Physical activity and behavioral regulations for exercise in patients with noncommunicable disease in central Saudi Arabia
Franziska Vanadis Isabelle Saller1, Amal Mohammed2, Fahad Al Dhaferi2
1 Department of Project Management, Universidad Internacional Iberoamericana, Campeche, México
2 Department of Outpatient, Prince Mohammed bin Abdulaziz Hospital, Riyadh, Saudi Arabia
|Date of Submission||15-Jul-2020|
|Date of Decision||04-Sep-2020|
|Date of Acceptance||07-Sep-2020|
|Date of Web Publication||18-Oct-2020|
Ms. Franziska Vanadis Isabelle Saller
Department of Project Management, Universidad Internacional Iberoamericana, Calle 15 Num. 36, Entre 10 y 12, IMI III, CP 24560, Campeche
Objective: Saudi Arabia’s population has experienced a significant raise of noncommunicable diseases (NCD) over the past decade. Physical activity (PA) is recognized to positively impact the course of NCD, but existing evidence indicates poor PA protocol adherence across the nation. The self-determination theory (SDT) proposes that perceived autonomy and motivational quality for exercise play a determining role in behavioral regulation. The aim of this study was to explore SDT-based constructs and PA-related characteristics in Saudi patients with four major NCD.
Materials and Methods: A questionnaire-based, cross-sectional study was conducted to evaluate the relations between PA and relative autonomy for exercise in patients with cardiovascular disease (CVD), diabetes (T1DM and T2DM), and hypertension (HTN) in a hospital in Riyadh.
Results: Two hundred and sixty-three patients >18 years participated in the study. Patients accumulated 2016 metabolic equivalent minutes of PA per week (standard deviation = 1683.40). PA levels differed significantly between CVD and HTN, CVD, and T1DM patients (P < 0.00). T1DM was the most active and CVD the least active patient group. PA levels were highly correlated with the degree of perceived autonomy for exercise (r (244) = 0.65, P = 0.000) and differed significantly between some patient groups (P < 0.05). Motivational quality significantly predicted PA level in the sample (F[4, 241] = 48.639, P < 0.000, R = 0.447).
Conclusion: Our results indicate that perceived autonomy and motivational quality are underestimated determinants of PA in patients with T1DM, T2DM, HTN, and CVD in Saudi Arabia. Differing NCD-PA profiles suggest the need for disease-specific treatment approaches.
Keywords: Noncommunicable disease, physical activity, Saudi Arabia, self-determination theory
|How to cite this article:
Saller FV, Mohammed A, Al Dhaferi F. Physical activity and behavioral regulations for exercise in patients with noncommunicable disease in central Saudi Arabia. Saudi J Sports Med 2020;20:13-21
|How to cite this URL:
Saller FV, Mohammed A, Al Dhaferi F. Physical activity and behavioral regulations for exercise in patients with noncommunicable disease in central Saudi Arabia. Saudi J Sports Med [serial online] 2020 [cited 2020 Dec 18];20:13-21. Available from: https://www.sjosm.org/text.asp?2020/20/1/13/298437
Despite the importance of regular physical activity (PA) for positive health practice, Saudi Arabia (KSA) still ranks among the nations with the highest levels of physical inactivity worldwide.,, This is contributing to a continuously rising incidence of noncommunicable diseases (NCD), with expected further growth over the next years., The adaptation of a regular PA protocol in addition to disease-specific pharmacotherapy is recognized to positively impact the course of the disease and related symptoms., Unfortunately, existing evidence demonstrates generally poor PA protocol adherence in KSA., Cultural- and patient-specific knowledge about particularities in health behavior determinants is a crucial decision-making basis for the health-care professional in charge. Thus, this research aimed to contribute to disease-specific knowledge within the field of health education and clinical exercise psychology for a selection of the most common NCD in KSA.
On the theoretical basis of the self-determination theory (SDT),, this study focused on the investigation of behavioral regulations, perceived autonomy and motivational quality toward PA in Saudi patients with cardiovascular disease (CVD), diabetes, and hypertension (HTN). Ryan and Deci assume that human motivation is strongly dependent on the degree of autonomy a person perceives, which refers to the feeling of having control over ones’ own actions without being external forced or influenced.,
The SDT proposes a taxonomy of three different motivational types (amotivation, extrinsic motivation, and intrinsic motivation) and six associated behavioral regulations (nonregulation, external, introjected, identified, integrated, and intrinsic), differing in the degree of perceived autonomy and reflecting the degree to which the very behavior has been internalized or integrated into one’s self., Evidence shows, that a greater degree of internalization and a higher degree of perceived autonomy is associated with better adherence to medications and intervention compliance and better disease self-management outcomes. Community- and patient-specific knowledge of the prevalence of motivational quality and characteristics of the underlying behavioral regulations for exercise in patients with NCD can support the health-care professionals in charge in the development of strategies to facilitate internalization processes for PA behavior and in this way potentially increase the efficacy of respective treatment approaches. The results of this study will hopefully illustrate the impact potential behind psychological determinants of PA in patients with NCD diseases in KSA and serve as an anchor point for future studies to target respective field of research.
