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Abstract

Background

Physical activity (PA) levels of stroke survivors are far from recommended levels. To develop specific interventions targeted at improving PA after stroke, there is a need to consider the barriers to PA faced by stroke survivors.

Objective

To use the comprehensive Barriers to Physical Activity Questionnaire for People with Mobility Impairments (BPAQ-MI) to identify intrapersonal, interpersonal, organizational and community barriers to PA faced by stroke survivors in Singapore.

Methods

We conducted a face-to-face survey with stroke survivors recruited from Singapore National Stroke Association platforms. Participants were eligible for the study if they were 21 years old and above, had a medical diagnosis of stroke, and had a weak arm or leg.

Results

38 stroke survivors participated in the survey. More than half had moderate or moderately severe disability, and needed assistance for activities of daily living or walking. Of the 63 barriers spanning across intrapersonal, interpersonal, organizational and community domains, the top three most commonly reported barriers include lack of accessible classes/programs at fitness centre (21/38; 55%), lack of assistance from fitness centre staff (19/38; 50%) and feelings of tiredness/fatigue (18/38; 47%). Of the top 10 most commonly reported barriers, four were organizational barriers, four were intrapersonal barriers and two were community barriers.

Conclusions

Stroke survivors in Singapore want to participate in PA, but are often limited by barriers associated with fitness centres, self and the environment in the wider community.

Keywords

barriers physical activity stroke

Introduction

Regular physical activity (PA) has been recommended to reduce the risk of recurrent strokes, and improve mental, physical and psychosocial outcomes of stroke survivors.¹ Despite these benefits, PA levels remain below recommended levels of PA after stroke. A systematic review found that on average, stroke survivors took 5535 steps in the subacute phase and 4078 steps in the chronic phase.² In Singapore, stroke survivors took a median of 4870 steps per day in the subacute phase.³ These numbers are less than the recommended 6500–8500 steps/day for people with disabilities or chronic illnesses,⁴ and far from the recommended 10,000 steps/day for the healthy population.⁵

To develop interventions targeted at improving PA after stroke, it is important to consider the barriers limiting stroke survivors from being physically active. Although many studies had been conducted to evaluate the barriers to PA after stroke,^6,7 most were conducted in Western countries (e.g., United States, United Kingdom, Canada and Australia),^6–8 few were conducted in non-Western countries (e.g., China, Africa, Brazil)^9–11 and none had been conducted in Singapore. It is worthwhile to consider country-specific barriers as barriers to PA are likely to differ across countries with varying public health infrastructure. For example, barriers such as cost of gym membership and lack of places to exercise (reported by stroke survivors in the United States, Africa and Brazil)^9,10,12 might not be as frequently encountered by stroke survivors in Singapore as all Singapore citizens and permanent residents are accorded $100 credit to access public gyms and swimming pools for free (https://www.myactivesg.com/), and free group workout sessions are readily available in shopping malls and parks around Singapore (https://www.healthhub.sg/programmes/170/StayWell).

Several surveys have been used to measure barriers to PA in stroke survivors,^8–17 though most have a disproportionate number of items focusing on either personal factors (such as tiredness, lack of motivation, lack of support from friends and family), or organizational and community factors (such as cost of gym membership, lack of transport to fitness centre, cracks or gaps in sidewalks). For example, only 0–25% of items focus on organizational and community factors in the Barriers to Physical Activity after Stroke Scale (BAPAS),¹⁴ the Stroke Exercise Preference Inventory (SEPI),¹³ the Barriers to Being Active Quiz (BBAQ),¹⁵ the Exercise Benefits/Barriers Scale (EBBS),^9,10 the Barriers to Health Activities for Disabled Persons scale (BHADP),¹⁶ the Barriers to Physical Activity and Disability Survey (B-PADS),¹² while none of the items focus on personal factors in the Facilitators And Barriers Survey of environmental influences on participation among people with lower limb Mobility impairments and limitations (FABS/M),¹⁷ and Craig Hospital Inventory of Environmental Factors (CHIEF).^8,11 The Barriers to Physical Activity Questionnaire for People with Mobility Impairments (BPAQ-MI) is an exception,¹⁸ where a more equal proportion of items was placed across personal factors (41%), and organizational and community factors (59%) out of 63 barriers. Such a comprehensive survey will allow a more accurate representation of barriers faced by stroke survivors, particularly if ranking the barriers, and using the top-ranked barriers to guide development of interventions. As stroke survivors are known to be a heterogenous population,^19,20 it is important to identify participant characteristics that might be associated with the barriers faced. Considering the influence of gender, age, time since stroke and disability on stroke recovery,^19,21 we are also interested in the associations between these participant characteristics and barriers to PA. This will allow the identification of subgroups who might respond better to specific interventions and help to shape the inclusion criteria of future trials and the design of future interventions targeted at improving PA after stroke.²⁰

