Attitudes of women in midlife to web-based interventions for promoting physical activity

Abstract

We explored the attitudes of women at midlife to web-based interventions for promoting physical activity. 145 women volunteered to participate in one of four online forums. The forums were for four major racial/ethnic groups. 90 volunteers were recruited for the online forums (29 Whites, 23 Hispanics, 21 African Americans, and 17 Asians). Two sets of topics on attitudes to physical activity and racial/ethnic contexts were used. Each topic had some introductory questions and related prompts, and these were posted on the online forum sites in a serial fashion during the six-month period. We used a thematic analysis. Four major themes emerged: (1) ‘a matter of the source of the information’; (2) ‘I can pace myself’; (3) ‘lack of interpersonal interactions’; and (4) ‘culture-specificity and low cost.’ The women in all ethnic groups thought that the source of the information was much more important than the medium of the information (e.g. web-based, booklet or face-to-face). They liked the self-controllability in web-based interventions. They preferred web-based interventions to other types of interventions because of easy accessibility, but they were concerned about lack of interpersonal interaction. None of the White or African American women indicated the need for culture-specificity in web-based interventions, but Hispanic and Asian women indicated that culture-specific interventions should be provided. Web-based interventions appear to have several advantages over conventional approaches to promoting physical activity.

Introduction

Many physical activity promotion interventions have been developed for people in midlife, but they have rarely succeeded in achieving their goals.¹ Web-based interventions have been reported to be more effective in delivering interventions than conventional interventions (e.g. printed literature about interventions or face-to-face interventions).^2,3 Despite some arguments about the pros and cons,^4,5 web-based interventions have been reported to be effective in increasing physical activity in women at midlife. However, little is known about the attitudes of these women to web-based interventions for promoting physical activity.

The purpose of the present study was to explore the attitude of women at midlife to web-based interventions for physical activity promotion among four major racial/ethnic groups in the US. The study was a secondary analysis of qualitative data from an Internet study on the attitude of women at midlife to physical activity.^6,7 A feminist perspective was taken and feminist assumptions were made. More information on the feminist perspective and assumptions can be found elsewhere.^6,7

Methods

The study was approved by the appropriate ethics committees. Through Internet communities/groups, 545 participants were recruited for the Internet survey (not reported here). Of these, 145 women volunteered to participate in one of the online forums.

The inclusion criteria were women aged 40–60 years: (a) who were ambulatory and able to participate in all forms of physical activity; (b) who could read and write English; (c) who had access to the Internet; and (d) whose self-reported ethnic identity was non-Hispanic (N-H) White, Hispanic, N-H African American or N-H Asian. Those who had high cardiovascular and musculoskeletal risk factors were excluded by using screening questions.⁸

A total of 119 (82%) of the volunteers were eligible. Of these, 90 were recruited for the online forums (29 Whites, 23 Hispanics, 21 African Americans, and 17 Asians). Table 1 summarizes their sociodemographic characteristics.

Table 1

Background characteristics of the participants

Characteristics		White	Hispanic	African American	Asian	Total
Number of subjects		29	23	21	17	90
Mean age, years (range)		49 (40–59)	49 (42–57)	51 (41–60)	49 (40–59)	49 (40–60)
Education, %	No college	4	13	5	12	8
	College	62	44	67	29	52
	Postgraduate	35	44	29	59	40
Employment, %	Yes	72	91	86	71	80
Employment, %	No	28	9	14	29	20
Family income*, %	Very hard	35	9	10	0	16
	Somewhat hard	28	30	48	53	38
	Not hard	38	61	43	47	47
Number of children, %	None	24	26	10	24	21
	1–2	45	61	67	59	57
	More than or equal to 3	31	13	24	18	22
Religion, %	Catholic	14	61	14	6	24
	Others^†	45	35	71	47	49
	No religion	41	4	14	47	27
Marital status, %	Married/partnered	76	57	52	88	68
Marital status, %	Non-married/separated	24	44	48	12	32
Country of birth, %	Born in the U.S.	93	83	100	24	79
Country of birth, %	Born outside the U.S.	7	17	0	77	21
Mean length of stay in the US^‡, years (SD)		44.0 (5.7)	27.8 (15.5)	−	19.5 (11.1)	23.9 (13.6)
Mean general health score^§ (SD)		3.8 (1.2)	3.7 (1.2)	4.0 (0.5)	3.9 (0.6)	3.8 (0.9)
Mean body mass index, kg/m² (SD)		29.3 (8.2)	29.2 (7.3)	30.4 (6.5)	23.5 (3.9)	28.4 (7.2)
Diagnosed diseases,**%	Yes	24	61	52	41	43
Diagnosed diseases,**%	No	76	39	48	59	57
Menopausal status, %	Premenopausal	10	13	10	18	12
	Early perimenopausal	45	44	24	35	38
	Late perimenopausal	4	0	10	6	4
	Postmenopausal	41	44	57	41	46

