Health Education Research Advance Access originally published online on January 31, 2007
Health Education Research 2007 22(6):827-838; doi:10.1093/her/cyl159
‘I wouldn't have been interested in just sitting round a table talking about cancer’; exploring the experiences of women with breast cancer in a group exercise trial
1 MRC Social and Public Health Sciences Unit, 4 Lilybank Gardens, Glasgow G12 8RZ, UK
2 Macmillan Education Unit, Glasgow University, Glasgow G12 8LW, UK
3 Department of Sport, Culture and the Arts, Strathclyde University, Glasgow G13 1PP, UK
4 Beatson Oncology Centre, Glasgow G11 6NT, UK
5 Cancer Care Research Centre, University of Stirling, Stirling FK9 4LA, UK
* Correspondence to: C. Emslie. E-mail: C.Emslie{at}msoc.mrc.gla.ac.uk
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Abstract |
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There is evidence that physical activity improves the psychological and physical health of patients with cancer. However, relatively little attention has been paid to understanding their experiences of exercise. This focus group study explored the experiences of women undergoing treatment for breast cancer who had taken part in a supervised group exercise trial. We found that setting up classes solely for women with breast cancer, led by an expert instructor, helped to reduce gender-related barriers to physical activity, such as difficulties in prioritizing exercise over caring roles and worries about changed appearance. For example, some women challenged traditional expectations of femininity by removing their wigs in the classes in order to exercise in comfort. Respondents valued exercising with women in the ‘same boat’ because of the empathy and acceptance they received and the opportunities to exchange information and form friendships. However, the action-orientated format of the group was preferred to a talk-based format such as a support group; some respondents felt that the ‘last thing’ they wished to do was to talk about cancer. Our findings therefore challenge stereotypes about women invariably preferring to cope with cancer through emotional disclosure.
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Introduction |
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TopAbstractIntroductionMethodsFindingsDiscussionConflict of interest statementAcknowledgementsReferences |
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Breast cancer is the most common cancer among women in the United Kingdom; >43 000 women were diagnosed in 2003 [1]. Due to early diagnosis and more effective treatment over the last 20 years, survival rates have improved greatly [2]. As both incidence and survival rates from breast cancer are high, many women are living with the diagnosis of breast cancer. This makes it increasingly important to develop interventions which improve the psychological and physical health of women with breast cancer.
Psychological interventions such as counselling, support groups and cognitive-behavioural therapies may help patients cope with cancer and the effects of cancer treatments. However, they are unlikely to help with common complaints such as fatigue, nausea, loss of strength and flexibility, and weight gain [3]. There is good evidence that exercise is a rehabilitation treatment which can help with these problems [4–6]. Three recent papers have reviewed this literature. Two [7, 8] found promising effects on both physiological and psychological outcomes, while Stevinson et al. [9] found moderate increases in physical function, but could not determine from the evidence whether exercise interventions had beneficial effects on quality of life or psychological symptoms. All three papers are critical of the standards of many studies, and conclude that the evidence is dominated by studies from North America. Since these reviews were published, the first UK randomized controlled trial (RCT) of a group exercise programme for women with breast cancer has been conducted; it found advantages for the intervention group in both physical functioning and psychological health [10, 11].
Relatively little attention has been paid to understanding the experiences that patients with cancer have of physical activity. Until recently, research tended to focus narrowly on why patients find it difficult to start, or continue, exercising; some of these barriers are similar to those reported by the general population (e.g. lack of time and motivation, dislike of exercise, child care and work responsibilities) while others are specific to patients with cancer (e.g. scars healing and treatment-related fatigue) (see, for example, [12, 13]). In addition, much of this work is quantitative. Qualitative studies are better suited to eliciting patients’ detailed understandings and perceptions of illness than quantitative studies which ask participants to indicate their preference from a limited range of answers.
