Twenty-one adults (57% males) with an established diagnosis of CF participated in the study. The mean ± SD age of subjects was 35 ± 8 years, with 16% of participants having undergone lung transplantation. Participants’ characteristics and demographics are outlined in Table 1.
Data analysis identified four key themes relating to factors that influence PA engagement in adults with CF: (i) PA barriers underpinned by five subthemes including fatigue, energy levels, time, weather and exercise-related confidence; (ii) motivation with sub-themes of enjoyment and perceived competence; (iii) value of exercise-related outcomes, underpinned by sub-themes of accomplishment and affect regulation; and (iv) exercise preferences. Each quote is followed by a pseudonym and the individual’s age. To further contextualize the data, additional quotes are provided in table 2.
Barriers to PA participation
Participants reported both internal and external barriers to PA participation. The most common internal barriers included fatigue: “There are some days where I’m just really mentally drained…So, the idea then of having to get up on a bike can be a huge barrier because I just feel so exhausted” (Amy, 32); “I’ll just be generally really tired…so that might get in the way of being motivated, I don’t want to push myself (Dorothy, 29), and low energy: “Energy would be a big one. Sometimes I’ve just enough energy to get up and do my nebs, and I don’t really have the energy to do other things” (Hannah, 50). Participants also reported barriers pertaining to exercise-related confidence, such as self-consciousness: “In gyms and public when you’re coughing, there’s people looking at you to say what is wrong with you?” (Eric, 50), and concerns of capability; “The thing that turns me off PA is the fear of not being able to do [it], if that makes sense? Everyone in the class is jumping up and down on the step and I’m like oh my God, I can’t keep up” (Hannah, 36).
External barriers to regular participation in PA included time: “I just generally don’t think I get the time” (Mary, 30); “Essentially it’s time. Time is the major one for me… prior to the kids…I was getting much more exercise, but time is the main thing” (Richard, 49); and the weather: “The weather here in Ireland is just…you could plan to go and have a round of golf, or play tennis at the weekend, and then it’s raining all day so that stops that” (Matthew, 28); “If the weather is bad, my motivation is squat. I’m very much a fair-weather walker, you know?” (Jenny, 44).
Motivation was a dominant theme identified throughout, with several participants displaying higher levels of motivation: “I’m always very self-motivated actually, I suppose from a young age I always kind of realised that…, it’s me that’s going to do it, nobody else can do it for me” (Amy, 32); “I’m very self-motivated, I don’t need somebody shouting at me in a gym” (John, 31), compared to others who were primarily motivated by external drivers, such as guilt: “It’s more guilt than anything I have to say. I go through stages of doing it but it’s guilt more than anything else” (Eric, 50); and “It’s hard to keep motivated because you know you have to do it” (Mary, 30). Enjoyment and perceptions of competence appeared to underpin PA motivation.
Enjoyment underpinning motivation
Participants who expressed positive attitudes towards and enjoyment of PA: “It’s always been a positive, I have been really active most of my life now” (Kevin, 33); “Yeah, very positive. I feel the more exercise I do, the better I feel” (Richard, 49), seemed to engage in more regular PA: “I go to the gym five days a week; I do twenty-five minutes of cardio and then I do one particular muscle”” (Kevin, 33), and “I’m very active, I’d get up at 7 o’clock I go for a 3km run…then in the afternoon I go to the gym for an hour weight session. And I do that for 2 days and then I have the third day off…then I go through all that again” (Robert, 41). Exercise enjoyment appeared to be a motivating factor for adherence: “I think the main thing is to do something you enjoy. Anytime I’ve been successful at kind of maintaining sport, it’s just doing something I enjoy” (William, 34); “I suppose …the main reason is, I enjoy it” (Matthew, 28).
In contrast, some participants reported a lack of enjoyment as a reason for their physical inactivity: “None of it. I’m going to be very honest with you, I do not enjoy PA at all” (Eric, 50); “To be honest, I don’t particularly enjoy it!” (Mary, 30); “Mainly, I just don’t like exercise” (Peter, 19), which was typically underpinned by poor engagement: “At the moment I would say my PA is pretty much zero… I haven’t been doing much exercise” (Peter, 19), and/or negative past experiences with PA: “Very negative. For me, PA was just hard” (Jenny, 44); “I suppose negative. I wouldn’t be going to the gym. I wouldn’t be interested in any of that” (Eric, 50).
