Physical activity level and its barriers among patients with type 2 diabetes mellitus attending primary healthcare centers in Saudi Arabia.

INTRODUCTION: Physical activity (PA) plays an important role in diabetes management. This study aimed to evaluate the level of PA and the barriers toward practicing regular PA among patients with type 2 diabetes mellitus (T2DM) attending primary healthcare centers (PHCs) in Jeddah during 2018.
MATERIALS AND METHODS: A total of 250 patients were interviewed face-to-face in three PHCs. Two questionnaires were used in this study. The first questionnaire measured the level of PA of the participants. The second questionnaire aimed to identify barriers to PA. For analysis, simple descriptive statistics, Chi-square, T-test, and analysis of variance were used.
RESULTS: The prevalence of physical inactivity was found to be 38.4%. Males and females composed 40% and 37.4% of the participants, respectively. Lack of social support, lack of energy, fear of injury, and lack of skills were identified as significant barriers to PA according to the level of PA.
CONCLUSION: Our findings may provide baseline data for future research on this topic and information for healthcare professionals to improve their efforts in promoting the overall health of patients with T2DM.

Introduction

The prevalence of diabetes in adults age 20–79 years old in Saudi Arabia has risen from 13.6% in 2010 to 17.6% in 2015. The financial burden of diabetes in Saudi Arabia is considerably high, costing around 4300 SAR per person. In 2015, the number of deaths among adults in Saudi Arabia due to diabetes was 23,420 people.[1]

Physical activity (PA) has a vital role in the management of type 2 diabetes mellitus (T2DM). It significantly improves glycemic control, by lowering hemoglobin A1c by an average of 0.6%–0.8%.[2] PA is defined as any bodily movement that substantially increases energy expenditure, whereas “exercise” is the series of planned, structured, and repetitive movements done to develop or maintain physical fitness, which may include cardiovascular, strength, and flexibility training options.[3]

It is recommended to perform at least 150 min of moderate-intensive aerobic activity, or at least 90 min of vigorous aerobic exercise per week. In some patients, PA may be contraindicated, but the new guidelines recommend moderate PA intensity for most patients, particularly those with T2DM.[4] Any PA improves glucose uptake and insulin sensitivity and helps in glucose homeostasis by lowering blood glucose levels for 2–72 h after the last session of activity.[3]

Many studies have reported that minority of patients with T2DM follow these recommendations.[2] In 2015, the prevalence of physical inactivity in Saudi Arabia was found to be 60.1% among males and 72.9% among females.[5]

Several studies in different countries have reported numerous barriers to perform PA in patients with T2DM. Hence, understanding barriers to perform PA among diabetic patients in Saudi Arabia needs to be explored to intervene properly.[6]

This study aimed to evaluate the level of PA among patients with T2DM attending primary healthcare centers (PHCs) in Jeddah during 2018. Also, the barriers toward the practice of PA were explored.

Materials and Methods

This study is a cross-sectional study which was carried out at three PHCs (Specialized Polyclinics, Bahra Center, and Iskan Center) affiliated with the Ministry of National Guards Health Affairs (MNGHA) in Jeddah, Saudi Arabia. The healthcare services provided by the National Guard in Jeddah are dilevered through King Abdulaziz Medical City, including a well-equipped 751-bed hospital, and three PHCs scattered all over Jeddah. These centers provide all medical services under the supervision of family medicine specialists. In each center, there are specialized clinics called chronic diseases clinics, which were the main area for our study. Data collection was conducted using face-to-face interview. Participants were interviewed before entering the clinic while waiting for their medical appointment. A particular private location was selected in each center for the interview.

All adult patients with T2DM who could walk, regardless of their sex and type of management, age between 25 and 75 years, were eligible and invited to participate in this study between February and June 2018. Questionnaires with more than 30% of missing data were excluded from the analysis. This study was approved by King Abdullah International Research Center.

