Social-Ecological, Motivational and Volitional Factors for Initiating and Maintaining Physical Activity in the Context of HIV

Abstract

Sport and exercise can have several health benefits for people living with HIV. These benefits can be achieved through different types of physical activity, adapting to disease progression, motivation and social-ecological options. However, physical activity levels and adherence to exercise are generally low in people living with HIV. At the same time, high drop-out rates in intervention studies are prevalent; even though they often entail more favourable conditions than interventions in the natural settings. Thus, in the framework of an intervention study, the present study aims to explore social-ecological, motivational and volitional correlates of South African women living with HIV with regard to physical activity and participation in a sport and exercise health promotion programme. The qualitative data was produced in the framework of a non-randomised pre-post intervention study that evaluated structure, processes and outcomes of a 10-week sport and exercise programme. All 25 participants of the programme were included in this analysis, independent of compliance. Data was produced through questionnaires, participatory group discussions, body image pictures, research diaries and individual semi-structured interviews. All participants lived in a low socioeconomic, disadvantaged setting. Hence, the psychological correlates are contextualised and social-ecological influences on perception and behaviour are discussed. The results show the importance of considering social-cultural and environmental influences on individual motives, perceptions and expectancies, the fear of disclosure and stigmatisation, sport and exercise-specific group dynamics and self-supporting processes. Opportunities and strategies to augment physical activity and participation in sport and exercise programmes in the context of HIV are discussed.

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96 The Open AIDS Journal, 2015, 9, (Suppl 1: M6) 96-103
1874-6136/15 2015 Bentham Open
Open Access
Social-Ecological, Motivational and Volitional Factors for Initiating and
Maintaining Physical Activity in the Context of HIV
Clemens Ley*,1, María Rato Barrio2 and Lloyd Leach3
1Universität Wien, Institut für Sportwissenschaft, Austria
2Palacky University Olomouc, Department of Development Studies, Czech Republic
3Department of Sport, Recreation and Exercise Science, University of the Western Cape, Cape Town, 7535, South Africa
Abstract: Sport and exercise can have several health benefits for people living with HIV. These benefits can be achieved
through different types of physical activity, adapting to disease progression, motivation and social-ecological options.
However, physical activity levels and adherence to exercise are generally low in people living with HIV. At the same
time, high drop-out rates in intervention studies are prevalent; even though they often entail more favourable conditions
than interventions in the natural settings. Thus, in the framework of an intervention study, the present study aims to
explore social-ecological, motivational and volitional correlates of South African women living with HIV with regard to
physical activity and participation in a sport and exercise health promotion programme. The qualitative data was produced
in the framework of a non-randomised pre-post intervention study that evaluated structure, processes and outcomes of a
10-week sport and exercise programme. All 25 participants of the programme were included in this analysis, independent
of compliance. Data was produced through questionnaires, participatory group discussions, body image pictures, research
diaries and individual semi-structured interviews. All participants lived in a low socioeconomic, disadvantaged setting.
Hence, the psychological correlates are contextualised and social-ecological influences on perception and behaviour are
discussed. The results show the importance of considering social-cultural and environmental influences on individual
motives, perceptions and expectancies, the fear of disclosure and stigmatisation, sport and exercise-specific group
dynamics and self-supporting processes. Opportunities and strategies to augment physical activity and participation in
sport and exercise programmes in the context of HIV are discussed.
Keywords: Culture, disadvantaged, disclosure, exercise therapy, HIV, motivation, sport, stigmatisation.
INTRODUCTION
Sport and exercise can have several health benefits for
people living with HIV. For instance, aerobic and resistance
training can have a positive impact on cardiovascular fitness,
fatigue, body composition, psychological well-being and
quality of life [1-5], in addition to reducing the health risks
and diseases associated to a sedentary lifestyle. These
benefits can be pursued through a wide range of different
types and levels of physical activity, adapting to disease
progression, individual motivation and social-ecological
options [6].
Despite many of these benefits [7, 8], the physical
activity level and adherence to sport and exercise are
generally low in people living with HIV [9]. At the same
time, high drop-out rates in intervention research are
prevalent even though they often have more favourable
conditions than interventions in the natural setting of people
living with HIV [6, 9-12].
Studies about the underlying reasons for the low physical
activity level in people living with HIV are scarce [6].
