I Can Move Better, Baby!: Determinants of Exercise Adherence in

The Diabetes Wellness Project

 

 

Amanda Gammon

Spring 2005

 

 

 

 

 

 

 

 

I. Abstract

 

Diabetes is an increasing health concerns in the United States.  Though diabetes can be controlled through exercise and risk factors such as sedentary lifestyle and obesity are modifiable, many interventions have been less than effective in promoting regular physical activity. This research focused on the role of the Diabetes Wellness Project, a community-based wellness program, in improving exercise adherence for people with diabetes.  Data for this study included interviews with 20 participants enrolled in the Diabetes Wellness Project of Asheville.  The results of this study suggest that the Diabetes Wellness Project was successful in increasing physical activity for participants. This program aided participants in overcoming various barriers to physical activity and aided participants in better health management practices.  The results of this study may be useful in identifying aspects of this program that were successful in changing health outcomes for participants of community-based wellness programs.

II. Introduction

 

In the last decade, the prevalence of chronic diseases, such as Maturity Onset (Type II) Diabetes, Essential Hypertension, and Atherosclerotic Vascular Disease, that result in large measure from the interaction of obesity, inactivity, and poor diet with poorly understood genetic vulnerabilities, have increased dramatically in the United States, particularly in the South.  The burden of such illnesses and the morbidity that attends their delayed or inadequate treatment disproportionately affects the poor, the undereducated, the elderly and racial and ethnic minorities. 

Diabetes, lack of physical activity and adequate health care, obesity, and poor nutrition are issues that plague our nation today and North Carolina and Western North Carolina in particular.   Ethnic and racial minorities, low-income people and the elderly disproportionately carry the burden of chronic diseases such as these.  Diabetes is a major health problem is North Carolina that disproportionately affects African-Americans and Native Americans, women and people over 45.  In addition, rates of diabetes in people who live beneath the poverty level are three times higher than those with higher incomes  (Diabetes in NC, 2002).  Programs such as the YWCA of Asheville’s Preventative Health Project, which is part of the Diabetes Wellness Project, seek to address health disparities and improve community wellness by addressing the link between chronic disease and physical exercise and by providing community education and services to underserved populations in Buncombe County.

The goal of this study was to a) explore the benefits of the program participants of the Diabetes Wellness Program; b) examine and define barriers to adherence to this exercise program; c) explore ways in which participants overcome those barriers as well as ways that the program facilitated exercise adherence for its participants. 

Much research has already been done at both the state and national level to examine the issues of health disparities and the links to chronic diseases and other health concerns among at risk populations.  However, there is a paucity of research on the effectiveness of community-based exercise interventions for people suffering from diabetes.  More research needs to be done in order to design and test interventions that can be of maximum use and effectiveness among local community organizations and health care providers.  This type of research is necessary to fill gaps in knowledge about the effectives of health interventions in underserved populations through community-based health and wellness programs. 

Many other communities have adopted wellness programs in order to deal with the growing problem of diabetes.  The Winnebago Tribe of Nebraska and the Cherokee of North Carolina are two examples of such communities (Foxman 2004).  These programs try to incorporate holistic and culturally appropriate care in the interventions in order to deal effectively with diabetes.  The results of this study may help to make the Diabetes Wellness Project a model wellness program for other communities.

 

III. Background

            Diabetes is a chronic disease in which the body does not make or properly use the hormone insulin (Cox, 2004).  Diabetes is a chronic disease that affects over 18 million Americans or 6.3 percent of the population, according to the National Diabetes Information Clearing House.  In North Carolina the prevalence of diabetes increased 42% from 1995 to 2000 and was the fifth leading cause of death in North Carolina in 2000 (Valeriano et al, 2002).  The economic cost of diabetes is considerable.  In North Carolina estimated hospital costs for diabetes and diabetes related complications totaled more than 1.5 billion dollars in 1998 (Valeriano et al, 2002). 

Research has shown that the prevalence of the disease varies by economic status, race, age and gender.  Healthy People 2010 suggests that the disparity between populations is believed to be a complex interaction between environmental factors, genetics and varying health behaviors (Ngui, 2002).  The prevalence of the disease is higher in some minority populations than in whites, in women than men, in people over 45 and those considered low-income.  African Americans are 1.5 times more likely to be diabetic than whites and Native Americans are 1.7 times more likely to be diabetic than whites.  Socio-economic factors seem to affect the prevalence of diabetes.  Rates of diabetes in household making less than 15,000 dollars are 3 times higher than household with incomes over 50,000 dollars.  Mortality rates among minorities are 2.5 times higher than whites.  The prevalence of diabetes and the mortality rate is also slightly higher for women of all races than for males.  Diabetes rates increase as age increases.  People over 45 constitute 84 percent of all persons with diabetes (Valeriano et al, 2002).  Clearly, diabetes is a major health concern for North Carolina. 

Studies show that diabetes can be prevented through increased exercise in those with a predisposition to the disease (Diabetes Prevention Program Research Group, 2002).  It can be controlled through weight reduction, exercise, a healthy diet and regular monitoring of blood glucose levels (American Diabetes Assoc., 2001).  According to Kirk (2004:3), “regular physical exercise has the potential to improve glycemic control, cardiovascular risk factors, and the quality of life of people with type two diabetes.”   In addition, diet modification and exercise have been shown to reduce or delay the progression of type two diabetes by 58 percent (Diabetes Prevention Program Research Group, 2002). 

Despite the evidence of the benefits of exercise, 60 percent of Americans lead a sedentary lifestyle and do not exercise enough to receive the health benefits (Izquierdo-Porrera, 2002).  Seventy-five percent of diabetes patients sampled in one study had been advised by their doctors to exercise, but only twenty five percent were getting enough exercise to receive benefits (Cox et al, 2004). Even when people begin an exercise program, 50 percent of them will relapse within 3-6 months (Izquierdo-Porrera et al, 2002).  For many sedentary Americans, information on the benefits of exercise alone is to promote physical activity, even among those who are in the most need of it.  Clearly, effective interventions are needed to promote and maintain exercise, particularly for those with diabetes.

The high rates of exercise relapse are alarming.  However, adherence rates are higher for community based exercise programs than for individual ones.  For example, the results of the Sedentary Women Exercise Adherence Trial showed that beginning a center-based exercise program increased exercise adherence when compared to beginning exercise at home (Cox, 2004).  This suggests that a culturally sensitive approach to healthcare that includes center-based education and exercise programming are most effective in encouraging disease management and increased physical activity among people with diabetes. 

