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Research and Theory for Nursing Practice: An International Journal, Vol. 29, No.

1, 2015

Korean Immigrant Womens


Physical Activity Experience:
A Situation-Specific Theory
Eun-Ok Im, PhD, MPH, RN, CNS, FAAN
School of Nursing, University of Pennsylvania

Sun Ju Chang, PhD, RN


School of Nursing, Chungbuk National University, South Korea

Giang Nguyen, MD, MPH, MSCE


School of Medicine, University of Pennsylvania

Lynn Stringer, PhD, RN, FAAN


Wonshik Chee, PhD
School of Nursing, University of Pennsylvania

Eunice Chee, BS(c)


School of Engineering and Applied Science, University of Pennsylvania

To develop successful physical activity promotion programs for midlife immigrant


women, especially for Korean immigrant midlife women, concrete theoretical bases
are needed. However, virtually no theoretical frameworks and/or theories exist that
can explain the influences of immigration transition on the physical activity experience of midlife immigrant women in general or Korean immigrant midlife women
in specific. The purpose of this article is to present a situation-specific theory on
physical activity experience of Korean immigrant midlife women (SPAKIM) with its
development process. An integrative approach was used to develop the theory based
on the midlife womens attitudes toward physical activity (MAPA) theory, the transitions theory, a review of the relevant literature, and two studies on midlife womens
attitudes toward physical activity. The proposed theory includes nature of transitions,
nonmodifiable and modifiable transition conditions, contexts of daily life, patterns

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2015 Springer Publishing Company

http://dx.doi.org/10.1891/1541-6577.29.1.10

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of response, and nursing therapeutics as major concepts, and each major concept
includes several related subconcepts. Because several concepts of the theory were
developed mainly based on the literature review, the major concepts and related
subconcepts need to be further developed and evaluated in future studies.

Keywords: nursing theory; midlife women; Asian American; immigrant;


physical activity

ith an increasing number of immigrants across countries, immigration


has become a prominent international phenomenon throughout the
world (Gallup, 2013). Immigrants are vulnerable to various types of health
risks because they tend to earn less income, are more likely to be unemployed or
underemployed, are more likely to live in low-income situations, and are under
tremendous stress by immigration itself (Meyer, Torres, Cermeo, MacLean, &
Monzn, 2003). Also, ethnic minority immigrants, including midlife Korean immigrant
women, have been reported to have an increased risk of cardiovascular diseases,
Type 2 diabetes, obesity, hypertension, and all-cause mortality, which frequently
results in health disparities among the populations (Eyler et al., 1999). Moreover,
midlife Asian immigrants including midlife Korean immigrant women tend to have
central obesity, which is frequently associated with Type 2 diabetes, cardiovascular
diseases, and increased mortality (Crespo, Yoo, & Hawkins, 2011).
Researchers have suggested that increasing physical activity would be a low-cost
way to prevent disease occurrence and the protective effects of physical activity, especially for midlife immigrant women, would be greater than that for other
groups of women (U.S. Department of Health and Human Services [USDHHS],
2013). However, in comparison to nonimmigrants, immigrants are reported to
have much lower rates of participation in health promotion programs, including physical activity promotion programs, because of multiple barriers including
language and communication barriers, cultural beliefs and traditions, and daily
socioeconomic challenges (Huh, Prause, & Dooley, 2007; Meyer et al., 2003). Thus,
researchers have pointed out the necessity of unique physical activity promotion
programs that effectively work for midlife immigrant women (Eyler et al., 1999;
USDHHS, 2009). To develop successful programs for midlife immigrant women,
especially for Korean immigrant midlife women, concrete theoretical bases are
needed. However, virtually no theoretical frameworks and/or theories exist that
can explain the influences of immigration transition on the physical activity
experience of midlife immigrant women in general or Korean immigrant midlife
women in specific.
Im and Meleis (1999) proposed situation-specific theories as a new type of theories that could be ready-to-wear in nursing practice and research. Despite some
argument on the typology of situation-specific theories, situation-specific theories
are the theories that focus on specific populations or to particular fields of practice;
that consider sociopolitical, cultural, and historical contexts of nursing encounters;
and that include blueprints for action (Im & Meleis, 1999). Thus, to develop a theoretical basis that could be used to explain the impact of immigration transition on

