"If somebody had told me I'd feel like I do now, I wouldn't have believed them" (qualitative)

Key points

1. 01All participants with arthritic knee pain reported significant reductions in pain and improved function by the end of the trial
2. 02Participants living with persistent low back pain described substantial symptom improvement, with the exception of one person who withdrew
3. 03Group camaraderie, social connection, and the instructor's personality were cited as the strongest drivers of continued engagement
4. 04Participants overcame fear of injury and maladaptive beliefs about ageing through progressive challenge and peer support
5. 05Adherence remained above 90% even when face-to-face classes shifted to home-based training due to COVID-19 restrictions

How it was conducted

Design

Qualitative study using in-depth semi-structured interviews with reflexive thematic analysis, embedded within the BELL pragmatic controlled trial

Participants

28 insufficiently active older adults (13 men, 15 women) aged 59-79 years (mean 68.8 +/- 4.6 years), all Caucasian Australians

Intervention

12-week moderate-to-high intensity group hardstyle kettlebell training: 6 weeks face-to-face (3x/week) then 6 weeks home-based (2x/week) due to COVID-19

Data collection

In-depth semi-structured Zoom interviews conducted 6-15 May 2020, immediately after the intervention period, by the lead author who also delivered the training

Analysis

Inductive reflexive thematic analysis underpinned by critical realism; four higher-order themes constructed from 21 initial broad themes; thematic saturation reached

What they found

• 28 of 32 recruited participants completed at least 6 weeks of training; 4 withdrew (substance abuse/mental health, low back pain, viral infection, uncontrolled hypertension)
• All participants with painful arthritic knees reported significant reduction in knee pain and improved function at the end of the trial
• Every participant living with back pain (except one with a 50-year history who withdrew) described significant improvements in symptoms and function
• Adherence rates remained above 90% during the home-based phase, with every participant recording a personal best on the final training day
• Approximately one-third of participants who commenced training in February 2020 continued training together beyond the intervention period and were still training weekly at time of pre-print publication
• Four higher-order themes emerged: (1) enjoying physical and psychosocial benefits, (2) change in a long-term health condition, (3) overcoming challenges, (4) feeling part of a group/community

Limitations

• The lead author conducted both the training intervention and the interviews, creating a dual role that may have positively skewed participants' responses toward favourable accounts
• Reflexive thematic analysis reflects the researcher's subjective interpretation shaped by their disciplinary and ideological position, which may not fully represent participants' lived experience
• All participants were Caucasian Australians, limiting transferability to other ethnic or cultural groups
• The degree to which individual personality traits influenced results is unknown, and the study cannot account for these as confounders

Why it matters

For patients

Older adults with chronic pain, arthritis, or low back pain may find that supervised group kettlebell training reduces their symptoms and builds confidence for daily activities.

For clinicians

Group-based kettlebell programs with an enthusiastic, participatory instructor appear highly acceptable to older adults across a wide range of health conditions, and may challenge maladaptive pain beliefs more effectively than standard exercise advice.

For readers

This qualitative companion to the BELL trial provides participant-level insight into why kettlebell training achieved high adherence in older adults, pointing to social belonging and instructor quality as key mediators.