Journal of Physical Activity and Health, 2015, 12, 931  -941 http://dx.doi.org/10.1123/jpah.2014-0049 © 2015 Human Kinetics, Inc.

ORIGINAL RESEARCH

Perceived Benefits, Facilitators, Disadvantages, and Barriers for Physical Activity Amongst South Asian Adolescents in India and Canada Divya Rajaraman, Natasha Correa, Zubin Punthakee, Scott A. Lear, Krishnaswamy G. Jayachitra, Mario Vaz, and Sumathi Swaminathan Objectives: The purpose of this study was to understand perceived benefits, facilitators, disadvantages, and barriers for physical activity among South Asian adolescents in India and Canada. Methods: Thirteen focus group discussions with South Asian (origin) adolescent boys and girls of different nutritional status and socioeconomic status in rural and urban India and urban Canada. Results: Across the groups, fitness and ‘energy’ were perceived to be major benefits of physical activity. In India, better academic performance was highlighted, while health benefits were well detailed in Canadian groups. In all settings, friends, family, and teachers were perceived as facilitators of as well as barriers to physical activity. Lack of a safe space to play was a major concern for urban adolescents, while academic pressures and preference for other sedentary recreational activities were common barriers across all groups. Girls were less likely than boys to be interested in physical activity, with girls’ participation in India further limited by societal restrictions. Conclusion: The study suggests key areas for promotion of physical activity among South Asian adolescents: balance between academic pressure and opportunities for physical activity, especially in India; urban planning for a built environment conducive to physical activity; and gender-sensitive programming to promote girls’ activity which also addresses culture-specific barriers. Keywords: qualitative research, health behavior

Physical activity in young people ensures healthy development of musculoskeletal tissues and the cardiovascular system, helps to maintain a healthy body weight, and creates opportunities for socialization and integration.1 However, physical activity drops sharply in adolescence,2,3 and about four-fifths of the world’s adolescent population does not meet minimum recommended levels.4 This is a major contributor to rising overweight and obesity,5,6 which significantly increases risk for a range of adverse health outcomes in children and adolescents, including early onset of type 2 diabetes, cardiovascular disease, nonalcoholic fatty liver disease, and poor mental health.7–9 Reviews of the research indicate that low physical activity levels in youth track into adulthood.10,11In adults, inadequate physical activity is the fourth leading risk factor for mortality, and accounts for about 6% of deaths, on par with smoking and obesity.12,13 It is associated with increased risk for coronary heart disease, high blood pressure, stroke, metabolic syndrome, type 2 diabetes, breast cancer, colon cancer, and depression.4 Physical activity is therefore important for ensuring healthy development and preventing disease in adolescence, as well as for reducing morbidity and early mortality in adulthood. Rajaraman ([email protected]) and Jayachitra are with the Division of Epidemiology, St John’s Research Institute, St John’s National Academy of Health Sciences, Bangalore, India. Correa is with the Faculty of Medicine, University of Toronto, Toronto, ON, Canada. Punthakee is with the Depts of Medicine and Pediatrics, McMaster University, Hamilton, ON, Canada. Lear is with the Faculty of Health Sciences, Simon Fraser University and Division of Cardiology, Providence Health Care, Vancouver, BC, Canada. Vaz is with the Division of Health and Humanities, St John’s Research Institute, Bangalore, India. Swaminathan is with the Division of Nutrition, St John’s Research Institute, Bangalore, India.

In high income countries such as Canada, the United Kingdom and United States of America, South Asian migrants are less physically active compared with the rest of the population at all ages; studies have indicated that physical inactivity among South Asian adults in these countries ranges from 60 to 77%.14–18 In India, a country with a population of 1.2 billion,19 a recent survey conducted across multiple states found that 50% of the rural population and 65% of the urban population was physically inactive.20 There is concern that these patterns are being established at a young age, as studies have reported low physical activity levels in urban Indian school going children, which decline in adolescence, especially in girls.21 Compared with other ethnic groups, South Asians are at high risk of developing a range of chronic lifestyle diseases, such as metabolic syndrome, cardiovascular disease, and type 2 diabetes.22–24 Differential risk among South Asian children may start to appear at an early age with regard to development of adiposity,25 and cardiovascular disease manifests earlier in South Asians compared with other ethnic groups.26 Early intervention to promote physical activity is therefore important in this population. The most successful health promotion interventions address environmental, policy and social/cultural influences on behavior.27,28 However, relatively few studies have aimed to assess adolescents’ unique perspectives on voluntary physical activity; the limited research has been conducted mostly in Western settings and has not included South Asians.29–31 Better information is needed on the drivers of physical activity among young people of South Asian origin to design health promoting interventions in this population. We report on a qualitative study conducted among adolescents living in urban and rural India, a resource-limited country experiencing rapidly rising rates of noncommunicable disease, and adolescents of South Asian origin living in Canada, a fully industrialized country. By gathering information on adolescents’ attitudes, beliefs and experiences, this study aimed to identify 931

932  Rajaraman et al

factors affecting voluntary physical activity among adolescents of South Asian origin across gender, nutritional status, socioeconomic status, urban/rural residence and country (India and Canada), to inform current intervention-planning and policy review, as well as generate hypotheses for future research.

used to develop interview guides that would explore participants’ perceived benefits, facilitators, disadvantages and barriers to physical activity in the physical and social environments. Table 1 provides examples of the lead question asked within each of these themes. Probes and prompts were used as needed to explore topics in depth.

Recruitment and Data Collection

Downloaded by Washington Univ In St Louis on 09/16/16, Volume 12, Article Number 7

Methods

We conducted 8 FGDs with adolescents in South India and 5 FGDs with adolescents in Canada. To capture variation between sociodemographic and nutritional status groups, FGDs were stratified by gender (male/female), body weight (overweight/normal weight), and, in urban India, socioeconomic status (SES) of participants. The composition of the sample for the FGDs is shown in Table 2. The research protocol received ethics approval from the St John’s Medical College Institution Ethics Committee in India and the Hamilton Health Sciences/McMaster University Health Sciences Research Ethics Board in Canada. In India, 14- to 15-year-olds were recruited from schools in the city of Bangalore (urban) and Palamaner area in the state of Andhra Pradesh (rural). Fee structures of the schools were used as an initial indicator of the SES of the adolescent/family to include participants of low and high SES. A short screening questionnaire which gathered information on house ownership, parental occupation and education and household assets was administered to Indian adolescents to validate the SES classification. Anthropometric measurements were taken to categorize nutritional status, using the WHO Growth Reference standards.35 Indian FGDs were conducted in schools in the language preferred by participants (Kannada, Telugu or English) by a member of the research team. In addition to the FGD facilitator, a note-taker was present at each of the FGDs.

