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Perceived barriers and facilitators to exercise in kidney transplant recipients: A qualitative study

Abstract Background Exercise has the potential to attenuate the high levels of cardiovascular morbidity and mortality present in kidney transplant recipients (KTRs). Despite this, activity levels in KTRs remain low. The aim of this qualitative study was to explore the barriers and facilitators of exercise in KTRs. Methods Thirteen KTRs (eight males; mean ± SD; age 53 ± 13 years; estimated glomerular filtration rate 53 ± 21 ml/min/1.73 m2) were recruited and completed semistructured one‐to‐one interviews at University Hospitals of Leicester NHS Trust. All KTRs were eligible if their kidney transplant was completed >12 weeks before interview and their consultant considered them to have no major contraindications to exercise. All interviews were audio recorded, transcribed verbatim and subject to framework analysis to identify and report themes. Results Themes were organized into personal, behavioural and environmental factors based on social cognitive theory. Facilitators of exercise were largely internal: enjoyment, exercise for general health and health of the transplanted kidney and desire to maintain normality. Social interaction, support and guidance of healthcare professionals and goal setting were perceived as motivational. Harming the kidney, a lack of guidance, self‐motivation and accessibility were barriers to exercise. Conclusion These results provide detailed insight into the development of interventions designed to increase physical activity in KTRs. They provide strong evidence that specific exercise guidelines are required for this population and that the healthcare system could have a key role in supporting KTRs to become more physically active. Interventions need to be multifaceted to appeal to the differing levels of support desired by KTRs. Patient or Public Contribution KTRs were involved in the development of the interview topic guide to ensure all relevant topics were explored.


| INTRODUCTION
Adopting a healthy lifestyle with exercise is recommended by the clinical practice guideline for the care of kidney transplant recipients (KTRs). 1 It is estimated that less than one in three KTRs reach the minimum level of 150 min of moderate-intensity physical activity per week as recommended by the World Health Organization. 2 Cardiovascular disease (CVD) remains a leading cause of morbidity and mortality in KTRs, which has been associated with the elevated traditional and nontraditional risk factors present in this population. 3 Exercise in the general population associates with a less deleterious CVD risk-factor profile, less cardiovascular morbidity and mortality 4 and a better quality of life. 5 Although abundant empirical evidence is lacking for these associations in KTRs, positive effects of exercise have been reported, 6 and it remains an important therapeutic choice in posttransplantation management.
Encouragement from healthcare providers (78%) was also a frequently endorsed facilitator. The majority of studies outlining the barriers and facilitators to exercise in KTRs are survey-based. Studies that widen the focus to explore why and how these factors influence physical activity behaviour beyond a fixed response would provide valuable evidence to inform future practice. For example, what type of encouragement from healthcare providers serves as a facilitator to physical activity. This would allow identification of specific factors that could be drawn upon to design appropriately tailored guidelines and to develop and implement behaviour change programmes designed to promote increased activity in this unique population. The need for this detailed information has been highlighted and the importance of developing evidence-based exercise guidelines and individually tailored exercise regimens based on the needs and resources of the individuals has been stressed. 8 The aim of this study was to identify and explore the perceived barriers and facilitators to exercise in greater depth than the current literature provides. These results can be appropriately utilized in the development of future interventions addressing the low levels of physical activity in KTRs.

| Study design
This study was conducted under the constructivist paradigm allowing the formation of assumptions and construction of meaning to be drawn from the data. 9 Social cognitive theory (SCT) was used as a conceptual framework to organize the data and to portray how the findings could be utilized in future intervention development. Data were collected using one-to-one semistructured interviews to explore perceptions and experiences of exercise. The wider study was approved by the NRES Committee East Midlands-Northampton ( with a maximum sample size of 15. This was with consideration to time restraints and resources with respect to gathering and analysing the data. This was in line with recommendations and evaluation of prior research by Francis et al. 10 It is also in line with 'typical' sample sizes for phenomenological studies, 11 which suggest that a sample size of 12 is likely to lead to saturation of the data.

| Recruitment
Participants were recruited using a convenience sampling method from University Hospitals of Leicester NHS Trust (UHL) kidney outpatient clinics. Consultants screened clinic lists based on study inclusion/exclusion criteria. Eligible patients were approached after their clinical consultation and were given a patient information sheet.
All patients who had received their kidney transplant >12 weeks were eligible unless their clinician deemed them to have a major contraindication to exercise. Although no physical exercise was required for this study, it was considered unsuitable to ask these participants exercise-related questions. Exclusion criteria were: unstable angina or myocardial infarction during the previous 6 weeks, severe heart failure, severe chronic obstructive pulmonary disease, severe lower limb orthopaedic problems or severe lower limb neuromuscular disease.