Minorities are at an even greater disadvantage when it comes to health care and physical activity.  Minorities are over twice as likely to be physically inactive (Crespo et al., 2000).  Many minority and low-income people do not have equal access to healthcare, wellness programs and fitness centers (Kumari, 2004).  Minorities and low-income groups fall behind whites in many of the leading health indicators including social and economic well-being, have higher rates of communicable diseases, obesity and other diseases such as heart disease and cancer.  Many do not have health insurance and have limited access to medical treatment (Racial and Economic Health Disparities, 2003).  Diabetes health education and wellness programs are vital in order to help people with diabetes to control their disease.  Furthermore, such programs must be made accessible to low-income people, the elderly, women and minorities.

Programs are needed to support diabetes patients in controlling their diabetes through exercise while addressing racial and economic disparities and health care inequalities and increase accessibility to preventative services which can help to combat the incidence effects of chronic disease.  The YWCA’s Diabetes Wellness Project (DWP) is one such program.  Located on South French Broad in Asheville, the YWCA’s mission is to eliminate racism and empower women.  The YWCA meets important needs of the community by addressing and reducing health care disparities within the community.  The goal of the DWP is to  “empower those with diabetes to develop the habit of exercise in order to manage their illness.”  Program participants are primarily women and 75 percent are African American.  The target population is primarily lower income older adults.  This population is at high risk for chronic disease such as diabetes because of the combination of race, class and gender inequities.  Interventions that address these inequities and target at risk populations are needed to effectively promote lifestyle changes.

Theoretical Models of Exercise Adherence

Because diabetes and its complications can be managed and even prevented, behavior modification related to diet, exercise and lifestyle choices are essential to disease management.  Behavior changes associated with increased physical activity and exercise adherence have been conceptualized using a number of theories.  These include the Health Belief Model, Self-Efficacy and Social Cognitive Theory, Stages of Change Model, Locus of Control, and Ecological Models (Rhodes et al., 1999; Nahas, Goldfine and Collins, 2003).  These theories can provide a framework for understanding behaviors and guiding interventions (Nahas, Goldfine and Collins, 2003).

In order to understand how these models can help explain the ways in which physical activity can be influenced, I will briefly summarize these theories.  The Health Belief Model “contends that health related behaviors depend on an individual’s perception of the severity of a potential illness… along with the perceived benefits and barriers to preventative action” (Nahas, Goldfine and Collins, 2003).  Though the perceived threat of disease may not be a major motivator for most people, it can be for people living with the threat or the consequences of a chronic disease such as diabetes and its complications.  In my research, I found that the perception or the actual severity of one’s illness had strong causal links to exercise adherence. 

Bandura’s Social-Cognitive Theory contends that environmental influences and personal factors affect behavior change itself. Derived from Social Cognitive Theory, self-efficacy represents one’s perceived ability to perform a specific physical activity given a specific circumstance. Self-efficacy is highly correlated with physical activity (Nahas, Goldfine and Collins, 2003) and the initial adoption of exercise.  It determines “whether an individual attempts a given task, the degree of persistence when the individual encounters difficulties and the ultimate success or failure” (Rhodes et al., 1999:10).  Social Cognitive Theory has implications for exercise adherence, the adoption of lifestyle change and the willingness to try new activities that will be discussed later in the paper.

Changes in exercise habits by people with diabetes can be conceptualized through the Transtheoretical Change model.  In the Stages of Change, or Transtheoretical Model, behavioral change can be identified by five stages of change.  These stages include precontemplation, contemplation, preparation, action, and maintenance (Understanding How People Change, 2004). People with diabetes are considered to be in precontemplation while they may not be aware of any health problems or be unwilling to make any lifestyle of behavioral changes.  Those in the contemplation phase may be thinking about exercise of lifestyle changes.  Once in this stage they will be most likely to respond to education and information about their health problem and ways to improve their health.  The preparation stage consists of those who are committed to change and are looking for a “plan of action” and ways to change their behaviors.  Those in the action and maintained stages are actively making changes in their lives.  During this time it is important for social reinforcers to be in place in order to support people during the later stages of change. 

Diabetes Wellness participants can be understood as in contemplation when they first receive information about diabetes or are willing to make changes in their lifestyle.  This could be because of an initial diagnosis from their doctor or from other feedback about their health.  People in preparation are inquiring about wellness programs such as the DWP.  These people are committed to change and are looking for a source of support and guidance as to how to change.  Action and maintained people participate in the program by exercising, coming to lectures and other informational meetings, and eating better.  Practically, this model can be used to design interventions and outreach educational programs that are appropriate to individuals’ stages of change.  This application will hopefully move people closer towards action and eventually, maintenance.

Studies have shown that physical activity, counseling and individualized intervention using this model promote physical activity in people with type two diabetes (Kirk et al, 2004; Diabetes Program Prevention Group, 2002).  A significant increase in physical activity was reported in patients receiving physical activity counseling such as a personal trainer over a 12-month period (Kirk, 2004).  The Diabetes Wellness Program uses group trainings, individual physical activity counseling and information on exercise and nutrition over a 12-month period to improve people’s activity levels and help people to control their diabetes.  Studies have shown this program model to be effective in creating health and behavioral changes in people with diabetes (Kirk 2004, King et al 2000).

Locus of Control theory suggests that individuals are more likely to continue a behavior such as exercise if they believe that they have some personal control over their health.  Though this theory has not been clearly demonstrated to be a predictor of adherence among older adults (Rhodes et al., 1999), it has applications in a health intervention such as the Diabetes Wellness Program.  It suggests that levels of personal responsibility, accountability and knowledge of one’s fitness program as well as the level of knowledge about the prevention and management of diabetes might be related to an individual’s exercise success.

The Ecological Models consider the need for supportive environments on multiple levels in the promotion of physical activity.  Sociological and environmental influences (social, cultural, physical and instructional) can directly and indirectly influence a person’s behavior (Nahas, Goldfine and Collins, 2003).  This model suggests that multiple levels of support are needed to help an individual succeed.  Health interventions such as the Diabetes Wellness Program should provide different types of support for clients in order to increase their chances of success.

While no single model or variable can explain why adults do or do not exercise, these theories can be useful in exploring ways that physical activity behaviors can be modified.  In my research, I found the concept of self-efficacy and the Ecological Models to be the most germane in creating a conceptual framework for my data.

