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Discussion #2: Qualitative Research

Read the posted article.

**Refer to this week’s assigned textbook readings for support.**

Respond to the questions below by reviewing the article and identifying those elements (state the page number you found the element). As you discuss the researcher’s use of the element, make sure your discussion is properly supported by your textbook.

Your critique responses should reflect upon the following:
1. What type of qualitative approach did the researcher use? Provide a definition of the type of approach.
2. What type of sampling method did the researcher use? Is it appropriate for the study? Why or why not?
3. Discuss whether the data collection focused on human experiences.
4. How did the author address the protection of human subjects?
5. How did the researcher describe data saturation?
6. What procedure for collecting data did the researcher use?
7. Describe the strategies the researcher used to analyze the data.
8. How did the researcher address the following:

Credibility
Auditability
Fittingness

9. What is your cosmic question? (This is a question you ask your peers to respond to based on this week’s topic of Qualitative Research).

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1Kennedy A, et al. BMJ Open 2018;8:e017813. doi:10.1136/bmjopen-2017-017813

Open Access

Attitudes and barriers to exercise in
adults with a recent diagnosis of type 1
diabetes: a qualitative study of
participants in the Exercise for Type 1
Diabetes (EXTOD) study

Amy Kennedy,1 Parth Narendran,2 Robert C Andrews,3 Amanda Daley,4
Sheila M Greenfield,4 for the EXTOD Group

To cite: Kennedy A,
Narendran P, Andrews RC,
et al. Attitudes and barriers
to exercise in adults with
a recent diagnosis of type
1 diabetes: a qualitative
study of participants in the
Exercise for Type 1 Diabetes
(EXTOD) study. BMJ Open
2018;8:e017813. doi:10.1136/
bmjopen-2017-017813

► Prepublication history for
this paper is available online.
To view these files, please visit
the journal online (http:// dx. doi.
org/ 10. 1136/ bmjopen- 2017-
017813).

Received 17 May 2017
Revised 15 August 2017
Accepted 28 September 2017

1The Institute of Metabolism and
Systems Research and Centre
for Endocrinology, Diabetes and
Metabolism, The Medical School,
University of Birmingham,
Birmingham, UK
2The University of Birmingham
and The Queen Elizabeth
Hospital, Birmingham, UK
3Institute of Health Services
Research, University of Exeter
Medical School, University of
Exeter, Exeter, UK
4Institute of Applied Health
Research, University of
Birmingham, Birmingham, UK

Correspondence to
Dr Robert C Andrews;
r. c. andrews@ exeter. ac. uk and
Dr Parth Narendran;
p. narendran@ bham. ac. uk

Research

AbstrACt
Objectives To explore attitudes and barriers to exercise in
adults with new-onset type 1 diabetes mellitus (T1DM).
Design Qualitative methodology using focus group (n=1),
individual face-to-face (n=4) and telephone interviews
(n=8). Thematic analysis using the Framework Method.
setting Nineteen UK hospital sites.
Participants Fifteen participants in the Exercise for
Type 1 Diabetes study. We explored current and past
levels of exercise, understanding of exercise and exercise
guidelines, barriers to increasing exercise levels and
preferences for monitoring of activity in a trial.
results Five main themes were identified: existing
attitudes to exercise, feelings about diagnosis, perceptions
about exercise consequences, barriers to increasing
exercise and confidence in managing blood glucose. An
important finding was that around half the participants
reported a reduction in activity levels around diagnosis.
Although exercise was felt to positively impact on health,
some participants were not sure about the benefits or
concerned about potential harms such as hypoglycaemia.
Some participants reported being advised by healthcare
practitioners (HCPs) not to exercise.
Conclusions Exercise should be encouraged (not
discouraged) from diagnosis, as patients may be more
amenable to lifestyle change. Standard advice on exercise
and T1DM needs to be made available to HCPs and
patients with T1DM to improve patients’ confidence in
managing their diabetes around exercise.
trial registration number ISRCTN91388505; Results

bACkgrOunD
Regular physical activity plays a key role in the
management of patients with type 1 diabetes
mellitus (T1DM). It improves insulin sensi-
tivity, reduces cardiovascular risk factors such
as blood pressure (BP) and lipid profiles,
improves quality of life and reduces mortality.1
As a result, patient guidelines currently
recommend undertaking at least 150 min per
week of moderate to vigorous aerobic exer-
cise, spread out during at least 3 days, with

no more than two consecutive days between
bouts of aerobic activity. Patients should also
be encouraged to perform resistance exercise
‘at least two times per week on non-consecu-
tive days’.2 3