A systematic random sampling technique was used in this study. Chronic diseases clinics in each PHC center are divided into two clinics, one for males and the other for females. Hence, two data collectors including the researcher collected the needed data. Subjects who accepted to participate in the study and fulfilled the inclusion criteria were included. The first patient was selected randomly using random numbers generated by Microsoft Excel Program, and then every other patient was selected from each clinic. The expected daily number of patients with T2DM attending each clinic ranges between 10 and 15 patients.

Two questionnaires were used in this study. The first questionnaire measured the level of PA of the participants. The second questionnaire was used to measure and identify barriers to PA. The first questionnaire was the Global Physical Activity Questionnaire (GPAQ), developed by the World Health Organization for PA surveillance.[7] It collects information on PA participation in three domains as well as sedentary behavior, comprising 16 questions (P1–P16). The domains included were activity at work, activity during travel to and from places, and recreational activities. This questionnaire is available and it is validated in many languages including Arabic language, which was the version we used.[89] When using GPAQ, all the questions must be asked. Skipping any other questions or removing any of the domains will restrict calculation of results.

The second questionnaire which was used to measure the barriers to PA was adopted from the Centers for Disease Control and Prevention.[10] The translated and validated Arabic version was used after gaining permission.[11] This questionnaire includes 21 questions for barriers to PA. A scoring system was used to indicate how likely a person would answer each statement about barriers (very likely = 3, somewhat likely = 2, somewhat unlikely = 1, and very unlikely = 0). Scores of three related questions were added together to identify a category as a barrier to PA. The highest possible score of one category was 9. A score of 5/9 or above in any category would indicate a significant barrier.[10]

The estimated total population of adult patients with T2DM attending all PHCs is 15,000. The sample size with estimated prevalence of PA among Saudi population in Jeddah was around 35%, according to the Municipality of Jeddah, with confidence level of 95% and margin of error 6%. The sample size calculation was 240, and then it was increased to 250 to compensate for nonresponse or incomplete data.

Data were encoded and analyzed using Statistical Package for the Social Sciences (SPSS), version 21. Measures of central tendency and dispersion (mean, median, standard deviation, and range) were used to describe the numerical data. Categorical variables were presented as frequency and percentage. Independent t-test and analysis of variance tests were used to compare means. Chi-square test was used to measure associations between categorical variables. The statistical significance that was considered is at P value <0.05 and a confidence interval of 95%.

Results

Demographic profile of participants

The total number of participants from the three centers was 250 subjects [Table 1]. The percentages of participants from each center, Specialized Polyclinics Center, Bahra Center, and Iskan Center, were 47%, 34%, and 19%, respectively. The mean age of those who reported their age, 236 subjects, was 56 ± 9 years.

Table 1

Sociodemographic profile of the study population according to study location

Character	Center, n (%)			Total
	Specialized polyclinics (47%)	Iskan (19%)	Bahra (34%)
Gender				247
Male	44 (37.6)	15 (31.2)	33 (40.2)	92
Female	73 (62.4)	33 (86.8)	49 (59.8)	155
Age (years)
Mean±SD	56.6±9.6	54.7±8.6	55.4±9.3	236
Marital status				248
Married	104 (88.9)	42 (87.5)	75 (90.4)	221
Single	13 (11.1)	6 (12.5)	8 (9.6)	27
Monthly income				102
<5000	13 (50)	7 (27)	6 (23)	26
5000-10,000	30 (43.5)	17 (24.6)	22 (31.9)	69
>10,000	5 (71.4)	0	2 (28.6)	7

SD: standard deviation

PA level

The overall prevalence of physical inactivity was found to be 38.4% [95% confidence interval (CI) 32.4%–44.4%]. Inactive males represent 40%, and 37.4% of females were inactive. However, the difference was found to be statistically insignificant. Moreover, there was no statistically significant difference between physically active and inactive participants according to study location, marital status, and income. On the other hand, age was found to be statistically significant. The number of inactive participants was 92 with a mean age of 58.7 ± 7.5 years, in comparison to the active subjects who were 144, and their mean age was 54 ± 9.9 years (P = 0.0005). The mean difference in age between active and inactive subjects was 4.7 years (95% CI 2.5–7 years). None of the subjects reported that they were practicing vigorous-intensity physical activities at work or as a recreational activity.