Variables Affecting Physical Activity

Determinants are factors that influence physical activity and may have causal effects (Sallis & Owen, 1999).  There area a variety of factors associated with exercise behavior, including facilitators that promote physical activity and barrier to behavior change (Nahas, Goldfine and Collins, 2003).  Regular adherence to an exercise program can be influenced by interpersonal, social and physical environmental variables (Sallis and Owen, 1999).  Some factors that influence exercise adherence include self-efficacy, enjoyment of activity, perceived benefits and barriers, and social support (Sallis & Owen, 1999).  Demographics, exercise experience, physical factors such as functional mobility, knowledge about exercise and perceived social support are also indicated in exercise adherence, particularly among older adults (Rhodes et al. 1999).

Some determinants are not modifiable, such as race, sex and age.  Many psychological and environmental factors are modifiable through interventions (Nahas, Goldfine and Collins, 2003) and can be used to create more effective intervention strategies.  Non-modifiable variables, on the other hand, can be used to identify at risk populations and sub-groups.  Modifiable and non-modifiable variables can be used within the contextual framework provided by the above theories to create interventions that are effective in encouraging behavior change and create specific interventions that target high risk populations.

Programs such as the Diabetes Wellness Project attempt to encourage behavioral changes, increase physical activity and provide participants with tools to better manage their diabetes.  The goal of my study is to measure the effectiveness of the DWP in accomplishing its goals of increasing physical activity and quality of life among people with diabetes.  By addressing key factors effecting the wellbeing of diabetes patients, these  programs will be better able to serve their target populations.

 

IV. Methods

The Setting

Research was conducted at the YWCA of Asheville, which serves as a gym and community resource center for local residents.  YWCA programs include childcare, after school programs, fitness classes and preventative health programs such as the Diabetes Wellness Program.  Subjects for the study were current participants in the Diabetes Wellness Project as well as non-adherers to the program.  The Diabetes Wellness Project combines group and personal training and education on issues related to diabetes in order to help people better manage their disease.  The program includes gym membership, monthly personal training sessions, twice weekly group training sessions, and monthly educational lectures. All fees are based on a sliding scale. The program is supported by the Mission Health Care Foundation and the Buncombe County Medical Society Endowment. All participants become members of the YWCA at $40 a year. After that, the program costs are based on a sliding scale, using household income. This fee ranges from $0 to $75 a month.

The program is twelve months in duration during which time participants must exercise at the gym at least eight times a month in order to meet the program requirement.   Located in a traditionally African American neighborhood, the program serves a diverse group of individuals.  Approximately seventy-five per cent of diabetes participants are African American.

The subjects

            I conducted semi-structured interviews with nineteen diabetics who are currently or were enrolled in the YWCA of Asheville Diabetes Wellness Project.  In order to be included in the study, subjects must be (a) eighteen years or older; (b) be or have been enrolled or be currently enrolled in the DWP between the months of February 2004 and January 2005; and (c) be diagnosed type one, two, gestational or borderline diabetes.  The Diabetes Wellness Project compiled a list of potential subjects for the study.  Potential subjects were contacted by the researcher by telephone and asked to consent to an interview. 

Participant included fifteen females and four males.   Of those, four were Caucasian (three females, one male), fourteen were African American (11 females, 3 males) and one was of undisclosed ethnicity (female).  Participants ranged from 28 to 83 years in age with a mean age of 55. 

Data collection and analysis

During January and February 2005, I conducted semi-structured individual interviews.  Interviews were held at the Asheville YWCA or on the phone according to the participant’s preference and availability, however most interview were at the YWCA.  The option for phone interviews was available particularly to non-adherers who might not feel comfortable coming to the YWCA or to those with injuries or other issues that would prevent them from coming to the YWCA.  Interviews lasted between ten and thirty five minutes.  Interviews were taped, except phone interviews, and participants were asked to sign an informed consent prior to the start of the interview.  In the case of the non-adheres, the interviews focused on the reasons for leaving the program or not meeting the minimum exercise requirement of exercising twice a week.

During each interview subjects were asked to reflect on their experiences as part of the YWCA’s Diabetes Wellness Project.  They were asked to describe the benefits, and shortcomings of the program, main factors that aided them in program adherence and the main barriers to program adherence.

The primary challenge for my data collection was recruitment.  Though only one person refused an interview, many stated that they were too busy, were sick, bad weather, inconvenient timing or other barriers and unable to give an interview.  Others were late to their interviews, forgot or just did not show up.  These reasons that prevented them from making it to the interview echoed the reasons informants gave for not exercising. 

My collection methods may have skewed the data because people who consented and followed through with the interviews were most likely to be people who were already active in the program.  People came for their interviews before or after working out or attending a lecture, for example.  Thus, the sample may represent those who were active participants in the program rather than a more diverse stratum of participants.

Interviews were analyzed using an interpretive approach using open and closed coding techniques described by Esterberg (2002) and Schensul et al. (1999).  Names have been changed and other identifying had been altered slightly to ensure confidentiality.

 

V. Results

           

            My results include respondents’ perceived barriers to regular exercise, facilitators, or factors aiding in exercise adherence, and benefits the program for participants of the Diabetes Wellness Project.  In this section, I attempt to outline and explain some of the primary perceived barriers for participants and the ways in which they overcame those barriers, which I categorized as either internal or external.  I then explore the primary emotional and physical benefits of program adherence for those individuals who were able to overcome their perceived barriers. 

 

Barriers

 

“From August till when I did start this I walked by this gym everyday and I didn’t set foot in it.” - N

 

            Despite having access to the facilities at the YWCA, two of the women I interviewed were employees of the YWCA and could use the gym facilities in the building free of charge.  Though they had access to the workout facilities, they told me that they had walked by the gym on the way to their offices almost every day - one for months, another for several years- without using the facilities.  N, a 28 year old diagnosed with gestational diabetes, was an employee at the YWCA in the childcare department but she never even used the gym.  S, another employee, stated that she passed by the gym for years but only worked out about once a year.  M, a YWCA member, had to pass by the gym everyday to drop off her granddaughter at daycare.  She said, “I had joined the Y because my grand baby had to go to daycare and I came for a year before I started doing anything.  I’d come up here and do nothing.”  Despite the fact that they had access to workout facilities, several participants had not used the gym.  What barriers to physical exercise did they experience?

