Health Education Research Advance Access originally published online on December 21, 2004
Health Education Research 2005 20(5):600-611; doi:10.1093/her/cyh007
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Health Education Research Vol.20 no.5, © Oxford University Press 2005; All rights reserved
‘I feel totally at one, totally alive and totally happy’: a psycho-social explanation of the physical activity and mental health relationship
1 School of Sport and Leisure, University of Gloucestershire, Gloucester GL2 9HW, 2 School of Sport Science and Psychology, York St Johns College, York YO31 7EX and 3 Department of Psychology, University of Leeds, Leeds LS2 9JT, UK
4 Correspondence to: D. Crone; E-mail: dcrone{at}glos.ac.uk
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Abstract |
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This paper reports findings from a qualitative investigation into the relationship between physical activity and mental health from the experiences of participants on exercise referral schemes. A grounded theory methodology was adopted which used focus groups and semi-structured interviews with participants from three exercise referral schemes in England. Schemes were representative of different types within the UK, and included a local authority leisure centre, a private health club and a local authority leisure centre scheme with organized countryside hikes. Pre- and post-exercise referral intervention focus groups, and interviews with purposively sampled individuals, were undertaken. Eighteen people participated and interviews were audio-taped, transcribed and analyzed. A conceptual framework emerged, and provides a psycho-social explanation for the physical activity and mental health relationship from the perspectives of the participants' who experienced it. The explanation of the relationship from this perspective identifies the core category ‘self-acceptance’, and the importance and interrelationship of context-related factors (such as social support and the physical environment), for the elicitation of positive experiences for people on exercise referral schemes. Investigating participant's experiences within the social contexts of exercise referral schemes provides an understanding about whether schemes have the potential to influence the mental health of referred patients.
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Introduction |
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The positive relationship between physical activity and health has been well documented [see, e.g. (Blair et al., 1995
; Blair and Connolly, 1996; Biddle et al., 2000a; Biddle and Mutrie, 2001)]. As a result physical activity has been included into public health policies (Department of Health, 1999, 2004; DCMS/Strategy Unit, 2002) and an emergence of evidence-based practice in physical activity promotion within primary care has developed (Taylor et al., 1998). Arguably the most common programmes available are ‘exercise referral schemes’, where a health professional, usually a General Practitioner, refers a patient to an exercise professional for a programme of supervised exercise. Patients referred include those with one or more coronary heart disease risk factors such as hypertension, diabetes and obesity.
Research into the effectiveness of exercise referral schemes has predominantly focused on physical health parameters, such as blood pressure and body composition, using positivist methodologies (Dugdill et al., 2005). As a consequence, there is little recognition of the holistic worth of schemes for health, specifically mental health. The well-established link between physical activity and physical health, along with the assumption that mental health is more commonly researched and defined in terms of disease states (e.g. depression), rather than having a positive dimension (i.e. well-being) (Ryff and Singer, 1996, 1998; Pilgrim and Rogers, 1999), may be responsible for this. The dominance of positivists methodologies and the definition of mental health in disease terms has led to an evidence base that has evaluated and understood exercise referral schemes purely in terms of their clinical and therapeutic outcomes, rather than in terms of their ability to enhance well-being and positive mental health. Given that the Department of Health's aim is to ‘improve the health and well-being of the people of England’ [(Department of Health, 2003), p. 1; author's emphasis] surprisingly little attention has been paid to well-being within the exercise literature. The National Health Service Plan (Department of Health, 2001a), in its core principles, stresses the importance of focusing on the promotion of health and the prevention of disease to achieve quality of life. It also recognizes that social, environmental and economic factors play a part in the health of the nation. Coupled with this has been an increasing acknowledgement of the importance of investigating lay perspectives in the understandings of health and of the value this has in developing interventions to promote health (Secker et al., 1999). However, despite calls for alternative and holistic evaluations in health promotion, and specifically of exercise referral schemes (Taylor, 2003), to date little research has been published.