*Address correspondence to this author at the University of Vienna, Auf der
Schmelz 6a, 1150 Wien, Austria; Tel: 0043 699 1720 8761;
E-mail: clemensley@gmail.com
Research in other population groups has identified several
correlates, both psychological and social-ecological ones, for
initiating and maintaining physical activity. Psychological
determinants include, for instance, evaluation of previous
experiences; outcome expectancies; awareness of risks,
vulnerability and need to change; control beliefs, i.e. self-
efficacy; intention strength and self-concordance; and
perceived barriers and resources [10, 13-16]. Several models
describe motivational and volitional processes covering the
building of intentions, action and coping planning, initiation
and maintaining action [17-22]. However, various authors
[23, 24] criticise adopting a mere psychological-behavioural
approach, and focusing only on individuals’ lifestyles as a
primary cause for disease, especially as individuals take
choices in the social-ecological context. “While most
observers acknowledge that social forces influence these
choices, most interventions focus on changing individuals”
[23]. Social-ecological correlates include, for instance,
family and friends; social-cultural beliefs, norms and
practises; perceived environment, such as safety; living and
work conditions; policies; and the use of the space and
infrastructure [24-28].
This article aims to explore the correlates of motivational
and volitional processes of women living with HIV with
regard to physical activity and the participation in a sport and
exercise health promotion programme. This was done in the

Motivation for Physical Activity The Open AIDS Journal, 2015, Volume 9 97
framework of an intervention study in a low-socioeconomic,
disadvantaged setting in South Africa. Hence, individual
psychological correlates are contextualised, and the role of
social-cultural, environmental and gender-specific influences
on perception and behaviour are investigated.
METHODS
Design
Two qualitative case studies were performed in a
disadvantaged urban setting in South Africa, in order to
conduct the research at community level with people living
with HIV. One was placed in a university setting and the
other in a nearby disadvantaged community. The data was
produced in the framework of a 10-week sport and exercise
health promotion programme that was evaluated in a non-
randomised pre-post study design [29]. Study inclusion
criteria were for participants to be HIV-positive and willing
to participate in the exercise programme. Exclusion criteria
were acute infection (e.g., active tuberculosis), pregnancy,
uncontrolled hypertension, and any other disease or infection
that was contra-indicated for sport and exercise participation.
No selection to the project was based on HIV stage, disease
progression, medication use or associated illnesses or
physiological changes. Although regular reminders were sent
to the 50 persons who were initially interested, only 36
arrived for baseline testing. Of these, three were without
HIV-infection but were allowed to participate in all activities
together with the other participants (in order to avoid
stigmatisation and to secure the support of friends), but these
participants were precluded from the data analysis. Another
five of the participants were excluded from the project
because of acute tuberculosis (n=1), a recent operation (n=1),
pregnancy (n=1) and uncontrolled high blood pressure (n=2).
Of the 28 HIV-positive participants remaining, all were
asked to participate in the final measurement independent of
their compliance. Five participants were not available for the
final testing, because of relocating to another suburb (n=3)
and not being contactable (n=2). All 25 female participants
of the programme were included in this analysis,
independent of compliance to the programme.
Participants
All participants lived in a disadvantaged setting
characterised by limited choices in daily life, limited options
for individual and social-economic development, and high
stigmatisation of people living with HIV. Group A was less
disadvantaged than group B in the sense of having access to
institutional knowledge and academic support. The subjects’
ages ranged between 20 and 44 years. CD4+ cell count and
percentage ranged from 155 to 1315 cells/µl (M = 535.32;
SD = 256.064) and 9 to 41% (M = 25.77; SD = 9.402),
respectively. At baseline, 13 participants were taking
antiretroviral medication and their viral load was not
detectable. The viral load of the other participants was
between 1751 and 152063 RNA cps/ml (M = 16676.5; SD =
36729.41). Ten participants were classified by the medical
doctor in WHO stage I; six in WHO stage II; five in WHO
stage III and two in WHO stage IV.
Research Procedures and Measures
After ethical clearance was obtained from the
university’s research committee (Reg. Nº: 11/4/17+18) and
the municipal health committee (Reg. Nº: 10258),
participants were recruited either through a collaborating
community clinic, health forum or non-governmental
organisation (NGO). They were informed about the research
by oral presentation and a written information sheet,
available in Xhosa and English. Bilingual researcher
assistants and translators were present at all times and used
when the participants wished. All participants gave their
informed consent.
