Exploration of Physical Activity Barriers and Facilitators Among Adults in Kathmandu,Nepal

Introduction

Physical activity (PA) refers to the bodily movement for occupational, household, transport, and leisure activities that results in energy expenditure and produces health benefits (World Health Organization [WHO], 2019). Physical inactivity is a significant public health concern causing a substantial health and economic burden worldwide (Pratt et al., 2020). Around one in four adults worldwide do not meet the WHO recommendation of at least 150 minutes of moderate PA or equivalent per week (WHO, 2019). The rising inactivity level will have implications for the future burden of chronic diseases, including type 2 diabetes, cardiovascular diseases, hypertension, obesity, and breast and colon cancers (Warburton & Bredin, 2016). Evidence also shows that inactive individuals have a higher risk of premature all-cause mortality compared with those who are active (Warburton & Bredin, 2016). Strong links between PA and positive mental health, functional independence, healthy aging, and quality of life have been well documented, providing further impetus to address inactivity (Guthold et al., 2018; Paterson & Warburton, 2010).

In Nepal, the prevalence of low PA (those not meeting the recommended 150 minutes per week of moderate PA or equivalent) among adults aged 15 to 69 years has more than doubled between 2013 and 2019, with an increase from 3.5% to 7.4% and a further sharper rise among women (Aryal et al., 2014; Dhimal et al., 2019; Nepal Health Research Council, 2019). In 2019, 6.6% of men and 8.2% of women had insufficient levels of PA (Dhimal et al., 2019). Furthermore, middle-aged adults (40–69 years) and those residing in urban municipalities were more likely to have low PA (Dhimal et al., 2019). Occupational and transport-related activities are the dominant PA forms among Nepalese adults, with minimal engagement in leisure-time PA (Aryal et al., 2014; Nepal Health Research Council, 2019).

A range of individual, interpersonal, and environmental factors interact to influence an individual’s engagement in PA (Bauman et al., 2012). Studies in diverse social and geographical contexts have reported factors such as cultural expectations, social responsibilities, awareness of the links between PA and health, neighborhood safety and aesthetics, built environment, and weather affect PA participation (Al-Hazzaa, 2018; Barnett et al., 2017; Medagama & Galgomuwa, 2018; Uddin et al., 2018). The extent of the impact of these factors might be different for males and females as some of the barriers, such as household responsibilities, disproportionately affect females (Koyanagi et al., 2018; Uddin et al., 2018). However, there has been little research to date concerning the major influences upon PA in Nepal. One quantitative study among people with type 2 diabetes found that factors such as family responsibilities, a busy schedule, and family discouragement act as deterrents to engagement in PA. In contrast, factors such as physical fitness, strength and flexibility, better sleep at night, social interaction, and longevity were identified as facilitators (Kadariya & Aro, 2018). Another study among mothers of young children in Nepal suggested lack of leisure time, family responsibilities, feeling lazy, absence of parks and playgrounds, and feeling embarrassed to be physically active in front of others were major barriers (Oli et al., 2018).

Multitiered interventions addressing age- and gender-related determinants of PA are recommended in low- and middle-income countries (LMICs; Koyanagi et al., 2018). Understanding the barriers and facilitators among different population segments is crucial for the effective design and implementation of strategies to promote the adoption and maintenance of PA. Furthermore, exploration of the influences upon PA for men and women provides an opportunity to understand the role of gender, and explore whether simultaneous interventions or gender-specific tailored interventions are required. However, studies providing this information among Nepalese adults are almost nonexistent. Given the increasing life expectancy in Nepal leading to the rise in the proportion of middle- and older aged adults in the population (Chalise, 2018), and the trend toward increasing physical inactivity among this age group (Aryal et al., 2014; Nepal Health Research Council, 2019), a focus on PA research and interventions among adults is critical. Hence, the objective of this study was to explore the perceived barriers and facilitators of PA participation, particularly occupational and transport-related PA, among Nepalese adults aged 40 years and above to inform PA policies and programs in this context.

Method

Results

Facilitators of PA Participation

During the focus groups, participants were asked to share the facilitating factors that boosted their PA participation. Most of the factors that participants referred to as “facilitators” related to the removal of barriers mentioned above. Besides these, a few factors were identified that enhanced participants’ engagement in PA such as health benefits, integration into domestic work, opportunities for social interaction, and social support, which are explained below. Table S3 summarizes the themes, subthemes, and relevant quotes related to the facilitators of PA participation (see Supplemental File 4).

