Background: Research shows that unhealthy diets and low physical activity are associated with high rates of obesity-linked chronic diseases amongst Nunavut Inuit. To provide contextual insights and deepen our understanding of the factors that underlie these lifestyle choices, we explored the perspectives of Nunavut Inuit on the barriers and enablers of healthy diets and physical activity participation in the community of Iqaluit. Methods: One-on-one semi-structured photo-elicitation interviews were conducted with 16 participants of 18 years and over . The interviews uncovered the participants’ perspectives on the factors influencing healthy diets and physical activity in their community. Interviews were audio-recorded, transcribed, and uploaded to QSR NVIVO Version 12. Data analysis was achieved using an inductive thematic approach. Results: Six main factors were identified as barriers or enablers to energy balance-related behaviors: cost and affordability of healthy choices; availability of traditional foods and activities; weather conditions and climate change; infrastructure and community resources; social networks of family and friends; and effect of substance use. Conclusion: This study identified six broad areas that should be considered while mapping out interventions to reduce the burden of obesity-related chronic diseases in Nunavut communities. Inuit diets and activity patterns have significantly changed over the past five decades in response to the socio-cultural and environmental transitions in the Arctic. The population has transitioned from the traditional hunter-gatherer subsistence living to Euro-Canadian ways of life. This lifestyle transition is characterized by steady increases in the consumption of energy-dense processed foods ,2,3 and Although the Inuit population is growing at a rate higher than the national average , many InA body of research evidence has demonstrated comparative health, social, and economic benefits of sustained harvesting of traditional foods in the Canadian Arctic over energy-dense store-bought processed foods ,13,14. HTo date, there have been limited studies that aimed at advancing our understanding of the determinants of diet and physical activity among Inuit ,7. NotabIn line with the proposed research objectives in this Indigenous population, we employed a photo-elicitation method for this qualitative inquiry. According to Harper , photo-eThis study was part of a larger project that aimed to explore the determinants of dietary behavior and physical activity in the Canadian Arctic. The Inuit population in Nunavut and the nature of the built and food environments have been previously described ,7. We utThe Inuit are one of the three Indigenous peoples of Canada . The InuData collection was divided into two phases. Phase one consisted of photoshoots in the community and collection of historical photographs for the photo elicitation interview (PEI). PEI is defined as the insertion of photographs in an interview. Photographs are used in qualitative inquiry to trigger memory and evoke responses to interview questions. In the current study, we included photographs in the semi-structured interviews that were conducted with Inuit participants.Two interviewers, VOA and TOF, took photographs of the contemporary built and food environments in Iqaluit during the summer and winter, and collected a few historical photographs of the neighborhoods, streets, houses, motor vehicles, walkways, playgrounds, fitness/sports center, etc. The historical photographs depicted the community built and food environments as they were 30 to 50 years ago. The contemporary photos included photographs of food items in the two main grocery stores with prices, as well as traditional foods, to gather photographic representations of the current food environment. These photographs were then included in the photo elicitation interviews to advance our understanding of how certain components of the food environment might affect dietary choices for Iqaluit residents. In addition, photographs of roads, streets, walkways, parks, and the sport/fitness center, as well as objects such as buildings, motor vehicles, snow mobiles, etc., were taken to capture the current state of the built environment in Iqaluit. Photograph selection for the interviews  was guided by the perceived environmental attributes in the built environment and known to influence walking behavior ,26. The Participants were recruited using a purposeful sampling technique . The samOne-on-one semi-structured interviews were conducted based on the photographs. Each participant was asked to select five photos from the 10 photographs that were presented by the researcher for discussions of food and built environments. Each participant chose five photographs of interest from a list of healthy traditional and non-traditional foods, including caribou meat, seal meat, arctic char, pasteurized milk, berries, spinach, etc.; and unhealthy foods such as potato chips, frozen pizza, white bread, cookies, sugar-sweetened beverages, etc. Healthy and unhealthy diets amongst Nunavut Inuit were previously described in detail in a systematic review . Five phData analysis was conducted using an inductive thematic approach . By way Transcribed data were uploaded to QSR NVIVO Version 12 to conduct text searches and word-frequency queries, find connections within data, and generate patterns and themes. We utilized a three-stage coding system. In the first stage, each transcript was read repeatedly to identify phrases that could be organized into general themes. In the second stage , the initial codes that were developed in stage one were grouped into smaller themes. In stage three (selective coding), all codes were reviewed and further refined into thematic categories. The second coder, TOF, cross-checked the three coding stages, and based on discussion with VOA, made changes to the codes with mutual agreement. The thematic categories were then linked through logical deductions to achieve the highest level of validation for the central themes and subthemes presented below. In the Results section, it is stated whether the participant was male (M) or female (F).The factors hindering and facilitating physical-activity participation and healthy eating among Canadian Inuit from participants’ perspectives are categorized under six broad themes: cost and affordability of healthy choices; availability of traditional foods and activities; weather conditions and climate change; infrastructure and community resources; social networks of family and friends; and effect of substance use.The main perceived barrier to healthy food choices and participation in physical activity that participants identified was affordability. Participants mentioned that many community residents cannot afford the high costs of healthy foods, both traditional , and non-traditional foods such as beef, milk, eggs, fruits, and vegetables, which could be 50% to 300% higher than the prices in the southern part of Canada. They noted that unhealthy (junk) foods are cheaper and preferred by many Inuit with low income. According to the participants, traditional foods are increasingly becoming expensive because of the cost of hunting equipment and lower availability of hunters with the appropriate hunting skills:“If you consider everything, it will drive you crazy, so you have to stop looking at the prices… … Every now and then I’ll look at the price, but not very often because it just drives you crazy. Although, I get to the point when I’m really angry because I know I don’t need to pay this much, you know? So you kind of walk over … You’re not angry at anybody, you’re just kind of angry that you have to pay this much”.(F)“I believe they’re the ones that are in control of the food prices for many of the healthy foods. If there were other ways to bring it up north, more in bulk, and cheaper ways, I think food prices would be lower cost, they’re the ones controlling it all I believe”.(M)“Especially having lived elsewhere where the food was affordable, then it’s great, you know. But if you haven’t gone anywhere then they don’t know any better, you know? We ordered a club sandwich from the snack, it cost us $50. She actually posted it and said, “Look, a $50 club sandwich”.(F)“…and ordered breakfast and paid a $30 price for breakfast, which would only cost $7 in Ottawa, you know?”.(F)Cost and affordability impact physical activity as well. The high cost of hunting equipment, resulting in less hunting activities, and the exorbitant cost of registration fees at fitness centers or sports equipment in the face of relatively low household income, all combine to reduce physical-activity rates and fitness levels in the Inuit population:”You know, there’s a difference. Not every family, in a family has machines to go hunting. When we all had dogsleds, everybody went, everybody could go, but now we have machines to take us everywhere, and none of them are under 10 grand”.(F)“You’ve got to be rich to play [ice] hockey. So you’ve got to make sports accessible to Inuit and not charge them a lot because it’s them that suffer when you do a bit pull like that, do you know what I mean? It’s only mostly the elite which are all from the southern part. So hockey maybe not be a good example to show me”.(F)Another barrier that was mentioned by participants was related to availability of healthy choices including traditional foods and cultural activities. Some participants argued that it is one thing to know the importance of healthy food choices and be interested in adopting healthy eating as a lifestyle, and be able to afford this, while it is a different issue entirely to find these healthy food options in the store on a regular basis. Explaining further, some respondents commented that there are certain government regulations that restrict the number of animals such as caribou that can be harvested in certain parts of the territory, thus impacting its availability and accessibility.“[Traditional food] is accessible to certain degree. For example, we have the country food shop near the library, which is nice. We can go there and grab tuktu, grab fish, but sometimes there’s also moments where you’ll go looking for something and you can’t find that. That’s one. Two, there’s also like the days where you can’t really go hunting because of the weather, because nowadays the weather is very topsy turvy. You can’t predict it as much so I’d say those are the two main factors”.(F)“For caribou when my nephews and cousins travel to the west, where they have no quota limit on caribou, if it’s available and they are coming back with fresh caribou. If family or friends share their, what they have, if it’s family dinner going on”.(M)Several decades ago, traditional hunting was a lifestyle and a cultural activity that promoted active living and provided healthy food supplies to households. Inuit lived a nomadic and active lifestyle, promoting physical health and fitness. One participant stated:“I think back then it was a lot more physical activity because we were, and what I know we were often migrating with the animals, following their migration routes. Moving from camp to camp, consistently looking for food and maintaining shelters, and clothing, hunting tools. I believe one was never idle back then, I think idle back then was considered lazy and I believe today there’s a lot more, more things are given to us, and we are taking it for granted. That they’re able to, not required to do as much to live in today’s age”.