Therefore, we aimed to use the BPAQ-MI to answer the following research questions:

a) which of the personal, organizational and community barriers are commonly reported by stroke survivors in Singapore?

b) are certain participant characteristics associated with the prevalence and size of barriers?

Methods

Study design and setting

We conducted a face-to-face cross-sectional survey with stroke survivors living in the community. The survey was conducted from June 2019 to December 2019 through Singapore National Stroke Association (SNSA) platforms. SNSA is a voluntary welfare organization, and the national support group for stroke survivors and caregivers in Singapore (http://www.snsa.org.sg/). Prior to COVID-19, SNSA runs monthly in-person events ranging from exercise classes to social activities (e.g., evening strolls, coffee chats and tea dance party). Information about the study was distributed through web-based methods (e.g., SNSA mailing list, Facebook page) and announcements at SNSA events. If interested, participants contacted the research team members who gained written informed consent from participants. Research team members then conducted the survey in-person during or after SNSA events. Upon completion of the survey, participants received a $20 voucher to reimburse them for their time and effort in completing the survey. Ethical approval for the study was granted by the Singapore Institute of Technology Institutional Review Board (project number: 2019102).

Participants

Participants were recruited from the community, and were eligible for the study if they were 21 years old and above, had a medical diagnosis of stroke, and had a weak arm or leg. If participants had speech deficits but were able to understand and respond to simple commands, they were included.

Survey

We collected two types of data in our survey: a) participant characteristics, and b) barriers to physical activity. For the questions on participant characteristics, we asked participants about their age, gender, ethnicity, time since last stroke and most frequent walking aid used. We also used the Modified Rankin Scale (MRS) to describe the level of disability, or assistance needed by participants to conduct their daily activities. To ensure standardised scoring of the MRS, we used the same structured interview that had previously shown increased agreement between raters.^22,23 To evaluate the prevalence and size of barriers to physical activity, we used the BPAQ-MI.¹⁸ The BPAQ-MI had 63 items which were equivalent to 63 barriers across four ecological domains: a) intrapersonal, which focuses on personal factors and involves health, attitude and impairment; b) interpersonal, which focuses on social relationships with family, friends and professionals; c) organizational domains, which focuses on attributes of institutions/fitness centres within the community, such as programs and staff; and d) community, which focuses on community-at-large factors such as public transportation and the built and natural environment. To determine the prevalence of barriers, participants were asked regarding the absence/presence of a barrier, and if present, the size of the barrier on a scale of 1 (very small) to 5 (very large). Respective questions were worded as follows: “Thinking over the past 3 months, were there any times when you wanted to participate in physical activity but didn’t or was more difficult because [insert barrier, e.g., you get tired or fatigued]” and “In general, when you encounter [insert barrier, e.g., tiredness or fatigue], how much of a barrier is [insert barrier, e.g., tiredness or fatigue], on a scale from one to five with one being very small and five being very large?” (see Supplementary material 1). The BPAQ-MI was estimated to take 15–20 min to complete, and had previously demonstrated moderate to very good internal consistency of items in domains, good test-retest reliability and moderate criterion validity between most of the BPAQ-MI subscales and exercise subscale of the Physical Activity and Disability Survey.¹⁸