|Materials and Methods|
A cross-sectional design was used to determine the prevalence of PA levels, sitting time, degree of relative autonomy, and predominant behavioral regulations for exercise in patients with one of four major NCD in a clinical setting in central Saudi Arabia. This studied was approved by the Ethics Committee of the International Iberoamerican University (UNINI) on March 22, 2019, and by the Ethics Committee of the Prince Mohammed bin Abdulaziz Hospital on May 5, 2019 (obtained May 14, 2019; approval no. CR-018-MX).
The study population included adult male and female patients (>18 years) of Arab ethnicity who were visiting the outpatient department during data collection period for the treatment of one of the following diseases: CVD, diabetes type 1 (DMT1), diabetes type 2 (DMT2), or HTN. Participation in this study was on a voluntary basis. In total, 276 patients of both genders participated in the study. In the process of data cleaning, response data of 15 participants were considered as inauthentic and excluded as outliers prior to statistical data analysis. In the end, 263 (n = 263) participants were included in the statistical analysis, with 52% (n = 135) being female and 49% (n = 127) male.
The study sample was generated using a probability-based, simple random stratified sampling technique, based on a daily list-based sampling frame of all eligible patients registered in the endocrine and cardiology department during the data collection period between May and December 2019. A minimal daily sample size of 50% of all daily patients in each department was priorly determined.
Randomly selected patients were approached by the data collector in charge and asked for participation. Standardized explanations about the purpose, duration, anonymity, and volitional participation were given to each prospective participant. A signed informed consent was obtained from each participant prior to participation.
Data collection tool was a paper-based questionnaire available in Arabic and English language.
Demographic and anthropometric data
The survey covered gender, age groups, nationality, marital status, having children or not, educational level, occupation, and two anthropometric questions for self-reported weight (kg) and height (cm). Furthermore, participants had to indicate their primary diagnosis and existing secondary complications besides the primary diagnosis.
Physical activity and daily sitting time
PA levels were assessed with the short version of the International PA Questionnaire short form (IPAQ-SF) [Supplementary Material 1a] [Additional file 1], a frequently used instrument to measure PA levels and sitting time., The questionnaire consists of seven items regarding the individuals’ recall of the PA level and sitting duration across the past 7 days. The instrument takes measure of three different exercise intensity levels (vigorous PA, moderate PA, and walking). PA frequency (days per week) and duration (time per day) are separately collected for each activity type. Only adaption applied to the original instrument was the provision of closed, fully structured answer options to each question. This adaptation has been made to facilitate item coding and subsequent cross-lingual data analysis.
Behavioral regulations for exercise
An Arabic version of the Behavioral Regulations for Exercise Questionnaire, third Version (BREQ-3,) [Supplementary Material 1b] [Additional file 2] was used to measure the participants’ behavioral regulations toward exercise. The BREQ-3 has been reported as a valid and reliable instrument in populations of different ethnicity., An internal consistency coefficient (Cronbach’s alpha) of 0.91 was obtained for the BREQ-3 scale in this study. The instrument includes 24 items distributed across six factors based on the STD. Each factor contained four items assessing the six behavioral regulatory styles. A five-point Likert scale was used for response collection and ranged from “not true at all for me” (1) to “very true for me” (5).
Instrument translation procedure
Originals of all instruments were initially available in English language. Translation procedure was guided by the development guidelines and adoption criteria of Health Survey Instruments of the European Commission and included professional forward and backward translation of all questionnaires [Supplementary Material 2] [Additional file 3].
All statistical analysis was conducted using IBM SPSS Statistics for Windows, Version 20.0. Released 2011; (Armonk, NY: IBM Corp.). First, data were screened on writing errors, inconsistencies, value credibility, and outliers. Descriptive statistics was initially used to present the data. To assess the differences between categorical variables, Pearson’s Chi-square test was employed.
The IPAQ-SF data were scored on continuous level, calculating the total metabolic equivalent of task (MET) per week for each participant. Scoring of the BREQ-3 responses was carried out according to the author’s guidelines and included the calculation of single subscale scores, as well as the “Relative Autonomy Index” (RAI), a unidimensional score measuring the degree to which the participants felt autonomous in their behavioral regulation for exercise.