Health benefits

Participants mentioned that the health benefits of being physically active motivated them. Those without a chronic condition seemed to be more attracted toward the immediate benefits of PA such as positive thinking, weight loss, and improved sleep and appetite rather than the long-term disease-prevention benefits.: “. . . if we are busy, we get tired, can sleep well and our appetite improves. We feel hungry, and even simple food tastes delicious.” For some of the female participants, PA was also essential to maintain their weight and prevent unhealthy snacking. A female participant stated,

I am not sure whether we will be protected from disease, but it helps in lowering our body weight and decrease our shortness of breath . . . Now, since I have started walking regularly, I have lost some weight and can walk a longer distance.

Another female added, “On days, when I take a nap in the afternoons, I tend to eat a lot, sometimes even junk foods, after waking up.” However, those who had already been diagnosed with chronic diseases and were prescribed exercise as part of their disease management plan were more conscious about being active regularly to prevent their health from further deterioration.

Integration into domestic work

Some of the participants indicated that they wanted to do the household and fieldwork manually to be physically active. A female participant questioned, “If we stop doing the household chores as well, what else will be doing”? However, some other female participants were not happy with the quality of output from home appliances, especially from washing machines: “They [washing machines] do not wash clothes properly; clothes will still have stains and also are quite harsh on the clothes.”

Opportunities for social interaction

Several participants indicated that they were motivated to be physically active because it provided opportunities to meet friends and helped to stay updated about social issues. A male participant said, “Compared to staying at home, if we walk around we get updated about social issues and sometimes could get some business as well [such as selling/buying land].” Another female participant added that walking up to the nearby park provided PA opportunities for elderly who otherwise are isolated at home and could not engage in other PA forms because of their physical limitations.

Social support

Some females indicated that encouragement and moral support from family members motivated them to undertake PA. One participant shared, “My family members will be happy if I am going for a walk. Sometimes when I complain about a headache, they relate this to the lack of exercise.” Peer support was important for both males and females. Participants shared that if they were with some friends, they were more likely to walk to the destination and even prolong their walk. Some participants also indicated that walking in groups or with friends also minimized the risks while walking in poorly lit and quiet neighborhoods.

The study results are conceptualized in line with the ecological model and depicted in Figure 1.

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Figure 1.

Conceptualization of barriers and facilitators of PA in Nepal “grounded” in the ecological model.

Discussion

In this study, we explored the multilevel influences on PA participation, including occupational and transport-related domains, among Nepalese adults. It adds to our understanding of the multiple individual, interpersonal, and broader environmental factors that interact to shape the PA behavior of adults in a low-income country undergoing demographic, socioeconomic, and epidemiological transitions. Furthermore, this study contributes to the scarce qualitative literature on barriers and facilitators of different domains of PA among nonimmigrant South Asians.

Most study participants reported being adequately active, although those with chronic diseases were more conscious about staying active. A Nepalese study has shown that almost half of the people with type 2 diabetes had only started PA after recommendation from their doctor upon diagnosis (Kadariya & Aro, 2018). A study from India has also found that those suffering from chronic diseases were more likely to be physically active than those who are not (Chandra & Nongkynrih, 2019). This appeared to be because PA was a part of their treatment and rehabilitation, and they were worried about an adverse prognosis caused by sedentariness. A previous systematic review of qualitative studies among migrant South Asians has indicated that primary prevention was often compromised as participants were less likely to visit a clinician unless they were sick (Horne & Tierney, 2012) and not everyone diagnosed with a chronic disease followed the doctor’s advice on PA (Little et al., 2017). Considering that lack of knowledge often limited PA participation, awareness raising using different mass media platforms will be vital; however, further research will be required to identify the most effective communication method.

Among participants, PA was mostly the result of routine activities or because there was no other alternative. Consistent with a previous Nepalese study (Kadariya & Aro, 2018; Paudel et al., 2020), women were primarily involved in household activities, whereas active commuting was the dominant form of PA for men. However, women with chronic diseases participated more frequently in other nondomestic forms of PA compared with those without these diseases.