As English and Chinese were the most common languages spoken at home in Singapore (https://www.singstat.gov.sg/find-data/search-by-theme/population/education-language-spoken-and-literacy/publications-and-methodology), we translated the BPAQ-MI into Chinese, and used both English and Chinese versions in our study. The translation work was performed by a fluent English and Chinese speaker with experience in translating interview questionnaires, recruitment emails and insight reports from English to Chinese, and Chinese to English. To ensure accurate back translation, the Chinese version of the BPAQ-MI was then translated back into English by a team member fluent in both languages. Prior to the actual surveys, a 2-h training session was held to familiarise all team members to the BPAQ-MI questions. During the training session, team members went through each question, and practised asking the questions in a standardised manner that would be suitable in the local context of Singapore. For example, it was agreed that for question 27 of the BPAQ-MI, we would replace the words “Bally’s or YMCA (gyms)” with “ActiveSG (gyms)”, and allow the inclusion of bicycles, power-assisted bicycles, motorised and non-motorised Personal Mobility Devices (PMDs) (e.g., electric scooters) and Personal Mobility Aids (PMAs) (e.g., motorised wheelchairs) as part of the definition of “cars” for question 39 of the BPAQ-MI.

Data analysis

We used descriptive statistics to report the participant characteristics. For continuous variables, we reported mean (SD, standard deviation) and 25^th, 50^th and 75^th percentile. For categorical variables, we reported numbers (n) and percentages (%). To describe the prevalence of barriers, we reported the numbers (n) and percentages (%) (i.e., the number of stroke survivors who said “yes” to having encountered each of the 63 barriers). To describe the size of the barriers, we calculated the mean domain and sub-domain scores of the BPAQ-MI. Mean domain and sub-domain scores were calculated by taking the average of the size of the barriers within the respective domains and sub-domains. The domain and subdomain with the highest mean score indicates that stroke survivors perceived the barriers in the specific domain and subdomain to be the largest barriers to PA. If a stroke survivor did not encounter the barrier, his/her score was input as zero but included in the mean domain and sub-domain scores. We used the Wilcoxon-Mann Whitney test to detect significant differences between gender and barriers (prevalence and size) and the Spearman’s rank correlation to detect significant associations between age, time since last stroke, MRS and barriers (prevalence and size). All statistical analyses were performed in Stata (Stata Statistical Software: Release 14; StataCorp LP, College Station, TX, USA).

Results

Characteristics of participants

The characteristics of our participants are shown in Table 1. Of the 38 participants surveyed, most were male, of Chinese ethnicity and of middle age. All were in the sub-acute to chronic phase post-stroke. More than half of our participants (55%) had moderate or moderately severe disability (MRS = 3 or 4), indicating assistance required for basic and/or instrumental activities of daily living, and/or walking. More than half (61%) used a walking aid or personal mobility aid as their most frequent mobility aid. Most surveys were conducted in English, with a small number conducted in Chinese (n = 4).

Table 1.

Characteristics of participants with stroke (n = 38).

Characteristics	Mean±SD (25^th, 50^th, 75^th Percentile)^a
Age (years)	58.3±10.0 (52, 57, 63)
Gender (male), n (%)	27 (71%)
Ethnicity, n (%)
Chinese	34 (89%)
Indian	3 (8%)
Filipino	1 (3%)
Time post-stroke (years)	4.4±3.9 (1.1, 3.0, 6.0)
Modified rankin scale	2.5±1.0 (2.0, 3.0, 3.0)
Modified rankin scale, n (%)
1 = No significant disability	8 (21%)
2 = Slight disability	9 (24%)
3 = moderate disability	14 (37%)
4 = moderately severe disability	7 (18%)
5 = severe disability	0 (0%)
6 = Death	0 (0%)
Most frequent mobility aid used, n (%)
No aid	15 (39%)
Walking stick/Quad-stick	10 (26%)
Walking frame	1 (3%)
Motorized scooter/Electric wheelchair	11 (29%)
Manual wheelchair	1 (3%)

^aValues are mean (SD) (25th, 50th, 75th percentile) unless otherwise indicated. If the median and mean are similar and the outer quartiles are symmetrical with respect to the median, the variable may be interpreted as being normally distributed.

