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Arthritis negatively affects the health of nearly 1 in 6 adults (1–4). Participating in physical activity is a recommended strategy for improving disease management and health outcomes (5, 6). Minimum recommendations are to accumulate ≥30 minutes of moderate physical activity on 3 days each week (6, 7). However, most adults with arthritis are not sufficiently active, with insufficient activity impacting more women than men (8–11).
Identification of theory-based correlates of activity, with a particular focus on groups with arthritis at high risk for inactivity including women, is needed (9, 12–15). Self-efficacy beliefs may be one such correlate (13). According to self-efficacy theory (16), self-efficacy beliefs revolve around people's confidence to organize and execute specific actions needed to produce a given attainment. When the attainment is regularly doing planned physical activity, efficacy in capabilities to self-regulate is a key predictor (13, 16–19).
Self-regulation involves individuals exercising control over themselves in order to regularly achieve a desired outcome, such as physical activity (20). To do regular activity, individuals may need to self-regulate across the setting of activity goals, the self-monitoring of goal progress, the scheduling in of activity, and problem solving to cope with barriers (21, 22). Individuals who are efficacious in their abilities to self-regulate will expend considerable effort and persistence in such skills, resulting in a greater likelihood of meeting their desired activity outcomes (16, 19, 21, 23).
Although associations between self-regulatory efficacy to perform arthritis management behaviors, such as arthritis self-efficacy or self-efficacy for arthritis self-management (24, 25), and physical activity have been examined, the findings are inconsistent (26–28). This inconsistency may be partially due to the minimal correspondence between using more general measures of efficacy beliefs about disease management behaviors and the specific behavior of physical activity. Measures of efficacy beliefs more specific to the self-regulatory skills needed to engage in regular physical activity should exhibit stronger and more consistent relationships with activity (16, 23). Therefore, examination of self-regulatory efficacy is one means to delve more deeply and identify specific efficacy beliefs that may be very important for doing regular activity as a way to better manage arthritis.
The efficacy of women with arthritis to self-regulate their physical activity by using strategies to cope with perceived barriers was of interest in this study. As Bandura (29) noted, we should be examining individuals who have been successful in their efforts to alter their lifestyle because we can learn from them, as opposed to only studying individuals who have not been successful. Therefore, we examined women with arthritis attempting to engage in moderate activity (i.e., both successful and attempting to be successful). Such women would have some mastery experience in coping with their disease and barriers to activity. Our focus was on the self-regulatory efficacy beliefs these women had about using their own cognitive and behavioral strategies to cope with perceived barriers and be active as planned (30). These self-regulatory beliefs are termed “efficacy to cope” in the remainder of the paper for clarity and brevity.
The extent to which individuals perceive the frequency of barrier occurrence, and the extent to which they limit participation in planned activity, varies. Some barriers may make it hard to do activity, but with the use of effective self-regulatory coping strategies will not totally prevent activity over time. Other barriers might totally prevent participation (31, 32). Active and insufficiently active individuals with arthritis perceive general personal barriers (e.g., lack of motivation) and situational barriers (e.g., lack of support) similar to other adult populations (27, 33–37). Arthritis-specific personal and situational barriers, such as arthritis pain and a lack of arthritis-specific activity programs, have also been reported (36, 37). Unfortunately, quantitative barriers research in samples with arthritis is characterized by some of the same conceptualization and measurement problems that occur in research with other populations (31, 32, 38).
The main problem is the use of generic barrier lists, which typically include only general types of barriers and require participants to respond to every barrier (27, 33, 35). Thus, individuals are forced to respond to both relevant and irrelevant barriers. Providing a one-size-fits-all list of general barriers does not adequately measure arthritis-relevant barriers, which have been reported in qualitative research as posing self-regulatory difficulties in deterring or preventing planned physical activity participation (31, 36, 37).
Open-ended elicitation procedures may better identify personally relevant barriers that pose frequent self-regulatory difficulties to respondents (31, 39). The frequency of barrier occurrence, the extent to which relevant barriers limit participation, and the efficacy to cope with barriers should all be assessed (31, 38). Among asymptomatic adult populations, as barriers were experienced with a higher frequency and/or became more limiting and as efficacy to cope with barriers decreased, physical activity declined (39, 40).
To our knowledge, the recommended barrier assessment protocols have not been used among the population with arthritis (31). However, the relationship between efficacy to cope with investigator-provided lists of general barriers and physical activity has been examined. Study results have been inconsistent (27, 34). This type of approach assesses efficacy to be active if individuals were to experience a barrier, but does not provide any information on how individuals attempt to self-regulate and cope with barriers. In other words, previously used self-regulatory efficacy measures do not capture the ability/coping actions that respondents use to overcome barriers.
Individuals report more accurate efficacy beliefs when considering their confidence to perform specific self-regulatory coping actions (16). The method we suggest and that we used in our study required participants to state their personal strategies and respond about their efficacy for making these strategies successful. Obtaining this type of information may inform theory and provide potentially valuable information for interventions targeting the use of specific, effective coping actions and related improvements in efficacy.