The scientific consensus linking physical activity to mental health (Biddle et al., 2000a) has resulted in recommendations that exercise should be used for the promotion and maintenance of mental health and in the management of mental health problems (Burbach, 1997; Grant, 2000; Biddle and Mutrie, 2001). These recommendations were made despite uncertainty over the actual mechanism(s) by which physical activity affects mental health. Several mechanisms have been suggested, and come from a variety of disciplines including biochemistry, physiology and psychology (Carless and Faulkner, 2003). However, the mechanism responsible for the relationship remains open for debate (Biddle and Mutrie, 2001). The lack of consensus on the mechanism(s) by which exercise affects mental health may be because researchers have concentrated on establishing a relationship, rather than asking why a particular incident, experience or situation is important to the participant (Marsh and Sonstroem, 1995; Fox, 2000). This research is dominated by positivist approaches and there are suggestions that an integrated psycho-physiological model may be needed to explain the relationship more fully (Boutcher, 1993; Mutrie, 2000). In support of this suggestion, rather than searching for a biochemical explanation for the relationship, a complementary approach is to investigate the ‘whole experience’ of people participating in exercise [see (McAulay et al., 1991, 1995, 1999; Wankel, 1993; Turner et al., 1997; Hardcastle and Taylor, 2002)]. Qualitative research investigating the exercise environment and participant's interaction with it may also help to provide insight into the perceived relationship between physical activity and mental health (Fox, 2000). To date, qualitative work within the exercise environment has highlighted the importance of social support, social norm and social interaction to participants' positive experiences (Faulkner and Sparkes, 1999; Hardcastle and Taylor, 2001; Stathi et al., 2004), and of the importance of social constructs to mental health (Morrissey, 1997; Singh, 1997) and exercise adherence (Smith and Biddle, 1999). However, the qualitative research in these papers has not concentrated on investigating the physical activity and mental health relationship (the phenomenon). As a consequence, the aim of this study was to adopt a qualitative methodological approach (grounded theory) to specifically investigate the physical activity and mental health relationship from the perspective of the participants who experience it, within exercise referral schemes. By investigating participant's perspectives of this relationship, further insight into its integrated nature may emerge. This approach has also addressed, in part, Taylor's (Taylor, 2003) call for more holistic evaluations of exercise referral schemes.
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Method |
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The research adopted Tashakkori and Teddlie's (Tashakkori and Teddlie, 1998
) perspective that individuals produce and define their own understandings of the experiences/phenomenon. It recognizes that to understand the effect of participation in an exercise referral scheme for a person's mental health, it is important to examine participant's perceptions and experiences. The perspective adopted is concerned with how the individual experiences the social world (Crotty, 1998).
As such it aims to present the participant's points of view, and their understandings and meanings of the experience. This paper therefore describes the events and situations that form the experiences, and presents the participants' feelings, actions and thoughts within the text (Charmaz, 1995). A grounded theory approach (Strauss and Corbin, 1998) was used to develop a conceptual framework to help explain the physical activity and mental health relationship. This approach is in line with the move toward patient choice and patient-centred approaches within the NHS (Department of Health, 2000) and exercise referral schemes (Department of Health, 2001b). The study formed part of a PhD thesis, and as such was scrutinized by the appropriate university research committees for ethical issues and conformed to the ethical guidelines of the British Association of Sport and Exercise Sciences.
Sample
Participants (n = 18; M = 5, F = 13, mean age 55.5 years, SD = 10.78) from three exercise referral schemes were interviewed using focus groups and individual interviews. In all cases health professionals (typically the General Practitioner) had referred respondents onto schemes from primary health care settings to normally address physical health concerns. None of the respondents had been referred with a diagnosis of a mental health problem. In the first two schemes [Study 1: local authority leisure centre (n = 6; M = 1, F = 5, mean age 48 years, s = 12.9); Study 2: private health club (n = 7, M = 1, F = 6, mean age 56.6 years, s = 6.6] respondents were involved in pre- and post-exercise referral intervention focus groups with a respondent from each study selected for in-depth interviewing to enable an elaboration of their experiences. The third study (a local authority leisure centre scheme with organized countryside hikes, n = 5; M = 3, F = 2, mean age 63.2 years, s = 7.6) explored the experiences of regular attendees through interviews, either individually or in pairs. The three schemes were based in geographically disparate areas, one of which (Study 3) was in a recognized area of deprivation (Department of the Environment, Transport and the Regions, 2000), and were representative of three common types of schemes identified by Biddle et al. (Biddle et al., 1994).