The data presented in this paper were gathered as part of a larger qualitative study to consider adolescent attitudes toward and perceptions of physical activity, healthy eating and body image among adolescents and their mothers in urban and rural India and in Canada. As this was an exploratory study to identify the range of variables that influence South Asian adolescents’ participation in physical activity in different settings, focus group discussions were selected as the preferred method. For the purposes of the study, the definition of physical activity was limited to recreational sports and outdoor games or exercise to improve health or physical appearance (ie, discretionary leisure time activity). Routine physical activity such as household work, agricultural work, and walking to school were not included, given that the motivations and constraints for these activities are very different. Focus Group Discussions (FGDs) were selected as the qualitative method, as they are useful for providing information about a range of perceptions and attitudes among individuals and groups, as well as indicating differences between groups.32 The Health Belief Model suggests that individual health behaviors are influenced by perceived susceptibility to and severity of disease; perceived threat of disease; perceived benefits of and barriers to preventive action; and, cues to action.33,34 This broad framework was Table 1  Composition of Focus Groups India Boys (14–15 years) Normal weight Urban low SES

5

Urban high SES

8

Overweight

Canada Girls (14–15 years)

Normal weight

Overweight

Boys (11–18 years) Normal weight

Overweight

Normal weight

Overweight

6

4

10*

5

5 5

7

Girls (11–18 years)

6

Abbreviations: SES, socioeconomic status. Note. Cell values indicate the number of participants in each focus group discussion (FGD). * There were 2 FGDs among normal weight girls in Canada, each with 5 participants

Table 2  Focus Group Discussion Questions on Physical Activity Theme

Question

Introduction to the subject

What do boys/girls your age prefer to do in your spare time?

Physically active behaviors

What do boys/girls your age do that gives you physical activity or exercise?

Benefits of physical activity

What are the benefits of being physically active?

Facilitators of physical activity

Who or what encourages you to be physically active?

Relevance of physical activity to participants

Do boys/girls your age need to worry about getting enough exercise? Why/why not? If not, when should people worry about getting enough exercise?

Disadvantages of physical activity

Are there any disadvantages to be being physically active?

Barriers to physical activity

Does anyone or anything discourage you from being physically active?

Girls’ physical activity

Is it okay for girls your age to play sports? What are the advantages and disadvantages?

JPAH Vol. 12, No. 7, 2015

Physical Activity in South Asian Adolescents   933

Downloaded by Washington Univ In St Louis on 09/16/16, Volume 12, Article Number 7

In Canada, South Asian adolescents aged 11 to 18 years were recruited from a Hindu temple, a church and a South Indian ethnocultural association in the Greater Toronto Area. The FGDs were conducted in English by a member of the research team, following a religious service at the temple and church, and during an annual community festival organized by the ethno-cultural association. In Canada the focus groups were divided by gender and nutritional status only. Due to small numbers, all SES groups were combined. The FGD facilitator took detailed field notes. In both countries, written parental consent and written informed consent was obtained from all participants. In Canada, participants received a compensation of 5 Canadian dollars for their time. The FGDs lasted between 45 minutes to 90 minutes and were audio recorded and transcribed (non-English FGDs were first translated to English). Transcripts were reviewed by the FGD facilitators and note-takers for accuracy. Data Analysis.  A framework approach was used for the data

analysis.36 Drawing from the transcripts and field notes, a detailed summary was written for each of the focus group interviews; this formed the basis for an analytical framework. The major higher order themes were perceived benefits, facilitators, disadvantages and barriers for physical activity. After a detailed reading of the Focus Group Discussion summaries, 2 members of the research team created a set of lower order inductive categories within each of these themes, to capture all relevant factors mentioned by participants. This was the basis of the initial coding framework, which was modified once, after being tested on 2 Indian and 2 Canadian transcripts. Four members of the research team coded the data, and the lead author reviewed a sample of interviews to ensure interrater reliability. The qualitative data software NVivo 9.2 was used to code the interviews.37 The data were charted by category and focus group using Microsoft Excel spreadsheets, before thematic analysis and interpretation.

Results Table 3 provides a summary of the results by focus group.

Perceived Benefits of Physical Activity Physical Fitness, Energy, and Health.  All groups in India spoke about fitness and ‘energy’ being key benefits of physical activity. In addition, a common perception across the Indian groups was that physical activity would prevent lethargy and promote general interest in life. Typical comments from Indian adolescents were:

“Our bodies [feel] free, actually, because you don’t feel any heaviness, you just escape and be. If you don’t go to play, you will feel heaviness in your legs and body.” “We will not feel lazy [after exercising].”

“[If you are physically active] you feel good and accomplish more and feel less lazy.” Canadian overweight group participants similarly spoke of physical activity being important to remain energetic: “. .. To keep you energized [. . .] it keeps you active and healthy.” “You are more active, but if you are fat and chubby you are lazy.” While there was much discussion of fitness and ‘energy’ across all the adolescent groups, the discussion of specific health benefits among Indian adolescents was more limited and general in nature. For example, participants in the Indian overweight boys group mentioned that physical activity is “good for health,” while Indian overweight girls mentioned that it is important to start exercising early in life to establish healthy habits for later in life. In contrast, almost all the Canadian adolescent groups spoke in some detail about the health advantages conferred by physical activity, showing greater understanding of the physiological pathways for impacting health. Examples of Canadian participants’ observations on benefits of physical activity include “your heart rate is lower,” “metabolism becomes better,” “[preventing] clogged arteries,” and“[you have] a longer life.” Stamina and endurance were commonly mentioned as benefits of physical activity in India, in 5 of the 8 focus groups, with no specific patterns across gender, nutritional status, SES and location (urban/rural). Examples of Indian comments include, “We will have the capacity to bear certain pains.” “When we don’t have breakfast in the morning and if we get pain we will be able to bear it.” “If we run, we don’t even feel tired if we do any work.” “From childhood, if we do [exercise], our bones will become stronger. In the future we will have stamina to do the work.” In Canada, stamina and endurance were specifically mentioned as a benefit in only one of the Canadian groups (normal weight boys). Mental Alertness, Stress Relief, and Academic Performance.  In India, all groups of adolescents, across SES, nutritional status, location, and gender, spoke about physical activity helping to achieve clarity of mind, as well as mental alertness and focus. This was often spoken of in relation to more effective studying and consequently better academic performance. Typical statements across the Indian focus groups were:

“[Physical activity] clears the mind.” “The mind will be fresh.”

