A total of 15 participants (11 females and 4 males), aged 17-59 years participated in this feasibility study. There was over 95% attendance rate in all sessions. Participants who missed a training pass often did so because of caring for their sick child or if they were unwell themselves. Participants were predominantly were of Middle Eastern origin with a few Europeans, and Asians. Table 1 includes a description of the participant’s demographics. Although all the fifteen participants considered themselves active through performing daily household chores they had not been involved in physical activity or training ahead of their participation.
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Process evaluation of the Physical Activity Intervention
On exploring, the focus group interviews concerning participant’s views on the physical activity intervention revealed four main themes including sense of fellowship, striving for inclusion and equity, changing the learner perspective and health beyond illness.
Sense of Fellowship
Sense of fellowship in this study was about how individuals developed interest over time to be physically active and healthy through being inspired by others in the group. Participants, who were initially disinterested and joined the intervention program for the sake of their friends, started liking the activity within the group eventually. They believed that they gained more while being in a group and desired to be role models to others.
Before participating in the physical activity intervention, participants perceived lack of motivation to train by themselves. They frequently chose not to train if they were to train alone. They needed a companion who could drive them to train and even participate in the intervention program.
”When I enrolled myself, I had no desire to come and train, whatever type of training it be, I came because my friend persuaded me to.”(Pre-interview, female)
However, when participants started training they started to develop a sense of togetherness with other participants in the group, which positively influenced them to continue training. Participants felt committed to the group and were determined not to miss training passes due to respect for the fellow participants.
“Tomorrow, I have a scheduled training pass, Ohh it is tomorrow.. I feel tired and believe I cannot manage. But, no I cannot do that, I must respect. I must respect others in the group. We must keep our word, if we promise.” (Post- interview, female)
On starting to train, participants started to gain interest in training especially since they were training in a group. They usually felt demotivated when they had to train all by themselves.
“It was nice training with the group. Because we laugh, we talk, it's fun for us, so. When we train by ourselves, it's boring. It's not possible" (Post- interview, female)
Participation in the program also made participants glad as it was also about meeting new people and getting to know them, thus expanding their social network in the locality. Becoming familiar with more persons increased their sense of safety in the locality.
"Through training in these new groups, with new people, gives a sense of security in the locality. We get to know new faces” (Post- interview, female)
Participants also expressed their desire to share the knowledge they had received with others. However, they believed that taking care of self, practicing a healthy lifestyle, training and showing others through action could help spread the intervention to others more effectively than merely sharing experiences verbally.
”Taking care of oneself, like to live healthy, train and we try to show it to others by being a role model. Thus, for example, people are watching me, they see that I have lost weight in the last month. I said I had been in training, and I told them what we were doing during this month. "(Post- interview, female)
Striving for Inclusion and Equity
Striving for inclusion is a voluntary action taken to meet the needs of different people. It includes creating environments or situations where everyone feels included and welcome. Through the discussions with participants emerged a general sense of isolation among citizens in this locality. The citizens, predominately women restricted themselves to their homes, and often avoided external contact. Many were not even aware of the activities and possibilities available in the locality. This was primarily owing to their family situation, psychosocial conditions and the lack of interest. There was a general lack of motivation particularly to get involved with physical activity. They were dependent on the company of their friends or family members to go out of their homes.
Participants described lack of access to health related activities for women in the locality at the beginning of the intervention, but with eventual participation, they started to believe that they had the potential to drive change. Towards the end of their participation in the intervention participants realized that they can create a positive atmosphere which welcomes especially those that were excluded.
Women from Middle Eastern culture do not train in public places such as recreational facilities and sport gyms due to the presence of men. Participants perceived that there was a lack of access to recreational activities, specially directed to women in the close proximity. Women in the locality felt excluded since they were not able to perform physical activity even if they desired to do so. Some women had disabilities preventing them from going to the sport centers or gym even if they had exclusive training times for women. They really wanted to train but often excluded since there were no activities adapted to needs and capabilities of women.
“ There is no access to training or physical activity targeting woman in the locality earlier. There was a need for training or swimming or something else that is adapted and is only for women. They just sit here and cook or sew or do something. But do nothing special like exercise. ” (Pre- interview, female)
When participants started attending the intervention program, they came to understand that the responsibility to create an open environment was within every individual. In the current study, most of the women participants did not mind participating in the intervention program together with men. Some women who refused to perform certain activities within the intervention program in front of men, made notes and videos of training and tried it at home instead. They also had the opportunity to film themselves and take help from the trainer. Participants believed that they could also be part of building social health where everybody cares for the other.
“I believe that it is we who can create this a welcoming environment for people. It is only we who can open the doors for everyone. We need more of this "community care" we can together build social health wherever we are. "(Pre- interview, female)
After participation in the intervention program, participants felt that they could spread positive energy to others that in turn makes others in the locality feel more welcome to participate.