Respondents were selected through purposive sampling, which allowed for the selection of information-rich cases (Patton, 1990) pertinent to the phenomenon, the physical activity and mental health relationship (Erlandsen et al., 1993). The selection criteria included the respondent's willingness to take part in an interview through gaining their informed consent and their ability to provide an information rich case (Patton, 1990). This was determined, in Studies 1 and 2, by what had been said in the focus groups and its relevance to the phenomenon. Respondents were provided with written documentation in their letter of invitation which outlined the aims of the study, the requirements of their involvement and confidentiality and anonymity assurances. This information was again imparted verbally at the start of each focus group and interview, and respondents' verbal informed consent to participate in the research was received.
A pilot study (Crone-Grant and Smith, 1998) provided the framework for the semi-structured interview guides for both the focus groups and interviews. The guides, based on Patton's (Patton, 1980) guidelines, were developed from the research questions (detailed in Table I), and were formed to enable people to describe their experiences of physical activity in the past and, more specifically, throughout their journey on the scheme.
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Focus groups were chosen as a method of data collection because the interaction between respondents enables them to express their view of the world, beliefs and attitudes using their own words. They also allow respondents to ask questions of each other, which provides an opportunity for them to reconsider or re-evaluate their own understandings of their experiences (Kitzinger, 1994
, 1995). According to Morgan and Krueger (Morgan and Krueger, 1993) they are particularly useful when a researcher wants to explore the degree of consensus on a given topic and at the preliminary stage of a study (Krueger, 1988). The focus groups were complemented by individual interviews which were used to explore specific experiences of individuals, their beliefs, perceptions and accounts about the phenomenon (Smith, 1995). Individual interviews were chosen to complement the focus groups to further investigate the specific experiences of chosen individuals.
The first two studies followed the pre- and post-intervention focus group and purposive sampling of an individual for interview. In Study 3, however, it was decided to concentrate solely on individual interviews with selected respondents at the end, or near completion, of the exercise referral scheme. This procedure, theoretical sampling (Strauss and Corbin, 1998), allowed for a more specific focus on respondents' positive experiences and is a unique aspect of grounded theory methodology. Theoretical sampling and the amending of data collection procedures allowed for theoretical saturation, which was reached following Study 3 when the data collected complemented that previously and no new themes or subthemes emerged. Themes were then deemed fully saturated and thus provided the conceptual density required in grounded theory studies (Strauss and Corbin, 1998).
Analysis
The focus groups and interview discussions were taped and transcribed verbatim, and analysed using the grounded theory method (Strauss and Corbin, 1998). This process included the six grounded theory strategies of simultaneous collection and data analysis, a coding process (open, axial and selective coding), comparative methods (focus groups and interviews), memo writing, purposive and theoretical sampling, and, finally, the development of the conceptual framework (Charmaz, 2000).
The variety of methods used (i.e. focus groups and interviews) helps to address the credibility of the research through triangulation (Denzin and Lincoln, 2000). Trustworthiness and authenticity were ensured through employing techniques suggested by Lincoln and Guba (Lincoln and Guba, 1985) and included prolonged engagement in the research process (5 years), triangulation, and purposive and theoretical sampling of information-rich cases. Reflexivity of the researcher's (D. C.) role and function within the process was also engaged in through reflection and a diary, which, according to Finlay (Finlay, 2000), also addresses the integrity and trustworthiness of the research.
The QSR NUD*IST 4 computer programme was used to search, store, explore and organize the qualitative material. Analysis resulted in a conceptual framework (Figure 1), which includes types of themes with properties (characteristics) and dimensions (the range of the properties of a theme) (Strauss and Corbin, 1998). These are explained in Table II.