(M)According to some participants, a general shift from traditional hunting as a means of subsistence to a wage economy also influences availability:“So not everybody can do that. Most of our people are working nine to five, Monday to Friday, so they don’t do this on a regular basis, but they may go out and do a variation of this on the weekend”.(F)Moreover, colonization and sociocultural assimilation have disrupted Inuit cultural practices and disparaged traditional values, such that many Inuit have attached less social significance to hunting and as a way of life, and suggesting that “food sharing” practices should be promoted as traditional value to improve access.“But we’re totally immersed in this [Euro-Canadian] culture here in….. not so much in the communities”“I get access to … If I had relatives that went hunting, people share. They’re on Facebook, people saying, “We’re having the meal today, please come. Anybody come.” Those are the other options. The third option, final option, would be to go to a store. We have a country food store here. It’s an arm and a leg, but when we’re craving we crave big”.(F)The changing climatic conditions were identified by some participants as contributing to low participation in activities that are tied to healthy diets and active living. As well, it was suggested that the long winter season that ranges from six to eight months at very low temperatures are deterrent to engagement in physical activity, thus reducing participation rates.Commenting on the effect of weather on physical activity, a participant opined:“Sometimes it’s cold outside. You don’t wanna walk all the way……so you just decide not to go, you know? But yeah, also the weather conditions. You know that a lot of people don’t even like getting out of their house during the winter ‘cause it’s so dark out, you know, so mentally they just kind of don’t wanna do that stuff anymore”.When asked of one perceived barrier to active living as a lifestyle, one participant said:“The cold weather. If it’s very cold out, I try and stay indoors”.(M)According to one participant:“[The government] is not willing to acknowledge that climate change and global warming, are occurring and having a large impact on the circumpolar nations…..and [Inuit] culture will slowly diminish away, where they will not be able to practice their traditional practices of hunting on their land. Because if global warming continues, then [this] particular ice flow, this ice rift that’s here, will become much wider apart, and it’ll be far unsafe for this particular person to go out on the land to hunt for any sea animals”.(F)Further into the discussion on weather-related challenges that Inuit face while trying to access resources during winter, one participant emphasized the need for adequate facilities and the need for these amenities to be strategically located in the community. She argued:“…but some people who live, for example, all the way in Happy Valley, or not even Happy Valley, in like Tundra Valley or something. They’re gonna probably be less likely to drive all the way, especially in the winters, drive all the way to work and they drive all the way back. It’s not something that a lot of people do, so just having the facilities open, whether that’s closer to a lot of household places, in buildings, stuff like that”.(F)Nunavut is a resource-limited environment compared to southern provinces. The availability of adequate resources and the level of infrastructural development in Inuit communities continue to pose barriers to healthy diets and active living, according to respondents. Thus, increasing community-level resources would increase the participation rates in physical activity and the chances that a healthy eating behavior would be adopted in the population:“…We don’t have sidewalks here in Iqaluit. We have no sidewalks, so we walk on pavement. So to have sidewalks where people could actually walk on. A place where you can put salt on to de-freeze things, you know, preventing you from slips, of black ice, where most people can actually walk, because if you were to have those things set up, then perhaps people would want to engage in more activities outdoors”.(F)“…in the winter the sidewalks are not as maintained. In the summer you could sort of go anywhere, and everywhere quicker as compared to walking in deep snow, or snow banks to go around”.(M)Commenting further, a participant commented on the need to engage community elders as resource persons to teach Inuit traditions and transfer cultural legacies such as hunting to increase the number of Inuit who are accessing healthy traditional foods:“… And…[give] opportunities to children and adolescence to learn the skills of hunting. Because it’s important to continue the traditions onward as opposed to it simply dying from the elders and not being passed through the intergenerational learning”.(F)Although resources and infrastructures are limited, adequate funding and personnel continue to pose significant challenges to the maintenance of existing infrastructures in the community:“Hmm. It exists, at least from my understanding, it exists from the infrastructure that’s present within the north. It’s quite difficult to maintain sidewalks, because realistically, we are living north of 60. We are in a circumpolar area, and that results in lots of snow falling. And the maintenance of infrastructure such as sidewalks is uncertain, because I’ve seen before that there are sidewalks that were created by putting large rocks on the side of the road. And this creates a sidewalk, giving that illusion that it is that. But at the same time, in order for it to change, it’s difficult, because you can’t do so much with the municipal budget to create a sidewalk that will eventually get covered up by snow”.(F)Healthy choices tend to converge with those of close social connections, including family and friends, especially in settings where communal lifestyle and social inclusion and cohesiveness are important cultural values. Norms of appropriate food choices and participation in physical activity are set, or at least influenced, by the behaviors of other people, but also by shared cultural expectations and environmental cues. Participants indicated that Inuit are likely to follow choices that are perceived “acceptable” based on social comparison:“To keep healthy, but also my parents tease me a lot so I think that’s another reason why I work out. ‘Cause I came back from international travel. I went to Africa for a couple of weeks, and so I ate a lot of rice there. My parents came up and they saw me and they’re like, “…, I think you’ve gained some weight.” They don’t bother me about it. They just kind of mentioned it, but I’m like, hey, and I also feel like my pants are a bit tighter now. So I’m, “Okay, I need to actually buckle up and to get a bit healthier.” Also you feel good too, so …yeah”.(F)“Primarily just my family household. My dad works out, my brother works out. We go hiking and stuff like that. That’s one thing, but other things? If I was to be totally honest with you I think a lot of it is also just how people … You know, like fat shaming, stuff like that…”.(F)“Social things like how, if you’re fat you’re “fat,” in quotation marks. If you’re fat then you’re just less of a human being. So I think there’s a lot of social stigma that goes around it. For me though, specifically, I think it’s just wanting to look healthy and fit for myself”.(F)Further, participants were asked about other healthy and unhealthy habits they engaged in, and whether any of these played a role in healthy eating behavior and physical activity participation. Engagement in certain unhealthy behaviors was a barrier to participation in physical activity and healthy diet choices for many of the participants and relatives. One participant said:“Because I smoke cigarettes all the time and it makes me tired if I try to exercise”.(M)A packet of cigarette costs $20 to $25 in Nunavut, and on average a smoker consumes about 10 sticks per day. Alcohol consumption is significantly high, even in communities where alcohol is prohibited. A bottle of liquor is sold for over $200. In many households, cigarette/marijuana smoking, drug use, and alcohol consumption all combine to decrease the available funds to purchase healthy foods, ice-hockey equipment, and gym memberships. On why a lot of people do not exercise, one participant responded:“Smoking weed? Drinking booze? There’s too many… that drink and smoke weed, so it affects their kids too. So yeah, it affects a lot of kids”.(M)Another participant corroborated the influence of these unhealthy behaviors:“It affects us a lot, especially for us people that have no employment. That are seeking like … drug dealing or bootlegging, they resort to that, because they don’t have money to feed their children or to put food on the table. So they have to you know, make … find another way to make money you know”.(M)Some respondents emphasized the need to promote Inuit health through public education, ensuring that people understand the benefits of quitting binge drinking, smoking and drug use, and promoting the adoption of healthy behaviors such as healthy food choices and active living as a living lifestyle:“We need to tell people to quit smoking, to find a new habit, we need therapy … we need a lot of therapy for our cigarettes”.(M)The aim of this study was to explore the barriers and facilitators of healthy diet and physical-activity participation among Canadian Inuit adults in Nunavut. Findings from participant interviews and data analyses indicated that six factors, acting either as barriers or facilitators, are essential to the promotion of healthy eating and physical activity promotion amongst Nunavut Inuit: cost and affordability of healthy choices; availability of traditional foods and activities; weather conditions and climate change; infrastructure and community resources; social networks of family and friends; and effects of substance use.The most significant perceived barrier to a healthy energy-balance-related behavior is the cost and affordability factor. This is largely due to low incomes and high levels of poverty amongst Nunavut Inuit, and is further aggravated by the exorbitant costs of both traditional and non-traditional foods. In addition, the high costs of hunting equipment, resulting in fewer hunting activities, and the exorbitant cost of registration fees at fitness centers or sports equipment, in the face of relatively low household income, all combine to reduce physical-activity rates and fitness levels in the population. Our findings are corroborated by a body of research evidence ,33,34,35In a similar manner, the cost-affordability factor also plays an influencing role on physical-activity participation in Nunavut. According to participants, hunting equipment is not affordable and accessible due to its high cost, resulting in fewer hunting activities. Moreover, the exorbitant cost of sporting equipment and registration fees at fitness centers limit Inuit participation in physical activity. Participants’ views on barriers and enablers and attitude toward participation are well corroborated by the results of a previous study that