"It's good that there is someone who can help others. That they feel welcome to train together in a group. To give them also the energy and chance to train now, even if they can't do it all by themselves. "(Post- interview, female)
Changing the learner perspective
Changing the learner’s perspective was about strengthening individual knowledge and capabilities in collaboration with others such as a physical instructor or members in a group. Individual participants moved from stage of seeking knowledge to becoming coaches themselves during the process of participation in the intervention program.
Prior to the intervention start, the participants believed that having a personal instructor was ideal since it would help them create an individually adapted training regime however, they could not afford such a service, as it was expensive. Through the intervention program participants felt that they had, the opportunity to learn from a person with such a knowledge. The coach who was also a health promoter was not an external person but was also from the locality and he shared knowledge concerning the challenges and needs of the citizens in the locality. Participants believed that they could learn better under the guidance of the coach about what was most suitable for them as individuals.
“I want to start by learning what to do, to make my body feel better, learn about health, food and training. For example, which training is better for me. I want to do something that is good. He can teach me, and he knows which is best, so one can feel good and be healthy ” (Pre- interview, female)
Participants were aware that physical activity and food were interrelated determinants of healthy body functioning. Therefore, they were curious to learn how to work with both so the body is in a state of balance.
“I think food and training are completely for the body, because if you train and eat sweets and fatty food, it does not work. And it’s the same, if you eat healthy and don’t move your body. One must learn how to balance with both.” (Post- interview, female)
After starting to train with the help of the instructor and learning for themselves, participants went on to spread their knowledge to their family members. Participants aspired being instructors in future and hence tried sharing what they learnt from their own participation in the program with their own families.
“I have started to train at home with my mother, father and my siblings. I do the same things that we do here, as to talk and train with them. I try to teach them what I myself have learned here." (Post- interview, female)
At the end of the intervention program participants expressed their desire to be future ambassadors for the program and spread it to more people from the location.
”I think , I would like to be a coach like a training group leader and show others what I have learnt.” (Post- interview, female)
Health beyond illness
There was a general lack of trust in the health care system among citizens in the locality which was reported ahead of participation. The citizens in the neighborhood expressed that the health system was not similar to that in their home country. They also believed that they did not get the help they expect when they approached the primary care centers and thus did not trust the system. Participants perceived that patients had to wait for long to meet a doctor. Even if they did meet a doctor for a specific problem, they were not provided diagnosis and treatment in time. Most patients are offered paracetamol and asked to wait for prolonged periods before being diagnosed and actual treatment is provided. They felt uninformed about their health and the different health parameters that can be monitored early in time to understand the risk of getting exposed to diseases such as diabetes and other cardiovascular disorders.
After participation in the physical activity program participants developed an understanding that healthy lifestyle and training contributes to better physical and mental health and thereby a better quality of life.
“I feel healthy and brisk and there is a difference since the beginning to now. I think of my body, and what exercise I have to do, which food is better, which is not so good. Exercise makes me feel good and I started to feel that my body works, that I feel good mentally, it is beyond just health .. I am happy.” (Post- interview, female)
Participants were very excited about the health tests since there was a lack of trust in the health system in general. Participants appreciated the health test even better since they had been offered the time and contact when being tested that they had the opportunity to learn the significance of different parameters tested.
“I have no confidence in the health care system, so I felt it was so luxurious to do tests. There came a guy there and we asked about every thing he tested, what does that mean? What does this mean? How can I do that? Can I do something about it? Then, that you were told that you were like 20, 25, it just did something even better for us." (Post- interview, female)
Some participants were curious about their results after participation in the intervention program, and were extremely disappointed if the results were not as they expected. It was perceived that they were intending to quit the program if their health status did not change.
” Some in the group are eagerly awaiting the results of the test. They think about it all the time. If results are not as expected they are disappointed. It could make them give up, and not continue. ” (Post- interview, female)
Some others in the group were careful in not drawing motivation for participation through the results from the health tests. Participants believed that they must focus on their own health and lifestyle through being physically active and eating a healthy diet. By doing so, they believed that the changes in health status might eventually happen.
“I don't focus much on the testing. I focus on my health and on my lifestyle, how it should be. With diet, exercise and one can improve one’s own health by themselves. ” (Post- interview, female)
The scores for the domains Physical Health, Psychological Health, Social Relationships and Health Satisfaction were significantly higher/better after participation in the 12-week physical activity intervention program compared to the pre-test scores (see Table 2), with a moderate effect size in all domains. However, the tests did not elicit a statistically significant change in scores representing the Environmental domain, as well as, self- rated quality of life after participation in the 12- week physical activity intervention program. Table 3 includes a description of results from the Wilcoxon’s signed-rank test.
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The Wilcoxon Signed Rank test and the paired samples t-test showed that there was no statistically significant mean difference between the values of biomedical parameters, viz. BMI, heart rate at rest, systolic and diastolic pressure, as well as, glycosylated hemoglobin, measured before and after the physical activity intervention on a group level (Tables 4 and 5).
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