Regarding the three questions in the domain “activity at work,” 80 subjects (32%) reported positively to the first question, “does your work involve moderate-intensity activity that causes small increases in breathing or heart rate such as brisk walking [or carrying light loads] for at least 10 minutes continuously?” About the other two questions “In a typical week, on how many days do you do moderate-intensity activities as part of your work?” and “How much time do you spend doing moderate-intensity activities at work on a typical day?” the median days of practicing moderate-intensity physical activities as reported by participants were 5 days/week, with an average of 4 and a range of 3–7 days/week. A total of 17 (21%) participants reported that they perform moderate-intensity activities 7 days/week, and 21 (26%) reported 3 days/week. The median time duration of practicing moderate-intensity activities was 2 h/day and the average being 3.5 with a range of 0.5–4 h/day.

Regarding the domain “travel to and from places,”out of 250 subjects, 114 (45.6%) responded positively to the question “Do you walk or use a bicycle (pedal cycle) for at least 10 min continuously to get to and from places?” The other two questions under this domain, “In a typical week, on how many days do you walk or bicycle for at least 10 min continuously to get to and from places?” and “How much time do you spend walking or bicycling for travel on a typical day?” the median days was 5 days/week, with an average of 6 days ranging from 1 to 7 days/week. The median time duration was 15 min/day, and the average was 45 min with a range of 15 min to 1 h/day.

Considering the domain: “recreational activities,” out of 250 subjects, 141 (56.4%) responded positively to the question “Do you do any moderate-intensity sports, fitness or recreational (leisure) activities that cause a small increase in breathing or heart rate such as brisk walking, [cycling, swimming, volleyball] for at least 10 minutes continuously?” The median days of practicing moderate-intensity recreational activities were 5 days/week, and the range was 2–7 days/week with an average of 5. The median time duration of practicing moderate-intensity recreational activities was 30 min/day, and the average was 1 h and 45 min/day with a range of 15 min to 2 h/day.

Barriers to PA

Barriers to PA are shown in Figure 1, which are presented in the order from the most common to the least common barrier. Table 2 shows the barriers to PA according to the level of PA. Barriers to PA according to gender are shown in Table 3. These findings were found to be consistent with the previous results shown in Table 2.

Figure 1

Barriers to physical activity among the participants

Table 2

Barriers to physical activity according to the level of physical activity

Barriers to physical activity	Physical activity, n (%)			P, RR (95% CI)
	Inactive	Active	Total
Lack of resources
Yes	41 (34)	80 (66)	121	0.15, 0.79 (0.58-1.09)
No	55 (43)	74 (57)	129
Lack of willpower
Yes	45 (41)	64 (59)	109	0.4, 1.14 (0.83-1.5)
No	51 (36)	90 (64)	141
Lack of energy
Yes	41 (49)	43 (51)	84	0.016, 1.47 (1.08-2.0)
No	55 (33)	111 (67)	166
Lack of skills
Yes	42 (56)	33 (44)	75	0.0005, 1.8 (1.3-2.45)
No	54 (31)	121 (69)	175
Lack of time
Yes	26 (41)	38 (60)	64	0.67, 1.08 (0.76-1.5)
No	70 (38)	116 (62)	186
Lack of social support
Yes	28 (52)	26 (48)	54	0.022, 1.5 (1.08-2.0)
No	68 (35)	128 (65)	196
Fear of injury
Yes	18 (58)	13 (42)	31	0.016, 1.6 (1.15-2.5)
No	78 (36)	141 (64)	219