Before starting the programme, a short questionnaire was
attached to the registration form that included questions
regarding motivation and goals to participate in the physical
activity programme, as well as preferences regarding time,
type of physical activity and organisation.
This was followed by a participatory group discussion in
which participants discussed needs, perceptions,
expectancies and preferences with regard to intervention
setting, conditions and contents of the programme. Extensive
notes were taken by the principal researcher and checked and
completed by the bilingual research assistance.
Furthermore, eight body image pictures were used in the
study to deepen the participants understanding on related
goals and perceptions. This research tool was validated in the
South African context and used in a very similar context [30,
31].
A survey was developed containing questions (a)
assessing psychological-behavioural determinants, such as
outcome expectancies, self-efficacy, implementation
intentions and planning, predominantly adopted from studies
on the Health Action Process (HAPA) Model [22, 32] and
the Motivation-Volition (MoVo) model [20, 33], and (b)
assessing social-ecological influences on cognitions and
behaviours [24, 34].
A questionnaire was administrated at the end of the
programme to evaluate the outcome experiences and
perceived changes in the participants. It also allowed for
detecting further barriers and challenges that were not
mentioned at the beginning of the intervention.
The principal researcher and facilitator recorded research
diaries based on their participatory observation during the
period of the intervention. The researchers´ participation in
the intervention allowed them to establish a trustworthy
relationship with the participants in order to produce rich and
comprehensive data and to obtain a deeper understanding of
the emotions, cognitions and behaviours of the participants.
Furthermore, the two participatory observers contrasted their
observations among each other continuously and with the
research team as well.
Individual semi-structured interviews were conducted.
The questions dealt with participation, motivation for
participation, anticipated future participation in physical
activity, the challenges and barriers to participation and any
recommendations for future projects.
During the period of the intervention, compliance was
monitored in both groups by keeping a register of

98 The Open AIDS Journal, 2015, Volume 9 Ley et al.
attendance. Non-compliance was assigned when a participant
took part in the programme on average less than once a
week, that means, less than one third of the total sessions.
Data Management and Analysis
All interviews were recorded and later transcribed into
written records. Group discussions were captured by means
of extensive notes. Participatory observation was recorded in
research diaries, while open-ended questions were answered
in the questionnaires. All qualitative data was analysed
according to the themes that emerged from the data
(inductive coding) and the theory (deductive coding). If
differences among the two intervention groups were
detected, data referring to group A (University setting) and B
(Community setting) was marked accordingly in the text.
Research Challenges
The research is based on a limited number of participants
and a high drop-out rate in the intervention. Getting people
living with HIV to participate in the intervention study was
very challenging. However, recruitment problems are also
mentioned by other researchers in the field: “In an attempt to
recruit enough participants, the discovery was made that
HIV is still a highly stigmatised disease in both Mpumalanga
and Gauteng. After eighteen months of negotiations with
AIDS clinics, mine groups and a newspaper advertisement,
only three participants were enrolled ” [35]. In our case, we
consider the following reasons as predominant: mistrust
about participating in intervention studies; fear of HIV
disclosure; competing immediate priorities and daily-living
challenges.
The high drop-out is also discussed in the literature [10].
Regarding a 40% loss of exercise participants with HIV in an
individualised 12-week exercise programme, Neidig et al.
[12] stated that “individuals who were lost from the study
were often among the working poor and reported abrupt
changes in employment, unreliable transportation, and
increased family responsibilities.” Apart from
socioeconomic and socio-cultural constraints, non-adherence
to treatment or health programmes are often related to
individual factors, such as self-efficacy, depression and
psychosomatic diseases. Petroczi et al. [9] mentioned that
“actual physical fitness level or other physical
characteristics” seem to be less influential on adherence to
physical activity. Conversely, Stringer [36] suggested that
“patients with chronic diseases such as HIV sometimes have
decreased motivation to perform regular aerobic exercise....
This lack of activity results in a vicious cycle of decreased
exercise, pain, slow recovery from activity, loss of lean body
mass, anxiety of exercise, de-conditioning, and reduced gain
from aerobic exercise sessions.”
Another research challenge was the heterogeneous
composition of the group, representing a broad diversity with
regard to disease progression, medication, signs and
symptoms and living situation.
RESULTS AND DISCUSSION
Perceptions and Expectancies Regarding the Social
Environment and Programme Structure
The initial participatory group discussion captured the
perceptions and cognitions regarding the intervention setting
and conditions with reference to the environment and social-
cultural beliefs.