A number of recent qualitative studies have found that patients with cancer value exercising in a group context. Hennessy et al. [14] interviewed female cancer survivors who had participated in the ‘race for life’ organized by Cancer Research UK. Taking part in the race had helped them to feel less isolated as they shared the experience with so many other cancer survivors. It also aided their physical and psychological recovery and helped them to regain ‘normality’. The other studies investigated how patients with cancer perceived supervised group exercise programmes. Stevinson and Fox [15] interviewed both men and women in order to evaluate the feasibility and acceptability of an exercise programme. Respondents enjoyed exercising with a group of similar people as it gave them a sense of support and solidarity. They also liked taking part in an activity which did not focus directly on their identity as a ‘cancer patient'. A Danish research team [16, 17] found that patients were motivated to take part in an exercise programme because of physical debilitation. Most of the patients reported increased strength and energy from the programme, and found exercising in a group was fun and provided motivation and support. Participants felt that they were part of a ‘team’ and found that the exercise programme provided a distraction from their illness and gave them an opportunity to rebuild their self-confidence. Finally, another study by the same team [18] concluded that physical activity had a positive impact on men's ability to cope with the physical, psychological and social consequences of cancer. Their respondents used humour to support each other and found solidarity and comradeship through exercising with other men.
This paper reports the findings of a focus group study which explored the perceptions and experiences of those taking part in the first UK RCT of a group exercise programme for women with early stage breast cancer.
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Methods |
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Background: the group exercise RCT
The RCT recruited 203 women undergoing treatment for early stage breast cancer in the west of Scotland. Participants were randomly allocated into either the control group (usual care plus monitoring) or the intervention group (usual care plus a supervised group exercise programme, twice weekly for 12 weeks, led by qualified instructors specifically trained in providing exercise for patients with cancer during treatment). The classes consisted of a warm-up, 10–20 min exercise, a cool down and relaxation period and a discussion about exercise goals. The intervention group had significantly better physical functioning (walking capacity and shoulder mobility), psychological health (positive mood) and quality of life in relation to breast cancer than the control group in both the short- (after the 12 week intervention) and the long-term (after the 6 month intervention follow-up) [11].
Qualitative research
We used qualitative methods to gather in-depth information about how women with breast cancer perceived exercise and to explore their perceptions of the trial. We were particularly interested in exploring how respondents in the intervention group perceived the group intervention (i.e. exercising with women in a similar situation, as opposed to exercising alone). For this reason, we decided to replicate the group context by using focus groups (structured discussion groups) rather than individual interviews. Focus groups are commonly used in health research [19] and are an excellent way to study both what people think and why they think as they do [20]. The interaction between respondents ensures that priority is given to their language, concepts and frameworks for understanding the world [21]. Ethical approval for the study was obtained from the West Ethics Committee of Greater Glasgow Health Board.
Respondents
Respondents were selected in order to obtain a maximum variation sample (see Table I) as we wished to explore the experiences of women in the intervention and control groups, and include those who perceived themselves as frequent exercisers and those who did not. Respondents were sent a letter and an information sheet about the study and then were telephoned and asked if they would like to participate. Informants were contacted by C.E., who had not had any previous contact with any women in the study. In this way, we hoped to emphasize the ‘distance’ between the focus group facilitator and the trial, in order to encourage respondents to discuss both negative and positive aspects of the study. After an explanation of the study and assurances about confidentiality, all respondents were asked to give informed consent and permission for the discussion to be tape-recorded.
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As the professional role of qualitative researchers may influence data [22], two members of the study team, with different professional backgrounds, led the focus groups: C.E. (a social scientist) facilitated the groups, stressed her lack of medical knowledge and encouraged respondents to give their own views on each topic, while F.W. (a cancer lecturer/practitioner) took notes and at the end of the discussion answered any disease or treatment-related questions which had been raised by respondents. This division of labour seemed effective; it not only enabled respondents to talk freely without feeling they were giving any (medically) ‘wrong’ answers but also allowed them to receive answers to questions which had been bothering them.
The focus groups were guided by a semi-structured schedule which covered positive and negative experiences of taking part in the trial, barriers and facilitators to exercise, reactions of friends and family and perceptions of changes in identity. There was also an opportunity for respondents to raise topics which were important to them. The schedule was tested on respondents who had taken part in the pilot study of the RCT. Six further focus groups, lasting between 70 and 105 min, were held with respondents from the main RCT. Respondents were provided with refreshments and offered travelling expenses.