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Im et al.

physical activity experience of midlife Korean immigrant women and that could
be used to guide the development of physical activity promotion programs for this
specific population, we aimed to develop a situation-specific theory. The purpose
of this article is to present the situation-specific theory on physical activity experience of Korean immigrant midlife women (SPAKIM) that we developed using the
integrative approach by Im (2005). In this article, the term of Korean immigrant
women restrictively refers to immigrant women having origins in South Korea.
First, the methods used to develop the SPAKIM are briefly explained. Then, the
multiple sources of theorizing used to develop the theory are described. Finally,
the major concepts and subconcepts of the SPAKIM theory and the relationships
among the concepts are presented with the evidence from the reasoning and
theorizing process.

METHODS: THE INTEGRATIVE APPROACH


The development process of the SPAKIM theory followed the integrative approach
by Im (2005). The integrative approach includes several steps that could be cyclic:
(a) checking assumptions for theorization, (b) initiating theorization through
multiple sources, (c) reasoning through critical analyses, (d) documenting theorization, and (e) reporting and sharing theorization. We followed these steps in
our theoretical development of the SPAKIM. First, the assumptions for the theory
development were clarified as suggested in the approach. Then, the phenomenon
(physical activity experience of Korean immigrant midlife women) was explored
using multiple sources of theorizing. Based on the sources, reasoning through critical analyses and theorizing were done to conceptualize the major concepts and to
ascertain the relationships among the concepts. Because more refinement of the
theory would be needed, this article could be the first step in reporting, sharing,
and validating that could be the last step suggested in the integrative approach.
The following sections are organized by these steps suggested in the integrative
approach (Im, 2005).

CLARIFICATION OF THE ASSUMPTIONS


The first assumption of this theorizing process was that diversities and complexities
could exist within the phenomenon of Korean immigrant womens physical activity
experience, and the proposed theory would represent only a part of the diversities
and complexities of the phenomenon. Second, the theory development process was
assumed to be cyclical and evolutionary and occur in specific sociopolitical contexts, which would subsequently limit the application of the SPAKIM theory. Third,
it was also assumed that the uniqueness of Korean immigrant womens physical
activity experience could come from the womens continuous interactions with
their psychosociocultural environment and from the biases that would represent
their and their health care providers perspectives. Finally, the womens physical

The SPAKIM Theory

13

activity experience was assumed to be influenced by ethnicity, race, gender, and


social class that would provide the basis to structure the womens relationships
with others.

THE MULTIPLE SOURCES OF THEORIZING


Korean immigrant womens physical activity experience was explored through
multiple sources: (a) existing theories, (b) an integrated literature review, and
(c) two research studies.

Existing Theories
The midlife womens attitudes toward physical activity (MAPA) theory by Im,
Stuifbergen, and Walker (2010) and the transitions theory by Meleis, Sawyer, Im,
Messias, and Schumacher (2000) were used as a source for developing the SPAKIM
theory. The MAPA theory is a situation-specific theory that was developed based
on a midrange theorythe attitude, social influence, and self-efficacy (ASE) model
by de Vries, Dijkstra, and Kuhlman (1988), an integrative literature review, and the
findings of a research project called the MAPA study (Im, Chee, Lim, Liu, & Kim,
2008). Because the MAPA theory aimed to explain the relationships between midlife
womens attitudes toward physical activity and their actual participation in physical activity, it would provide a comprehensive theoretical framework that could
explain all the related factors that might influence the physical activity experience
of Korean immigrant midlife women. The transition theory, a midrange theory,
was also developed through continuous theoretical works related to transitions,
an integrative literature review, and five research studies. The midrange transitions
theory was chosen for this theoretical work because physical activity experience of
Korean immigrant midlife women would be directly linked to the situational transition that they would experience as a result of their immigration from South Korea
to the United States.