The discussion was strongly dominated by worries about
serostatus disclosure and HIV-related stigma. Most of the
participants were not living openly with their HIV status.
Serostatus was hardly disclosed in the most intimate circles,
such as partners, family members or close friends: “only my
partner knows”; “I don’t speak with anybody about it”; “only
my best friend, she knows”. As a reason they discussed that
stigmatisation of people living with HIV is very high in the
community: “In my community, they call you with bad
names if they know that you have HIV”; “they change their
behaviours towards you” [cf. 37-39]. Hence, there was
consent among the participants in the present study that
disclosure of serostatus must be avoided by all means:
“nobody must know it”; “not to speak about it”.
In dealing with the risk of serostatus disclosure, two
different “voices” were identified amongst the participants.
One “voice” was concerned about who should participate in
the physical activity group. Some participants argued that
everybody should take part “independent of HIV” or
“without questioning HIV status”, hence “to take part as
anybody else”. Therefore, the programme should be open for
both HIV-positive and HIV-negative participants. Some
expressed that they would not take part in a programme only
for people living with HIV. These arguments were related to
the perceived risk of disclosure. However, there was also the
second “voice” that argued for not wanting to get labelled or
to be treated as “ill” or “different”. It was argued that they
should be able to play and exercise the same as anybody
else. Consequently, these fears and concerns were an appeal
for mainstream physical activity opportunities, such as
recreational sport teams, to be available for all and that do
not isolate and deal specifically with HIV.
Conversely, some participants also voiced the wish to
speak about their problems and concerns, which would only
be possible for them in a group of people, all living with
HIV. This was more prevalent in the group B (Community
group) where the need for mutual support was more voiced
by the participants. This wish calls for specific physical
activity opportunities, such as supportive sport and exercise
groups, that deal with challenges related to HIV and where
members can share experiences and support each other.
In the group discussion, the participants stressed, in a
common voice, the need to preserve confidentiality at all
times. “HIV-status must neither be revealed in the group nor
outside the group”. If a participant wanted to disclose his/her
status, he/she could do so personally in the group or to a
member, but “it must be your own choice to speak about it”,

Motivation for Physical Activity The Open AIDS Journal, 2015, Volume 9 99
thus “nobody must speak about it” and, for example, “the
trainer should not know why I am coming to exercise”. In
that regard, the only participant who was living and talking
openly about her status had the following to say in an
interview: “I don’t greet the others [participants], unless they
first greet me. People know my status. I tell them [the other
participants] that it is up to them to come to me. It is their
decision”. She first gives the choice to the participants, who
can then act in that situation to avoid the possible stigma of
being associated with HIV. Also one researcher argued that:
“I always stress to everyone that I do research on health
promotion, and that I have several projects, inclusive of HIV.
If people know that I am working only with people living
with HIV, they might question the status of those I am
walking and/or talking with during work time”. Bearing this
in mind, the research programme was not presented as an
HIV programme, but rather as a general sport and exercise
health promotion programme for all who were interested in
participating. The participants agreed that, for research
purposes and for giving individual feedback and advice, the
principal researcher and the participating doctor should know
their HIV-status. Those who wanted an HIV-specific group
especially articulated the importance that all members of the
group must take personal responsibility and commit to
treating all information as confidential, and not to talk to
people outside of the programme about happenings in the
programme: “it must stay in the group”; “not to speak about
it outside”. These disclosure-related concerns were also to be
observed in other contexts, such as in relation to who should
participate in the HIV-related support groups, and what
setting and conditions were needed in the HIV-specific
support groups.
Thus, two different programme settings were identified
in the discussion. The participants of Group B preferred to
train in a group setting. The programme setting was a school
within the community, who kindly made their premises
available for the sport and exercise health promotion
programme in the afternoons. Conversely, participants of
Group A preferred to train individually in a fully-equipped
training centre in a university setting. The reasons mentioned
by these participants were that they had predominantly
diverse times of availability, and also expressed doubts about
the maintenance of confidentiality in the group setting.
Although the physical activity intervention consisted of
individualised exercise training, it was proposed that they go
for training in small groups in order to boost exercise
adherence. In fact, some expressed being “motivated by
training together in pairs”. However, training in small groups
was also challenged by the diverse times of availability.
Thus, several participants asked if they could bring along a
friend (even if they were HIV-negative) as that would
improve their participation, and two of the participants did
so. This indicated the need for social support or peer-
support, but essentially trustful and confidential support,
from a good friend.
