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Theses Dissertations and Theses

2020

The Positive Effects of Exercise on Active Transplant Recipients

and its impact on Medication Adherence
Travane Morrison
Department of Health and Leisure Studes, Institute of Technology, Tralee, Kerry, Ireland.

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Medication Adherence" (2020). Theses [online].
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 Munster Technological University
SWORD - South West Open Research
Deposit

Theses Dissertations and Theses

2020

The Positive Effects of Exercise on Active Transplant Recipients

and its impact on Medication Adherence
Travane Morrison

Follow this and additional works at: https://sword.cit.ie/allthe

The Positive Effects of Exercise on Active Transplant Recipients and
its impact on Medication Adherence

By
Travane Morrison
A thesis submitted in the fulfilment of the requirement for the degree Master of
Science by Research

Department of Health and Leisure

Institute of Technology, Tralee
Supervisors: Dr. Karen Weekes and Dr. Michael Hall
Acknowledgement

This research would not be possible if not for the involvement of the Institute of Technology,
Tralee, Health and Leisure Studies Research department and the UNESCO Chair at the
Institute
Special thanks to the Irish Kidney Association for being so involved in sourcing the research
participants for the research.
Finally thank you to my supervisors Dr. Karen Weekes and Dr. Michael Hall.

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 Contents
Acknowledgment I
Table of Contents II
List of Tables V
List of Figures VI
Abstract VII
Table of Contents
Chapter 1 Introduction 1
1.1 Study Overview 1
1.2 Problem Statement 2
1.3 Purpose 3
1.4 Research Questions 3
1.5 Significant of study 3
1.6 Definition of terms 4
1.7 Chapter outlined 4
Chapter 2 Literature Review 6
2.1 Introduction 6
2.2 Adherence to Medication 7
2.2.1 Non-adherence to Medication 8
2.2.2 Combating medication non-adherence 9
2.3 The Kidney 10
2.3.1 Kidney Disease 10
2.3.2 Kidney Transplant 12
2.4 The Heart 13
2.4.1 Heart Disease 14
2.4.2 Heart Transplant 15
2.5 The Lungs 14
2.5.1 Lung Disease 15
2.5.2 Lung Transplant 16
2.6 The Liver 16
2.6.1 Liver Disease 16
2.6.2 Liver Transplant 17
2.7 Transplant Medication 17
2.8 Survival Rates Post-Transplant 19
2.9 Psychological Issues after Organ Transplant 21
2.10 Effect of exercise on the organs 23
2.10.1 Exercise after organ Transplant 24
2.10.2 Benefits of exercise 28
2.10.3 Why some transplant recipients do not exercise 29
2.11 Conclusion 29
3.0 Chapter 3 Methodology 31
3.1 Introduction 31
3.2 Background 32
3.3 Choosing an Approach 32
3.4 Qualitative 33
3.4.1 Phenomenology 34
3.4.2 Grounded theory 34
3.4.3 Interview Questions 35

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3.5 Quantitative research 36
3.5.1 Sourcing and Sampling 36
3.5.1.1 Limitation of Sample 37
3.5.1.2 Delimitation of Sample 37
3.6 Piloting 40
3.7 Data analysis 41
3.7.1 Analysing survey question 41
3.7.2Analysing interview question 42
3.8 Ethical consideration 47
3.9 Limitation 47
3.10 Conclusion 48
4.0 Chapter 4 Results 50
4.0 Overview 50
4.1.0 Trends in the pre and post-transplant data 51
4.1.9 Transplant recipient’s activity level 53
4.2 Transplant medication and adherence 54
4.2.1 Medication load 54
4.2.2 Transplant specific medication 55
4.2.3 Adherence to medication regimen 56
4.2.4 Factors that support adherence 57
4.2.5 Factors affecting adherence 58
4.2.6 Side effects of transplant medication 59
4.2.7 Exercise and side-effects 60
4.3 Physical limitations 61
4.3.1 Limitations after transplant 61
4.4 Cross tabulations 62
4.5 Interview results 76
4.5.0 Final thematic themes 77
4.5.1 General Dimension themes 79
4.5.1.1 Benefits of exercise 79
4.5.1.2 Benefits of exercise 82
4.5.1.3 Transplant limitations 85
4.5.1.4 Medication non-adherence 87
4.5.1.5 Exercise pre-transplant 89
4.5.1.6 Exercise post-transplant 91
4.5.1.7 Physical ability 93
4.5.1.8 Exercise adherence 94
4.5.1.9 Exercise information 95
4.5.1.10 Exercise non-adherence 98
4.5.1.11 Medication coping 99

5.0 Chapter 5 Discussion 101

5.1 Introduction 101
5.2 Benefits of exercise 103
5.2.1 Psychological 103
5.2.2 Physical 103
5.2.3 Social 104
5.2.4 Pre-transplant activity 105
5.2.5 Post-transplant activity 105
5.3 Exercise Adherence/non-adherence 105

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 5.4 Benefits of transplant 106
5.4.1 Physical 106
5.4.2 Lifestyle 107
5.5 Medication adherence/ non-adherence 107
5.5.1 Gender and its impact on medication adherence 108
5.5.2 Side effects and its impact on adherence 109
5.5.2.1 Exercise vs side effects form medication 109
5.5.3 Limitations and its impact of adherence 110
5.5.3.1 Transplant limitations 110
5.5.3.1.1 Mental 110
5.5.3.1.1.2 Exercise vs limitations 111
5.5.4 Exercise and medication adherence 111
5.6 Summary 113
6.0 Conclusion 114
6.1 Recommendation 114
References 116
Appendices

Appendix A the organs description and functions

Appendix B Ethical Approval
Appendix C interview questions
Appendix D Survey question
Appendix E phase 1 interview coding
Appendix F phase 2 open and axel coding
Appendix G selective coding -phase one
Appendix H selective coding phase two
Appendix I general dimension themes
Appendix K SPSS
Appendix K Consent form

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List of Tables

Table 1. Activity level after transplant 27

Table 2 Participants in the survey’s demographics 38
Table 3 Defines the different activity levels associated with this research 39
Table 4. Phase one (Interview coding) 43
Table 5. Phase 2 (Selective coding) 44
Table 6. Selective coding phase two 45
Table 7. General dimension theme 46
Table 8. List of figures 49
Table 9 Exercising before and after transplant comparison 51
Table 10. The worst part about taking medication and its impact on adherence 63
Table 11. What helps with adherence and its effect on adherence. 65
Table 12. Gender and its relationship with medication adherence. 67
Table 13. When participants started exercising after transplant versus have you 68
ever missed a medication?
Table 14. Activity level and its impact on adherence medication adherence 69
Table 15. Physical limitations post-transplant and its effect on adherence 70
Table 16. Participant’s activity level versus physical limitations felt after surgery 71
Table 17. Side effects from medication and if effect on adherence 72
Table 18. The participants responded to whether or not exercise help with side 73
effects from transplant medication.
Table 19. Participants activity level versus side effects form medication 75
Table 20. Final themes
Table 21. Benefits of exercise 77
Table 22. Benefits of transplant 79
Table 23. Transplant limitation 82
Table 24. Medication non-adherence 85
Table 25. Exercise pre-transplant 87
Table 26. Exercise post-transplant 89
Table 27. Ability 91
Table 28. Exercise adherence 93
Table 29. Exercise information 94
Table 30. Exercise non-adherence 95
Table 31. Medication coping 98
99

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List of Figures

Figure 1 Kidney disease 10

Figure 2. Kidney transplant 13
Figure 3 The heart transplant process 15
Figure 4 The Lungs 15
Figure 5 The liver 17
Figure 6 Living donor liver transplant 19
Figure 7 Type of transplant 39
Figure 8 How active the participants are after transplant 53
Figure 9 How many medications are you taking currently? 54
Figure 10 How many are specific to the transplant? 55
Figure 11 Have you ever missed a dosage of medication? 56
Figure 12 What helps your adherence to your medication? 57
Figure 13 What do you regard as the worst part of taking
medication? 58
Figure 14 Have you ever experienced and side effects since the
surgery? 59
Figure 15 Does exercise help side effects? 60
Figure 16 Limitations after transplant 61

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Abstract
Organ failure is a life-threatening condition (Daugirdas et al, 2014). Non-adherence to
medication is one of the main causes of the failure of a transplanted organ (Oberlin et al, 2016).
In an effort to combat non-adherence to medication, research had employed intervention
studies to tackle the main cause of non-adherence (Chisholm-Burns, 2013).
The aims of this project are three fold. Firstly it aims to find if complications associated with
organ transplant affect the individual’s medication adherence. Secondly, it explores the
connections between exercise and medication adherence. Thirdly the research explores if
exercise assists with possible complications associated with an organ transplant.
The methodology adopts a mixed methods approach, incorporating qualitative and quantitative
methods using interviews and a survey respectively. The pilot study took place at a Kidney
Transplant Wellness seminar in Dublin, which sparked changes to be made in the survey and
interview questions.
The primary data collection took place in Italy at the 2018 European Transplant and Dialysis
Games, thereby ensuring ecological validity. Forty four participants (N=44) completed the
survey questions and fifteen participants (N=15) took part in the interviews.
The results suggest that non-adherence may be as simple as being forgetful, however results
also indicate that factors such as side effects from medication may also affect adherence.
Furthermore, results suggest that exercise does not directly affect medication adherence, rather
it helps with some factors that may affect adherence to medication.
This research suggests that organ transplant recipients should be encouraged to start light
exercises within a month following a transplant to increase their chances of being 100 percent
adherent to their mediation regime. In addition, findings from this research suggest that
exercise participation should reduce the risk of possible side effects from the medication and
complications associated with organ transplant.

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1. 0 Introduction
1.1 Overview
In 2016 226,670 solid organ transplants were performed globally, of which 84,347 were kidney,
27,759 were liver, 7,023 heart, 5,046 lung, 2,299 pancreas and 196 small bowel transplant (Mahillo
et al, 2018). In 2018 a total of 231 transplants were carried out in Ireland, 120 of which were
kidney transplant, 18 hearts, 27 lungs, 56 livers and five pancreatic transplants (Gorman, 2018).
50% of transplant failure is due to non-adherence to transplant medication with other failures being
attributed to death such as car accidents, and transplant failure during surgery (Oberlin et al, 2016).
The literature review explored research relating to organ transplant. Reading the relevant literature
illuminated evidence that adherence to medication was a negative factor affecting the survival of
the transplant organ as the medications weaken the immune system that would otherwise slowly
kill the transplanted organ because it regards it as foreign to the body (Oberlin et al, 2016). In
order to counteract these risks, patients have to undergo certain psychiatric tests to ensure they are
fit and able, to not only undergo surgery, but also to demonstrate that they are mentally strong
enough to keep taking their transplant-preserving medication on time every day (Beaumont
Hospital, 2016). To ensure transplant recipients are aware of the dangers of missing their
medication, the doctors not only inform the recipient and their family of what may happen, but
they are normally kept in the hospital until the patient demonstrates that they are competent enough
to adhere to taking the required medication on their own.

The current research began to explore potential links between exercise and medication adherence
in organ transplant recipients. The research then evolved, during the literature review process,
where the author realized that specific medication adherence or non-adherence was the primary
focus of the study, and given that transplant medications do not differ greatly amongst different
organ transplants, the decision was then made to include the most common organ transplants,
specifically kidney, heart, lung and liver transplant.

When trying to understand why some people are non-adherent to their medication, it is important
for the researcher to be devoid of any pre-conceived opinion. As one may be of the opinion that
“why would you not take the medication if you know there is a chance it may cause you to die or

1
end up needing another transplant?” It is important for the reader to keep an open mind when one
does not understand the degree of difficulty of adhering to transplant medications.

Adherence to medication for transplant recipients proves challenging. Transplant medications are
to be taken at a set time every day with some being twice a day 12 hours apart, for example Prograf
is to be taken at 9am and 9pm (Beaumont Hospital, 2016). Nevins et al. (2014) found that poor
social support, race and poor perceived health as risk factors that contribute to non-adherence.
However, Parente and Pruett (2016) found that some methods such as building a foundation of
trust and employing multiple interventions can improve adherence while recognizing that no one
intervention is superior to another.

Once the necessary information regarding organ transplant and non-adherence to medication were
attained, it was then important to examine literature that explored exercise and explored if there
was any research relating to the impact of exercise on transplant recipients, specifically exercise
after an organ transplant. Exercise helps to make organs such as the heart and lungs stronger
(Gellish, 2007). It is very important for organ transplant recipients to be active because possible
side effects from transplant medications include high blood pressure and weight gain (Yango,
2006; Donnelly et al, 2014), exercise could assist in counteracting these negative side effects.
Organ transplant recipients are recommended, but not limited to doing at least thirty minutes of
light exercise daily (Conlon et al, 2016). One fundamental advantage of exercise is that it seems
to be a great way to ward off the possible psychological ailments that are associated with organ
transplant, such as depression (Denhaerynch et al, 2006). According to Ceskin (2015), exercise
has shown to improve self- esteem, happiness and optimism. It is however understood that organ
transplant recipients refrain from exercise because of fear of injury (Painter, 1999). With all the
information gathered, a narrow approach had to be made focusing on a specific problem in order
to conduct the research.

1.2 Problem Statement

The process of undergoing a successful organ transplant is only a fraction of the difficulties which
face an organ transplant recipient. The individual has to then ensure they adhere to the medication
regimen they were given by medical experts in order to protect the transplant organ. Research was
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carried out to explore the factors that affect adherence as well as methods that may improve
adherence. Exercise is known to not only contribute to physical fitness but also to improve mental
fitness (Burra and De Bona, 2006). There are mental and physical risk factors that may occur
following a transplant, and the medications may come with side effects which may affect
adherence (Beamount Hospital, 2016). This research will explore the adherence behaviors of
active organ transplant recipients.

1.3 Purpose

This research seeks to explore the influence of physical activity (exercise) on adherence to
medication after organ transplant. Furthermore it explores possible links between exercise and
other factors that may affect a transplant recipient such as side effects, non-adherence to
medication and physical limitation.

1.4 Research Question

In order to find out the effect exercise has on kidney transplant recipients in adhering to
medication, the following questions have to be answered.

1) Do potential complications associated with transplants affect medication adherence?

2) Does exercise help curtail possible complications associated with organ transplant?

3) How adherent to medication are transplant recipients who exercise?

1.5 Significance of Study

The intent of this study is to build on current information available to worldwide associations
which support transplant recipients, in relation to exercise and medication adherence for transplant
recipients. This research explores the ideal time to start exercising and the optimal activity levels
in which a recipient can potentially improve adherence and combat possible complications
associated with transplant medication and surgery.

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1.6 Definition of Terms

Relevant terms, and the context with which they are used within the current study, are listed below:

Adherence: The extent to which transplant recipients follow the instructions they are given for
prescribed treatments.

Non-adherence: A missed dosage of transplant medication

Recipients: A person with an organ transplant

1.7 Chapters Outlined

Chapter 1. Overview

Chapter one serves as a research guide. In chapter one the issues that prompted the research are
highlighted as well as the purpose, significance, and the questions the researcher wishes to explore
thereby illuminating new evidence within the area of transplant recipients and adherence to
medication.

Chapter 2: Literature Review

This chapter reviews relevant literature on the following areas : firstly an understanding about
the human organ, the organ transplant process, and organ transplant medications; secondly, the
factors linking to non-adherence to medication and methods to counteract non-adherence; thirdly
possible issues associated with organ transplants; fourthly the physiology of exercise and the
benefits of exercise; finally research carried out in relation to exercising after transplant and why
organ transplant recipients refrain from exercise.

Chapter 3: Methodology

This chapter explains the methodological processes that went into the current study. Based on the
information in the literature review and the research questions to be answered, the decision was
made to employ a mixed methods approach. Complete information regarding the ethical approval
process, how the data was collected and how the data was analyzed is presented within Chapter 3.

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Chapter 4: Findings

This chapter consist of the bar charts, cross tabulations, and tables that reflects the answers to the
questions in the questions asked in the survey and interview. This chapter has two sections, the
first section reflects the answers to the survey questions and. To illustrate these answers bar charts,
a table and cross tabulations were implemented. The second section reflects the answers to the
interview questions and the themes gathered from those answers. Tables were implemented to
highlight the responses and themes.

Chapter 5: Discussion

Chapter five discusses the findings of the current research and compares these findings with
previous research carried out in the area, as was presented within the Review of Literature Chapter.
The findings are divided into topic headings which present and delve into the revealed concepts
which link exercise and medication adherence.

Chapter 6: Conclusion and Recommendation

This chapter houses the researcher’s final conclusions, following on from the research journey
undertaken, and makes recommendations for transplant recipients in relation to exercise and
medication adherence. Furthermore, recommendations are made for future studies in similar
areas.

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2.0 Literature Review
2.1 Introduction

A high percentage of patients presenting for transplantation are physically inactive or have very
low levels of exercise capacity (Painter et al, 2003). It is known that cardiovascular and metabolic
diseases (hypertension, diabetes, hyperlipidemia, or obesity) affect mortality and morbidity in
solid organ transplant recipients. This is in part due to the nature of the immunosuppressive drugs
(medication used to weaken the immune system) taken by patients (Pilmore et al, 2010). It is also
well established that immunosuppressive therapy often results in numerous adverse effects,
including osteoporosis, sarcopenia, and weight gain (Cordier et al, 2000; Grotz et al, 1995).
Conversely, according to Painter and his colleagues, there is a consensus that regular physical
activity is not only healthy but can counteract cardiovascular and metabolic diseases, osteoporosis,
sarcopenia, and numerous risk factors derived from physical inactivity and a sedentary lifestyle
(Painter et al, 2003). Notwithstanding this knowledge, until now the study of the role of exercise
after transplantation has previously been largely evaded. As pointed out by Gordon et al (2005)
there is no uniform agreement among transplant professionals about the need for exercise, how
exercise should be re-introduced, or recommendations for what the amount of exercise after
transplantation might be. There are challenges in studying the introduction or re-introduction of
exercise post-transplantation. These include patient attitudes, such as lack of motivation and
interest or fear of injury and cultural beliefs that ignore the benefits of exercise. This may be
derived in part from the silence of transplant professionals about the benefits of exercise or from
the common belief that other medical issues are more important than exercise (Gordon et al, 2005).
Another organizational aspect that usually is not taken into account arises from the difficulties that
transplantation patients may have in accessing appropriately supervised exercise facilities, a
common problem found with patients with other illness (Gecht et al, 1996; Muller et al, 1996).

Transplant patients usually complete a rehabilitation period before discharge after surgery, but
generally receive only advice and suggestions on the benefits of exercise as oppose to a detailed
exercise plan that would increase the physical activity level of the patient that is not only effective
for their health but also safe enough for someone who has had surgery (Crouch, 2013). As a

6
consequence, the preventive role which physical activity can play is largely underutilized because
health care professionals do not consistently promote exercise to support the recovery of
transplantation patients. Furthermore, exercising is not routinely incorporated into routine patient
management (Gordon et al, 2005). After a patient leaves the care of the primary medical team,
partaking in physical activities can help manage the possible negative consequences of the side
effects associated with the immunosuppressive medications (Crouch, 2013). It is very important
to establish what physical activities are best for each individual organ transplant patient and how
these can be accessed conveniently to provide a beneficial impact.