reported cost and affordability as limiting factors to participation in physical activity among Australian Indigenous adults . The proApart from direct personal costs in the face of limited income, a majority of Inuit participants in the current study raised concerns regarding inadequate community resources and infrastructural development compared to southern cities and communities. They attributed their low participation in physical activity to very limited availability of community resources, including sporting centers, limited options for traditional and western-oriented sporting activities, and poor conditions of roads and walkways for walking. In addition, absence of road and rail transportation presents a critical infrastructural deficit in Nunavut that adversely affects healthy food supplies from the southern part of Canada, where over 80% of the food items are sourced. In contrast to other jurisdictions in Canada, there are no roads or railways connecting Nunavut to any of the southern provinces, or between any two Nunavut communities. Air travel is the only means of travel and transportation of goods between communities, and from the rest of Canada , except Participants also raised climate and environmental concerns as barriers to their healthy dietary choices and physical-activity participation. There is a widespread belief amongst Inuit that global warming has disrupted Inuit cultural practices generally, and specifically has adversely impacted their ability to go on the land for caribou hunting or on the sea for seal hunting. Hunting activities have been significantly reduced as a result of the global increase in temperatures, which is melting ice and disrupting the migratory patterns of animals in the Arctic. A study by Wesche and Chan  describeFurther, participants in the current study indicated that they are likely to follow choices that are perceived “acceptable” based on sociocultural expectations. In clear terms, they expressed how family members and friends play key roles in their dietary choices and influence their participation rates in physical activity. Social networks of families, friends, neighbors, and others have been shown to have remarkable influence on health behaviors ,45,46 anLow participation rates in physical activity are attributed to engagement in substance-use behaviors, and invariably link low energy, interest, and tiredness to substance use. Generally, cigarette smokers spend considerably less time on sports and aerobic activities compared to non-smokers, given that nicotine-dependent smokers are less likely to engage in physical activity . This isThe generalizability of the study may be limited due to the complex environment in Nunavut and variabilities across the 25 communities. Community resources, community-level capacities, and infrastructural development vary from one community to another. This particular study was conducted in Iqaluit, the territorial capital and the most diverse, resourced, and populated community in Nunavut. Despite the differences across communities, it would be logical to contextualize our findings, extrapolate, and make some inferences, based on our understanding of Nunavut communities and their characteristics. For example, the barriers identified by participants in Iqaluit may be aggravated in other smaller communities because of the relatively limited resources and community infrastructure. Another limitation is the use of photographs that were provided by the researchers, instead of a more empowering approach in which participants would take and select their own pictures for interviews, as is the case in Photovoice method ,52. WhilIt is also worthy to note that only participants who spoke and understood the English language were recruited and included in the study. This presents a limitation, given that unilingual participants were excluded from the study and their contributions might have enriched the data. While there is a concern that our approach may have introduced some bias in the research, we acknowledge that a significant proportion of Nunavut Inuit is fluent in English language, thus providing a good pool of potential participants to provide Inuit perspectives on the subject. This pool covers a broad range of demographic groups independent of age, gender, socioeconomic class, and geographic locations in the community. One comparative advantage of the recruitment of English-speaking participants is that it removed the potential challenges of exorbitant cost and technical difficulties that are usually experienced with translations and reverse translations from and to the local Inuit language (Inuktituk) and the multiple dialects that are spoken by residents who moved from other communities to Iqaluit.Despite the limitations to the present exploratory qualitative study, it is evident from our findings that the following key factors are critical to the promotion of healthy energy balance-related behaviors in Iqaluit: cost and affordability of healthy choices; availability of traditional foods and activities; weather conditions and climate change; infrastructure and community resources; social networks of family and friends; and effects of substance use. While the findings of this study may be generalizable across Nunavut communities, additional qualitative studies involving smaller communities across Nunavut are required to deepen our understanding of the subject. Quantitative research across Nunavut communities also is required to assess the relative importance of identified facilitators and barriers in promoting physical activity and healthy eating in the population. These two complementary approaches will further strengthen the development of sustainable intervention efforts. More importantly, the strategic role of transportation infrastructure in the food systems, with regard to access, affordability, and the overall impact on the health and general well-being of Nunavut Inuit, compels a call for both political and policy interventions by the territorial and federal governments. Such interventions would address this critical infrastructural gap that exists between Nunavut and the rest of Canada. In addition, an effective and sustainable food policy intervention by both governments is required to reorient food-supply systems and improve the food environment for the residents.


Patient experience surveys are increasingly conducted in cancer care as they provide important results to consider in future development of cancer care and health policymaking. These surveys usually include closed-ended questions (patient-reported experience measures (PREMs)) and space for free-text comments, but published results are mostly based on PREMs. We aimed to identify the underlying themes of patients’ experiences as shared in their own words in the Swiss Cancer Patient Experiences (SCAPE) survey and compare these themes with those assessed with PREMs to investigate how the textual analysis of free-text comments contributes to the understanding of patients’ experiences of care.n = 844) of SCAPE survey respondents (n = 2755).SCAPE is a multicenter cross-sectional survey that was conducted between October 2018 and March 2019 in French-speaking parts of Switzerland. Patients were invited to rate their care in 65 closed-ended questions (PREMs) and to add free-text comments regarding their cancer-related experiences at the end of the survey. We conducted computer-assisted textual analysis using the IRaMuTeQ software on the comments provided by 31% . Further analysis of this last class showed that patients’ comments related to the following themes: ‘initial shock’, ‘loneliness’, ‘understanding and acceptance’, ‘cancer repercussions’, and ‘information and communication’. While A computer-assisted textual analysis of free-text in our patient survey allowed a time-efficient classification of free-text data that provided insights on the personal experience of living with cancer and additional information on patient experiences that had not been collected with the closed-ended questions, underlining the importance of offering space for comments. Such results can be useful to inform questionnaire development, provide feedback to professional teams, and guide patient-centered initiatives to improve the quality and safety of cancer care. Health care research is becoming increasingly patient-centered, highlighting the importance of considering patients’ perspectives and experiences when evaluating the quality of care . This haWhile quantitative results of closed-ended survey questions are widely published, analysis of free-text responses to open-ended questions or free-text sections are rarely performed and published. Indeed, manual thematic analysis of large amounts of text generated from open-ended questions remains time and resource intensive; therefore, the additional insights within this type of data often remain underutilized. However, such analyses can now be more easily performed thanks to information technology opportunities –15, yielThe aim of this study was to identify the underlying themes of patients’ experiences shared in their own words at the end of a cancer survey, using computer-assisted textual analysis, and to compare these themes with patient-centered care dimensions assessed in closed-ended questions (PREMs) to investigate how the textual analysis of free-text comments contributes to the understanding of patients’ experiences of care.Textual analysis of free-text data collected between October 2018 and March 2019 in the multicenter cross-sectional Swiss Cancer Patient Experiences (SCAPE) survey.Patients aged 18 or older having received stationary or ambulatory care between January 1, 2018 and June 30, 2018 for breast, prostate, lung, colorectal, hematologic cancers  or melanoma, were eligible for inclusion in the SCAPE survey. The latter was conducted in four Swiss hospitals: the Lausanne university hospital, the Geneva university hospitals, and the cantonal hospitals of Fribourg and Valais.The SCAPE questionnaire, a comprehensive cancer care survey, was based on a French translation of the UK CPES  adapted To analyze the free-text comments, we performed a computer-assisted textual analysis using the IRaMuTeQ software . This is a tool particularly recommended for the analysis of large amounts of text . Using tData interpretation was performed by three researchers who proceeded as follows: 1) they read all the comments while formatting the corpus to become familiar with the data; 2) once the software had classified the text into classes, they looked at the typical words and extracts associated within each class to make a preliminary thematic interpretation; 3) they went back to the original text in order to recontextualize the typical extracts and limit over-interpretation; 4) they discussed their thematic interpretation and labeling of classes with the multidisciplinary research team ; and 5) they matched the thematic classes identified with the textual analysis to questions and dimensions of patient-centered care assessed in the closed-ended questions.n = 844) were more likely to be female, speak French, be more educated, and have breast cancer than those who did not leave a comment (n = 1912)  completed and returned the questionnaire. Of these, 2755 (88.3%) reported having either breast, prostate, lung, colorectal, hematologic cancers or melanoma and