An Integrated Literature Review


In the development of the SPAKIM theory, an integrative literature review was also
conducted by searching multiple databases including PubMed, PsycINFO, and the
Cumulative Index to Nursing and Allied Health Literature (CINAHL). The criteria for
the articles that were included in the literature review were (a) written in English,
(b) published in the past 10 years, and (c) data-based publications. When we searched
the literature related to immigration transition of Korea midlife women using the
keywords midlife, Korean, women, immigration, and/or transition, 255 articles, all
in English, were retrieved and 33 articles met the inclusion criteria. The literature
on factors influencing the physical activity experience of midlife women in general was also searched and included in this review because very few studies were
found specifically on Korean immigrant midlife women. When the literature was
searched using the keywords midlife, women, physical activity, Asian American, and/or

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immigrant, 122 articles were retrieved. Only 69 of these articles met the inclusion
criteria. Thus, 102 articles were included in the literature review. Then, the articles
were sorted according to the major foci of the theory development process. The
major findings of the articles were then analyzed to support specific associations
of various factors to the physical activity experiences of Korean/Asian American
immigrant midlife women.

Two Studies
To develop the SPAKIM theory, we also used the findings from two studies: (a) one
study on attitudes toward physical activity in a diverse sample of American women
in midlife (Study 1; Im et al., 2012) and (b) the other study on Korean immigrant
midlife womens needs for and attitudes toward physical activity (Study 2; Im &
Choe, 2001). The major goal of Study 1 was to explore ethnic differences in attitudes
toward physical activity among four major ethnic groups of midlife women in the
United States, including Whites, Hispanics, African Americans, and Asians. Study
2 aimed to explore womens own needs for and attitudes toward physical activity
among Korean immigrant women in the United States using feminist approach
and transition theory. More detailed information on the two studies can be found
elsewhere (Im et al., 2012; Im & Choe, 2001).

REASONING AND THEORIZING: THE SPAKIM THEORY


The proposed SPAKIM theory includes the nature of transitions, modifiable transition conditions, nonmodifiable transition conditions, contexts of daily life, patterns of response, and nursing therapeutics as major concepts (Figure 1). All these
major concepts basically came from the midrange transitions theory (Meleis et al.,
2000) and were further developed based on the findings from the multiple sources
described earlier.

Nature of Transitions
The nature of transitions includes the types, patterns, and properties of transitions as in the middle-range transitions theory. The transitions that the women
are experiencing include immigration, menopausal, and healthillness transitions.
In the literature, it was also clear that the women were experiencing significant
challenges because of their immigration transition and indicated changes in cultural
norms, socioeconomic status, language, and living environment (Afable-Munsuz,
Ponce, Rodriguez, & Perez-Stable, 2010; Yang et al., 2007). However, other transitions that Korean American midlife women might experience simultaneously
were rarely explored, and little is known about the properties of their transitions
(e.g., awareness of their transitions, their engagement during the transition, etc.).
In Study 2, Korean American midlife women were experiencing immigration
transition. Their immigration transition was sometimes the only transition that they
were experiencing, but most women were experiencing multiple transitions at the

Healthillness
transition

Other related outcomes


Perceived health
BMI

Korean American midlife


womens physical activity
experience
Types, amount, frequency,
and intensity of physical
activity
Needs for physical activity

Patterns of Response

Contexts of Daily Life

Nursing therapeutics:
Evidence-based social marketing approaches
The English as a second language (ESL) curricula-based programs
Web-based programs

Modifiable transition conditions


Attitudes toward physical activity
Self-efficacy
Barriers
Social influences

Nonmodifiable transition conditions


Background characteristics
Health/disease status and
menopausal status

Transition Conditions

Figure 1. The SPAKIM theory.


Note. SPAKIM 5 situation-specific theory on physical activity experience of Korean immigrant midlife women; BMI 5 body mass
index.

Types
Patterns
Properties

Menopausal
transition

Immigration
transition

Nature of Transitions

The SPAKIM Theory


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same time. For example, many of these women were experiencing their menopausal
transitions, and some of them were experiencing a healthillness transition because
of a diagnosis of a chronic disease such as diabetes, hypertension, and so on.