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To assist with providing insight into the lived experiences of the respondents the quotations from the respondents are included within the explanation of each theme (names given to respondents are pseudonyms to ensure their anonymity). Each quotation is followed by a code, e.g. Mary 1fg2 67, which includes the respondents pseudonym, the study number, the type and sequence of interview, (i.e. fg1 = pre-intervention focus group or i2 = the second interview), and a line number corresponding to the text unit's location in the transcript. This is provided to further assist with ensuring trustworthiness, by providing an audit trail for the location of the specific quotation (Erlandson et al., 1993
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Results |
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Self-acceptance ‘I feel totally at one, totally alive and totally happy’ [Mary, 1i3 73]
Respondents understood mental health as self-acceptance within the scheme. Self-acceptance focused on respondents' acceptance of themselves, their health and social status, and life situation and provided respondents with self assurance or confidence:
Out on the bike I feel at one with the whole of life and the whole of creation [self-acceptance]...I feel that that is the extreme of what a human being can feel in pleasure and in being alive. I just love life and when you use everything, your body and your mind, to achieve the best then you get the best feeling. [Mary, 1i3 161]Properties of this theme included the act of participating in physical activity and the realization that participation was achievable. These provided both self-acceptance and inner contentment:
When I go out on a bike some moments...I sweat and physical things like that but the greatest moments are those moments when I feel totally at one, totally alive and totally happy. [Mary, 1i3 73]Other properties include the challenge of mentally persuading the body to undertake a physical task, the dimensions of which included a number of stimuli and experiences, both cognitive and visual, and provided self-assurance:
Paula: We were walking up cliff faces which was really enjoyable...when we got onto the height bit well the wind just blew you off, and you had to hold on to one another because it were blowing you and there was a big drop.
D. C.: How did that make you feel?
Paula: Ahh, brilliant. [3i1 132–136].The remaining property was their perception, which improved over time, that physical activity was ‘age appropriate’ behaviour: ‘...and finding other women my sort of age and shape and size and things; that it wasn't all you know leotard slim fits’ [Alison 2i1 164]. The degree of self-acceptance (i.e. the dimension of the theme) was dependent on time in the facility, the inclusive nature of the scheme, self-efficacy, body image perceptions and feeling comfortable.
Social context
Four themes exist within the social context: social support, social network, culture and environment.
Social support
Social support was provided, both formally and informally. Formally from scheme staff (both leisure and health) who offered support in the their professional roles, and more informally through their personal qualities and personalities. Other users also contributed to the supportive environment:
Donna: And these two are brilliant. It's just their personality, and they are not threatening at all.
Alison: It's nice that actually.
Flo: Because they're young people, who can talk to people.
Donna: But these girls have a laugh.
Elaine: They are quite relaxed themselves actually. [2fg2 691–696]Properties therefore included scheme staff, other respondents and family. The dimensions included level and quality of contact and support.
Social support had a number of functions including motivation, adherence, confidence to operate the exercise machines and feeling at ease in an unfamiliar environment. Positive social interaction with others created a conducive atmosphere for adherence and enjoyment, which assisted with self-assurance:
Swimming is, again, a very much a go it alone activity...if I was...with a group...throwing a ball around in the water or something I would probably stay in a lot longer and enjoy it more [Martin, 3i3 82]
Social network
Social network is a structure that facilitates social support. Properties included the type of scheme, the roles of the members of staff within the scheme, and the structure and protocol of the scheme. The dimension to the type of scheme included its philosophy and its location, be it gym-based, pool-based, leisure centre, private health club or one that uses the external environment.
The third property, the structure and protocol of the scheme, focuses on whether specific social interaction opportunities are included as integral to the workings of schemes, such as coffee breaks or group outings. These structured opportunities resulted in a sense of belonging and security: ‘They are a lovely group you know, they make you so welcome...they bring you straight into their group’ [Eliza, 3i2 153].
The dimension of this theme includes the evidence of a social network, for example, structured opportunities for social interaction, the number of staff available as part of that structure, professional qualities of staff, scheme structure and location, and the attitudes and philosophies of the health and scheme staff involved within it.