2.2 Medication Adherence

Adherence can be defined as the extent to which people follow the instructions they are given for
taking prescribed medication on a regular basis (Low et al, 2014). Many kidney transplantations
end up failing due to non-adherence to medication (Oberlin et al, 2016). The immunosuppressive
therapy given to help the body tolerate a new kidney has to be adhered to in order for the
transplanted organ to remain viable in the long term (Low et al, 2014). Researchers such as
Prendergast and Gaston (2010) studied ways to improve patient outcomes after kidney
transplantation, and in doing so, reported that reasons for non-adherence varied for different
recipients. Treatment duration, complexity and the nature of the severity of the disease a patient
has, are amongst the main factors that result in non-adherence. Furthermore, factors related to the
characteristics of the disease and medication side-effects also diminish some patients desire to
continue taking mediation on a regimen (Gottlieb, 2000). Martin et al. (2005) reported that reasons
for non-adherence stem from cognitive and interpersonal factors, patient involvement and
participatory decision making, patients attitudes, culture as well as the patients overall emotional
health. Understanding the nature of adherence requires a multi-method approach to give a clear
and accurate picture of whether and how medical directions are being followed. However,
adherence itself can be measured using multiple tools. For example, adherence to antidepressant
medication might be assessed by pill count or patient self-report (Thompson et al, 2000; Hamilton,
2003). The combination and reconciling of various assessment techniques can be quite valuable,
as individual measures of adherence have been shown to differ from one another by as much as
37% according to Milgrom et al. (1996). To understand adherence it is imperative that one
understands why an individual becomes non-adherent.

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2.2.1 Medication Non-adherence

Transplantation is the preferred treatment option for people with end-stage kidney disease
(Williams et al, 2014). Once a transplant has occurred, adherence to medication is crucial for
optimal success.

According to Oberlin et al. (2016), while vital for survival, adherence to medication is not
practiced at the highest degree. Reflecting this over 50% of kidney transplants fail within two years
due to patients not adhering to immunosuppressive medication regimen and has been observed in
almost half of the graft losses. Failure to take immunosuppressive drugs results in decreased graft
function. Furthermore, it results in an increased risk of kidney loss, and even premature death
within two to four years for a large number of recipients (Oberlin et al. 2016). Some patients have
a poor attitude towards medication, which coupled with being forgetful are factors that contribute
to non-adherence (Williams et al. 2014). Nevins and his colleagues (2017) found that risk factors
associated with non-adherence include poor social support, poor perceived health, and race/
ethnicity. The major change associated with kidney transplant is the medication regime. The fact
that recipients have to adhere to these medications in order to keep the kidney working, coupled
with the side effects that are associated with the medication, adds to the emotional toll of preparing
for the transplant for the patient. Exploration into the factors of non- adherence found that
depression is a factor (Denhaerynch et al, 2006).

Prendergast et al. (2010) found that in kidney transplant recipients, men are more adherent to their
medication than women. Hadayati et al (2017) support this finding in their explanation that this
non-adherent behavior in women is due to the side effects they suffer such as headache and high
blood pressure. Women however appear to adapt to the overall life-style changes better than men
after a transplant (Germani et al, 2011).

There are different dimensions of life-style changes associated with kidney transplants which
everyone has to adapt to, for example the use of sun screen to protect the skin as the
immunosuppressive medications increase the risk of skin cancer. In addition, adhering to
medications in order to protect the kidney while also eating and exercising to ward off the possible
side effects associated with the medications (Hadayati et al, 2017).

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Rodrigue et al (2013) while studying transplant recipients and their adherence to medication have
categorized different levels of adherence, if a recipient missed their medication ‘about once a
week’ or ‘more than once per week’ they were classified as missed dose non-adherent. However
if they missed ‘no more than a few times a month’ they were classified as altered dose non-adherent
and those who have never missed a dose are adherent.

2.2.2 Combating medication non-adherence

Chisholm-Burns (2013) did a 15 months investigation involving 12 months intervention and 3

month follow-up period. The intervention involved a pharmacy care group (N=74) and a standard
patent-tailored care group (N=76). The methods used included providing information about
adherence to medication, highlighting the consequences of non-adherence, a behavioral
intervention which identify lifestyle changes that can improve adherence, and an emotional
intervention which used motivation from ‘significant other’. In this study, the pharmacy refill
record showed that adherence rate improves if the days between refills was less than or matched
with total number of days’ supply; the monthly adherence was estimated by comparing refill
records to the prescribed regimen documented in medical records. The results showed the
intervention to be successful as the percentage of non-compliant patients reduced from 57.3% to
23.9%. Hardstaff (2002, 2003) did an intervention using a behavioral study incorporating
electronic monitoring devices and a one-off electronic feedback from a nurse about adherence
levels. No difference was discovered between the intervention group and the control group.
Hardstaff’s (2002) research also showed that a large number of patients adhere to their medication
during the intervention but stopped when the intervention was over.

Most intervention methods used in a significant number of studies includes emotional, behavioral,
informational or practical ways of finding a way to help clients remember to take the medication.
Some mentioned implementing an intervention by loved ones but adherence remains a complex
matter that is not fully understood (McDonald, Garg & Haynes, 2002). Oberlin, Parente and Pruett
(2016) believe although no intervention strategy is superior to others, there are five ways to combat
non-adherence: (1) Build a foundation of trust; (2) Employ multiple interventions; (3) Stratify the
population; (4) Develop collaborative partnerships; and (5) Embed medication adherence into the
organization's culture.

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To understand what happens to transplant patients post-transplant both physically and emotionally
it is important to understand the purpose of the organ, the diseases that affect them and the
transplant process.

2.3 The Kidney

As can be seen in Figure 1, the kidney is a complex organ. The best way to describe the kidney is
that it is bean shaped. There are two of them in the body located on either side of the spine below
the ribs and behind the belly, they are about the size of a large fist about 5 inches long (Hoffman,
2014). Details about the kidney and kidney functions can be found in Appendix A.

Figure 1. Kidney disease (Reproduced from WebMD, 2014)

2.3.1 Kidney Disease

The inability of the kidneys to perform their functions fully is known as Chronic Kidney Disease
(CKD). In CKD, the kidneys lose the ability to filter effectively and as a result the body retains
fluid (Daugirdas et al, 2014). It usually occurs over time due to several factors that can affect the
kidney. Diabetes is an example of one such factor. Diabetes is an overload of glucose in the blood
stream which as a result damages the small blood vessels in the kidney leading to an eventual
failure. Other causes are high blood pressure and inflammation in the kidney known as nephritis

10
(Opelz et al. 1998). Another major kidney disease is known as Polycystic Kidney Disease (PCKD)
which is a genetic disorder characterized by the growth of numerous cysts within the kidney. These
cysts are non-cancerous round sacs of water-like fluid (Mayo Clinic, 2017). Other kidney related
disease includes Kidney Artery Stenosis which is a narrowing of the lining of the main artery
(blood vessel) that supplies the kidneys (Lao et al. 2011). Obstructive Nephropathy is a kidney
disease caused by a blockage to urine flow through the urinary tract (Skalar, 2000). Pyelonephritis
is a bacterial infection of one or both kidneys. Chronic pyelonephritis is kidney damage caused by
recurrent or persistent kidney infections (Fulop, 2017).

Before a kidney fails it usually shows some symptoms that it is deteriorating over time. The kidney
makes urine so when the kidney is deteriorating it is common for the person to see a change in
normal urination. In addition, the individual may feel a pressure when urinating, with patients
reporting they would always feel like urinating but when they get to the bathroom they can only
pass a few drops (Wedro, 2017). The second symptom of a failing kidney is swelling. The kidney
is responsible for filtering out fluids from the body if this is not being done at a regular pace there
tends to be a buildup which will result in swelling of the hands, ankle, legs and face. Most patients
have reported that the noticed area swelling took place was the ankle, with patients reporting they
often cannot get their shoes on due to swelling (Mayo Clinic, 2017). The symptom which follows
the swelling is fatigue. The kidney makes erythropoietin which is a hormone signaling the body to
make more oxygenated red blood cells. The muscles cannot function well without a strong
presence of red blood cells as this leaves muscles and brain feeling weak, referred to as anemia
(Hruska et al. 2008). Patients have reported feeling drained even when they are not doing anything
active. The fourth symptom is developing rashes and itches due to a buildup of waste in the blood
stream which happens when a kidney is failing as it cannot effectively eradicate the waste when it
is not working well. A build-up of waste products in the blood (called uremia) can make food taste
different and causes bad breath patients may also notice that they stop liking to eat meat, or that
you are losing weight because you don't feel like eating, patients describe it as a foul taste in your
mouth almost like you’re drinking iron (Mayo Clinic, 2017). In order to survive CKD and other
kidney related failures a patient may be recommended to try dialysis.

Dialysis is a treatment used to perform the task of a kidney that can no longer carry out its functions
by filtering and purifying the blood using a machine that balances the electrolytes and fluids

11
(Daugirdas et al, 2014). Patients have two options when considering using dialysis being
hemodialysis and peritoneal dialysis (Conlon et al, 2016). According to Conlon (2016) both are
used to filter waste from the body, the decision is predicated on whether or not the patient want to
administer their dialysis at home or in the hospital.

2.3.2 Kidney Transplant

Kidney and transplant refers to placing a healthy kidney from a live or deceased donor into a
person whose kidneys no longer function properly in a surgical procedure (Mayo Clinic, 2015). In
1906 the first attempt was made at kidney transplant when a French doctor by the name of Mathieu
Jaboulay transplanted the kidneys of a pig and a goat into two patients with kidney disease by
attaching the renal vessel to the brachial vessel (Morris, 2004). However, the first successful
transplant did not happen until December 20th 1954 when Doctor Joseph Murray’s team performed
a transplant between identical twins (Merrill, et al. 1956). Nowadays before a patient is added to
the waiting list for a possible kidney transplant they first have to go through extensive tests to get
their blood type, check for viruses such as HIV test, hepatitis B as well as kidney and cardiac
functions. Once these tests are completed the patient will then be called in to the hospital to meet
with a transplant team. The meeting will highlight the pros and cons of kidney transplant
procedures. If the test results are acceptable the patient will be added to the kidney transplant
waiting pool.

Patients cannot receive a kidney from just anyone. Patients whose blood type is O must receive
from donors with O blood type; patients with A blood type can receive from donors who have A
or O blood type; patients who have a B blood type can receive from a donor who has a B or O
blood type; and patients who have a AB blood type can receive from donors who have O, A, B or
AB blood type (Dunne et al, 2014).

The patient will need to remain contactable while in the waiting pool as a kidney may become
available at any time. It is very important that a sample blood is sent in to the transplant laboratory
at least every three months to ensure their status have not changed and they have not contracted
any diseases or viruses. If these blood samples are not kept up-to-date, the patient’s name will be
suspended from the transplant waiting pool (Dunne et al, 2014). When the patient receives a call
that a possibility of a suitable transplant has occurred, they will need to get to the hospital as soon

12
as possible where different blood tests, x-rays and heart monitors will be administered. They are
then seen by a surgeon and anesthetist, and when these evaluations are available a final decision
to carry out the transplant can then commence (Beaumont Hospital, 2017).

During the surgery, unless the old kidneys are causing problems they are left intact and in situ, the
new kidney is placed in the right or left side of the lower abdomen just above the hip bone (Figure
2). The arteries of the new kidney are connected onto the blood vessels going to the legs, and the
renal artery and the renal vein from the new kidney is connected to the renal artery and renal vein
of the old kidney the renal pelvis is connected to the bladder, a process normally takes 3 to 4 hours.

After a successful kidney transplant, recipients may notice an improvement in their quality of life
(Mendonca et al, 2014).

Figure 2. Kidney and pancreas transplant (Adapted from Beaumont, 2017)

2.4 The Heart

In humans the heart is the size of a large fist and is located in the thoracic rejoin of the body
between the lungs, protected by the rib cages. The heart can weigh 227 to 283 grams in women
and 283 to 340 grams in men (Lewis, 2016). The description and functions of the heart can be
accessed in Appendix A

13
2.4.1 Heart Disease

Cardiomyopathy is a diseases that enlarges and thicken the muscles in the heart causing the muscle
tissues to turn into scar tissues, making them weak and as a result the heart will not be able to
pump the required amount of blood needed by the cells in the body (American Heart Association,
2016). In some patients the artery that returns the blood to the heart becomes narrow and hardens,
which is caused by a buildup up of cholesterol and plaque on the inner wall. This is known as
coronary heart disease. The occurrence of a blood clot can limit or cut off the supply of blood to
the heart and that will lead to angina and heart attack (Medline Plus, 2016).

2.4.2 Heart Transplant

A heart transplant is carried out for patients who have undergone treatments and medication for
diseases that leads to heart failure but is not getting any better (American Heart Association, 2016).
It is rather difficult to get a donor for a heart transplant as the only option for a transplant is from
a deceased donor (Miller et al, 2007). Not everyone is a candidate for heart transplant, therefore
patients have to undergo psychological evaluations, diagnostic tests and other preparation methods
before being given the clearance for heart transplant blood tests (Mehra et al, 2006). If successful
for heart transplant surgery, on the day of the transplant the patient will be put to sleep and attached
to a heart-lung bypass machine in order to keep oxygen rich blood flowing through the body
(Hopkins, 2017). An incision is made in the chest opening the sternum and opening up the rib
cages in order to get to the heart (Medline Plus, 2017). The diseased heart will then be extracted
from the patient and the donor’s heart will be put in place and the major vessels are then attached
and sewn together (Mayo Clinic, 2017). Figure 3 illustrates the heart transplant process.

14
Figure 3. The heart transplant process (Adapted from Mayo Clinic, 2018)

2.5 The Lungs

On each side of the thorax are two sponge like air-filled organs known as the lungs. They are
protected by the rib cages and work together with the heart to get oxygen into the body as seen in
Figure 4. The description and functions of the lungs can be accessed in Appendix A.

15
Figure 4. The structure of the lungs (reproduced from American Cancer Society, 2012)

2.5.1 Lung Disease

The most common type of lung disease is known as Chronic Obstructive Pulmonary Disease or
COPD. This permanent and progressive disease obstruction of airflow through the airways and out
of the lungs. Another common lung disease is Pulmonary Fibrosis or Interstitial Lung Disease or
ILD, which is a term used to explain an array of disorders that affects the inner walls of the lungs
damaging the air sacs causing the lungs to become stiff and reduced in volume (Gottlieb, 2008).
Cystic fibrosis is a life-threatening lung infection caused by unusually thick mucus build up
causing a clot in the lungs as well as obstructing the pancreas and stops natural enzymes from
helping the body break down and absorb food (Cystic Fibrosis Ireland, 2013). Pulmonary
hypertension is a type of high blood pressure, which occurs when the pulmonary arterioles and
capillaries are narrowed or blocked, or even worse, is destroyed (Hartert et al, 2008). These
diseases make it hard for the carrier to breathe, and physical activities become unbearable due to
the struggle to fill the lungs with oxygen. As a result these patients may need a lung transplant in
order to live a normal life.

2.5.2 Lung Transplant

The first human lung transplant was done in 1963 (Grover et al, 1996) after a couple failed
experiments in the 1946, through the 1950s and the early 1960 (Belfield and Wein, 2000). As of
June 20, 2011 39,835 adult lung transplant were performed over the world since January 2000
(Christie, 2012). In order for a patient to be considered for lung transplantation the patient must
first participate in post transplantation exercises conducted by the clinic they are set to use.

2.6 The Liver

The largest organ in the body is the liver (see figure 5), it is the size of a football and can weigh
up to three pounds in an adult male (Francicus, 2015). Further description and functions of the
liver can be found in Appendix A.

16
Figure 5. The liver (Adapted from Mayo Clinic, 2018)

2.6.1 Liver Disease

Some of the most common causes of liver disease that may lead to needing a transplant are
autoimmune liver disease, autoimmune hepatitis (AIH) biliary cirrhosis (PBC), primary sclerosing
cholangitis (PSC), alcoholic cirrhosis, cryptogenic cirrhosis and hepatocellular carcinoma (Prince,
2002). In Europe and North America alcoholic liver disease is the most common cause of liver
failure since the late 1980s. Those who need a transplant from after having liver disease from
drinking is unlikely to be granted a transplant as the belief is that those recipients will not be able
to stay away from drinking and the result will be a failed transplant (Belle et al, 1997).

2.6.2 Liver Transplant

The first ever human liver transplant was done in 1968 (Hudson, 2002). The transplant procedure
works by removing the liver that has failed and no longer function properly and in place put a
healthy liver donated by a living or diseased donor (Mayo Clinic, 2018). A large number of people
are placed on a waiting list every year but the number of patients outweigh the number of
donations, therefore transplant officials are hesitant to operate on those whose liver failure is a

17
result of alcohol abuse (Prince, 2002). Mayo Clinic (2018) on their website explained that in the
year 2014, 7,200 liver transplants were performed in the United States of America, and while that
is a large number the registration list had nearly 15,000 on the liver transplant waiting list. In order
to go on a waiting list. The doctor of a patient would have to recommend that they do a transplant,
they would then select a transplant center. The patient will then be evaluated by a transplant
professional. The evaluation aims to find out if the patient can manage the transplant and the
transplant process namely are they healthy enough for a liver transplant, finding out if they have
any medical conditions that interfere with the transplant, and test their psychological state to make
an assumption as to whether or not they will take the medications after the transplant. It is very
important that patients stay healthy before the transplant by taking their prescribed medications,
adhere to the diet guideline, and appointments with health care team. If the donor is a deceased
donor, the liver is removed from the donor. A section of the liver is removed if the donor is alive
(Figure 6) a proposed recipient is then contacted and requested to come to the hospital. Once at
the hospital the individual will undergo test to make sure they are healthy enough for surgery. The
surgery begins by putting the patient to sleep using anesthesia. Once the patient is fully asleep the
transplant surgeon will make an incision across the abdomen the recipient’s liver is removed and
the donated liver is put in its place by attaching the blood vessels and bile ducts. Once the new
liver is place in the incision will be closed using stitches and staples. This process may take up to
12 hours. If stable (no signs of possible complications) the recipient remains in the hospital for
five to ten days after the surgery to recuperate. If the recipient is not stable they will remain in
intensive care to be monitored for complications. Once the recipient leaves the hospital they will
be required to have frequent checkups which lessens over time. A liver transplant recipient is
expected to be fully healed in six months following surgery depending on how sick they were
before the transplant (Mayo Clinic, 2018; Prince, 2002; Neuberger, 1999).

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Figure 6. Living donor liver transplant (Adapted form Mayo Clinic, 2018)

2.7 Transplant Medication

According to Kwee (2017) transplant medications are known as anti-rejection medication designed
to suppress the immune system which is imperative for the survival of the new kidney. Kwee
(2017) went on to state the two categories in which transplant medications are classified. These
categories are known as induction agents which are used only at the time of the transplant and
maintenance agents which are used throughout in order to keep alive.

The Beaumont Hospital Kidney Centre, Ireland, (2014) released a full comprehensive list of
medications that recipients are required to take after a kidney transplant. Medications are used for
anti-rejection, anti-bacterial and medications to protect the stomach. These medications are not
found at the regular pharmacies as these are classified as “high end” medication that can only be
obtained at specialized outlets. Transplant medications include Tacrolimus (prograf and advagraf),
Cyclosporine (Neoral), Mycophenolate (Cellcept and Myfortic), Sirolimus (Rapamune) and
Predisone (steroid).

Tacrolimus and Cyclosporine which are the drugs used for anti-rejection are used by 40%-60% of
recipients after transplants (Bechstein, 2000). They work by suppressing the immune system to
stop it from fighting against the new organ. These are available for patients after transplant in 0.5,
1 and 5 milligram/s, and they are available in capsule gelatin coated and injection solution form

19
(Beaumont Hospital, 2016). The dosage decided by the transplant team is based on the progress of
the transplanted organ, however this medication has to be taken every 12 hours. It is important that
this medication is not taken on an empty stomach which means it should not be taken 1 hour before,
or 2 hours after consuming food. It is also important to note that grapefruit should not be consumed
while taking tacrolimus as grapefruit juice may increase the amount of tacrolimus in the body
which can lead to serious side effects (Donnelly et al, 2014).