Fear of disclosure was repeatedly an issue also
throughout the duration of the programme (see below
discussion about barriers for participation and drop-out).
Motives, Intentions to Initiate Physical Activity and
Outcome Expectancies
At the registration of the programme, a questionnaire was
used to capture the initial motives and interest for
participating in the physical activity programme. These were
further discussed in the initial participatory group discussion,
especially their expectations, as well as the programme
content and types of physical activities to include.
The participants’ main motives were health-orientated: “I
want to improve my healthiness”; “I want to live a healthy
lifestyle”; “To build up my immune system more”; “To stay
healthy”; “To improve my health, immune system + and to
be happy”; however, frequently they included a special
reference to the body and appearance: “I want to keep my
body healthy”; “To [be] physically fit”; “I want to get
strong“; “to lose weight”; “lose some weight, as I have
gained a lot since last year”; “I want to look and feel healthy,
physically and mentally”. Participatory observation
throughout the programme confirmed the paramount
importance that appearance was given. Appearance was
important in the participants’ strategies of avoiding HIV-
related stigma. “In our community, people who are very thin
are thought to have HIV”; “if you are thin, people will think
that there is something wrong, that you are ill” [30, 40, 41].
A researcher remarked in his diary: “One participant told me
concerned that she already perceives the effects of the
‘gyming’, that she is losing weight. I was surprised, as the
training only just started a few weeks ago and I suspected
other reasons for the weight loss; and as I saw her concern, I
asked her if that would not be a good result to lose weight.
She replied that she is afraid of losing too much weight”. In
conclusion, most of the participants, “Want to reduce weight
in the stomach area, but not to be thin”.
Perceptions of appearance was also analysed by means of
a questionnaire showing a normed sequence of eight pictures
of a female body with gradually increasing body dimension
[30, 31]. The questionnaire served two purposes. Firstly, it
was used to analyse appearance and weight-related goals by
asking them, individually, which picture represented them
best at the moment and, secondly, it was used to identify
which picture they aimed to be. Their perception on which
picture represented them best was compared with the
anthropometric measurements actually taken, i.e., height and
weight that were used to calculate Body Mass Index (BMI).
In addition, they were asked which picture represented a
healthy person. The results showed a concurrence between
subjective perceptions and objective anthropometric
measurements. The goal body picture identified by the
participants ranged mainly between a healthy perceived
person (with a normal BMI following WHO classification)
and a slightly overweight person (BMI between 25 and 30
kilograms per square metre). These results confirm the
above-stated goal for a number of participants which was not
to lose too much weight, but rather to stay a little bit more
overweight. These results are also in agreement with other
studies that conclude that fear of HIV-related stigma,
encourage black African women to be rather “slightly

100 The Open AIDS Journal, 2015, Volume 9 Ley et al.
overweight, but not obese, than thin and having people think
they were infected with HIV or they had AIDS” [30]. In
South Africa, where 29% of men and 56% of women are
classified as either overweight or obese [42], the stigma
related to HIV “may be responsible for fuelling the obesity
epidemic among black African women” [30]. It definitely
influences behaviour and goal setting with regard to physical
activity.
Finally, the potential to gain knowledge was another
motive for participation; “I want to know how exercise
impacts upon my health status”. While most participants
were expecting positive outcomes, some participants, were
less convinced (“I really would like to see the outcomes”).
Therefore, feedback on their progress was given
continuously and, most importantly, after the medical and
fitness assessments at the beginning and end of the 10-week
research period. The participants showed much appreciation
for the feedback. Most of them asked many questions, which
demonstrated a keen interest in gaining knowledge.
According to these motives for participation, the physical
activity programme included moderate aerobic exercise and
progressive resistance training. In addition, in group B,
modified sports and games were played. Members of group
A trained individually. In both groups, the intention was to
train regularly, ideally three times or more, but at least twice
a week, and to learn and build up skills and habits that
facilitated the inclusion of physical activity in daily life.