| Data collection
All one-to-one semistructured interviews were conducted by R. E. B. in a private room at UHL following written informed consent. Participants had no pre-existing relationship with the researcher. An interview topic guide was developed and piloted with two KTRs.
Adjustments were made in accordance with feedback before proceeding (see Supporting Information A). Interviews had two parts: (1) general exercise, and (2) high-intensity interval training. This report focuses on (1) general exercise due to a large volume of data produced. Part 1 covered the following topics: general exercise attitudes; current exercise; benefits of exercise; negative elements of exercise; barriers to exercise; reasons for exercising; exercise benefits and drawbacks with a specific focus on being a KTR. Interviews lasted between 20 and 60 min. Probes were used to ensure rich detailed data. All interviews were recorded digitally, anonymized and professionally transcribed verbatim. All transcripts were read whilst simultaneously listening to audio files to ensure accuracy. All audio files and transcripts were imported into NVivo 11 (QSR International NVivo 11 Pro). Demographic and clinical data were extracted from medical records. Current weekly physical activity was descriptively obtained from interview data.

| Data analysis
Data were analysed using framework analysis, providing a flexible pragmatic approach to explore a broad area of research without being bound to a particular epistemological position. 12 The flexibility of framework analysis allowed for a complementary inductive and deductive approach to analysis. The inductive approach allowed us first to gain insights into the key barriers and drivers of exercise, which subsequently allowed us to identify a suitable theory, which could be used to apply a deductive approach to our analysis. 13 Gale et al. 13 have broken down the original five-phase analysis 14 into seven phases in the context of multidisciplinary health research, which were followed for the present analysis: (1) transcription, (2) familiarization with the interview, (3) coding, (4) developing a working analytical framework, (5) applying the analytical framework, (6) charting the data into the framework matrix and (7) interpreting the data. Initial coding of two transcripts was completed by two researchers (R. E. B. and C. S.) to ensure consistency of interpretation. A working analytical framework was agreed upon and applied to the remaining transcripts by R. E. B. Newly identified codes were added throughout the process and the framework was not finalized until the final transcript. Some of the themes presented can be identified as both barriers and facilitators to exercise. Patterns based on age, gender and exercise frequency were searched for in the data. No patterns were identified based on age or gender. Patterns based on exercise frequency are reported within the results.
The themes identified were compatible with SCT that provides a framework to explain how the interaction between personal, behavioural and environmental factors influence behaviour. 15 SCT was utilized to inform the analysis and themes were categorized according to the three factors.

| RESULTS
Thirty-two KTR were invited to take part in the study. Thirteen were recruited and completed a one-to-one semistructured interview (participant characteristics are outlined in Table 1). Interviews ranged in duration between 19 and 59 min, with a mean duration of 34 min.
Nineteen patients declined to participate or did not meet the inclusion/exclusion criteria. Patients were not required to give reasons for declining participation but, for those who did, the main reasons for decline (and for exclusion) were: lack of time, distance to travel, language barrier, burden of comorbidities and low transplant function. These results describe the perceived barriers and motivators of exercise in KTR in the context of SCT.

| Personal factors
Four themes were identified relating to personal factors, each with several subthemes. Table 2 presents example quotations for each theme.
3.1.1 | Physical and mental benefits (subthemes: General well-being, improvements in specific health factors, musculoskeletal, mental well-being, longevity of the new kidney and stress relief) The majority of participants described the physical benefits of exercise to their general well-being as their motivation. Those who did not exercise acknowledged the health benefits and expressed that they 'should be doing it'. Preserving the longevity of the transplanted kidney was defined as highly important and exercise was suggested as a strong contributor to achieving this: 'Not only because obviously it lowers levels but [I] also know damn well what effect it has on the kidney and ultimately I want it to last as long as possible…' (Male, Age 59). Participants reported the role of exercise in reducing specific health risks, including elevated weight, high cholesterol and hypertension, with the desire to manage these being a significant incentive to becoming or staying active. Participants discussed the musculoskeletal benefits of exercise, including preserved mobility and increased muscular strength, and the importance of this to their kidney condition. Exercise was perceived to impact positively on mental well-being by making participants 'feel better' and giving them mental 'clarity'. Some participants defined exercise as a 'stress-relief' and others as a way to 'take their mind off' their transplant and related worries.