Possible side effects of Tacrolimus and Cyclosporine include abdominal or stomach pain,
abnormal dreams, agitation, chills, confusion, convulsions (seizures), diarrhea, dizziness, fever
and sore throat, flu-like symptoms, frequent urination, headache, itching, loss of appetite, loss of
energy or weakness, mental depression, muscle trembling or twitching, nausea, pale skin, seeing
or hearing things that are not there, shortness of breath, skin rash, swelling of the feet or lower
legs, tingling, trembling and shaking of the hands, trouble sleeping, unusual bleeding or bruising,
unusual tiredness or weakness and vomiting (Donnelly et al, 2014). Less common side effects of
tacrolimus are blurred vision, chest pain, and increased sensitivity to pain, muscle cramps,
numbness or pain in the legs, ringing in the ears and sweating. Rare side effects of tacrolimus are
enlarged heart, flushing of the face or neck, general feeling of discomfort or illness and weight
loss. It is important for patients to contact their doctors if they have any of these symptoms, as the
doctor may reduce or remove the dosage (Beaumont Hospital, 2016)

Corticosteroids- the main steroid used for transplant patients is Prednisone. The immune system
is designed to destroy anything that is foreign to the body, and anything that does not match the
tissue and blood typing the immune system will attack it, therefore steroids are used in the early
stages of the transplant to reduce the risk of rejection. They are also used in the case of acute
rejection where the body may start to fight the organ while the surgery is being performed. Steroids
are used in a high dosage at the start in order to fully suppress the immune system, and as the
tolerance level of the body increases, the dosage decreases until the patient can stop taking them
completely (Mudge, 2016). The problem many are having with steroids is the fact that they may
work too well. Steroids stop the body from being able to fight against the simplest of infections,
hence it is imperative that the patent tries as much as possible to avoid infections during this time
as they are at immense risk. The simplest of infections can lead to death, so therefore patients are
required to cover their mouth and nose whenever they are around anyone or when they are outside.

20
Common side-effects from steroids include weight gain and increase toxicity in the kidney (Steiner
and Awdishu, 2011).

Mycolat is another anti-rejection medication used by kidney transplant patients. The generic name
is Mycophenolate Mofetil (Beaumont Hospital, 2016). According to (Rowex Limited, 2013) much
like Prograf, Mycolat suppresses the immune system to protect the transplanted kidney.

The most common side effects associated with transplant medications are increased blood
pressure and blood sugar, headache, tremor, trouble sleeping, diarrhea and nausea, trouble sleeping
and infection (Kwee, 2017).

2.8 Survival Rates Post-Transplant

Getting a transplant done is only one part of the process. Another major concern is the survival of
patients post-transplant. According to Yusen et al, (2016) a report of registered adult patients who
underwent primary lung transplant between January 1990 and June 2014 had a median survival of
5.8 years, with unadjusted survival rates of 89% at three months, 80% at one year, 65% at three
years, 54% at five years and only 32% at ten years. The survival rate of lung transplant patients
has been far less than the other organ transplant recipients but it has been better in the past several
years (Thabat & Mal, 2017). According to Brown (2015) almost 50% of liver and pancreas
transplant recipients may end up needing a second transplant five years post-transplant. Survival
rates in solid organ transplants such as heart, liver and kidney have seen a significant improvement
over the past year, with around 88% of patients surviving the first year after transplant surgery,
75% surviving for five years and 10-year survival rate is around 56%. With these improved
survival rates there is an increase attention on the quality-of- life in physical related healthy
activities (Nichols, 2014).

2.9 Psychological Issues after Organ Transplant

In order to determine whether a patient has physiological or psychosocial characteristics that may
negatively affect post-transplant outcomes, patients have to go through a psychosocial evaluation.
This evaluation assesses psychosocial factors including cognitive, behavioral, psychological, and
social issues which may interfere with adjustment to transplantation or ability to adhere to post-
transplant medical regimen (Dimartini et al. 2008) According to Grover and Sarkar (2012) there

21
are many psychological issues that may arise in patients before and after an organ transplant. These
include the anxiety of awaiting a possible match or a donor and the uncertainty of life which does
take a toll on the minds of the patients. Some patients may be on the waiting list for a new organ
such as a liver due to an addictive illness such as over-reliance on alcohol, and after a liver
transplant the patient has to abstain from drinking, which may cause a relapse or psychological
breakdown (Engle, 2001). It is important to assess patients before the transplant for any
psychological problems that may affect the result of the transplanted organ before commencing
the operation. A study carried out by Telles-Correia et al. (2009) found that psychiatric disorders
can affect the quality of life of an individual awaiting a liver transplant. The study found that
‘physical and mental wellbeing in liver transplant candidates were influenced far more by
psychiatric factors such as depression and coping strategies than by clinical and sociodemographic
factors’ (p.85).

Waiting for a transplant is a hard task. It is often overlooked how difficult it is for a patient to
constantly waiting for a lifesaving procedure yet maintaining the hope that an organ will be made
available to them soon. Patients are often on the waiting list for two to fifteen years before an organ
is available to them (Wright et al. 2007). Some patients tend to ignore the possibility of death and
end up in a state of denial in the hope, trying to maintain positivity, but a long delay along with
these factors may cause depression (Quill, 2000).

Following the transplant process, up to 20% of kidney recipients, 30% of liver recipients and 63%
of heart recipients have been found to develop disorders such as depression, anxiety, hepatic
disease, cardiac disease and advance pulmonary especially during the first post-transplant year
(DiMartini et al. 2005). Those with end-stage lung disease tend to suffer from anxiety disorders
such as panic disorder more than patients with other end-stage organ disease (Dobbels et al. 2006).
There are multiple psychosocial stressors facing these patients such as reduced quality of life,
reduction in physical ability, the financial strain from preparing for the surgery, medications and
physiological impairment such as electrolyte imbalance, thyroid disorders, and nutritional
deficiencies can produce secondary psychiatric symptomatology (Dobbels et al. 2006). Among
patients evaluated for transplantation, many will be psychologically worn down by the effects of
worsening chronic disease and the mental strain from maintaining hope (Levenson, Olbrisch
2000). Others with acute failure may be overwhelmed with the suddenness of their disease and its

22
life-or-death implications (Dew et al. 2005). Apathy, fatigue, and memory impairment due to
depression can interfere with a patient’s ability or motivation to adhere to a post-transplant regimen
of medications, self-monitoring, exercise, and clinic appointments (DeVito et al. 2003). Excessive
or irrational fears due to an anxiety disorder can cause patients to avoid tests, treatments, hospitals,
and other circumstances that raise their level of distress. Anxiety and depression may therefore
negatively impact their adjustment to transplantation and early intervention is recommended
(Bunzel et al. 2000).

2.10 The Effects of Exercise on the Organs

In the previous sections, transplant and the diseases that lead to them were explored. In order to
find the link between exercise and transplant it is important to understand the exercise itself and
what happens to the organ when one exercises. One of the key components of exercise is the
cardiovascular system and how it changes. When one begins to exercise the medulla in the brain
incites the cardiac function. The medulla then regulates the heart using the pacemaker in the right
atrium. The right atrium is stimulated by the sympathetic and parasympathetic nerves which raises
and lowers the blood pressure respectively (Colman, 2006). During exercise the motor cortex of
the brain will stimulate the medulla, match the muscles being recruited the sensory nerves in the
muscles are responsible for telling the medulla the metabolic status of the muscle, the blood
pressure in reported to the medulla via the high pressure baroreceptors in the artery. When the
intensity of the exercise is increased the sympathetic system causes a reduction of blood flow to
the stomach, intestine, the kidney and the skin, the exercising skeletal muscles releases metabolites
causing vasodilation of the arteries leading to active fibers. However the muscles can accept too
much blood flow therefore the sympathetic nerves attached to the exercising muscles must increase
resistance to maintain blood pressure (Palmer, 2015). There are two types of blood pressure
systolic and diastolic, systolic blood pressure is the pressure against the artery wall when the heart
beats, this changes as the intensity of the exercise increases or decrease, diastolic blood pressure
is the pressure of the blood against the artery walls while the heart is resting between beats, this
should remain constant (American Heart Association, 2017).

23
At rest the heart rate (HR) for a normal person should vary between sixty to eighty beats per
minute, as a person ages the resting heart rate may go up to one hundred beats per minute. An
active person especially endurance type athletes HR may vary between twenty-four to forty beats
per minute. What is significant about the heart rate is each beat pumps a certain amount of blood
through the left ventricle, this is known as the stroke volume (SV). The lower the SV is means the
heart has to beat more times for the body to get the myoglobin and hemoglobin to the tissues
(Davis, 2017). What is evident is the fitter a person is the higher the SV, the higher the SV, and
the less the heart has to beat to supply blood to the body even while under stress. In addition the
cardiac output (Q = volume of blood per minute) is higher and blood pressure (force of the blood
against the blood vessels) is lower in those who exercise (Gulati, 2010). Prior to exercising,
competing in sports or running away from the neighbor’s dog there is something in the body known
as an anticipatory response which is the body releasing adrenaline and noradrenaline into the blood
stream which instantly speeds up the HR. The heart rate will speed up while exercising, by how
fast will be determined by the intensity of the exercise and fitness of the individual the approximate
maximum heart rate is measured by subtracting the person’s age from two hundred and twenty
(HRmax = 220-age) this however is not the most accurate way to measure HR max (Gellish, 2007).
The heart in fact is a muscle, muscles are known to the increase in size and effectiveness with
systematic training. An athlete is who does continuous training is known to have a larger heart that
an average person, which means a higher stroke volume with a low heart rate which will equal to
the cardiac output (Q= SV*HR). However in some cases an enlarged heart can be detrimental.
The heart has a limit as to how fit it can really get, and at some point during training the heart will
plateau, which means the HR and SV will be at a constant giving that the level of exercise remain
at the same or higher intensity and frequency (Whyte, 2008).

2.10.1 Exercise after organ transplant

A 2019 study by Chen et al. while studying the effects of exercise on the cardiac risk factors
associated with kidney transplant revealed that exercise intervention improve arterial stiffness and
overall quality of life but has no bearing on cardiovascular disease. Low physical function is
expected following renal transplant as patients often suffer reduced muscle mass and impaired
physical capacity due to dialysis, side effects from the medication or limitations brought on by the
illness, especially in elders (Yango, 2006). However assuming the surgical wound had healed, on

24
average a kidney transplant recipient can begin exercising four to six weeks after the transplant.
The surgery does not limit recipients from exercising or sports, rather it improves their overall
quality of life as dialysis and end stage kidney disease leave patients feeling weak. Recipients are
usually sensitive about starting exercising after kidney transplant, but studies have shown that
patients started travelling and having children after recovery from surgery (California Pacific
Medical Center, 2014).

Bellizzi et al. (2014) highlighted that as long as the energy is being expended and the skeletal
muscles are being moved, it is considered physical activity, but on the other hand physical in-
activity (sedentary) is the absence of exercise or any physical activity. The research by Bellizzi et
al (2014) did categorize the different level of activities after kidney transplant:

Sedentary activities included reading, watching television, listening to music, driving a car,
washing dishes cooking, dancing slowly and walking 2-3 kilometers per hour and so on.

Moderate activities are slow cycling, walking 5-6 kilometer per hour, gardening, swimming,
playing golf climbing stairs and so on.

Vigorous activities are skiing, trekking, playing tennis, dancing as sport, intense cycling etc. Very
vigorous activities included jogging, swimming as sport, playing football and playing basketball
(see Table 1).

Exercise has a lot of benefits on the whole, but patients who have undergone transplant surgery
benefit greatly from getting active (Conlon et al, 2016). Recipients are not limited to only taking
an occasional walk. Rather, depending on the age group, they have a wide range of sports to choose
from which many patients compete at a high level at the annual Transplant Games. Transplant
patients range of motion is usually hindered after surgery but exercises and participation in
sporting activities have shown to have improved physical function. Dialysis and kidney disease
leaves the muscles feeling weak and deteriorate the bones, even after surgery some lingering
effects of this still remains but exercise improve muscle strength, develop stronger bones, control
body weight and lower level of blood fats. What is important to note is that transplant surgery
comes with a risk of cardiovascular issues the best way to reduce risk of getting a cardiovascular
disease is to regularly participate in exercise activities. Exercise not only gets the blood flowing in
the body allowing increased oxygenated blood to flow to the tissues but it also releases chemicals

25
such as such as endorphins in the brain which helps reduce stress, depression and helps for a better
sleep (Donnelly et al, 2014).

Transplant medications may cause side effects. These side effects may include weight gain and
high cholesterol (Conlon et al, 2014). An organ transplant provides the patient with a fresh start at
life, physical activity is needed in order to ward off the side effects associated with the
immunosuppressive drugs that have to be taken but many patients finds it psychologically difficult
to participate in psychical activities post-transplant (Burra and De Bona, 2006). According to
(Conlon, 2016) exercise is imperative for organ transplant patients because eating more due to the
medications they are on and exercising less will cause the body to have a high levels of
triglyceride, cholesterol and glycaemia in blood values causing fat to develop around the waist,
this is known as metabolic syndrome as well as chronic cardiovascular illnesses. The
recommended training session for patents who had a solid organ transplant is usually aerobic
exercise for thirty to forty minutes three to six times per week depending if the patient’s decides
to use a stationary bike or walk. The recommended strength program is twice a week, they claim
patients should do two sets of twenty repetitions using thirty-five percent of the maximum weight
they can lift. Exercise is not only healthy and a possible way to improves on the quantity of time
the patient may last, but it improve the quality of life for patients both physically and mentally
(Burra and De Bona, 2006).

According to Nichols (2014) most heart transplant patients can return to normal activities after
their transplant but less than 30% return to work for varying reasons. High-intensity exercise was
deemed safe and more effective for heart transplant patients compared to moderate training, as the
effect on exercise capacity and blood pressure control is superior to moderate-intensity training

The body relies on the lungs to bring oxygen into the body and to remove carbon dioxide. If the
lungs start to lose the ability to function properly this reserve air will no longer be there, what will
happen is a reduced tolerance to exercise and other strenuous activities (American Thoracic
Society, 2016). Before being considered for a lung transplant, patients on the waiting list are
required to participate in pulmonary respiratory training before the transplant at very low intensity
as this helps to improve breathing, helps the patient tolerate the surgery and above all the patient
will feel better while waiting to get a transplanted lung (American Thoracic Society, 2016).
According to the Transplant Physiotherapy Team (2017) patients can and should participate in

26
exercise programs such as low impact aerobics, yoga and biking, also they can participate in sports
such as swimming, badminton and tennis less than three months after the transplant. Three months
after the surgery patients can step up to high impact aerobics, running, heavy weight lifting and so
on.

Table 1. Activity level after transplant (Adapted from Bellizzi et al., 2014)

After organ transplantation, many recipients believe they will get hurt or feel uncomfortable
exercising. However, it is more likely that regular exercise, especially aerobic exercises after an
organ transplant is not just safe but may significantly reduce risk of disease, while improving

27
recovery (Romano et al, 2012). Furthermore, after a transplant, regular exercise may help boost
energy levels and increase strength, thereby assisting in maintaining a healthy weight, reducing
stress and prevent common post-transplant complications such as hypertension and
hypercholesterolemia (Mayo Clinic, 2016).

Exercise is very important after an organ transplant and each recipient is recommended to get at
least thirty minutes of exercise in at least five days a week. If time is an issue the workout can be
broken up into 10 minute exercises throughout the day (Weahner, 2017). According to Schmidt,
Biwer and Kalscheuer (2001) short bouts of exercises separated throughout the day provide the
same effect as continuous exercise. The aim of the researches was to compare different groups of
exercises. The results came back that whether a person does thirty minutes of exercise once a day,
15 minutes of exercise twice a day or ten minutes of exercise three time a day the progress they
made were the same. Furthermore the only time someone needs to do continuous exercises is when
they are training for a specific sport as the downfall of the ten minute workout is that it will not
improve a person’s endurance. If short of time all a person needs is ten minutes to spare before
their shower in the morning, during lunch break and just before dinner. There is no need to worry
about burning calories, all that is important is finding a schedule that works. If a person has the
need to do a continuous workout then that can be done on the weekend when they have more time
but there is no need to be sedentary during the week (Weahner, 2016).

2.10.2 Benefits of Exercise

There are four main types of benefits that exercise provides, these benefits may be physical,
mental, social and health. Researchers suggest that those who take part in regular exercise
experiences a difference in their mood (Cekin, 2015). Cekin found those who exercise tend to
show a higher level of self-esteem, happiness and optimism. He further went on to explain the
importance of these factors in the operation of a normal day to day life of the average human, for
example finding a partner, or acquiring a job. Exercise is known to help control body weight, but
exercise also decreases the risk of heart disease by lowering cholesterol and high blood pressure
there by lowering the risk of premature death (Berg and Bradshaw, 2001). Kidney transplant
patients are prone to anxiety and depression (Levenson and Glocheski, 1991) which is known to
contribute to cardiovascular risks (Celano and Huffman, 2011). Furthermore, the quality of life is

28
affected by having to undergo dialysis (Romano et al, (2012). Exercise is known to reduce these
effects and improve the quality of life in kidney transplant patients (Roman et al, 2010).

2.10.3 Why some transplant recipients do not exercise

Following a transplant patients who refrain from exercise initially, is due to their surgery and the
fear of re-aggravating their wound from the surgery (Painter, 1999). A transplant does not only
affect the transplant recipients but it also affect their family, and the because of the family’s fear
of their loved one getting hurt, family members and friends of the patient tend to be overprotective
and encourage the patients to stay away from all strenuous activities (Surgit et al, 2001). Many
transplant professionals are not believers of exercise either therefore they do not advise patients to
exercise or inform them of the possible benefits (Painter, 1999) which may be because of the
difference in culture and ethnicity or how exercise is viewed in the different societies (Tudor-
Locke et al, 2003). After the transplant wound have properly healed, and the initial fear of opening
the wound is conquered some recipients may still be hesitant to exercise due to them feeling
healthy and as a result do not feel the need to exercise (Romano et al, 2012). There is a lack of
information regarding exercise that is safe for transplant recipients and as a result those who have
received a transplant but is ignorant towards exercise would not feel comfortable venturing into
exercise (Gordon, 2005).

2.11 Conclusion
The literature review explored the world of organ transplant, thereby allowing this current
researcher to acquire the knowledge of the current issues facing transplant recipients as well as
learning about the main organ transplants. It is evident that organ transplants are becoming
increasingly in demand, Due to this increase in demand, and the sheer magnitude of the procedure
those involved in organ transplant are reliant upon, research to help limit the number of transplant
failures is therefore of utmost importance.

A transplant may fail for different reasons, for example premature death due to rejection or being
involved in a car accident, but 50% of transplant failures occurs because of medication non-
adherence (Oberlin et al, 2016). Organ transplant recipients have different factors that affect their
adherence to medication and no one intervention used to promote adherence supersedes another.

29
The transplant-specific medications used are similar amongst all of the organ transplants and the
function of each is profoundly affected by non-adherence. Being forgetful and other elements such
as gender or poor social support seem to be a theme which causes non-adherence. Exercise has its
benefits and is being increasingly promoted in the transplant community. Exercise can help with
possible side effects that may be associated with the medications. But does exercise help with
adherence to medication?

In order to provide answers to this question one has to employ the appropriate research
methodological approach to help collect the appropriate data, which will now be described in
Chapter 3.

30
3.0 Methodology
3.1 Introduction
After completing the literature review in Chapter 2 and understanding the needs of this study,
such as making contact to transplant recipients and getting to know their lived experiences in order
to answer the research questions, Chapter 3 will explore the methodology used to answer the
research questions presented in Chapter 1. Chapter 3 will also detail the steps taken by the
researcher to ensure the methods selected were best suited for the study.