            Barriers to exercise are complex and multifaceted and different for each individual.  Perceived barriers to health promoting behaviors such as exercise and diabetes management are important determinants of physical activity (Nahas, Goldfine and Collins, 2003).  While some perceived barriers may not “reflect actual external barriers in reality” (Rhodes et al., 1999), they are strongly correlated to exercise behavior (Sallis & Owen, 1999).  Some barriers are personal in nature, such as depression or illness, while others are situational.  Weather, work or lack of childcare can be considered situational.  Still others are external factors that hinder one’s ability to exercise, such as lack of transportation, facilities or instruction (Nahas, Goldfine and Collins, 2003). 

            Reported barriers include lack of time due to work or family responsibility, illness, stressful life events, lack of social support, inconvenience of facilities schedules and cost, according to a study by Sechrist et al. (1987). Additional barriers cited in the study included being too uncomfortable or too embarrassed to exercise as well as lack of enjoyment of exercise.  Lack of time is the barrier reported most frequently (Sallis & Owen, 1999). 

Internal barriers

“Just getting here” was a primary barrier for most participants.  “Just getting here” reflects both internal and external barriers to regular exercise.  Internal barriers included physical condition, lack of motivation, difficulty prioritizing health, depression, low self-confidence and embarrassment and fear of the gym. 

Physical condition, injury or fear of injury, functional mobility and fitness levels were barriers to physical activity.  Many people cited physical problems as barriers to beginning or continuing exercise.  For example, personal illness or the illness of a family member was cited by the majority of interviewees as a reason for missed exercise sessions.  Five interviewees reported injury as a reason for missed or limited fitness sessions.  Fear of injury is also a powerful dissuader, particularly for elderly people.  In reviewing the literature on exercise adherence and older adults, Rhodes et al. (1999) found physical condition to be a barrier to physical activity, particularly among elderly individuals.   In addition, years or perhaps a lifetime of physical inactivity coupled with being out of shape and overweight make physical activity a challenge.  Pain, lack of physical fitness, limited functional mobility, injury and illness were some of physical barriers experienced by my informants. 

Several participants believed that they lacked the initial fitness level to begin a regular exercise program.  M described her initial barrier to physical activity.  She said, “Well at first I couldn’t do it. Physically I couldn’t do it.  I could not walk on treadmill for 5 minutes.”  With individual support from a personal trainer, M was able to increase her fitness level and time on the treadmill incrementally until she could walk for forty-five minutes.  For people such as M, programs that meet participants at their fitness level are needed.   Though such people may have been advised by their doctors to exercise, they may need additional guidance in how to exercise and at what level.  Interaction with a personal trainer and other participant at the same fitness level has helped people such as M to develop fitness and self-confidence in her physical self.  

Functional mobility was found to be a significant factor associated with exercise participation (Jette sited in Rhodes, 1999).  Pain, lack of movement confidence, fear of injury or injury were significant impediments for several informants.  Mr. L began the Diabetes Exercise Project in preparation for a hip replacement.  Overweight and under active, he began working out despite the pain in his hip when he walks.  Mr. L, like several other informants, has turned to exercise in order to manage pain, but must also negotiate the pain associated with physical activity.  These respondents have developed alternative strategies for exercise, including non-impact activities such as water aerobics.  The YWCA gym facilities offer a variety of activities at a wide range of levels.  Offering alternate forms of exercise, such a water aerobics, assists participants in designing an exercise routine that works for them as well as increase their sense of personal control over their own health. 

Lack of motivation and time to exercise were primary barriers for the men and women I interviewed.  Fitting a regular exercise routine into one’s lifestyle and schedule is difficult for everyone.  However, the motivation and priority placed on exercise may be a critical to making time for exercise.  Wanda explains,  “I’m always busy.  I just didn’t want to sacrifice what I was doing to go and exercise even though it was benefiting me.”  Despite the known benefits of exercise, some participants were reluctant to change their routines and priorities. 

According to Rhodes et al. (1999), reported obstacles to regular exercise can be explained through individuals’ priorities and perceptions.  For example, barriers such as lack of time and work or social responsibility are reported equally among those who exercise and those who don’t.  This may reflect more on the priority individuals give to exercise than on the actual time limitations.  Sallis and Owen (1999) suggest that lack of time may in fact be a “convenient excuse” rather than a true reason for lack of exercise.  Regardless of whether barriers are reflective of real barriers or “convenient excuses,” perceived barriers have a substantial impact on one’s ability to adhere to an exercise program.

Difficulty prioritizing their health was a barrier to regular exercise for many participants, particularly for the women in the study.  Many of my informants were used to “saying yes” to others and found it difficult to place their own heath before the needs of others.  This seemed to be true, particularly for women in my study, perhaps because they were used to putting others first because of their role as caretakers.  Bessie, a 57-year-old teacher who is working on her bachelors in teaching, said that she “needs to put me first then do homework.”  This is difficult for many people, especially women, who are used to putting others first.  In addition to external barriers such as care giving responsibilities, the challenge of making time for personal health was a primary barrier for some informants.

Additional internal barriers to exercise and program adherence included depression, embarrassment and stigma associated with being out of shape and overweight, lack of self-confidence and fear of the gym.  Many informants spoke about the isolation and shock associated with their initial diagnosis of diabetes.  For B., a 57-year-old retired teacher, her initial diagnosis “put her into a tail spin.”  Denial of her diagnosis, isolation and lack of shared experience were major barriers to exercise adherence and successful management of her diabetes.  The information and social support provided by the program has been integral part of health management.  By coming to the program, B found out that there was others with diabetes who had a hard time accepting their diagnosis too.

R, a 55 year old African American man, explains the health trauma that motivated him to enroll in the program.

“I’ve been a diabetic for about 25-30 years but I always exercised and moved pretty good so I didn’t have too much to worry about, but after I lost my kidneys due to high blood pressure I kind of got lackadaisical so I wasn’t doing much exercise.  In fact I was in a slump because I didn’t think my kidneys would fail, and when they failed it was kind of like a shock.  So that’s when I started gaining weight.  So that made my blood sugar go up again.”

 

For them, the program has been an integral part of making sense of life with the disease.  It has been a support group, resource for information, and a key aspect of turning their health around.  