Culture
The culture theme is the atmosphere and social norms existent within schemes. This is created by other users and scheme staff and is perceived as a consequence of the behaviour patterns and attitudes of these individuals. Culture is dependent on a number of factors, and can be perceived positively or negatively, which can either assist or prevent positive experiences. The following quotations illustrate these extremes. The first, a positive perception, was as a result of the friendly behaviour and social interaction opportunities:
I was a little apprehensive like you said, about being on your own. Before we went I mean, when come to, I know so many people there in fact I try not to talk too much because I've worked with them or I've known them because I'm a local person... [Cath, 1fg 2 67–72]The second, a negative perception, was a consequence of attendance when other users were preoccupied with their own activity and thus provided a less conducive atmosphere for social interaction:
It's interesting what you say about going because I found it just the opposite because every time I went which was usually about 8.30 a.m. in the morning to 9.30 a.m....everybody was so heavily into what they were doing nobody would speak...Everybody looks the other way if you sort of say ‘how does this work?’...they are really there to do a job but they don't want to stop and just help you at all I found,...I found it just the opposite nobody has spoken. [Barbara, 1 fg2 80–84]The dimensions of the theme included the time of day respondents visit (because different ‘types’ of people attend at different times), the kind of user or fellow exerciser who shares the experience with respondents either directly, as part of the scheme, or indirectly, as another exerciser in the facility at the same time: ‘Some of them are like me..., so they are having trouble as well. That is a boom, because we can commiserate together..., so that helps’ [Mary, 1i3 97].
Environment
The environment was defined as the physical environment in which the exercise took place. Properties include the exercise equipment and the physical quality of the facilities, i.e. the changing rooms, the specific environment: ‘Its fantastic [walking], ...I mean I really enjoy it...you can go and its thundering and lightening and pouring with rain but you have just done your things and you are out, it doesn't matter what, nothing makes you stop’ [Eliza, 3i2 66] and the characteristics of those different settings: ‘...and it's shabby and you go to the loo and all the paint's falling off’ [Alison 2fg2 204].
The dimension of the exercise equipment relates to the complexity of operation: ‘Well there are so many buttons’ [Cath 1fg2 287]. Complexity related to the level of computerization, the number of machines respondents needed to remember how to operate and information about how to execute an exercise:
Lucinda [fitness instructor] wasn't there, and I couldn't work out what to do with things, I really found it hard I've been half a dozen times but, I just, you know, thought how the hell does this work, you know, especially with that stepper thing and things like that. [Barbara 1fg2 284–287]Perseverance and time are dimensions to this theme: ‘I feel...at home here now, I don't as yet feel as comfortable in the [another fitness facility]...because I haven't gone as much’ [Alison, 2i1 134], in addition to the specific environment, or the actual setting, where the physical activity takes place.
Actions
There are three action themes; playing a role, coping mechanisms and act of coping. These three themes represent actions that were taken to resolve problems to enable respondents to facilitate self-acceptance.
Playing a role
Playing a role involves social interaction and is typically associated with the social network theme. It is a process whereby respondents adopted a specific role or purpose for both themselves and others within the social network of the scheme. This role varied and included being a joker, an advocate or a welcoming host to new scheme participants:
If I see any new chaps come, I always try and make them...[welcome], I say ‘are you all right?’ cos I remember my first day, you don't really know anybody and you think ‘what do I do?, who can I sit with? and shall I go to her?’ and you do think you are a bit out of it...so I usually say ‘is it your first day? come over with us’ like, and you soon get into a group you know, and you learn a name every time then. [Robert, 3i2 154]
Coping mechanisms
The coping mechanism theme involved strategies that were employed by respondents and is associated with the environment theme. Mechanisms included strategies to manage challenges such as difficulties with orientation, reading instructions due to poor eye sight, and reducing boredom and unpleasant factors associated with the exercise routine and exercise machines:
But you know I was looking around to see what everyone else was doing, I thought these people must have reading glasses or have they all got contact lenses, and then I realized they had been coming long enough so they knew their programmes. [Donna, 2fg2 569–571]
Act of coping
The act of coping is an action theme, but is not directly associated with any one independent conditional theme. It included both the realization that involvement in the scheme required an ability to cope with the challenges that would be encountered and a reliance on the scheme to facilitate coping in other aspects of life: ‘When you've got your glasses off it does present that bit more of a problem, finding yourself around a strange place’ [Alison, 2i1 140]. Respondents recognized that coping was required to make the experience more conducive.