The design of the research was guided by the issues that were illuminated in the Literature Review
presented in Chapter 2. In order to answer the research questions, and meet the aims and objectives
listed in Chapter 1, the best option for the researcher was to use a mixed methodology
incorporating both paradigms, specifically qualitative and quantitative approaches.

For the qualitative study the researcher designed a questionnaire that was issued to transplant
recipients who not only exercise, but also participated in the International Transplant Games. It
was important to speak to them as they have personal real-life experiences of transplant procedure,
and therefore could give credible answers to the research topic “the positive effects of adherence
to exercise and medication after kidney transplant”. Furthermore they gave insights into the
specific research questions in chapter one, for example ‘does exercise affect adherence to
medication?’

Qualitative research is used to record, identify, interpret and understand the feelings and thoughts
of the participant, which will allow the researcher to gain understanding through the participant’s
experience on a certain topic (Austin, 2015). The qualitative component also included structured
interviews, using carefully planned questions to interview persons who are slightly active and
those who are very active.

Finally, the literature reflected that information about specific exercises that can be done by organ
transplant recipients is lacking. One research question seeks to find out if transplant recipients
were prescribed exercises that are suitable for them, and whether or not they would adhere to
completing the exercises prescribed.

31
3.2 Background Research
This research began with the topic “the positive effects of adherence to medication and exercise
after kidney transplant”. In gathering data for this research the researcher began by doing a
literature search relating to ‘the positive effects of exercise and medication after kidney transplant’
in the search engine ‘Google Scholar’. While reading through articles and getting familiarized with
the issue at hand, the researcher then did a search looking into ‘transplant medication’, ‘exercise
amongst all transplant recipients’, ‘the history of transplant’, ‘how a transplant is done’
‘psychology of transplant’ and ‘reasons for non-adherence to medication’. These searches were
carried out by various means, including exploration of the Institute of Technology website, online
libraries and Google Scholar. In addition, books and articles relating to transplants, transplant
sports and transplant medication were sourced via the Institute of Technology, Tralee library and
online articles sourced by the Institution.

3.3 Choosing a Methodology

Following an in-depth literature review, research carried out by Hedayti et al. (2017), Rodique et
al. (2013) and Bellizzi et al (2014) helped to guide this study. In order to gather data Hedayati and
his colleagues (2017) constructed a questionnaire aimed at the participant’s adherence practices,
demographics and disease treatment. Rodigue et al. (2013) used interview questions to collect their
data to gather information about ‘physical activity and renal transplant’. The decision made by the
current researcher was to emulate the methods used by Bellizzi et al. (2014) who used a mixed
methodology by incorporating semi-structured interviews and questionnaires consisting of 21
questions.

The appropriate methodology is very important for collecting the correct data needed for a valid
research study. With consideration to the ethical approval granted from the Institute of Technology
Tralee Ethics Committee (Appendix B) and the necessary information needed for this research, a
decision was made to do a mixed method approach. The mixed methods approach gives a
researcher a better understanding of a topic by collecting, analysing and mixing both qualitative
and quantitative data (Creswell, Clark, 2011).

32
According to Minchiello et al, 1995, qualitative conceptual data is concerned with understanding
human behaviour from the informant’s perspective and assumes a dynamic and negotiated reality
while methodological data is collected through participant observation and interviews. Data is
analysed by developmental themes gleaned from descriptions made by informants, with that data
being reported in the language of the informant.

Quantitative research according to Minchiello et al, (1990), is concerned with discovering facts
about social phenomena and assumes a fixed and measurable reality. Data is collected through
measuring, which is then analysed through numerical comparisons and statistical inferences which
is then reported through statistical analyses.

3.4 Qualitative approach

Qualitative research methods are a very effective way of gathering data because by using
qualitative methods, one will engage in elements relating to the research and give an in-depth look
into the matter (Mason, 2002). Qualitative research is widely used as a research method because
it is potentially phenomenological in nature (Schutz, 1976). In order to highlight and explain daily
life experiences and attach proper meaning to them in a systematic and subjective way, one must
consider doing qualitative research (Burns and Grove, 2009). According to Creswell (2007),
qualitative research is a distinct method to explore a social or human problem or phenomenon.
According to McLeod (2001) the closest we can come to understanding human nature and to
achieving a scientific understanding of the human’s world is by arriving at a truth that makes a
difference and opens new possibilities for understanding. The framework of qualitative research
is focused on grounded theory approach (see Section 3.4.2), as it is conceptual thinking and theory
building as oppose to theory or hypothesis (Glaser & Strauss, 1967).

A qualitative approach was adopted because it was important for this research to explore the lived
experiences of the participants who have had an organ transplant, without trying to sway their
answer in any particular direction, hence adapting in some respects, the phenomenological aspect
of qualitative research. The questions within the current study were based on what was read in the
literature, therefore grounded theory guided the gathering of data. This research therefore
incorporated elements of phenomenology, which were guided by a grounded theoretical approach.

33
It is important to understand what phenomenology and grounded theoretical approaches involve,
therefore these are now explained in more detail.

3.4.1 Phenomenology
Phenomenology is the philosophical term that refers to the method of investigating the meanings
of ones lived experiences as they remember them (Husserl, 1931). The term ‘Epoché’ means that
one has to enter a resounding sense of openness to the experience of phenomena they are trying to
understand in its pre-reflective sense. ‘Reduction’ refers to trying to close in on the meaning of the
phenomenon as it appears in the experience being examined (Van Manen, 1990). All experiences
can be studied phenomenologically as the focus of interest is solely on how a lived experience is
remembered. Husserl and his colleagues were responsible for the movement which launched the
movement of phenomenology as a tradition into the 20th century, because of that movement, ethics,
metaphysics and epistemology was replaced as the heart of this philosophy (Heidegger, 1962).

3.4.2 Grounded Theory

Punch (1998) reported that grounded theory is not a theory, rather it is a method, an approach, a
strategy. In the author’s opinion, grounded theory is best defined as a research strategy whose
purpose is to generate theory from data. ‘Grounded’ means that the theory will be generated on
the basis of data; the theory will therefore be grounded in data. ‘Theory’ means that the objective
of collecting and analysing the research data is to generate a hypothesis. The essential in grounded
theory is that theory will be developed inductively from data. Charmaz (2014) added that grounded
theory is focused on inductive strategies for data analysis. It starts with abstract concepts to explain
and understand data. The journey of theory development in grounded theory approach starts and
ends with the data. This journey is best explained by the Strauss & Corbin (1998) who stated that:
‘Data collection, analysis, and studies that incorporate grounded theory approach are basically a
step towards conceptual thinking and theory building rather than empirical testing of the theory’
(p.12). Hence, a qualitative research approach is used in these types of studies. Specifically it is
conceptual thinking and theory building, which may explain why researchers usually are going to
conduct an inductive, constructivist ‘Grounded Theory’ approach. As it is the systematic
development of theory in social settings, it depends upon inductive approaches which is
appropriate for the studies which focus on theory development (Glaser & Strauss, 1967).

34
3.4.3 Interview Questions
According to Cavana and his colleagues (2001) “Interviews provide a unique opportunity to
uncover rich and complex information from an individual’ (p. 138). They went on to highlight the
different modes used to collect data. Data can be collected by using interviews by way of using
structured, semi-structured, open-ended, face-to-face, telephonic, one-to-one, computer-assisted,
and focus group interview. An interview allows the participants to divulge more information about
a question and gives the researcher a better understanding through what the participant says as well
as the demeanour exhibited while speaking (Austin, 2015).

The interview questions in the current study were designed based on the research questions
presented in section 1.4 and based on the literature review seen in chapter 2. These topics sparked
questions such as, have you ever missed a dosage of medication? What side effects have you
experienced since the transplant? Do you exercise and how often?

While reading articles that are related to non-adherence after kidney and other organ transplants,
what became evident included the following questions areas: a transplant comes with a life-style
change that recipients and their family have to adapt to; The medications can cause side effects;
taking medications at a specific time every day may take its toll on some; and there could be
lingering effects from dialysis and or the kidney disease and recovering from the surgery may be
harder for some more than others (Denhaerynch et al, 2006, Nevins, et al, 2017; Bechstein, 2000,
Mudge, 2016, Williams, Manias, Gaskin and Crawford, 2014, Chisholm-Burns, 2013 and
Hardstaff 2002, 2003).

Questions regarding exercising after transplant and its impact on the recipients were conducted
based on the research questions in Section 1.4 (such as does exercise affect adherence to
medication) and based on the Literature Review chapter in Section 2.9.1 focusing on exercise after
a transplant and section 2.9.5 involving the benefits of exercise. These questions included ‘has
exercise helped you in any way after transplant?’, ‘have you ever missed a dosage of
medications?’, ‘what changed the most in your life after transplant?’ and ‘do you exercise and how
often?’ The full list of interview questions can be found in Appendix C.

35
3.5 Quantitative research
Quantitative research methodology is used by natural and social scientists to analyze data by using
statistical, mathematical, or computational techniques (Given, 2008). Quantitative research is used
to gather the view of a population by analyzing the views of a sampled portion of the population
being studied (Allen, 2017). A quantitative research approach is an important tool used to
understand how frequently a phenomenon occurs in a population (Allen, 2017). In order to collect
quantitative data a researcher may elect to use survey questions specific to the research in order to
get a large number of respondents to analyze the views of a section of the population (Cameron
and Carson, 1989). A method of analyzing quantitative data, and a popular choice by researchers,
is to use a program known as Statistical Package for the Social (SPSS) (Bryman and Cramer,
2011). It was this SPSS package using cross tabulations and frequency tables that was used to
process the data gathered in the current study.

3.5.1 Sourcing and Sampling

The participants for this research involved primarily kidney transplant recipients. The researcher
had a gatekeeper for gaining access to the participants, specifically the Head of the Irish Kidney
Association who invited the researcher to a Kidney Transplant Wellness Seminar. This provided
the opportunity for the researcher to conduct the pilot study for the research, while also gathering
contact information for those who were willing to participate in the research for the main body of
the study. The researcher then attended the European Transplant and Dialysis Games in Sardinia
Italy, where the primary data collection took place. The participants for the survey questions
(N=44) included kidney, liver, lung and pancreas transplant recipients. The interviewed
participants (N=15) were all kidney transplant recipients. These participants were all somewhat
active to very active. As seen in Table 3.5 being somewhat active refers to someone who goes for
at least a thirty minutes’ walk once a week to one who takes a light jog twice a week.

The total number of participants who took part in this survey was 51, but only 44 (N=44) surveys
were used for use in the research as some question sheets were not returned to the researcher.
Thirty eight were completed at the 2018 European Transplant and Dialysis Championships in
Sardinia, Italy (N=38), with the remainder being completed though phone calls (N=6) and the data
for this survey was analysed using the software known as Statistical Package for the Social

36
Sciences (S.P.S.S). Each question was added in variable view by typing word/s that represented
the question and the answers were added by clicking on value and by adding a number and the
answer which the number represented.

3.5.1.1 Limitations of Sample

The data for this research was collected in a competitive environment at the European Transplant
Games, therefore it was possible that the participants were potentially in a different mind-set,
focusing primarily on the event they were competing in, which could sway their answers in a
particular direction. The fact that the interviews took place during the Transplant Games, meant
that potential distractions may have been present. The limitations were outweighed by the merits
of ecological validity. Furthermore, the Games presented the researchers optimal chance to collect
the data due to finance, time allotted to the research and opportunity to source a large cohort of
organ transplant recipients.

3.5.1.2 Delimitation of Sample

The research set out to find the positive effects of exercise. By collecting the primary data in a
competitive environment (ensuring ecological validity) the researcher could observe the effects of
exercise on the participant while collecting the data. The researcher ensured that the interview and
questionnaire completion occurred after participants had finished competing and were in a relaxed
state, thereby ensuring the researcher did not impede on the athletes mental race preparation. In
addition having the interviews post event meant the answers were not rushed and the participants
were not distracted by pre competition nerves.

Participants:

The following information relates to the participants (N=44) who took part in this research, namely
their demographics, country of residence and type of transplant. 27 of the surveys were completed
in the presence of the author, while 17 of the participants did the survey alone.

Table 2. Participants in the survey demographic

Question Response Percentage

Country Ireland 59.1%

37
 Hungary 13.6%
Germany 9.1%
Spain 2.3%
Finland 4.5%
UK 9.1%
Bosnia 2.3%

Gender Male 45.5

Female 54.5
Age 20-32 27.3
33-45 18.2
46-55 31%
55-65 15.9%
>65 6.8%

The participants in this research are from seven different European counties. The participants
reside in Ireland (59.1%), Hungary (13.6%), Germany (9.1%), Spain (2.3%), Finland (4.5%),
United Kingdom (9.1%) and Bosnia (2.3%). This International cohort provides the research with
invaluable insight, providing perspectives from the different cultures and regions.

The demographics for this research consisted of females (N=24) and males (N=21).
The participants in this survey were between the ages of 46-55 years old (31%), 20-32 (27.3%),
22-45 (18.2%), 55-65 (15.9%) and over 65 (6.8%).

38
Figure 7. Participant’s transplant type.

As shown in Figure 9, the participants in this survey had the following transplant: kidney transplant
(63.6%), liver transplant (29.5%), and had a heart transplant, lung or pancreas transplant (2.3%).

Table 3. Defines the different activity levels associated with this research with reference to Bellizzi
et al (2010).

Intensity Type exercise Days per Time

week
Non-active none none none

Somewhat Low intensity 1 to 2 days >30 minutes

active (walking, light jog)

39
 Golf 1 to 2 days 30 to 60
minutes
Weight training 1 to 2 days >30 minutes

Active Cardiovascular 3-4 days 30 to 60

exercise (jogging) minutes
Low intensity 3-4 days 30 to 60
(moderate jog) minutes
Sports 3-4 days 30 to 60
minutes
Weight training 3-4 days 30 to 60
minutes
Cycling 3-4 days 30 to 60
minutes
Golf 3-4 days 30 to 60
minutes

Very active Sports (football, 5-7 days >60 minutes

running etc.)
Weight training 5-7 days >60 minutes
Cycling (high 5-7 days >60 minutes
intensity)

Table 3. Activity level rating

40
3.6 Pilot Study
The participants were a mixture of active and non-active kidney transplant recipients. Seven
participants (N=7) took part in the pilot study for this research. Codes were allocated to ensure
anonymity.

The pilot interviews had questions relating to demographics, questions relating to the transplant
such as what type of transplant they had, how long they stayed in the hospital after transplant and
how long it has been since the transplant. The pilot questions also targeted the participant’s
adherent behavior. Questions referred to the amount of medications they take and whether or not
they have missed a dosage of medication since the transplant as well as what helps with adherence.
While on the subject of adherence there were questions relating to ‘what helps you adhere to your
medications’ and ‘what you regard as the worst part of taking the medication’. The remainder of
the questionnaire focused on the exercise practices of the participants such as exercises done before
and after transplant, the type of exercises they participate in and for how long. See Appendix D
for the full listed pilot questions.

While conducting and analyzing the pilot questionnaire, the decision was made to make a few
changes to the questionnaire. For questions, ‘nothing’ had to be added to several questions and
questions such as ‘how long after your transplant before you missed a dosage of medication’ were
discontinued. These changes were made because some questions were getting constant answers
that were not an option in the list of answers.

The pilot gave validity to some claims found in the literature such as the type of medications
transplant recipients are required to take as well as methods used to remember when to take the
medication. Interestingly, the researcher witnessed a transplant recipient’s alarm going off as a
reminder to take his medication during their time with the researcher.

The participants also gave insights on the side effects they encountered with the medications such
as headache, and weight gain, which supported the literature.

Finally, the pilot suggested that there is a need for planned exercise to help transplant recipients
reintegrate themselves into exercising.

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3.7 Data analysis

3.7.1 Analysing survey questions

The answers for each question in the survey were assigned numbers to match the codes and typed
onto an excel sheet, the codes are set to match the values in SPSS (Appendix E). Once all survey
answers assigned to numbers in Microsoft Excel, they were then copied and pasted into ‘data view’
in SPSS. The data was then analysed by clicking on ‘analyse’ in SPSS, followed by selecting
‘descriptive statistics’, and then selecting ‘frequencies’. Here bar charts were created by dragging
the questions into the variable column. Beside the variable column is a button marked ‘statistics’,
here the researcher selected to have the system give the percentages for each answer. Beneath the
statistics button is one marked “charts”, here the researcher selected to have the system display bar
charts, and finally pressing “OK”. Once the system produced the bar charts, all charts where them
formatted to a chart size of 249.75 in height and 312 in width. The bars were converted to be 48%.

answers reflecting very active behaviour. The bar charts ranging from Figure 4.2.1 to 4.3 had the
colour red assigned to the answer with the highest frequency and purple to the answers with the
second highest frequency. The headings were removed and the labels were converted to normal
font and 8 font size.

3.7.2 Analysing interview questions

The interview questions were typed out verbatim under the appropriate questions (Appendix F).
Open and axial codes were used to represent what the participants were saying extracting the major
idea or ideas from the answers and progressing into the axial codes (Table 4 an Appendix G). The
open codes explain what the axial codes represented. The axial codes from all the interviews were
grouped into one table called “selective coding”, the row with the axial codes was highlighted by
placing the curser at the top of the row, waiting for the curser to turn into an arrow, then left click
to select. Click the A-Z option on “home” tab, select ascending and “ok” (Table 5 and Appendix
H). The axial codes with the same themes were grouped together and arranged in parallel with the
answers which matched them. The selective codes were further broken down by grouping all

42
themes under their appropriate topic or theme (Table 6 and Appendix I). These themes were further
broken down until no further analysis could occur, forming the final ‘general dimension themes’

(Table 7 and Appendix J), which totalled 32 themes. Quotes representing the general dimension

Axial code Open Code Interview

Transplanted Time since 1 year and a half two years in sept (I01)
transplant
years / 1.5

Q. What part of your life would you say changed the most
since your transplant?

Benefit of Changes after No problems everything is good, you have extra energy (I01)
transplant / transplant
Went on walks now and then but I had no energy so couldn’t
Energy
walk but after the kidney I walk and smile as I got my energy
back. (I01)

themes were then used to complete the qualitative analytical process for the purpose of supporting
(or not) the quantitative findings.