            One of the first barriers to making it to the gym for some participant was fear and negative assumptions about the gym itself.  As one female participant explained, “coming to a gym feels intimidating when you’re out of shape, overweight or don’t know the machines.”  Resistance to being in the gym was the first barrier she had to overcome in order to participate in the program.  Because she did not fit the profile of the stereotypical “hot, ripped” body she associated with a gym environment, she was reluctant to come and work out.  Lack of knowledge about the fitness equipment fed the feeling of isolation and sense of alienation many felt when attempting the exercise program.

Others, particularly women, felt embarrassed by their fitness level or body size.  Several women told me that they felt vulnerable in a workout setting because they perceived themselves as being “large” or “out of shape” in comparison to other gym members.  For one female participant, one of the biggest barriers was “being brave enough to get in. When you talked about challenges, that was one on the challenges of getting involved in a regular exercise program was just feeling like I’m so out of shape that it would be an embarrassment to get with people that are in really good shape.”  The pressure many women experience to look “good” can erode their self-esteem and confidence in their physical bodies (The National Women’s Health Information Center).  In a society that bases a woman’s self-worth on her appearance, those that do not fit the profile of thin, young, fit gym goers, may lose confidence in the value of their own bodies.  For many women, the fear and intimidation of working out in a gym setting is a barrier for participation in a community-based exercise program.  These internal barriers along with external barriers made it difficult for many of the participants to exercise.    

External Barriers

Barriers to “just getting here” had eternal components including physical as well as situational in nature. External barriers were often situational in nature such as scheduling, conflicting events, care giving and transportation.

Scheduling was the primary concern of most of my informants.  Scheduling problems such as fitness class and group meeting times were a challenge for many participants, particularly those with children or worked full time.  Lack of childcare at the YWCA prevented several women from working out as much as they would like or attending their favorite fitness classes.  One woman reported that she could not go to the “good aerobics class” because of lack of childcare.  Though many people appreciated the convenience of location, class times and flexible meeting times, most wished that there were more options for group meeting times.  However, as one participant pointed out, there used to be a group meeting at the time she could attend and she never went.  As the opening example suggests, thought convenience is as substantial barrier, it is not the only barrier to program adherence.

Getting to the fitness facilities is a challenge for those who are without reliable transportation or dependant on the public transit system. While alternate forms of transportation such as walking, riding the bus (and walking to and from the bus stop) can be a source of exercise, they can be a barrier from coming consistently to an exercise program.  Transportation to and from the gym was a problem for at least one participant.  Vonda, a 34-year-old mother of two, has been without a car since her injury last year.  Being without a car, she relies on her father for transportation.  Now that a family member is in the hospital, Vonda must take the bus to the YWCA from her house.  Because of her schedule, she sometimes rides the bus for more than an hour to get to the YWCA.  In addition to other barriers due to her injury, she must now schedule her workouts around the bus schedule.

Program location or lack of facilities and cold weather were additional barriers for some.  Several informants cited inclement weather as barrier because of fear of illness or personal discomfort from cold weather.  Lack of safety in her neighborhood because of loose dogs prevented one older woman from exercising outside the gym.  Others cited the long drive, over 20 miles one-way, to the YWCA as a barrier. 

These barriers can seem overwhelming, but, as I will discuss in the next section, a variety of facilitators can help to support and encourage exercise participants. 

 

Facilitators

“I love the people at the Y. They make you feel like your important.  You know?   I matter.  It seems like I matter to them.”

 

Support and encouragement from peers and from trainers and instructors can have a profound impact on one’s adherence.  N tells this story about her experience with Diabetes Coordinator and personal trainer Eliza Lynn.

 “One of the first days I got on the elliptical machine and Eliza was talking to me the whole time. And she kept looking at my heart rate and she was oh just do two more minutes.  We were talking and finish that. She said lets just do two more. And before I realized it I had already done 15 minutes.  And I remember walking by every day and my son said ‘have you been on that one” I said no that’s too hard for mommy to do. And I was able to tell him, look, mommy got on that machine today and I did it for 20 minutes.”

 

Just as there are barriers to exercise and program adherence, there are also facilitators that promote physical activity in participants.  As the Ecological Models suggest, multiple levels of support, including personal, social and environmental, are necessary for the promotion of physical activity.  Facilitators can be considered both internal and external.  Participants cite a variety of aspects that aided them in program adherence. Factors include individual and group support, exercise and fitness education, positive encouragement, and personal responsibility and accountability as well as perceived negative consequences. 

Internal Factors

Many participants felt motivated to begin an exercise routine because of the possibility of negative health outcomes if they did not adopt lifestyle changes.  As theorized in the health belief model, the perception of the severity of their disease is a factor in health related behavior. Primary motivations for some informants were health problem or complication or witnessing the health problems of others due to poor diet, lack of exercise and diabetes management.  Some witnessed the poor health of a friend or relative with diabetes or experienced their own health deterioration. Secondary reasons were concern of family and friends. D had tried several times to be more active on the advice of her doctor but was unable to exercise consistently.  After her health collapse last year she realized the severity of her health condition.  Coming to group meetings, she heard the stories of others who had more severe problems due to diabetes and could “see what my future looked like.”  R was told that he needed to loose weight and gain control of his blood sugars in order to receive a kidney transplant.  The threat of the progression of the disease or death from diabetes was a major motivation for several informants.

As I discussed, learning to prioritize their health is an internal facilitator of exercise adherence.  Some of the women I interviewed discussed their personal strategies for making time for exercise with me.  J shared,

“What I am going to have to start doing is thinking more about myself and putting myself first.  When it is time for me to come to the Y then don’t let anything else come between me and my appointment with the Y. Otherwise I’m wasting my money.”

 

C, who is now retired, balances her commitment to her community and her health by instead of saying “Yes”, saying “I can do it later” when others ask her for help.  Balancing their personal needs with the external demands and the needs of other has aided in program adherence for many participants.

Exercise enjoyment is moderately correlated with exercise frequency (Sallis &Owen, 1999).    Lack of enjoyment of exercise is a barrier to regular physical activity, but participants have found ways to make exercise enjoyable to them.  For example, finding activities that she enjoys has helped C stick with the program.  When she first started she was introduced to all the machines.  In the beginning she worked out on the weight machines but she had joint problems and didn’t like it.  She said, “After a while [the personal trainer] said, ‘it doesn’t have to be a job, just do what’s pleasant for you’ and I thought, ‘great!’ so that’s what I did.” Doing exercises that she enjoys prevents her from getting bored or developing the attitude that “I just don’t want to do this.”  Individualizing their exercise program to include activates that they enjoy has helped some participants to stick with a regular exercise program.