about a third wrote a comment at the end of the questionnaire (comment rate: 30.6%) and were included in the textual analysis : ‘cancer care pathways’ (18.9%), ‘breast cancer care pathways’ (13.5%), ‘medical care’ (22.5%), ‘gratitude and praise’ (15.2%), and ‘cancer and me’ (29.9%). The structure of the classification is provided in a dendrogram showing the hierarchical clustering of the classes : “Lumpectomy, excision of the sentinel lymph node, 25 radiotherapy sessions at the [name of clinic], hormonotherapy” ; “Relapse in July 2016” ; “Currently, hormonotherapy and regular checkups” .In this class, respondents recounted their cancer journey from diagnosis to treatment and follow up, mainly in a descriptive and neutral manner. Type and spread of cancer were often described, with details regarding cancer location, presence of cancer cells in lymph nodes as well as metastases. Respondents listed the examinations performed and types of treatment received. The course of disease, including remission and relapse, was also mentioned along with the frequency of follow-up appointments. Respondents often explained the timing and sequence of events. This class was overrepresented in those aged ≥65 yrs., in men, in those having left a neutral comment, with in those with overall satisfaction of 8/10, and respondents with prostate, lung and hematologic cancers.Patient quotes: “It was during the mammography exam at the screening center in August 2017 that they discovered a 3 cm tumor” ; “12 lymph nodes are affected” ; “Checkups every 6 months” .This class focused on breast cancer and was closely linked to the previous one. It included detailed descriptions of cancer care pathways, including technical terms, and specifications about the course of disease with temporal indications . As in the previous class, respondents mentioned the examinations performed , details about the cancer location, size, type and spread, and the treatment received (mainly surgery). Again, the tone was rather neutral and descriptive. In addition, respondents in this class reported the reason for which they first sought medical care, such as a screening test or because they had noticed a lump in their breast. This class was overrepresented in respondents with breast cancer, in those aged ≥75 yrs., in those having left neutral comments, and with an overall satisfaction of 10/10.Patient quotes: “The personnel were all stressed, including the doctors” ; “Junior doctors change too often and don’t know our situation” ; “It took 26 phone calls to the [name of hospital] to get an appointment” ; “despite our requests, the records and test results do not always follow and the documents I receive are sometimes not up to date with the latest decision taken by the doctor” .In this class, respondents related their experiences concerning cancer care, especially in regards to physicians. The majority of text in this class was negative. The frequent changes in staff at the junior physician level were often mentioned and described as problematic from the patient’s perspective. Staff were described as not being aware of the patients’ medical record, looking tired or overwhelmed and lacking time and supervision. The absence of senior physicians in direct patient care was also reported. Furthermore, respondents described poor organization and coordination of care including problems concerning their medical records, appointments and inter-professional communication. This class was overrepresented in women, in those having left predominantly negative or mixed comments, and in those with overall satisfaction of ≤7/10.Patient quotes: “I’ll take this opportunity to thank all of the hospital personnel  for their good care, their tact, their capacity to listen and their kindness” ; “The whole team saved my life, thank you from the bottom of my heart” .In this class, respondents expressed their gratitude and praise towards hospital staff as a whole or more specifically to professional groups or individuals including physicians, nurses, caregivers, therapists, technicians, social workers, receptionists and cleaning personnel. Respondents thanked health care professionals for the care provided, their competence, professionalism, kindness, empathy, benevolence, support and respect. The quality of care was highlighted both in terms of human relations as well as medical and technical expertise. Moreover, a few respondents mentioned the resulting effects including life-saving, reinforcing peace of mind, courage and trust. Those having left positive comments, those with an overall satisfaction of 10/10 and respondents with colorectal cancer were overrepresented in this class.As the ‘cancer and me’ class included a large amount of text (29.9%), we repeated the analyses on this class separately in order to have a more detailed understanding of its content. The secondary analysis of this class resulted in five sub-classes, labelled as follows (percent of text segments classified within each group indicated in parenthesis): ‘initial shock’ 3.6%), ‘loneliness’ (6.0%), ‘understanding and acceptance’ (5.0%), ‘broad impacts of cancer’ (6.2%), and ‘information needs’ (9.1%). The structure of the ‘cancer and me’ sub-classification is provided in a dendrogram showing the hierarchical clustering of the subclasses ; “There is no good way to announce cancer, once the word is said it’s a real tsunami” ; “At the time of the cancer diagnosis, under shock, we don’t retain anything, the need for information comes later” .In this class, respondents reported negative experiences regarding the manner and circumstances in which they were told about the cancer diagnosis or the treatment needed, resulting in a state of shock. Respondents’ criticism included being told the diagnosis in a brusque manner, without empathy, over the phone, in a shared hospital room with little privacy, or when alone without the presence of a friend or family member. The sense of shock was also reported by patients who reported being told in a tactful manner, resulting in difficulty in retaining information and in making decisions at the time. Suggestions for improvement included receiving written information on the disease, disease course and treatment after receiving the news, in a follow-up appointment. This class was overrepresented in respondents having left negative comments.Patient quotes: “I struggle alone to pull through” ; “We feel alone and not always heard. At each appointment with the oncologist we repeat our side effects, they are recorded in the computer as if it were normal” ; “And then comes the hormonotherapy, no more information, just a prescription and ‘we’ll see each other in 3 months’ … we discover the side effects alone, they can be very difficult. We just know that it will be for a long time, a very long time.” ; “I felt alone, abandoned by the doctors, lost after the treatment” .In this class, respondents described the loneliness felt during treatment, either lacking support from medical personnel or from friends and family. Loneliness was also expressed regarding the side effects of treatment, especially when met with a lack of understanding or solutions from medical staff. Respondents expressed how they had to deal with these side effects “alone”, turning for example to alternative medicines. Another recurrent theme was the loneliness felt at the end of treatment, when respondents felt “abandoned” and having to deal by themselves with the difficulties of returning to work or with the incapacity to work, resulting in financial difficulties for some respondents. This class was overrepresented in respondents with an overall satisfaction of 9/10, those having left positive comments and with prostate cancer.Patient quotes:“I wanted to function like before my illness, everyone was pushing me, they didn’t understand, didn’t accept that I’m unable to” ; “The empathy, interest, understanding, asking for news and the messages of support from family, friends, work colleagues and acquaintances are very important in order to accept the disease and always useful for the morale” .Elements concerning the patients’ understanding and acceptance of the disease and its treatment were expressed in this class. On the one hand, the lack of information and poor communication with medical staff or the lack of opportunities to share experiences with fellow patients created barriers to understanding and acceptance of the disease. On the other hand, adequate information from staff or external sources  facilitated understanding and acceptance. “Understanding” from others was also expressed as either present and of great importance to patients, or as absent. Lack of understanding, be it from medical staff, loved ones, employers, colleagues or insurance companies, was a source of suffering for some patients. This class was overrepresented in respondents with hematologic cancer and in those with an overall satisfaction of 10/10.Patient quotes: “How to live a normal life with this relentless pain” ; “The disease destroyed my marriage and my family” ; “After 6 months of sick leave and three surgical interventions my employer pushed me to leave” .In this class, the respondents’ discourse focused on the period during which the treatment took place and the way in which the disease and its treatment disrupted their quality of life as it affected their physical and emotional health. They described the negative impacts on different aspects of their life including friends, family, work and leisure. For example, respondents reported the difficulties they had to reconcile their professional life with care . Respondents also mentioned adverse effects of treatments, such as pain or insomnia, as well as financial issues linked with treatment costs and their inability to work. From within this turmoil, respondents related their aspirations to be able to lead once again – a “normal life”. No category of respondents was overrepresented in this class.Patient quotes: “I rarely received the essential information spontaneously; [it was a] wrestling match to obtain answers to my questions” ; “It’s necessary to improve information to patients about side effects, which are sometimes harder than the cancer itself” ; “Nurses are more open than the doctors to talking about benefits of homeopathy, osteopathy and hypnosis. It’s a complementarity that helped me a lot because I decided to do something that made me feel good rather than to “suffer” under the prescribed treatments” .This class includes comments on the information and communication around cancer. Respondents expressed difficulties obtaining information on the disease, the treatment, the side effects, their results and medical reports, as well as on the range of programs and help available to patients. Shortcomings included the content, the amount (too much/too little), the form  as well as the timing (too early/too late) of the information delivered. Respondents also provided suggestions to improve communication; for example, they proposed that information could be communicated orally and in written form using clear simple language. A particularly frequent theme in this class was the lack of information on side effects and sequelae, the lack of understanding, compassion and help for side effects from medical professionals and the desire for more information on complementary therapies. Medical professionals, especially