“It keeps you active, if you are physically fit.”

“Whatever we study, it will stay in the mind.”

“We will do any work with interest.” Canadian adolescents also spoke about the importance of physical activity for maintaining energy. For example, participants from normal weight groups mentioned, “If you have a really unhealthy body, you are really drowsy [. . .] and you can’t really concentrate on anything.”

“We will understand clearly what we are studying.” “Good performance in school.” “[Without physical activity], mentally they will be dumb. Physical activity should be done at least for sometime in daily life, even if you don’t do that you will be dumb.”

JPAH Vol. 12, No. 7, 2015

934

JPAH Vol. 12, No. 7, 2015

Physical fitness and energy, mental, alertness/academic performance, stress relief/ mental relaxation, enjoyment, opportunity to spend time with friends, ideal body shape

Physical fitness and energy, general health, mental alertness/academic performance, stress relief/ mental relaxation, ideal body shape (weight loss)

Physical fitness and energy, stamina/endurance, general health, mental alertness/ academic performance, stress relief/mental relaxation, ideal body shape (prevention of overweight and growth promotion)

Physical fitness and energy, stamina/endurance, general interest in life, mental alertness/academic performance, stress relief/ mental relaxation, ideal body shape (prevents overweight)

Physical fitness and energy, stamina/endurance, general health, mental alertness/ academic performance

Indian urban boys high SES normal weight

Indian urban boys high SES overweight

Indian urban boys low SES

Indian urban girls high SES normal weight

Indian urban girls high SES overweight

Benefits

Fatigue, body pains, injuries, gym has negative impact on growth

Injuries, negative impact on academics, gym has negative impact on growth

Injuries

Friends, parents, teachers, media messages and role models, health care providers, nearby playground

Friends, parents

Friends, parents, teachers

Fatigue, negative impact on Lack of safe space, parents’ academics discouragement, neighbors’ discouragement, pollution

Parents

Parents’ discouragement, academic pressures, other household responsibilities, lack of interest/motivation, no perceived benefit

Parents’ discouragement, teachers’ discouragement, academic pressures, other preferences for recreational time, lack of interest/motivation

Lack of safe space, parents’ discouragement, teachers’ discouragement, academic pressures, other preferences for recreational time, lack of interest/ motivation

Lack of safe space, no friends to play with, parents’ discouragement, teachers’ discouragement, academic pressures, safety concerns

Fatigue, injuries, takes time away from other activities, negative impact on academics

Friends, parents, teachers, media messages and role models, nearby playground

Barriers

Disadvantages

Facilitators

Table 3  Summary of Perceived Benefits, Facilitators, Disadvantages, and Barriers for Physical Activity

Downloaded by Washington Univ In St Louis on 09/16/16, Volume 12, Article Number 7

(continued)

Girls’ lack of interest, menstruation, societal concerns about girls’ reputation, relatives’ discouragement of girls

Girls’ lack of interest, societal concerns about girls’ reputation, menstrual period pains, parents’ advice not to exercise during menstruation

Girls’ lack of interest

Fewer sports for girls/women

Parents discourage girls, girls’ concerns about appearance, lack of encouragement from teachers for girls

Gender-specific barriers

JPAH Vol. 12, No. 7, 2015

935

Physical fitness and energy, stamina/endurance, interest in life, mental alertness/ academic performance, opportunity to spend time with friends

Physical fitness and energy, stamina/endurance, mental alertness, ideal body shape (weight loss)

Physical fitness and energy, general health, mental alertness/academic performance

Physical fitness and energy, stamina/endurance, ideal body shape (avoid weight gain)

Physical fitness and energy, general health, academic performance, enjoyment, ideal body shape (weight loss)

Health, mental relaxation

Physical fitness and energy, general health, ideal body shape (weight loss)

Indian rural boys low SES

Indian rural girls low SES

Canadian boys normal weight

Canadian boys overweight

Canadian girls normal weight

Canadian girls overweight

Benefits

Indian urban girls low SES

Table 3 (continued)

Injury, takes time away from other activities Fatigue, physical appearance, eating more

Friends, parents

Injury

Fatigue, takes time away from other activities

Injury

Teachers, selfmotivation

Parents, teachers, schools

Friends, teachers/ coaches, media messages, nearby playground

Parents, teachers, relatives

Injury, fatigue, heat-stroke

Fatigue, takes time away from other activities

Parents, teachers, media messages, health care providers

Friends, parents, teachers

Disadvantages

Facilitators

Perspectives of male peers on ideal female body shape

Teachers’ lower expectations for girls and physical activity

No perceived barriers

No perceived barriers

Girls’ lack of interest, societal concerns about girls’ reputation

Gender-specific barriers

Lack of time, parents’ discouragement, academic pressures, other preferences for recreational time, safety concerns, health problems, weather

Girls’ lack of interest

Lack of time, academic pressures, Lack of female role models, safety concerns, no perceived gender stereotypes, girls’ benefit concern about appearance

Lack of time, lack of safe space, distance to playground, parents’ discouragement, academic pressures, weather

Lack of time, distance to playground, other preferences for recreational time, lack of interest/ motivation, lack of family participation, weather

No perceived barriers

Weather

Lack of safe space, parents’ discouragement, neighbors’ disapproval, academic pressures, other preferences for recreational time, lack of interest, health problems, being overweight

Barriers

Downloaded by Washington Univ In St Louis on 09/16/16, Volume 12, Article Number 7

936  Rajaraman et al

In contrast, only the Canadian normal weight girls’ group mentioned mental relaxation as a specific benefit of physical activity. The only reference made to academic benefits among the Canadian groups was made in the overweight boys group, where one participant spoke of receiving academic credit as a benefit of enrolling in physical education classes: “I joined the volleyball team and got a 92. [I get] extra credit for joining clubs.”