The primary study purpose was to examine whether barrier frequency, barrier limitation, and efficacy to cope were predictors of planned physical activity among adult women with arthritis, who are at particular risk for inactivity (8–15). Based on past research and theory, all variables were expected to predict activity (16, 39, 40). A secondary study purpose was to provide a phenomenologic description of the self-identified barriers and coping strategies reported by study participants.
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As hypothesized, barrier limitation and efficacy to cope were significant, independent predictors of planned physical activity. These findings are similar to prior research with asymptomatic adult populations (39, 40, 47). Contrary to hypotheses, barrier frequency did not predict activity. Self-efficacy theory (16) offers insight regarding a possible explanation for the study findings. Individuals with high self-regulatory efficacy beliefs to cope may have an altered perception of the limiting impacts of relevant barriers on their planned physical activity participation. Indeed, high efficacy helps to motivate individuals' persistence in overcoming impediments (16, 19). Therefore, rather than the frequency of relevant barriers deterring physical activity, the perception of relevant barriers posing self-regulatory difficulties may be the deterrent, as captured by lower efficacy beliefs and higher perceived limitation.
All participants reported arthritis-specific personal barriers, which were also perceived as being moderately or more limiting to planned physical activity. Considerably fewer participants reported general barriers, with most of these barriers perceived as being less than moderately limiting. The reporting of ≥1 arthritis-specific barrier by all study participants and, in particular, of pain by 50% of the sample and fatigue by nearly 40% of the sample, is extremely high and in contrast to the lower reporting of various types of population-specific and general barriers in asymptomatic adult populations (39, 40). Disease-related barriers may be common in posing self-regulatory difficulties and limiting activity among women with arthritis. Although qualitative research has reported arthritis-specific barriers (36, 37), the present disease-specific results would not have been observed if generic barrier lists were used (31, 38).
Study participants used arthritis-specific strategies to deal with barriers, such as the cognitive strategy of thinking about the disease-specific health benefits of activity and the frequently reported behavioral strategy of activity modification. The latter strategy has also been reported in previous focus group research with individuals with arthritis (37) and may be characteristic of this population due to disease flare-ups and associated increases in pain/joint soreness and fatigue. Overall, participants were efficacious in their abilities to successfully use their arthritis-specific coping strategies to deal with a perceived barrier and be active as planned. Although participants also used general types of self-regulatory cognitive and behavioral coping strategies (e.g., direct action) similar to asymptomatic adults in other research (30, 43), their confidence to use these strategies was only moderate.
Underscoring the phenomenologic data is the importance of the methodologic point raised earlier; the disease-specific coping responses and self-regulatory beliefs observed in the current study would not have been gathered had we used general measures, as has been done in past research with asymptomatic populations and populations with arthritis. The reporting of higher efficacy in arthritis-specific coping strategies illustrated that participants' distinct, disease-specific self-regulatory skills may have aided them in dealing with barriers and participating in their planned activities.
Taken together, the specificity of measurement in barrier and coping-related constructs and their correspondence with the outcome of planned physical activity are the reasons for the strong predictive relationships. The current study findings suggest that contrary to past research (15, 45), general and arthritis-specific demographics were not significant predictors. The low correspondence between the demographics and activity may account for their low correlation. The advantage of identifying more specific, changeable, theory-based correlates of activity is that once consistently observed, the correlates can be used to inform researchers about their potential for change and consequent impact on planned activity (12).
The present, theory-based study (16, 17) was the first to our knowledge among adult women with arthritis to investigate the associations between perceived barriers, self-regulatory efficacy to cope, and activity. The present study used an open-ended elicitation approach for participants with arthritis to report their perceived barriers and was the first to assess their frequency of occurrence and extent of limitation on planned activity. This methodologic protocol alleviated some of the conceptual and measurement problems previously identified in physical activity barriers research (31, 38). The focus on efficacy to cope through the use of personal strategies was novel. Based on the number of participants who reported limiting arthritis-specific barriers and who were efficacious in their arthritis- specific coping strategies, using generic or borrowed measures of barriers and coping strategies may not capture the variability and specificity in disease-related responses associated with the physical activity context of women with arthritis (31, 38). Standard measures of barriers and efficacy to cope through the use of specific strategies may be produced over time if additional research is conducted that demonstrates consistent and relevant barriers and effective coping strategies among the population with arthritis.
Although our study offers interesting correlational information, study limitations exist. Any theory-driven conclusions about social cognitive variables causing activity cannot be drawn. The sample primarily represented white, middle-income women, many of whom were moderately active. Generalizing findings to women of different races, incomes, activity levels, and/or who are more disabled by arthritis would be inappropriate. Although the sample size was sufficient to detect a medium-to-large effect (48), having additional participants may have been beneficial. The self-report measure of the frequency of planned activity was also a limitation.
Obtaining an objective assessment of activity frequency, which would correspond with some of the independent variables of interest in the present study (i.e., barrier frequency), should be pursued in future research. Other investigations should include a diverse study sample to determine whether the present findings are reproducible (49) and whether disease severity is a moderator. Other potential moderators, such as pain acceptance (50), should be examined. Pain was reported as a barrier by 50% of the study sample. Women with more pain acceptance may have more self-regulatory resources available to cope with their pain and be active (19, 20). Finally, prospective research would provide insight about a possible temporal relationship between barrier limitation, self-regulatory efficacy to cope, and planned activity.