physicians, were described as being closed to complementary therapies, though they featured regularly as a means by which patients coped with the side effects. No category of respondents was overrepresented in this class.Comparisons between the thematic classes from the textual analysis of free-text comments and the patient-centered care dimensions assessed in the closed-ended questions are presented in Table This computer-assisted textual analysis of free-text comments provided by patients with cancer in response to an invitation to share cancer-related experiences and suggestions for improving care at the end of the SCAPE questionnaire (31% comment rate) allowed us to identify five main thematic classes: ‘cancer care pathways’, ‘breast cancer care pathways’, ‘medical care’, ‘gratitude and praise’, and finally ‘cancer and me’. This latter class was further divided into five subclasses: ‘initial shock’, ‘loneliness’, ‘understanding and acceptance’, ‘cancer repercussions’, and ‘information and communication’. Apart from the first two classes, the thematic classes of the free-text comments related more to the personal and emotional experience and consequence of having cancer and receiving care, while the dimensions of the closed-ended questions assessed mainly the factual aspects of people’s experience of patient-centered care.self, on the emotional experiences of living and coping with cancer, aligning with experiences reported in previous meta-analyses on living with cancer and symptom experiences [We also observed a sharp contrast within the free-text comments between the factual descriptions of medical history and care pathways, grouped in the ‘cancer care pathways’ and ‘breast cancer care pathways’ themes and the more personal aspects of living with cancer, especially present in the ‘cancer and me’ class. The described care pathways encompassed diagnosis to treatment through to remission or relapse, framed by key examinations, interventions, treatments and results. On the other hand, personal elements included emotional and social aspects related to cancer and care, such as coping with cancer and its treatments and the interactions with health care providers. This distinction in the free-text comments may reflect the way patients and health professionals interact. Their interaction has been described as being structured by two distinctive needs: professionals’ needs of ‘knowing and understanding’ and patients’ needs of ‘feeling known and understood’ . In our eriences , 28. ComThe challenges patients face when confronted with cancer and cancer symptoms, as well as the discontinuity of care brought about by the frequent changes at the junior physician level along with the faulty inter-professional communication expressed in the ‘medical care’ theme, illustrates the need for ongoing and better care coordination and multifaceted support. This theme is a recurrent theme reported in other similar studies on the analysis of free-text comments, highlighting the importance of this aspect to individuals with cancer , 19, 21.In all classes, except the two classes about care pathways, participants expressed positive and negative statements when describing their care experiences, which may further guide quality improvement initiatives. Negative comments identify aspects that need change while positive comments help staff identify how they are valued and what they are doing well, providing motivation to continue . The negConcerning positive feedback, an entire class was dedicated to expressing ‘gratitude and praise’ toward health care professionals for their medical/technical expertise and the quality of human relations. If respondents felt the need to express gratitude and difficulties in this questionnaire, it maybe that they did not have sufficient opportunities to do so during care and in the section of the questionnaire with closed-ended questions. Previous studies have also reported frequent positive feedback in free-text comments, ranging from one third of comments related to appreciation and gratitude  to two tThe use of a computer-assisted textual analysis method represents the main strength of this study, having allowed comprehensive analysis of all free-text comments within a large survey sample in a time-efficient way. It resulted in the identification of important themes for individuals with cancer, some of which have been reported in other studies using different approaches, both inductive and deductive and manual or computer-based methods , 19, 21.In cancer patient experience surveys, providing space for free-text allows respondents to express themselves in their own words and to report in more details about their personal experiences of living with cancer, contributing to the better understanding of their experiences and going beyond the standardized evaluation of patient-centered care. Indeed, the analysis of free-text comments sheds light on important themes and aspects of care that patients choose to report freely and that closed-ended questions may not reveal, providing complementary insights. It also underlines the importance of offering space for comments and highlights the diversity of cancer patients’ journeys and experiences, encompassing aspects outside of health care. Such results are particularly useful to inform questionnaire development, provide feedback to hospitals and healthcare teams, and guide quality and safety of care initiatives aiming at enhancing the patient-centeredness of care and improving the cancer care experience overall.


Objective: This focus group study aims to describe older adults’ perceptions of the use of technologies to engage in physical exercise programs. Methods: Fifteen participants were randomly selected from a sample of 40 older adults who completed a randomized controlled trial that investigated the benefits of using technology in the context of group-based exercise programs. Separate post-intervention focus groups were performed with an exergaming group, a conventional physical training group, and a no training group (control). Data were mapped onto constructs from the four domains of PL: affective, physical, cognitive, and behavioral. Results: Generally, participants expressed positive perceptions about the benefits of using technology to engage in PA. These positive feelings outweighed the costs and the lack of familiarization with technology. Common themes for the three groups emerged from the discussions and included familiarization with technology, using fitness tracker to monitor PA, previous exposure to technology, and interaction with peers, staff members, and relatives. In particular, participants from the exergaming group explored the ideas of training their cognitive skills while using the exergame accessories, exercising in an alternative way, competitive versus cooperative play, changes in sense of humor, skill transferability from game to real environment, progressions of the exercise intensities, and the potential use of exergames for rehabilitation. Conclusions: Participants in this study reported positive perceptions about implementing technology into exercise. Emphasizing the benefits of using technology in group-based exercise programs may increase older adults’ PL levels and their future technology adoption. The potential implementation of technology into conventional exercise programs should focus on older adults’ lifelong values, biopsychosocial conditions, and the possibility of reducing age-related risk of injuries and chronic diseases.Insufficient physical activity (PA) levels observed among older adults remain extremely high and pose a danger to developing and maintaining their physical literacy (PL). Each person’s level of PL partly depends on their physical and cognitive skills, confidence level, and degree of motivation to practice PA daily. New technologies, such as exergames and wearable fitness trackers, may enable older adults to increase their PL, stimulating uptake and ongoing PA participation.  According to the United Nations’ report , the proThe aging effects on health behavior, such as a sedentary lifestyle, strongly influence how older adults perceive and experience their surrounding environment . The avaIdentifying key determinants of an active lifestyle and how these determinants can be promoted is central to successful healthy aging . PreviouAs a promising strategy to achieve lifelong participation in PA, physical literacy (PL) could be a meaningful approach to reducing sedentary behaviors and prevent associated chronic diseases . PL is dThis study aims to examine older adults’ perceptions of the use of wearable and exergame technologies to engage in physical exercise programs.A focus group approach was used to collect perceptions from three groups of participants in a broader research study designed to increase the PL levels of older adults. The research was conducted in a community facility located in Calgary, Canada from August to December 2018. The study was approved by the Conjoint Health Research Ethics Board, University of Calgary, under the reference protocol number REB16-1633. An interpretive description methodological approach was used to guide data collection, analysis, and presentation of results . Data wen = 15), conventional training , and no training . Inclusion criteria for eligible participants were as follows:Participants aged 65 years and over;Able to ambulate independently without an assistive device;Able to adequately see and hear to interact with the game;Able to read and speak English to follow instructions.As part of a larger, randomized controlled trial, 40 older adults were recruited from community and independent-living centers, and randomly allocated to one of the three study groups: exergame training  ;Took part in a PA program within three months before the study started;Were diagnosed with a balance or neurological disorder that seriously affected motor function .Participants were excluded from the study if they did the following:All participants wore a Fitbit Flex 2™  for the duration of the study. Participants did not have access to the data from the Fitbit until the end of the study. CT and ET groups downloaded the Fitbit data once a week before training. The participants in the NT group were asked to commute to the community facility once a week to meet with the researchers to download the Fitbit data, but did not have contact with the other groups.Both the ET and the CT programs were supervised by a physiotherapist and an assistant. Participants in the ET group used the Nintendo Wii-U and its accessories, such as the Wii Remote and Wii Balance Board to perform the exercise program with the Wii Fit-U sub-games. The CT program consisted of exercises done seated on or standing behind a chair and laying down on an exercise mat. Participants from both exercise groups were asked to attend every session conducted three times a week for six weeks. ET and CT participants were divided into three groups each  with approximately five participants in each group. In the facility, two similar exercise rooms were used with three time periods, two in the morning and one in the afternoon, so that training was matched for time and group size. The participants in the NT group did not engage in any exercise training and were advised to maintain their usual daily routine.Within one week of the end