A large percentage of patients with T1DM
do not reach these guidelines. In a retrospec-
tive analysis of the Diabetes and Complica-
tions Trial, 19% of (271/1441) participants
were not achieving American Diabetes Associ-
ation (ADA) activity level recommendations.4
In the EURODIAB prospective cohort study of
2185 patients with T1DM from 16 European
countries, 786 (36%) patients were doing
none or only mild physical activity.5 Similarly
23% of patients with T1DM were classed as
sedentary and a further 21% were doing less
than one session of exercise per week in the
Finnish Diabetic Neuropathy Study.6

Little is known about attitudes and barriers
to exercise in patients with T1DM. In two
Canadian studies of patients with established
T1DM,7 8 fear of hypoglycaemia was the stron-
gest barrier to regular exercise. A qualitative
study from our group in the UK suggests that
although fear of hypoglycaemia is a factor

strengths and limitations of this study

► This is the first qualitative interview study to examine
attitudes and barriers to exercise in patients newly
diagnosed with type 1 diabetes mellitus.

► Patient recruitment was from UK sites covering both
large teaching and district general hospitals and
participants spanned a wide age range.

► Study participants may have been more interested
in exercise than those who declined and interest in
exercise education and management of diabetes
around exercise may be lower in the general clinic
population.

http://bmjopen.bmj.com/

http://dx.doi.org/10.1136/bmjopen-2017-017813

http://crossmark.crossref.org/dialog/?doi=10.1136/bmjopen-2017-017813&domain=pdf&date_stamp=2018-01-23

2 Kennedy A, et al. BMJ Open 2018;8:e017813. doi:10.1136/bmjopen-2017-017813

Open Access

when patients with established T1DM consider exercise,
external factors, such as lack of time, work pressures and
bad weather were greater barriers to physical activity.9

No studies have examined attitude and barriers to exer-
cise in patients recently diagnosed with T1DM, a time
when exercise habits may be greatly influenced. This
qualitative study aimed to explore attitudes and barriers
to exercise in adults with new-onset T1DM.

MethODs
recruitment
Study patients were from the EXercise for Type 1 Diabetes
study (EXTOD) whose protocol has been described previ-
ously.10 In brief, all patients aged between 16 and 60 years,
diagnosed with T1DM in the previous 3 months from 19
UK hospital sites were invited to participate. EXTOD
had two phases, Phase 1 which consisted of the qualita-
tive study reported here. This was designed to inform on
the most feasible and patient-friendly way of motivating
patients newly diagnosed with T1DM to undertake and
maintain a graded exercise programme and to determine
attitudes and barriers to exercise. This understanding was
essential for the conduct of Phase 2, a pilot randomised
controlled trial to assess uptake, intervention adherence,
dropout rates and rate of uptake in the usual care group
during a 12-month exercise intervention (not the subject
of this report). Participants were approached by a member
of the clinical team (doctor/diabetes nurse/dietitian) at
their local site and gave written informed consent.

Interviews
Initially it was intended to use focus groups but geograph-
ical spread and the time interval between identification of

participants meant one to one and telephone interviews
had also to be offered.

Interviews were carried out by AK, using a semistruc-
tured topic guide,10 and lasted between 30 and 60 min.
Areas for discussion included current and past levels of
exercise, understanding of exercise and exercise guide-
lines, barriers to increasing exercise levels and prefer-
ences for monitoring of activity in a trial.

Analysis
Interviews and focus groups were recorded and tran-
scribed. Data analysis was ongoing during the collection
period to enable full exploration of themes identified
in earlier interviews and to identify when saturation had
been achieved.11 Data were managed using N-Vivo 9 (QSR
International, Victoria, Australia). Themes and a coding
frame were developed independently by reading and
re-reading interview transcripts and through discussions
between research team members (AK, PN and SG). Inter-
views were then analysed using a framework approach to
further examine identified themes.12

results
Participants
Fifteen participants were interviewed: one focus group
of three participants, four face-to-face and eight by tele-
phone (table 1). Eleven were male, median age was 29
(range 18–53 years) and 12 were of White-British ethnic
origin. The median length of time from diagnosis to
interview was 66 days.

themes
The interviews yielded rich data on five main themes.
These were: exercise context (attitudes to and current

Table 1 Participant demographics

Participant Age group Gender Centre Ethnic origin Interview format Group

A 40–44 m Bir Asian or Asian British—Indian FG, Face-to-face CONCERNED

B 20–24 f Bir White—British FG, Face-to-face CONCERNED

C 50–54 m Bir White—British FG, Face-to-face CONCERNED

D 50–54 m Bir Black or Black British—Caribbean I, Face-to-face CONCERNED

E 20–24 m Bir White—British I, Face-to-face CONFIDENT

F 35–39 m Tau White—British I, Face-to-face AMBIVALENT

G 20–24 m Glou White—British I, Face-to-face AMBIVALENT

H 20–24 m Brist White—British I, Telephone CONFIDENT

I 50–54 m Bir White—British I, Telephone CONCERNED

J 20–24 f Wake White—British I, Telephone CONFIDENT

K 45–49 f Glou White—British I, Telephone CONFIDENT

L 15–19 m Bir White—British I, Telephone AMBIVALENT

M 35–39 m Tau Mixed—White and Black African I, Telephone CONCERNED

N 25–29 f Bir White—British I, Telephone CONCERNED

O 15–19 m Brist White—British I, Telephone CONFIDENT

FG, focus group; I, individual interview.