*Family income was measured with a question on how to pay for basics such as food, housing, clothing and heath care.

^†Others included Protestant, Buddhism and Muslim.

^‡Those born in the US were excluded in the calculation of the length of stay in the US.

^§General health score: 1 = very unhealthy to 5 = very healthy.

** Diagnosed diseases were any diagnosed diseases that the women self-reported, such as diabetes mellitus, hypertension, allergies.

Online forum topics

Two sets of topics on attitudes to physical activity and racial/ethnic contexts were used.⁷ Each topic had some introductory questions and related prompts, and these were posted on the online forum sites in a serial fashion during the six-month study period. For example, one of the topics was ‘women's preferences for physical activity promotion programs.’ The topic included nine prompts including “What do you think about the accuracy and authenticity of the resources and information available on the Internet, by phone, and as a booklet?”, “Because you are a woman, were (or are) the resources and information available on the Internet, by phone, or as a booklet, especially advantageous for you to use? What caused (or causes) the advantages?”, and “What would be the ideal physical activity promotion program for you?”

The women were provided with user IDs and passwords to log into the forums. The topics and related prompts were posted as new discussion threads in a serial manner throughout the online forum period. Whenever a new topic was posted (biweekly), the women were reminded through email messages. The women could then post their messages in any forms they wanted (e.g. stories, conversations, responses to others' messages). In the sixth month, the women were asked to post any additional topics that they wanted to discuss with other participants, but no topic was added.

Data analysis

We used a thematic analysis.⁹ Three researchers started the analysis using transcripts from the digital records of the discussions in the online forums and a coding book that was developed from the original Internet survey. They categorized the codes and extracted themes reflecting commonalities and differences in the women's attitudes to web-based interventions among racial/ethnic groups. The research team formulated relationships among the categories by mapping associative links among the categories using an interactive process that involved reading and re-reading text. The research team tried to produce more abstract and refined ideas about domains of interest. Themes were extracted through a series of discussions. To ensure the rigour of the analysis, we used the standards for rigour in feminist research.¹⁰

Results

Four major themes emerged from the data analysis: (1) ‘a matter of the source of the information’; (2) ‘I can pace myself’; (3) ‘lack of interpersonal interactions’; and (4) ‘culture-specificity and low cost.’

‘A matter of the source of the information’

In all the ethnic groups, the women agreed that web-based interventions would be useful for them. They regarded information through the Internet as very helpful and easily accessible, and 36 of them (40%) had previous experience in searching for information via the Internet. In all the ethnic groups, the women perceived that the medium for information (web-based, booklet or face-to-face) did not matter. Rather, the accuracy of information was important to them. In terms of obtaining new information, they preferred web-based interventions, especially from authoritative sources such as university hospitals or medical centres. They wanted security measures to protect their identities and ensure the authenticity of the information sources.

‘I can pace myself’

Twenty-nine women (32%) liked the easy accessibility of web-based interventions because they did not need to travel and they already had access to the Internet. Most of them, (26, 29%) preferred web-based interventions to face-to-face interventions. In all ethnic groups, the women liked the self-controllability that they could have in web-based interventions because they could make a selection of when, what and how they could approach the information that they needed and because they were not interrupted by others.

‘Lack of interpersonal interactions’

Although all the women liked to use web-based interventions for information, they were concerned about the lack of interpersonal interaction. They felt that interpersonal interactions were essential in motivating them to actually participate in physical activity, which could not be obtained through web-based interventions. When the women talked about their ideal physical activity promotion programmes, 27 women (30%) talked about the programmes that would involve interpersonal interactions with their neighbours, friends or professional trainers. The women believed that interpersonal interactions could motivate them to continue to do physical activity.

