scheduling (allowing differences in age preferences). Educational materials should include video and audio tape formats. Traditional behavior modification techniques should be included to address barriers such as lack of discipline and discouragement. Furthermore, interventions should consider barriers related to poor health and pain while remaining responsive to age, gender, and ethnic differences in physical activity barriers and program preferences.
Patients with arthritis are aware of the importance of exercise but lack the necessary information for initiating and maintaining an exercise program (Rosemann et al., 2006). Much needed exercise interventions in the clinical setting for chronic disease patients such as those with arthritis could be optimized by collaboration between physicians and rehabilitation nurses. Lack of time is the most prevalent physical activity counseling barrier reported by physicians (Walsh, Swangard, David, & McPhee, 1999). Although it is important for the physician to write a prescription for exercise type, intensity, and duration based on the presence of arthritis and other co-existing and limiting chronic diseases, nurses can play a critical role in assisting the patients with implementing these prescriptions. Nursing professionals can design or adapt available patient educational materials related to exercise, apply basic behavioral modification techniques, and use a self-management approach to helping patients exercise regularly (Blixen, Branstedt, Hammel, & Tilley, 2004; Kinion, Christie, & Villella, 1993; Tulloch, Fortier, & Hogg, in press). They can provide the majority of education and behavior reinforcement through initial and follow-up counseling sessions. They can address barriers to physical activity, discuss relapse prevention, and collaborate with the physician to provide optimal exercise counseling with minimal physician time commitment. Nursing interventions reduce time demands on physicians, yet provide individualized care necessary for physical activity maintenance.
With increasing evidence supporting the benefit of exercise for patients with arthritis, nursing professionals can take a lead role in exercise counseling in an effort to improve quality of healthcare delivery for patients with arthritis. Because of the pivotal role that nurses play in patient care and their clinical knowledge and experience, they are particularly well-suited for helping patients address the health-related barriers reported in our study. The complementary nature of the nurse and physician clinical roles could be used as an opportunity to help patients with arthritis become more active and, in so doing, potentially improve their quality of life.
This work was supported by Georgia Affiliate American Heart Association Grant-in-aid.
About the Authors
Hammad A. Bajwa, MD, is a rheumatology fellow at the University of Minnesota.
Laura Q. Rogers, MD MPH is associate professor of medicine at SIU Department of Medicine. Address correspondence to her at SIU School of Medicine, Department of Medicine, PO Box 19636, Springfield, IL 62794-9636.
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