Downloaded by Washington Univ In St Louis on 09/16/16, Volume 12, Article Number 7

Ideal Body Shape.  The importance of physical activity for attain-

ing ideal body shape was a commonly mentioned theme in most Indian and Canadian groups. In India, normal weight participants were more likely to speak about exercise for growth and achieving a good body build. In India and Canada, overweight participants spoke more about the importance of physical activity for weight management and improving physical appearance, although this was also mentioned in some of the normal weight groups. A participant in the overweight Indian boys’ group mentioned that physical activity was critical to avoid getting ‘fat,’ while a participant from the Canadian normal weight boys’ group spoke about physical activity being important to prevent obesity and therefore avoid diseases such as bulimia.

There were no consistent patterns differentiating the influence of friends across the countries, gender, SES, or location. Family and Teachers.  In Indian and Canadian groups, some

participants mentioned that their parents and teachers encouraged physical activity, with parents playing a more important facilitating role. A male participant from India quoted his mother as saying, “go and play so that your mental stress will come down,” while several adolescent girls in Indian urban groups said that their mothers forced them to do a few minutes of exercise every day. All Canadian groups (except overweight boys) reported that their parents and teachers encouraged physical activity through verbal prompts to be active.

Media Messages.  Adolescents in Canada and urban India mentioned that television images of celebrities being physically active (including sports stars) provided encouragement to be physically active. As noted, by some of the Indian normal weight boys, “We see cricket and we feel like playing.” At the same time, television shows that discuss the benefits of physical activity, especially with doctors providing advice, were considered to be important sources of information and encouragement for physical activity among Indian urban adolescents. Rural Indian groups did not mention media messaging as a determinant of physical activity behavior.

Social Inclusion.  In all settings, physical activity was also perceived to promote social inclusion and combat exclusion. Several groups in India and Canada noted that physical activity provides an opportunity to be close to friends (“We can be close to our friends by playing”). At the same time, urban overweight boys in India mentioned that exercising could help to address peer pressure or teasing for being lazy, while Canadian overweight girls and normal weight boys reported that being identified as overweight by peers was a strong motivator for exercising. In the words of one of the Canadian participants,

Negative Physical Effects.  Disadvantages of being physically active were discussed in greater depth by adolescents in India, compared with Canadian adolescents, who perceived fewer disadvantages. Across the settings, adolescents reported getting tired, injured, tanned, and sunburnt as disadvantages to being physically active. As noted by boys from the Indian groups:

“If someone calls you fat, you will feel bad and you are going to want to exercise.”

“We have no interest in doing anything [after physical activity], we are sleepy and cannot concentrate on any work.”

Other Benefits.  Other benefits of physical activity that were

However, in identifying disadvantages, many of the adolescents also discussed solutions to overcoming them such as staying healthy, eating well and not exercising on busy days to avoid getting tired (discussed by Indian adolescents), and using sunscreen and not going outside early in the afternoon to avoid the harmful effects of the sun (discussed by Canadian adolescents). Adolescents boys in India in urban high and low SES groups also made specific reference to the potential negative consequences of body-building and weight lifting, stating that it could have detrimental effects on their growth.

mentioned less frequently, and mostly in boys’ groups (in both India and Canada), were the simple enjoyment of playing active games and the potential to be a good sports player.

Perceived Facilitators of Physical Activity Friends.  In India and Canada, adolescents across the different stratifications perceived friends as a key motivator and facilitator for physical activity—friends provided encouragement through verbal prompts, positive reinforcement and praise, as well as companionship. A Canadian girl spoke about her friends’ reactions to her starting to take dance lessons:

“I was talking to my friends about the dance class and they said, ‘oh tell me if you are going to join it because then I will join it too!’ And one of my friends says, ‘oh yeah, you are very good at it! Do it!’ They always encourage you.” One adolescent boy in Canada admitted that he participated in physical activity not so much out of his own interest, but because of his friend’s preference: “I have only one friend . . . he is too much into sports. I want to go home or McDonalds, but he wants to hit the gym. So anywhere he tries to get me to go, I have to go.”

Perceived Disadvantages of Physical Activity

“We get body pain by playing.”

Competing Priorities (Academic Pressure and Preference for Other Sedentary Activities).  Perceived negative impact of physi-

cal exercise on academic performance was a potential barrier for Indian and Canadian participants. Among Indian adolescents, many focus group participants perceived physical activity as a ‘waste of time’ when it cut into study time. Closer to the examination period, teachers were reported as advising students to stop playing outdoors and focus only on their studies, while using the physical education periods for extra teaching. Students also worried that fatigue after exercising or playing outdoor games could reduce the effectiveness of their studying time. One adolescent boy explained, “Now as the exams are coming nearby, we don’t [go out to play]. You go play and come back, you feel very tired and you feel like taking rest, so we manage [by] going weekly just once on Sundays . . . .”

JPAH Vol. 12, No. 7, 2015

Physical Activity in South Asian Adolescents   937

Among Canadian groups, too, many participants said that they prioritized academic pursuits over participating in physical activity. Typical comments included, “It is about making a choice and priority. Right now, my priority is school. I am not going to worry about physical activity but about school. . . . Yeah time and school [discourages me from being physically active], it’s like you got to get your priorities straight.”

Downloaded by Washington Univ In St Louis on 09/16/16, Volume 12, Article Number 7

Apart from academic pressure, laziness and a preference for more sedentary activities were also cited as reasons for reduced physical activity among Indian and Canadian groups. Among Indian adolescents, television was identified as a common distraction that reduced physical activity, while Canadian adolescents talked about electronics more broadly as an alternative activity to exercise or physical games: “All the electronic things are distracting the kids from being active.” “Now we have more technology and everything is so convenient, so we stay in rather than going out.”