Self-Concordance and Strengths of Intentions
The intention to participate in the programme and to
exercise regularly was mainly determined by their
motivation to look and to live healthy. Firstly, exercise in
order to look healthy, was constructed mainly on their
motivation to protect themselves from external HIV-related
stigma and to avoid discrimination. This motivation was
particularly strong. Thus, the physical activity training,
specifically the resistance training or “body-building
exercises” seemed for them to fit in well with this
motivation. Their motivation was especially high for these
kinds of exercises. Then, secondly, exercising in order to live
healthy, seemed mostly intrinsically motivated, such as “I
always have been interested in exercise, but I just do not
have the time”. However, others showed more extrinsically
motivated intentions to exercise, for example, a woman
referred to her intention to participate, “when I heard that the
programme was going to be helpful for our health”. Some
also expressed doubts, for example, “I really would like to
see the outcomes” and asked many questions in the initial
group discussion about how physical activity would help
them.
It is noteworthy to mention briefly, in this context, that
the women were not motivated through the environment or
through the community to exercise and to be physical active.
In the disadvantaged community, for example, women
generally are not seen running in the street for exercise and
health reasons. This situation might be due to a lack of safety
and security in such areas, but also due to social-cultural
norms and attitudes about women in the black African
community [41, 43-45]. On the one hand, women are not
supposed to play, since only young girls play, but once they
reach adulthood they have to fulfil their family duties and
responsibilities. Sport is mainly engaged and dominated by
young men and children. As a consequence, the group B
(Community group) was conducted in the afternoons in the
inner yard of a school in order to be less visible from the
community and, in that way, reduce possible inhibitions in
the participants to play or to train. On the other hand, with
the transitional changes (urbanization, socio-economic
growth, etc.), being sedentary has become a luxury. So far,
walking was used as a coping strategy in daily life, for
example, to walk long distances in order to get water. In the
black African community, being sedentary might be
perceived as a symbol for social-economic wellbeing.
Therefore, we consider that the social-cultural and
environmental situation were not directly motivational for
women to exercise. Although, indirectly, the HIV-related
stigma, might have stimulated the motivation to exercise in
order to look healthier.
The motivation and intention to fulfil the set goals were
perceived as very high in the beginning: “participants were
quite happy to join, laughed and seemed very motivated”;
they expressed positive emotions about the programme; “it is
refreshing”, “feeling good exercising”; “it really reminded
me of the good old days when I used to be an athlete,
handball player, netball player, so it was fun”. Most
participants felt that physical activity was high on their
priority list. However, throughout the duration of the
programme, it seemed that the reality of daily life was
overwhelming, and gradually the participants mentioned
steadily increasingly competing priorities, such as studies (in
group A, especially during exam time) and the need for
getting financial income (work or getting bursaries,
especially in group B); or “something urgent that I need to
attend to”. For example, a participant wrote an email to the
principal researcher: “Good morning, I’m sorry for not
having been available at gym this week but I was struggling
in terms of school work; it was a hectic week for me, but I
promise next week I will be there during my time slots; I’m
sure I will at least be above the water then, because as of
now am slightly sinking. Thank you for your concern”.
Further barriers and time management challenges are
discussed later on; here, we conclude that the intention to
achieve the goals were generally perceived as very high but,
nevertheless, standing in direct opposition to the emerging
priorities and challenges of daily life.
Barriers for Participation and Drop-Out During the
Intervention Process
During the sport and exercise intervention programme,
expressions of fear and continuous avoidance of HIV
disclosure by participants were dominant and were
considered as obstacles for participation: “Before going to
the gym, if I was with friends, they would ask me where I
was going. So, sometimes, it was difficult to go to the gym”;
“My friends asked about why I go to gym”; “Others asked
me, what was the programme for”; “My neighbour was
asking where I go, and then also if she can join me, and I
didn’t know how to say no”. In fact, twice a neighbour was
brought along in group B, which created an uncomfortable
situation among the participants. They discussed it and
decided that we have to declare the group full, in order to

Motivation for Physical Activity The Open AIDS Journal, 2015, Volume 9 101
avoid any disturbance by new and unknown members, as
well as to avoid disclosure and stigmatisation of the group.