External factors

External factors included social support, education and environmental support. The DWP seeks to encourage, motivate and educate participants by providing group training two times a week, monthly personal training and monthly educational programs about issues relating to Diabetes.  Once enrolled in the program, participants were aided by friendly staff, group and individual support from fellow exercisers as well as the program coordinator. 

Social Support

            Many studies have found a significant association between physical activity and social support from family, friends, and program staff in supervised settings (Sallis & Owen, 1999).  Social support, including family, doctor and peer support, is strongly associated with proper diabetes management, diet and exercise adherence. (Albright, Parchman and Burge, 2001)  In addition, Wilson (1986) found that social support was one of the strongest predictors of self-care behavior for people with non-insulin dependant type two diabetes.  Indeed, the participants I interviewed cited small group support and exercise as facilitators to exercise adherence.   They found social support to be a source of motivation, support and accountability that was influential in their exercise success. 

            YWCA staff members, the DWP coordinator, other group members and people outside the group, such as family and coworkers, provided social support to the participants.  Informal support networks sometimes evolved out of the more structured groups activities and exercise classes.  For this study, I categorized social support can be direct or indirect.  Direct support relates to situations such as exercising together while indirect support can include talking or encouraging someone to exercise.  I found that social support took several forms for program participants, including group, individual and institutional support as well as outside that was important to their adherence to the program. 

Group support 

              The DWP seeks to foster by social support in part by offering twice weekly small group training sessions.  Led by the coordinator, these sessions last for approximately one hour.  During this time clients receive and share information, participate in group activities, warm-up and share stories. Weekly small group training sessions enable participants to get to know one another and develop group rapport with each other.  Getting to know other people in the program has made a difference for many participants.  Hearing one another’s stories, exchanging advice and seeing one another in the gym and in fitness classes has helped participants to develop a larger support network for themselves. Moreover, it allows them to address the sense of isolation many feel when they were first diagnosed as diabetic.

              Group training sessions function on multiple levels as places of social interaction, fitness instruction and social support.  During a group session, participants may warm up, go over information covered in a recent lecture or share recent experiences.  It was an opportunity to get to know one another, see familiar faces, exchange information and encouragement, check in with one another and hear others’ stories about their successes and challenges.  Sessions also provide opportunities to share information and to gain perspective from listening to others.  Participants share their own exercise and management strategies as well as community resources for healthier living.  For example, one female informant shared that during group sessions she can “find out where to buy vegetables that are on sale or breads and some of the tricks and things that they do and that they found that help them.  So you help each other.  It’s like rock soup.  Everyone brings something to put in the pot.”  The exchange of information and different perspectives aids in the formation of a network of social support.

For others, the group sessions helped to create a feeling of camaraderie with others with similar health problems.  By creating a space for participants to introduce themselves, get to know one another, seeing each other on a regular basis and sharing stories, struggles and triumphs, groups trainings help facilitate group bonding.  According to B, her group has turned into “a pretty tight bunch”.  Hearing the stories of others with diabetes and witnessing their struggles increased feelings of accountability to the group and to individuals in the group.  For one female participant, having met the other women and hearing their stories, she wants all of them to succeed so she “wants to pull her weight on the team.”   

            The camaraderie fostered by group support helps combat the isolation felt by people with the disease.   Meetings provide opportunities for social interaction and meeting new people, particularly for older adults who are retired or homebound.  Others experience feelings of shock and isolation upon diagnosis.  One participant expressed the impact of the program on her experience of the disease. When first diagnosed with diabetes she felt overwhelmed and angry because she didn’t want to have a condition, she felt isolated, and that she was struggling to come to terms with her illness alone.  But now with the help of a whole network of support, including support outside the program, she doesn’t “feel like she’s in this alone.”

Feelings of connectedness, mutual support and accountability, and sense of context provided by peer interactions during group meetings help participants make sense of their lives with the disease and take incremental steps towards regular exercise and lifestyle change.  Group interaction fosters feelings of mutual support that, for many, developed into friendships outside the meetings.  Peer interactions in and outside of group sessions help to increase social support, perceived confidence in participants’ ability to exercise and manage their disease and social support. 

Peers also provide encouragement on an individual level through direct and indirect support.  Direct support includes calling each other, working out with others, encouragement and friendship.  Having a workout partner was a strong motivator for many.  For Ms. C, having a partner pushed her to be consistent by making workout plans, calling her to check in when she was not at the gym encouraged her to make working part of her daily routine. Having the support and encouragement of others like them gave many the courage to try new activities and the safety of knowing that others are “watching out for them.”  For example, D, a type one diabetic, feels more comfortable increasing her activity level when she knows that other people in the class are aware of her condition and are available to help in the event of an “insulin reaction”. The indirect support of seeing others they know at the gym or in fitness classes was a source of comfort and motivation for most informants. 

Peer interactions can be formalize, such as the newly forming mentorship program, or informal friendships formed at the gym.  Informal mentorships and friendships between participants are another source of support and encouragement, particularly for those at different stages of the disease.  Participants with more self-care and exercise experience share information, community resources and suggestions and strategies on diet and exercise with others.  Diabetic work out buddies, mentors and friends encourage, assure and motivate each other in part because they understand the challenges associated with being diabetic, out of shape or overweight.  Support from other fellow diabetics are powerful factors that increase exercise adherence.   

Individual support

Individual support is provided by the Diabetes Wellness Coordinator and personal trainer, other peers who serve formally and informally as mentors, “workout buddies” and other individuals who are consultants to the program.  These support sources facilitate exercise adherence by providing encouragement, individualized attention, and accountability.   The combination of support sources along with medical treatment creates a broad network of support for people trying to create lasting life changes.

The program also provides one-on-one support and attention in the form of individual meetings and training sessions with the program coordinator who is also the personal trainer.  The DWP provides monthly individual personal training sessions by the personal trainer and project coordinator.  In addition to monthly fitness sessions, participants interact with the personal trainer on a weekly basis at group meetings and informally in the gym.  These meetings provide an opportunity for individual fitness education and counseling as well as encouragement and attention.

Many people cite a one-on-one fitness instructor as a major source of support and encouragement.  Working with a fitness professional increased self-efficacy for many participants.  This guidance helped them to set realistic goals for themselves and increase their exercise when appropriate.  As N’s story at the begining of the section suggests, this type of encouragement promotes and maintains physical activity for many participants.