Prevalence and size of barriers

Tables 2–4 illustrate the prevalence of barriers while Table 4 illustrate the size of barriers. Numbers and percentages for the top 10 most commonly reported barriers are reported in Table 2, while numbers and percentages for the top 10 most commonly reported medium to very large barriers are reported in Table 3. Table 4 show the size of barriers via the mean domain and sub-domain scores reported for all participants. Of the 63 barriers, the top three most commonly reported barriers include lack of accessible classes/programs at fitness centre, lack of assistance from fitness centre staff and feelings of tiredness/fatigue, with 21 (55%), 19 (50%) and 18 (47%) of stroke survivors reporting these barriers respectively (Table 2). The remaining barriers within the top 10 included lack of motivation to be physically active, fear of getting injured while being physically active, cars driving too fast, lack of accessible exercise equipment at fitness centre, being in pain, lack of access to public restrooms, and fitness centre membership fees being too high. Of the top 10 most commonly reported barriers, four were within the organizational domain, four were within the intrapersonal domain and two were within the community domain. No barriers pertaining to interpersonal domains were reported in the top 10 most commonly reported barriers.

Table 2.

Top 10 most commonly reported barriers.

BPAQ-MI items reported as barriers	Number that reported barrier, n (%)
1. Lack of accessible classes/programs at fitness center	21 (55%)
2. Lack of assistance from fitness center staff	19 (50%)
3. You get tired or fatigued	18 (47%)
4. You lack the motivation to be physically active	16 (42%)
5. You were afraid of getting injured while being physically active	16 (42%)
6. The cars drive too fast	15 (39%)
7. Lack of accessible exercise equipment at fitness center	14 (37%)
8. You were in pain	14 (37%)
9. Lack of access to public restrooms	12 (32%)
10. Fitness center membership fees were too high	12 (32%)

Table 3.

Top 10 most commonly reported medium to very large barriers.

BPAQ-MI items reported as medium to very large barriers	Number that reported barrier as medium to very large, n (%)
1. Lack of accessible classes/programs at fitness center	18 (47%)
2. Lack of assistance from fitness center staff	15 (39%)
3. You get tired or fatigued	15 (39%)
4. You were afraid of getting injured while being physically active	13 (34%)
5. The cars drive too fast	12 (32%)
6. You were in pain	12 (32%)
7. You lack the motivation to be physically active	11 (29%)
8. Fitness center membership fees were too high	11 (29%)
9. Lack of accessible transportation to fitness center	11 (29%)
10. Lack of inclusive marketing	11 (29%)

Table 4.

Overview of BPAQ-MI scores.