‘Culture-specificity and low cost’

When the women were asked about their ideal physical activity promotion programmes, the answers could be categorized into two sub-themes: (a) culture specificity and (b) low cost. White and African American women did not mention the need for web-based interventions to be culture-specific, but Asian and Hispanic women did so. White and African American women thought that web-based interventions could be universal and did not specify any cultural aspects that they wanted to be incorporated. However, two Hispanic women thought that web-based interventions should use Spanish and should be culture-specific. Also, Hispanic women mentioned culture-specific Hispanic role models that they could follow. Two Asian women thought that culture-specific information related to physical activity would be much more helpful than general information on physical activity.

In all the ethnic groups except Asian, the women also talked about low cost or free programmes for physical activity promotion regardless of the medium of the programme (web-based, booklets or face-to-face). Thirteen women (14%) mentioned that the high cost of existing programmes had been a barrier for them to participate, and that low cost or free programmes would definitely motivate them to participate in and continue to be active in physical activity promotion programmes regardless of the medium. Four women (4%) mentioned incentives and rewards that would be provided to them when they reached their goals.

Discussion

The beneficial aspects of web-based programmes reflected in the first three themes can be found in the literature. For example, web-based interventions provide easy access.^11,12 Self-controllability and no interruptions by others are also advantages, because the users can control learning-related factors (e.g. the content, time, location, speed and learning schedule) for themselves.^13–16 User convenience has been reported, because users can access the interventions at any time and they can freely express their feelings.^13,17,18 There is also convenience since web-based interventions provide less stressful communication environments because of anonymity.^17,19

The theme of ‘lack of interpersonal interactions’ also agrees with the literature on web-based promotion of physical activity. Bosak et al.²⁰ reported that maintaining contacts with their research participants was critical in the administration of their web-based intervention. Webb et al.²¹ also suggested the use of additional methods of communication (e.g. SMS, text messages, Skype) in web-based interventions to increase interpersonal interactions and promote health behaviours.

The ‘culture-specificity’ of the last theme has rarely been reported in studies comparing different ethnic groups, although it has been reported in specific ethnic groups.^22–24 Belza et al.²² suggested that physical activity programmes for ethnic minorities should provide culture-specific exercises; Martyn-Nemeth et al.²³ proposed that culturally focused strategies (e.g. dancing, walking, gardening, and family-oriented activities) should be incorporated into programmes for Hispanic populations; and Wilbur et al.²⁴ emphasized the importance of role models of physically active women in programmes for Hispanic women.

The ‘low cost’ of the last theme was also reported in one study,²⁴ which reported that the women wanted low-cost facilities and programmes that were specifically designed for women. However, this theme has rarely been reported in other studies. Rather, the literature emphasized the low cost involved in web-based interventions.^13,15 The benefits of web-based interventions include low cost due to avoided transportation, no need for papers and pencils, no need to store hard copies of intervention materials and no need to hire interventionists. Thus, further clarification of this theme as a component of ideal web-based physical activity promotion programmes is needed. Also, the reason that the ‘low cost’ theme was not found among Asian women needs to be determined. It might be a consequence of Asian cultural attitudes which avoid directly talking about money.²⁵

The present study was limited by the inclusion of women who were already using the Internet for a variety of purposes. Because of their previous usage of the Internet, they could be biased towards being positive about using it for physical activity promotion. Thus, the findings of this study need cautious interpretation. Despite this, there are implications for the future development of web-based programmes for physical activity promotion. First, interpersonal interactions should be incorporated into the future development of web-based programmes for physical activity promotion. For example, web-based programmes could include a chat group or discussion board so that the users can share their experiences and obtain support from other users. Also, regular group meetings in real community settings (e.g. quarterly meetings) could be incorporated into the activity promotion programmes. Finally, web-based programmes for promoting physical activity should consider language and culture specificity by providing versions in more than one language and by including culture-specific exercises, such as yoga or Tai-chi.

Footnotes

Acknowledgements

The original study that provided the data for the present analysis was funded by the National Institutes of Health (NIH/NINR/NHLBI, R01NR010568).

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