Perceived Barriers Female Gender.  In Canada and India, there were marked gender

differences in perceived expectations of parents and teachers with regard to girls’ participation in exercise and sports, societal values, and expressed level of interest and achievement in physical activities. While all Indian and Canadian groups of girls were ostensibly encouraged to be physically active by their parents, teachers and friends, they also received subtle and indirect cues that could deter exercise and sports. For example, Indian adolescent girls mentioned that they were not allowed to play outdoors when they were menstruating, that they faced concerns about getting dark complexioned if they spent too much time outdoors in the sun, and that spending time playing outdoors could affect their reputation. An urban Indian male participant related how the girls’ physical education teacher in his school not only allowed girls to sit down and chat during their physical education period, but also joined them in their conversation. In Canada, similarly, a male participant mentioned, “At school we have a fitness unit and our teacher’s expectations for the boys are always higher than the girls.” Overall, girls were more likely to mention that they were not interested in outdoor activity or exercise, admitting that they preferred to chat with friends than play physically active games (Indian girls) or select curricular options such as cosmetology over physical education in school (Canadian girls). Indian girls admitted, “We like to chat more than playing.” “Sometimes, when we go out . . . for cycling or something, your friend meets you there, we just start talking to her and time just goes on.” Similarly, a Canadian adolescent girl in the overweight group stated that “girls are not that interested like guys to be participating in sports,” and spoke about how sign up lists for male sports teams in her school filled up very fast, while the girls’ teams were never full. Overweight Canadian girls, especially, discussed lack of interest in physical activity, and preference not to participate in classes at all.

One Canadian girl pointed out that boys’ better performance in sport is probably linked to their greater interest: “People say that boys are so much better in sports, but I think that it is not that boys are better; it is that they are more interested in it.” A wider societal lack of interest in female sporting achievements may play a role in girls’ lack of interest in participating in sports, as there are few positive sporting role models for adolescent girls. In the words of one Canadian female participant, “For . . . girls, it is not . . . out there as much, like there is the NBA (National Basketball Association) and then there’s the WNBA (Women’s National Basketball Association) and they are very good and I watch it sometimes but they are not that popular. . . . They (women) don’t get credited as much (for playing sports).” In Canada, a few normal weight girls also mentioned physical appearance as a barrier to physical exercise, for example not wanting to “break a nail” or “get sweaty and all” while overweight Canadian boys also suggested that girls may be reluctant to participate in physical activity because of fears about boys’ perceptions of their physical appearance. Family.  For both male and female participants in India and Canada,

discouragement from family was reported as a deterrent to physical activity. Apart from parents’ concern about physical activity distracting from studies and the gender issues discussed above, participants reported that their parents forbade or discouraged them from playing outdoors because of fear about their safety. One Indian urban adolescent boy complained, “[My mother] says ‘don’t go so far, if you want you can play here.’ But I don’t play because none of my friends are there, so I’m isolated.” Similarly, a Canadian boy said that he would like to walk more, but his mother felt that this was too unsafe. Canadian adolescents also spoke about their families prioritizing other activities, and not engaging in physical activity with them. For example, participants noted, “I was raised in a family that does not care about being active.” “[My family does] not discourage physical activity . . . but they prefer to watch a movie with the family and not, say, go jogging.” In Canada, overweight adolescents also described being teased about their weight and ridiculed about their preferences to be physically active by family members. One Canadian girl described how her uncle had ridiculed her plans to enroll in dance lessons while another who had planned to join a dance class was advised by her mother to use the money to get a driver’s license instead.

Access.  In urban India (low and high SES groups) and in Canada, lack of outdoor space was a serious constraint to physical activity for many adolescents. Urban Indian adolescent boys generally spoke about how they were limited from playing outdoors with friends if they did not live close to a playground, while several girls’ and boys’ groups in India spoke about how neighbors’ concerns about potential damage from the children’s games and traffic prevented them from playing freely in their neighborhood. Similarly, in Canada, a couple

JPAH Vol. 12, No. 7, 2015

938  Rajaraman et al

of groups mentioned that their ability to be active was affected by geographical proximity to a location such as a playground, gym or school. One Canadian boy explained, “If it’s very far you don’t want to go as much. . . . If you’re going to go walk there the whole time then you’re going to have only 10 minutes to play and then you have to walk all the way back.” None of the Indian rural groups identified safe space as being a barrier to physical activity. Weather.  In India, only rural boys mentioned weather as a poten-

Downloaded by Washington Univ In St Louis on 09/16/16, Volume 12, Article Number 7

tial deterrent to physical activity, noting that they could not play outdoors if it was too hot and sunny. However, weather was commonly reported as a barrier across all the groups in Canada, with snow, rain, and extreme heat and cold all discouraging adolescents from being active outside.

No Perceived Benefits.  Lack of perceived personal benefit

could be a barrier to engaging in physical activity among Indian overweight boys and girls and Canadian normal weight girls. An Indian overweight boy spoke about experiencing no difference between whether he went to academic tuition classes or engaged in physical activity: “Now I go to play and tuitions. I don’t feel much difference between both, it’s the same. Because sitting in the tuitions makes me tired as much as physical activity. That is mental activity, this is physical activity.” Overweight Indian girls showed little interest in going to the gym, and one participant stated, ‘going to the gym is senseless,’ eliciting general agreement from the rest of the group. Among Canadian normal weight girls, who felt that they were already at an ideal weight, physical activity was seen as having little utility in their current life: “You already have the body you want so why work to make it better?” “You know when you are skinny its like, ‘oh I’m skinny I don’t have to exercise’ and it (physical activity) wouldn’t really have that much effect.”

Discussion This qualitative study provides valuable insights into factors that motivate, facilitate and inhibit physical activity among South Asian adolescent girls and boys in urban and rural India and urban Canada. Some of these factors are similar to those faced by other ethnic and cultural groups worldwide, some are specific to urban settings, and some appear to be linked to culture and context. Across all settings, there was a perception that girls were less interested in physical activity than boys. Stereotypes about girls’ activity and social proscriptions (in the Indian context) were perceived to reduce likelihood of girls being physically active. Another major barrier to physical activity among adolescents was limited access to safe space in urban settings. In the Indian and Canadian settings, academic pressures appeared to be a significant barrier to physical activity; but paradoxically, improved academic performance was also commonly considered a benefit in Indian settings. In a similar vein, parents and teachers could act as barriers, discouraging their children from physical activity for academic, social or safety concerns. While rural Indian adolescents perceived fewer barriers to physical activity than