BPAQ-MI domains, sub-domains and items	Mean domain and sub-domain scores	Number that reported barrier, n (%)	Number that reported barrier as medium to very large, n (%)
Domain 1: Intrapersonal	0.91
Sub-domain: Health	1.13
1. You get tired or fatigued		18 (47%)	15 (39%)
2. You were in pain		14 (37%)	12 (32%)
3. You believe physical activity requires too much work/effort/energy		6 (16%)	5 (13%)
4. You didn’t have an appropriate fitness level to be physically active		9 (24%)	7 (18%)
5. You felt physical discomfort while being physically active		10 (26%)	9 (24%)
6. You were afraid of getting injured while being physically active		16 (42%)	13 (34%)
7. You were depressed		10 (26%)	9 (24%)
Sub-domain: Beliefs/Attitudes towards physical activity	0.72
8. You lack the motivation to be physically active		16 (42%)	11 (29%)
9. You don’t have confidence in your ability to be physically active		10 (26%)	8 (21%)
10. You were embarrassed about your appearance while being physically active		3 (8%)	3 (8%)
11. You have not seen positive results from previous physical activity		10 (26%)	8 (21%)
12. You feel you are too old to be physically active		5 (13%)	3 (8%)
13. You didn’t think physical activity would help you		5 (13%)	3 (8%)
14. Being physically active is not enjoyable		11 (29%)	7 (18%)
15. You don’t see a reason to be physically fit		5 (29%)	4 (11%)
Domain 2: Interpersonal	0.35
Sub-domain: Friends	0.40
16. You did not have another person with a disability who was physically active to look up to		5 (13%)	3 (8%)
17. Your friends didn’t assist you to be physically active		4 (11%)	3 (8%)
18. Your friends are not physically active		5 (13%)	3 (8%)
19. Your friends don’t talk about being physically active		3 (8%)	3 (8%)
20. Your friends were not encouraging or supportive of your efforts to be physically active		4 (11%)	3 (8%)
21. Your friend’s priorities take precedence/priority over you being physically active		3 (8%)	3 (8%)
Sub-domain: Family	0.28
22. Your family’s culture, beliefs, or morals did not place physical activity as a priority		1 (3%)	1 (3%)
23. Your family did not assist you to be physically active		4 (11%)	3 (8%)
24. Your family members are not physically active		5 (13%)	5 (13%)
25. Your family members were not encouraging or supportive of your efforts to be physically active		4 (11%)	4 (11%)
26. Your family did not think physical activity would be helpful to improve your health		0	0
Domain 3: Organizational	0.83
Sub-domain: Fitness center built environment	0.72
27. In the last 3 months, there were times that you wanted to go to a fitness center or gym but couldn’t		31 (82%)
27a. Lack of accessible exercise equipment at fitness center		14 (37%)	10 (26%)
27b. The walkways/aisles were too narrow or had obstacles		7 (18%)	6 (16%)
27c. Lack of accessible door handles		4 (11%)	3 (8%)
27d. Lack of accessible curb cuts at fitness center		10 (26%)	7 (18%)
27e. Ground that you walk/roll on was not accessible		6 (16%)	6 (16%)
27f. Lack of accessible ramps at fitness center		8 (21%)	7 (18%)
27g. Lack of accessible bathrooms at fitness center		8 (21%)	7 (18%)
27h. Lack of accessible showers/locker rooms		7 (18%)	7 (18%)
27i. Lack of accessible elevators at fitness center		9 (24%)	8 (21%)
27j. Lack of accessible parking at fitness center		4 (11%)	3 (8%)
27k. Lack of access to indoor track for walking/wheeling		2 (5%)	2 (5%)
Sub-domain: Staff/Program/Policy	0.96
27L. Fitness center membership fees were too high		12 (32%)	11 (29%)
27m. Your health insurance plan do not cover membership fees		8 (21%)	7 (18%)
27n. Lack of inclusive marketing		11 (29%)	11 (29%)
27o. Lack of accessible classes/programs at fitness center		21 (55%)	18 (47%)
27p. Other fitness center members were mean or rude		5 (13%)	4 (11%)
27q. Lack of accessible walking/rolling paths at parks		4 (11%)	4 (11%)
27r. Lack of assistance from fitness center staff		19 (50%)	15 (39%)
27s. Lack of accessible sport opportunities at fitness center		8 (21%)	8 (21%)
27t. Signs showing where things are located were not accessible		3 (8%)	3 (8%)
27u. Lack of interpretive services		2 (5%)	2 (5%)
Domain 4: Community	0.71
Sub-domain: Community built environment	0.84
28. Lack of access to public restrooms		12 (32%)	8 (21%)
29. Uneven or crooked sidewalks		10 (26%)	9 (24%)
30. The sidewalks have cracks, gaps, or are under construction		11 (29%)	10 (26%)
31. Lack of rest areas		10 (26%)	8 (21%)
32. Potholes in the street, driveways, or parking lot		11 (29%)	10 (26%)
33. Sidewalk’s cross slope is too steep/slanted		6 (16%)	6 (16%)
34. The crosswalks lack traffic lights		2 (5%)	2 (5%)
35. Lack of accessible curb cuts in community		6 (16%)	6 (16%)
36. Lack of accessible transportation to fitness center		11 (29%)	11 (29%)
37. Sidewalks were not wide enough		5 (13%)	4 (11%)
Sub-domain: Safety	0.50
38. Excessive crime or fear of crime in neighborhood		0	0
39. The cars drive too fast		15 (39%)	12 (32%)
40. Excessive car traffic in my community		7 (18%)	5 (13%)
41. The traffic lights or crosswalk signals change too quickly		6 (16%)	4 (11%)
42. Lack of adequate street lighting at night		2 (5%)	1 (3%)
43. Loose dogs in community		1 (3%)	1 (3%)