The ability to cope was enhanced by the belief that involvement in the scheme assisted respondents in coping with stressful life events such as retirement and thereby improving people's sense of well-being: ‘You can take that for life as well, people will help you but you have to play your part and this scheme is helping and you have to play your part and join in’ [Mary, 1i2 187].
Outcomes
Three outcomes emerged and include a sense of belonging, a sense of purpose and physical health.
A sense of belonging
The belonging theme is the feeling of being a part, or player, in the scheme and that it is an appropriate activity or pursuit for respondents to be engaged in. Properties include other users, staff and environmental competence. The first two of these are strongly associated with social interaction; informally with other users, and both formally and informally with staff: ‘The staff, Marcus and Philip are brilliant ...they treat you as equals that's what I like about it we are all in the same thing’ [Paula, 3i1 120 and 122]. The number of staff, their professionalism, availability and personal qualities, such as equity and inclusiveness, are dimensions to this in addition to scheme protocol. The third property, environmental competence, is associated with the physical environment, such as coping with machines, steep hills in the countryside or the changing rooms.
A sense of purpose
Involvement in the scheme provided respondents with a sense of purpose. This was provided through having something to do or by enabling them to have a role within it. The purposeful activity provided respondents with something to do with their time, often filling a gap for them socially and structurally, within their week: ‘I've basically got into it, 'cos I enjoy it, 'cos when you are at home all day, it's 2 days a week, it passes your day’ and ‘I look forward to Tuesday and Thursdays 'cos I know its going to be a day when I've got something to do’ [Robert, 3i2 9 and 53, respectively].
A sense of purpose was specifically derived from knowing that participation in purposeful activity was beneficial:
I felt a sense of well-being from the exercise I get bodily enjoyment...you feel alive, you feel as though you are experiencing life, you know that life is in technicolour, when you've done that and not just sitting back and it's all going by...and you are part of it. [Mary, 1i1 48]
Physical health
The consequences or outcomes of involvement included perceived physical health benefits. Properties included the properties of body composition changes, e.g. improved respiratory function: ‘Well my breathing's better, after an operation I was having trouble with my chest and I've got asthma, but that's definitely better, definitely’ [Elaine 2fg2 81] and a reduction in medication. These outcomes are indicative of increased physical activity levels, but demonstrate how people experience changes in fitness levels. The range of these outcomes (i.e. the dimensions) was dependent on the length of time on the scheme and regularity of attendance.
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Discussion |
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The conceptual framework explains the experiences and understandings of the social world of respondents on exercise referral schemes with respect to the physical activity and mental health relationship. Respondents report mental health benefits which are conceptualized into the core category, self-acceptance. Self-acceptance focused on respondents' acceptance of themselves, their health and social status, and life situation, and provided respondents with self-assurance or confidence. Whilst self-acceptance has not been reported elsewhere in the physical activity and mental health literature, other themes and properties, such as social support, social norm and social interaction, are supported by qualitative work (Faulkner and Sparkes, 1999
; Hardcastle and Taylor, 2001; Stathi et al., 2004). The framework reinforces these and other findings from qualitative studies [e.g. (Morrissey, 1997; Singh, 1997)] that show the importance of social constructs to mental health. By providing a framework, however, it develops previous research by providing a model of the psycho-social aspects of the phenomenon and their interrelationships that exist for positive mental health experiences to occur for participants on exercise referral schemes.
Fontaine (Fontaine, 2000), Biddle and Mutrie (Biddle and Mutrie, 2001) and others have suggested that the mechanism responsible for the physical activity and mental health relationship lies in a combination of biological, psychological and social factors. Self-acceptance is affected by a number of factors, not solely the exercise per se, but the contexts in which people's experiences are embedded. This study has empirically demonstrated that the context related factors of social network, environment, culture and social support aspects of such schemes are influential and interrelated. These findings further develop and enhance what is known about the physical activity and mental health relationship, and support the calls for the adoption of interpretive methodologies within this area of research (Biddle et al., 2000b; Burnard and Hannigan, 2001; Taylor, 2003).