Table 4. Phase 1, Interview coding (the first phase of the interview coding process)

43
Table 5. Phase 2, selective coding one (second phase of the interview coding process)

Ability/ Fit I think I’m pretty fit (I06)

Pretty fit I think (I11)
well its good only that I can’t take any supplements so I can’t
improve my body the way I want to I have to avoid protein
supplements and things like that but I think I’m in great shape (I13)
Ah that’s a hard one… I do pretty well, I push my body to limits that
I never thought would be possible. (I14)
Well I can exercise I know my blood count was low when I was on
dialysis so it’s good not to be dealing with that right now but, I am
fitter than when I was on dialysis I can do most things now so I’m
grateful. (I15)
I teach classes I am very fit I am ok with it. (I02)
I’m very fit at the moment I can run marathons in good times so I’m
very happy where I am in that sense I can’t complain with it. (I10)
I can run fast, I think I’m okay and I’m getting even better every
year. (I09)
I am really fit, still think I can be better but I can’t complain with
how well I can cycle, I can cycle a lot of kilometres and that is great
for me. (I08)
Not bad, ah 50 push ups, jogging running, no discomfort I feel good
doing it so what can I say I think I’m in pretty good shape. (I12)
Not bad, ah 50 push ups, jogging running, no discomfort I feel good
doing it so what can I say I think I’m in pretty good shape. (I12)
Ability/ un-fit I’m unfit but mobile. (I04)
I’m not massively fit, I do think I should exercise more (I07)

44
Table 6. Phase 2, selective coding phase two

Ability/ un-fit I’m unfit but mobile. (I04)

/ Fit I’m not massively fit, I do think I should exercise more (I07)

I think I’m pretty fit (I06)

Pretty fit I think (I11)

well its good only that I can’t take any supplements so I can’t
improve my body the way I want to I have to avoid protein
supplements and things like that but I think I’m in great shape (I13)

Ah that’s a hard one… I do pretty well, I push my body to limits that

I never thought would be possible. (I14)

Well I can exercise I know my blood count was low when I was on
dialysis so it’s good not to be dealing with that right now but, I am
fitter than when I was on dialysis I can do most things now so I’m
grateful. (I15)

I teach classes I am very fit I am ok with it. (I02)

I’m very fit at the moment I can run marathons in good times so I’m
very happy where I am in that sense I can’t complain with it. (I10)

I can run fast, I think I’m okay and I’m getting even better every year.
(I09)

I am really fit, still think I can be better but I can’t complain with
how well I can cycle, I can cycle a lot of kilometres and that is great
for me. (I08)

Not bad, ah 50 push ups, jogging running, no discomfort I feel good

doing it so what can I say I think I’m in pretty good shape. (I12)

Not bad, ah 50 push ups, jogging running, no discomfort I feel good

doing it so what can I say I think I’m in pretty good shape. (I12)

45
Table 7. General dimension theme

Fit I’m very fit at the moment I can run marathons in good times so I’m very
happy where I am in that sense I can’t complain with it. (I10)

I think I’m pretty fit (I06)

pretty fit I think (I11)

well I can exercise I know my blood count was low when I was on dialysis
so it’s good not to be dealing with that right now but, I am fitter than
when I was on dialysis I can do most things now so I’m grateful. (I15)

I am really fit, still think I can be better but I can’t complain with how
well I can cycle, I can cycle a lot of kilometers and that is great for me.
(I08)

I teach classes I am very fit I am ok with it. (I02)

“I can run fast, I think I’m okay and I’m getting even better every year.”
(I09)

“Well its good only that I can’t take any supplements so I can’t improve
my body the way I want to I have to avoid protein supplements and things
like that but I think I’m in great shape” (I13)

“Not bad, ah 50 pushups, jogging running, no discomfort I feel good

doing it so what can I say I think I’m in pretty good shape. (I12)

Ah that’s a hard one… I do pretty well, I push my body to limits that I

never thought would be possible”. (I14)

Un-fit “I’m not massively fit, I do think I should exercise more, the transplant is
not a hindrance like… its more my lack of doing it rather than having a
new kidney” (I07)

46
 “I’m unfit but mobile”. (I04)

3.8 Ethical considerations

In society, ethics refers to what the majority of the population would consider normal or the
“norms”, these actions distinguish between what is acceptable and unacceptable behaviours
(Renik, 2011). In research ethics traditionally refers to the researcher being honest about the
findings of the research by not distorting the data. It is important that confidentiality is not breached
at any point, and participants sign an informed consent while having the right to withdraw at any
time (Coghlan and Brannick 2001; Winter and Mubb-Giddings 2001). The ethics of this current
research was governed by the academic guidelines of the Institute Technology, Tralee. This
research was approved as a “minimal risk” research by the Quality Assurance office located at the
Institute of Technology, Tralee. All the participants in this study were informed about the research
and what was required of them as well as their right to withdraw at any time. The participants that
did an interview signed a consent (see Appendix K) form allowing the researcher to record the
conversation and use the information they gave for the purpose of this research only. Given that
the research data was collected in while the researcher was attending the European Transplant and
Dialysis Games 2019, this ensured ecological validity as the data was collected in a real-world
setting (Brewer, 2000).

3.9 Limitations
Although the results from this research supported other reviewed research, it is important to add
that the number of participants in the survey (N=44) was limited and that is not a high enough
number to make a definitive conclusion primarily due to the low number of heart and lung
transplant recipients who participated in the data collection therefore was unable to truly have a
deeper understanding. However it was enough to see a trend therefore giving general indications.

The majority of the participants were kidney transplant recipients therefore the findings most
closely resemble that of kidney transplant recipients, however no significant differences were

47
found among the answers given by kidney transplant recipients and other organ transplant
recipients.

The response to the interview questions were short and to the point, which indicates that the
questions could be a bit vague or could have had other prompts that may have sparked a longer
response. That being said the interviewees did provide enough information that answered the
questions being asked and the themes they gave matched responses found in other articles.

The number small number of heart and lung participants is a direct result of using a random
systematic sampling technique.

3.10 Conclusion
In conclusion, the methodology used in this research was a mixed method study utilizing interview
questions in order to gain insights into the lived experience of transplant recipients and survey
questions to find the frequencies of a particular issue. The results gathered from the methodology
can be found now in Chapter 4.

48
4. Results
4.0 Overview
This chapter contains the results of the survey questions and interviews and is structured as
follows;

The bar charts and Table in section 4.1 are associated with answers from the survey questions and
highlight the participant’s level of exercise (days per week, duration and type of exercise) of the
participants before and after transplant. Table 9 highlights the relationship between the participants
in the survey “before transplant exercise” and “after transplant exercise”. The different exercise
categories (days per week, duration and type of exercise) are then compared to each other to
explore the changes in each category before and after transplant. The exercise categories were then
used to determine the activity level of the participants which is presented in Figure 8. These activity
levels were determined by using the criteria found in Table 3 in the Methodology chapter.

The bar chart in 4.2 data presents results from the survey questions which focused on transplant
medications and adherence. The bar charts in relation to the transplant medication focused mainly
on the amount of medications being taken on a daily basis and how many are specific to the
transplant. The bar charts on adherence present information on whether or not the participants have
ever missed a dosage of medication, what aids medication adherence and what negatively impacts
medication adherence.

The bar chart in section 4.3 is the participants answer to the survey question which focused on
physical limitations felt post-transplant. A list of the bar charts can be found in table 4.0.1.

Table 8. List of bar charts

Number Name
Table 9 Exercising before and after transplant comparison
Figure 8 How active the participants are after transplant
Figure 9 How many medications are you taking currently?
Figure 10 How many are specific to the transplant?

49
Figure 11 Have you ever missed a dosage of medication?
Figure 12 What helps your adherence to your medication?
Figure 13 What do you regard as the worst part of taking medication?
Figure 14 Have you ever experienced and side effects since the surgery?
Figure 15 Does exercise help side effects?
Figure 16 Limitations after transplant

50
4.1.0 Trends in the pre- and post-transplant data.
The survey data was combined for inter-relationship. Below (Table 9) compares the exercise habits
of the participant’s pre and post- transplant.

Table 9. Exercising before and after transplant

Before Transplant % After Transplant %

Days per week
15.9% Never 0%
36.4% 1-2 days per week 25%
34.1% 3-4 days per week 40.9%
13.1% 5-7 days per week 34.1%
Duration
13.6% Zero 0%
13.6% Less than 30 minutes 9.1%
45.5% 30 - 60 minutes 65%
27.3% Over 60 minutes 25%
Type of Exercise
13.6% None 0%
11.4% Weight training 9.1%
11.4% High Intensity 4.5%
38.6% Sports 61.4%
18.2% Low Intensity 25%
6.8% Other 0%

Table 9 above N=44 shows the participants exercising at their best before their transplant and
exercising after the transplant. What is evident in these results is that the 15.9% of participants
who did no form of exercise before their transplant are doing some form of exercise since their
surgery as there are no results for ‘never exercising after the transplant’. Changes can also be seen
in frequency of exercises as well. Exercising 1-2 days a week was at 36.4% before transplant, but
at 25% after transplant, that 11.4% difference can be seen in exercising 3-4 days per week as that

51
number changed from 34.1% before transplant to 40.9% after transplant. The biggest change
between before and after transplant is exercising 5-7 day per week; only 13.1% of the participants,
at their highest level, exercised 5-7 days per week, but after transplant 34.1% said they exercised
5-7 days a week.

52
4.1.1 Transplant recipient’s activity level.

Figure 8. How active are the participants after transplant.

Figure 8 represents the activity levels of the participants based on the combined answers to the
questions “how often do you exercise since your transplant?” “Typically how long are these
sessions?” and “select the workout/s that you participate in”. 43.2% of the participants were very
active, 34.7% of the participants were active and 22.7% were somewhat active.

53
4.2 Transplant medication and adherence

4.2.1 Medication load.

The survey result below highlights the volume of medications transplant recipients have taken on
a daily basis.

Figure 9. How many medications are you taking currently?

Figure 9 (N=44) represents the number of medications the participants were taking at the time of
the study. Most the participants (38%) were taking 7 different medications per day, 13.6% were
on 2 medications and also another 13.6% had to take 6 medications per day. 9.1% was on 1 and 3
medications respectively, 11.4% were on 5 medications daily and the smallest percentage at 4.5%
was 4 daily medications.

54
4.2.2 Transplant specific medication.
To explore participants, knowledge of their medication they were asked to state how many of their
current medications were ‘transplant-specific’.

Figure 10. How many are specific to your transplant?

Figure 10 (N=44) represents the transplant specific medications the participant were on at the time
of the study. The majority at 32.8% only had two medications that was specific to their transplant.
22.7% only had 3 medications that was specific to the transplant, 15.9% had 5 transplant specific
medications, while 11.4% only had 1 medication that is specific. 9.1% had 4 transplant specific
medications. Of the 17 persons (38.6%) who have to take 7 medications a day, only 3 (6.8%) has
all 7 prescribed for their transplant. The remaining 2.3% had 6 medications specific to their
transplant.

55
4.2.3 Adherence to medication regimen.
Figure 20 below suggests that approximately half the respondents have missed a dose of
medication at some point since the transplant.

Figure 11. Have you ever missed a dosage of medication?

Figure 11 (N=44) represents whether or not participants have been non-adherent (see section 1.4
for non-adherence definition) to their medication. 50% of the participants have missed a dosage
and 50% have never missed a dosage.

56
4.2.4 Factors that support adherence
There are factors that may help patients adhere to their medication. The participants response were
as follows:

Figure 12. What helps your adherence to your medication?

Figure 12 (N=44) represents the participants views on factors which aid the participants adherence
to medication. The majority (50%) reported that fear helped them adhere to the medication. 22.7%
adhere to medication for a better quality of life. 11.4% adhere to medication so they can keep on
exercising. 9.1% uses some form of reminder to help their adherence, and for the remaining 6.8%,
adherence is aided by family and friends.

57
4.2.5 Factors affecting adherence.
While there are factors that may help adherence there are also factors which negatively impact
adherence. Some factors which affect these participants are as follows:

Figure 13. What do you regard as the worst part of taking medication?

Figure 13 (N=44) presents what the participants regard as the obstacles to taking medications
(factors that affect adherence). The long term duration and the number of medications are the main
factors reported (29.5%) that the participants regard as the worst part of taking the medications,
20.5% reported it is hard to remember to take the medications and the other 20.5% reported nothing
is bad about taking the medications.

58
4.2.6 Side effects of transplant medication.
Transplant medication may come with side effects which may affect adherence to medication.
These participants were asked about any side effects felt after transplant, and Figure 23 represents
their responses.

Figure 14. Have you experienced side effects since the surgery?

Figure 14 (N=44) represents the side effects experienced by the participants. 36% of the
participants have never experienced any side effects from the medications; 22.7% however
experienced headache, 22.7% experienced weight gain. 13.6% experienced high blood pressure
and 2.3% experienced nausea and tremor.

59
4.2.7 Exercise and side-effects
To explore the question of exercising being linked with positive management of side effects, the
participants were asked if they thought there was a relationship between exercise and the
alleviation of side effects. Figure 24 presents the responses.

Figure 15. Does exercise help with side effects?

Figure 15 reflects the participant’s response to whether exercise help with their side effects or not.
77.3% responded that “yes” exercise may help with side effects. 13.6% responded that “no”
exercise does not help with side effects and 9.1% responded that they are “not sure” if exercise
help alleviate side effects.

60
4.3 Physical Limitation.
Participants were asked if they experienced any physical limitations that discouraged them from
participating in exercise in the first weeks after transplant.

Figure 16 Limitations after transplant.

Figure 16 (N=44) represents types of physical limitations felt by the participants after surgery. The
majority at 45.4% had issues walking after surgery. 31.8% found it difficult sitting up. 9.1%
couldn’t get up off the bed, 4.5% found it hard picking up and object and 2.3% had other limitations
after transplant, however 6.8% reported having no limitations after transplant.

61
4.4 Cross tabulations
To further explore the impact of exercise on kidney transplant recipients and on adherence to
medication, the relationship between different variables were studied by means of cross
tabulations. These were done in order to find the common tendencies of the participants by finding
the link between two questions.

The list of cross tabulations are as follows:

Table 10. The worst part about taking medication and its impact on adherence

Table 11. What helps with adherence and its effect on maintaining adherence.

Table 12. Gender and its relationship with medication adherence.

Table 13. When participants started exercising after transplant versus have you ever missed a
medication?

Table 14. Activity level and its impact on adherence medication adherence

Table 15. Physical limitations post-transplant and its effect on adherence

Table 16. Participant’s activity level versus physical limitations felt after surgery

Table 17. Side effects from medication and if had any effect on adherence

Table 18. The participants responded to whether or not exercise helped with side effects from
transplant medication.

Table 19. Participants activity levels versus side effects from medication

62
Table 10 portrays the possible relationship between what the participants considered was the worst
part about taking their medication and if those reasons might be linked to non-adherence. These
results show that of the participants who felt it is hard to remember to take the medications, 66.7%
reported that they missed a dosage in the past while despite the challenge of remembering to take
the medications 33.3% reported that they never missed a dosage.

N=44 Have you ever Total

missed a dosage
of medication?
Yes No
Worst part Hard to
about remember % 66.7% 33.3% 20.0%
taking Too much
medication medicine
to take % 38.5% 61.5% 30.0%

Long
term % 46.2% 53.8% 30.0%
duration
Nothing
% 55.6% 44.4% 20.0%
Total
% 50.0% 50.0% 100.0%

Table 10. The worst part about taking medication and its impact on adherence

The possible relationship between what the participants considered the worst part about taking
their medication and if those reasons might be linked to non-adherence. These results show that of
the participants who felt it is hard to remember to take the medications, 66.7% reported that they

63
missed a dosage in the past, while despite the challenge of remembering to take the medications
33.3% reported that they never missed a dosage.

29.5% of the participants in this survey (Figure 22) believed they have “too much” medication to
take on a daily basis. Of these 38.5% reported missing a dosage of medication in past, and 61.5%
(8 people, Table 10) reported they never missed a dosage even with the amount being a challenge.
The long term duration these recipients have to take their medications is one of the main factors
which are considered the worst part about taking the medication, 46.2% of these participants have
been non-adherent in the past while 53.8% have been positive with keeping their adherent practices
perfect.

20.5% of the participants claimed they do not consider anything to be the worst part about taking
the medication. Even though they have no problems with the medication, 55.6% have been non
adherent in the past while 44.4% have never missed a dosage. For some of these participants taking
the medication is inconvenient but all know of the importance of the medication in the survival of
the transplanted kidney. This led to the question as to what patients use to motivate them to take
their medications and does it work 100% of the time.

64
Table 11. What helps with adherence and its effect on adherence cross tabulation.

N=44 Have you ever Total

missed a dosage
of medication
Yes No
What helps Fear
your % 63.6% 36.4% 50.0%
adherence Family
to and % 33.3% 66.7% 10.0%
medication friends
Better
QOL % 40.0% 60.0% 22.0%
Exercise
% 40.0% 60.0% 11.0%
Reminder
% 25.0% 75.0% 10.0%
Total
% 50.0% 50.0% 100.0%

Table 11 above shows the link between what helps the participants in this research in their plight
for adherence and non-adherence to medication. 50% of the total number reported that they fear
having complications if they fail to take the medication, and that helps them adhere to their
medication regime. The majority of the participants (63.6%) have missed a dosage of medication
in the past, while 36.4% have never missed a dosage. For those who are motivated by family and
friends, 66.7% have never missed a dose and 33.3% have missed a dose. Having a better quality
of life is also a motivation for some of these participants to adhere to medication, 60% of these
participants have never missed a dose, while 40% have been non adherent in the past. 11.4% of
the total number of participants said exercise helps them with their adherence, of these participants,
60% have never missed a dose of medications and 40% have missed. Some people employ simple

65
methods such as using an alarm to remind them when to take their medications. 9.1% of these
participants use a reminder to help them adhere to their medication. Of these participants using the
help of a reminder, 75% have never missed a dosage while 25% have missed a dose at some stage.

66
Table 12. Gender and its relationship with medication adherence.

N=44 Have you ever Total

missed a dosage
of medication
yes no
Gender Male
% 52.4% 47.6% 47.6%

Female
% 47.8% 52.2% 52.4%

Total
% 50.0% 50.0% 100.0%

The cross tabulation presented in Table 12 explored if there is a difference in adherence of taking
medication between male and female. 48% of the participants were male and of the total number
of males 52.4% have been non adherent at some stage, and 47.6% have never missed a dosage of
medication. As for the females a similar percentage can be found in the opposite effects as 52.2%
of the females in this survey have never missed a dosage of medication and 47.8% have missed a
dose.

67
Table 13. Time participants started exercising after transplant versus have you ever missed taking
medication.

N=44 Have you ever Total

missed a dosage of
medication
Yes No
How long <1month
after % 33.3% 66.7% 20.0%

transplant 1 to 3
% 50.0% 50.0% 36.0%
before you months
start <1 year
% 50.0% 50.0% 22.0%
exercising?
>1 year
% 66.7% 33.3% 20.0%
Total
% 50.0% 50.0% 100.0%

Table 13 represents a cross tabulation between when participants started exercising after transplant
versus non-adherent behaviour.

Of the participants who started exercising less than one month after transplant, 33.3% have missed
a dosage of medication and 66.7% never missed a dosage of medication. Of the participants who
started exercising one to three month/s, but less than a year after transplant, 50% have missed a
dosage and 50% have never missed a dosage. In addition, of the participants who started exercising
over three months but less than one year, 50% have missed a dosage and 50% have never missed
a dosage. Finally, of the participants who started exercising more than one year after transplant,
66.7% have missed a dosage and 33.3% have never missed a dosage. Their level of activity may
also be a factor that affects adherence to taking medication.

68
Table 14. Activity level and its link with adherence medication adherence cross tabulation.

N=44 Have you ever missed Total

a dosage of
medication?
Yes No
How Somewhat
active active % 40.0% 60.0% 22.0%

Active
% 53.3% 46.7% 34.0%
Very active
% 52.6% 47.4% 43.0%
Total
% 50.0% 50.0% 100.0%

Table 14 above is a cross tabulation between the activity level of the participants and their
adherence to medication. Out of 100%, 22.7% are somewhat active, 34.7% are active and 43.2%
are very active.

Of the participants who were somewhat active, 40% have missed a dosage of medication and 60%
have never missed a dosage. Of the participants who were active 53.3% have missed a dosage of
medication and 46.7% have never missed a dosage. Of the participants who were very active,
52.6% have missed a dosage of medication and 47.4% have never missed a dosage.

69
Table 15 Physical limitations post-transplant and its effect on adherence cross tabulation.

N=44 Have you ever Total

missed a dosage
of medication
Yes No
Physical None
limitations % 0.0% 100.0% 7.0%

experienced Walking
% 60.0% 40.0% 45.0%
post-
Sitting
transplant
up % 50.0% 50.0% 32.0%

Getting
off bed % 50.0% 50.0% 9.0%

Picking
up % 0.0% 100.0% 5.0%

object
Other
% 100.0% 0.0% 2.0%
Total
% 50.0% 50.0% 100.0%

Table 15 presents the cross tabulation between the limitations the participant experienced after
transplant and adherence to medication.