3Kennedy A, et al. BMJ Open 2018;8:e017813. doi:10.1136/bmjopen-2017-017813

Open Access

and previous exercise behaviour); diabetes (impact of
diagnosis and knowledge); consequences of exercise;
barriers to increasing exercise; confidence (in exercising
and managing diabetes).

Specific numbers of participants are not routinely
given throughout as these are not generally used when
reporting qualitative research, the aim of sampling being
to represent the spread of views rather than proportions
which can be generalised to a larger group.13

Attitudes to and current and previous exercise behaviour
All participants were already doing some form of exer-
cise with the majority wanting to increase activity levels.
Activities that participants classed as exercise varied from
walking during their working day to swimming or going to
the gym. Table 2 shows the exercise that each participant
was taking part in. Ten participants were doing moderate
activity, one moderately vigorous activity and three
vigorous activity. Five participants reported a reduction in
the amount of time they spent exercising, and seven had
changed the type or reduced the intensity of activities they
were doing since diagnosis. Most participants were either
unaware there is guidance on the minimum amount of
exercise adults should undertake each week or uncertain
as to the amount recommended. Many were pleasantly
surprised recommendations were not higher and felt
they should be able to achieve this even if they were not
already doing so. Some felt a universal guideline was inap-
propriate as it could not include individual circumstances
and a personalised target would be preferable.

‘Because each person should be done individu-
ally. And the doctor should say yes, you’re capa-
ble of doing this. No, you’re not …because he’ll
have your medical records, …Not the government

telling you, you should do this or you should do that.’
(Participant C).

Impact of diagnosis and knowledge of diabetes
All participants talked about the impact of their T1DM
diagnosis, most commonly describing the sudden nature
of the diagnosis of as a ‘shock’ (A, D, H, I, K, M and N).
Other descriptions were as being ‘hit’, a ‘kick in the teeth’
(both participant C) and feeling ‘stunned’ (participant I).
Several participants described their diagnosis as a loss of
normality (wanting to get back to a ‘normal life’) or role
(uncertainty about being able to work).

Participants reported four different fears and anxieties
regarding their T1DM diagnosis: managing new interac-
tions with healthcare services; impact on employment,
concerns for the future and blood glucose control. Some
reported feeling overwhelmed by the amount of contact
they had with healthcare services since diagnosis.

‘Every other week I’m getting different, another let-
ter through with different things which could be re-
lated to it’ (Participant D)

‘there’s too many things going on at the moment,
I think for me.’ (Participant K)

For several participants, T1DM had negatively impacted
on work. Some had still not gone back to work and were
anxious about their ability to cope. One (N) had lost
their job.

‘I’m quite concerned about going back to work actu-
ally. Because I know that I’m going to be on the go
all the time and whether I’m going to be able to cope
with doing 8 hours worth of walking on a daily basis’.
(Participant B)

Table 2 Activities described as exercise by participants

Participant Activities prior to diagnosis Current activities

A Jogging, rope skipping, playing football Walking while at work (4–5 hours a day)

B Walking at work, gardening, do it yourself (DIY) jobs, gym, squash Occasional gym session, DIY

C Physical job, gardening, DIY, repairs None

D Regular attendance at the gym (cardiovascular and weight training) Walking

E Marshall arts/boxing Active job 2 days a week

F Walking while at work Walking while at work

G Swimming, jogging Swimming, jogging

H Combat karate Jogging, some weights

I Walking/jogging outside Walking on treadmill

J Gym Gym

K Gardening Gardening, walking

L Walking Walking

M Running Running

N Rugby, football, cycling Cycling on static bike

O Badminton/golf Badminton and golf

4 Kennedy A, et al. BMJ Open 2018;8:e017813. doi:10.1136/bmjopen-2017-017813

Open Access

‘That’s the problem, going back into a job now, know-
ing if you can do it.’ (Participant C)

Some participants had concerns for the future and
reported uncertainty about their future health. One
participant had discussed this with their general practi-
tioner (GP).