Perceived competence underpinning motivation
Several participants reported high levels of perceived competence that appeared to underpin their exercise motivation: “You know, even though I have this illness, I never really felt like I did because it really didn’t keep me from setting records on the leader board when I was younger…I was very fast” (Carol, 36): “But it’s just the realization that I am as fit as most of them in the room and it’s at that… and keeping that level up, it’s keeping me on par with most of them in the room and for my own benefit as well” (Robert, 41); “I know I’m well able to do it” (Emily, 50).
Other participants did not identify as being the sporty or exercise type : “I’ve probably never been that person. I was never a sporty person” (Jenny, 44); “Exercise wouldn’t be in my remit. I wouldn’t be interested in any of that. I wouldn’t be a gym bunny; I’d be far from it. As far away from it as you can imagine” (Eric, 50), and expressed low perceived competence in their ability to perform PA: “I’ve been thinking a lot about this, and it’s not being able to do it. The thing that turns me off PA is the fear of not being able to do the activity if that makes sense” (Hannah, 36).
Value of exercise-related outcomes
The majority of participants who were regularly physically active reported exercise-related outcomes, such as accomplishment and affect regulation as drivers for continued engagement in PA. Many of the participants identified with the importance of keeping healthy: “I mean, just being healthy and not getting sick. Feeling good…and my lung functions being good, that motivates me” (Brenda, 35); “To try and stay as healthy as possible is a motivator” (Richard, 49); “I just realise that if I want to be healthy and if I want to live a kind of normal life, I have to do this…so that pushes me to keep myself as healthy as I can be” (Robert, 41).
With several participants being motivated by a sense of accomplishment: “I do like it in the end…when you feel like you have accomplished something” (Mary, 30); “I like…the feeling after that you have accomplished being able to physically do an activity” (Emily, 50). Affect regulation emerged as a key influencing factor among participants who regularly engaged in PA: “I like how it makes me feel good and I’m always in a better mood, like it releases endorphins and I’m a happier person afterwards definitely” (Brenda, 35); “Just how you feel after doing them, you just feel well and it’s good for everything, not just CF, but your mental health and everything…whether you are sick or not, you do feel great about yourself” (Paul, 30).
The majority of participants reported a preference for exercising within their home environment, as opposed to the gym: “I love doing my treadmill and stuff at home…it reduces the risk of infection as well” (Mary, 30); “At home, just because it’s less time consuming and less daunting… it’s easier than going to the gym…if your treadmill is sitting there looking at you” (Dorothy, 29); “Home-based…like it can be stressful for me to go to the gym…it’s germy and noisy and if you don’t feel well you kind of just want to leave once you get there” (Carol, 36).
The concept of attending a gym was perceived negatively by a large number of participants, due to the risk of cross-infection: “They say the worst place to pick up germs that are bad bacteria is in the gym, because everyone is in there sweating. And people that feel sick still go to the gym and they are coughing all over the place and sweating and that kind of puts me off” (Robert, 41); “Going to anything like a gym I just have total war against…I think they’re a hive of infection. I think they’re the most unclean environments you could possibly get”, and illness-related embarrassment: “I don’t like when people listen to me coughing when I’m in the gym…and if I have any secretions, at least if I’m at home, I’ll get rid of it there” (Mary, 30); “Going to the gym, especially on Oxygen and things is quite intimidating for people…it’s very easy to feel self-conscious so, I think home programmes for people… might help” (William, 34).
Many participants highlighted the Exercise Grant, made available biannually by CF Ireland, as a beneficial tool for enabling home-based exercise: “I have a treadmill at home that I was able to get through the CF Ireland Exercise Grant, which is fantastic, and that is what I would use at home. And, I have got a few little weights…it’s easier for me than driving to the gym, which takes more time out of my day” (Emily, 50), and “From a CF Ireland point of view, the Exercise Grant is really good because it can kind of help with the financial burden of exercise” (William, 34).