The participants who experienced no limitations post-transplant reported that they have never
missed a dosage. As for the participants who had trouble walking, 60% have reported to have
missed a dosage while 40% have not. 50% of the participants who experienced difficulty sitting
up as well as those who had issues getting up off the bed. The participants who had difficulties
picking up and object have never missed a dosage while the participants who had “other”
limitations reported to have been non- adherent on occasion.

70
Table 16. Participant’s activity levels versus physical limitations felt after surgery cross tabulation

N=44 Physical limitations experienced post-transplant Total

None Walking Sitting Getting Picking Other
up off bed up
object
How Somewhat
active active % 0.0% 40.0% 40.0% 0.0% 20.0% 0.0% 22.0%
Active
% 6.7% 53.3% 26.7% 13.3% 0.0% 0.0% 34.0%
Very
active % 10.5% 42.1% 31.6% 10.5% 0.0% 5.3% 43.0%
Total
% 6.8% 45.5% 31.8% 9.1% 4.5% 2.3% 100.0%

Table 16 above is a cross tabulation between the participants activity level and physical limitations
felt after transplant. Out of 100%, 22.7% are somewhat active, 34.7% are active and 43.2% are
very active. Of the participants who were somewhat active, 40% had difficulty walking, another
40% had difficulty sitting up and 20% found it hard picking up an object. Of the participants who
were active, 6.7% had no limitations, 53.3% had difficulty walking, 26.7% had difficulty sitting
up and 13.3% had difficulty getting up off the bed. Finally, of the participants who were very
active, 10.5% had no limitations, 42, 1% had difficulty walking, 31.6% had difficulty sitting up,
10.5% had difficulty picking up an object and 5.3% had other limitations.

71
Table 17. Side effects from medication and if this had an effect on adherence cross tabulation.

N=44 Have you ever Total

missed a dosage
of medication
Yes No
Side None
effects % 43.8% 56.3% 36.0%
from
medication Headache
% 40.0% 60.0% 22.0%
Nausea
% 100.0% 0.0% 2.0%
High
blood % 50.0% 50.0% 13.0%
pressure
Weight
gain % 70.0% 30.0% 22.0%
Tremor
% 0.0% 100.0% 2.0%
Total
% 50.0% 50.0% 100.0%

Table 17 above is a cross tabulation between side effects and adherence to medication. Of the
participants who experienced no side effects from the medication, 56.3% reported they have never
missed a dosage while 43.8% reported they have missed a dosage. Of the participants who have
experienced headaches, 60% have never missed a dosage while 40% reported they have missed a
dosage. Of the participants who experienced high blood pressure 50% reported they had never
missed a dosage. As for the participants who have experienced weight gain, 70% have been non-
adherent to taking their medication since their transplant.

72
Table 18. The participants responded to whether or not exercise helped cope with side effects from
transplant medication cross tabulation.

N=44 Does exercise help side Total

effects?

Yes No Not
sure
Side effects None
from 75.00% 6.30% 18.80% 36.00%
medication Headache
80.00% 20.00% 0.00% 22.00%
Nausea
100.00% 0.00% 0.00% 2.00%
High blood
pressure
50.00% 33.30% 16.70% 13.00%
Weight gain
100.00% 0.00% 0.00% 22.00%
Tremor
0.00% 100.00% 0.00% 2.00%
Total
77.30% 13.60% 9.10% 100.00%

Table 18 represents the answers to whether or not exercise helped participants (N=44) with side
effects. Out of 100% 36.4% had no side effects, 22.7% had headache, 2.3% had nausea, 22.7%
had high blood pressure, 22.7% had weight gain and 2.3% experienced tremor. Of the participants
who have never experienced any side effects, 75% said they believed exercise helped combat the
side effects, 6.3% do not believe exercise had anything to do with why they don’t have side effects,
and 18.3% are not sure if exercise helps. Of the total number of participants who have had
headaches, 80% said that exercise did help in coping with their side effects, while alternatively,
20% said that exercise failed to help with their side effects.

Of the total number of participants who have experienced nausea 100% said exercise helped coping
with experienced side effects.

Of the participants who have experienced high blood pressure, 50% said exercise helped with their
side effects, while 33.3% said exercise did not help with their side effect and 16.7% said they are

73
not sure if exercise helped with coping with the side effects resulting from medication. Of the total
number of participants who have experienced weight gain, 100% said exercise helped with their
side effect. Of the total number of participants who experienced tremor, 100% said exercise did
not help with their side effect. 77.3% of the overall participants said exercise helped with their side
effects, which suggests that exercise does help combat side effects from transplant medications.

74
Table 19. Participants activity level versus side effects form medication cross tabulation.

N=44 Side effects from medication Total

none headache nausea high weight tremor
blood gain
pressure
How Somewhat
active active % 60.0% 20.0% 0.0% 10.0% 10.0% 0.0% 100.0%

Active
% 33.3% 26.7% 0.0% 20.0% 20.0% 0.0% 100.0%
very
active % 26.3% 21.1% 5.3% 10.5% 31.6% 5.3% 100.0%

Total
% 36.4% 22.7% 2.3% 13.6% 22.7% 2.3% 100.0%

Table 19 above represents a cross tabulation between the participants (N=44) activity level after
transplant and the side effects from medication. Out of 100%, 22.7% are somewhat active, 34.7%
are active and 43.2% are very active.

Of the participants who were somewhat active 60% never had side effects, 20% experienced
headaches, 10% had high blood pressure and 10% had weight gain. Of the participants who were
active, 33.3% never had side effects, 26.7% had headaches, and 20% had high blood pressure. Of
the participants who were very active, 26.3% never had side effects, 21.1% had headache, 5.3%
had nausea, 10.5% had high blood pressure, 31.6% had weight gain and 5.35 had tremor.

75
4.5 Interview results
The interviews facilitated an in-depth look at the lived experiences of 15 kidney transplant
recipients (N=15). Initially the interviews were read closely by the author and then were typed out
verbatim. The statements were therein coded as axial codes which were explained by open codes.
Each new point made by a participant was given a new row, with the participant’s pseudonym /
code noted at the end of the sentence, thereby providing the author to keep track of who said what
throughout the entire coding process. All the axial codes from the subsequent interviews were
merged together and added to a table. Similar axial codes were grouped and tabulated along with
the interviews, this was called “selective coding”. Each of the selective codes were then broken
down into one emergent theme that represents the general statement being made by the
participants, this was the final phase of coding, where the data cannot be broken down any further,
a process which produces ‘general dimension themes’.

76
4.5.0 Final thematic themes
This section highlights the final general dimension themes that emerged from the coding process.
The themes along with the questions that prompted the response are seen in Table 20.

Question Theme %
Accomplishment 13%

Psychological Joy 40%

Health (mental)
Benefits of 67%
exercise Health
Physical Fitness
33%
(Physical)
Social Socialization 40%

Energy 53%
Physical Fitness 27%

Sports 20%
Benefits of
transplant Freedom (from
47%
dialysis)
Lifestyle
Normal
33%
Quality of life

Forget 73%
Reasons for
non- Timing 13%
adherence Miss
13%
information

Active 20%
Exercise
Very active 47%
Pre-
transplant Somewhat
27%
active

77
 Non- active 27%

Activity Somewhat
33%
Post active
Transplant Very active 67%

Average
33%
physical
Advance
20%
Transplant physical
limitation
Mental 13%

None 20%

Fit 67%
Ability
Un-fit 13%

Exercise Life style 7%

adherence Team 20%

Time 7%

Exercise Procrastination 7%
Non-
adherence Self-doubt 7%
Injury 7%

Medication
Positive 100%
Coping

Exercise Lacking 87%

Information Not Lacking 27%

78
4.5.1 General Dimension Themes
4.5.1.1 Benefits of Exercise

The participants in the interviews expressed the benefits of participating in exercise as a transplant
recipient. The results are now presented in Table 21. The left hand column presents the theme, the
mid column includes the relevant corresponding quotes and finally the third column presents the
percentage of participants who reported experiencing that theme.

Theme Quotes % of
15
Accomplishment “Since I started exercising I am doing things that I never thought was
possible, like lift heavy stuff around the house and in the gym.” (I05)

“Depending on how long you were on dialysis for you might be

really unfit and mentally drained, so this is a chance to build
yourself back up again, unfortunately I had to do that several times
in my life after the drugs and steroids that I usually take I mean this 13%
is why I was ill all the steroids and ironically I had to be taking
prednisone after the transplant so the kidney doesn’t fail and
calcium tablets to rebuild the bones so yeah I have dealt with a lot
but I’m still here.” (I12)
Energy “Definitely it helps me with energy, help me play with my kids.” (I10)

“It gives me more energy and freedom I can meet people.” (I03)

“Definitely, just walking, I tend to walk to places I normally drive 20%

to.” (I04)
Joy “Fantastic, it’s never lost, no matter if u had a transplant or not it
makes you feel alive.” (I06)

“I feel good when I exercise.” (I08)

40%
“It makes me feel better, gave me a lot of joy.” (I09)

“..And coming to these games being around other transplant people

is fun because you can share experiences and lifestyle so it’s really
good that there is a championship for us.” (I13)

79
 “I would do a lot a cycling it’s fun its relaxing and I can go anywhere
on my bike.” (I08)

“Confidence wise you feel great when you exercise and exercise
make you look good.” (I11)
Fitness “Fitness wise it does help get my fitness up.” (I11)

“I love being fit…” (I12)

“It’s the most important thing in my life because it keeps me fit and I 33%
was sick of getting tired from walking a short distance and now I
know my body can take a lot of pressure so I can push my body to the
limit…” (I13)

“Well, for fitness ah…” (I14)

“Helps my diet as well because the more you exercise is the more
you diet and drink more water, so it helps you that way as well, it
makes you more health conscious because I think if you don’t
exercise you just eat stuff for the sake of eating but when you
exercise you more go for food that will help you achieve your goal.”
(I10)
Health “My blood pressure have been on par for so long (I06) I eat healthy,
I read a lot about health, and I try my best to keep as healthy as
possible.” (I06)

“…Exercise a lot help with my health…”(I13)

“Feel fit, feel healthy when I train never had back pain that other
people my age has, most people just walk but that alone won’t get you
fit.” (I02) 67%

“I mean all the benefits I get from exercising all the people I have
met and the health benefits, makes everything easier.” (I07)

“I would say your physical and mental wellbeing is the main thing
that it helps.” (I15)

“Yeah my general feeling of wellness have improve.” (I05)

80
 “I now have a sense of accomplishment have help my mental health.”
(I05)

“For your mental health, I feel if I am feeling down I can go to the

pool and swim for an hour and I will feel so fresh feeling like a new
person.” (I14)

“My mental health.” (I08)

“It helps me get out, it helps with the conditions, I can hear the birds
sing it helps me to get out…” (I03)

“It’s good for my mental health, if I don’t at least walk around I

start feeling stiff and like crap so have to get out and walk for my
sanity.” (I01)
Socialization “Ah… it definitely makes me feel fresher, it help me socially I get to
meet and talk to people when I exercises so that’s always good…”
(I11)

“It’s helped me a lot, I have met a lot of people through the tennis
club.” (I07) 40%

“These exercise groups get you out of the house and it’s good to not
be alone all the time and being around so many people who are going
through the same thing and everyone is on the same page so you have
people to relate to when you come to games like these and are a part
of the transplant team. These people give you the opportunity to get
your fitness back up and it’s not easy I mean you lose your muscle…”
(I12)

“It give me more energy and freedom I can meet people.” (I03)

“I get to be a part of a team again and you miss that, that locker room
feeling when you’re about to compete, this. The transplant team is
giving you a chance to do that for another 30 years.” (I09)

“I met new friends who understand what I have been through...”

(I09)

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4.5.1.2 Benefits of Transplant
The participants gave insights into how much their lives changed after the transplant. Some
changes they found are presented now in Table 22

Theme Quotes %
Energy “No problems everything is good, you have extra energy.” (I01)
“Just happy to have my energy back since the transplant so I can get
back to what I love to do.” (I02)
“I still lack energy, but I have improved since.” (I03)
“..Have more energy since the transplant.” (I04) 53%
“Got renewed energy, felt significantly better than before.” (I05)
“More energy.” (I10)
“That made it easier to get active after the transplant because when I
noticed I had some much more energy after the transplant I realize I
can do a lot more.” (I11)
“…Also with the transplant for me I see things in different light things
I see vivid colours and the transplant gave me energy to do things…”
(I14)
Fitness “Couldn’t do that 3 years ago…, I did an 8km recently think I’m
really fit.” (I06)
“Definitely my fitness, before I couldn’t do anything active, but now I
can do it all, 6 months before my transplant I could hardly walk 27%
anywhere without being winded because.” (I11)
“I would say your physical and mental wellbeing is the main thing
that it helps.” (I15)
“Yeah my general feeling of wellness have improve.” (I05)
Freedom “Freedom… the ability to exercise the ability to travel and do what I
want where I want when I want, not having to be tied to a dialysis
machine or tied to a dialysis time table.” (I09)
“Since the 2nd transplant I have more freedom… I have more freedom
to go on holidays I can eat what I want, my diet changed because on

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 dialysis you can’t eat and drink a lot of things so yeah it gives me a
far better life.” (I10) 47%
“The first thing is it make you free from having to go to dialysis 3
times a week. Instead of going to dialysis 3 times a week you have to
take immunosuppressive drugs maybe twice a day so noting can
compare to that freedom…” (I14)
“No dialysis, I am free from that so it’s great.” (I15)
“The biggest change was the dialysis, I used the at home dialysis, so
now I can go to bed and wake up when I wish…” (I04)
“The fact I never realize, the effect it would have on my life, the
transfer from one dialysis, I never realise how difficult dialysis was
until I got my transplant.” (I06)
“I had the at home dialysis so had some freedom from that, my diet
got freed up a bit as well I am free in the nights because I had to hook
up on the dialysis machine and run it for 10 hours usually I would
have to fit it when it goes bad and now I don’t have to travel anymore
to fix it when it goes bad.” (I03)
Normal “Now all I have to remember is taking my medications and I can be
as normal as anyone else.” (I08)
“I can live a normal life as a healthy person because I have no
limitations now I can live a normal life I just need to take my
medication and that’s it...” (I13)
“I feel normal like I belong I don’t feel different I’m the same as the 47%
next person.” (I14)
“I do karate every day, train and teach I’m happy I could go back to
what I was doing before I got sick.” (I02)
“Could return to work, could return to work and that was missed.”
(I01)
“Oh god... Em… I don’t really know I was 8 so I just adapted to
having a transplant as oppose to it being a life changing thing, I was
right back to school afterwards I just got on with it.” (I07)

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 “My overall health I was very well I am anaemic, my doctors told me
my kidney lost its function luckily I got a kidney in two weeks’ time so
I didn’t have to go on dialysis so I consider myself very very lucky…”
(I12
Quality “I also have a better quality of life and that is hindered when you are
of life on dialysis as well as it allow you to work…” (I14)
“…I can travel more, hop on a plane without a machine. Its life
changing.” (I06) 33%
“…I can travel more and move around since the transplant.” (I04)
“Have more time to play with my kids, I have 3 young daughters I
have more time to spend with them more energy because before that I
would get tire very easily and my kids didn’t understand why I would
get so tired easily because well they are young so they may feel daddy
don’t want to play with them and I couldn’t really explain to them
what was happening.” (I10)
“Yeah ah my life have changes a lot, I’m thinking more positive about
life because earlier when I knew eventually my kidneys would fail,
and when they failed I had dialysis to worry about.” (I08)
Sports “I was on dialysis but now I can play football I can run I feel really
rejuvenated.” (I11)
“I can do the sports that I want I can live the life that I want so it’s
great.” (I13) 20%
“Like come to the transplant games I do pretty high intensity sports
like tennis, swimming, cycling which are the high intensity events her
at the games and I can do them now…” (I14)
“No, it enhanced my physical wellbeing if anything.” (I14)

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4.5.1.3 Transplant Limitations
The participants were asked “do you find any challenges with physical activities before or after
transplant?” Table 23 represents the physical limitations the participants in this interview
experienced after transplant.

Theme Quotes %
Average “It’s hard to do house work.” (I03)“Well yeah, in the first few days
Physical it was hard to sit up or get up off the bed, but after that I can do
everything I’m doing weight lifting using a lot of weights now so not
limited at all.” (I13) 33%
“Lack of energy.” (I03)
“Well I find it hard to walk, felt like I was well but the scar limited
what I could do.” (I01)
“Only the surgery itself and the effects that it has on you in the
initial stages but after you have recovered from that then the
physical fitness came back and you can do most things again so it
didn’t affect my physical ability.” (I12)
None “No, it enhanced my physical wellbeing if anything.” (I14)
“No I am mindful of the scar but I can do most things.” (I04) 20%
“I don’t think so, I went back to school soon after like normal like a
month after as if noting happen.” (I07)
“Em… No it kinda went well noting specific like, I mean I had to
adapt to having the surgery but em…” (I07)
Advance “Well its good only that I can’t take any supplements so I can’t
physical improve my body the way I want to I have to avoid protein
supplements and things like that but I think I’m in great shape.”
(I13) 20%
“Yes fighting…. Well I can do most of the training but I don’t do
competitive fighting anymore because I don’t want to get kicked on
my kidney.” (I02)

85
 “It’s hard to lift heavy weights and other physical activities had to
stop fighting because I fear someone may damage my new kidney.”
(I02)
“My chest feels tight when I try to do high intensity exercises.”
(I06)
Mental “Not use to taking medications because I travel a lot its
uncomfortable to take the medication on the go.” (I02) 13%

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4.5.1.4 Medication Non-adherence.
Table 24 below represents the participant’s reasons for missing medication.

Theme Quotes %
Forget “What causes me to miss a dose is sometime I forget when I have a
special event or I’m travelling and have to leave earlier in the morning for
example I might forget to take the dosage.” (I08)
“Once since the last transplant I forgot, you know had a night out and
completely lost track of the time and completely forgot about it.” (I10)
“Yeah I have sometimes I’m out and about and didn’t get to take them but
I always try to remember them.” (I15)
“Once maybe twice can’t remember the reason, sometime I fall asleep 73%
early so may miss the evening, I think I’m good at managing my tablet.”
(I06)
“Yeah few times, usually I forget to take them before bed or it’s a bit
late.” (I07)
“Recently I have forgot them but it’s because I changed my job, I’m now
doing shift work I work later in the evening now and I usually take 2 in the
morning and 2 in the evening but due to change in my job I keep
forgetting the evening ones due to the change in time. I don’t think I have
missed more than 4 times overall though.” (I12)
“Yes, it’s hard to maintain the time you have to take it, can’t take loads of
medication in front of people at work, and it’s easy to forget…” (I01)
“Oh yeah…sadly yes I did the transplant 11 years ago and one night me
and my friends went out into the town for a party and I just forgot to take
it then, sometimes you have a change in the normal day to day activities
and you may forget but it didn’t happen much.” (I13)
“Yes, I forgot one morning and I was at work and I couldn’t leave but
over the 12 years that I did the transplant I can count on one hand the
amount of time that I have missed maybe once or twice in the 12 years but
it’s not something I would take very lightly.” (I14)

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 “It’s quite hard to remember and stuff but if you find an easy way to
remember it’s very doable, I mean the pills are small so they are not hard
to take but giving the nature of how you have to take them at a specific
time it is quite hard to remember. I don’t really get side effects maybe just
a little headache here and there but that’s about it.” (I11)
Timing “If I have things that does not fit in my routine if I for example go to a
wedding, but I have a system.” (I03)
“Couple of the evening ones, because of being away teaching or working 13%
out but I take them before I go to bed for sure.” (I02)
Miss- “..I didn’t realize I had to take the cel-cep 12 hours apart so I would take
informed at 10am and 8pm.” (I03) 13%
“…Can’t take loads of medication in front of people at work, and it’s easy
to forget…” (I01

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4.5.1.5 Exercise Pre-transplant.
Table 25 represents the participant’s activity levels.