Traditionally defined gender roles played a crucial part in shaping participants’ engagement in PA, particularly occupational PA. The burden of household and family responsibilities was a key barrier for women. They reported being exhausted with household chores, and either considered that they did not need to engage in other PA forms or were too short of time to undertake other PAs outside the home. Although younger men seemed to support female household members, older men were reluctant. This finding is consistent with previous studies from Nepal (Kadariya & Aro, 2018; Oli et al., 2018), South Asia (Medagama & Galgomuwa, 2018; Morrison et al., 2019), Saudi Arabia (Al-Hazzaa, 2018), and migrant Indians (Ramanathan & Crocker, 2009), which have reported gender norms, cultural expectations, and family responsibilities limited women’s PA participation. The patriarchal setting in many South Asian communities seldom allocates decision-making power to women (Herath, 2015). According to the 2016 Nepal Demographic and Health Survey (NDHS), around 42% of women do not participate in making decisions regarding their health care (Ministry of Health Nepal et al., 2017). This lack of decision-making power often leads to the distribution of non–income-generating activities such as household work to women, which reduces time to attend to their own well-being (Herath, 2015; Medagama & Galgomuwa, 2018; Patel et al., 2012). Furthermore, because South Asian women do not usually socialize outdoors during their youth, they find it harder to undertake outdoor PA during adulthood (Horne & Tierney, 2012). Nevertheless, women living with chronic conditions reported the need to engage in other forms of PA to get adequate health benefits.

Support from family members in sharing the household workload along with encouragement and moral support were instrumental in ensuring women initiate and sustain PA. Family support has been consistently reported as a facilitator for PA participation in multiple contexts (Mailey et al., 2014; Smith et al., 2017). A study by Ghimire (2017) has highlighted the crucial role of children and spouses in ensuring compliance to exercise among people with type 2 diabetes in Nepal. Another study among South Asian immigrants has emphasized the importance of sharing household responsibilities so that females get time for themselves (Rathanaswami et al., 2016), and our study supports this. Future interventions might consider involving family members and providing opportunities for being physically active with the family. A previous qualitative study has also shown that South Asians prefer family-based PA, and having a partner interested and participating in PA can act as a motivator (Gupta et al., 2017). This not only would enhance awareness about the importance of PA in the family but also could be valuable in addressing the traditional gender roles and ensuring women are well supported and feel safe.

The findings also suggest that participants were concerned about the decreasing trend of active commuting, and the probability of a further decline. They attributed this mainly to increased ownership of private vehicles such as cars and motorcycles, which mostly was independent of their economic status because of the availability of financing options. Motorcycles constitute 78.6% of total registered vehicles in Nepal, and the rate of motorcycle ownership has almost doubled between 2014 and 2018 (Ministry of Finance, 2019). It was primarily male participants in the study who owned these vehicles, and this finding is reflective of this age group across the country based on our observation. Men who were engaged in formal employment also reported that strict working hours and lengthy travel times made them exhausted, and there was no time for engaging in PA, in line with a previous study from Bangladesh (Mailey et al., 2014). Workplace PA interventions might be valuable to address decreasing PA and increasing sedentariness among those employed in desk-based roles.

Consistent with other LMICs (Nantulya & Reich, 2002), higher traffic congestion and poor road conditions increased road traffic accidents, making pedestrians more vulnerable. Lack of dedicated cycling or walking routes and inadequate streetlights further increased perceived risk and discouraged PA participation. Safety is a crucial factor that positively influences adults’ PA participation (Barnett et al., 2017). Our study findings are congruent with a previous review (Salvo et al., 2018) and a U.K.-based study among low-income families in an urban, deprived, multicultural community (Cronin-de-Chavez et al., 2019) that found that participants appreciated basic amenities such as resting areas, public restrooms, and drinking water facilities, and that these factors enabled PA. Older people and those with chronic diseases more frequently reported these barriers. In line with these studies (Cronin-de-Chavez et al., 2019; Salvo et al., 2018), our study also highlights the need for collaboration between health and other sectors such as planning, urban design, and transport to create built environments that support sustained PA.

Another barrier that was identified was the lack of support for PA at the community level, which was reflected in a social norm that PA outside of routine activities was uncommon and of low acceptability. Participants expressed concerns that they were likely to be the topic of gossip if they walked when there is the option of taking public or private vehicles. Consistent with our study, lack of social support has been reported as a barrier in studies from Saudi Arabia (Al-Hazzaa, 2018), Sri Lanka (Medagama & Galgomuwa, 2018), and Nepal (Ghimire, 2017; Kadariya & Aro, 2018). A qualitative study among people with diabetes in India has also found that participants were worried about being labeled “abnormal” when engaging in PA (Little et al., 2017). However, peer support was instrumental in promoting PA for both males and females, consistent with the studies among the Afro Caribbean populations (Alvarado et al., 2015) and South Asians (Horne & Tierney, 2012). Participants were more likely to commute actively and walk a longer distance if they were walking with friends. Another Nepalese study has shown that participants felt motivated and preferred going for a walk or engaging in other forms of PA with their peers (Kadariya & Aro, 2018). This highlights the importance of family, peer, and social support for promoting PA. Behavioral and social interventions such as buddy systems and walking groups may offer promise for social support (Heath et al., 2012). However, further research is needed to identify effective ways of generating these types of support among Nepalese adults. It should be noted that the telecommunication environment of Nepal has experienced rapid change in recent years. The COVID-19 pandemic may have also substantially changed how Nepali users of social media and internet-enabled devices access public health information, and the opportunities to obtain informational and other forms of support through these channels.