Nonmodifiable Transition Conditions


Nonmodifiable transition conditions influencing Korean immigrant womens physical
activity experience include (a) background characteristics and (b) health/disease
status and menopausal status.
Background Characteristics. The background characteristics that might influence
Korean immigrant womens physical activity experience include age, marital status,
high education, high income, length of stay in the United States, and English proficiency. In Yang et al.s (2007) study, educational level was significantly associated
with less occupational activity and more sport/exercise activity, and marital status
was significantly associated with more sports/exercise activity. In Wang, Quan,
Kanaya, and Fernandezs (2011) study, the more acculturated group was more likely
to be physically active. In August and Sorkins (2011) study, both English-proficient or
limited English-proficient Asian/Pacific Islanders aged 4564 years were less likely to
be engaged in moderate and vigorous physical activity. The literature was also clear
that socioeconomic factors and social norms change from one generation to the next
might lead to higher or lower levels of physical activity (Afable-Munsuz et al., 2010).
In the qualitative interviews included in Study 1, the overarching theme of the
racial/ethnic commonalities in midlife womens physical activity experience was
gender disparities. Because of their gender, the women had certain unique physical activity experience. For instance, a common theme labeled not encouraged
showed gender disparities in physical activity experience. In the womens patriarchal
cultures, womens physical activities were discouraged to preserve their energy for
childbearing and childrearing. In Study 2, Korean American midlife womens needs
for physical activity were significantly different according to several sociodemographic characteristics including family income, education, health/disease status,
language preference, ethnic origin of close friends, self-reported ethnic identity,
and the length of stay in the United States (p , .05).
Health/Disease Status and Menopausal Status. The other nonmodifiable transition condition would be health/disease status and menopausal status. In the study
by Parikh, Fahs, Shelley, and Yerneni (2009), higher physical health scores were
positively associated with physical activity. Also, they reported that better mental
health status was positively associated with greater physical activity. In the study by
Ceria-Ulep, Serafica, and Tse (2011), physical limitations related to diseases such as
hypertension, peripheral vascular disease, arthritis, and diabetes were associated
with physical activity.
In Study 1, the number of menopausal symptoms had a direct effect on physical
activity scores only in Asians including Korean immigrant midlife women (p , .01).
The paths from number of menopausal symptoms to physical activity scores were
mediated by self-efficacy scores in Asians including Korean immigrant midlife
women (p , .01). In Study 2, Korean American midlife womens needs for physical

The SPAKIM Theory

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activity were significantly different according to health/disease status (p 5 .02).


Also, in the qualitative interviews of Study 1, it was obvious that some of the women
participated in physical activity because of their family histories of specific diseases.

Modifiable Transition Conditions


The modifiable transition conditions that may influence Korean immigrant womens
physical activity experience include (a) attitudes toward physical activity, (b) self-efficacy,
(c) perceived barriers, and (d) social influences.
Attitudes Toward Physical Activity. The literature supported that attitudes toward
physical activity could influence physical activity of Korean American midlife women.
Pham, Harrison, and Kagawa-Singer (2007) reported that cultural attitudes toward
physical activity influenced physical activity. The participants considered physical
activity and exercise to be beneficial to the overall health of individuals through
increasing energy and strength, improving physical and mental well-being, promoting
weight loss, and preventing illness. However, physical activity was perceived to
include not only common sports and games but also cooking, household chores,
and yard work. In a study among Korean immigrant midlife women, attitudes toward
physical activity predicted the intention of leisure time physical activity, although
they did not significantly predict the leisure time physical activity (Lee & Im, 2010).
In Study 1, controlling background characteristics and perceived health and
menopause status, the attitudes scores (partial R2 5 .05, p , .01) significantly
influenced the physical activity scores as well. In path analyses, direct paths from
attitudes scores (p , .01) to physical activity scores were statistically significant. In
Asian Americans, attitudes scores (p , .05) were identified to influence the physical
activity scores when controlling background characteristics and perceived health
and menopause status. In the qualitative part of Study 1, all the women across ethnic
minority groups including Korean immigrant midlife women considered physical
activity a luxury because of lack of time and overburdened family responsibilities,
which negatively influenced their actual participation in physical activity.
In Study 2, Korean immigrant womens attitudes toward physical activity were
also found to influence their physical activity experience, and three themes reflecting
the womens attitudes toward physical activity were reported. The themes were
(a) physical activity is certainly different from exercise, (b) full of physical activity
but lack of exercise, and (c) no physical activity during menstruation. The women
perceived that physical activity was a broad term that even included breathing, eating,
and every human activity, and exercise was regarded as a type of physical activity with
an intentional purpose. Subsequently, they described that their daily lives were full
of physical activities such as cooking, cleaning, and laundry; childrearing activities;
educating Korean language and customs; and their work outside the home. However,
the women thought that their work occupied all their time and left them no time for
exercise. Their new work experience outside the home made them overburdened
and did not allow any time for exercise. Finally, Korean American midlife women did
not move their body as much as usual during their menstrual period because they
were usually very tired, sleepy, and emotionally fragile during the period.