Theme Quotes %
Very Active “I am more active now, I mean I was active when I was younger
but then I got a bit lazy I did play a lot more football, I played
even when I was sick put it this way I played before the transplant
and I continued after so football was always something I do. When
I was sick if I played 5 a side football I was so unfit I actually
throw up after 5 minutes of playing, but now I can play for an
hour no problem.” (I12)
“Before I played football once a week.” (I04) 47%
“I played football but then I had some knee problems so I went I
started cycling before the transplant and since the transplant I
cycle even more that before.” (I08)
“But before I got sick I played everything, I played football,
hurling, soccer, as long as you could get a medal for it I would do
it.” (I09)
“Not much may play golf here and there.” (I05)
“Yeah I was doing the games when I was on dialysis so like my fist
games were in 2004 when I was on dialysis I was sick when I was
8 so been there for a while.” (I15)
“I swam a lot before but I had to stop when I was on dialysis and
that’s how I got into tennis, I can’t remember fully but it was
about a year or two after transplant before I got back into tennis,
but I would have been massively active as a kid yeah.” (I07)
Active “I always cycled before dialysis not a lot I was doing it because I
was overweight, I think I exercise while on dialysis but don’t
remember but don’t look back, I only think about the future.” (I06) 20%
“I exercise 3 or 4 times a week, I would do a lot a cycling.” (I08)

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 “I did a bit but I couldn’t lift a lot, I could run, but I did what I
could, it obviously wasn’t as much as right now but I stayed as
active as I could.” (I11)
Non-active “No I didn’t, I go into the sport after transplant because my twin
brother got a transplant 3 months before I did so I got to see what
was in store for me after my transplant. He got involved in the
transplant sports and I followed along.” (I13)
“No, I mean I work as a bolder, so the only exercise I got was 27%
lifting heavy stones up all day but that’s about it.” (I09)
“No, I was always interested in sports but when I was sick I didn’t
have much energy but I always keep myself as fit as I could but I
definitely never thought I would be doing cycling at the level that I
am doing it now…” (I14)
“I was too sick to exercise before the transplant, I retired from all
sports at 24 when I was diagnosed and so haven’t done anything
from 24 to 51.” (I09)
Somewhat “I walked a lot while I was on dialysis and did some hiking but I
active would be some very slow pace walking my fitness level was not as
good as it is no.” (I14)
“Went for walks or any other planned activities because well you 27%
can imagine how tiring it is to be lifting stones all day, you don’t
really want to exercise after that just want to get a beer.” (I10)
“House work and a bit of walking while on dialysis, before
dialysis I was busy as a nurse.” (I03)
“Try to walk on the stairs instead of taking the elevator when I go
to work.” (I05)

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4.5.1.6 Exercise Post-transplant.
Table 26 present the participants responses to exercises done after transplant surgery

Theme Quote %
Very “Right now I go to the gym 3 – 4 times a week, some days it will vary from
active weight lifting some card I play football with my lads but I love going to the
gym.” (I11)
“Ah 3 to 4 times a week... at the moment I would do some running 2 days a
week, tennis one day a week and a gym session one day a week.” (I09)
“Like 4 to 5 times a week depending on what competitions I have coming
up so just depends different weeks I would have longer runs, then closer to
a competition I would do shorter faster stuff. I compete in road races,
marathons and on the track I would do the 1500 meters and I train with a
club so I have running mates to go along with. So yeah I’m heavily 67%
involved in this sport right now.” (I09)
“Yeah I do high intensity exercise specific to track and field, I’m just trying
to be a better athlete so I train with a club and do normal training just like
any other athlete 5 to 6 days a week and it varies from gym work and track
work sometimes I will go in the ring and do some throwing.” (I13)
“I play football mainly I do a bit of skateboarding, cycling and some free
running so I’m just enjoying life man.” (I12)
“Yes I would exercise 5 out of 7 days a week…” (I14)
“I exercise 5 times a week I will walk, run, and swim stuff like that.” (I15)
“…Because I do triathlon and training for the virtual triathlon in the
transplant games, in general you need to be doing a discipline every day or
every other day so maybe swimming and cycling I have to do them a least
one day a week.” (I14)
“3 formal exercises and golf 2 days a week.” (I05)
“Now I try to play tennis two times a week but because it’s an outdoor
sport it does vary depending on the weather but I do try to go out twice a

91
 week right now I have a training group that meets twice a week but if it’s
raining noting can be done.” (I07)
“I try for 4 to 5 times per week if weather permits, I play golf twice a week
and power walk when I can.” (I06)
“I do karate every day, train and teach I’m happy I could go back to what I
was doing before I got sick.” (I02)
Somewh “Yes here and there, I go throw my phases I only swim…” (I01)
at active “I walk a little, it depends on the weather or free time. But if I am pushed
to do it I would.” (I03)
“At the moment I try to get out for a good walk 3 days a week, I take the
long walk to the store which may take 45 minutes go to the park or the pier
just to get some. I try to walk as much as I can I don’t have any structured 33%
workout.” (I04)
“Went for walks or any other planned activities because well you can
imagine how tiring it is to be lifting stones all day, you don’t really want to
exercise after that just want to get a beer.” (I10)
“House work and a bit of walking while on dialysis, before dialysis I was
busy as a nurse.” (I03)
“I walked a lot while I was on dialysis and did some hiking but I would be
some very slow pace walking my fitness level was not as good as it is no.”
(I14)
“I try for 4 to 5 times per week if weather permits, I play golf twice a week
and power walk when I can.” (I06)

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4.5.1.7 Physical Ability
The participants were asked to give their opinion on their current physical ability. Their response
was as follows are seen in Table 27.

Themes Quotes %
Fit “I’m very fit at the moment I can run marathons in good times so I’m
very happy where I am in that sense I can’t complain with it.” (I10)
“I think I’m pretty fit.” (I06)
“Pretty fit I think.” (I11)
“Well I can exercise I know my blood count was low when I was on
dialysis so it’s good not to be dealing with that right now but, I am
fitter than when I was on dialysis I can do most things now so I’m
grateful.” (I15)
“I am really fit, still think I can be better but I can’t complain with how
well I can cycle, I can cycle a lot of kilometres and that is great for
me.” (I08)
67%
“I teach classes I am very fit I am ok with it.” (I02)
“I can run fast, I think I’m okay and I’m getting even better every
year.” (I09)
“Well its good only that I can’t take any supplements so I can’t
improve my body the way I want to I have to avoid protein supplements
and things like that but I think I’m in great shape.” (I13)
“Not bad, ah 50 push-ups, jogging running, no discomfort I feel good
doing it so what can I say I think I’m in pretty good shape.” (I12)
“Ah that’s a hard one… I do pretty well, I push my body to limits that I
never thought would be possible.” (I14)
Un-fit “I’m not massively fit, I do think I should exercise more, the transplant
is not a hindrance like… it’s more my lack of doing it rather than 13%
having a new kidney.” (I07)
“I’m unfit but mobile.” (I04)

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4.5.1.8 Exercise Adherence
The participants explained what helped them adhere to exercise. Below are the themes gathered
from their responses, shown in Table 28.

Theme Quotes %
Life style “I feel good when I exercise because I have done it all my life so I need
it, it’s a life style.” (I08)
7%
“I always want to maintain and improve my fitness so I keep to my
program and ensure I stay fit.” (I08)
Team “Yes I would be interested because it would be a nice routine to follow
a routine that’s is for me.” (I03)
“I do follow my program really well because I am in training
I took up the running which just come naturally to me, I mean I find it
challenging but we are used to tough things and having challenges so
nothing new here.” (I10)
“I would rather have a class that I pay for that keeps me honest.” (I07) 20%
“I tend to do exercise when it is a group thing rather than on my own.”
(I07)
“I would rather have a class that I pay for that keeps me honest” (I07)
“I tend to do exercise when it is a group thing rather than on my own.”
(I07)

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4.5.1.9 Exercise Information.
The participants were asked to give their thoughts on the availability of information regarding
exercises for transplant recipients. The themes gathered from their response follow in Table 29.

Theme Quote %

Not “…My brother studying to become a trainer and I am his test subject
from time to time but… ah yeah something structured would be great.”
Lacking
(I01)
“Yes I believe there is enough information I don’t think everyone.” (I08)
“Once you’re involved in it your know about the games and some on, I
mean when I did my transplant maybe they told my mom and she didn’t
want me to get involved in it but, I don’t know I guess most of the
27%
information is in Beaumont and I was in the children’s hospital I mean
there is loads of information now but I suppose I’m in kind of that circle
now being a part of the transplant team Ireland so yeah I’m connected so
I don’t know getting into it how difficult it might be.” (I07)
“I have been doing athletic for 4 years now, when I just started it was
really hard because I never did athletics before so it was pretty hard to
adjust to it but once I did I go to training everyday there is a session and
now it is a big part of my life and I can do as much as an athlete who
didn’t do a transplant.” (I13)
Lacking “No I don’t think so, I never ask to be honest, the dieticians will motivate
me to walk to get down the weight, but my diet helps.” (I03)

“No, I mean from the point of view where you can ask someone and they
87%
tell you.” (I04)

“No… I think there should be more out there for everyone regardless of
their age because I think that is important. Not everyone is willing to risk
anything by exercising especially if they never did it before.” (I12)

95
“No... No em… a lot of people over the country don’t know about the
games or even the association but the more the games go people find out
more about it and I think it’s good for others to join in.” (I09)

“No I don’t think so, because I don’t think everyone that did a transplant
know about these games unless they follow social media and stuff like
that.” (I11)

“Probably not, I did my first transplant in 2000 and I didn’t hear about
the games or exercise anything like that I found out about the games
couple years later so I think there should be more emphasis on giving
people information about exercises, at least give them the information
and leave it up to them to do it but yeah they need to know what can be
done and what kind support is out there so yeah more information should
be given.” (I10)

“No I know from my days as a transplant surgeon that there is not

enough or any for that matter, there is a need for someone to developed
programs to at least give recipients an idea what to do.” (I05)

“No they you should exercise but that’s it, they only mention walking but
that can’t be it a walking is easy. No one tells me any specific exercise
that I can do I have to be proactive.” (I06)

“Well it’s hard to say I don’t know because lot of people did a transplant
in my family so when I did my transplant I could just follow their lead and
choose what I would like to get involved in.” (I13)

“I don’t think there is enough information out there but how I am the way
I work is I push myself to the limit and my body will tell me when to
stop.” (I14)

“No, I’m involve in the local transplant sports group and not everyone
know about it.” (I15)

96
“Well I only found out throw the IKA about the games and such when I
was 19 like I have been planning tennis for year, I never know about these
European transplant games world transplant games and so on, like I
would just train in my local tennis club, I mean I guess they are better at
communicating it now that before.” (I07)

“But a website would be great to tell you what to do.” (I04)

“I find floor exercises great, because of my feet but something planned

will be great so I have something to work with.” (I01)

“They just refer you to exercise but you don’t know when to start and
when you can do certain exercises.” (I04)

“I tend to do exercise when it is a group thing rather than on my own, I

would rather have a class that I pay for that keeps me honest.” (I07)

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4.5.1.10 Exercise Non-adherence.
The participants highlighted factors that may affect their participation in exercise. The factors
can be seen below in Table 30.

Themes Quotes %
Time “But being a surgeon doesn’t allow much time for exercising to be 7%
honest.” (I05)
Procrastination “Because I keep saying I would do is keep saying I will do it
tomorrow, I will do it tomorrow and I would never get done, I
suppose it would be good to have something tailored but I would
have to be in a group setting where I have a specific time and 7%
place to be I would find it better otherwise ill just say “its grand I
will do it tomorrow.” (I07)
“… It’s more my lack of doing it rather than having a new
kidney.” (I07)
Self-doubt “..And they don’t think they are capable of doing it so it would 7%
help significantly.” (I05)
Injury “Yeah I tore a meniscus doing some exercises.” (I05) 7%

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4.5.1.11 Medication Coping
The participants were asked how well they cope with their medications. Their response can be
found below in Table 31.

Theme Quotes %

Positive “Grand no problem, once I remember to take them I’m fine, it has no
adverse effect on me.” (I09)
“Because it is keeping me fit and it’s keeping the kidney working so
it’s no problem. For the first 6 months I had to take everything really
seriously but after I could live a normal life.” (I13)
“Very well, I am use to prescribing these medications to people I
understand why need them.” (I05)
“It’s ok, the medication is no problem to me at all…” (I13)
“Very well…” (I03)
“I mean I’m only on one medication now and I know some people are
on a lot more so it a lot easier for me to take.” (I07) 100%
“I take it as it goes, I am good with the medication.” (I02)
“Eh…very well I don’t see any disadvantage of the medication, I take
them when I should I don’t really have a problem.” (I08)
“Ah...grand, I’m ok with it.” (I15)
“Generally I have been very well, prior to that I was a nightmare when
it take to taking medications but I know the severities of not taking
these tablets. It does make me wonder sometimes though because I am
literally poisoning myself in order to be healthy but I know I have to do
it for the kidney to keep working.” (I12)
“Very well I’m on a very low regimen, I take two tablets and they are
both immunosuppressant one is prograf and the other is cel-cept I’m
on a very minimal dose of that on a daily basis I am very sensitive to
the drugs my body only tolerate a very low dose but I have been very

99
steady my blood pressure have been very steady for the past few
years.” (I14)
“It’s quite hard to remember and stuff but if you find an easy way to
remember it’s very doable, I mean the pills are small so they are not
hard to take but giving the nature of how you have to take them at a
specific time it is quite hard to remember. I don’t really get side effects
maybe just a little headache here and there but that’s about it.” (I11)
“Very well, I have a regime, I carry a pouch with back up meds, to
ensure I have medicines to take, I have everything in a container so it
is available.” (I06)
“Yeah I cope alright, I have a routine, I wake up in the morning I take
a dosage, when I have my first lunch break at work at around 10 I
would take another dosage, I don’t really stick to the 10 and 10 to be
honest when I’m going to bed at.” (I10)
“Eh…very well I don’t see any disadvantage of the medication, I take
them when I should I don’t really have a problem.” (I08)

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 5.0 Discussion
5.1 Introduction

This research began by looking into literature that explored the transplantation process, the organs
that can be transplanted and the challenges faced by the transplant recipients. Background research
then helped us understand the life after transplant, the different types of required medications, their
purpose and possible side effects that may come with them. The next step was to find why
adherence to the necessary medication might be a problem, and what has been done so far to
combat non-adherence. Information relating to exercise and its role with medication was then
explored, as well as noting the overall benefits of exercise. Literature demonstrating the positive
effects of exercise on transplant patients in terms of the overall wellbeing of the individual is
supported by authors such as Burra and De Bona (2006), Conlon, Donnelly and Dunne (2016).
Findings suggesting why the people do not adhere to medication supports research by authors such
as Prendergast and Gaston (2010) and Gottlieb (2000). Information gleaned from previous authors
exploring the subject area guided the current study’s specific research questions and methods.

To date (2020) research regarding the adherence to medication after organ transplant and the
effects of exercise post-transplant have been primarily intervention studies, for example research
by Chislom-Burns (2013), Hardstaff (2002 & 2003) and McDonald, Garg & Haynes (2002). The
current research originally explored the inclusion of a structured exercise programs and monitor
the changes in the subject, however that idea had to be set aside as in order to have a credible
conclusion the intervention would have to be ongoing for at least a year as shown by previous
research in the area. That time-frame was not conducive to the time-frame of the current study.
Incorporating a mixed method approach, the author used both qualitative and quantitative methods
to collect data, giving the author a better understanding of a topic by collecting, analysing and
mixing both qualitative and quantitative data, supporting findings from Creswell and Clark (2011).
The qualitative approach gave the researcher a better understanding of the lived experience of the
participants, which assisted in answering the questions of this research, a theory supported by
Mason (2002).

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Using a mixed methods approach, the researcher employed interview questions for the qualitative
approach and survey questions for the quantitative approach. Participants for the pilot study (N=7)
guided the main body of research involving transplant recipients (N=44) from the European
transplant Games. The pilot showed a link between exercising pre-transplant and post-transplant,
showing that those who exercised before their transplant tend to be more likely to exercise after
their transplant. Those who exercised reported to having no side effects. Furthermore, the pilot
cohort reported that their main reason for non-adherence to medication was that they sometimes
forget to take a dosage, which usually happened when there was a change in their daily routine. A
few changes were made to the pilot questionnaire and the researcher then attended the European
transplant and dialysis games to conduct main study. The results of the interviews were brought
through a rigorous qualitative analytical process to answer the important research questions.

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5.2 Benefits of exercise

5.2.1 Psychological

The expressed benefits the participants proclaimed to have gained from their participation in
exercise included a sense of accomplishment (13%). This was felt by a number of the participants
who took part in exercise. The data suggests that to finish a task one may not have thought was
possible, exercise helps to improve confidence in one’s abilities and this give a better outlook on
life. While for others exercise is fun and they feel a sense of joy (40%) when they exercise. These
themes found in the current research match with the literature, namely Cekin (2015) who found in
his research the benefits the participants gained from exercising were a rise in self-esteem,
happiness and optimism. Though the participants in this research used different words to describe
their feelings, both are relating to the same type of emotions and the same mood. ‘Positive mental
health’ was also a phrase used by the participants in relation to the psychological effects of
exercise. This attribute supports work by Dobbels, Verleden, Dupont, Vanhaecke, De Geest,
(2006) and Bunzel, Laederach-Hoffman, (2000) who spoke about in their literature. These
participants are expressing how exercise helps to manage or eradicate the physiological stressors
that may occur after transplantation, such as anxiety and depression. An unexpected theme in
regards to physiological benefits of exercise after transplant was discovered. This was reported by
one participant who explained that his life before transplant was riddled with bad choices which
led to him needing a transplant, but exercise and participation helped him to rebuild his mindset
and thereby helped in rebuilding his life.

5.2.2 Physical

Being free from dialysis is one of the main benefits the participants in this research enjoy. Based
on the literature, some physical benefits one can gain from participating in exercise are
independent health and fitness (Colman, 2006; Palmer, 2015; Davis, 2017; Gulati, 2010; Gellish,
2007; Whyte, 2008). The participants in this research support this finding. 27% of the interviewed
participants pointed to fitness as one benefit of exercise, which is coupled with the 7% who pointed
to a change in diet as a major benefit that exercise added to their overall health (27%) and
wellbeing. There is a synergistic effect that seems to happen for these participants when they

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exercise; the finding suggest that the participants enjoy the physical benefits that comes from
participation, such as fitness. Furthermore, the exercise aids the participants need for dieting, for
example Interviewee I10 when speaking about exercise said that:

“…Helps my diet as well because the more you exercise is the more you diet and drink
more water, so it helps you that way as well, it makes you more health conscious because
I think if you don’t exercise you just eat stuff for the sake of eating but when you exercise
you more go for food that will help you achieve your goal.”

