Las historias de los niños

The individuals interviewed in this study expressed their lived experience of AOR and their specific reasons for non-adherence. Although this study did not intend to combine the individuals‟ lived experiences into a single statement, any

convergence across the cases was noted to help improve the participant adherence rate for AOR. The aim of AOR was correctly understood by non- adhering participants, but the medical referral to the PA intervention was experienced differently. A key reason behind non-adherence to AOR was the individual needs not being understood by the health and/or fitness professional and dissociation with the gym environment. With regard to each individual‟s experience of AOR, being listened to, receiving support during the behaviour change, and having an opportunity to re-engage in the scheme were considered positive elements. Increasing PA levels was not viewed as a positive behaviour change by all, although alternative options of more appropriate activities were suggested. The myriad of perceptions about PA were built on past experiences and future expectations. Nevertheless, individuals could relate to the benefits of an active lifestyle for an enhanced quality of life. The individuals‟ self-awareness and personal reflection was focused either on the problems related to performing PA or enhancement of current health conditions. Within the narratives,

acceptance of themselves and by others seemed to resonate as a positive contributor to change and this was articulated through an array of change talk.

3.6 Discussion

This study aimed to collect robust, rich data of the lived experience for those referred to a PA intervention to make up for less superficial qualitative studies (Williams et al., 2007) by providing methodological detail (Section 3.4) and including the processes used to enhance trustworthiness (Section 3.4.4). The researcher was acknowledged as the primary analytical instrument (Fade, 2004, p. 2) and the non-adhering participants gave an account of their experience. Ultimately, the aim was to understand the experience of non-adhering

participants so that the underlying issues can be interpreted to enhance practice (Reid et al., 2005). On analysing the non-attendees‟ accounts of their lived experience, it is hoped that a more effective referral scheme is developed to better meet their needs, potentially enhancing adherence to AOR. The super ordinate themes (Section 3.5.10) included the referral process, the individual, PA itself, relationship to others, and perception of change. There was little reference to time as a major barrier during the interviews unlike in previous studies

(Sports Council and Health Education Authority, 1992; National Health Service, 2007), probably because in this qualitative research, the participants could clearly express the reasons behind their non-adherence. However, as reported two decades ago (Health Education Authority, 1992), physical, emotional, and motivational concerns were expressed.

The following recommendations are made from the IPA for non-adhering

participants. The AOR process would be improved if the referral was appropriate as specified in the NQAF guidelines (Department for Health, 2001). Once the referral had been discussed with the health professional and patient, the induction experience should be welcoming and thorough to ensure the participant needs are understood, enabling them to feel comfortable in the

environment. This was also suggested by Allender et al. (2006). This

collaborative conversation between the health professional and patient would imply that the individual is guided to, rather than prescribed, AOR. Throughout the intervention, and especially at the induction, fitness professionals are encouraged to be engaged in the behaviour change process with the individual and to continue to provide support and guidance, as recommended in the

Halisham study (Taylor et al., 1998), e.g. physical concerns such as Max‟s knees and Dav‟s back could be addressed by trained staff. Additionally, mental health needs expressed by Heidi and Mr T may need to be addressed prior to the physical referral. Social integration may help the individual feel part of the environment and this could be achieved by the interaction with fitness

professionals and other leisure centre users, as suggested by Hardcastle and Taylor (2001); however, it should be noted that this study was based on older women and social interaction was generally considered valuable by them. Morton

et al. (2008) reported that using previous participants as peers to support new

PARS participants enhanced relatedness, but this may not be appropriate for all participants, e.g. Dav resisted attending the gym perhaps because of loss of confidence and not accepting his physical condition, even though disabled men have reported PA to be a positive experience in their efforts to get back into social life (Robertson, 2003).

By understanding the individual‟s perception of PA, appropriate activity can be referred; this helps the individuals feel empowered and that they are able to choose what is best for them. Heidi clearly expressed her inclination towards dance, Mr T preferred to swim, and Patsy‟s preferred choice of PA was walking. Therefore, a wider choice of activities needs to be made available, as suggested by Wormald and Ingle (2004). The weather was an important factor for Linda G

and affordability was the reason why Mr T chose a private facility, akin to the two factors associated to sedentary behaviour by Salmon et al. (2003). Linda G‟s case exemplifies that adherence to AOR can be enhanced by making an

appropriate phone call to re-engage once barriers such as injury and bad weather have passed. This was also noted in the Welsh PARS where it was stated that a third of all participants re-engaged if contacted within four weeks of induction (Murphy et al., 2010).

The common theme arising with regard to the relationship with professionals and receiving support was that of the participants wanting to be heard. This is

something that was not reported in previous surveys (Sports Council and Health Education Authority, 1992; NHS, 2009). Dav, Heidi, and Max felt they were not listened to. Mr T had lost faith in the system and Patsy was disappointed with the level of care she received from fitness professionals at the referral leisure centre. On the other hand, Linda was very happy with the relationship she shared with the fitness professional and the level of service provided at the second induction, and Poll had no complaints, so for these two individuals, the relationship with the health/fitness professional was not considered the barrier to adherence to the PA intervention.

One of the key elements throughout this study was the individuality of the perspective which if met could encourage engagement in a PARS. In this study, this was found via IPA – an ideographic methodology (Smith et al., 2011). The engagement in the referral process may be the first step to actual PA behaviour change. In addressing the key elements highlighted above, adherence to PARS may increase. From the participants interviewed, five out of seven perceived AOR to be a positive opportunity for appropriate referrals; this was a higher

proportion of positive attitude towards the PARS than that in a previous study, an unexpected outcome from this study (Taylor et al., 1998). However, it is difficult to compare outcomes because of missing details in later studies that quantified a “positive experience”.

Rather than measureable outcomes such as PA levels, especially for participants that do not adhere to PARS and hence who are not present to collect the

information, a qualitative study enables data collection through relationship- building with the participants and by engaging them in the research process (Black, 1994). This approach helps one understand how to improve adherence to PARS at a local level, as suggested by Singh (1997). This qualitative study used a systematic transparent process to assess PARS effectiveness by asking non- adhering participants about their lived experience of the PA intervention and includes detail of the methods used for data collection and IPA analysis (Smith et

al., 2011) – these aspects are not explained in previously reported qualitative

studies (Allender et al., 2006). With the hope that future PARS reviews, unlike the most recent one by Pavey et al. (2011), include qualitative studies so that the patient‟s experience is part of the evaluation process as recommended in the NQAF (Department for Health, 2001) to ultimately provide a preventative,

patient-centred, and productive service (NHS, 2009).