urban Indian adolescents, there was little difference between high SES and low SES urban Indians in terms of perceived benefits, facilitators, disadvantages and barriers. This suggests that policy interventions to promote physical activity among Indian adolescents might be broadly applicable across groups of different SES in urban settings. Finally, while overweight adolescent groups in both India and Canada were more likely than normal weight adolescent groups to talk about the benefits of physical activity for weight loss and the possibility of social exclusion from being overweight, the perceived benefits, facilitators, disadvantages, and barriers were broadly similar across groups of different nutritional status. The findings of the study highlight 3 areas to be addressed in policies and programs to promote physical activity in young people: girls’ participation in physical activity and sport, addressing the impact of academic pressure on ability to engage in physical activity, and, the impact of urban growth on ability to play and exercise outdoors. These are discussed below. In both India and Canada, female gender was perceived by adolescent boys and girls to be associated with lower interest and/ or engagement in physical activity. Among our study participants, adolescent girls’ lack of motivation to participate in physical activity appeared to be linked to stated intrinsic preferences to be sedentary, aesthetic concerns, as well as social cues and norms, such as lower expectations for girls’ performance in school sports, lower societal value for women’s competitive sports, and (in the Indian setting only), concerns about girls’ reputation and safety if playing outdoors. Lower participation of girls in physical activity compared with boys has been documented in other settings, and has been attributed to societal norms that influence attitudes and have also resulted in a lack of opportunities to participate in sport and physical activity. In high-income countries such as the United States and the United Kingdom, this has led to the development of specific interventions to promote girls’ participation in sport.38,39 However, these have often not been designed with adequate care.40 The findings of our study suggest a strong need to promote girls’ physical activity across society and specifically in schools. Culture specific issues such as reputational risk for teenage girls playing outdoors, concerns about tanning, and restrictions on exercising while menstruating will also need to be addressed specifically within interventions that cater to South Asian population in India. There is some evidence supporting the impact of media messaging to increase physical activity in adolescents,41,42 and this could be drawn upon specifically to increase interest in female sports and support for girls’ physical activity among South Asian populations. A significant theme that emerged from this study is the perceived relationship between academic work and physical activity. In the Indian context, there appeared to be a particular emphasis on the utility of exercise for clearing the mind for more effective studying. However, paradoxically, urban Indian adolescents also spoke much more about their parents preventing them from engaging in physical activity before and during examination periods, in comparison with the Canadian South Asian adolescents. Indian adolescents also reported that their teachers sometimes took away their physical activity periods to deliver extra lessons. In all settings, adolescents mentioned reducing the amount of time they engaged in physical activity as a result of their academic pressures, because they did not have enough time, and they did not want to tire themselves out before studying. Studies that have examined the relationship between physical activity and academic achievements in children and adolescents suggest either a moderate benefit or no effect of physical activity on academic performance.43–48 While studies of children’s perspectives on physical activity in other countries have

JPAH Vol. 12, No. 7, 2015

Downloaded by Washington Univ In St Louis on 09/16/16, Volume 12, Article Number 7

Physical Activity in South Asian Adolescents   939

found ‘lack of time’ to be a barrier,49 this was linked more to distance to physical activity classes and facilities, other leisure activities, or parents’ lack of time. Other studies have not documented academic pressure and parental concern about academics as a major barrier to physical activity. Given the importance of physical activity for mental and physical health, it will be critical for education policy and school health promotion interventions in India to address the high level of academic pressure on students, and to ensure that parents as well as teachers are included in efforts to promote physical activity as children transition to adolescence. In industrialized countries, school-based initiatives have been effective in improving average physical activity among target populations, as well as in reducing inequities in physical activity between population groups.50 Nevertheless, for such initiatives to be scaled up, a recent United States report from the Institute of Medicine underscored the importance of a whole-school approach for supporting children and adolescents to adopt and maintain healthy life-long physical activity habits, requiring the involvement of government, district, and school administrators; teachers; and parents.51 Multipronged efforts will certainly be important in the Indian and Canadian settings as well. The enjoyment of playing active games was an important motivator for physical activity for boys in India and Canada, which is consistent with other studies of children and adolescents.49,52 However, a major barrier in urban settings to playing in active games was access to safe space and facilities. This is a commonly recognized challenge in urban areas across the world, and has been recorded in qualitative studies conducted solely in high-income country settings as well.46,49,52,53 The importance of a built environment that facilitates physical activity is now well recognized and is increasingly being incorporated into urban planning in high income countries.54,55 However, such initiatives are few and far between in low income countries such as India and tend to be limited to private initiatives taken within higher income neighborhoods.56 A built environment that is conducive to physical activity should be a critical policy priority to prevent chronic disease.57 Substantial advocacy will be required in India and other South Asian countries for formulation and implementation of such policies. It will also be necessary in high-income countries such as Canada to ensure equitable access to spaces for physical activity, across ethnic and socioeconomic lines. The strengths of this study are that it provides insights into the behavior and experiences of South Asian adolescents both in urban and rural settings in their country of origin as well as in a migrant population in an industrialized country. This allows for identification of factors that are both cultural and may influence physical activity even in migrant South Asian populations, as well as those that are contextual and specific to a particular country. The study nevertheless has several limitations. While the focus group methods allowed for a wide range of opinions and experiences to be captured, it did not allow for in-depth exploration of the experiences of individuals or of the interplay of different factors that resulted in an individual’s experience or attitude. In addition, the sample was limited to just 1 city and 1 village in India and 1 city in Canada. It therefore does not capture the entire range of experiences and attitudes of South Asian adolescents. We were not able to conduct multiple focus groups within each stratum, which limits our ability to assess whether we reached data saturation. Finally, being a qualitative study, this analysis does not provide representative data on the prevalence of the different attitudes, barriers and facilitators identified and their link to actual behaviors, sociodemographic characteristics or nutritional status. However, the study has identified important areas for further investigation in future quantitative and intervention studies. It also provides immediate insights for policy and programming to

promote physical activity in adolescents in India and among South Asian origin adolescents in Canada.

Conclusion There is continuing need to prioritize stronger societal support and access for South Asian adolescent girls’ physical activity; to enable students to perform well at school, without crowding out the time for engaging meaningfully in physical activity, especially in India; and, to advocate for a conducive built environment for adolescent physical activity in low and high income countries. Acknowledgments The study was funded by a team grant jointly supported by the Indian Council for Medical Research and the Canadian Institutes of Health Research. Lear holds the Pfizer/Heart & Stroke Foundation Chair for Cardiovascular Prevention Research at St. Paul’s Hospital, Vancouver.