‘I goes to him [the GP] ‘how long are you going to
live on it?’ He goes ‘if you don’t look after yourself, he
says, 5 years’. I thought, what! That’s a serious thing.’
(Participant D)

‘it’s just nobody has sort of come out and said like,
‘This is exactly like, you know, what’s going, what’s
going to happen and stuff like that.’ (Participant F)

Some participants were concerned about blood glucose
levels and many were anxious to get optimal glycaemic
control. Participants expected their blood glucose levels
would become ‘balanced’ with time and they would then
be able to keep them within a tight range.

Importantly, all said being diagnosed with diabetes had
given them additional motivation to exercise than before
diagnosis (even those who did not plan to increase activity
levels).

‘it’s changed my ethos of taking time to do some exer-
cise in some, you know, going for walks. It’s changed
my mind, my what I think.’ (Participant K)

‘I mean generally the reason most diabetics start, or
people in general start doing more exercise is be-
cause of the fear. At the end of the day I think it’s the
fear factor of being afraid that if I don’t then my life
is going to be worse.’ (Participant E)

Twelve participants wished to increase activity levels,
although some had more concrete plans than others.

‘but actually, I could do my 10 min [bout of exer-
cise], because we do have a room that nobody ever
goes into, erm, so I could do that here, and that’s
a thought, maybe I could consider.’ (Participant M)

the consequences of exercise
Perceptions about the consequences of exercising were
mostly positive and included; health benefits, improved
fitness, enjoyment, a feeling of well-being and weight
loss. Some participants cited exercise benefits specifi-
cally related to diabetes such as lower blood glucose and
insulin requirements.

Although health benefits were commonly mentioned
as a motivation to exercise, often participants were vague
about them and unable to give specific examples. A few
mentioned positive effects on BP, cholesterol and heart
disease risk.

Blood glucose lowering was seen to be a positive effect
of exercise by some, for others this was a negative result
as it was associated with hypoglycaemia. Those partici-
pants were particularly concerned about hypoglycaemia
and whether this would counteract the health benefits of

exercise, both directly as a consequence of hypoglycaemia
and also secondary to the need to increase carbohydrate
intake.

Participant C in particular felt there was little point in
exercising as although he had previously been active, this
had not prevented him developing T1DM.

‘all of a sudden they get diabetes, and they say you’ve
got to have insulin, then they say you’ve got to exer-
cise to reduce your insulin. Well hang on, I’ve been
exercising all my life, and why have I got to end up
taking insulin?’ (Participant C)

barriers to exercise
Two main subthemes emerged, medical barriers and the
influence of healthcare practitioners (HCPs). In addi-
tion, individual barriers to increasing exercise mentioned
by participants were noted (table 3).

Medical barriers to exercise
Most medical factors were diabetes-related. Most
frequently cited was hypoglycaemia (nine participants).
For some, this related to actual experience of hypogly-
caemia during or after exercise, others were worried
about hypoglycaemia but had not yet experienced this.
Seven participants cited lack of knowledge or confidence
in managing diabetes around exercise. Four people
mentioned the need to plan for exercise with diabetes,
for example, checking blood glucose before and during
activity and preparing for hypoglycaemia, as a discour-
aging factor. Fatigue (which may be related to hypergly-
caemia) was cited by four people. Three people talked
about other aspects of physical health being a barrier to
exercise; all had experienced an injury.

Influence of healthcare practitioners
HCP advice could be either positive or negative. Four
participants said HCPs had advised them not to exercise.

‘They advised me to do no exercise basically at the
hospital until they felt like I could.’ (Participant B)

‘Because I was asking in the hospital, I kept going,
have you got a gym here? ‘oh, you’ve got diabetes,
you can’t be going to the gym’ and stuff like that.’
(Participant D)

Some participants (who were successfully exercising)
described how helpful and supportive (of exercise) they
had found HCPs.

‘I was a bit cautious, erm, about, erm, doing any-
thing to start [laughs] with, really, but I spoke to the
nurses and they were just, you know, within reason,
they just said, ‘Carry on your life as normal,’ really’
(Participant N)

‘because when I asked about the fact that I go run-
ning, ‘Yeah, that’s brilliant. That’s great,’’ (Participant
M)

5Kennedy A, et al. BMJ Open 2018;8:e017813. doi:10.1136/bmjopen-2017-017813

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However, one participant although generally posi-
tive about HCP support, did comment that this was not
routinely offered.

‘my team have been brilliant with me so far, and [ex-
ercise is] perhaps something I haven’t remembered
necessarily to ask when I’m there, but at the same
time I’m not sure it’s offered that freely.’ (Participant
N)

Several participants thought they had been given
conflicting advice about exercise and diabetes and felt
some HCPs were not well informed about T1DM. Partici-
pants found this frustrating.