Analysis
Focus groups were audiotaped, transcribed verbatim and checked for accuracy and field notes were written soon after the groups took place. Focus groups were conducted in two batches (three in 2004 and four in 2005) which meant that preliminary analysis could begin during fieldwork and that initial findings could be discussed by the research team. The software package QSR NVivo was used to facilitate the analysis of focus groups and field notes. Following McCracken [23], analysis moved from the particular (a detailed analysis of language in each transcript) to the general (a comparison of patterns and themes across all the transcripts). Hypotheses were formulated, tested against the transcripts and where necessary reformulated in a cyclical process. Quotations from respondents are presented below in order to illustrate each theme. Each quotation is followed by a code to indicate which respondent is speaking and the focus group which they attended (e.g. R1, FG1 indicates Respondent 1 in Focus Group 1).
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Findings |
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A total of 36 respondents took part in seven focus groups, with an average of five women in each group (range 3–7). The mean age of respondents was 53 years (range 40–76 years). Our sample was diverse, varying by marital, parental and socio-economic status (deprivation category based on postcode [24]) and by cancer treatment (see Table II). The sample was ethnically homogenous (all from the majority white population), reflecting the relative lack of ethnic diversity in the west of Scotland.
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Overview
Overall, respondents in the intervention group were very positive about the exercise classes (‘I just feel I was privileged to be on it’, ‘I really looked forward to going to it’). Many women had continued exercising after the end of the intervention and so the classes acted as a catalyst either for introducing women to exercise or for helping them return to exercise if they had been active in the past. Respondents described the benefits they had gained; these included positive mental states (‘high’, ‘buzz’, ‘uplifted’, ‘energized’, ‘alert’ and ‘happier’), better physical functioning, improved mobility in their arms, improved sleep and being less tired, improved confidence and feeling more in control (see also [14, 17, 18]). The most commonly voiced complaint was that the classes stopped too abruptly, leading to some women feeling abandoned after 12 weeks of support. Some women requested more classes in additional locations, and preferred locations which had a comfortable room where they could chat after exercising. Women in the control group were disappointed not to be part of the exercise intervention and some had not understood the concept of randomization, despite the process being explained by researchers and on the information sheets (see [25] for similar findings).
A specialist exercise class: tailored to your needs and no need for explanations
Respondents stressed the importance of exercising with other women who had breast cancer and valued the expert instruction and support. After being diagnosed and beginning treatment, they often felt very vulnerable and were wary of injuring themselves; the classes helped to rebuild their confidence in their ability to participate in physical activity (see also [17]). Respondents described how they felt ‘safe’ and ‘secure’ in the classes, were ‘stretched’ the correct amount and were pleasantly surprised by how much they could achieve under guidance. The instructors were highly praised for their expertise and ability to adjust the pace and exercises according to the composition of the class.
Respondents made explicit comparisons between the exercise intervention and the standard exercise classes, with the latter faring badly. One of the most important features of the intervention was that respondents did not have to explain to the instructor what was wrong with them and did not feel self-conscious in front of others. ‘Not having to explain yourself’ was an important advantage:
To go along to a class at your local sports centre in no way would measure up to what's offered by Anna (instructor) ... it is tailored to your needs and you don't have to explain yourself. And that's really important, because you don't want to be explaining yourself all the time! You just want to be relaxed. (R1, FG2)
Some women in the control group had negative experiences when they tried to return to exercising at standard classes. Some were advised not to exercise during treatment, while others felt demoralized due to their lack of energy and loss of confidence or felt that they stood out or were regarded as lazy because they could not work as hard as others:
I've joined a keep-fit, but I thought it was a bit strenuous, but it was just after the chemo. I think maybe I started too early. (R2, FG5)I tried going to exercise classes ... and found that I was being asked to do things that actually hurt. ... when I said ‘I'm sorry I can't do that’, it was kind of like ‘well why not’ and I was ‘well because I've had a lump out of my breast and I've had a bit out of my arm and I can't lift that weight’. And there was a kind of annoyance ... so in the end you stop going ... (R6, FG7)
The exercise intervention provided motivation and a sense of achievement for some respondents. Getting out of the house twice a week for something they enjoyed, as opposed to their treatment, was a welcome distraction (the ‘nice part of being not well’). The classes also gave a structure to the day for some women, which was lacking when they were not in paid work, and provided a sense of control:
I thought it would just ... help the weeks go by and give me a focus other than attending hospital and all the horrible things ... something positive to do. (R3, FG2)You felt you were doing something FOR yourself ... whereas other things are being done TO you and it gives you ... a wee bit of control. (R4, FG6)
The group context: interaction, support and sharing information
It was a wee kind of light for me at the end of a big long tunnel. And I just think having contact with other women ... that was what really appealed to me. (R4, FG1)
Respondents strongly emphasized the importance of exercising in a group, partly because they thought it would have been very difficult to motivate themselves to exercise alone at home. Some of the women who had participated at the beginning of the trial were able to compare their experiences of exercising in very small groups (or even on a one-to-one basis with the instructor) with their experience in bigger groups later in the trial. They much preferred the social interaction and atmosphere in the bigger groups, and described being motivated by other women as well as by the instructor.
