Nghĩa của việc tham gia chương trình tập thể dục và chăm sóc sức khỏe cho người tiểu đường - Nghiên cứu của Rebekkah Jane Middleton tại Đại học Wollongong

University of Wollongong Research Online University of Wollongong Thesis Collection University of Wollongong Thesis Collections 1954-2016 2016 The Meaning of Involvement in an Exercise and Health Promotion Program for People with Diabetes Rebekkah Jane Middleton UOW, rmiddle@uow.au Follow this and additional works at: https://ro.au/theses University of Wollongong Copyright Warning You may print or download ONE copy of this document for the purpose of your own research or study. The University does not authorise you to copy, communicate or otherwise make available electronically to any other person any copyright material contained on this site. You are reminded of the following: This work is copyright. Apart from any use permitted under the Copyright Act 1968, no part of this work may be reproduced by any process, nor may any other exclusive right be exercised, without the permission of the author.

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Unless otherwise indicated, the views expressed in this thesis are those of the author and do not necessarily represent the views of the University of Wollongong. Recommended Citation Middleton, Rebekkah Jane, The Meaning of Involvement in an Exercise and Health Promotion Program for People with Diabetes, Doctor of Philosophy thesis, School of Nursing, University of Wollongong, 2016.au/theses/4909 Research Online is the open access institutional repository for the University of Wollongong. For further information contact the UOW Library: research-pubs@uow.au The Meaning of Involvement in an Exercise and Health Promotion Program for People with Diabetes A thesis submitted in fulfillment of requirements for the degree of Doctor of Philosophy from University of Wollongong by Rebekkah Jane Middleton, RN, BN, MN(Res) School of Nursing, Faculty of Science, Medicine and Health 2016 Abstract The aim of this study was to explore and understand the meaning that people with diabetes attribute to being involved in a specialised program involving exercise and health promotion. Diabetes is a prevalent and chronic disease both in Australia and internationally with known benefits and outcomes from involvement in physical activity.

However, there is still a lack of commitment and sustaining of exercise regimens by people with diabetes. In order to understand and interpret the meaning behind the reasons why the 15 participants chose to engage in an exercise and health promotion program, a phenomenological approach was used. More specifically, an approach using Heideggarian interpretive phenomenology, using van Manen’s (1990) methodological framework provided a structure and a guide to the inquiry into the lived experiences of the participants who had diabetes and were participating in a program called Beat It. The research study was designed in a way so as to answer the question: ‘What does it mean for people with diabetes to be part of a therapeutic recreation program involving exercise and health promotion?’.

Participants were invited to share their stories and uncover meanings in their experiences, and to facilitate this, data collection occurred in two phases. First, semi-structured, conversational individual interviews occurred, and then, once preliminary analysis of themes had occurred, a focus group was held to member check. Data analysis conformed to van Manen’s Six Step Methodical Structure (1990), which uses a Heideggerian hermeneutical research methodology and enabled identification of thematic statements. II Within the participants’ story-telling, the meaning of the program Beat It, for people with diabetes, emerged through methodical synthesis of participant voices in interviews and a focus group.

The meaning that participants’ ascribed to their experience was revealed in two themes: people and structure. Within the themes, elements were identified. The theme, People, entailed three elements: motivation, connectedness and psychological benefits. The theme, Structure, consisted of two elements: physical benefits and instructor.

Embedded within the participants voices and stories was the essence of their experiences – the meaning that each participant attributed to their experiences of undertaking the exercise and health promotion program. This essence was found to be person-centred program efficacy that gave meaning to the experience. Understanding the meaning that people with diabetes attribute to being involved in a specialised exercise and health promotion program, facilitates the development of more tailored programs that can better enhance health and wellbeing in this population of people. The development of person centred diabetes programs can then help to minimise preventable health conditions associated with the disease.