Kruskal–Wallis test was executed to investigate the differences of the nonnormally distributed data, while one-way analysis of variance (ANOVA) was used to assess these differences in the normally distributed variables. If a main effect was detected, Bonferroni post hoc procedure was conducted to specify the significant effect within the groups. Bivariate correlation analysis and Pearson’s correlation coefficient was calculated to assess the associations between interval scaled variables. Finally, a multiple linear regression analysis with dummy variables was calculated to predict PA level (MET min./wk. = DV) based on primary diagnosis (IV1) and motivational quality (RAI score = IV2).
Demographic characteristics, body mass index, and primary diagnosis
Demographic and anthropometric characteristics of the study participant are summarized in [Table 1], [Table 2], [Table 3]. Body mass index (BMI) data interpretation followed the WHO guidelines for weight class categorization, evidencing a mean BMI of 28.08 (standard deviation [SD] = 4.86, 95% confidence interval [CI] [27.5–28.7]) and an overweight or obese prevalence of 68% in the sample [Table 3]. The most common primary diagnosis was T2DM (39%, n = 103), followed by CVD (34%, n = 90), HTN (22%, n = 59), and T1DM (4%, n = 14) [Figure 1]. Most frequent reported complications were HTN (58%, n = 76), neuropathy (11%, n = 14), and renal disease (11%, n = 14).
|Figure 1: Frequency distribution of the noncommunicable diseases patient groups N = 263|
Levels of physical activity and sitting time across the entire sample
PA level was coded according to the WHO guidelines for minimal recommended PA-related MET minutes (min.) per week (wk.): Low level of weekly PA: <600 MET min./wk., moderate level of weekly PA: 600–2999 MET min./wk. and high level of weekly PA: ≥3000 MET min./wk. On average, participants accumulated 2016 MET min./wk. (SD = 1683.40, 95% CI [1812–2220]) through the execution of light, moderate, and vigorous PA. Close to 20% of all participants demonstrated a low or very low (<300 METs) level of total weekly PA. Around 60% of the sample reported a moderate level of PA. The remaining 20% fell under the high PA level category [Figure 2].
|Figure 2: Histogram graphic of total metabolic equivalent of task minute distribution across the sample. N = 263, M = 2015.91; standard deviation = 1683.4, METmin = 00, METmax = 7754, Med = 1606, Q1 = 689, Q3 = 2894|
Daily sitting time across the sample was primarily characterized by equal proportions (37% respectively) of sitting most of the day (n = 98) or move and sit similar amounts of time during the day (n = 97).
Levels of physical activity and sitting time across the different noncommunicable diseases patient groups
T1DM patients were the most active individuals (M = 3040, SD = 1073.33), followed by HTN (M = 2503, SD = 1643.85) and T2DM patients (M = 2156, SD = 1979.58). Least active were CVD patients, demonstrating the lowest average MET min./wk. (M = 1411, SD = 1132.69). Due to nonnormal distribution of the MET data, Kruskal–Wallis test (H-test) was used to detect whether the central tendencies between the MET minutes and the four different disease groups differed significantly. Test results confirmed a significant difference between the group ranks χ2 (3) = 23.373, P = 0.000. Dunn-Bonferroni post hoc test verified a significant PA level difference between CVD and HTN (z = 3.96, P = 0.000) and CVD and T1DM patients (z = 3.54, P = 0.002) at 0.05 level of significance. No significant differences were found between the other patient groups (P > 0.05). Effect size according to Cohen was: CVD × HTN: R = 0.24 and CVD × T1DM: R = 0.22, suggesting a medium effect of the detected differences [Table 4].
|Table 4: Descriptive statistics of total metabolic equivalent of task min/week across the four patient groups|
Relationships between physical activity level, sitting time, demographic, and anthropometric data
H-Test showed MET scores to differ significantly across the age groups χ2 (5) = 51.22, P = 0.000 [Figure 3]. Similarly, sitting time and age group affiliation also differed significantly from each other χ2 (20, N = 262) = 70.33, P = 0.000. Sitting time increased proportionally with age. Education level also resulted to be significantly related to MET score χ2 (4) = 49.60, P = 0.000, with the differences being significant between the uneducated/illiterate subjects and those with low educational level, when compared to higher education level (P ≦ 0.03). The relation between sitting time and education level also turned out to be significant χ2 (20 = 262) = 67.05, P = 0.000. MET ranks did not significantly differ by gender (P = 0.06) and BMI (P = 0.26) at 0.05 level of significance. Either did sitting time significantly differ by gender χ2 (4, N = 262) = 5.85, P = 0.21 or BMI χ2 (12, N = 256) = 4.50, P = 0.21.
