Socio-demographic characteristics of the participants
Of the 523 participants, 80% were between 31 and 60 years of age. It was an ethnically mixed group, and included patients who came from 12 different countries. The majority (87%) had a Dutch, Moroccan, Turkish or Surinamese background (Table
1). The mean residence duration for the Turks and Maroccans was around 19 years and for the Surinamese this was about 4 years longer. Of the Turks and Moroccans, 13% and 11% had paid jobs compared to 30% and 36% of the Dutch and Surinamese respectively. The Turks and Moroccans also had a lower level of education: 63% of the Moroccans and 79% of the Turks had had no education or primary school only, compared to 19% of the Dutch and 37% of the Surinamese. There were also differences in marital status: 83% of the Moroccans and 73% of the Turks were married or living together with a partner, compared to 40% of the Dutch and 35% of the Surinamese. The Turks (42) and Moroccans (39) were in general younger than the Dutch (47) and Surinamese (49). Turks and Moroccans generally had more children (2.1 and 2.6 respectively) than the Dutch and Surinamese (0.8 and 1.2 respectively). Finally, almost all participants suffered from obesity irrespective of ethnic background (Table
1).
At the time of intake, 80% to 90% of the participants reported they did not exercise on a health enhancing level. A small proportion mentioned exercising (e.g. swimming or gymnastics) two hours a week or more. Most participants (76%) did report leisure-time physical activity; in particular walking and biking. However, they reported to do these activities at a low to average degree of intensity. Furthermore, the majority of the participants (61%) considered their level of activity to be inadequate.
At the time of intake, most participants in all groups were quite motivated to start exercising. Overall, they had a positive attitude, perceived social support and had a high self-efficacy towards exercising (Table
2). Although there are some significant differences between the ethnic groups (Table
2), the patterns were inconsistent.
Participants reported a moderate level of support from their social environment. There were no ethnic differences in the perception of social support from relatives and friends. However, Turkish (2.04) participants significantly felt less supported by their partners than the Dutch participants (mean 2.49). Most participants appeared to have a moderate to high degree of self-efficacy. The Dutch generally reported higher self-efficacy expectations than the other groups. For example, they have a higher self-efficacy expectations than the Turks when the weather is bad (2.80 and 2.45 respectively) or when they experience stress (2.65 and 2.34 respectively).
Appealing elements of the intervention
In-depth interviews were used to further explore the elements of the intervention participants considered to be important for joining the ERS. Five characteristics of the intervention emerged and are described below.
The Facilitating role of the health professional
About half of the participants highly valued the doctor's advice that they should become physically active. They experienced this advice as being either optional or compulsory. This advice was understood differently by the various ethnic groups. Many Dutch experienced the advice as being 'just a recommendation', which meant it was not experienced as a deciding factor in becoming physical active. It helped them find a place where they felt comfortable exercising. Many migrant participants, however, experienced the GP as someone 'who knows better' and participated in the intervention because they were told to do so.
If the doctor tells me that being overweight is not good for my health and that I have to lose 10 kilos, that's what I'll do. (Turkish woman, age 53, respondent no.24)
Specifically among Turkish and Moroccan participants, the referral's importance concerns the social environment. Some female participants said their partners generally did not allow them to leave the house, but that they allowed them to participate in the ERS because of the significance of the GP's opinion that the women needed to exercise for health reasons. So for these women, the referral appeared to have had the additional effect of providing a legitimate reason to exercise.
Supportive environment
There were strong feelings of shame about body weight among the participants, and in particular among overweight Dutch women. Some participants mentioned they did not dare go to a sport school because the women who exercise there are all slim. Other participants see the small groups in this ERS intervention as a step towards daring to enter bigger fitness centres.
