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Research Reports |
E Swärdh, PT, MSc, is a PhD student, Division of Physiotherapy, Department of Neurobiology, Care Sciences and Society, Karolinska Institutet, 23100, SE-141 83 Huddinge, Sweden, and Physical Therapist, Department of Physiotherapy, Karolinska University Hospital, Stockholm, Sweden
G Biguet, PT, MSc, is a PhD student and University Lecturer, Division of Physiotherapy, Department of Neurobiology, Care Sciences and Society, Karolinska Institutet
CH Opava, PT, PhD, is Professor, Division of Physiotherapy, Department of Neurobiology, Care Sciences and Society, Karolinska Institutet, and Department of Rheumatology, Karolinska University Hospital
Address all correspondence to Ms Swärdh at: emma.swardh{at}ki.se
Submitted June 20, 2007;
Accepted May 21, 2008
 | Abstract |
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Participants: Fourteen women and 4 men with RA of at least 2 years’ duration, selected from 4 hospitals or primary health care physical therapy clinics, participated. They had exercised regularly at least twice weekly during the previous 2 months with various levels of support from a physical therapist, and they had attempted to exercise without support outside of the health care environment during the previous year.
Method: A phenomenographic approach was used to analyze semistructured interviews. A pattern of categories of descriptions was constructed based on the participants’ conceptions and ways of understanding the phenomenon of exercise maintenance.
Results: Five categories were identified: "external control," "sticks and carrots," "a joint venture," "the easy way," and "on one's own terms." The categories became clear by elucidating 2 aspects related to exercise maintenance: (1) the way the participants talked about and experienced the type of support needed and (2) personal factors.
Discussion and Conclusion: The results highlight the importance of finding the proper context and support for each patient's needs. Furthermore, preparing for exercise maintenance by strengthening the patient's beliefs in his or her ability to exercise in different settings, by discussing pros and cons of exercise, and by exploiting the patient's ability to adapt and continue exercise outside of the health care environment might be valuable.
| Introduction |
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The term "health behavior" refers to actions of individuals and groups, personal attributes (eg, beliefs, expectations, and values), and personality characteristics and habits that relate to health.14 Exercise is a complex health behavior. Physical therapists thus need to recognize and understand that no single factor explains exercise behavior, but that different combinations of factors are influential in different ways and at different times. Some critical factors highlighted in reviews on exercise behavior in young adults, older adults, and patients with arthritis are the role of the health care providers,15 patients’ attitudes,16 past exercise participation,17 and perceived benefits.18 Additional factors that might be helpful to identify are social support,19 self-efficacy,20 and perceived health.21
Many individuals drop out of exercise programs,22 and it has been suggested that those who successfully change behavior do not necessarily maintain the new behavior.23 Considering this, it is emphasized that behavioral maintenance strategies for physical activity may differ from strategies for adoption.24–26 Research on different population subgroups such as patients with fibromyalgia,27 patients with coronary heart disease,28 and women who are healthy29 indicates that stress, pain, disability, social support, self-efficacy and lack of time are associated with physical activity maintenance. It has been suggested that maintenance should be understood from a combination of psychological, social-environmental, demographic, physiologic, health status, and physical activity variables,29 but little is yet known about exercise maintenance in patients with RA.
Previous research on physical activity and exercise has been based mainly on assumptions related to work physiology. However, during the past decade, the importance of integrating theory from other fields30 has received greater focus. Several behavioral theories and models have been used to understand factors associated with behavioral change such as physical activity and exercise.31 It may be questioned, however, whether these generic models are sufficient and whether they contain the correct combinations of factors determining physical activity and exercise behavior in people with a disability such as RA.32 More basic empirical behavioral research, using both deductive and inductive procedures, has been recommended to increase our understanding of why people do or do not engage in physical activity and exercise.30
To improve health care and to develop any discipline, it is crucial to identify different ways in which individuals understand and experience phenomena.33 Qualitative methods may offer such in-depth insights into individuals’ experience and perceptions.34,35 Some studies using qualitative methods have focused on acceptability of and motivation to exercise,36 adherence factors,37 and overcoming obstacles to behavior change38 in relation to physical activity and exercise in different chronic diseases. However, qualitative studies of perspectives of patients with RA on physical activity and exercise are still scarce and have focused on attitudes to physical activity,39 factors perceived to influence exercise,40 and perceptions related to physical activity in everyday life.41 Furthermore, to our knowledge, no qualitative study has focused specifically on the phenomenon of "exercise maintenance" in patients with RA, with "exercise" defined as planned and structured activities performed at least twice a week and for 30 minutes at a time among those who need to continue ongoing exercise. In the present study, "maintenance" was pragmatically conceptualized as a general term for continuing regular exercise behavior. The aim of this study, therefore, was to explore and describe ways of understanding exercise maintenance among individuals with RA who have already started to exercise.