References 1. World Health Organization. Global recommendations on physical activity for health. Geneva: WHO; 2011. 2. Dumith SC, Gigante DP, Domingues MR, Kohl HW, 3rd. Physical activity change during adolescence: a systematic review and a pooled analysis. Int J Epidemiol. 2011;40(3):685–698. PubMed doi:10.1093/ ije/dyq272 3. Knuth AG, Hallal PC. Temporal trends in physical activity: a systematic review. J Phys Act Health. 2009;6(5):548–559. PubMed 4. Hallal PC, Andersen LB, Bull FC, Guthold R, Haskell W, Ekelund U. Global physical activity levels: surveillance progress, pitfalls, and prospects. Lancet. 2012;380(9838):247–257. PubMed doi:10.1016/ S0140-6736(12)60646-1 5. Hills AP, Andersen LB, Byrne NM. Physical activity and obesity in children. Br J Sports Med. 2011;45(11):866–870. PubMed doi:10.1136/bjsports-2011-090199 6. Sallis JF, Hinckson EA. Reversing the obesity epidemic in young people: building up the physical activity side of energy balance. Lancet Diabetes Endocrinol. 2014;2(3):190–191. PubMed doi:10.1016/ S2213-8587(13)70193-1 7. Song SH, Hardisty CA. Early-onset Type 2 diabetes mellitus: an increasing phenomenon of elevated cardiovascular risk. Expert Rev Cardiovasc Ther. 2008;6(3):315–322. PubMed doi:10.1586/14779072.6.3.315 8. Schwimmer JB, Deutsch R, Kahen T, Lavine JE, Stanley C, Behling C. Prevalence of fatty liver in children and adolescents. Pediatrics. 2006;118(4):1388–1393. PubMed doi:10.1542/peds.2006-1212 9. Biddle SJ, Asare M. Physical activity and mental health in children and adolescents: a review of reviews. Br J Sports Med. 2011;45(11):886– 895. PubMed doi:10.1136/bjsports-2011-090185 10. Telama R. Tracking of physical activity from childhood to adulthood: a review. Obes Facts. 2009;2(3):187–195. PubMed doi:10.1159/000222244 11. Swaminathan S, Vaz M. Childhood physical activity, sports and exercise and noncommunicable disease: a special focus on India. Indian J Pediatr. 2013;80(Suppl 1):S63–S70. PubMed doi:10.1007/ s12098-012-0846-1 12. World Health Organization. Global health risks: mortality and burden of disease attributable to selected major risks. Geneva: WHO; 2009. 13. Lee IM, Shiroma EJ, Lobelo F, Puska P, Blair SN, Katzmarzyk PT. Effect of physical inactivity on major non-communicable diseases worldwide: an analysis of burden of disease and life expectancy. Lancet. 2012;380(9838):219–229. PubMed doi:10.1016/S01406736(12)61031-9 14. Misra A, Shah P, Goel K, et al. The high burden of obesity and abdominal obesity in urban Indian schoolchildren: a multicentric study

JPAH Vol. 12, No. 7, 2015

Downloaded by Washington Univ In St Louis on 09/16/16, Volume 12, Article Number 7

940  Rajaraman et al

of 38,296 children. Ann Nutr Metab. 2011;58(3):203–211. PubMed doi:10.1159/000329431 15. Misra KB, Endemann SW, Ayer M. Leisure time physical activity and metabolic syndrome in Asian Indian immigrants residing in northern California. Ethn Dis. 2005;15(4):627–634. PubMed 16. O’Loughlin J, Maximova K, Tan Y, Gray-Donald K. Lifestyle risk factors for chronic disease across family origin among adults in multiethnic, low-income, urban neighborhoods. Ethn Dis. 2007;17(4):657– 663. PubMed 17. Daniel M, Wilbur J. Physical activity among South Asian Indian immigrants: an integrative review. Public Health Nurs. 2011;28(5):389–401. PubMed 18. Fischbacher CM, Hunt S, Alexander L. How physically active are South Asians in the United Kingdom? A literature review. J Public Health (Oxf). 2004;26(3):250–258. PubMed doi:10.1093/pubmed/ fdh158 19. Registrar General and Census Commissioner. Census of India 2011. Rural Urban Distribution of Population (Provisional Population Totals). New Delhi: Government of India; 2011. 20. Anjana RM, Pradeepa R, Das AK, et al. Physical activity and inactivity patterns in India—results from the ICMR-INDIAB study (Phase1). [ICMR-INDIAB-5] Int J Behav Nutr Phys Act. 2014;11(1):26. PubMed doi:10.1186/1479-5868-11-26 21. Swaminathan S, Selvam S, Thomas T, Kurpad AV, Vaz M. Longitudinal trends in physical activity patterns in selected urban south Indian school children. Indian J Med Res. 2011;134:174–180. PubMed 22. Rajpathak SN, Gupta LS, Waddell EN, et al. Elevated risk of type 2 diabetes and metabolic syndrome among Asians and south Asians: results from the 2004 New York City HANES. Ethn Dis. 2010;20(3):225–230. PubMed 23. Hippisley-Cox J, Coupland C, Vinogradova Y, et al. Predicting cardiovascular risk in England and Wales: prospective derivation and validation of QRISK2. BMJ. 2008;336(7659):1475–1482. PubMed doi:10.1136/bmj.39609.449676.25 24. Hippisley-Cox J, Coupland C, Robson J, Sheikh A, Brindle P. Predicting risk of type 2 diabetes in England and Wales: prospective derivation and validation of QDScore. BMJ. 2009;338:b880. PubMed doi:10.1136/bmj.b880 25. Nightingale CM, Rudnicka AR, Owen CG, Cook DG, Whincup PH. Patterns of body size and adiposity among UK children of South Asian, black African-Caribbean and white European origin: Child Heart And health Study in England (CHASE Study). Int J Epidemiol. 2011;40(1):33–44. PubMed doi:10.1093/ije/dyq180 26. Joshi P, Islam S, Pais P, et al. Risk factors for early myocardial infarction in South Asians compared with individuals in other countries. JAMA. 2007;297(3):286–294. PubMed doi:10.1001/jama.297.3.286 27. Smedley B, Syme S. Committee on capitalizing on social science and behavioral research to improve the public’s health. Washington, DC: National Academy Press, Institute of Medicine; 2000. 28. Glanz K, Rimer BK, Lewis F. Theory, research, and practice in health behavior and health education. In: Glanz K, Rimer BK, Lewis F, eds. Health behavior and health education. San Francisco: Jossey-Bass; 2002:22–39. 29. Zaragoza J, Generelo E, Julian JA, Abarca-Sos A. Barriers to adolescent girls’ participation in physical activity defined by physical activity levels. Journal of Sports Medicine Physical Fitness. 2011;51(1):128– 135. PubMed 30. Kelly EB, Parra-Medina D, Pfeiffer KA, et al. Correlates of physical activity in black, Hispanic, and white middle school girls. J Phys Act Health. 2010;7(2):184–193. PubMed 31. Robbins LB, Pender NJ, Kazanis AS. Barriers to physical activity perceived by adolescent girls. J Midwifery Womens Health. 2003;48(3):206–212. PubMed doi:10.1016/S1526-9523(03)00054-0 32. Rabiee F. Focus-group interview and data analysis. Proc Nutr Soc. 2004;63(4):655–660. PubMed 33. Stroebe W. Social psychology and health. 2nd ed. Buckingham, Philadelphia: Open University Press; 2000.