The importance of exercising with women in similar circumstances was emphasized time and time again; indeed phrases such as ‘the same boat’, ‘the same position’ or ‘people that are the same as you’ were used in every discussion with respondents from the intervention group. Women valued the empathy they received from others, and described moving from feeling isolated to feeling accepted. Friendships formed among women in the exercise groups. Indeed, respondents in FG1 (who had taken part in the pilot RCT 3 years before) had remained friends and still sometimes exercised together. Women also shared information as well as experiences; for example, they discussed Government benefits available to those with cancer, obtaining travel insurance and the advisability of using perfume and of massage. This information-gathering function was illustrated during the focus groups. As women in the control group had not necessarily had the opportunity to discuss their experiences or to ask questions about breast cancer or their treatment, these focus groups lasted considerably longer than those with the intervention group.
Do the group aspects of the exercise intervention serve a similar function to cancer support groups?
Respondents valued the solidarity, friendship, empathy, acceptance and information that they gained from others in the group exercise classes. These benefits sound like they have much in common with the experiences reported by people who attend cancer support groups [26, 27]. Indeed, respondents in different focus groups spontaneously described the classes as ‘self-support groups’ and ‘a kind of informal counselling and support’. However, when asked directly whether the exercise groups were similar to support groups, respondents in only one focus group (FG2) agreed there were similarities. One woman summed up the predominantly negative perception of support groups, and then went on to express her surprise at how helpful she found the group support in the exercise intervention:
Obviously, you've got involved with support groups. You see, I would never have done that ... I'd have probably just gone ‘that's not for me’ ... But it (intervention) did turn out to be a support group ... the exercise bit definitely was what I responded to, and the other bit (support), I didn't expect, it was an actual absolute boon and a bonus. (R1, FG2)
Respondents described two main differences between the intervention and support groups. First, support groups were perceived as depressing, morbid and dwelling on illness, while the exercise classes were seen as upbeat, enjoyable and fun (‘you have to joke to cope’), giving people a chance to forget about their illness for a while. Thus, people who went to support groups were constructed by some respondents as needy, lonely, in poor mental health and obsessed with their illness. One woman compared her experience of going to a support group to going to Alcoholics' Anonymous:
I remember going to one ... it was like ... ‘My name's So-and-So, and I'm an alcoholic’, because they went round ... and ‘My name's So-and-So and I've got such-and-such cancer, and I've had it for 14 years’ ... To me it was like that's all their life was. (R3, FG1)
Secondly, discussions at support groups were perceived to consist of deep, meaningful and exhausting conversations, whereas it was seen as ‘optional’ to talk about illness at all, or in depth, at the classes where the main focus was on exercise. Respondents valued this flexibility about choosing to share experiences. While some women found it helpful to discuss their illness with people who understood, others said the last thing they wanted to do was talk about cancer. This latter group is interesting as their statements contradict the common perception that all women wish to discuss their feelings and emotions about cancer:
I certainly preferred the exercise class (to support group) ... I get bored listening to myself far less anybody else! Just want to get away from it ... I mean there is something else in life as well (as cancer). (R3, FG3)
I wouldn't have been interested in just sitting round a table talking about cancer, I'm sorry, you know, that's really the last thing you want to do. I mean ... we did, talk about it quite a lot because we were right in the middle of it (treatment) ... But it was kind of alongside of what you were doing (exercise), it wasn't the main focus of why you got together. (R4, FG1)I was being a wee bit, ‘I'm not going to any support group, to hell with that’ you know. ... Do I REALLY want to meet 3 million people who have got the same thing as me? I don't think so, no. (R2, FG6)
We suggest that these negative descriptions served to construct a positive identity for women who attended the exercise classes. Table III shows how respondents described those in support groups (gloomy and obsessed with illness) and some other patients with cancer (not helping themselves). In contrast, women in the exercise intervention were positioned as actively getting on with their life, energized and not always wanting, or needing, to dwell on their illness.