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Understanding and experience as conceptions were the focus of interest in the present study. A conception is the basic unit of description and is generally accessed through language.43 Conceptions are "the by-products of our thoughts, education, experience, culture, history, and the ideals and values that society insists on."33(p219) Furthermore, conceptions are considered fundamental to the way in which people act, form beliefs, and experience phenomena such as exercise maintenance and the way in which people explain to themselves and others (eg, physical therapists, other health care professionals) what goes on around them.33
Descriptions of the differences and similarities in understanding a phenomenon such as exercise maintenance are central to the phenomenographic approach and create a rich understanding of the actual phenomenon.33,43 Categories of descriptions are used to characterize people's conceptions and are formed to explore the data in terms of the ability to explain the full range of variations.33 The purpose of the categories is to reach a summary expression of the content as close to the data as possible.43 However, these categories are not descriptions of the experience itself and often are based on ways of understanding expressed in more than one interview. Furthermore, categories of description are mutually exclusive, and, because issues of frequency and distribution are not regarded as relevant to the aim of phenomenography, it is not considered appropriate to provide the number of participants in each category of description.
Each category of description is part of the "outcome space."44 The outcome space is an empirical map and a structural relationship of the qualitatively different ways in which people can experience and understand this phenomenon.33 Defining this relationship can be a step in a phenomenographic analysis. This map is presented as a hypothetical outcome developed from the researchers’ analysis and interpretation of the collective understanding among individuals with RA at this particular point in time. In the present study, the outcome space was a representation of exercise maintenance, just as the categories of descriptions are representative of conceptions. The structure of the outcome space often can be hierarchical, but it does not always need to take this form.44 The final outcome space in the present study, therefore, reflected both the data and the researchers’ judgment in interpreting the data.
Phenomenography should not be confused with phenomenology, even though they both aim to reveal human experience and awareness as an object of research. While both traditions seek to describe the world as people experience and explain it, phenomenography is less interested in individual experience than it is in emphasizing collective meaning.33 Where the phenomenologist describes how things really are according to a first-order perspective, in phenomenography researchers describe peoples’ experiences and understanding, through the eyes of another, by stepping back from their own experience and observing from the outside to get a second-order perspective.43 Furthermore, the phenomenographic approach aims to explore the range of meanings within a sample group, and this means that data from one participant cannot be understood in isolation from data from other participants.44
Participants
Criteria for inclusion in the study were: age above 18 years, a diagnosis of RA45 confirmed at least 2 years previously, ongoing physical therapy intervention, and performance of planned regular exercise during the previous 2 months. Experience of regular exercise with support from a physical therapist as well as attempts to perform regular exercise without support, outside of the health care environment, during the past year also were required. In addition, the participants should not have had obvious difficulties with the Swedish language. Fulfillment of the exercise criteria was determined by each participant's physical therapist and confirmed by the interviewer (ES) before the interviews were carried out.
To ensure a wide variety of conceptions by capturing as many aspects as possible of the phenomenon under study, patients fulfilling the above criteria were chosen purposefully46 from 4 hospitals or primary health care physical therapy clinics. The participants represented both sexes, different ages, and a variation in disease duration, estimated activity limitations according to the Health Assessment Questionnaire,47 occupational and family status, and exercise frequency as well as experience of exercise in different settings within and outside of the health care environment (Table). The sample was chosen for heterogeneity rather than for representativity in terms of distribution along demographic lines. The participant sampling and data collection through interviews continued until no new aspects of the phenomenon under study emerged and the data were replaced only by new data with the same meaning. Satisfactory variation seemed to be achieved with the inclusion of 18 participants. All participants gave written informed consent before participating.
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Two of the researchers (ES, GB) discussed and compared the emerging categories of descriptions several times with the content of the original interviews. Several revisions were made before the researchers came to a consensus on the final categories of descriptions. The essence of the similarities in conceptions within each category of description was described. Representative quotes from the interviews, translated from Swedish to English by a professional translator, were chosen to illuminate the main content of the final categories of descriptions. Finally, the structural relationship of the categories of descriptions—the outcome space—was established,25 interpreted, and reflected upon by the researchers.