| Anxiety and self-confidence (subthemes:
Harming the transplant, confidence in ability, perception of age, restrictions and heightened self-awareness) Participants held concerns about exercise harming their transplant, and felt they lacked knowledge of appropriate exercise and how hard they should be 'pushing' themselves. Concerns were felt to be greatest during the early stages of transplant, as participants 'got used to it' and as they were still healing. Some of the participants' feeling of anxiety stemmed from a 'lack of self-confidence' in their appearance and ability to exercise: 'I think it's just having that confidence to do things because I think going to the gym, unless I did it with someone else, I'd feel really anxious about going and just really like self-conscious…' (Female, Age 32). However, only two participants reported that their concerns prevented them from exercising.
Martial arts and contact sports were frequently mentioned; some participants expressed disappointment that they could not participate in these activities posttransplant. One participant expressed that initial restrictions on lifting (e.g., heavy items, weight lifting) posttransplant elicited a natural tendency to restrict such activities for longer periods of time: 'Some of it is perceived I think as well because obviously you get told you can't lift but that doesn't mean to say you can't lift light weight I'm sure. But, straight away you then start putting more restrictions on yourself and then obviously it just compounds' (Male, Age 59). Participants reported a heightened sense of self-awareness during exercise in terms of 'listening to their bodies'. They reported being much more aware of feeling unwell and

| Environmental factors
Four themes related to environmental factors with various subthemes identified within each major theme. Professional support 'Maybe they need someone specific that works with the dietician possibly and the doctors, so they are the recreational advisors'. (Female,57) reassurance that what they are doing is not going to harm the kidney in any way. The least active participants discussed this type of guidance more. It was not expected that this supervision would be long-term.

| Healthcare professionals influence
(subthemes: Importance of key healthcare providers and professional support) Overall participants expressed the importance of their healthcare provider as a factor in supporting and facilitating exercise behaviours.
They perceived needing support and encouragement to start or return to exercise. Those with less exercise experience appeared to require greater support. Those who did exercise before transplant

| Behavioural factors
Two themes were identified as behavioural factors with underlying subthemes. Table 4 presents example quotations for each theme.
3.3.1 | Goal setting (subthemes: Setting goals, selfmanagement, tracking improvements and achievement) Setting goals was perceived by participants to be a motivator for continuing exercise. A structured approach was defined as a key 'aid' to exercise achievement: 'I suppose just having structure, that's the biggest aid I have. And again going back to how much exercise has taught me about setting goals and achieving them and setting stress targets but also setting, doing it with baby steps' (Male, Age 36).
Those who exercised explained how they had specific aims in mind and strived to complete them and that being able to self-manage was a contributor to increased confidence. Goals were largely autonomous, but one participant reported a preference for a professional to set goals: '…you maybe not be doing the right form of exercise for what you want or might be doing the right exercise but the wrong way' (Male, Age 47). Observing improvements to functional and clinical outcomes after fulfilling aims was considered a motivating factor for participants to engage in sustained exercise.

| Exercise preference (subthemes: Activities)
Participants highlighted that their individual exercise preferences had a big impact on enjoyment which in turn seemed to influence continued exercise behaviours. A big factor in this was the location with many participants favouring exercise that was outdoors with 'views' and 'fresh air'. Participants perceived this as a more 'pleasurable' experience: 'Yeah it's much more pleasurable being in the countryside than exercising at home, cycling's just strolling through nice places for me really' (Male, Age 42). Many participants reported walking as their preferred activity as it could be easily fitted into daily life. Some participants described how they preferred exercise classes as these were more structured and motivational. Several participants described their 'housework' and general chores as their way of being active. The gym was not perceived by many participants as a favourable exercise environment; often it was described as 'boring'. Fear of injuring the transplanted graft, insecurity with the body, and body signals have been previously postulated as a reason for lower levels of reported physical activity in KTRs. 8,16 Whilst this was present in the current study, participants expressed that a lack of guidance and a fear of the unknown were contributing factors. In solid organ transplant recipients (SOTR), lack of expertise of healthcare professionals was reported as a barrier to physical activity and support from professionals was identified as a strong facilitator. 16 This is not isolated to transplant recipients; the positive impact that healthcare professionals can have on patient behaviours including physical activity is widely known. 17 Improved education of lifestyle self-management in CKD was identified as a need in the 'Kidney