Implications for researchers and diabetes service providers are centred on the need for further research exploring the subjective views of people with diabetes, with a focus on partnering with and engaging those with diabetes in designing and planning programs that facilitate commitment. III Certificate of Authorship and Originality of Thesis I, Rebekkah Jane Middleton, declare that this thesis, submitted in fulfulment of the requirements for the award of Doctor of Philosophy, in the School of Nursing, University of Wollongong, is wholly my own work unless otherwise referenced or acknowledged. The document has not been submitted for qualifications at any other academic institution. Rebekkah Middleton Date: 20 March 2017 IV Copyright Statement Copyright © Rebekkah Jane Middleton 2017 All rights reserved.

V Table of Contents Abstract.II Certificate of Authorship and Originality of Thesis. IV Copyright Statement. X Publications and presentations emanating from this research. XI Manuscripts published.

XI Manuscripts submitted under review. XI Conference presentations .XII Definition of Key Terms .XIII Chapter 1 – Research Overview. 4 Rationale and significance of the research study. 5 Organisation of the thesis.

5 Conventions within the thesis. 6 Chapter 2 – Background and Context. 12 Prevalence and associated mortality. 13 Diabetes and exercise/physical activity.

16 Physiological benefits of exercise on diabetes. 18 Diabetes and required levels of exercise. 25 Diabetes management, self-management and maintaining a healthy lifestyle. 27 Psychological benefits of exercise.

36 Diabetes and engagement in exercise programs and interventions. 43 History and Definition of Therapeutic Recreation (TR). 43 The contribution of Therapeutic Recreation to diabetes health promotion. 45 Diabetes and Therapeutic Recreation.

57 Beat It and older adults. 59 Programs supported by professionals. 60 Diabetes, Therapeutic Recreation and Meaning. 70 Contributions of this research study.

73 Chapter 3 – Research Design. 76 Role of the researcher. 92 VI van Manen’s Six Steps of Methodical Structure. 93 Trustworthiness of the data.

215 Section 1 – The essence of meaning. 269 Section 2 – Theoretical links and contribution of theory to the research. 273 Diabetes related behaviour and motivation. 273 Self-Determination Theory.

289 Chapter 6 – Conclusion and Recommendations. 295 Theoretical Contribution to knowledge. 298 Recommendations for further research work. 304 Appendix 1 – Ethics approval.

335 Appendix 2 – Consent form. 339 Appendix 3 – Participant information sheet. 341 Appendix 4 – Focus group letter. 343 Appendix 5 – Focus group participant information sheet.