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Well, she (the physical therapist) knows what movements we should be doing ... she can see we do it right. (Participant 13)It's the fact that she does it with us that makes you try your hardest. She really has her beady eyes on us! (Participant 5)
It's security, that you can always ask, or that she (the physical therapist) can see some improvement, too, hopefully. (Participant 12)
You'll be informed and guided, so you perform the things right. Well, it's the competence; you have to trust them, so to speak. (Participant 16)
Usually, no great effort is made to continue regular exercise independently after the time-limited period of supervised exercise in the clinical setting. Home exercise programs exist, but they are not performed regularly and are seen as rather boring and difficult to prioritize.
Problem is, I'm kind of terrifically undisciplined at home. So you decide to take time and do it, but something always comes in between. (Participant 5)To be honest, I'm rather careless about it. The rubber strap hangs on the stair rail ... it's just a matter of getting down to it ... you forget. (Participant 13)
It's just the motivation. There's always a heap of things to do instead of this. (Participant 16)
To get external support, it is necessary to wait for the next supervised and organized exercise period unless symptoms increase, which then calls for an earlier appointment with a physical therapist.
Now, I'll have to sit and wait till I get worse so I can start training again. See, you have to wait till you're worse and so on, and if you get better, you have to have a new referral. This is how it'll be, back and forth like this. (Participant 5)Then she (the physical therapist) urged me to start training again on my own at a gym ... but I thought, they don't think I'll go. Her hope of getting me transferred to some gym, it didn't work. There's some kind of resistance in me. (Participant 12)
Sticks and Carrots
Support and guidance facilitate exercise maintenance, but they demand relating to organizational aspects of exercise sessions, such as making agreements, and are perceived as being of even greater importance. Even the risk of being discharged from the exercise group and having it replaced with "exercise homework" can be experienced as positive demands for exercise behavior.
That you have someone to motivate you ... "makes this, no ... you have to" ... or "you have a place in this group, but you can also be dismissed." (Participant 4)I think it'd be enough if the physical therapist told me, "Do this at home for next time." I'd do it, because then I'd have gotten it as homework. (Participant 9)
It's better that there are demands, you're forced...that's how it is for me ... you've fixed a time—that's when it works. (Participant 4)
The physical therapist's role is to encourage and motivate during the exercise sessions as well as to instruct and observe, and to adjust the exercise content in order to prevent injuries.
I reckon if you're in pain, they can see this, they give tips and guidance, do this instead, you can do it like this, or they see if you're in difficulties. (Participant 11)Just this help, that you've got someone who says, "Now you've done this," and you move on ... you need encouragement. (Participant 9)
To meet other people with rheumatic diseases and support each other is one reason for preferring exercise in clinical settings. A feeling of solidarity with others and discussions on disease-related issues also support a regular exercise behavior.
Perhaps it's because you depend on being together in a group for it to work ... this is my contact with other young rheumatics ... well, we have the disease in common. (Participant 4)To meet people with the same kind of problem ... there, you get an understanding. (Participant 11)
Although other types of exercise outside of the health care environment are known, giving up exercise with support from the physical therapist is not an option. This is mainly because of lack of confidence and insecurity in personal ability to find appropriate exercise or to adjust the actual type of exercise.
I work myself up or think that this is going to hurt ... but I suppose there are also versions that are a bit gentler, that you can begin with. (Participant 4)It's tremendously difficult to find groups that are at the level you can manage. You get nervous and think it's tough. How am I to train now? How can I fix it? Am I going to be able to come back? (Participant 11)
A Joint Venture
Exercise maintenance calls for inspiration regarding exercise variation and shared responsibility for the heavy burdens of the disease and self-management. Thus, exercise maintenance without support is not a matter of course, as support is a self-evident part of a joint venture. The physical therapist is always a part of the total "exercise package," including several exercise options and the framing of individualized exercise programs and follow-ups. Collaboration is perceived as essential.
You have to ... vary this training, not just do it at home ... somehow, you need this psychological push from outside from time to time. (Participant 3)You simply have to change surroundings, to get away to a different environment even if you're perhaps doing the same thing. (Participant 3)
If you don't get a recall appointment ... then you fall behind ... we need a stimulus ... I think we all felt that way ... so I usually say that you should save one of those appointments for a follow-up. (Participant 6)
Training on your own or with a physical therapist is not an alternative—I usually do both, anyway. (Participant 3)
Giving movement guidance and updating exercise programs also are important aspects of the physical therapist's role. The therapist often can step aside after a while, when the program has been learned. The therapist then assumes the role of motivator and coach.