of the intervention period, six participants from each group were randomly selected and invited to participate in focus group interview sessions. Separate post-intervention focus groups were performed with each study group. Participants signed a consent form agreeing to participate and allowing the moderators to audiotape the conversations.General impressions about the study: “Please describe your overall experience throughout this program.”Using technology for PA engagement: “Do you think that technology can help you to be more active?”Physical literacy perception: “After describing Whitehead’s definition of PL, do you think that your PL level changed throughout the study (last six weeks)?”Future technology adoption: “Would you be interested in continuing to use technology in your physical activities in the future?”The principal investigators created an open-ended, semi-structured interview guide. The topic guide for all the three focus group interviews included a guiding question and prompts in the following areas: The focus group sessions were led by a trained moderator and a note-taking assistant, who did not participate in the exercise programs. Refreshments were served to compensate the participants for their time.Immediately after each focus group, the moderator and assistant discussed the group dynamics, noting common themes and unexpected items. The audiotapes were transcribed verbatim and the transcriptions were checked for accuracy against original recordings. All participant identifiers were replaced by a study code to protect their confidentiality. Transcripts and research field notes were the data products used for analysis.Interpretive description methodology  and analn = 6; CT, n = 4; NT, n = 5) attended the post-intervention focus group interviews. Three participants  did not show up for their focus group session. Two gave no reason and one had the wrong day in his calendar.Focus group sessions lasted an average of 38 min . Of the 18 invited, 15 participants  identified as female (66.6%), representing 37% of female participants in the main study (n = 27). The average age of the focus group participants was 73.53 years (ranging from 65 to 85 years), compared to 72.6 years (ranging from 65 to 95 years) from the main study. Participants reported being independent community-dwelling older adults and two of them  were residents in an independent-living facility.Ten focus group participants  mentioned the following: “When I was young, there was nobody who taught us: ‘oh, you should be exercising three times a week.’ Just hearing about your study with technology already makes a big difference.” P8  commented on her perceptions in regards to the feedback provided by the Fitbit: “It showed me what I was doing and, you know, what [parameters] I need to improve a little bit more.” Meanwhile, the participants from the NT group expressed their curiosity about the exergame training: “Do you have different expectations according to the age of the participant?” . Participants from the ET group further explored the ideas of training their cognitive skills while interacting with the exergames. For example, P4  described her experiences while playing a dual-task game: “Several times I was like, ‘okay, I’ve got to remember to always look on that top one [bar].’ Because if I was only working on the one below, I learned that my score went down. It was probably good for my brain.”The affective domain was reflected by the participants’ perceptions of their confidence, motivation, and enjoyment in relation to their technology adoption to engage in PA. For example, P10  stated the following: “I have got a Fitbit and that got me motivated because I could see my [number of] steps and it challenged me a lot… I think it [Fitbit feedback] really makes you feel better about yourself.” P6  shared his perceptions after engaging in the exergaming program: “I think it was great. I am disappointed it’s coming to an end, but it really got me motivated again… So, I’m really glad for the luck that I got in the Wii group because it was way more fun than standing over there doing exercises, you know, seriously.” Participants who engaged in the exergame training discussed the role of competitive versus cooperative play on their experiences. For example, P3  mentioned the following: “There was some level of competition between us. It was fun though. I also had fun when we had a common goal and it was that tunnel”, referring to the game in which the participants were asked to statically walk on the balance board, lifting their feet in order to mimic the motions of pedaling a bicycle. P4  replied the following: “Well, it was a supportive competitiveness.” The discussion continued with P2  expressing her point of view: “It’s a bit of competitiveness with yourself. You know, when I did this the last time, I was like, ‘oh, I got to another level.’ I felt good.” In addition, participants in the ET group were grateful for being able to participate in the study, identified a change in their sense of humor, and wished that the participants from the other groups could have had the same experience: “We [participants from ET group] sort of ended up melding in our sense of humor with a bit of competitiveness sometimes. The control group is probably disappointed.” .The analysis of the behavioral domain showed that participants from the three groups were able to compare their previous exposure to technology with the current experience. P11  mentioned that she had a fitness tracker device before starting the study: “I had a Fitbit before. So, I could set a goal of two hundred steps every hour between 7:00 a.m. and 7:00 p.m. If I didn’t complete them, it would giggle and tell me I’ve got to get up and exercise. I couldn’t do the same [setting] with yours [Fitbit].” In addition, P7  mentioned the following: “I used to be active a number of years ago and the last few years I just haven’t been. So, it was a great chance to participate, get more familiar with the Fitbit, and sort of moving forward from being sedentary.”Participants from both exercise training groups presented a higher sense of commitment to wear and charge their Fitbit while attending the sessions three times a week, compared to NT group. For example, P5  mentioned the following: “I never took it off, except to recharge it.” P8  also stated the following: “It [The Fitbit] kept me engaged in the study. Like, I felt the responsibility to recharge it and come to the sessions. If you volunteer for the study, you feel the responsibility to do it. It’s like you’ve paid for a device or for a fitness class. So, you want to get your money’s worth.” One of her peers  agreed: “Yes, when I paid for a trainer, I found lots of reasons not to go and I still ended up paying for it. I’ve never paid for this [study] and I never missed a single session.” However, the majority of the participants from NT group agreed that they forgot to recharge the Fitbit often. P13  tried to justify why he forgot to recharge his device: “Half of the time I forgot the thing [Fitbit] was there. I think it is because we didn’t have access to our accounts, and we had to come only once a week. There was nobody to remind us [about recharging the device]. So, as a result, we didn’t charge it when we should have done so.”ET participants, in particular, expressed their perceptions of trying a new way of exercising. P1  reported the following: “I like the variety of them [Wii Fit-U sub-games]. I could tell my body was using different muscles. When you’re not doing anything, you think ‘they are all right’. Then, you use them and you think ‘oh, that’s a new muscle’.” P5  hypothesized the following: “I loved the Wii. If I had one, I could just sit it in front of the T.V. and sometimes I would flip the switch to exercise.”As for the social/economic domain, participants from the three groups shared similar perceptions about the interaction with their peers, staff members, and relatives during the study. Participants from the intervention groups enjoyed exercising with their peers. However, participants from the ET group perceived that their interactions were more related to socializing while playing the exergames. For example, P2  stated the following: “I never missed one of these sessions at all. A lot of it was because of the people, to be honest with you.” P1  engaged in the conversation and continued: “It was more than just the exercise that we were doing. It was the people that we were working with. The staff members were just incredibly great to have in the room, because they were always supportive and they were always there for us.” Participants from the ET group spoke about their attitudes towards playing exergames with their grandchildren. P4  mentioned the following: “One [participant] of our group is going to buy one [Nintendo Wii-U]. Her nephew has one and he suggested to her to buy it. So, it’s another way to interact with our grandchildren.” Participants from the CT and NT groups demonstrated their gratitude for the support given by the staff members in regard to issues with their fitness trackers. They also revealed that they sought help from their relatives with the placement of the device.The cost to purchase the equipment used in the study was a shared subtheme that emerged from the conversations between participants that engaged in both exercise programs. Participants focused on their perceptions of the cost–benefit ratio. P1  summarized as follows: “I might consider even buying one [Nintendo Wii-U]. It doesn’t matter its cost.” The subtheme named willingness to try new technologies was brought up by the participants from the NT group. Based on the comments, participants who did not engage in any of the exercise training seemed willing to try the exergames. Moreover, they appreciated the caring context in which the study was offered.In the physical domain, participants from the CT group expressed their perceptions about using technology to monitor their physical competencies, such as their heart rate and number of steps. P8  who owned her own Fitbit, commented on how the device was helpful to her: “Because I’ve got a really low heart rate, I’ve got to move more. So, the Fitbit really helps me to monitor these things, like my BPMs [beats per minute], number of steps, and so on.” Participants from the ET group presented different perceptions about their experiences using the Wii Balance Board. For example, P3  and P4  shared their frustrations while using the exergame accessory: “Last Friday, we had two boards that were almost dead on battery. They just were not working properly. It was just really a frustrating day for some of us.” (P3); “I felt bad because I got to a new level on that game on Wednesday, but when I tried it again on Friday, I couldn’t get closer [to the same level]. That’s why I was frustrated.” (P4). In addition, P1  stated the following: “The board’s malfunction was the only complaint, and that’s not your guys’ fault. You don’t build those boards, and I don’t think they were that great.”Trainer’s name] was always on me to do it properly. That’s one thing you don’t get with the Wii. I mean, if [staff members’ names] weren’t here correcting our forms, I wouldn’t correct it myself.”Participants from the ET group discussed their previous experiences engaging in conventional exercise training as opposed to the