Health Promotion International, Vol. 24 No. 4
doi:10.1093/heapro/dap031
Advance Access published 30 September, 2009
# The Author (2009). Published by Oxford University Press. All rights reserved.
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Barriers to regular exercise among adults at high risk
or diagnosed with type 2 diabetes: a systematic review
EVELIINA E. KORKIAKANGAS*, MAIJA A. ALAHUHTA
and JAANA H. LAITINEN
Finnish Institute of Occupational Health, Oulu, Finland
*Corresponding author. E-mail: [email protected]
SUMMARY
The aim of this systematic review was to identify the
reported barriers to regular exercise among adults either at
high risk or already diagnosed with type 2 diabetes (T2D),
because of the importance of exercise in the prevention of
T2D. We searched the MEDLINE, Cinahl and PsycINFO
databases. All potentially relevant articles were reviewed by
two researchers, and 67 titles were found, of which 13
papers met inclusion criteria. Internal and external barriers
to exercise were identified among adults either at high risk
of T2D or already diagnosed. Internal barriers were factors
which were influenced by the individual’s own decisionmaking, and external barriers included factors which were
outside of the individual’s own control. It is important for
counselling to identify the internal and external barriers to
regular exercise. In this way, the content of counselling can
be developed, and solutions to the barriers can be discussed and identified. Further research on the barriers to
regular exercise is needed.
Key words: barriers; exercise; type 2 diabetes; high risk of type 2 diabetes
INTRODUCTION
An increase in the number of sedentary adults
is one reason behind today’s continuously rising
prevalence of type 2 diabetes (T2D). The total
number of people with diabetes is estimated to
increase from 171 million in 2000 to 366 million
by 2030 (Wild et al., 2004). This predicted diabetes pandemic means that hundreds of millions
of people are at high risk of T2D. Lifestyle
changes such as regular exercise, healthy
dietary habits and weight loss are important
in the prevention of T2D (Hu et al., 1999,
2001; Tuomilehto et al., 2001; Knowler et al.,
2002; Kosaka et al., 2005; Laaksonen et al.,
2005; Lindström et al., 2006). Exercise improves
insulin sensitivity, and thus prevents T2D
(Swartz et al., 2003; Yamanouchi et al., 1995). It
also has several benefits to the health of type 2
diabetic individuals (Albright et al., 2000). The
question of how to motivate sedentary adults to
exercise regularly is an important issue which
needs to be answered.
Perceived barriers to exercise are important
in the self-management of T2D (Glasgow et al.,
1997; Hays and Clarke, 1999; Koch, 2002; Cox
et al., 2004) because by identifying the barriers,
an individual can find solutions to them and
possibly focus on the benefits more strongly
than the barriers or disbenefits (Nagelkerk
et al., 2006). This information is needed in order
to develop effective exercise counselling contents, methods and campaigns to motivate and
help sedentary overweight adults at high risk
or already diagnosed with T2D to exercise
regularly. Earlier studies on barriers to regular
exercise have been carried out in several patient
groups such as those with osteoporosis and
osteoarthritis (Shin et al., 2006), urinary incontinence (Nygaard et al., 2005) and haemodialysis
416
Barriers to regular exercise
(Goodman and Ballou, 2004) and also among
healthy adults of different ages (Plonczynski,
2000; Resnick and Spellbring, 2000; Stutts,
2002; Schneider et al., 2003; Schutzer and
Graves, 2004; Thurston and Green, 2004;
Kilpatrick et al., 2005; Allender et al., 2006;
Kaewthummanukul et al., 2006; Teixeira et al.,
2006; Lee et al., 2007; Sit et al., 2008). The
purpose of this systematic review was to evaluate what is known about the barriers to regular
exercise among individuals either at high risk or
already diagnosed with T2D.
METHOD
Search protocol
An extensive search of the literature published
up to June 2008 was undertaken using the
electronic databases MEDLINE, PsycINFO,
Cochrane and Cinahl (Cumulative Index to
Nursing and Allied Health Literature). The
used keywords and phrases were barrier or barriers, and the following MeSH terms: exercise
or physical activity, and T2D. The Cochrane
database contained no paper on this subject.