|Figure 3: Distribution of physical activity levels, measured in metabolic equivalent of task minutes (mean) per week across the six age groups|
Behavioral regulations for exercise
Results for each separate behavioral regulations for exercise questionnaire, third version subscale across the entire sample
The majority of the sample (65%) scored low on the amotivation subscale (M am = 1.38, SDam = 0.75, n = 249) and highest on the identified regulation scale (Miden = 3.58, SDiden = 0.96, n = 247) [Figure 4]. Boxplot data visualization, however, indicated a considerable number of outliers on the amotivation scale (n = 20). Outlier examination revealed that high amotivation scores were associated with the female gender, CVD, obesity, and low levels of PA. Across the other subscales, the participants scored similarly on external and integrated regulatory styles (Mex = 2.66, SDex = 1.06) and the introjected and integrated behavioral regulation (Mintro = 2.47, SDintro = 1.17; Mint = 2.49, SDint = 1.23) [Table 5].
|Figure 4: Bar chart of the sample scores across the six behavior regulation styles. Amotivation: N = 254; external r.: N = 250; introjected. r.: N = 250, identified r.: N = 252; integrated r.: N = 249; intrinsic r.: N = 251|
|Table 5: Descriptive statistics for the behavioral regulations for exercise questionnaire, third version subscales and the relative autonomy index|
Results of the relative autonomy index-degree or relative autonomy across the entire sample
Mean RAI score was 4.80 (SD = 7.57, 95% CI [3.8–5.8]), indicating a slightly positive tendency toward more relatively autonomous, rather than relatively controlled behavioral regulation for exercise across the sample (n = 246).
Association between the relative autonomy index scores and physical activity levels across the sample
Bivariate correlation analysis and Pearson’s correlation coefficient revealed a strong correlation between PA level (MET scores) and degree of relative autonomy for exercise (RAI scores): R (244) = 0.65, P = 0.000 at 0.01 level of significance. Forty-two percent of the variance in the MET data were predictable from the RAI data (R2 = 0.43).
Distribution of relative autonomy index scores across the four noncommunicable diseases patient groups
One-way ANOVA showed that the perceived relative autonomy for exercise differed significantly across the patient groups (F[3, 242] = 5.93, P = 0.001), with an indicated medium effect (η2 = 0.068). T1DM patients scored highest on the RAI (MT1DM = 11, SDT1DM = 5.88), while T2DM and HTN patients scored considerably lower on average (MT2DM = 5, SDT2DM = 7.84; MHTN = 6, SDHTN = 7.38) CVD patients demonstrated the lowest levels of relative autonomy for exercise (MCVD = 3, SDCVD = 6.88). Bonferroni post hoc analysis confirmed these differences to be significant between the T1DM and T2DM patients (P = 0.048), T1DM and CVD patients (P = 0.002), as well as HT and CVD patients (P = 0.028) [Table 6].
|Table 6: Mean, standard deviation, and one-way analysis of variance in relative autonomy index scores and primary diagnosis|
Predictive characteristics of primary disease and motivational quality on physical activity level
A multiple linear regression analysis with dummy variables was calculated to predict PA level (MET min./wk. = DV) based on primary diagnosis (IV1) and the degree of relative autonomy for exercise (RAI score = IV2). Beforehand, the categorical “primary diagnosis variable” (IV1) was transformed into four dummy variables (Dummy T1DM, Dummy T2DM, Dummy HTN, and Dummy CVD). Dichotomous variables were coded: 1– NCD existed, 0– NCD did not exist. The CVD variable was selected as the control variable, since it was the only variable with negative influence on the DV. A significant regression equation was found (F[4, 241] = 48.639, P < 0.000), with an R2 of. 447. Accordingly, the participants’ predicted PA level was equal to 416.327 * T1DM + 472.196 * T2DM + 581.827 * HTN + 138.888 * RAI + 1061.142. T2DM and HTN were significant predictors of higher PA levels when compared to CVD.
The degree of perceived autonomy for exercise significantly predicted PA level in the sample (P = 0.000). Hence, the regression model resulted to be significant (P = 0.000) and is considered useful for prognostic purposes. Nonetheless, with 45% (R2= 0.45), the goodness-of-fit of the model is still mediocre and can only explain less than half of the variation in the MET score around its mean.
This study aimed to contribute to the understanding of PA behavior and underlying regulations in patients with NCD in KSA.