Almost all the participants mentioned that buildings had replaced agricultural land and open spaces, and national data show a decline in those involved in agriculture from 55% in 2011 to 51.5% in 2016. In the same period, engagement in professional/technical/managerial work has increased by 2% (Ministry of Health Nepal et al., 2017). Those who owned small pieces of land had either leased these to others or were adopting motorized agricultural equipment such as tractors. Not only farm work, but also household activities such as cleaning and washing clothes were becoming mechanized. Some of the women in this study considered that this eased their workload. In contrast, others preferred to do this work manually, either because they wanted to be physically active or were not happy with the quality of mechanized household work. This opportunity to integrate PA with domestic work provided a strong motive for participants, especially women, which has also been suggested in previous studies (Boutevillain et al., 2017).

PA participation differed across the seasons. Although females and those with cattle reported their workload remained constant throughout the year, farm work was seasonal. The study highlighted that walking was severely affected during the rainy season because of muddy conditions and potholes on the road. This was particularly relevant in the regions with unsealed roads. A Sri Lankan study (Medagama & Galgomuwa, 2018) has also reported that puddles, uneven roads and pavements, and being chased by unrestrained animals (e.g., stray dogs) limited PA participation. Another study from Bangladesh has reported that women feared falling over on muddy roads and uneven paths and the resultant embarrassment, which in turn discouraged PA participation (Morrison et al., 2019). This further reinforces the need for multisectoral collaboration in ensuring PA-friendly built environment.

Awareness and experience of the physical and mental health benefits of PA, as well as opportunities for social interaction, were given as motives for prioritizing PA, in line with previous studies from Nepal (Kadariya & Aro, 2018) and elsewhere (Cronin-de-Chavez et al., 2019; Horne & Tierney, 2012; Rathanaswami et al., 2016; Salvo et al., 2018; Wallace et al., 2016). Our study also highlighted that participants were more attracted to the shorter-term health impacts of PA, such as improved appetite and sleep and weight loss, rather than the longer-term gains, such as disease prevention. Getting better sleep at night, decreased fatigue, and increase mental alertness were found to be key motivators for being physically active in a previous study among people with type 2 diabetes from Nepal (Kadariya & Aro, 2018). Likewise, a qualitative study among Afro Caribbean women has also reported that the PA benefit of weight loss was more attractive than long-term health effects (Alvarado et al., 2015). This suggests that it might be necessary for future interventions to highlight both the short- and long-term benefits of PA participation.

Consistent with the ecological model (Bauman et al., 2012; Sallis et al., 2015), our study results indicated that PA behavior was shaped by the interaction within and between the determinants identified at the individual, interpersonal, and environmental levels. Among women, an example is an interaction between perceptions of already being active (individual level), household responsibilities (interpersonal level), and mechanization of household activities (environmental level). Interaction between these factors then hindered participation in PA. Furthermore, the elderly and those with chronic disease (personal limitations at individual level) were more likely to report lack of resting areas (environmental level) as a barrier. This reinforces that multisectoral and multitiered strategies are core to effective PA promotion.

Conclusion

Applying an ecological framework, this study revealed how individual, interpersonal, and environmental factors are influencing PA participation among middle-aged adults in Nepal, who represent a high-risk group for chronic diseases. PA was found to primarily constitute routine household and transport-related activities, which were determined by the circumstances and the environment participants lived in. The study suggested the critical impacts that gender relations, economic development, technological change, the quality of the built environment, and community norms have upon PA in this context. PA promotion interventions focusing upon families and highlighting both the short- and long-term benefits represent an opportunity to facilitate the adoption and maintenance of behavior change and to ensure women are better supported. Community-based interventions will be essential to establish PA as a normative behavior. Beyond the level of the individual, engagement of policy makers responsible for infrastructure such as roads, urban design, and transport in design and implementation of structural interventions is vital.

Supplemental Material