‘because it seems like, you know, everybody seems to
have slightly different things to say about it, whoever
I ask.’ (Participant H)

‘I also have a problem though, that you’ve got doc-
tors in a hospital telling one thing to you, not the dia-
betic team, another doctor telling you you’re type 2.’
(Participant K)

Importantly, participants who reported doing most
activity (J, K and O) were among the group who had
had positive experiences. Conversely, participants who
reported doing no exercise at all (C, D, H) said they had
either been told not to exercise or received conflicting
advice.

Individual barriers to exercise
Twenty-one different barriers to increasing exercise
levels were mentioned (table 3), most commonly hypo-
glycaemia and work commitments (nine participants).
Barriers fell into four categories, either external (medical,
time, work and environment) or internal factors (social
and personal, psychological). Participants tended to cite
a variety of external factors, with only a few discussing
internal barriers.

Confidence in exercising and managing diabetes
Participants’ confidence both in their ability to perform
activities and manage their blood glucose around exercise
was a major factor influencing determination to increase
exercise levels.

When considering confidence, participants described
three areas: managing diabetes, exercising and managing
diabetes around exercise.

Some participants felt they had little control over their
diabetes or that something had knocked their confidence,
whereas others had developed or maintained confidence
in their ability to cope with blood glucose fluctuations.

‘because I’ve had this problem where everything has
gone a bit odd, for the last couple of weeks, I think it’s
set me back a bit and perhaps I want to be more con-
fident, I want to make sure I’ve got my background
insulin right’ (Participant K)

Table 3 Barriers to increasing exercise cited by participants

External Barrier (number of people mentioning barrier)

Medical Hypoglycaemia (both actual and fear of) (9)

Lack of knowledge/confidence in managing diabetes (6)

Fatigue (4)

Advice from healthcare professionals to stop exercising (4)

Planning for diabetes (eg, checking blood glucose/preparing for hypoglycaemia) (4)

Other physical health problems (eg, injuries) (3)

Feeling overwhelmed by diagnosis. (1)

Time, work and environmental Work commitments (9)

Family and other time commitments (6)

Availability and location of facilities (4)

Cost (4)

Weather/season (3)

Lifestyle (2)

Internal Social and personal Lack of fitness (3)

Lack of motivation (2)

Lack of enjoyment in certain activities (2)

Laziness (1)

Previous negative experience of exercise (1)

Psychological Feeling uncomfortable exercising (eg, at a gym) (2)

Feeling scared of exercising on own (2)

Feeling daunted at prospect of starting (2)

6 Kennedy A, et al. BMJ Open 2018;8:e017813. doi:10.1136/bmjopen-2017-017813

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I’m a lot more aware of being out on my- even just be-
ing out on my own, especially at the beginning, sort
of, if I was asked to babysit and I, kind of, went, ‘Oh,
are you sure you trust me? What if something hap-
pens to me?’ (Participant N)

Some participants lacked confidence in exercising
prior to diagnosis, others were not sure if there were any
special considerations due to their diagnosis.

‘I was never good [at exercise] at school’
(Participant M)

Other participants discussed their confidence in exer-
cising now they had been diagnosed with diabetes.

‘my confidence is, I at the moment, I’ve had a cou-
ple of sessions when I’ve been doing gardening
and I’ve said oh, my legs feel a bit wobbly. Then I
go and take a reading and then I’ve realised I’m like
3.5 reading, [right] and that worried me a little bit,’
(Participant K)

‘Now I’m just—I’ll get on with it like anything else
really, but I’ll just take in mind that it’s something
I need to think about when I’m preparing for a ses-
sion.’ (Participant E)

‘I’ve been given numbers to aim for at the start of
exercise, so check before you start and if it’s about
that then go ahead. If it’s a bit lower then have a little
snack of something. I’ve got quite a lot of informa-
tion about sport.’ (Participant O)

There was a wide spectrum of confidence levels, from
those for whom the anxiety around managing their
diabetes during activity prevented most physical activi-
ties (eg, participant C) to those who had confidence in
their ability to manage their blood glucose and concrete
plans to increase exercise levels (eg, participant N).
The biggest influences on participants’ determination
to improve activity levels were motivation and confi-
dence. Participants broadly fell into three groups: those
confidently building up their activity levels already or
who had concrete plans to do so (CONFIDENT), those
keen to increase exercise levels but inhibited by their
anxieties (mainly relating to diabetes management)
(CONCERNED) and those not particularly interested in
currently increasing activity levels (AMBIVALENT). Even
highly confident participants had concerns about some
aspects of diabetes management.

Several factors emerged that may contribute to an
individual’s confidence levels. The most important to
the majority was information regarding management
of diabetes around exercise. In addition, time since
diagnosis, experience (both prior experience of exer-
cise and experiences since diagnosis) and confidence
in and communication with HCPs were also important.
Many participants mentioned information and education
about blood glucose management during exercise in this
context.

While many participants felt they had received inad-
equate information about diabetes management
around exercise, some felt they had got all the informa-
tion needed and one felt they had more than enough
information.

