title: What's keeping people after stroke from walking outdoors to become physically active? A qualitative study, using an integrated biomedical and behavioral theory of functioning and disability.
abstract: BACKGROUND
  In general people after stroke do not meet the recommendations for physical activity to conduct a healthy lifestyle. Programs to stimulate walking activity to increase physical activity are based on the available insights into barriers and facilitators to physical activity after stroke. However, these programs are not entirely successful. The purpose of this study was to comprehensively explore perceived barriers and facilitators to outdoor walking using a model of integrated biomedical and behavioral theory, the Physical Activity for people with a Disability model (PAD).
  
  
  METHODS
  Included were community dwelling respondents after stroke, classified ≥ 3 at the Functional Ambulation Categories (FAC), purposively sampled regarding the use of healthcare. The data was collected triangulating in a multi-methods approach, i.e. semi-structured, structured and focus-group interviews. A primarily deductive thematic content analysis using the PAD-model in a framework-analysis' approach was conducted after verbatim transcription.
  
  
  RESULTS
  36 respondents (FAC 3-5) participated in 16 semi-structured interviews, eight structured interviews and two focus-group interviews. The data from the interviews covered all domains of the PAD model. Intention, ability and opportunity determined outdoor walking activity. Personal factors determined the intention to walk outdoors, e.g. negative social influence, resulting from restrictive caregivers in the social environment, low self-efficacy influenced by physical environment, and also negative attitude towards physical activity. Walking ability was influenced by loss of balance and reduced walking distance and by impairments of motor control, cognition and aerobic capacity as well as fatigue. Opportunities arising from household responsibilities and lively social constructs facilitated outdoor walking.
  
  
  CONCLUSIONS
  To stimulate outdoor walking activity, it seems important to influence the intention by addressing social influence, self-efficacy and attitude towards physical activity in the development of efficient interventions. At the same time, improvement of walking ability and creation of opportunity should be considered.
authors.affiliation: Research Group Lifestyle and Health, Research Centre for Innovations in Healthcare, Hogeschool Utrecht University of Applied Sciences, Heidelberglaan 7, 3584CS, Utrecht, The Netherlands. jacqueline.outermans@hu.nl.
authors.forename: Jacqueline
authors.identifier: http://orcid.org/0000-0003-4439-0883
authors.initials: J
authors.lastname: Outermans
authors.affiliation: Research Group Lifestyle and Health, Research Centre for Innovations in Healthcare, Hogeschool Utrecht University of Applied Sciences, Heidelberglaan 7, 3584CS, Utrecht, The Netherlands.
authors.forename: Jan
authors.initials: J
authors.lastname: Pool
authors.affiliation: Revant, Brabantlaan 1, 4817JW, Breda, The Netherlands.
authors.forename: Ingrid
authors.initials: I
authors.lastname: van de Port
authors.affiliation: Utrecht University Medical Centre, Heidelberglaan 100, 3584CX, Utrecht, The Netherlands.
authors.forename: Japie
authors.initials: J
authors.lastname: Bakers
authors.affiliation: Research Group Lifestyle and Health, Research Centre for Innovations in Healthcare, Hogeschool Utrecht University of Applied Sciences, Heidelberglaan 7, 3584CS, Utrecht, The Netherlands.
authors.forename: Harriet
authors.initials: H
authors.lastname: Wittink
mesh_terms: D006233:Persons with Disabilities / Q000523:psychology* / Q000534:rehabilitation; D015444:Exercise / Q000523:psychology*; D005260:Female; D006801:Humans; D033182:Intention; D008297:Male; D008875:Middle Aged; D036301:Qualitative Research; D020377:Self Efficacy; D020521:Stroke; D000071939:Stroke Rehabilitation / Q000523:psychology*; D016138:Walking
keywords: Community ambulation; Outdoor walking; Physical activity; Stroke