When we considered only the proportion of medium to very large barriers, the top three medium to very large barriers were similar to that of all barriers (Table 3), in that more barriers were reported in the intrapersonal and organizational domains than the community and interpersonal domains. Barriers in the intrapersonal and organizational domains were also reported to be larger than barriers in the community and interpersonal domains. This was in line with the mean domain scores of each ecological domain, with the intrapersonal domain scoring 0.91, organizational domain scoring 0.83, followed by the community domain scoring 0.71 and the interpersonal domain scoring 0.35. The domain with the highest mean score indicates that stroke survivors perceived the barriers in the intrapersonal and organizational domains to be the largest barriers to PA. Of the 63 barriers, 61 barriers were listed by at least one stroke survivor as a barrier to PA except for two barriers: “your family did not think physical activity would be helpful to improve your health” and “excessive crime or fear of crime in neighbourhood”.

Associations between participant characteristics and barriers (prevalence and size)

There was a statistically significant difference between gender and the prevalence of barriers, with female stroke survivors reporting a higher number of barriers (z = −2.063; p = 0.04), and higher number of medium to very large barriers (z = −2.241; p = 0.03) compared to male stroke survivors. Female stroke survivors also perceived barriers in the subdomains of “Beliefs/Attitudes towards physical activity” (under Intrapersonal domain) (p = 0.01), “Family” (under Interpersonal domain) (p = 0.001), and Community domain (p = 0.04) to be larger compared to male stroke survivors. There was a statistically significant association between disability (MRS) and prevalence of barriers. As disability increased (i.e., higher MRS), the prevalence of barriers also increased (r_s = 0.36; p = 0.03), along with the prevalence of medium to very large barriers (r_s = 0.34; p = 0.03). This pattern was also observed for the size of barriers. As disability increased, the size of barriers also increased for the subdomains of “Staff/Program/Policy” (under Organizational domain) (r_s = 0.40; p = 0.01), “Community Built Environment” (under Community domain) (r_s = 0.34; p = 0.04), Organizational domain (r_s = 0.33; p = 0.04) and Community domain (r_s = 0.41; p = 0.01). No statistically significant associations were found between age and time since last stroke and prevalence of barriers. With regards to the size of barriers, there was a statistically significant negative association between age and size of barriers for subdomain of “Family” (under Interpersonal domain) (r_s = −0.34; p = 0.03). And Interpersonal domain (r_s = −0.41; p = 0.01). This indicated that as age decreased (i.e., as stroke survivors become younger), the size of barriers associated with family members increased.

Discussion

Our study is the first to demonstrate barriers to PA in stroke survivors in Singapore. Stroke survivors reported wanting to exercise in the past 3 months, but faced many barriers including organizational barriers (associated with fitness centres), intrapersonal barriers (associated with self), community barriers (associated with the environment) and interpersonal barriers (associated with friends and family). Of all the barriers, the most commonly reported barriers were organizational barriers (e.g., lack of accessible classes/programs at fitness center, lack of assistance from fitness center staff), followed by intrapersonal barriers (e.g., tiredness/fatigue, lack of motivation, fear of injury). Most of these barriers to PA were also identified by stroke survivors as being medium to very large in size. Stroke survivors who were female and were more disabled reported more barriers and more medium to very large barriers to PA. More disabled stroke survivors reported larger organizational and community barriers, while female stroke survivors reported larger community barriers, and younger stroke survivors reported larger interpersonal barriers.