Paper selection
A total of 67 potentially relevant papers were
identified from the databases. The inclusion
criteria were that the paper was: (i) written in
English; (ii) a peer-reviewed scientific article
and (iii) involved barriers to exercise or physical
activity among persons either at high risk or
already diagnosed with T2D. Exclusion criteria
of the papers were: (i) focus on children or
adolescents; (ii) focus on persons with serious
mental illness or (iii) no focus on the content of
the barriers. Both quantitative and qualitative
studies were included in this review due to the
limited number of papers.
A five-phase process was used (Figure 1).
During the first stage, the researcher (E.E.K.)
examined the titles and in the second stage, the
abstracts. In the third stage, the researcher
(E.E.K.) evaluated the retained papers as
whole articles. Next the researcher (M.A.A.)
examined the papers again, independently,
according to the selection criteria. The researchers
discussed papers considered ‘borderline’ for
inclusion until consensus was reached.
417
After screening titles and abstracts, we
retrieved 30 articles in full text. Sixteen studies
were eliminated, mainly due to no mention of
barriers in the focus and results of the study
(Hays and Clarke, 1999; Aljasem et al., 2001;
Koch, 2002; Cox et al., 2004; Wen et al., 2004).
One of the eliminated studies did not include
any factors on how the risk of T2D was evaluated (Carter-Nolan et al., 1996). In their review,
Kirk et al. (Kirk et al., 2007) studied physical
activity consultation for people with T2D and
also demonstrated barriers to regular exercise.
Their review contained two studies, one of
which (Swift et al., 1995) is also included in this
review. The other was eliminated because its
content did not deal with barriers to regular
exercise (Wilson et al., 1986). Due to this, Kirk
et al.’s study (2007) was not included in the
present review. A process of this systematic
review is described in Figure 1. Inclusion criteria were met by 13 articles altogether. Table 1
shows the included qualitative studies and
Table 2 contains the quantitative studies.
Data analyses
Data were analysed by inductive content analysis (Graneheim and Lundman, 2004; Elo and
Kyngäs, 2008), the process of which is presented
in Table 3. First, the results from the included
papers were gathered; the barriers with the
same meaning were grouped into subcategories
named according to the content. Then the main
categories were identified.
RESULTS
Methodological characteristics of the studies
Aims, designs, samples and data collection of
the study reports were analysed (Tables 1 and
2). The included studies had several different
aims, but each of them described barriers to
regular exercise. Data were collected by questionnaires in quantitative studies (n ¼ 9) and by
interviews with different techniques in qualitative studies (n ¼ 4). The studies were executed
between 1991 and 2007 in six countries: the
UK, the USA, South Africa, Kuwait, Australia
and Canada. The numbers of interviewed individuals were from 23 to 39 in qualitative
studies. The total number of study participants
was 3465, ranging from 23 to 1000 in the
418
E. E. Korkiakangas et al.
Fig. 1: Process of systematic review of barriers to exercise among adults at high risk or already diagnosed
with type 2 diabetes.
individual studies. One study included individuals at high risk of T2D, and the others (n ¼
12) included individuals already diagnosed with
T2D.
The barriers to regular exercise among persons
at high risk or already diagnosed with T2D
Two kinds of barriers to regular exercise were
identified within the papers reviewed. These
were internal and external barriers (Table 3).
The internal barriers included factors which
could be influenced by the individual’s own
decision-making, for example lack of time.