Exercise is often seen as a means of changing people either to meet an aesthetic ideal (i.e. before and after) or to achieve a physical fitness or health goal (e.g. losing fat). The findings from this research emphasizes the importance of the experience of exercising itself, irrespective of the outcomes it may lead to. It also demonstrates how exercise referral schemes can make people comfortable with who they are now, not with who, or what, they may become in the future. Most exercise referral schemes, however, focus on what will be achieved as a result of the exercise intervention and evaluations typically look at ‘pre’ and ‘post’ physiological measures. Whilst this is not surprising given that people are generally attracted to such schemes for these changes, the results of this study suggest that professionals involved in the development, management, delivery and evaluation of exercise referral schemes should consider a change in their world-view, and focus more on how people feel whilst on a scheme and how effective the scheme is at promoting self-acceptance. Participants on exercise referral schemes sometimes present with what, in the long term, may be a terminal condition (e.g. cancer, coronary heart disease or HIV) for which exercise can have a beneficial physiological effect. However, for these people, an exercise prescription that is about long-term fitness change, or which adopts a performance model (i.e. seeking ‘pre’ and ‘post’ interventions changes in physical work capacity), may not lead to the positive self-acceptance found amongst the respondents in this study. Exercise referral schemes need not be about delayed gratification, they can and arguably should, be about feeling good ‘now’. The central theme of self-acceptance found in this study finds an echo in the work of Singh who, in a qualitative study within exercise referral schemes, reports that respondents found that the scheme ‘contrasted with the usual passive role of the patient’ [(Singh, 1997), p. 236]. It may be that through this empowerment ‘patients’ reclaim a sense of ‘personhood’ which leads onto the self-acceptance found in this study.
There were a number of limitations within this study which included the restricted participation of men. This was despite attempts, in Study 3, to address this through purposive sampling of respondents. At the early stages of the research the desire to include schemes that were representative of types categorized by Biddle et al. (Biddle et al., 1994) prevented the application of theoretical sampling of scheme type until after Study 2 had been completed. However, although the scheme type for Study 1 and 2 had been predetermined, their location within the country had not. Using a combination of opportunistic sampling (Strauss and Corbin, 1999) and an aim to have schemes from a range of geographically disparate areas within the UK allowed for a degree of theoretical sampling to be employed.
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Implications |
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The results from this study have a number of implications for professional practice. Arguably the most important is the role of the fitness instructor in helping to attach meaning to the experiences that people have whilst exercising. If the mindset of health and exercise professionals involved in the design and delivery of exercise referral schemes is that the purpose of the scheme is to achieve improvements in physiological variables, they are unlikely to help people to become comfortable with their body and the concept of themselves as exercisers. Training and qualifications of professionals within this area have traditionally focused on the physical and technical aspects of exercise; to assist with a shift in their views and practice, training providers should integrate these psycho-social elements within nationally recognized exercise referral scheme qualifications. This study also serves to remind practitioners that participants on exercise referral schemes are often older people, and that care needs to be taken over practical issues such as font size on exercise cards and the use of electronic exercise equipment.
Based on this work further research should focus on a wider range of people's exercise and physical activity experiences, both positive and negative, in schemes from a variety of other environments including, e.g. mental health units, residential units for the elderly, green gyms and walking programmes. A wider range of people should include those living in poverty and also men, whose presence within this study is a limited, and investigations into past exercise experiences and their significance to current physical activity experiences. Additionally a range of settings may develop a theme that was not included in this conceptual framework that reflects a fear of crime and personal safety. Work on the area of fear of crime and physical activity is developing [e.g. (Kilgour, 2003)] and may produce further insight into this area.
An inclusive research strategy, incorporating qualitative methodologies such as grounded theory, addressing these individuals and social contexts will also provide more understanding about whether exercise referral schemes have the potential to influence social exclusion and health inequality. These factors are prominent in the current political climate within both public health (Department of Health, 1999a; 2000; Social Exclusion Unit, 2003) and in exercise referral scheme development (Department of Health, 2001b). These issues need to be addressed further if exercise referral schemes are to be recognized for holistic health maintenance and benefits.
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References |
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Received on May 18, 2004; accepted on November 16, 2004
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