exergame training. P1  shared his perspective: “When I was paying a trainer to do the job, part of the benefit was because I was being taught a proper form.  three times. If I did three, I felt that I was working out somewhat near maximum [exertion].” Another participant , who had a knee replacement, mentioned his perspective of the potential use of the exergames for his physical rehabilitation: “I had to get my knees replaced two years ago. So, I’m not supposed to run. But on that activity [running on the spot], I’m not really running. I’m not putting a lot of pressure on my knees and I felt great. I will ask my physio to include these [activities] in my therapy.”This qualitative study explored older adults’ perceptions of using technologies, such as exergames and fitness trackers, to engage in physical exercise programs. The focus groups’ analysis was primarily guided by an interpretive description of older adults’ perceptions under the PL theoretical framework. This methodological approach was initially developed for clinical contexts; however, in the study described in this article, the participants were physically independent and did not present any functional impairments. Here, each main theme is discussed from the standpoint of how technology may be utilized to promote lifelong PA engagement and its potential use in the prevention and rehabilitation of a variety of diseases.From a holistic perspective, Whitehead  proposedIndividuals exchange knowledge, experiences, values, and beliefs in constant adaptation to the environment in which they are living. Many older adults are not comfortable with technologies; therefore, adoption may be a challenge ,30. MoreFamiliarization with new technologies is fundamental and influences the success of implementation to engage in PA programs. Research indicated that, despite becoming increasingly familiar with technology, older adults generally have different abilities and competencies compared to their younger counterparts ,33. The Researchers investigated the factors that employ a strong influence in older adults’ attitudes toward and adherence to the use of technology to engage in PA. Matz-Costa et al.  demonstrGothe  showed tWhitehead  considerThe social interaction provided by group-based exercise programs proved beneficial for older adults to overcome psychosocial conditions, such as loneliness, depression, and low self-esteem . MoreoveTheories on the relationship between the accessibility to technology, its regular adoption, and possible cost savings in healthcare increased substantially . The theThe relatively low cost to purchase equipment and a sense of commitment to the study were shared subthemes between participants who engaged in the exercise programs. These findings are consistent with previous studies suggesting that the perception of potential benefits was more indicative of technology acceptance than a perception of cost .Adopting technology and maintaining regular PA engagement by older adults might be the most important challenge. While older adults may have ceased regular PA engagement or believe they would not be able to partake in PA, participation in such technology-based experiences can give them a sense of involvement in physical exercise and “keeping up” with modern times. Older adults’ behaviors tend to remain in patterns that were perceived as constructive in the past . AccordiAs relatively new technological tools, exergames are increasingly being used as an alternative to conventional rehabilitation-based exercises to improve daily PA levels and increase physical fitness in older adults . ResearcAlthough the participants from the current study enjoyed their PA experiences with new technologies and emphasized the likelihood of using them in the future, the results should be interpreted with caution, given the possible response bias of participants in the focus group settings and the type of technology used in the study. Firstly, the sample was small and predominantly female (66.6%). As such, the interpretation of overall responses may not apply to males. Amagasa et al.  demonstrSecondly, the sample included in the current study was considered healthy, independent older adults (age average of 73.53 years). It is important to consider that older adults constitute a diverse group due to their age-related functional declines. There is a possibility that the participants who signed up for the study were already physically active, presenting high motivation and confidence levels prior to engaging in the exercise programs. Thus, considering a larger sample size and further stratification of older adults’ characteristics, such as marriage and employment status, lifestyle, ethnicity, educational achievements, political affiliation, and physical–psychosocial impairments, could provide new insights into the research question, and potentially mitigate gender and age bias.Thirdly, a broad range of technologies that aide in PA engagement were developed, including commercial and customized types of fitness trackers and exergames. It is important to consider that developers of commercial devices usually do not target older adults as their main costumers. The technologies included in this study were selected based on their pragmatism to answer the research question and on their commercial accessibility. Furthermore, due to the relatively short duration of the exercise programs (six weeks), the participants might have had more positive perceptions because of the novelty of the activity. Increasing their health-related quality of life;Achieving recommended PA amount;Continuing their participation in social, economic, and cultural activities ,28,60.Including the inductive approach to data analysis aided the exploration of the raw data to reveal the social/economic domain as a main theme. Despite the common application to younger populations, the constructs of PL recently emerged as a promising strategy to increase lifelong PA participation for older adults . CurrentIn general, participants presented positive perceptions about implementing technology into their exercise programs. Participants expressed concerns regarding their lack of familiarization with new technologies and socioeconomic factors, such as the accessibility and the cost of the devices. Intrinsic and extrinsic motivators were identified as stimulating uptake and ongoing PA participation.As mentioned, there are a number of limitations related to sample characteristics and the novelty of the experience. Nevertheless, the findings from this study could help inform technology developers about older adults’ preferences in order to design programs and equipment for this specific population. In addition, practitioners may use the results to consider possible adaptations to commercially available technologies, thereby increasing the potential for older adults’ acceptance and regular adoption.Mitigating negative experiences by providing formal training and accessibility to technology may introduce and integrate these opportunities into the lives of older adults. Emphasizing the perceived benefits of using technology in group-based exercise programs may be helpful in developing and maintaining older adults’ PL levels, and their likelihood of adopting technology to assist with exercise activities. The potential implementation of technology in conventional exercise programs should focus on older adults’ lifelong values, their biopsychosocial conditions, and the possibilities of reducing age-related risk of injuries and chronic diseases.


The health problems of North Korean (NK) refugees living a new life after surviving the dangers of life and death traumas is an issue that must be taken very seriously. Adolescent refugees may be particularly vulnerable to adverse physical and mental health issues because of major physical, cognitive, and psychosocial developmental changes during adolescence. This study examines the positive roles two active coping strategies—problem-focused coping and social support-focused coping—can play in NK refugee adolescents’ health self-awareness. The analysis found that “social support-focused coping” alleviates the negative relationship between traumatic experience and health perception, acting as a protective factor. Contrary to our prediction, the protective effect of adopting “problem-focused coping” in this study was not verified. The findings suggest that providing interventions for developing appropriate coping strategies help them live healthier, both physically and mentally, in South Korean society. In most cases, refugees settle in a new country after experiencing long periods of severe suffering and hardship. In this process, many health risks arise. Adolescent refugees may be particularly vulnerable to adverse physical and mental health issues compared to adult refugees, being in an unstable period characterized by major changes in physical, cognitive, and psychosocial development.In Korea, there is a group of North Korean (NK) adolescent refugees that can be classified as youth refugees. The Korean Peninsula has not had any civilian exchanges for more than 70 years since it was divided into South Korea and North Korea. Here, “NK refugees” refer to those who enter South Korea, escaping from North Korea’s political persecution or oppression of human rights. As of 2020, the number of NK refugees entering South Korea is estimated at around 34,000, of which about 5000 are adolescents . HoweverA look into their health status indicates that the height and weight attained by NK refugee adolescents are less than those of South Korean adolescents . SpecifiAccording to a study by Kim  on the hAs stated at the outset, the health status and subjective health perception of NK refugee youths is highly influenced by traumatic events occurring before and after defection. In general, NK refugees suffer incidents that are difficult for ordinary people to go through once in their lives. In fact, according to a survey conducted in South Korea, 96.5% of NK refugees were found to have experienced traumas before entering South Korea . In a stFirst, before they escape from North Korea, NK refugees experience several crises in the course of living in North Korea. In fact, North Korea experienced an economic crisis called “the arduous march” in the 1990s . FollowiIt can be said that the traumatic experiences they suffer in the process of defecting after they escape from North Korea are even more serious. As mentioned, youth who escaped from North Korea find their way to South Korea while sheltering in third countries, see Furthermore, those who have overcome the fear of death repeatedly, and have successfully entered South Korea, experience another level of trauma in South Korean society. They are subject to social discrimination and exclusion through their status as “refugees” and “thirders”, living in extreme poverty, or being targeted for violence. According to a study by Kim, Kim, Choi, and Nam , 10% of As such, NK refugees experience numerous traumas in the period before and after defection. However, since NK adolescent refugees are less mature than NK adult refugees in physical, emotional, and cognitive terms, the shocks from the traumatic incidents are inevitably greater for them. This problem is often found not only in NK refugee youth but in refugee youth generally. Davidson et al.  conducteResearchers