Due to these factors, the individual feels that the
reasons, goals and benefits of exercise are insufficient (health problems, exercise is not motivating) compared to the costs of exercising ( pain,
tiredness, feeling that exercise is uncomfortable,
negative emotions). Internal barriers also
included emotions such as shame (Swift et al.,
1995; Shultz Armstrong et al., 2001; Mier et al.,
2007), laziness (Van Rooijen et al., 2002; Dye
et al., 2003; Mier et al., 2007; White et al., 2007)
and fear of exercise (Swift et al., 1995; Wanko
et al., 2004; Donahue et al., 2006; Lawton et al.,
2006; Mier et al., 2007). At the root of these feelings was poor health or overweight (Swift et al.,
1995; Shultz Armstrong et al., 2001; Mier et al.,
2007). Overweight subjects often found exercise
Table 1: Qualitative studies reviewed regarding barriers to regular exercise among subjects either at high risk or already diagnosed with type 2
diabetes
Reference
Country
Aim of the study
Sample
Qualitative/
quantitative
Findings
Roles, norms and responsibilities: lack
of time (work, home duties), fear and
shame (being unfamiliar with their
local neighbourhood and difficulties
in speaking English); external
constraints: lack of culturally sensitive
facilities (in cases of cultural taboos
such as not being allowed to swim)
and weather conditions; perceptions
and experiences of disease;
activities and active respondents:
short term goals in exercising, ‘I do
enough already’
Lack of time due to work and family
obligations, taking care of children or
grandchildren, physical pain,
depression, lack of motivation, being
overweight, weather, environmental
barriers such as traffic, lack of
sidewalks, poor street lighting, gang
activity, lack of facilities and
transportation
Tiredness, health problems, lack of
convenient venue for exercise,
unwillingness to exercise on
Thursdays because church obligations,
or on a clinic day because of the long
waiting periods, unwillingness to
exercise with people who do not have
type 2 diabetes, social responsibilities,
cost of transport, family affairs,
difficulties at home, laziness, feeling
unwell
Bad feet because of diabetes, arthritis,
not wanting others to know unfit they
are, no energy to exercise, feeling too
sleepy to exercise
Lawton et al., UK
2006
To study experiences of
physical activity as part
of diabetes self care
23 Pakistani and 9
Indian diabetes
patient
Qualitative
Subjects were interviewed
in depth
Mier et al.,
2007
USA
To identify barriers to
physical activity in a
population of Mexican
Americans with type 2
diabetes
39 Mexican Americans
with type 2 diabetes
in six groups (aged
30– 55 years)
Qualitative
60– 90 min discussions in
groups, questionnaire
on demographic
characteristics.
Qualitative study
Van Rooijen
et al., 2002
South Africa To study barriers to
exercise
28 black women
diagnosed with type
2 diabetes
Qualitative
Interview study
Dye et al.,
2003
USA
31 people over the age
of 55 with type 2
diabetes
Qualitative
Focus group interview
(four focus group)
To identify factors that
affect the nutrition and
exercise behaviours of
people over the age of
55 with type 2 diabetes
Barriers to regular exercise
Data collection
419
420
Reference
Country
Aim of study
Sample
Qualitative/
quantitative
Serour et al.,
2007
Kuwait
334 Kuwaiti adults with hypertension,
type 2 diabetes or both
Quantitative
Questionnaire
Weather, always busy,
co-existing disease
Donahue
et al., 2006
USA
522 adults at high risk of type 2
diabetes
Quantitative
Mail survey
Questionnaire
97 patient with type 2 diabetes
Quantitative
Mail survey
Questionnaire
To study perceived factors that 406 patient with type 1 or type 2
prevent patients from
diabetes, mean age 56, mean
increasing physical activity
duration of diabetes 10 years
Quantitative
Questionnaire
To study attitudes, beliefs and
barriers to exercise
Quantitative
Questionnaire
Exercise is a low priority,
worrying about injury,
difficulty finding time for
exercise. Fewer physically
active individuals reported
these than active individuals
Exercise not high priority;