CI: Confidence interval, RR: Relative risk

Table 3

Barriers to physical activity according to gender

Barriers to physical activity	Gender			P, RR (95% CI)
	Female	Male	Total
Lack of resources
Yes	76 (63)	44 (37)	120	0.08, 0.97 (0.7-1.34)
No	79 (62)	48 (38)	127
Lack of willpower
Yes	75 (70)	32 (30)	107	0.037, 1.23 (1.02-1.5)
No	80 (57)	60 (43)	140
Lack of energy
Yes	64 (78)	18 (22)	82	0.005, 1.4 (1.18-1.7)
No	91 (55)	74 (45)	165
Lack of skills
Yes	59 (80)	15 (20)	74	0.0005, 1.44 (1.2-1.7)
No	96 (55.5)	77 (44.5)	173
Lack of time
Yes	39 (62)	24 (38)	63	0.8, 0.098 (0.78-1.23)
No	116 (63)	68 (37)	184
Lack of social support
Yes	40 (74)	14 (26)	54	0.035, 1.2 (1.02-1.5)
No	115 (60)	78 (40)	193
Fear of injury
Yes	24 (77)	7 (23)	31	0.051, 1.28 (1.03-1.6)
No	131 (61)	85 (39)	216

CI: confidence interval, RR: Relative risk

Discussion

This study aimed to evaluate the level of PA among type 2 diabetic patients and to explore what are the most common barriers among patients with T2DM in Jeddah. Generally, the prevalence of physical inactivity was found to be 38.4%. Males and females who are known to be physically inactive composed 40% and 37.4% of the participants, respectively. Although these findings were found to be statistically insignificant, they are consistent with the findings found in studies conducted in the United States,[12] Oman,[13] Saudi Arabia,[14] and Lebanon.[15] The findings of this study found that age is statistically significant. The number of inactive participants was 92 and their mean age was 58.7 ± 7.5 years, in comparison to the active subjects which were 144 and their mean age was 54 ± 9.9 years.

We found that lack of willpower, lack of energy, lack of skills, lack of social support, and fear of injury are the top barriers to PA among the participants. Lack of willpower and social support were also reported as top barriers to PA in the Saudi population attending primary care by AlQuaiz and Tayel[16] and Alghafri et al.[11] in Muscat, Oman. It was reported in the United States that the most reliable reported barriers to PA among adults with T2DM were pain (41%), followed by lack of willpower (27%) and poor health (21%).[17] However, in this study, lack of willpower was perceived more as a barrier among females than in males.

Interestingly, fear of injury was also reported to be significantly different between individuals at inactive versus active stages of change in PA in a study in Oman,[11] which could be explained by possible physical constraints concerning older age[18] and existing comorbidities in the current study population triggering fear of injuries associated with PA.[11]

Females predominantly reported a lack of social support in a study by Alghafri et al.,[11] similar to the result of this study. Meeting cultural norms and social expectations related to safety, security, and conservative dress mainly for females were reported as barriers to PA in South Asian (Pakistani and Indian) British population[171920] and populations in Arabic countries such as Qatar.[21]

Reports on lack of skills varied across subgroups, in particular older, unemployed, and uneducated individuals.[17] Unlike the study by Alghafri et al.,[11] significant scores for lack of time in this study were higher in females compared with males.

Factors which are dependent on an individual's decision-making, such as marital status and income, had no significant associations in the current study. These negative results may vary between studies in different languages due to the wording of the questions and their interpretation. To address these gaps in the literature, a qualitative exploration and further investigation on this matter may be warranted.

In conclusion, this is the first study conducted to identify the barriers to PA among patients with T2DM treated in PHCs in Jeddah, Saudi Arabia. Although the further research is needed, our findings provide the baseline data as a reference for future research on the topic, as well as information for the healthcare professionals to improve their efforts in promoting the overall health of the patients with T2DM.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.