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Barriers related to gender and identity (i): appearance and body image
Hospital programmes such as ‘Look good, feel better’ acknowledge the importance of changed appearance and body image due to cancer treatment (http://www.lookgoodfeelbetter.co.uk/). Therefore, it was not surprising that many of the women in our focus groups discussed how treatment for breast cancer had affected their appearance, particularly focusing on hair loss (and wearing wigs), weight gain (because of cancer treatment and/or being less physically active) and coping with the loss of a breast or part of a breast. However, our data also show the influence that perceptions of body image had on women's exercise behaviour.
Weight gain—or fear of it—was a major reason for taking part in the exercise study (see also [14]). Hormonal therapies such as tamoxifen were frequently linked to weight gain. The language that the women used suggested a battle (‘uphill struggle’ and ‘keep it at bay’) and constant surveillance (‘got to keep on top of it’). Respondents found it particularly difficult to go to standard exercise classes if they had lost (part of) a breast as going into a communal changing room and getting undressed made them feel self-conscious. Swimming posed particular problems, given the perceived need for a special prosthesis and the visibility of the figure in a tight swimming costume. In contrast, being in an exercise class full of women in the same position made it much easier to exercise.
Hair loss was raised by respondents in every focus group and usually discussed in detail. Hair seemed to be the aspect of appearance which was most bound up with gender identity, perhaps because it is such a visible symbol of femininity:
It's amazing how much (of) your identity is in the hair. (R5, FG7)I felt that I'd lost my femininity when I lost my hair. (R2, FG4)
Respondents described finding the group context very helpful when dealing with the problems of hair loss, through jokes and sharing experiences. In addition, a number of women described how, when exercising during a hot summer, they felt able to remove their wigs during the class in a way which would have been impossible in an ordinary exercise class. This was described as ‘liberating’ and ‘a confidence thing’. The following exchange from two women in FG2 illustrates this point:
R5: I chucked the wig—it was too hot— and had a head scarf for a while. But I think I would have gone on a lot longer with my wig or the head scarf perhaps if you hadn't been there.R3: And as unpleasant as it is not to have any hair, you don't feel as bad when you're amongst women who have been through the same thing.
