This study set out to establish the qualitative perspectives of people with T2D on the PA promotion they received from health care professionals. To freshen our understanding of these issues, we adopted a multi-point theoretical approach to explore the relevance of what the people needed with what they received. We also blended the familiar TTM (18, 19, 28) with key constructs from a less familiar framework, CM (22, 23), to help understand why people with T2D, who have so much to gain from adopting and sustaining PA, find it so challenging.
From a PA adoption perspective, our key finding is that low- and underactive people with T2D are dominated by superstructural issues in the BSPsyP. In everyday terms, this relates to attitudes, beliefs and preferences. PA promotion for people in the stages of Precontemplation, Contemplation and Preparation will need to address long-held beliefs regarding the appropriateness of PA for them and for managing their diabetes. Importantly, we found no interviewees who recognised that PA can effectively alleviate any need for T2D medications (29). On the other hand, we found substantial evidence corroborating recent research (30) showing that older Hispanic interviewees rehearse the idea that lost functioning is normal and that adopting PA is inappropriate at their time of life, even after securing substantial health benefits through a 24-month trial.
The BSPs affecting PA are strongly influenced by cultural infrastructure. Some BSPs seem ever-present (e.g. gender) while others act intermittently in response to key events (e.g., picking up and caring for grandchildren) and contexts (e.g., being in different locations). At the same time, the patients’ TTM stage provides a powerful guide for determining the BSPs that may best help start or maintain a PA program. Uniquely, we have summarised and simplified the relationship between the most cited barriers, the CM, the TTM stages and the BSPs. Doing so, we hope to encourage more health care professionals to promote PA while addressing the priorities of their patients’ real worlds.
Our evidence provides healthcare staff with approaches grounded in ‘real-world’ life and that may be better timed to meet changing needs. People living with diabetes who are in the low-active stages a BSPsyP is related to awareness and to personal relevance of PA issues. In contrast, people in the more active stages of change are affected by a BSSocP and the structure and infrastructure of the CM. The consequences for better PA promotion by healthcare staff deserve consideration as they face issues not only in promoting PA successfully, but also in attempting to refine their routine practice using study outcomes (18).
We recruited no entirely sedentary patients, meaning all did PA at some level. Pre-existing behaviour represents an important opportunity for health care promoters to promote further PA by helping patients to transfer their existing problem-solving skills to the perplexing problems thrown up by unstable daily lives. Simply focusing on the perceptions and intra-personal characteristics of T2D patients, healthcare staff is likely to overlook the powerful influence of successfully navigating what had previously been seen as insurmountable structural and infrastructural barriers. The resulting sense of agency is important; yet it runs counter to some current ‘solutions’. For example, many of the contemporary protocols and techniques proposed to improve the PA adherence (e.g. HIIT) may require expert supervision and/or access to sports facilities that many patients cannot acquire without substantial personal investment (21). In this regard, using high intensity protocols are unlikely to address ‘lack of time’ as patients perceive it, and will not produce positive behaviour change (13, 31). Heath care staff who follow-up on their PA interventions are only likely to become dispirited by such outcomes.
In these cases, while many patients may be able to enroll, few follow-up with healthcare recommendations once a study is discontinued(14, 32). For that reason, although studies may establish efficacy, they do little to help maintenance (which may be taken as a marker of effectiveness); PA adherence typically decreases at three to six months post-intervention(14, 32). To that end, we suggest that many studies have focused on PA adoption-adherence as a BSSocP, meaning it addresses the immediate infrastructural barriers during the study without addressing the wider, systemic, BSPsyP issues that were always likely to become prominent post-intervention. The recurrent challenges surrounding behaviour change in low socioeconomic status communities attests to this concern (33)
Left unaddressed, these high-intensity protocols and behaviour changes techniques may simply enhance the marketing of the PA. Indeed, our results suggest that the concept of PA continues to be seen as the concern of young-middle aged males and is seen as a luxury, rather than a biological or social necessity(34). For example, in Spain, during the breakdown of COVID-19 one of the things that was prohibited was to do PA outdoors. Relying on these marketing approaches is likely to add to the alienation from PA already experienced by many low-active T2D patients, who are lower income groups, female and elderly. To widen the appeal of PA, another cultural concept of PA has emerged: therapeutic exercise and ‘Exercise is Medicine’ (35, 36). However, without the capability of doing PA, even these approaches may create more barriers (i.e. economic barriers) than they solve (35).
We do not mean that overcoming the infrastructural barriers and find a way to help the patients throughout the BSSocP is unimportant, but we should not forget that some behaviour change techniques might not solve infrastructural and structural barriers. Also, patients may need to go through a BSPsyP and overcome the superstructure barriers that might arise in the first steps of change behaviour. To attach that BSPsyP it might be needed to rebuild the social PA concept throughout the structure and the infrastructure. Otherwise, we risk overlooking a huge number of vulnerable patients facing the greatest combinations of barriers to changing their lifestyles (i.e. lower-income, women and elderly patients). That so because PA and therapeutically exercise concept might enhance structural and infrastructural barriers.
Although participant homogeneity might be a limitation in the study, the sample featured representatives from the different stages of the TTM and the different levels of the CM paradigm. With that approach, a fresh interpretation of the ‘PA problem’ has emerged. Our approach has blended CM and TTM to establish a BSP. In this regard, we hypothesise that the TTM can be practically revised to two different BSPs; one reflects superstructure and the other structure and infrastructure levels.
This new interpretation aims to help healthcare professionals, who rarely have sufficient time to apply the TTM in consultations (15). The simplicity of this approach may help improve outcomes arising from the actions of healthcare professionals.