weather; choices of exercise
activities; health problems,
work, disliking exercise,
disliking sweating, too
overweight to exercise
Serious illness, changing job,
having children, developing
diabetes, moving house,
starting first job, getting
married, separating from
partner, leaving home, lack of
local facilities for exercise,
lack of time, difficulty taking
part in exercise, tiredness or
depression, something good
on television or other plans
with friends, bad weather
Disliking sweating, too
overweight to exercise, no
support from family to
exercise, exercise ‘makes me
feel uncomfortable’, afraid of
low blood sugar reaction,
exercise not important
Shultz
Armstrong
et al., 2001
USA
To study patients’ perceptions
of barriers to exercise
Thomas et al.,
2004
UK
Swift et al.,
1995
USA
To measure adherence and
barriers to complying with
lifestyle recommendations
among patients with high
cardiovascular risk factors
To describe physical activity
barriers and support of
patients at risk of type 2
diabetes
83 people with non-insulin-dependent
diabetes
Data collection
Findings
E. E. Korkiakangas et al.
Table 2: Papers reviewing barriers to regular exercise among subjects either at high risk or already diagnosed with type 2 diabetes
White et al.,
2007
Australia To examine why subjects do
or do not engage in regular
physical activity
Wanko et al.,
2004
USA
To determine physical activity
preferences and barriers to
exercise in an urban
diabetes clinic population
Dutton et al.,
2005
USA
To study barriers to physical
activity among
predominantly low-income
African-American patients
with type 2 diabetes
Searle and
Ready 1991
Canada
To determine what factors
may inhibit participation in
an exercise and weight
control programme
192 adults diagnosed with type 2
diabetes and or cardiovascular
disease, mean age 61 years, 67%
diagnosed type 2 diabetes only, 7%
diagnosed with cardiovascular
disease only, 25% diagnoses with
both
605 patients mean age 50 years, mean
duration of diabetes ¼ 5.6 years
Questionnaire
Laziness, lack of time, feeling
unwell, weather
Quantitative
Questionnaire
105 patient with type 2 diabetes mean
age 53 years
Quantitative
Questionnaire
1000 randomly selected subjects with
diabetes
Quantitative
Questionnaire
Pain, no willpower, insufficient
health, not knowing what kind
of exercise to do, no one to
exercise with, no convenient
or nearby place to exercise,
nowhere safe to exercise,
exercise not important
Health problems and pain, lack
of time, lack of social support,
lack of child care, lack of
access to exercise facilities or
equipment, bad weather, lack
of physician advice, special
occasions
Lack of energy, health problems,
lack of time, lack of partner,
lack of personal knowledge,
too expensive, shyness, lack of
transportation, no family
support
Barriers to regular exercise
Quantitative
421
422
E. E. Korkiakangas et al.
Table 3: Barriers to exercise among adults either at high risk or already diagnosed with type 2 diabetes,
presented by original expressions of results, both subcategories and main categories based on content analysis
Previous results
Lack of time (work or home duties)
Difficulty finding time for exercise
Lack of time
Unwillingness to exercise on clinic day because of long
waiting periods at clinic
Exercise is a low priority
Exercise is not important
Laziness
Lack of motivation
Activities and active respondents: short-term goals in
exercising, ‘I do enough already’
No willpower
Something good on television or other plans with friends
Lack of energy
Disliking exercise
Disliking sweating
Exercise ‘makes me feel uncomfortable’
Physical discomfort from exercise
Too overweight to exercise
Perceptions and experiences of disease
Health problems
Fear of hypoglycaemia
Feeling unwell
Pain
Insufficient health
Afraid of low blood sugar reaction
Physical pain
Coexisting disease
Feeling unwell
Depression
Tiredness
Too overweight to exercise
Shyness
Unwillingness to exercise with people who do not have
type 2 diabetes
Not wanting others to know how unfit they are
Laziness
Lack of motivation
No willpower
Serious illness, changing job, having children, developing
diabetes, moving house, starting first job, getting married,
separating from partner, leaving home
Lack of child care
Taking care of children/grandchildren
Special occasions
Social responsibilities