The respondents who were most negative about themselves and their body image were single women from the control group. Their concerns about the change in their appearance, their gender identity and their sexuality were expressed very strongly, perhaps because they had not had the opportunity to discuss their worries with a group of similar women before or because they did not have the support of a partner:
I'm single so I went through real crisis ... at one time I was actually contemplating not going for treatment rather than lose the breast. (R5, FG5)
Well I'm a single female so my whole life is just devastated ... it's just beyond me to go and meet somebody new and take off my clothes ... I look completely different. I'm a different person. It's horrible, absolutely horrible, I liked the old me, didn't want anything to change and all of a sudden this has thrown me ... I don't have mirrors in my house at all—even now. (R2, FG7)
Barriers related to gender and identity (ii): women's social roles
Respondents were generally very positive about the practical and emotional support they had received from partners, family and friends. However, after probing, some women in the intervention group revealed that their families had been concerned that the exercise classes would be too tiring for them (‘they did try to cocoon me a wee bit’, ‘wrapped me up in cotton wool’). The extracts below illustrate the concern that some relatives initially expressed:
My husband thought I was going too often and I was doing too much. During chemo, he didn't see the benefits of it (class) until he saw me feeling a lot better, and then he sort of understood, but to begin with he was a bit sceptical. ... he was one of the ones who would say, ‘sit down, put your feet (up) and don't do too much’. (R3, FG2)The families could cope with you doing that because it was a university trial so it would be doing you good, whereas if you were just to say ‘I'm off for a walk’—‘oh, do you think you should be doing that?’ (R5, FG4)
Prioritizing exercise over traditional female-caring roles (looking after children and older relatives) was sometimes difficult. There was some suggestion that it was perceived to be more acceptable (both to respondents and their families) to prioritize time for the exercise classes while in the study than it was to maintain exercise afterwards. Some women felt guilty asking relatives to look after their children so they could exercise. Others coped with this conflict by arguing that exercise was beneficial for the whole family (‘I just drag my children with me!’). Women also discussed problems in fitting in exercise around their work lives, especially when they were working shifts or long hours. The first extract illustrates the difficulty of moving from putting oneself last to prioritizing physical activity, while the second illustrates the pressures of trying to find time to exercise, even when the desire is there, due to the demands of paid work and caring for elderly relatives:
For such a long time I had been—through choice—bottom: three young children, a husband, a house. So therefore it was the first time. I thought, ‘no, (need to) get on with it (exercise)’ .... I think I was ... typical ... had been very fit, got married, had children, became very unfit! (R5, FG4)I do want to (keep on exercising) but I don't have enough space on the disc to do it all. I've still got quite a tight schedule going on, and I just can't make my own time, exercise time, within any time that I have available to me. And I am pressurising myself because I know I should be, and I want to be. (R3, FG6)
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Discussion |
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TopAbstractIntroductionMethodsFindingsDiscussionConflict of interest statementAcknowledgementsReferences |
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This qualitative investigation of the experiences of women with breast cancer taking part in an exercise trial has highlighted a number of important issues. Setting up specialist group classes solely for women with breast cancer, led by an expert instructor, helped to dismantle gender-related barriers and empowered participants to exercise in comfort without feeling self-conscious. In addition, this study emphasizes the importance many women placed upon taking part in physical activity (as opposed to discussing their illness) within a positive and supportive group atmosphere.
Some benefits reported by women in this exercise study are strikingly similar to those reported by people in support groups. For example, Ussher et al. [26] identified a strong sense of community, warmth and humour, safety and lack of judgement, an opportunity to collect information and help in regaining control over their lives as ‘unique factors’ of cancer support groups. However, most women in our study rejected the idea that the group exercise classes served a similar function to support groups and were relatively negative about support groups and the people that attended them (see also [15, 16]). While they appreciated the support they received from others in the trial, the main attraction of the exercise intervention was its focus on action rather than a focus on sharing the emotional burden of their illness. Given that women continue to perform most of the ‘emotional work’ in families (e.g. listening to and comforting children, giving emotional support to partners and doing things to improve or maintain relationships), it may be that some respondents do not wish to continue this function in support groups [28].
Our research has a number of limitations. First, our choice of method—focus groups—has the disadvantage that majority opinions (or strongly expressed opinions) may close down discussion, making some respondents less likely to express minority points of view. It is therefore possible that the dominant perception of the exercise intervention as positive may have suppressed different views held by others. However, using focus groups in this study had the advantage of reproducing the group context of the exercise intervention and so provided an ideal opportunity in which to observe at first hand the support and humour which women described. Second, it could be argued that our sample was self-selected and biased towards women who had a positive experience of the trial and were committed to exercise. This is, of course, possible but we did try to guard against it by sampling women who had attended fewer of the exercise classes, those in the control group and those who did not exercise regularly.