Other challenges experienced were concerns with time
management or competing priorities (“Not enough time”;
“Sometimes I had something urgent to attend to. If it
happened that I finished on time where I am was going, I can
even come by later, before the gym closed, because I would
really feel bad if tomorrow's session would go to waste”; “I
had to get the bursary”), family responsibilities (“I have a
child that I have to take care of”; “I got pregnant”; “The last
two weeks I was not feeling well, I was not even able to
come to the gym, I was vomiting, having severe pains. I
decided to go and see the doctor only to find out that I'm
pregnant. So, me and the father of the baby decided together
to abort the baby, that will be on the 5 September, so please I
would like you to give me a week or 2 weeks so that I could
recover this, as I'm not gonna be able to start with gym
immediately after I have done this”) and illness (“Sickness”;
“flu”, “vomiting”, “pain”, “too tired” (fatigue); “I was
stressed”; “Participants suffer from different illnesses and
were getting sick during the period of the programme”). One
participant explained that the reason for dropping-out was
because of the change in her work situation, and another one
stated that she had to miss out due to traveling (“I am sorry I
could not come to the training last week, because I went
home and its far for me to travel”). Transport problems were
mentioned in group A, because it was a challenge to come to
campus in holidays due to lack of funding (“The school is
closed and my aunt is not giving me money for transport,
and in that way I can´t be present at the gym”).
Discomfort from exercising (“pain after training”, “pain
the next day”) was mentioned, but was seldom. The
discomfort due to the exercising setting in the gym (“noisy”,
“people watching”) was reported more frequently. Others,
however, in converse, stated that it was comfortable in the
gym where they were “exercising just as anybody else”.
Participation was also influenced by the changing
situation during the month; “having to stand in lengthy cues
for getting bursaries at the beginning of the month” and
“having more money available at the end of the month, after
being paid” were mentioned.
Approximately 50 % of the participants were non-
compliant, attending on average less than once a week.
Drop-out was higher in the individual exercise group A (80
% drop-out) than in the group intervention B.
Control Expectancies
Compliant participants showed a higher task self-efficacy
(“I am confident that I can be physically active 5 times a
week”) (t = 2.191; p = 0.04) than the non-compliant
participants. They also expressed more often having a coping
plan (“I have a plan about what to do in difficult situations in
order to stick to my exercise intentions”) (t = 2.435; p =
0.025).
Most of the participants were confident that the
challenges and barriers of participation would decrease in
future, and that “next year it will be easier”. Some of them
expressed that even though they could not attend regularly
“it was the first time they had joined a gym” and that this
first step was important in order to join a gym in future and
to maintain an active lifestyle.
Outcome Experiences and Perceived Results (After the
Programme)
Once the programme ended, most participants in group A
(individual training) expressed the wish to participate in a
group intervention in future: “I don’t want to exercise
alone”; “Next time, we would like to do it in a group”. In
this group, there was hardly any interaction observed among
the participants, even though some of them trained at the
same time.
In the group intervention (group B), mutual support was
observed. They often exchanged experiences and opinions
about ARV medication, avoidance of side-effects, coping
strategies and nutrition. They also discussed concrete plans
of together building a gardening project to plant vegetables,
as this produce was too expensive for them to buy (“Even if
we know what to eat, we cannot afford it. Healthy food is too
expensive”). Participants in this group made friends and
supported each other even outside the programme. They
often collected each other in order to come together to the
programme. They also left together and walked together to
their homes. When one of the participant died one year later,
the other participants went together to visit the deceased’s
family and assisted with the funeral. These self-supporting
processes were possible, as this group was only for members
living with HIV and, thus, they could disclose status to each
other, if they wanted to, and be able to speak about HIV-
specific challenges without fear of repercussions.
In general, the programme was perceived as “refreshing”,
they were “feeling good exercising”, and “enjoying every
moment”. One participant stated that “it really reminded me
of the good old days when I was an athlete, handball player,
netball player, so it was fun”. Enjoyment was an important
motivational factor for the participants as a way of opposing
the daily hassles and challenges of living with HIV.
Statements regarding the perceived changes from
participating in the programme were quite diverse: “I
disliked food before, but now I eat a lot, I like that”; “weight
loss”; “I feel more energetic”; “small increase in muscle
mass”; “feel more power”; “my appearance improved”; “I
feel so strong about myself”; “to be able to face life
challenges, having a positive attitude towards life, and the
most important thing is that I accept myself”; “the way in
which I feel about myself”; “before the programme, I was
always exhausted, but while I was on the programme I did
not get exhausted at all”; “the programme made me more
interested in exercising”; and “eager to make friends”. These
aspects indicate a trend towards several psychosocial
improvements.