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Physical Activity Self-Efficacy. Physical activity self-efficacy could be another


modifiable transition condition that might influence Korean immigrant midlife
womens physical activity experience. In the study by Yang et al. (2007), self-efficacy
was a significant predictor of physical activity among Korean immigrant midlife
women in the United States. Also, in the study by Choi, Wilbur, and Kim (2011),
self-efficacy was a predictor of the time spent in leisure time physical activity.
In Study 1, controlling background characteristics and perceived health and
menopause status, the self-efficacy scores (partial R2 5 .06, p , .01) significantly
influenced the physical activity scores of midlife women from four ethnic groups. In
the hierarchical multiple regression analyses in Asians including Korean immigrant
midlife women, self-efficacy scores (p , .05) significantly influenced the physical
activity scores when controlling background characteristics and perceived health
and menopause status. Direct paths from self-efficacy scores (p , .01) to physical
activity scores were statistically significant across four ethnic groups. Also, paths
from attitudes scores to physical activity scores were mediated partially by selfefficacy scores (p , .01). In addition, self-efficacy scores fully mediated the relationship between level of acculturation and physical activity scores and fully mediated
the relationship between total number of menopausal symptoms and physical
activity scores (p , .01). According to the path analyses in Asians including Korean
immigrant midlife women, self-efficacy scores had direct effects on physical activity
scores (p , .05).
Perceived Barriers. In the literature, perceived barriers to physical activity were
significant factors that influenced physical activity of Korean immigrant midlife
women. Brownson, Baker, Housemann, Brennan, and Bacak (2001) reported that
lack of time, feeling tired, feeling that they were active enough at their jobs, and
lack of motivation influenced womens participation in physical activity. Melillo et al.
(2001) also reported barriers such as fear and a feeling of inappropriateness. Pham
et al. (2007) also reported that, as major barriers to physical activity and exercise,
their research participants cited lack of time and money, language barriers, lack of
information, safety issues, and the lack of space and organized sports programs.
In Study 1, controlling background characteristics and perceived health and
menopause status, the barrier scores (partial R2 5 .04, p , .01) significantly influenced the physical activity scores. In the hierarchical multiple regression analyses
in Asians, the barrier scores were a significant factor that influenced the physical
activity scores. Direct paths from barrier scores (p , .05) to physical activity scores
were statistically significant. Also, paths from attitudes scores to physical activity
scores were mediated partially by barrier scores (p , .05). Barrier scores also fully
mediated the relationship between total number of menopausal symptoms and
physical activity scores (p , .01).
Social Influence. Social influence would consist of the opinion of family, friends,
colleagues, and health professionals but also the general opinion of society (Im et al.,
2010). The influence of family and friends was repeatedly reported to have a
positive influence on physical activity behavior in healthy people. Wallace, Raglin,
and Jastremski (1995) reported that women who joined fitness programs with
their spouses had a higher rate of adherence after 1 year than those who joined

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without spouses. Taylor et al. (2008) reported the importance of peer pressure,
mutual support, and the encouragement of friends in adhering to regular physical
activity regimens among Chinese immigrants.
In the quantitative part of Study 1, however, social influences were not a significant
predictor of midlife women across all ethnic groups, and paths from social influence
scores to physical activity scores were not significant. Only in White women, the
social influence scores were a significant factor that influenced the physical activity
scores (p , .05). Considering Asian cultural heritage that emphasizes family as a
central unit of their society, this finding needs to be further investigated though.
Interestingly, in the qualitative interviews of Study 1, a common barrier reported
by midlife women across the racial/ethnic groups was lack of encouragement and
support and environmental factors. The women reported that they were ready to
be engaged in physical activity if their barriers in their environments and social
influences had been eliminated/minimized.