Encouragement and monitoring also took the form of informal “check-ins” while in the gym, phone calls and reminder cards.  Formal and informal encouragement from a “cheerleader” as well as consistent monitoring increased motivation and accountability for most participants.  One female participant explained that, “[the coordinator] is good about communicating with us and calling us, trying to get us motivated to come…. Calling does help.  Knowing that we’re not forgotten about.”  For others, knowing that they are accountable to another person who is keeping track of their progress increased their motivation to exercise. 

For many people, this type of one-on-one encouragement was the most helpful because it showed them that others were concerned about their health.  For L, “seeing that people like you and Eliza are interested in our wellbeing and it tells me that if they are interested you should be as well.”  The genuine care and attention shown by a staff member, particularly the group leader, helped others to be more engaged in their own health.   

Participants had difficulty adhering to a treatment protocol when they felt their treatment lacked of individuality or autonomy.  However, aspects of the program that encouraged individuality and autonomy helped participants to take ownership of their own health management and their exercise routines.  As Ferzacca (2000) points out is his study of diabetics at a VA clinic, the majority of his participants felt that both their disease and their medical advice and treatment they received “infringed upon their unique sense of self” (p13).  The threat to their personal autonomy made them resistant to the diabetes management treatments proposed by their doctors.  For example, the ability to personalize one’s fitness routine by choosing the type and amount of exercise as well as the time of exercise helped many informants to “stick with the program.”  Strategies employed by the DWP to individualize exercise plans can be an important approach to increasing program adherence.    

By providing a realistic framework for beginning an exercise program, the program makes getting active and increasing one’s fitness level manageable for many participants.  Moreover, the program encourages lifestyle modification by increasing self-efficacy and belief in one’s ability to actualize change one step at a time.  As one participant put it, “I got to feeling better, doing better, feeling more better, doing more better.”  Broadening the definition of success to include those who can only walk on the treadmill for 5 minutes but are still trying, helps individuals to reexamine their own notions of success.  “When I’m on treadmill and I finish, I don’t care if its ten minutes or fifteen minutes if I can’t go the rest of the way, I feel good because I did make time for it.  That is the best feeling to me because I feel like for the first time I am doing something that is the most important to my life.”

Clear guidelines and requirements established at the beginning of the program helped and enforcement, or threat of enforcement, by the project coordinator helped participants to adhere to the program.  For example, several participants reported that they continued to exercise despite perceived barriers because they “knew they would get kicked out” if they didn’t.  For one participant, “knowing that once a week there would be a group meeting and [the coordinator] would be around to check on me and make sure I was doing what I needed to do” helped her to continue with a regular exercise routine.  The emphasis on personal responsibility and accountability through clear expectations and rules of the program allowed people to make better choices about their health and exercise program.  As the Locus of Control Theory suggests, the emphasis on personal responsibility helped participants to feel personally responsible for their own wellbeing.

Education

Educational lectures encouraged people to better manage their diabetes and provided another form of positive reinforcement.  For one informant, the lectures on nutrition show her what and how to eat.  Others knew or had heard health information before. However, the reinforcement of health information as well as tools to practice lifestyle changes in incremental steps allowed them to implement dietary changes.  For B, “those are things I heard before but somehow hearing them in that context made an impression.”  The information in conjunction with the support and encouragement to take manageable steps towards a healthier lifestyle increases self-regulatory skills. In addition, support and encouragement from speakers who were “congratulatory” and affirming provided positive feedback about participants’ efforts at lifestyle change.  As perceived competence in one area of diabetes management increased, participants began to explore changes in other areas.

The combination of education and exercise helped participants to better manage their diabetes. The combination of education, support and accountability has helped them to set realistic goals for their age, health and fitness level. By creating space for practice at the new behaviors and lifestyle changes, the wellness program has provided them with tools to get healthier and set realistic goals.  The unique combination of multiple levels of support, exercise and education provides a practical application for health information.

Organizational

The atmosphere and type of the workout environment was an important factor of program adherence from participants in this center-based program. The friendly, non-threatening atmosphere of the Y, along with the helpful staff, helps participants, particularly women, to feel more comfortable with working out and with trying new exercises.  The type of facility and the atmosphere of the facility had a significant impact on self-efficacy and program adherence, particularly for women.  The creation of a “pleasant”, non-threatening environment was important in creating an environment that was conducive to working out.  Having a relaxed, non-competitive and non-crowded environment with knowledgeable and helpful staff made them feel more comfortable, especially in the beginning stages of working out. 

In addition, the diverse gym staff and gym membership that included people of varying size and color gave my informants others with whom they could identify, someone who “looks like me”.  The comfort of the YWCA for members could be attributed in part by its position as a community center in a racially and socio-economically diverse area as well as being a facility that aims to involve people of color and lower economic standing. Seeing others like them that are actively involved in lifestyle change gave them the courage to continue their own health management programs.  The environment of inclusion and acceptance created by the Diabetes Wellness Project and by the YWCA was an important factor in exercise adherence from participants. 

Conclusion

One of the strengths of the program is its flexibility in offering multiple levels of support.  Though many informants knew they needed to be more physically active and wanted to begin an exercise program, they lacked the self-esteem, knowledge, motivation and support to do so.  By providing group and individual support, peers and personal trainer, education and opportunities for action, the program provides a framework of support and consistency that assists participants exercising regularly.  For many of the participants, the program has provided tools for greater diabetes management and healthier living.

 

Benefits

            “Health is not the absence of illness, it’s the presence of wellbeing.”

                                                            -World Health Organization

 

            Before starting the program, S was depressed and mad at herself for having diabetes.  Her blood sugars were out of control. She was overweight, inactive, easily fatigued, and could not seem to make the time to take care of herself or work out, even though she had easy access to the gym.  After five months in the program, she reported that she has more energy and stamina and lower stress level.  Though she can only do a few minutes on the machines compared to those next to her, she sees the impact exercise is making on her life.  By increasing her physical activity and slowly changing her diet, she has reduced her A1C, a long-range measure of diabetes control, from 6.5 to 5.9[1].  More importantly, the program has helped her to feel more in control of her diabetes and has helped her to be more active and participate in her life and do things she enjoys. “I can finally walk the mall instead of avoid the mall,” she says.  The results of my study suggest that participants experience physical and emotional benefits as well as improvements in lifestyle management that lead to greater quality of life.

