Findings are presented in three major themes: 1) perceptions of physical activity, 2) facilitators of physical activity and 3) barriers of physical activity. All themes are described at the individual, social and family, and community/environmental level.
Perceptions of physical activity among PLWH at the individual level
Participants revealed differing interpretation of the terms “physical activity” and “exercise”. The term “physical activity” was translated to ("Shughuli za mwili" in Swahili) which was perceived as an abstract concept, while the "exercise" ("mazoezi" in Swahili) was a more commonly used term. Participants would generally describe physical activity practices with examples using the word "exercise". On occasions, participant’s distinct physical activity with certain practices including house chores and income generating activities involving walking long distances were described as “physical activity”, in contrast to “exercise” which was perceived as recreational activities with intentions of improving physical strength or endurance. Participants also perceived that income generating activities such as petty trading, walking long distances selling fruits were sufficient physical activity. In addition, the commonly mentioned physical activity practices were walking, running, rope skipping and playing football of which were reported to be easy to perform and suitable for many age-groups. For example, as reported by a participant:
“Physical activities can mean work that you can do at home maybe to clean a house by mopping the floor or cultivating surrounding grasses and exercise means maybe walking, rope skipping, going to the gym” [IDI-32 year old women].
Some participants perceived sexual intercourse was part of physical activity and this was reported at individual level as well as from participants discussions reflecting community perceptions. For example, as explained by a participant:
“Physical … sexual intercourse with a woman is an exercise” [IDI-47 year old man].
Further, participants working in small scale businesses, walking long distances perceived that the amount of walking and work they do is sufficient physical activity.
Based on these quotations, inadequate social understanding of physical activity which is subjected to the commonly used words representing physical activity created confusion and discouraged the efforts of PLWH need to put on physical activity performances.
Perceptions of physical activity among PLWH at the community level
Apart from the individual perceptions of physical activity in participants, community social –cultural shared values can also contribute to individual choices or behavior of physical activity. In the group discussions, participants expressed perceptions of physical activity practices which were rooted within the existing gender stereotypes and roles in the community. Thus, men were seen as being more active than women and out-door recreational activities were seen as appropriate for men while house-chores were for women. As mentioned in a discussion:
“(In) the society that surrounds me, men do the exercise like running though it’s just few of them. Women are only doing physical activities like house-chores and take it as exercise" [FGD-34 year old woman].
In addition, participants reported that other community members would associate certain types of exercise such as weightlifting, body building exercises practiced in groups, with criminal acts in preparation for robbery, burglary or other crime. This was reported in two FGDs and supported by the participants. As reported by participants in a group discussion:
“I remember I started exercising with my friend. We organized ourselves and then we started to exercise. After a short time, we inspired some other people and then formulated a group of seven people. After that we found a place which was an unfinished house. Then we created local equipment for our gym, but some people in the community don't know the meaning of exercise. They think that exercise is a source of crime and terrorism, so they reported us to the street leaders. Eventually, (the street leader) came at our gym. He saw our place then took our gym equipment. He took that equipment with him thinking that exercise is the source of terrorism and crime in the community. After a few days he came back again. He realised we were just doing exercise nothing else” [FGD-27 year old man].
PLWH women showed lack of enough confidence and competence to participate in out-door physical activity because of the underlying social-cultural rooted stereotypes and gender roles. In addition, poor interpretation of physical activity in the community, has led to contradicting efforts of encouragements and discouragements for PLWH willing to do physical activity.
Facilitators of physical activity among PLWH at the individual, social and family levels
Participants reported that the health benefits of physical activity, social support and interactions related to physical activity from family members and friends were the main facilitators of physical activity. Participants felt motivated to do physical activity because it restores their physical abilities and improves their health. Self-efficacy and self-esteem would also improve due to the ability to appear healthy and not be immediately recognized as PLWH. As explained by the participant:
“What inspires me is, I want my body to be healthy and fit even if I am sitting among the people living with HIV, I cannot to be recognized (as HIV-infected). I do it for my health, I want to stay well” [IDI-32 year old woman].
Family and friends’ encouragements and participation in physical activity practices was paramount in motivating participants in physical activity. As reported by a participant in an interview:
“We play with the children in my area, like rope jumping and sometimes we play netball… I even sometimes play football, I play with the youths there in our street” [IDI-32 years old woman].
Facilitators of physical activity among PLWH at the community level
The presence and access to football pitches and open spaces in the community for physical activity was mentioned as one of the facilitators of physical activity. As reported by the participants:
“In community there is no gym, but we have football pitches and many people use it to run” [FGD-45 year old men].
Barriers of physical activity among PLWH at the individual, social and family level
Participants commented that the main barrier of physical activity was time. Participants did not have enough time to do physical activity because of work-related activities. As a participant explained in an interview:
“I wish to walk more distance…I don’t have enough time… sometimes you find that I have a lot of work and there is no time to go walking” [IDI 23 years old woman].
Some participants also feared physical activity would worsen their HIV disease leading to more deterioration of their heath rather than development of physical strength. As it was reported by a participant:
“After diagnosis, I thought maybe doing hard work will make me weak, I thought like I will die and leave my children, but after some time I was okay” [IDI-45 years woman].
Similarly, participants also reported that family members perceived physical activity practices to potentially worsen their HIV disease and for that matter, family members discouraged them to do physical activity. However, this was mentioned by few participants. As reported by the participant:
“ My mother she doesn’t advices me” she fears my condition [IDI-30 years old man].
Further, some family members discouraged physical activity due to lack of their time to support in these physical activities. This was observed, that even the immediate family members did not discuss or advise any issues pertaining physical activity for participants. As reported by the participant:
“ Neither her husband nor her children tell her about doing any exercises” [IDI-36 years old woman].
Lack of resources or money to pay for access to fitness centers was also reported as a barrier of physical activity. As highlighted by the participant:
“I won’t agree if they tell me to pay ten thousand (for gym) while I earn five hundred thousands, it will be difficult …my income has to be in line with the gym costs” [IDI-61 years old man].
Barriers of physical activity among PLWH at the community level
Lack of social groups participating in physical activity was also reported as a barrier to physical activity in participants. In addition, the lack of promotional physical activity messages from health officials and other government officials was also perceived as a barrier. The health care professionals mainly emphasize on maintaining a healthy diet, good hygiene and ART treatment adherence. As reported by a participant in a group discussion:
“There is no place or groups for doing exercises. They never talk about exercise for sure” [FGD-43 years old man].
PLWH have clearly revealed that the main barriers to physical activity in the community were poor social support and lack of conducive environment to do physical activity. Healthcare professionals often do not deliver good advice to PLWH on physical activity.