Information people said they needed ranged from
which exercises were suitable for someone with diabetes
and which to avoid, to what to expect with blood sugars
during exercise, to information on the benefits of exer-
cise to people with T1DM.

‘Yeah I wasn’t aware, I thought that, as soon as I did
exercise it would happen immediately as well, that
my sugars would drop and then I’d go funny—so I’d
thought I’d be fine the first time I went to the gym …
and then a couple of hours later I’d had a hypo, as I
didn’t realise. Nobody told me that that would hap-
pen as well.’ (Participant B)

‘Erm so yeah, as I say, if I was better informed
about what exercise could do to blood sugar lev-
els, then maybe I’d have got back into it quicker.’
(Participant H)

‘I need more explanation of—into things, what you
can do and what you can’t do.’ (Participant C)

‘Educating them that they understand the benefits of
exercise; that maybe will encourage them to do it, re-
ally.’ (Participant M)

Prior experience of exercise and experiences of exer-
cise since T1DM diagnosis could either positively or nega-
tively impact on participants’ confidence. For example,
participants with previous positive experiences of exer-
cise (eg, D, E and N) were more confident than those
who had not (eg, M) and those who had experienced
problems with hypoglycaemia or performance since diag-
nosis (eg, B) were also less confident.

The participants’ relationship with their HCPs was
important, some getting a lot of support and informa-
tion (eg, N, O), others having negative experiences such
as being advised not to exercise (B, C, D), information
about activity and blood glucose management not being
forthcoming (B) and getting different messages about
diabetes from different HCPs (eg, generalist versus
specialist personnel) (K).

Several participants felt that information/knowledge
about how to manage diabetes during exercise was out
there but just not accessible.

‘Information. Because I mean Olympic athletes are
doing it, so they must have some kind of regulato-
ry system that they know about that helps you while
you’re exercising. I mean that would be helpful to
disseminate that information’ (Participant D)

‘I mean like yeah, if, if there was some like, you know,
stuff like perfect rule book for if you do X amount
of this type of exercise, you know, your blood sugar
might be changing by such amount, or something
like that.’ (Participant H)

7Kennedy A, et al. BMJ Open 2018;8:e017813. doi:10.1136/bmjopen-2017-017813

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suggestions to improve activity levels
Participants suggested a number of ways to improve
activity levels. A few felt they would not need further
encouragement or motivation as they had plans in place.
Ideas included additional education, supervised or group
activity sessions, a programme of gradually increasing
exercise, help with goal setting and a fitness advisor.
Although some participants mentioned cost as a potential
barrier, nobody felt assistance with this would be particu-
larly helpful.

educational material
Nearly all participants felt education about diabetes
management was vital in helping improve exercise levels.
Some felt they needed more than they had already been
given, while others felt they had all they required but this
had been important. Participants most confident about
increasing activity levels tended to be happier about the
information they had received.

‘some kind of health organisation to kind of bring
forward a website or pamphlet or whatever about
people who want to do sports with diabetes type 1 or
even diabetes type 2 now and how to deal with certain
things and prepare for them.’ (Participant E)

Some participants (eg, Participant F) felt overwhelmed
by the information they had already been given (although
this had not specifically included management of diabetes
during exercise), did not currently want further informa-
tion, but thought it might be useful in the future. Others
were happy with the timing of their education or would
have preferred more information sooner.

supervised or group exercise
Many participants suggested an exercise group, with
other patients with T1DM or supervised exercise sessions,
with staff with T1DM training. Having a trainer with
specific T1DM expertise was important to most, as several
participants had experienced ill-informed remarks from
members of the public, however, generally it was not felt
an HCP was necessary. One person suggested although
specific expertise in the trainer was desirable, if there was
easy access to advice from the healthcare team, it may
not be required. The proposal of group activity sessions
was not universally liked and was rejected by some, who
preferred exercising under their own steam.

‘My dad had a heart attack last year and he got help
from the hospital and the hospital gym and he was
monitored in a way that he could feel confident with
going and doing exercise and helping him—help his
heart and diabetics don’t get that.’ (Participant B)

Fitness advisor
Regular contact with a fitness advisor, particularly one
with T1DM knowledge, was suggested by some as a poten-
tial motivator to improve activity levels. Even participants
who were happy setting their own programme and targets

felt regular checks would not be unhelpful. Some partic-
ipants wanted specific advice on a training programme,
while others wanted the regular contact and reassurance
of someone with greater experience advising them. For
some participants, it was very important the advisor could
guide them on diabetes management as well as exercise
training.