The anthropometric outcomes of our study are consistent with the results of previous studies reporting a high prevalence of overweight and obesity in clinical populations, and highlight a need for body weight reduction across all patient groups. Our findings that participants on average met with the minimum WHO recommendations for weekly PA were unexpected. Due to the predominant evidence of quite low levels of PA in KSA,,, we had also expected to discover rather poorly developed PA habits in our study population. Noteworthy was also the absence of significant associations between PA level and gender and PA level a BMI. Evidence of significant associations between these variables has been proposed for females in various occasions as being significantly less active than men,, and with a higher BMI commonly associated with lower levels of PA in KSA., We suspect the presence of a chronic disease and associated behavioral modifications to have an altering impact on these commonly demonstrated relationships. Nonetheless, the finding that PA levels were negatively associated with age was consistent with results of other regional studies,, just as the detected positive impact of education level on PA in the participants.,
Considering the disease-specific PA level, our results showed that some patient groups differed in their weekly activity level and daily sitting time. CVD participants were at a higher risk for inactivity, when compared to HTN and T1DM and T2DM patients. CVD patients were significantly less active than HTN and T1DM patients, with lower total MET min./wk. and higher levels of daily sedentary behavior.
A potential reason for this disease-specific PA-gap might be that exercise as a measure in secondary prevention in CVD is still not commonly propagated by health-care providers, but rather over emphasized in its potential risks for the patient living with a heart condition. Concerning behavioral regulations, we could confirm the SDT-based assumption that a higher degree of perceived autonomy for exercise is linked to a higher the likelihood to engage in it., The detected effect was consistent when assessed across the different patient groups, with the most active T1DM patients scoring significantly higher on the RAI than the least active CVD patients.
Therefore, when aiming to foster PA in patients with NCD in KSA, targeted improvement of the individuals’ perceived autonomy toward exercise might be a promising strategy to consider. The detected dominant prevalence of the identified regulatory pattern suggests that across the study population, PA behavior was predominantly regulated by the personal importance or conscious valuing of PA or exercise the patients were attributing to it. These results points toward the acceptance or identification of exercise to be personally important to the majority of the patients.,, The comprehensive efforts made by Saudi Arabia in recent years to promote PA and exercise in the nation might partially explain this outcome.
Amotivation was least common among the participants. However, a certain proportion of the sample deviated notably and demonstrated high levels of nonself-determined motivational patterns, and was characterized by the presence of low PA, high BMI, CVD diagnosis, and female gender. Therefore, certain NCD patient subgroups with low levels of perceived autonomy toward exercise behavior might share a set of characteristics or commonalities in risk profiles, whose identification might help the health-care professional to build more precise interventions aiming to foster the patient’s ownership of exercise-related behaviors. Finally, our findings confirmed the prognostic model of NCD group association and motivational quality on levels of PA to be useful for the task of prognosis to a certain extent. It also showed that in this connection the impact of motivational quality on PA was by far greater than the impact of disease group association.
There are two major limitations in this study that could be addressed in future research. First, the assessment of PA levels through a self-report questionnaire brings a number of disadvantages such as the decreased robustness of measure or the potential for social desirability bias. Although PA-questionnaires being common practice in research, the utilization of more robust real-time measures (e.g., pedometer and heart rate monitors) is worth considering in future studies. The second limitation concerns the scope and comprehensiveness of the theory-based measures. Even though motivational quality and perceived autonomy belong to the key components of the SDT, other theory-inherent constructs such as the three fundamental psychological needs, or life aspirations, are important constructs to consider in future studies if the basic exploratory research aims to inform theory-based behavioral interventions.
We conclude that perceived autonomy toward exercise and motivational quality is an underestimated determinant of PA in patients with T1DM, T2DM, HTN, and CVD in Saudi Arabia. We want to draw attention to the potential of differing NCD-PA profiles in specified subpopulations or communities and therefore varying needs of PA increment different NCD patient groups might have. Further research is encouraged to better understand cultural, psychosocial community-specific determinants of PA behaviors in patients with NCD in KSA. We aimed to meet with the criteria of internal and external validity by applying proper methodology (i.e., adequate sample size, randomized sampling, theory-based variables, validated instruments, and appropriate statistical analysis) and by creating inclusion criteria representative of the specified diagnostic subgroups of patients visiting the outpatient department of governmental hospitals in KSA. We therefore assume, that the results of this study will potentially be statistically generalizable to adult Saudi outpatient populations with diagnosed DM, CVD, and HTN, complying with a high degree of similarity to the geographic hospital setting (urban environment), as well as determined demographic population characteristics. However, replication of the study design in a different setting and population is needed to confirm this assumption.
The PI greatly appreciates the support by the research team on site in the process of data collection.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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