Barriers related to organizational factors (fitness centres) are often not reported in studies of barriers to PA in stroke survivors, as existing surveys often do not include items pertaining to fitness centres. In the two surveys that have asked about barriers pertaining to fitness centres (i.e., the EBBS^9,10 and the BPADS¹²), the coverage was often not comprehensive. For example, the EBBS only had one item specific to fitness centres (i.e., “exercise facilities do not have convenient schedules for me”),^9,10 while the BPADS had five items specific to fitness centres but did not include items pertaining to the built environment of the fitness centres such as accessible exercise equipment, or considered other items relating to staff/program/policy such as inclusive marketing.¹² Barriers related to fitness centres are therefore likely to be under-reported in the literature despite being more commonly reported than intrapersonal factors in our study. The use of the BPADS by Rimmer and colleagues allowed for some comparison with our study as the BPADS had three items that were comparable to the BPAQ-MI: cost of program at fitness centres, lack of transportation to fitness centres and feeling like the trainer is unable to help.¹² Compared to Rimmer’s study conducted on 83 stroke survivors in the United States, we had less people reporting on cost of program (32% vs 61%) and lack of transportation (29% vs 57%) as barriers to PA, but more people reporting on lack of assistance from fitness centre staff (50% vs 36%) as barriers to PA.¹² These differences highlight the need to consider country-specific barriers which are likely to exist due to differences in the size of the country, availability of fitness centres in residential areas, and capabilities of staff working in the fitness centres. These aspects warrant further consideration when developing PA programs for stroke survivors in specific countries.

Compared to organizational factors, intrapersonal factors are more commonly reported in existing surveys and hence some of our findings on intrapersonal barriers to PA are comparable to other studies. Our estimate of 47% reporting fatigue/tiredness as a barrier to PA was identical to the estimate reported in the United States (47%),¹² but was much lower compared to estimates reported in Brazil (76% and 72%) ⁹ and Africa (84% and 85%),¹⁰ while our estimate of 42% reporting reduced motivation as a barrier to PA was comparable to the estimates reported in the United States (45% and 53%).^12,15 Fear and being in pain were less commonly reported in surveys, though these were concerns in our study with 42% reporting fear of getting injured and 37% reporting concern about being in pain. These were asked as additional barriers by Debora Pacheco and colleagues⁹ in Brazil, though their estimates were much lower, with 7% reporting fear of feeling sick and 20% reporting pain in lower limbs as additional barriers to PA. These differences in estimates are likely due to a less disabled cohort in Debora Pacheco’s study compared to ours, as their study only included stroke survivors with mild disability who were able to walk in the community, while more than half of our cohort (55%) had moderate to moderately severe disability on the MRS.

The two community barriers highlighted in our top 10 most commonly reported barriers were cars driving too fast (39%) and lack of access to public restrooms (32%). Although prior studies in Canada and China have used the CHIEF to highlight environmental barriers faced by stroke survivors, the most frequent and largest barriers identified in both studies were non-specific and included the natural environment, design of home/community/work/school, surroundings and technology.^8,11 More specific barriers like those described in our study (from using the BPAQ-MI) might therefore provide more information that town councils/planners could use in order to remove barriers faced by stroke survivors when moving about in the community. Interestingly, shortly after the completion of our study, e-scooters were banned on footpaths in Singapore (https://www.channelnewsasia.com/news/singapore/e-scooter-ban-on-footpaths-singapore-lta-pmd-12061404) which would help to alleviate the fears that some stroke survivors had expressed about walking on footpaths in the community.

Our findings suggested that stroke survivors who were female, more disabled or younger faced more and/or larger barriers. These results are interesting as women are known to have poorer recovery outcomes compared to men post-stroke,^24,25 and younger stroke survivors have been identified to have many unique unmet needs in a healthcare system which tends to cater more for the older consumer.²⁶ For more disabled stroke survivors, it is perhaps not surprising that they reported more and larger barriers in the domains of organizational and community barriers. These suggest difficulties in accessing fitness centres and getting about in the community. To develop a targeted and personalised PA programme that will cater to all stroke survivors, the barriers faced by these sub-group of individuals will need to be considered carefully as they will have unique needs that are unlikely to be met by generic exercise programs targeted at milder strokes.

Limitations

Our study had several limitations. First, the sample size of 38 stroke survivors was small and recruited from the national stroke support group (SNSA). Although we used a comprehensive survey of 63 barriers, had no missing data and were able to reach out to a group of participants with limited mobility (55% had moderate or moderately severe disability), the sample size was smaller than other surveys of stroke survivors ^8–12 and is likely to include a cohort with unique features (e.g., stroke survivors who are more motivated to engage in PA) that might not be representative of the general population of stroke survivors in Singapore. Second, a small number of surveys (n = 4) was conducted in Mandarin using a translated version of the BPAQ-MI. Although training was conducted within the team to standardise the conduct of the survey, the psychometric properties of the Mandarin version of the BPAQ-MI have not been tested and this could influence the accuracy of results. Third, our survey (similar to other surveys) did not allow for more in-depth responses which are likely to be useful when considering solutions to address the barriers, or when understanding why certain patients face more and larger barriers compared to others. Future studies should consider recruiting a larger sample size, testing the psychometric properties of the Mandarin version of BPAQ-MI and combining the survey with semi-structured interviews or focus groups to further understand the barriers so that they can be addressed within the eco-system of community living after stroke.