The physical therapist doesn't need to be so wildly active once you've got your program, but is available and gives feedback to you when you've been at it for a time. (Participant 18)
Exercise led by physical therapists is experienced as more intensive: there is an urge to push oneself harder than when exercising alone. When a clinical period is ended, remaining needs and a feeling of being let down or of being thrown out may be perceived. Despite beliefs in the ability to perform different types of exercise in different contexts—and despite the knowledge, skills, and responsibility needed for doing so—backup and support from the therapist are still needed, and quitting is not voluntary.
Well, sometimes, it's just that I have to make time and do it, it's the knife at your own throat, you have to have that. I've actually also thought of ... in the long run ... reserving time in my diary, then I have that hour to do it at home, so to speak, then it becomes more directed. (Participant 18)All the time, you have to say "now I must." I mean, be smart on one's own... . It makes a massive demand on you, and you feel your surroundings are making demands. (Participant 6)
Actually, the demands you must make are on yourself ... knowing that this is useful and the experience of learning when you've done it are a satisfaction. (Participant 17)
You have to schedule it, and you have to stick to the time. You have to do it just when you've planned to and not put it off at all. (Participant 3)
I have my responsibility but I must be able to get guidance, coaching, or whatever you want to call it. (Participant 6)
The Easy Way
Even though all types of regular exercise could be managed without support from a physical therapist, from time to time there is a desire to enjoy support. The physical therapist can help establish exercise habits and is perceived as a provider of incentives in the form of exercise options and convenience.
It's much easier if I'm coached by a physical therapist ... it seems more fun somehow to have someone who's in charge a bit. (Participant 13)It's quite nice to have somewhere to go. (Participant 14)
You get spurred on, a bit pushed, and you can't cheat either then, as you perhaps do unconsciously otherwise. (Participant 13)
Beliefs in the ability to carry out regular exercise in most contexts, as well as to adapt the level to the course of the disease, are present.
Well, of course, it's great to get instructions from the physical therapist, who knows the way the joints work and how the body works and what's right and that you receive directions. And once you've got those and have learned them, then you can perform the program by yourself—it's not exactly necessary that you have a physical therapist once you've learned a program. Then, you do it the way it feels fun, feels comfortable. (Participant 7)
When an exercise period in a clinical setting ends, it is natural to keep on exercising. There is enough confidence to continue outside of clinical settings and to concentrate on exercise maintenance. Even though exercise without support is expressed as sufficient, the option of support from a physical therapist is perceived as convenient, pleasant, and positive, and it will not be rejected if offered.
When you've gotten going, you know what to do, so it works fine, anyway. (Participant 7)One's become so brainwashed about managing on one's own. So I was quite clear that I would continue managing on my own. (Participant 13)
It's kind of nice to have someone who tells you (to continue regular exercise) ... I think it's nice at the start, but then I think, you can manage it, once you have found out the way you should do it. Then, you have to keep going and, really, no one but you yourself can do that. (Participant 14).
On One's Own Terms
In this category, lack of opportunities to influence organized exercise (eg, scheduling and type) is pointed out as a barrier to exercise in clinical settings, even though the physical therapist is sometimes seen as helpful in creating and updating exercise programs and encouraging a person to continue regular exercise.
Yes, well, it's first and foremost time pressure. I can train at home as long as anything and take breaks when I want to ... you can't do that when you've got an appointment with a physical therapist. (Participant 8)Yes, often you've fixed a program, and then you follow this, and then she stands there and makes sure you're doing it right, gives tips ... she answers questions. (Participant 8)
A common idea is that knowing how to match the exercise to the course of the disease enhances belief in one's ability to perform, especially home-based and community-based exercise.
Well, it wasn't that hard to continue, for you'd learned a good deal of the program ... then, mainly you could probably change things here and there, adapt. (Participant 10)Freedom, I can feel myself how my strength is giving out or my body's saying "no." The physical therapist can't know this so exactly. (Participant 10)
An important facilitator of positive exercise behavior is a feeling of being independent and not being a burden on health care.
There are people that need help, but then there are others that don't need as much help ... they can try on their own without the feeling of being thrown out. You've got to be glad you can manage and are not ill ... that you can be inspired by it, that, actually, I wasn't so ill that I needed medical care—no, I can manage on my own. (Participant 8)
A strong feeling of autonomy, that is, not having external demands or pressure on exercise habits and living routines, is essential for the participants. On the contrary, they want to find their own ways and habits because independence is essential.