‘So you could see a nurse at the hospital or see like
a fitness erm—fitness expert at a gym because then
you’re actually at the place you’re going to do it, and
you’re seeing everybody else doing it, so you might go
‘I’ll do it’. (Participant D)

gradual introduction of exercise
Advice on types of activities and how to build this up was
suggested as potentially helpful by some. Others, gener-
ally those with previous experience of exercising success-
fully, felt it was unnecessary. In addition, most welcomed
the idea of someone checking on their progress and
thought they would find this motivating.

‘I probably would want advice of how if they say I want
you to increase erm from 30 min walking to an hour
walking, or to doing abs in the gym from half an hour
to 30 min, yeah,’ (Participant K)

targets
On a similar note, in general, participants felt target
setting would motivate them to increase their exercise
particularly if there was a regular check on progress with
an advisor.

‘I find targets very helpful because I know then—I
know what I have to try and get to—I know I have to
try and [hmm] reach really. [yeah] It’s a bit of com-
petition as well.’ (Participant J)

Monitoring of exercise during a trial
Although most participants were not familiar with the use
of an accelerometer to monitor activity levels, no one felt
their use during a trial would be onerous. All participants
stated they would be happy to keep a diary of their activi-
ties and would use a heart rate monitor.

DIsCussIOn
This is the first qualitative interview study to examine atti-
tudes and barriers to exercise in patients newly diagnosed
with T1DM. We have identified five themes discussed by
patients when they are asked about exercise levels. These
are: existing attitudes to exercise; feelings about diag-
nosis; perceptions about the consequences of exercise;
barriers to increasing exercise; confidence in managing
blood glucose.

Around half of participants reported a decline in
activity levels around the time of diagnosis. This is an
important finding, as if it is true of the wider T1DM

8 Kennedy A, et al. BMJ Open 2018;8:e017813. doi:10.1136/bmjopen-2017-017813

Open Access

population and not addressed, patients may be less
willing to be active than the general population. It is
reassuring that participants wished to increase their
exercise levels as a way to improve their health after a
T1DM diagnosis. It is possible that following diagnosis,
patients are keen to improve their lifestyle, as is seen in
studies of cancer survivors,14 15 making use of the ‘teach-
able moment’.

In general, exercise was felt to positively impact on
health. Some participants were unsure of the benefits
or concerned they may harm themselves through exer-
cise. These concerns could be addressed by HCPs during
diabetes education.

Many of the barriers identified here have been previ-
ously identified in healthy people, as well those with other
chronic diseases including longstanding T1DM.7 16–21
However, our interviewees placed greater emphasis on
fear of hypoglycaemia than previous studies of patients
with longstanding T1DM.9 Furthermore, the finding that
some patients with diabetes are being advised not to exer-
cise by HCPs has not been previously identified in T1DM
qualitative studies and was cited by participants from
three different sites.

This study identifies a number of ways in which improve-
ment in exercise levels might be facilitated in patients
newly diagnosed with T1DM. In this group particularly,
it is critical that confidence in managing diabetes around
exercise is addressed. Some interventions identified in
this study that may improve confidence in patients newly
diagnosed with T1DM and facilitate improved exercise
levels were: consistent advice from HCPs; support from
diabetes teams for exercise; patient education and time
to adjust to diagnosis.

Participants were frustrated by receiving conflicting
advice and incorrect information from HCPs. They
expected them all to have a basic level of knowledge
about diabetes, and this expectation is not being met.

Those who were successfully exercising reported
getting strong support from their diabetes team. It is diffi-
cult to say whether this was the reason for their success or
whether because they were exercising they obtained the
information that they required. It was suggested knowl-
edge and support was not forthcoming unless brought
up by the patient. Diabetes teams should more positively
encourage exercise from diagnosis.

Lack of confidence in managing blood glucose levels
around exercise was attributed to a lack of information
by most people. Patient resources about blood glucose
management around exercise are scarce and although
several participants reported searching for these, only
one had actually been given any written information.
Information on the benefits of exercise in diabetes would
have been valued by a majority of study participants.
A number of participants talked about the number of
appointments they had to attend since diagnosis, the
fact they were constantly injecting insulin and checking
their blood sugar. Their priority was to ‘get their diabetes
right’ before adding more complexity into the mix. Some

patients need more time than others to adjust to their
illness.

strengths and weaknesses
This study describes the attitudes to exercise of patients
recently diagnosed with T1DM, the first qualitative inter-
view study to do so. Due to the fact that we only inter-
viewed them at one time point, we are unable to comment
on any causal associations between recent diabetes diag-
nosis and changes in exercise behaviours. Recruitment
was from multiple UK sites, covering both large teaching
and district general hospitals, and participants spanned
a wide age range. Numbers of participants in qualitative
studies vary widely and it is important that saturation of
the data is achieved, as it was in this study.