Contexts of Daily Life


The contexts of daily life would be another important factor that influences Korean
American midlife womens physical activity experience. Taylor et al. (2008) reported
that multiple contextual factors circumscribing immigrants daily life influenced their
physical activity experience (e.g., weather conditions and safety concerns, a lack of
familiarity with their new city, the location of facilities, a lack of organized sports and
leisure activities for immigrants, financial difficulties). Ceria-Ulep et al. (2011) also
reported multiple contextual barriers to physical activity, which included multiple
competing role responsibilities in terms of family obligations, job constraints, and
community responsibilities.
In the qualitative part of Study 1, it was found that the womens daily cultural
contexts influenced midlife womens physical activity experience. Racial/ethnic
minority women including Korean immigrant midlife women were more familyoriented compared to white women and did not participate in physical activity
because of heavy family responsibilities. Especially when Asian immigrant women
had spare time, they spent their time to complete household chores and childcare
rather than participating in leisure time physical activity. Also, in the qualitative
part of Study 1, it was found that Asian midlife women including Korean immigrant midlife women tended to share White womens ideals about beauty, which
heightened their interest in increasing their physical activity to have a slim body.
In Study 2, Korean American midlife womens physical activity experience was
influenced by their immigration experiences in the contexts of their daily life. Despite
a large number of exercise facilities and fitness centers in the United States, the
women rarely had an access to the facilities because of their busy daily lives as
immigrants, financial problems, lack of social support resources and lack of skills
in English, or marginalized social status. Like other immigrant women, Korean
American women lacked social support resources; their extended families, close
relatives, and friends were in their country of origin. Because of the lack of social
supports, the women could hardly find anyone who could support their participation

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in regular exercise. Furthermore, their patriarchal cultural tradition emphasizing


womens roles as mothers rarely allowed them to leave their children behind for
their own physical activity needs.

Patterns of Response: Physical Activity Experience and Other


Related Outcomes
We conceptualized Korean immigrant midlife womens patterns of response related to
physical activity as physical activity experience and other related outcomes. Then,
the concept of physical activity experience was theorized with five subconcepts
including types, amount, frequency, and intensity of physical activity and needs for
physical activity. In the literature, these subconcepts were frequently used to report
research participants patterns of response related to physical activity. In Wong,
Beth Dixon, Gilbride, Chin, and Kwans (2011) study, they used the type, amount,
frequency, and intensity of physical activity to conceptualize physical activity experience and found that 89% of the participants met the recommendation of at least
30 min of moderately intense activity per day. In Crespo et al.s (2011) study, they
measured the total energy expenditure (kilocalories per week), total summary of
physical activity index per week, and total historical physical activity (hours per
year) to conceptualize physical activity experience.
In Study 1, types of physical activity were also important in determining ethnic
differences in physical activity experience of midlife women. The study findings
indicated no significant ethnic differences in the physical activity scores among
the four ethnic groups as a whole. However, significant ethnic differences in the
occupational index of the physical activity scores were observed; Asian American
women had significantly lower occupational index scores than other ethnic groups
(p , .05). Also, in the qualitative part of Study 1, racial/ethnic minority groups
including Korean immigrant midlife women preferred walking or other natural
physical activities over more organized or structured physical activities (e.g., going
to the gym). In Study 2, needs for physical activity were also operationalized as one
aspect of physical activity experience, and the 10 most frequently reported needs for
physical activity among Korean American midlife women were described. The most
frequently reported need was to maintain physical ability (91%), the second was
for leisure (78%), and the third was to increase body metabolism (78%).
Under the concept of patterns of response, the concept of other related outcomes is also theorized with two subconcepts: perceived health and body mass
index (BMI). The MAPA model and the literature (Kahn et al., 2002; Simmons et al.,
1998) supported that enhancing attitudes toward physical activity, self-efficacy,
perceived barriers, and social influences would increase physical activity and would
subsequently enhance perceived health and BMI. For example, a Korean American
midlife woman whose incorrect cultural beliefs related to physical activity are
changed through the educational sessions of a physical activity promotion program
could experience changes in her attitudes toward physical activity, increase her
physical activity, subsequently decrease her BMI (by decreasing her weight), and
enhance her perceived health.