I'm not one to have everything cut and dried... . I don't like being threatened to do something. It doesn't give you the same result. (Participant 10)
| Discussion |
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The preferred type of support (eg, control, guidance, and collaboration) was an important aspect of various ways of understanding exercise maintenance. This finding is consistent with other studies where social support constituted a powerful factor for,49,50 and a predictor of, exercise behavior.19,20 Support from the physical therapist seemed to be particularly important in the categories "external control," "sticks and carrots," and "a joint venture." Although the differences among them might seem slightly indistinct regarding the preferred type of support, the category "external control" might be characterized by "handing over" oneself and the responsibility for exercise to health care. In contrast, the category "sticks and carrots" could illustrate the notion of gaining positive benefits in guidance and demands from the physical therapist together with extensive social support from other group members.
It is interesting that the sense of being personally involved and responsible evident in the category "a joint venture" did not exclude a need for support from the physical therapist (eg, through shared responsibility). Individuals receiving social, physical, or physiological cues for their behavior—which generate positive consequences—are likely to repeat the behavior under the same or closely related conditions.51 This might be the reason why reinforcement from the physical therapist was so important in these 3 categories, which were generated by conceptions from patients accustomed to supervised exercise.
The specific need for shared responsibility, collaboration, and inspiration, as in the category "a joint venture," is supported by previous research that identified collaboration as an important aspect of physical therapy.52 Regular contact during the maintenance phase and feedback sessions after several months are important for physical activity behavior.19,25 Other types of preferred support, such as counseling in the category "the easy way" and minor advice in the category "on one's own terms," are in line with other studies suggesting that advice from health care professionals is important.40,53 The 5 categories clearly show that physical therapists have to be aware of the wide range of understanding that can exist among this patient population. The categories further underscore the importance of health care providers working closely with patients to design physical activity regimens that reflect each patient's preferences and capabilities.54
In this study, the type of support needed was closely related to appraisal of personal factors such as discipline, insecurity, demands, convenience, and autonomy. Lack of discipline and motivation, as in the category "external control," could be related to self-motivation to exercise, which is associated with exercise behavior.55 Without motivation and discipline, exercise maintenance might be facilitated only by a controlled context and situation as in a clinical setting. Insecurity, as in the category "sticks and carrots," might be due to low belief in one's ability to exercise in different settings, thus relating to self-efficacy—which is important for exercise behavior20—and prediction of its initiation and maintenance.26,56 Unfortunately, this insecurity might, in the long run, be strengthened rather than reduced in a clinical setting, where the context usually persists unchanged. Insight and discipline, as in the category "a joint venture," are valuable personal factors to exploit. Patients with these conceptions might be those who exercise responsibly as long as they get continuous feedback from a physical therapist. However, would these patients continue if the shared responsibility disappeared, or does the need for support constrain their own personal resources?
Another unclear personal factor is the need for convenience, as in the category "the easy way." Patients with this conception could be lazy and less responsible, but their behavior might be due to easy access to facilities for vigorous physical activity.57 Regardless of the reason for their need for convenience, however, patients with conceptions as in the category "the easy way" adapt to prevailing circumstances, and this may be a resource for exercise maintenance outside of the health care environment. There also may be some ambivalence regarding self-management and autonomy, as in the category "on one's own terms." The conceptions reflected in this category might reflect much independence regarding exercise behavior but could also reflect a reluctance to cooperate with the physical therapist and health care due to other circumstances.
The present findings related to exercise maintenance agree, in part, with those from previous qualitative studies on exercise adherence in different chronic diseases. Group support, regular monitoring, and supervision, as in the categories "external control," "sticks and carrots," and "a joint venture," also were important for long-term adherence in a group of patients with chronic obstructive pulmonary disease37 and as motivational factors for exercise in patients with osteoarthritis.36 Furthermore, active involvement by participants, as in the category "a joint venture," seemed to be related to greater adherence in patients with osteoarthritis.58 However, independence and autonomy, as in the category "on one's own terms," and the wish to have no external demands or pressure on exercise habits have not been described previously as important for exercise maintenance.