Due to slow recruitment, data were collected in
different ways (individual interviews, a focus group,
face-to-face and by telephone). Our results should be
interpreted with this in mind as participants may be more
forthcoming in some of these environments than others.
This may have affected individual responses, but could
also contribute to a greater breadth of data acquired.22

It is likely however that study participants were more
interested in exercise than those who declined, and
interest in exercise education and management of
diabetes around exercise may be lower in the general
clinic population. It is possible that patients in other
geographical areas and women (who were less well repre-
sented in this study) may have different views to those
reported here.

COnClusIOn/reCOMMenDAtIOns
Exercise should be encouraged (not discouraged) from
diagnosis, as possibly at this time, patients are more
amenable to lifestyle change. Advice, particularly on
managing insulin doses and carbohydrate intake around
exercise, needs to be available both to HCPs and patients
with T1DM so that we can help patients to develop confi-
dence managing their diabetes both generally and around
exercise. A consensus statement has been published on
exercise management in T1DM23 and based on these
guidelines we are developing an education programme
to guide insulin and carbohydrate adjustment for safe
exercise for HCP and patients with T1DM.24

Acknowledgements Nikki Jackson (University of Bristol), Dylan Thompson
and Keith Stokes (University of Bath), Mary Charlton (Queen Elizabeth Hospital,
Birmingham). Roger Holder and Sayeed Haque (University of Birmingham). We are
also grateful to Dr George Dowswell, University of Birmingham for the significant
contribution he made to this work, and who passed away in July 2016 – we are all
the lesser for this loss. We gratefully acknowledge the time and effort of patients
who have participated in this trial. We would like to thank staff and colleagues at
diabetes centres at the following hospitals for their help with the recruitment of
patients and with undertaking this study: Queen Elizabeth Hospital Birmingham,
Musgrove Park Hospital Taunton, Bristol Royal Infirmary, Southmead Hospital
Bristol, Gloucester, Yeovil, Queen Elizabeth II Hertfordshire, Pinderfields Yorkshire,
Churchill Oxford, Alexandra Redditch, George Eliot, Russells Hall, Walsall, New Cross
Wolverhampton, Heartlands Birmingham, City Birmingham, Weston General, Royal
United Bath, Royal Devon and Exeter.

9Kennedy A, et al. BMJ Open 2018;8:e017813. doi:10.1136/bmjopen-2017-017813

Open Access

Contributors The study was conceived and designed by PN, RCA, AD and SMG.
AK carried out the data collection and AK the analysis with support from PN. GD
and SMG. AK drafted the initial manuscript and all authors contributed to critically
revising further versions of the manuscript.

Funding This work was funded by the National Institute of Health Research grant
number PB-PG-0609-19093. SMG is part funded by the National Institute for Health
Research (NIHR) Collaboration for Leadership in Applied Health Research and Care
West Midlands (CLAHRC WM).

Disclaimer The views expressed are those of the authors and not necessarily
those of the NIHR, the NHS or theDepartment of Health.

Competing interests None declared.

Patient consent Not required.

ethics approval The study received ethical opinion approval from Birmingham,
East, North and Solihull Research Ethics committee in February 2010 (reference
number 10/H1206/4). The study was sponsored by the University of Birmingham.

Provenance and peer review Not commissioned; externally peer reviewed.

Data sharing statement The authors confirm that all data underlying the findings
are fully available without restriction. All relevant data are within the paper.

Open Access This is an Open Access article distributed in accordance with the
terms of the Creative Commons Attribution (CC BY 4.0) license, which permits
others to distribute, remix, adapt and build upon this work, for commercial use,
provided the original work is properly cited. See: http:// creativecommons. org/
licenses/ by/ 4. 0/

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unless otherwise expressly granted. This is an Open Access article
distributed in accordance with the terms of the Creative Commons Attribution

(CC BY 4.0) license, which permits others to distribute, remix, adapt and
build upon this work, for commercial use, provided the original work is

properly cited. See: http://creativecommons.org/licenses/by/4.0/
Notwithstanding the ProQuest Terms and Conditions, you may use this

content in accordance with the terms of the License.

Attitudes and barriers to exercise in adults with a recent diagnosis of type 1 diabetes: a qualitative study of participants in the Exercise for Type 1 Diabetes (EXTOD) study

Abstract
Methods
Recruitment
Interviews
Analysis
Results
Participants
Themes
Attitudes to and current and previous exercise behaviour
Impact of diagnosis and knowledge of diabetes
The consequences of exercise
Barriers to exercise
Medical barriers to exercise
Influence of healthcare practitioners
Individual barriers to exercise
Confidence in exercising and managing diabetes
Suggestions to improve activity levels
Educational material
Supervised or group exercise
Fitness advisor
Gradual introduction of exercise
Targets
Monitoring of exercise during a trial
Discussion
Strengths and weaknesses
Conclusion/recommendations
References

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