Clinical implications

In Singapore, several nationwide public health initiatives have taken place to promote PA in adults. These include free group workout sessions in shopping malls and parks (https://www.healthhub.sg/programmes/170/StayWell), $100 credit to access public gyms and swimming pools for free (https://www.myactivesg.com/), and nationwide initiatives such as the National Steps Challenge where individuals can track their own PA levels with wearables and smartphone applications, and are given financial incentives if they achieve the recommended steps/day.²⁷ These initiatives are largely targeted at the general population of adults without disabilities. Our results showed that stroke survivors wished to engage in regular PA but were limited by many barriers beyond their control. These included barriers associated with fitness centres (such as lack of assistance from fitness centre staff, lack of accessible programs at fitness centres, high fitness centre membership fees and lack of inclusive marketing) and barriers associated with the community (such as cars driving too fast, lack of access to public restrooms and lack of accessible transport to fitness centres). Possible solutions include building collaborative models of care between health and exercise professionals to allow better transition of stroke care from hospital to the community.²⁸ Town planners can also include stroke survivors in the planning of public infrastructure in order to build a more inclusive physical environment that is conducive for people with disabilities to access and use for exercise. Intrapersonal barriers should also be addressed. Health and exercise professionals can be trained and upskilled to provide the support that stroke survivors need to manage fatigue and pain, encourage motivation and empower stroke survivors so that they are confident in carrying out regular PA in the community without injuring themselves.

Conclusions

Stroke survivors in Singapore want to participate in PA, but are often limited by organizational, intrapersonal and community barriers. Most of these barriers (i.e., the organizational and community barriers) are beyond their control. To give stroke survivors the best chance to engage in regular PA after stroke, it is vital to address these barriers and ensure the same PA opportunities accorded to the healthy population are also made available to stroke survivors in Singapore. Collaborative models of care between health and exercise professionals, and training programs to upskill health and exercise professionals are possible solutions to target these barriers.

Supplemental Material

Supplemental Material - Barriers to physical activity of stroke survivors in Singapore: A face-to-face cross-sectional survey

Supplemental Material for Barriers to physical activity of stroke survivors in Singapore: A face-to-face cross-sectional survey by Raylynn Teo, Shamala Thilarajah, Liu Jiale, Favian Lim Fang Yu and Kwah Li Khim in Proceedings of Singapore Healthcare.

Footnotes

Acknowledgements

We are grateful for the support rendered by stroke survivors and staff at Singapore National Stroke Association in completing the study.

Author contributions

KLK and ST researched the literature and conceived the study. KLK,ST,RT,FL and LJL were involved in protocol development,gaining ethical approval,participant recruitment and data analysis. RT wrote the first draft of the manuscript. All authors reviewed and edited the manuscript and approved the final version of the manuscript.

Declaration of conflicting interests

The author(s) declared no potential conflicts of interest with respect to the research,authorship,and/or publication of this article.

Funding

The author(s) disclosed receipt of the following financial support for the research,authorship,and/or publication of this article: This work originated from a Honours Thesis project conducted as part of the undergraduate physiotherapy program at Singapore Institute of Technology. It is not supported by a grant.

Ethical approval

Ethical approval for the study was granted by the Singapore Institute of Technology Institutional Review Board (Project number: 2019102).

Informed consent

Written informed consent was obtained from all participants before the study.

Availability of data

The datasets generated and/or analysed during the current study are available from the corresponding author upon reasonable requests.

ORCID iDs

Shamala Thilarajah

Kwah Li Khim

Supplemental Material

Supplemental material for this article is available online.

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