One recurrent perceived change concerned the subjective
improvement of strength. This was in agreement with the
observed high motivation for the resistance training
exercises. Bearing in mind the relatively short duration of the
programme (10 weeks) and the irregular pattern of
participation, strength improvements were more likely to be
visible than other physical changes. In fact, the results of
further physical measurements were also reported in another
publication [29], which showed that in the compliant group,

102 The Open AIDS Journal, 2015, Volume 9 Ley et al.
strength improved significantly more than in the non-
compliant group (ANCOVA F=4.516 p=0.047); meanwhile
no significant changes were observed with regard to any
other physical measurements, such as fatigue (time on
treadmill). The improvement in perceived strength has
psychosocial importance, because appearing physically
strong is perceived as beneficial in protecting oneself from
forced HIV-disclosure. Thus, the improvements are aligned
with the participants’ goals. Therefore, muscular strength
training may be an important element of physical activity
programmes with people living with HIV, not only in order
to achieve health outcomes, but also to motivate
participation and adherence.
Nevertheless, some of the participants also expressed the
concern that they had not achieved what they wanted or
expected: “Because I was not attending the gym regularly, I
am not completely fit as I want to be.”; “I have [changed],
but if the programme had started earlier, I would have lost
more weight.”; “the days when I was absent, played a big
role in my levels.”; “physical strength, it didn't change much,
because I stopped attending”.
CONCLUSION
In order to plan and implement the sport and exercise
programme in accordance with the motives, intentions and
expectancies of the participants, the intervention study took
on an evolving and participatory approach, continuously
dialoguing and adapting according to the progressively
emerging results. Such an approach is convenient, as it
facilitates a more appropriate and subjectively meaningful
intervention, as well as more active involvement by the
participants.
The motives to exercise were strongly influenced by
HIV-related and social-ecological perceptions and
cognitions. The participants mostly wanted to lose weight,
but not too much, rather to be a little bit overweight rather
than too thin, because it might mistakenly be associated with
HIV. Thus, the main motive to exercise was to be strong and
obtain a healthy appearance. Accordingly, the sport and
exercise setting and participants’ behaviour were strongly
dictated by self-protection from HIV stigma and the fear of
disclosure of HIV serostatus. Two different intervention
groups were implemented: one was a main-stream
intervention where participants exercised, just as any other
person, in a gym-setting at the university, while the other
was a group intervention in the community, where the self-
supporting processes were facilitated through an ‘only
people living with HIV’ group. The latter one seemed to be
more successful, as compliance was higher, mutual support
was evident and the group dynamic was highly valued.
Strength training was important in both groups. Objective
and subjective strength improvements were perceived and
may have affected the motivation to exercise, as it is
concordant with the goals of looking stronger and healthier
and avoiding HIV disclosure.
Nevertheless, the high motivation to initiate a sport and
exercise intervention was opposed by strong challenges of
daily living and compounded by several barriers to
maintaining participation. During the sport and exercise
intervention expressions of fear and continuous avoidance of
HIV disclosure were dominant, and were considered as
obstacles to participation. Further reasons for non-
participation were competing personal priorities: family,
studies and work duties, challenges with time management
and coping with daily hassles and problems, changing
circumstances throughout the month and sickness (ranging
from fatigue to disease progression and comorbidities).
Feelings of discomfort from exercising were seldom
mentioned; but some discomfort was mentioned by the
participants due to the exercise setting. Compliant
participants showed a higher task self-efficacy and expressed
a higher degree of planning than the non-compliant
participants. Therefore, it would be crucial to increase the
knowledge, action planning and coping skills that are in
concordance with the personal and social-ecological
situation. At the same time, the sport and exercise
programme should put more emphasis on facilitating
experiences that promote self-efficacy.
Furthermore, the results show that both psychological
and socio-ecological perspectives should be combined, and
that multi-level interventions are needed. Such interventions
should also respond to the individual situation and living
condition, as well as to the social perceptions and cognitions
regarding people living with HIV and regarding exercising.
Participatory approaches offer valuable opportunities in this
complex field of research and intervention.
CONFLICT OF INTEREST
The authors confirm that this article content has no
conflict of interest.
ACKNOWLEDGEMENTS
We thank all the participants for their participation, the
community clinic, laboratory, HIV unit, health promoters,
nurse, facilitators and research assistants for their support.
We are very grateful for the continuous support granted by
the Technical University of Madrid (UPM). We thank the
University of the Western Cape, Programme Dynamic of
Building a Better Society (DBBS - VLIR) for supporting the
respective postdoctoral fellowships of Clemens Ley.
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Received: July 31, 2015 Revised: August 8, 2015 Accepted: August 16, 2015
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