Exploring the Influence of Culture on Adherence to Physical Activity Guidelines Among Older Adults with diabetes mellitus and/or chronic kidney disease in KSA: A mixed methods study

Abstract

Background: Physical activity (PA) is essential for managing chronic conditions such as diabetes mellitus (DM) and chronic kidney disease (CKD), particularly among older adults. In the Kingdom of Saudi Arabia (KSA), limited data exist on the PA behaviours of this population or the cultural and contextual factors that influence them. This study employed a sequential explanatory mixed-methods design to assess PA levels and explore the cultural dynamics influencing PA adherence among older adults with DM and/or CKD in Ha’il City. Methods: A sequential explanatory mixed methods design was employed in three phases. Phase 1 consisted of a scoping review to examine the influence of culture on physical activity behaviours among older adults with chronic diseases. Phase 2 involved a quantitative cross-sectional survey of 256 older adults using the Arabic version of the Physical Activity Scale for the Elderly (PASE-A). Descriptive, bivariate, and multivariable regression analyses were conducted to explore associations between physical activity and sociodemographic and clinical variables. Phase 3 comprised qualitative dyadic interviews with 15 older adults and their informal caregivers. Thematic analysis, guided by the Social-Ecological Model (SEM), was used to interpret the findings and contextualise the quantitative results. Results: PA levels among older adults in Ha’il with DM and/or CKD were low relative to published international reference values, with a mean PASE score of 30.6 (SD = 41.9). Household activity contributed to overall physical activity scores among a subset of participants, particularly women; however, household physical activity was unevenly distributed, with more than half of participants reporting no household activity. Participants with CKD were less active than those with DM, and longer disease duration was associated with lower PA levels, while higher educational attainment was positively associated with PA engagement. Qualitative findings identified multiple barriers to PA, including chronic illness, fatigue, restrictive cultural norms equating ageing with rest, gender-based mobility constraints, family overprotection, inadequate infrastructure, and extreme climatic conditions. Key facilitators included family encouragement, medical advice, social companionship, and increased awareness of PA benefits. Conclusion: This study demonstrates that PA among older adults with DM and/or CKD in KSA is limited and shaped by an interaction of individual, interpersonal, community, and societal influences. Multi-level interventions that address cultural norms, strengthen family and caregiver support, and improve community and environmental resources are needed to support sustainable PA engagement and improved health outcomes in this population. Keywords: Physical activity, Older adults, Diabetes mellitus, Chronic kidney disease, KSA, Mixed-methods, Cultural factors, Caregivers, Social Ecological Model