Clinical Implications
Of what use are the present findings to physical therapists? It might be particularly important to enhance beliefs in the ability to exercise outside of the health care environment among those with notions of the categories "external control" and "sticks and carrots," for whom exercise in a clinical setting was preferred and valued. Because self-efficacy can be influenced,56 physical therapists need to use strategies such as successful performance, role modeling, and verbal persuasion59 to enhance self-efficacy more systematically in clinical practice in order to prepare patients for exercise in different contexts. Patients with low motivation and lack of discipline, as in the category "external control," may benefit from a discussion comparing the pros and cons60 of exercise within and outside of the health care environment. This might raise their general knowledge of exercise, their awareness of the potential satisfaction of adopting self-management strategies, and their willingness to take more active care of their exercise behavior.
Although patients with conceptions as in the category "sticks and carrots" may need social support to continue exercising, their insecurity may be targeted with regimens related to flares and remissions of their disease and training in skills related to different types of exercise in different settings. Patients with conceptions as in the category "a joint venture" clearly seemed to benefit from regular follow-up sessions, but they might be challenged successfully to continue the exercise behavior for longer periods outside of the health care environment. Furthermore, physical therapists need to take on the challenge of supporting patients to transform their wish for convenience—as in the category "the easy way"—into exploiting their ability to adapt and continue exercise outside of the health care environment rather than just remaining content with their present situation. Autonomy in relation to exercise was valued in the category "on one's own terms." The creation of more exercise options and convenient exercise settings and meeting places outside of the health care environment, where individuals with RA can feel secure and not excluded because of their disease, would probably benefit patients with conceptions as in the categories "the easy way" and "on one's own terms." It also is important to be more open-minded when discussing exercise maintenance with patients who want to be independent and who possess self-determination such as those with conceptions as in the category "on one's own terms."
One may ask whether any of our 5 categories is preferable clinically. In terms of health economics, some might argue that the category "on one's own terms" is optimal. However, as the participants’ actual exercise intensity was not explicitly elicited in this study, the common clinical question of whether patients actually do continue at adequate exercise levels outside of the clinic reappears. Do patients with a chronic disease such as RA perhaps need regular follow-up appointments separated by long intervals in order to keep up their regular exercise at a healthy level? The physical therapist's goals, however, should be to pay adequate, but not excessive, attention to personal factors and to discuss exercise maintenance early in the treatment periods with the aim of finding the optimal long-term exercise solution for the patient, the health care system, and society.
Methodological Considerations
Our sample was small, with few men and with no participants with severe disability. However, in qualitative studies, sample size is considered less important than the variation in data that the sample generates.50 The few men mirror the population, and people with severe disability did not match our inclusion criteria, which required attempts to manage exercise outside of the health care environment.
Regarding the issue of trustworthiness, several strategies were used. To ensure that the data were approached from more than one perspective, one researcher was a physical therapist working primarily with rheumatic diseases, and the second researcher was a physical therapist and teacher with extensive experience in psychosomatic diseases and qualitative research. The interviewer was familiar with the population group through prolonged engagement and persistent observation in one of the settings. This was judged useful for interpretation of the findings and is likely to have influenced the outcome of the interviews. For this reason, the second researcher was used as a peer checker, and the research process was peer reviewed by an expert researcher in physical therapy with long-standing experience in rheumatology. The participants had no relationship to the interviewer and were not in positions of dependence. They described the role of the physical therapist as both important and less important, which probably indicates that there was little interviewer bias.
Finding depth in the interviews also is important, and our analysis and understanding indicated that even the shortest interview (25 minutes) yielded sufficient depth in the data. Feedback from the participants was not sought and is not regarded as an appropriate phenomenographic validity check; the aim is to not to capture a particular individual's understanding, but to capture the range of understanding within a particular group.44 One important question is whether the full variation of understanding "exercise maintenance" was captured in the categories described. There might have been more categories, but we judged that no new information was revealed during the last 3 interviews, and we, therefore, stopped recruiting participants. This accords with other studies indicating that about 20 participants might be needed to capture saturation, or satisfactory variation, in ways of understanding a phenomenon.48 A qualitative approach does not attempt to generalize the results to the whole population. Nevertheless, it is likely that the categories described could be identified in other patients with RA who have experience of regular exercise with and without support from a physical therapist.
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| Footnotes |
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Ethical approval for this study was obtained from the Regional Ethical Review Board in Stockholm.
An abstract of this work was presented at the International Congress of the World Confederation for Physical Therapy; June 2–6, 2007; Vancouver, BC, Canada.
The authors report that this research was supported by grants from: the Board of Postgraduate Education, KID Funding, Karolinska Institutet; the Center for Health Care Sciences, Karolinska Institutet; the Swedish Association of Registered Physiotherapists; and the Swedish Rheumatism Association.
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