Yes, because I'm not going to jump around among all those slim people. (Dutch woman, age 52, respondent no. 3)
Feelings of reluctance also originate from religious and cultural principles. Muslim women in particular mentioned feeling embarrassed in mixed-sex groups due to their cultural and religious backgrounds. Some of them even refused to participate in fitness lessons when the instructor was male or when there were male participants. Some ethnic Dutch women also said they preferred female groups to mixed ones 'just because it feels better'. Some mentioned being ashamed of their weight or physical condition as important factors. For both groups of women, being in a mixed group would mean they would feel uncomfortable about their clothing in front of men, including a male instructor.
Normally I wear a headscarf. If there were men present I'd have to wear a headscarf, now I don't have to. You don't have to wear a headscarf and you're among women and because of this you feel comfortable. (Turkish woman, age 22, respondent no. 27)
In addition to the small groups and their single-sex nature, in order to feel safe, a third element in the intervention seems to be important to the participants: they mentioned that they consider the ERS to be ideal because it gives them the opportunity to exercise with other people who have health problems. Some said they found it encouraging that the group was made up of friendly participants with similar health conditions, and this is also mentioned as a stimulus for continuing to exercise: 'If she can do it, maybe I can too.'
Financial incentive
Participants paid 22 euro's for the 20-week period of weekly exercise sessions. The majority of the participants perceived these costs as a difficulty. Nevertheless, they were prepared to pay these costs in order to improve their health. Some found paying for a sport facility to be self-evident, whereas others thought it should be paid for by their health insurance because they had been referred by their GP. Although the ERS was affordable for many participants, they considered the costs of regular sport facilities to be too high and as a barrier to continuing to exercise after the ERS. For half of them, it was actually a reason to stop exercising.
Well, I was enthusiastic about this, because I anyway wanted to start exercising. But a fitness centre will cost you around 45, 55, 65 euros, and I can't pay that. I'll be honest, we have a low income. I don't have a job, my husband doesn't have a job and because of that you have to get by with little things. So for me, this intervention was a way to do this. (Turkish woman, age 50+, respondent no. 25)
Supervision by fitness instructors
Supervision by a professional instructor was often given as a reason to participate. Some participants considered supervision to be of major importance in light of their health complaints. Some participants even think of the ERS as a medical project because of the GP's involvement and because they were referred on account of their poor health. In general, participants stressed the stimulus provided by the presence of the fitness instructor, who can give advice when necessary.
...other fitness centres don't have this – they don't have time for people who come there exercise. Although they do explain a little that you have to do this 10 times and so forth, they don't have time to talk to you about it. But people with chronic pain need this. This is what I think anyway – I can't speak for others, of course, but I find it helpful. (Surinamese woman, age unknown, respondent no.16)
Neighbourhood setting
The neighbourhood setting was mentioned in two ways. First, for many participants, the distance to the sport facility is an important factor. They prefer a facility in the neighbourhood so they can walk there. The Turkish and Moroccan women in particular said they were not familiar with public transportation and preferred to walk to the facility. Also, although some people who own a car do not feel put off by having to travel some distance, others are motivated by a facility in their own neighbourhood, irrespective of having a car.
Secondly, the neighbourhood setting was given as a reason for the unpopularity of sport activities in the evening among most of the women. Participants do not feel safe in their neighbourhoods, and for some this is a reason to stay at home. Participants who do go out are accompanied by a partner or a group of neighbourhood women.
I did not like the neighbourhood. The first time I came here I was so scared...I had to get off the tram by the market, but I got out at the wrong stop and had to walk along streets with all those men...I was scared and thought, what should I do? ...(Dutch women, age 59, respondent no.14)
Additionaly, Moroccan and Turkish women mentioned being anxious about potential gossip within their social community. Furthermore, Muslim participants would rather stay at home in the evening to fulfil their religious commitments.
We keep an eye on each other, we Moroccans...you know I'm always scared, if we are going at 21.00 o'clock and someone sees me he/she is going to wonder...I don't want others to talk about me... (Moroccan woman, age unknown, respondent no. 34)