Family affairs
Difficulties at home
Nowhere safe to exercise
Poor street lighting
Gang activity
Fear and shame (not being familiar with their local
neighbourhood and difficulties in speaking English)
Worrying about injury
Fear of hypoglycaemia
Subcategory
Lack of time
Subcategory
Exercise is not
motivating
Main
category
Internal
barriers
Exercise is not
interesting
Exercise is
uncomfortable
Physical health
Health problems
Mental health
Shame
Emotions
Feeling lazy
Stressful life situation
Fears
Continued
Barriers to regular exercise
423
Table 3: Continued
Previous results
No support from family for exercise
Lack of social support
No one to exercise with
Unwillingness to exercise with persons who do not have
type 2 diabetes
No knowing what type of exercise to do
Lack of physician advice
Lack of personal knowledge
Leaders not informed
Lack of convenient venue for exercise
Choices of exercise activities
Lack of local facilities for exercise
Difficulty in taking part in exercise
No convenient or nearby place to exercise
Nowhere safe to exercise
Lack of access to exercise facilities or equipment
Environmental barriers such as traffic
Lack of sidewalks
Poor street lighting
Gang activity
Environmental barriers such as traffic
Lack of facilities
Lack of transportation
Cost of transport
Too expensive
Lack of culturally sensitive facilities (in cases cultural
taboos such as not being allowed to swim)
Unwillingness to exercise on Thursdays because of church
obligations
Weather conditions
Whether
uncomfortable (Swift et al., 1995; Shultz
Armstrong et al., 2001; Mier et al., 2007).
Difficult life situations also presented barriers to
exercise (Searle and Ready 1991; Van Rooijen
et al., 2002; Thomas et al., 2004; Dutton et al.,
2005; Mier et al., 2007), and lack of time was a
common excuse (Searle and Ready, 1991; Shultz
Armstrong et al., 2001; Van Rooijen et al., 2002;
Thomas et al., 2004; Dutton et al., 2005;
Donahue et al., 2006; Lawton et al., 2006; White
et al., 2007). Difficulties in finding time for exercising were due to work or home duties.
External barriers included factors which are
independent of an individual’s decision-making,
such as weather (Shultz Armstrong et al., 2001;
Thomas et al., 2004; Lawton et al., 2006; White
et al., 2007; Mier et al., 2007; Serour et al., 2007)
or cultural barriers (Van Rooijen et al., 2002;
Lawton et al., 2006). These factors prevented
exercising through, for instance, the lack of
exercise facilities (Searle and Ready, 1991; Mier
et al., 2007). Factors such as lack of social
Subcategory
Lack of prompting/
acceptance
Subcategory
Lack of social
support
Main
category
External
barriers
Lack of knowledge
about exercising
Poor local facilities for
exercise
Lack of facilities
for exercise
Unsafe local facilities
for exercise
Lack of transportation
Costs
Religious and cultural
barriers
Cultural barriers
Weather
Weather
support (Searle and Ready, 1991; Dutton et al.,
2005) also affect motivation to exercise.
DISCUSSION
We evaluated in this review what is known about
the barriers to regular exercise among individuals
at high risk or already diagnosed with T2D. We
identified two kinds of barriers to regular exercise: internal and external barriers. This systematic review shows that limited knowledge exists on
the barriers to regular exercise among adults at
high risk or already diagnosed with T2D.
Exercise was not motivating because it was
uncomfortable and involved sweating, and physical discomfort. The feeling of being too fat to
exercise is a common barrier among overweight
adults (Ball et al., 2000); adults of normal
weight experience less barriers to exercise than
overweight adults (Deforche et al., 2006). Greater
weekly exercise and weight loss are significantly
424
E. E. Korkiakangas et al.
associated with fewer difficulties with exercise
(Carels et al., 2005). Furthermore, physically
active adults experience less barriers to exercise
compared with those leading more sedentary
lives (Kowal and Fortier 2007). Vandelanotte
et al. (Vandelanotte et al., 2008) have considered
that being overweight might be an extra motivator for changing health behaviours. Thus, obesity
and overweight need to be taken into account in
exercise counselling. Health problems included
pain, insufficient health, depression and tiredness.