344 Appendix 6 – Focus group consent form. 346 VII List of Figures Figure 1: Prevalence, potential impact and associated mortality of diabetes worldwide 2005-2015 …………………………………………………………………….14 Figure 2: Prevalence, potential impact and associated mortality of diabetes in Australia 2005-2015………………………………………………………………………….15 Figure 3: The Beat It program…………………………………………………….56 Figure 4: The Illawarrra region…………………………………………………….58 Figure 5: Location of Illawarra region in NSW, Australia…………………………….……103 Figure 6: Screen shot taken from journal………………………………………………….113 Figure 7: Screen shot taken from NVivoTM…………….117 Figure 8: Funnel design of the discussion guide…………………….120 Figure 9: Essence of meaning informed by themes and elements………………….145 Figure 10: Themes and elements that emerged from the data………….150 Figure 11: Elements of People theme……………………………………………………………….151 Figure 12: Motivation as element of theme People………………………………………….152 Figure 13: Connectedness as element of theme People………………………………….171 Figure 14: Psychological benefits as element of theme People…………………….184 Figure 15: Summary of elements of theme People……………………….190 Figure 16: Elements of Structure theme……………….191 Figure 17: Physical benefits as element of theme Structure…………………………….192 Figure 18: Instructor as element of theme Structure……………….………………………200 Figure 19: Summary of elements of theme Structure…………….…………………………213 Figure 20: The meaning of the TR program Beat It for participants….214 Figure 21: People theme and elements……………………………………………………….219 Figure 22: Motivation element……………………………………………………………………….220 Figure 23: Free bus route………………………………….………………………………………………225 Figure 24: Motivation to commit to the Beat It program…………………….230 Figure 25: Connectedness element……………………………………………………………….…237 VIII Figure 26: Psychological benefits element……………………………………………………….244 Figure 27: Structure theme and elements…………………………………………………………251 Figure 28: Physical benefits element…………………………………………………………………252 Figure 29: Instructor element……………………………………………………………………………259 Figure 30: The SDT model of health behaviour change adapted from Ryan, Deci and Williams (2008)………………………….278 Figure 31: TR opportunities for people with diabetes……………………….………………286 Figure 32: Essence of meaning………………………………………………………………….296 List of Tables Table 1: Recommended physical activity guidelines for people with diabetes compared to people without diabetes……………………………………………….19 Table 2: Benefits of participation in TR services……………………………………….47 Table 3: Summary of TR model……………………………….48 Table 4: Beat It program fulfilling the requirements of a TR model………….55 Table 5: Six step methodical structure…………………….94 Table 6: Interview questions and prompts…………………………………………………….107 Table 7: Focus group questions, phrases and prompts………………………………….121 Table 8: Participant information regarding participation in interviews and focus group……………………………………………………………………………………………….148 Table 9: Payment rates for age pension…………………………………………………………222 Table 10: Similarities between SDT and person-centredness………………………….287 IX Acknowledgements I would like to thank my two supervisors, Professor Lorna Moxham and A/Prof Dominique Parrish. Their ongoing support, encouragement and guidance throughout my PhD candidature has enabled me to remain focused and keep my eye on the target ahead. The learning I have gleaned from them has helped shape me as a researcher and be committed to completing this thesis in a timely manner.

Lorna thankyou for your honesty, encouragement and realism throughout this journey – you have made this a great learning opportunity and have exemplified supervision leadership. Dominique, your eye has ensured things make sense, thankyou! Thankyou to the people who encouraged me through the more challenging times and assured me this journey would be worth the effort. I am grateful to the people who willingly shared their stories and lived experience with me, making this thesis possible. Finally I want to thank my husband Mark for being patient with me and loving me unconditionally as I went through the ups and downs of completing this research.

This would not have been possible without his support, listening ear, and love. X Publications and presentations emanating from this research Manuscripts published Middleton, R, Moxham, L & Parrish, D 2016, ‘If you can’t engage them they won’t attend’, Australian Nursing & Midwifery Journal, vol. Middleton, R, Moxham, L & Parrish, D 2016, ‘Diabetes, older people and exercise: Recommendations for health promotion programs’, Australian Nursing & Midwifery Journal, vol. Middleton, R, Moxham, L & Parrish, D ‘Committing to a health promotion program: an Australian case study’.

In press: Global Journal of Health Education and Promotion. Middleton, R, Moxham, L & Parrish, D ‘The value of health promotion programs for older people with chronic conditions in the community – an overview of the literature’. In press: Australian Nursing & Midwifery Journal. Manuscripts submitted under review Middleton, R, Moxham, L & Parrish, D ‘Motivation to engage in therapeutic recreation programs for older people with diabetes’.

Submitted to and under review: World Leisure Journal. XI Conference presentations Middleton, R, Moxham, L & Parrish, D (presenting author: Rebekkah Middleton). ‘An exercise and health promotion intervention for people with diabetes: case study of an Australian program’. Oral presentation at the World Leisure Congress, Alabama, USA.

Congress theme: Leisure – Enhancing Human Condition. Middleton, R, Moxham, L & Parrish, D (presenting author: Rebekkah Middleton). ‘An effective leisure program for older people with diabetes’. Oral presentation at the World Leisure Congress, Durban, South Africa.

Congress theme: Challenges, Choices and Consequences.