            Many studies have documented the health benefits of exercise, particularly for diabetics (see introduction).  As described earlier in this paper, physical activity has been shown to delay or even prevent the onset of diabetes and its complication.  The physiologic benefits of regular exercise are numerous.   For those that were able to overcome the barriers to regular exercise, the emotional benefits may be just as important in increasing overall quality of life.  Participants in the study reported physiological and emotional benefits to the program as well as increased control and management of their diabetes and broader lifestyle changes.

All of the participants I interviewed reported significant benefits from the program.  These benefits were both physiological and psychological and short term and long term in nature.  Physical benefits included increased energy, better diabetes control, increased fitness level and improvement of other health problems.  Many people experienced greater energy and stamina throughout the day.  For example, S “went from not having energy to having energy.  I used to be just really heavy and it changed.”  Greater functional mobility, increased fitness level and stamina made working, moving and doing daily living tasks easier. One participant reported she could cut her toenails for the first time in years.  Several women reported that they could now play with their grandchildren.  The physical benefits of increase fitness have allowed them to live fuller lives.

All reported better control of their diabetes including greater glycemic control.  Five reported lower A1C’s six months after beginning the program.  Many were able to reduce the amount of medication or could take oral medication rather than insulin injects, while some reported that they were able to control their diabetes primarily through diet and exercise.  Diet and nutrition improvements were another benefit of program participation for many people.  Many reported being more conscious of types of foods and portion sizes and were actively using diet as a way to control their disease.  This was due to a combination of education, nutrition lectures and external supports.  Better management practices and increased physical activity levels had a significant impact on participants overall health. 

Participants experienced improvements in other health areas. Though many people did not loose a significant amount of weight, many lost inches in their waist and hips.  Lower blood pressure, cholesterol, and triglycerides along with improved heart rate were some of the other reported health benefits.  Some have turned to exercise, particularly water aerobics, as a form of pain management and report pain reduction.  Most just “feel better” after they exercise.

            “Feeling better” is emotional as well as physical benefit for participants.  Physical activity can bring about short and long-term physiological benefits, according to the International Society of Sport Psychology (1992).  It has been shown to improve symptoms such as low self-esteem, social withdrawal, anxiety, depression, and stress across all ages and genders.   Many participants reported improvements in mood and attitude, including depression and stress level. For S, exercise has helped her to deal with her stressful job. Taking time to stretch and exercise during the day allows her have a different attitude when she comes back to work. The tools for exercise translate into tools for living, giving participants a “better outlook on life.”

The program provides social outlets and is a source of self-esteem and personal empowerment. The program provides opportunities for increased social interaction for those experiencing social withdrawal because of their health conditions, limited mobility or retirement.  These interactions are times to make friends and connect with others or just get out of the house.  Small accomplishments in the program increase self-efficacy and sense of personal empowerment.  For those with health limitations, the program gives them a feeling of control over their lives and their health conditions. 

T, a 34-year-old diabetic, has been living with limitations of a severe brain injury for the past two years.  For this informant as well as many others, the rules and boundaries of her treatment are impositions that limit her sense of autonomy. As with the men in Ferzacca’s (2000) study on diabetic veterans, she felt that her disease and now her medical treatment threatened her autonomy and “sense of competency as an adult” (13).  T, who now lives with her parents, shares a room with her two sons and can no longer drive, feels powerless and that her life is out of her hands.  For her and for others, “this ain’t how life’s supposed to be.”  The program has helped her to adjust to the limits of her injury and makes her feel like she is “getting her life back.”  Setting realistic goals and achieving them is a source of self-respect and pride for her. She is proud of the results she sees and her ability to stick with the program.  She said, “I’m gonna finish.  This is my goal.  I’m not a finisher and I’m gonna finish this.  I’m gonna complete this task.”  Through increased self-regulation, goal setting and small steps towards health and fitness, participants feel that they are regaining control over their bodies and self-confidence.

Informants experience improvements in lifestyle management, better compliance to their diabetes protocol and increased self-management, including nutrition and dietary changes.  Success with an exercise program lead to changes in other areas of diabetes management for some participants. Overcoming barriers to exercise described in first section, participants have increased participants’ self-efficacy.  It has given them a set of tools that can be generalized to address other areas in their lives were change is need.  Moreover, some are inspiring change in the community by getting others to get involved in fitness activities.  N has begun to invite coworkers to work out with her at the YWCA.  B’s husband has begun to work out in the mornings with her, while V now walks with her overweight cousin.  The emotional, physical and lifestyle changes suggest that the program has a broader impact on the lives of participants and their community.

 

VI. Discussion

The results of my study suggest that the diabetes Wellness Project is successful in promoting and maintaining exercise and lifestyle change for many of the participants of this study.  Participants in this study experienced multiple levels of barriers that could be classified as both internal and external.  These barriers included: lack of time and motivation, difficulty prioritizing their health, embarrassment, fear of the gym, poor physical condition, scheduling, convenience and care giving responsibilities. 

Though participants experienced internal and external barriers, many were able to overcome those barriers with the help of multiple levels of support provided by the program.  Factors that aided in overcoming these barriers included, perceived severity of the disease, prioritizing health, enjoyment, social support, facilities and educational programs. 

Participants who were able to overcome their barriers reported significant physical and emotional benefits.  Benefits included lower A1C, increased energy and mobility, mood stability, increase social interaction, self-esteem and personal empowerment.  For many of the people I interviewed, the program has given them tools for better diabetes management and broader lifestyle changes.

 

VII. Limitations

            Limitations for this study include small sample size and skewed sample.  Because of time constraints and difficulty contacting nonadherers and under adherers, interviews tend to reflect the views and experiences of participants who are actively involved in the program.  Many of the participants of this study were already coming to the YWCA on a regular basis to work out and were able to give an interview either before or after an exercise session. 

VIII. Direction for future study

            Further study of nonadherers and those underrepresented in this study is necessary.  Analysis of how participants overcame initially preconceived barriers may offer insight into how the Diabetes Wellness Project could assist those unable to overcome their preconceived barriers.  Comparison of these two groups could better inform future interventions for this subgroup. 


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[1] A1C is a lab test that measures the average blood sugar over the past three months.  Optimal goal for diabetics is less than 6.5%, but lowering one’s A1C by any amount will improve their chances of staying healthy. (American Diabetes Association)