T A B L E 4 Behavioural factors example quotations
Health: Delivering Excellence' report. 18 However, participants discussed feeling as though exercise was not a priority of the healthcare service, which is akin to previous findings in a CKD population. 19 The

latest 'Management of Kidney Transplant Recipients by General
Nephrologists' curriculum states, in a section about weight control and exercise, that KTRs should be routinely and frequently counselled on the benefits of exercise. 20 However, physicians are not routinely trained in exercise and physical activity prescription and formal referral pathways for rehabilitation do not exist for KTRs.
Physicians who exercise regularly are more likely to counsel their patients to exercise and inadequate knowledge and experience is a barrier to counselling. 21 A lack of evidence-based exercise guidelines for KTRs is likely a factor in why there is suboptimal patient counselling from healthcare professionals, as well as a lack of time whilst providing essential care. Out of 34 Canadian physicians, only 18% were confident in performing physical activity counselling to their SOTR; lack of exercise guidelines was cited as one of the main barriers (53%). 22 Specific guideline development has been identified as a future research priority 23 and, healthcare professionals should have a key role in the development and implementation of these guidelines. 24 All participants expressed a desire for more exercise guidance and advice, even those who had received some guidance appeared to have unanswered questions. Participants discussed three types of guidance: standardized, prescriptive and supervised. Standardized written guidance was favoured by those who already exercise and was perceived as sufficient information to aid them in feeling confident about appropriate exercise. Other participants desired more prescriptive exercise, which has been previously reported. 25 Participants did not wish to have generic guidelines but instead preferred individualized regimens personalized by ability (not necessarily supervised). This was expressed by participants who were keen to set goals. Finally, supervised sessions were discussed mainly by the least active participants who felt that these sessions would give them confidence in their ability and reassure them that nothing they were doing would negatively impact the new kidney. Well-established supervised exercise programmes have been identified as one of the most likely reasons why heart and lung transplant recipients exhibit greater physical activity levels than KTRs. 24 A key influencer of exercise behaviours was social interaction. The relationship between social support and exercise has been linked to many theoretical perspectives: SCT, 15 Theory of Planned Behaviour 26 and Self-Determination Theory. 27 Social support (instrumental, emotional or informational) is thought to increase self-efficacy and induce perceived behavioural control, which facilitates physical activity adherence and maintenance, especially if positive intentions are formed. 28 Family support and inclusion was highly valued by participants as was exercise with friends. Exercising with someone or receiving encouragement to exercise was defined previously as an exercise strategy by KTRs. 25 One participant expressed that not knowing any other KTRs who performed exercise resulted in feelings of isolation. This is supported by the findings of Clarke et al., 19 who found that participants expressed a desire to attend CKD-specific exercise sessions, which would provide a safe environment. Sharing experiences and the support derived from fellow patients was beneficial during supervised rehabilitation in other chronic disease/pain management groups. 29,30 Self-efficacy (confidence in one's ability to complete a particular behaviour) and self-regulation (the control of one's behaviour through planning, setting goals and self-monitoring) are thought to be fundamental cognitive factors influencing behaviour change within SCT. The least active participants described a lack of self-confidence in their ability to exercise. Previous research has shown that fear of movement posttransplantation is related to low levels of physical activity and is strongly mediated by low self-efficacy. 31 Interventions should focus on improving self-efficacy to foster positive and sustained exercise behaviours. Setting goals and monitoring progress was perceived as motivational by participants in this study and in others. 16,19 Self-monitoring has been shown to be effective in improving physical activity in patients with CVD. 32 Although this study has provided new insights into a wide range of exercise determinants in KTRs, some limitations are acknowledged. It is possible that this was a 'self-selecting' group of KTRs who had an interest in exercise. Participant characteristics show that several participants were engaging in regular physical activity and therefore responses may not have captured the barriers to exercise experienced by those who are largely inactive. Nineteen participants declined to participate in the study. Interestingly, reasons for declining study participation, 33 as mentioned above, are factors that also influence physical activity levels, which might explain why those volunteering were quite physically active overall. The results therefore may not capture all of the potential barriers to exercise. Future similar studies would benefit from capturing higher numbers of inactive KTRs.
The sample was not as diverse as intended; the participants of this study were almost all of a White British ethnicity. UHL cares for an ethnically diverse population of kidney patients and therefore some bias may have occurred during recruitment, potentially due to a language barrier with the researcher. Given that perceptions and barriers to exercise can bear cultural differences, 33 future research should strive to include participants from a range of cultural backgrounds.
Some participants were less than 1-year posttransplant and described themselves as 'getting back into exercise'. Generally, during the year after transplant physical activity levels initially drop but then gradually increase above pretransplant levels. 34 As participants gained more confidence in their ability to exercise, they may have