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Nursing Therapeutics: Physical Activity Promotion Programs


The final major concept of the SPAKIM theory, nursing therapeutics, is conceptualized as physical activity promotion programs that can influence modifiable transition
conditions to improve physical activity experience of Korean immigrant women. In the
literature review, we could find three types of physical activity promotion programs
for Asian immigrants in the United States. One of them was evidence-based social
marketing approach suggested by Van Duyn et al. (2007). They found that evidencebased strategies to increase physical activity would need to be adapted for cultural
relevance for each racial or ethnic group. Another type of physical activity promotion
program identified in the literature among Asian Americans was a health education
program that incorporated English as a second language (ESL) curricula (Taylor et al.,
2008). They chose the specific approach because the ESL environment could be ideal
for health education (because immigrants in the ESL classes would be motivated to
improve their knowledge) and the ESL classes could make immigrants obtain health
information within the context of their daily life. Finally, web-based physical activity
promotion programs were identified in the literature. Wanner, Martin-Diener, BraunFahrlnder, Bauer, and Martin (2009) developed and tested a web-based physical
activity intervention in the general online population with positive results. Massoudi
et al. (2010) developed a personal health record application that delivered a highly
individualized, behaviorally based lifestyle physical activity intervention for sedentary
adults, also with positive findings. However, none of these programs was aimed at
Korean immigrant midlife women. Only the intervention that was identified to include
Asian immigrants was the one by Dunton and Robertson (2008), but their intervention
was not tailored to Asian immigrants including Korean immigrants (although they
included Asian immigrants in their study). In Studies 1 and 2, no physical activity
promotion programs were identified; they were descriptive cross-sectional studies
on physical activity experience of midlife women.

CONCLUSIONS
In this article, we presented the SPAKIM theory that could explain the associations
of multiple factors to the physical activity experiences of Korean immigrant midlife
women within the unique contexts of their daily life as immigrants in the United
States. Because of its specificity to Korean immigrant midlife women, the SPAKIM
theory could be easily linked to health care practice and/or research projects related
to physical activity experience of Korean immigrant midlife women. Especially,
the subconcepts of modifiable transition conditions in the SPAKIM could be easily
adopted and targeted in structuring physical activity promotion interventions for
Korean immigrant midlife women. For example, the womens cultural attitudes
toward physical activity (e.g., full of physical activity but lack of exercise) could
be targeted in the intervention development by designing educational sessions
to correct womens incorrect knowledge and perception on physical activity and
exercise embedded in their culture.

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Im et al.

The SPAKIM theory has several limitations. First of all, because the SPAKIM is a
situation-specific theory, it tends to have limitations in its applicability. Thus, this
theory cannot be easily applicable to other target populations without modification
and validation through research and practice in the target populations. Second,
because some concepts of the SPAKIM (e.g., nursing therapeutics) were developed
mainly based on the literature review, they need to be further developed and evaluated in future studies. Through further refinement and validation in additional studies
or in health care practice with this specific population, the theory could be further
strengthened to provide blueprints for actions for promotion of physical activity
in this specific population. Finally, because of the inherent nature of a situationspecific theory (applied to a specific time and place), this theory needs to be viewed
as an emerging theory that needs to be continuously developed and refined with
changes in time and place.

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Acknowledgments. The studies that were used for theorizing process were funded by the
National Institute of Health (NIH/NINR/NHLBI: R01NR010568) and the Sigma Theta Tau
International. No conflict of interest has been declared by the authors.
Correspondence for this article should be directed to Eun-Ok Im, PhD, MPH, FAAN, School
of Nursing, University of Pennsylvania, 418 Curie Boulevard, Philadelphia, PA 19104. E-mail:
eunim@nursing.upenn.edu

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