It is often argued that men and women with cancer have different needs and so cope in different ways; men are believed to prefer problem-focused coping strategies such as information gathering, while women are believed to cope through mutual support and emotional disclosure within groups [29, 30]. Adamsen et al. [18] argue that the camaraderie engendered through their physical activity intervention for men with cancer was very different from the intimacy and sharing of experiences which is often reported among women in support groups. However, women who volunteer to take part in an exercise intervention may be different to those who attend support groups. We found parallels in our data with the work of Adamsen and colleagues on men with cancer; in both studies, respondents used humour to express sympathy for each other and as a strategy for coping, and enjoyed the fact that the intervention was focused on physical activity rather than on discussion. Therefore, there may be more similarities than are often assumed in the preferences of men and women. Support for this position is found in the work of MacGeorge et al. [31] who tested the hypothesis that, when distressed, men value forms of communication that focus on fixing problems or distraction, while women value communication that validates and explores their feelings. They concluded that men and women were more similar than different in respect to their provision of, and responses to, supportive communication. Similarly, Seale's [29] work challenges the hypothesis that men and women invariably communicate in different ways. He explored men's contributions to a female-dominated breast cancer Internet support group. Many of these men were responding to the (potential) loss of a partner. Seale found that these men's messages had a form and content generally associated with women's communications (prioritizing emotional communication and the emotional welfare of family members), rather than displaying the emotional control traditionally associated with ‘masculinity’.
Our findings can be set in the context of wider debates about conceptualizing gender in late modernity. A number of theorists have challenged gendered dichotomies and the binary division of gender itself [32, 33]. They argue that people are inappropriately divided into two groups (‘men’ and ‘women’) and that a series of other characteristics are built on top of this division (e.g. male/instrumental/culture and female/expressive/nature), with ‘men’ and ‘masculine’ characteristics being privileged over ‘women’ and ‘feminine’ characteristics. This binary construction inevitably leads to an exclusive focus on gender difference and ignores commonalities across men and women and difference and diversity within men and within women (e.g. by geography, class, ethnicity, age and sexuality) [34]. Rather than being a fixed attribute, it is argued that gender is continuously constructed across the life course and that ways of ‘doing’ gender vary by context [35]. For example, Paechter [36] asserts that ‘we have a multiplicity of masculinities and femininities inhabited and enacted variously by different people and by the same people at different times’. (p. 69)
While we believe that it is vital to acknowledge the fluidity of constructions of ‘masculinity’ and ‘femininity’, it is also important to recognize the continuing salience of gender divisions in society [37]. The social construction of gender has important consequences for lived experience; few people are able to escape the power of gendered norms [38, 39]. These complexities are illustrated by our findings. Earlier we discussed aspects of our data which suggest that there are some commonalities in the coping strategies of women and men with cancer. Below we conclude by outlining some gender-specific recommendations, given the material realities which constrain women.
Our study suggests that women's traditional role as caregivers and their concerns about body image act as potential barriers to physical activity. We know from quantitative work that having children has a longer lasting impact on women's exercise patterns than on men's [40]. In addition, qualitative work among women with young children [41] suggests that stereotypes of the ‘good’ mother make it difficult for many women to prioritize their own physical activity over their child-rearing and domestic responsibilities and that negative feelings about body image after childbirth also act as a barrier. However, Lewis and Ridge [41] found that active mothers challenged these stereotypes by constructing positive meanings around making time for physical activity, rejecting oppressive social expectations about the ‘ideal’ female body and seeking out opportunities to be active in child-friendly environments. Similarly, in this study, we found that some women challenged expectations of conventional femininity by removing their wigs to exercise or by reprioritizing domestic responsibilities in order to exercise. Therefore, we suggest that barriers to physical activity can be overcome through using a gender-sensitive approach (women-only classes for patients with breast cancer) and providing a supportive group environment.
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Conflict of interest statement |
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TopAbstractIntroductionMethodsFindingsDiscussionConflict of interest statementAcknowledgementsReferences |
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None declared.
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Acknowledgements |
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TopAbstractIntroductionMethodsFindingsDiscussionConflict of interest statementAcknowledgementsReferences |
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Many thanks to Kate Hunt and Sally Macintyre for their comments. We are very grateful to the women who participated in the focus groups. The work described here was funded by Cancer Research UK. C.E. is funded by the UK Medical Research Council. F.W. is funded by Macmillan Cancer Relief.
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References |
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TopAbstractIntroductionMethodsFindingsDiscussionConflict of interest statementAcknowledgementsReferences |
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Received on April 7, 2006; accepted on December 19, 2006
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