34. Janz NK, Champion V, Strecher V. The health belief model. In: Glanz K, Rimer BK, Lewis F, eds. Health behavior and health education. 3rd ed. San Francisco: Jossey-Bass; 2002:45–66. 35. De Onis M, Onyango AW, Borghi E, Siyam A, Nishida C, Siekmann J. Development of a WHO growth reference for school-aged children and adolescents. Bull World Health Organ. 2007;85(9):660–667. PubMed doi:10.2471/BLT.07.043497 36. Gale NK, Heath G, Cameron E, Rashid S, Redwood S. Using the framework method for the analysis of qualitative data in multidisciplinary health research. BMC Med Res Methodol. 2013;13:117. PubMed doi:10.1186/1471-2288-13-117 37. QSR International. NVivo qualitative data analysis software. 9.2 ed. 2010. 38. Vu MB, Murrie D, Gonzalez V, Jobe JB. Listening to girls and boys talk about girls’ physical activity behaviors. Health Educ Behav. 2006;33(1):81–96. PubMed doi:10.1177/1090198105282443 39. Wetton AR, Radley R, Jones AR, Pearce MS. What are the barriers which discourage 15-16 year-old girls from participating in team sports and how can we overcome them? Biomed Res Int. 2013;2013:738705. 40. Rees R, Kavanagh J, Harden A, et al. Young people and physical activity: a systematic review matching their views to effective interventions. Health Educ Res. 2006;21(6):806–825. PubMed doi:10.1093/her/ cyl120 41. Huhman M, Potter L, Wong F, Banspach S, Duke J, Heitzler C. Effects of a mass media campaign to increase physical activity among children: year-1 results of the VERB campaign. Pediatrics. 2005;116(2):e277–e284. PubMed doi:10.1542/peds.2005-0043 42. Hieftje K, Edelman E, Camenga D, Fiellin L. Electronic media-based health interventions promoting behavior change in youth: a systematic review. JAMA. 2013;167(6):574–580. PubMed 43. Ahamed Y, Macdonald H, Reed K, Naylor PJ, Liu-Ambrose T, McKay H. School-based physical activity does not compromise children’s academic performance. Med Sci Sports Exerc. 2007;39(2):371–376. PubMed doi:10.1249/01.mss.0000241654.45500.8e 44. Carlson SA, Fulton JE, Lee SM, et al. Physical education and academic achievement in elementary school: data from the early childhood longitudinal study. Am J Public Health. 2008;98(4):721–727. PubMed doi:10.2105/AJPH.2007.117176 45. Coe DP, Pivarnik JM, Womack CJ, Reeves MJ, Malina RM. Effect of physical education and activity levels on academic achievement in children. Med Sci Sports Exerc. 2006;38(8):1515–1519. PubMed doi:10.1249/01.mss.0000227537.13175.1b 46. Trudeau F, Shephard RJ. Physical education, school physical activity, school sports and academic performance. Int J Behav Nutr Phys Act. 2008;5:10. PubMed doi:10.1186/1479-5868-5-10 47. Dwyer T, Sallis J, Blizzard L, Lazarus R, Dean K. Relationship of academic performance to physical activity and fitness in children. Pediatr Exerc Sci. 2001;13:225–237. 48. US Centers for Disease Control and Prevention. The association between school-based physical activity, including physical education, and academic performance. Atlanta, Georgia: Department of Health and Human Services; 2010. 49. Brunton G, Harden A, Rees R, Kavanagh J, Oliver S, Oakley A. Children and physical activity: a systematic review of barriers and facilitators. London: EPPI-Centre, University of London; 2003. 50. Vander Ploeg KA, Maximova K, McGavock J, Davis W, Veugelers PJ. Do school-based physical activity interventions increase or reduce inequalities in health? Soc Sci Med. 2014;112:80–7. PubMed doi:10.1016/j.socscimed.2014.04.032 51. Institute of Medicine. Educating the student body: taking physical activity and physical education to school. Washington, DC: Institute of Medicine; 2013. 52. Brockman R, Jago R, Fox KR. Children’s active play: self-reported motivators, barriers and facilitators. BMC Public Health. 2011;11:461. PubMed doi:10.1186/1471-2458-11-461 53. Kirby J, Levin KA, Inchley J. Socio-environmental influences on physical activity among young people: a qualitative study. Health Educ Res. 2013;28(6):954–69. PubMed doi:10.1093/her/cyt085

JPAH Vol. 12, No. 7, 2015

Physical Activity in South Asian Adolescents   941

56. Mohan V, Pradeepa R. Redesigning the urban environment to promote physical activity in Southern India. Diabetes Voice. 2007;52:33–35. 57. World Health Organization. Preventing chronic diseases. A vital investment. Geneva: World Health Organization & Public Health Agency of Canada; 2005.

Downloaded by Washington Univ In St Louis on 09/16/16, Volume 12, Article Number 7

54. Edwards P, Tsouros A. Promoting physical activity and active living environments. Copenhagen: World Health Organization Europe; 2006. 55. Frank L, Engelke P, Schmid T. Health and community design: the impact of the built environment on physical activity. Washington DC: Island Press; 2003.

JPAH Vol. 12, No. 7, 2015