have been trying to identify protective factors that will alleviate the negative effects of traumatic experience. Through empirical research on various target groups, research has verified protective factors in several dimensions of family variables, school variables, and community variables, such as parental attachment, family intimacy, relationships with peers and teachers, and social support ,30,31,32This study aims to examine what positive roles two active coping strategies  can play in NK refugee adolescents’ health self-awareness (among those who have experienced numerous traumas). This will be a useful resource for identifying effective intervention methods not only for NK youth refugees but also adolescent refugees with health problems around the world.The research questions being explored based on the above discussion are as follows: (1) what effect does the traumatic experience of NK adolescent refugees have on their subjective health perception? (2) What kind of role does the positive coping method  play in the relationship between traumatic experiences and health problems?The subjects of this study are “middle- and high school-age NK refugee youth living in South Korea” identified through a convenience sampling method. Since South Korea and North Korea are still in a political and military conflict, the personal information of NK refugees who have escaped North Korea is highly restricted . TherefoIn addition, because the majority of the participants were minors, the researchers also obtained parental consent forms.Furthermore, this study consisted of control variables, including a “school maladjustment” variable that can affect the dependent variable, and a “public support services” variable regarding the services they are being provided. The average level of school maladjustment was 2.01 ; the average level of experiencing public support services was 4.82 .Finally, the results of analyzing the actual conditions of the main variables of this research are as follows: the dependent variable “negative health perception” average was 1.71 . “Traumatic experience” was measured with multiple responses: 113 (67.3%) responded that they had experienced trauma in “North Korea”, 68 (40.5%) responded that they had experienced it in “third countries”, and 67 (39.9%) responded that they had experienced it in “South Korea”. “Active coping strategy” was a moderating variable for this study; the average of social support-focused coping was 2.99 , which was similar to the average of problem-focused coping—2.97 .Negative health perception consisted of a single question asking for subjective thoughts about one’s physical condition. The item was rated on a 4-point Likert scale ranging from: “very healthy” (1) to “very unhealthy” (4). The higher the score, the more negative the health perception.Traumatic Experiences was measured using the Yoon, Kim, and Han  NK traumThe active coping strategies were measured using the Moon and Kim  active cThe active coping strategies consisted of a total of 12 items. Problem-focused coping consisted of 6 items: (1) I knew what had to be done, so I doubled my efforts to make things work. (2) I made a plan of action and followed it. (3) Just concentrated on what I had to do next—the next step. (4) Changed something so things would turn out all right. (5) Drew on my past experiences; I was in a similar position before. (6) Came up with a couple of different solutions to the problem. Social support-focused coping consisted of 6 items: (1) talked to someone to find out more about the situation. (2) Talked to someone who could do something concrete about the problem. (3) I asked a relative or friend I respected for advice. (4) Talked to someone about how I was feeling. (5) Accepted sympathy and understanding from someone. (6) I got professional help.Each item was measured on a 4-point Likert scale . The mean of the questions was used. Cronbach’s α was 0.792 for problem-focused coping, and 0.863 for social support-focused coping strategies.Analyses were carried out in SPSS 25.0  A descriptive analysis was conducted to identify the general characteristics of participants and the conditions of major variables. A multiple regression model was used to test the relationship between traumatic experiences and negative health perceptions, and to verify the moderating effects of active coping .p < 0.001). The variance inflation factors (VIFs) were examined to check multicollinearity among variables. The VIF score range was from 1.07 to 2.69.Analyzing the results of model 1 shows that the higher the traumatic experience of NK refugee youths, the higher their negative health perception is. In addition, it demonstrates that among the stress coping strategies, the “problem-focused coping strategy” has a significant negative relationship with their negative health perception. Among the control variables, only school maladaptation was positively associated with negative health perceptionIn the analysis of model 2, which verified the multiple moderating effect, traumatic experience had a significant effect on negative health perception, as in model 1. The problem-focused coping strategy also demonstrated a negative effect on negative health perception. In the case of the multiple moderating effect, the social support-focused coping strategy verified it as an interaction effect. Specifically, it proves that the social support coping strategy can play a significant role as a “protective factor” for the relationship between traumatic experience and negative health perceptions. On the other hand, the interaction effect of problem-focused coping strategy was not statistically significant.The health problems of refugees living a new life after surviving the dangers of life and death traumas are an issue that must be taken very seriously. Refugees of various origins, both domestically and internationally, are exposed to a variety of traumatic events, from the process of escaping from their homeland to the process of settling in a new country, all of which can lead to their own serious health problems . Unlike This study was conducted on NK refugee youths who had escaped from North Korea and settled in South Korea. Currently, South Korea and North Korea are maintaining the Cold War system against each other, and NK adolescent refugees endure a great deal of trauma under this national situation. Human “health” is the basic element for leading a human life that everyone deserves. Therefore, it is very important to help them adapt to South Korean society in good health. Therefore, this study examines how the traumatic incidents experienced in a series of defection processes from North Korea to South Korea affect the subjective health perceptions of NK refugee youths, ultimately aiming to provide specific solutions through verification of protective factors.First of all, the traumatic experience of NK refugees had a negative effect on subjective health perceptions. This indicates that NK adolescent refugees who were frequently exposed to traumatic experiences have a tendency to negatively evaluate their own health status. According to a study by Yang  (p. 2), What is more, subjective health perception can be said to be a strong reflection of physical problems as well as psychological factors. As mentioned above, negative evaluation of one’s own physical ability or body image should be treated as important as it can lead to other problems such as maladjustment, delinquency, and suicidal thoughts ,50. HencMeanwhile, the protective factor that this study focuses on regarded the active coping method for NK refugees to deal with their stress effectively. Thus, this research has demonstrated the role that “problem-focused coping” and “social support-focused coping” can actively play. The analysis showed that “social support-focused coping” alleviates the negative relationship between traumatic experiences and health perceptions. In other words, it verified that the “coping method using social support resources” acts as a protective factor in their subjective health perception. This implies that NK adolescent refugees, who tend to negatively evaluate their health status due to their traumatic experiences, should be offered opportunities to choose a “social support-focused coping” method. Therefore, it also indicates that they need education and training on appropriate stress coping methods, while at the same time they need to have social support resources provided. In order for the “social support-focused coping strategy” to function properly, the basic premise should be that youth refugees are able to open up about their emotions, feelings, and experiences to others. In the case of NK adolescent refugees, they tend to be very alert to others, not easily opening up or exposing their own feelings . Hence, Finally, although the protective effect of adopting “problem-focused coping” in this study has not been verified, it is noteworthy that its main effect of alleviating negative health perception has been demonstrated. Similarly, according to the Lee et al. , who stuDespite a number of benefits, there are a number of limitations that affect the strength of the conclusions that can be drawn: (1) the subject of the research is not diverse. Since this study was conducted with adolescents who use safely accessible schools and institutions, adolescents outside the protection of schools or facilities were excluded from the study. Adolescents outside the protection of schools or facilities may show more serious health problems, so further studies need to be conducted to include them. (2) The sample size (n = 202) of these data is small. Although this sample size is about 10–12% of the total population, more samples are needed to increase the reliability of the results. Unfortunately, it is not easy for an individual researcher to approach NK refugees in South Korea since their personal information is strongly protected by the government for security reasons. (3) There is a possibility of reduced reporting and social desirability bias for some sensitive variables. Quantitative data in this study are from data that NK refugee adolescents responded to in a self-written manner. Thus, this study has its own limitations in that there is a possibility that they may report differently from the actual levels about school maladjustment, household income, or health awareness questions.NK adolescent refugees enter South Korean society with new aspirations. Currently, although the South Korean government and communities are seeking to provide many services and benefits to them, there are many obstacles that refugees must overcome in order to achieve successful settlement in South Korean society. In particular, they need more time and effort to adapt to society due to physical illnesses and emotional problems caused by traumatic experiences. As reviewed in this research, active coping strategies against stress can not only effectively solve the difficulties experienced by NK adolescent refugees who have negative health perceptions due to traumatic experiences but also contribute to the preparation of policy measures within the nation for the increasing population of young NK refugees. Above all, the author argues through this study that continuous efforts and interest are required to aid refugee youths worldwide who are suffering from health issues.