5.2.3. Social

Socialization was another expressed positive element of being actively involved in exercise
activities. These factors do tie in very well with mental health (27%), as being on dialysis and in
the hospital three days a week for four hours a day, being limited to where you can travel and
limited to what you can eat, may promote depression. Furthermore, the anxiety and lack of energy
that comes with being on dialysis can put a damper on a person’s social life. Therefore exercise
helps to revamp this aspect of the recipients life is seen as a major benefit. For some it is very
impactful for transplant recipients to socialize with other transplant recipients, Interviewee I09
spoke about their participation in the transplant sports “I met new friends who understand what I
have been through”, hinting the benefits and ease of communication one may experience when
conversing with someone who has lived similar tragedies. This is further explained by interviewee
I10 who said:

“These exercise groups get you out of the house and it’s good to not be alone all the
time and being around so many people who are going through the same thing and
everyone is on the same page so you have people to relate to when you come to games
like these and are a part of the transplant team. These people give you the opportunity
to get your fitness back up and it’s not easy I mean you lose your muscle”.

Turner et al (1998), Faser et al. (2002) and Resnick et at (2002) identified that social support is
synonymous with exercise adherence as having someone to share the experience or simply
converse with, can significantly impact the level of enjoyment one has while exercising.

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5.2.4 Pre- Transplant activity/ Active

Recent studies done by researchers such as Anding et al., (2015) Pechter et al (2003) and Chigira
et al., (2017), looked primarily at the effects of exercise while on dialysis and having a structured
program that that can help the patient while undergoing dialysis. The results in these studies show
exercise helped the patients with the issues that come with kidney disease and dialysis such as loss
of muscle strength, mental strains and lack of energy. This current research however was looking
into exercising before transplant and its effect of exercising after transplant. What might be
deduced from the current research is that those who exercise before transplant may be more likely
to return to being active after transplant, as 60% of the participants in the current cohort were
active before their transplant and all retuned to being active after transplant.

5.2.5 Post-Transplant activity

73.3% of the participants who participated in the interview for this research were very active since
their transplant, all participating in something sports related. This result was expected as a large
number of the participants were at the European Transplant Games at the time of the interview.
Exercise disciplines reported that 6.6% of the cohort participated in recreational activities such as
swimming, while 46.7% go on walks as a means of exercise, however only 20% used walks as
their only means of exercises. Some of these participants are very serious about the sport that they
participate in but explained they are limited to how good they can actually be because they do not
take supplements like regular athletes that is seen as a way to get their body to the next level. The
author did not find any specific research that speaks about the type of exercise kidney transplant
recipients usually get into, however literature by Conlon, Donnelly and Dunne (2016) does refer
to transplant sports and how the patients are not limited to what type of activity they can do after
transplant. Perhaps the patient may feel they have a self-imposed limitation given how they felt
after surgery.

5.3 Exercise Adherence/ Non-Adherence

A possible reason why the study’s participants increased their involvement in exercise activities
may be due to their exposure to the respective transplant teams in their countries. They were around
others who have had a transplant and they could see the positive effects other transplant recipients

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are having due to their involvement in exercise and sports, which may be a reason that helps them
adhere to exercise. There was more emphasis shown in starting or continuing sports after transplant
thereby acquiring more achievements and meeting new people, which add to their overall quality
of life. For some exercise and participation in sports is a part of their lives. As Interviewee I08
stated “I feel good when I exercise because I have done it all my life so I need it, it’s a life style I
always want to maintain and improve my fitness so I keep to my program and ensure I stay fit”.
For others having experienced the transplantation process they want to feel normal again.
Therefore they will try to get back to being active as soon as possible, even following a near fatal
illness. No decrease in activity levels were reported in this study, as was shown in Table 9,
therefore it seems that all participants who were active before their transplant, returned to being
active following the transplant. Not everyone shares the love and passion for exercise, therefore
they will have doubts in their ability to take part and that can affect how much they take part in
exercise related activities. Some may know they need to exercise but due to procrastination,
exercising is put on hold.

Some literature reports that factors that affect kidney transplant patients exercising include fear,
the interference of concerned family and friends, and the lack of information from transplant
professionals and culture and ethnic background (Tudor-Locke et al, 2003; Painter, 1999 and
Surgit, O et al, 2001). In this research when asked about the availability of exercise information,
87% of the participants in the interview reported that they believe there is a lack of information
hence supporting the findings in the literature.

5.4 Transplants – the benefits

5.4.1 Physical

The participants in this study identified the physical differences they noticed after transplant. As
expected, participants reported a noticeable increase in energy (53%), supporting literature that
found the symptoms of kidney failure comes with energy loss due to fatigue (Hruska et al, 2008).
It was also not surprising that other themes such as health and the ability to participate in sports
helped with overall fitness, and in turn improved the individual’s wellbeing were some of the main
answers to the changes experienced after transplant. An example can be seen in this quote: “I got
renewed energy, felt significantly better than before” (I05). This renewed energy experienced by
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the participants may have been a factor which drove them to start or restart exercising.
Furthermore, this may also explain why some may not want to exercise as they have been curtailed
by lack of exercise for an extended period of time and even though they feel revitalized, they are
fearful about what they participate in.

5.4.2 Lifestyle

Interviewee I01 described dialysis as a constant hangover, therefore one can understand why when
asked what changed in their life the most after transplant, one of the most popular responses was
freedom from dialysis (47% of the cohort reported this), a finding supported by Romano et al
(2012). Not having to be present at a hospital three days weekly for four hours, or being hooked
to a machine for seven to ten hours per night was embraced, a finding also found in research by
Daugirdas, Blake, and Ing (2014). Not having to be so isolated allows the recipients to feel normal
(33%). Participants explained they get to travel and spend time with family, supporting research
done by Mendonca (2014) and Grinyo (2013) who both found that having a successful kidney
transplant improves quality of life.

5.5 Medication adherence / non-adherence

In this research being non-adherent refer to the participants missing a dosage of medication. 50 %
of the participants in the survey have been non-adherent to medication since their transplant (see
Figure 11) while 73% of the participants in the interview have been non-adherent. Understanding
non-adherent behavior is rather complicated. It is imperative that organ transplant recipients adhere
to their medication in order to maintain a healthy transplanted organ, but not all recipients maintain
a good adherent behavior (Oberlin, 2016). There are several factors that may affect adherence.
According to Nevins et al. (2017), Williams et al (2014), Denhaerynch et al. (2006), Gottlieb
(2000) and Prendergast et al (2010), some factors which may affect adherence includes gender,
medication side effects, complexity of the disease and surgery, forgetfulness and poor social
support. The respondents in the current survey highlighted non-adherence occurred because of the
duration they have to take the medication for (29.5%), the amounts of medication are too much
(29.5%) and forgetting (20.5%). Within the interviews, 73% also reported these factors that

107
potentially affect their adherence. Forgetting due to factors such as change in routine, seem to be
a cause for non-adherence in most of the participants in the interview, as seen in Table 21. Results
also demonstrated that 66.7% of the participants who found it hard to remember to take their
medication have been non-adherent. However, respondents who found the medications to be too
much and are not happy about the life time commitment, 61.5% and 53.8% respectively have never
missed a dosage of medication. On the other hand, some respondents announced they had no
problem at all with the medication, yet in reality, 55.6% have been non-adherent. This result
suggests that having to take the medication is not the only factor that may affect adherence, rather
it is related to the mentality of the person. 50% of the respondents in the survey reported being
well aware of the complications that may arise from non-adherence and they explained the fear of
these complications helps them adhere to their medication. Even though these participants are
fearful of the complications, 63.6% have been non-adherent. This would suggest that
psychological factors are not a primary factor that supports positive adherence, but that those who
take their medication do so because they want to have a better quality of life. Some factors that
may affect adherence to medication include the recipient’s gender, the side effects of the
medication and the effects of exercise, which are now discussed in the following section.

5.5.1 Gender and its impact on medication adherence

Prendergast et al. (2010) and Germani et al (2011) found that men who had an organ transplant
are more adherent to medication than women. The results in Table 12 would differ with these
findings as it showed of the 50% of participants in the survey who have missed a dosage of
medication were equal, with 50% of male and 50% of females reviewed reporting adherence to
medication. This may be due to their participation in exercise, maybe active women are more on
par with men in terms of adherent behavior as their focus is on being as healthy as they can be.
Due to no organ transplant recipient in the survey reporting that they continually missed a dosage,
this may also suggest that men who are active can simply mis-manage their training time which
led to them missing their medication. When asked “have you ever miss a dosage of medication”
I02 (male) responded that “I missed a couple of evening ones, because of being away teaching and
working out but I take them before I go to bed for sure”. These results suggest that gender does
not determine non-adherent behavior.

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5.5.2 Side effects and its impact on medication adherence

Transplant medications may come with side effects such as weight gain, nausea, high blood
pressure, headache and tremor (Kwee, 2017). This research explores the relationship between side
effects and medication non-adherence, 36% of the participants in the survey however have never
experienced any side effects. Weight gain and headaches were the side effects which 22.7% have
experienced respectively. This research suggests that those who experience weight gain as a side
effect from their transplant medication may be at risk of being non-adherent as, of the 22.7% who
have experienced weight gain since their transplant 70% have been non-adherent but, of the 22.7%
who have experienced headaches after transplant 60% have never missed taking medication. Of
the 36% of the participants who have never experienced any side effects 56.3% have never missed
a dosage. This data suggests that side effects may be a small factor that contributes to medication
non-adherence but it may depend on the tolerance the individual has on the specific side effect and
the mindset of the person.

5.5.2.1 Exercise versus the side effects from medication

The chart in Figure 24 represents the participants’ responses as to whether or not they believe
exercise helps counteract the side effects occurring from taking medication. 73% of the
participants reported that exercise positively counteracted side effects. It is important to note that
these participants include those who have never experienced any side effects, hence they may
either believe exercise is a reason why they have no side effects or they are assuming exercise
should help with side effects. According to Hadayati et al (2017), along with eating a balanced
diet exercise is also used to help ward off possible side effects associated with transplant
medication.

This research did a cross tabulation, (Table 19) and found that 22% of participants who are
somewhat active, most (60%) have never experienced any side effects. Of the 34% of participants
who are active, 33.3% have never experienced any side effects and of the 43% of participants who
are very active 26% have never experienced any side effects. These results suggest that transplant
recipients are better off being somewhat active if they want to better their chance of avoiding side
effects. Furthermore, the results also suggest transplant recipients who are active and very active
may actually avoid experiencing side effects. Of participants who have experienced weight gain
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since their transplant, 90% are either active or very active. This suggests the side effects suffered
may have led to the level of activities these participants choose to participant in or these level of
exercise are best suited for dealing with these side effects. These results suggest some side effects
may affect adherence, however, exercise may help some side effects from transplant medications.

5.5.3 Limitations and its impact on medication adherence

Complications associated with transplant surgery may leave the recipient feeling depressed and
may lead to medication non-adherence (Denhaerynch et al, 2006: Nevins et al, 2017). Patients
adapt differently to surgery. A cross tabulation was done in Table 15 to explore the link between
physical limitations such as walking and sitting up, experienced after transplant and medication
adherence. The results suggest that patients who have experienced no limitations after transplant
adhere positively to the medication regimen. The results show that of those who have never
experienced any limitations (6.8%), none of these have ever missed a dosage of their medication.
While the percentage of respondents who have never experienced any limitations is small, it does
suggest that not having that constant reminder of the transplant positively affects the psychological
state of the individual. An absence of obvious limitations also seemed to make it easier for
participants to adhere to their medication because they are not constantly overwhelmed with their
limitations or pain hence they will not have a reason to believe the medication have any negative
impact on their lives. A high number of participants have found it difficult walking (45.4%) and
sitting up (31.8%) after surgery. These limitations following surgery are understandable given the
nature of the transplant as in order to receive a transplanted organ the recipient’s torso has to be
cut open. While understandable in the beginning, any lingering effects of the surgery may impact
the individual’s mental state which may contribute to negative medication regimen adherence
practices. The results in Table 15 showed that of the participants who had a difficulty walking 60%
have missed a dosage of medication since their transplant. As for the respondents who had
difficulty sitting up, 50% have missed a dosage of medication. Therefore, these results would
suggest that transplant recipients who experienced limitations after the transplant have a 50%
chance of being non-adherent, This may be attributable to the patient’s slow adaptation to the
transplant and how well their psyche changes after transplant in terms of their depression and

110
adjustment to life-style changes (Gottlieb, 2000; Martin et al. 2005; Denhaerynch et al, 2006).
These results suggest there is a slight link between some limitations experienced after transplant
and medication non-adherence.

5.5.3.1 Transplant limitations

5.5.3.1.1 Mental

In response to limitations felt after the transplant 26.7% said they felt normal after the surgery with
no noticeable physical limitation, and that they chose to focus on the positive side of having a
transplant such has getting back their energy. There was a level of fear of hurting the transplanted
kidney (6.6%) when doing physical activities, while others reported having trouble adapting to
taking the medications on a day to day basis, describing it as “uncomfortable” (6.6%), while
another 6.6% of respondents adapted to the transplant changes very easily. Adjusting to the
possible physical changes after a transplant can take a mental toll on the individual (Dimartini et,
al, 2008; Denhaerynch et al, 2006; Grover and Sarkar, 2012 and Engle, 2001)

5.5.3.1.2 Exercise vs. limitations

Musumeci (2015) explained that exercise nay have a significant impact on individuals with
physical limitations, by improving an individual’s ability to at minimum, perform household task
such as housework. However being fatigued may negatively affect one’s motivation to exercise.
Exercise may be affected by limitations such as lacking the ability to sit up without feeling pain.
To test if these participants’ activity levels were determined by their experienced limitations, a
cross tabulation was carried out between limitations felt by the participants and participants’
activity level. With reference to Table 16, there were no results to suggest that limitations affected
these respondents participation in exercise. This may be due to the fact that the physical limitations
goes away after a period of time or exercise was used to combat the physical limitations.

5.5.4 Exercise and medication adherence

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At the time of this research (2020) there were no journals found by the researcher that looked
directly at the link between exercise and adherence to medication for transplant recipients. As
stated above, 50% of the participants in this survey have been non-adherent at some point since
their surgery. Of those who have missed a dosage there was an exact same number of male and
female recipients who have missed hence not supporting findings by Germani et al (2011) stating
males are more adherent to medication than females.

To find the link between exercise and adherence, cross tabulations were done to compare questions
addressing exercise behaviour and non-adherence behaviour. One area explored the time after the
transplant when they started exercising. Based on the results in the survey, there are no differences
shown in participants who started exercising one to three months or less than one year after
transplant as they both showed a fifty, fifty adherence to non-adherence percentage. Minimal
differences were shown between those who started exercising less than one month after transplant
and those who started exercising more than one year after transplant. 66.7% of those who started
exercising less than one month after transplant have never missed a dose, and 66.7% of those who
started exercising more than one year after transplant have missed. There were no specific research
papers found that looked at the best time to start exercising after transplant at the time of this
research. The results in Table 13 would suggest that if doctors want to use exercise as an adherence
motivator, it is best to have patients start light exercises less than one month after their transplant.
The reason behind the positive result in those who started exercising less than one month after
transplant may be due to the early changes in their psychological state. What is meant by this
statement is the patient who started exercising early may experience one or two feelings in regards
to their physical state. Some may get a sense of relief. They might be able to comfortably do
exercises which, in turn, may decrease feelings of doubts they may have had about what their
physical condition would be after transplant. This would enhance the realization that they are back
to ‘normal’ and in an effort to maintain that feeling they ensure they do their part and fully adhere
to the medication. The second feeling that may arise is acute anxiety if they cannot complete the
exercise, which may cause or enhance depression which is a factor common for individuals who
have received an organ transplant. The results from this may be linked to non-adherent behaviour.

There were no obvious differences shown in the results which compared the activity levels of the
participants and non-adherent behaviour. Findings show that a small majority of the more active

112
participants being those active and very active (53.3% and 52.6% respectively), non-adherent. The
majority of the participants who were somewhat active (60%) have never missed a dosage of
medication, suggesting encouraging kidney transplant recipients to do light activities is more ideal
in helping them to adhere to their medication.

The findings from this research support the findings in the literature which attest to the fact that
no single method of adherence is more superior to others, being dependent on each individual
patient (McDonald, Garg & Haynes, 2002; Oberlin, Parente and Pruett 2016; Hardstaff 2002,
2003). The results from the current study suggest that there is no concrete link between when one
starts to exercise or how often one exercises and are medication adherent/non-adherent. However
the results do suggest that transplant recipients who start exercising very soon after transplant and
those who stick to a light basic exercise regimen are less likely to be non-adherent. This result
suggest that these participants are more focused on doing what they “need” to do in order to be
healthy, but they are not consumed by their sickness nor are they willing to let their transplant
overhaul their lives.

5.6 Summary
The results in this research highlight factors that may affect adherence to transplant medication.
Of all the causes of non-adherence, ‘forgetting’ to take the medication appears to be the biggest
cause for non-adherence. Other factors include transplant limitations, medication side effects and
the fact that recipients have to take transplant medication as a life time commitment. Furthermore,
taking part in exercise does not assist recipients to remember to take their medication. However,
the side effect and limitations may play a role in medication non-adherence and this research
suggests that exercise does help treat or ward off side-effects and limitations from transplant and
transplant medication. This research suggests transplant recipients would benefit from exercise as
it may positively affect possible side effects from the medications and possible limitations that
may be associated with transplant. However transplant recipients are not required to be very
involved in sports or strenuous exercise in order to stay healthy, doing light work may be best for
positive adherence.

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6.0 Conclusion

In conclusion, there are different factors that may affect adherence to medication and there are
different methods that can be used to help with adherence. What this research suggests is that
having the knowledge about the possible complications of missing medication is not enough of a
motivator for everyone to adhere to their medication. In the beginning this research set out to
answer three questions. Put succinctly, the answers to the questions posed are as follows:

Question 1: Do potential complications associated with transplant affect medication adherence?

The answer to this was that the results of the research suggests that the complications such as side
effects and limitations associated with organ transplant may affect medication adherence.

Question 2: How adherent to medication are transplant recipients who exercise?

Results suggest that judging by the harshest metric (missed a single dosage), transplant recipients
who exercise are 50% likely to be 100% adherent to their medication regimen.

Question 3: Does exercise help curtail possible complications associated with organ transplant?

Findings conclude that exercise positively affects the lives of transplant recipients and helps to
ward off complications associated with organ transplant. The results also suggest that organ
transplant recipients who start light exercises within the first month after their transplant and
continue with participating in light exercise activities have a high chance of being adherent and
more likely to not suffer any side effects from the transplant medications.

6.1 Recommendations

Based on the current research, the following recommendations were made for future research in
the area

1. Socialization and its effects on medication adherence after organ transplant

Socialization appears to greatly impact organ transplant recipients, therefore if transplant
recipients socialise, it may be able to positively impact medication adherence and other
issues associated with transplant similar to exercise.

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 2. Intervention study- Applying a transplant specific exercise program to transplant recipients
and assess their adherence behaviour.
An intervention study could explore whether or not exercise can be linked to medication
adherence by applying an exercise program to transplant recipient’s medication regimen.
This author would suggest that this would need to be a longitudinal study to provide
comprehensive results to determine if the intervention was beneficial or not to the
participant.

3. Time after transplant recipients are most likely to become non-adherent.

By further investigation into the timing that non adherence to medication occurs, for
example the days, weeks or months after transplant, the recipients are more likely to be
non-adherent, then steps may be taken to try and prevent it occurring. This would require
significant numbers of participants to help with ensuring accuracy within the findings.

4. What are the differences shown in transplant recipients who attend transplant based events
and those who do not?
While conducting this research the researcher experienced the Transplant Games
atmosphere and it is something special, where athletes had team support and socialisation
with fellow transplant recipients. It would be interesting to compare the lives of those
participating in the games and those who are not to test for numerous elements, for example
socialisation versus adherence to medication, or exercise levels versus adherence to
medication.

This research explored the effects of exercise on organ transplant recipients. The research proves
that exercise has positive effects on organ transplant recipients, but what the research also proves
is that more studies are needed in the field.

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