Exercise, either alone, or combined with weight
management may reduce self-reported depressive
symptoms (Smith et al., 2007). Regular exercise
helps increase the quality and amount of sleep
(Verkasalo et al., 2005) and sufficient sleep
improves weight control (Knutson et al., 2007),
while short sleep duration is associated with overweight and obesity (Taheri et al., 2004;
Gangwisch et al., 2005).
Prioritizing physical activity, making time for
exercise and lessening worry about injuries
should be focused on in counselling (Donahue
et al., 2006). In this way, counselling could
succeed in increasing physical activity in sedentary individuals at high risk of T2D. Based on
the results of this review, we suggest that both
external and internal barriers to regular exercise
are concrete challenges to the counselling of
adults either at high risk or already diagnosed
with T2D. The external barriers can be overcome through public knowledge of different
facilities for exercise and by further developing
the facilities. Information is often insufficient in
order to motivate people to exercise, but is an
essential part of the content of counselling.
However, we suggest that the internal barriers
may demand more individual counselling. It is
possible that all individuals are not aware of the
meaning of subjective barriers to motivation to
exercise, or own level of exercise. The present
review provided and suggested some content
the exercise counselling among adults either at
high risk or already diagnosed with T2D. The
methods in the counselling should support
motivation to exercise and at the same time
help to recognize and evaluate one’s own behaviour. Adults need help to identify the barriers to regular exercise during counselling,
followed by support to make decisions and
plans to overcome the barriers and thus make
changes to their own behaviour.
Our review is the first of its kind to try and
bring together the earlier knowledge-based
research on barriers to regular exercise among
adults either at high risk or already diagnosed
with T2D. Although we tried to widely search
studies from different databases, some relevant
studies in other databases or published in a
language other than English may have been
missed. The studies were executed mainly
between 2004 and 2007. T2D has only been
globally topical since the results of some
prevention studies (Hu et al., 1999, 2001;
Tuomilehto et al., 2001; Knowler et al., 2002;
Kosaka et al., 2005; Laaksonen et al., 2005;
Lindström et al., 2006) demonstrated that T2D
can be prevented by lifestyle changes such as
dietary habits and exercise. Thus, it is understandable that barriers to regular exercise
among adults either at high risk of T2D or
already diagnosed with T2D have only been
studied since those studies for a few years.
Limitations in inclusion and exclusion criteria
are possible.
Four reviewed qualitative studies were comprehensively executed and reported (Van
Rooijen et al., 2002; Dye et al., 2003; Lawton
et al., 2006; Mier et al., 2007). Qualitative data
were based on interviews with different
methods (Van Rooijen et al., 2002; Dye et al.,
2003; Lawton et al., 2006; Mier et al., 2007).
Interviewed individuals are not necessarily
reflective of the entire adult population either
at risk or already diagnosed with T2D.
Although the generalizability of qualitative
studies is limited, they provide valuable basic
outcomes regarding barriers to exercise which
are necessary in order to deepen further
research and verify the barriers using statistical
methods. The present paper reviewed nine
quantitative studies, mostly variables and items
for questionnaires, based on earlier literature
and studies, and were at most pretested, or the
content validity of the questionnaire ensured by
a panel of experts (Searle and Ready, 1991;
Thomas et al., 2004; Wanko et al., 2004; Dutton
et al., 2005; Donahue et al., 2006; White et al.,
2007). However, in order to make it possible to
compare the results of studies on barriers to
regular exercise between adults at high risk or
already diagnosed with T2D, further research
using repeatedly validated measures is needed.
As a conclusion to this review, we suggest
that it is important to help adults either at high
risk or already diagnosed with T2D to identify
the barriers to regular exercise and to learn how
to solve these problems. In order to achieve
Barriers to regular exercise
this, we need to develop the content and
methods of counselling. Further research is also
important because of a need to intensify counselling and improve its effectiveness.
FUNDING
This study was financially supported by the
Academy of Finland (grant no: 118176 and
grant no: 129248).
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