SCIENCE DISCUSSION(NO PLAGIARISM, A++ WORK, QUALITY, ON TIME)

Science assignment

WEEK 2 PPT

Welcome to Sports Finance

The main thrust of this course is the application of principles and practices of financial management, as it applies to organizations in the sport industry. This course seeks to develop the financial skills necessary to gain an understanding of an array of financial concepts that impact sport managers. Students will examine financial strategies related to sport entities and organizations and will be introduced to current economic and financial issues that impact the sport industry. Included in the course are the basics of accounting, budgets and budgeting systems, performance measures creation, and financial statement evaluation for the purpose of cost analysis and planning. Other topics include budget development, funding, capital projects, economic impact, and supply and demand in the sport industry.

After successfully completing this course, students will fulfill the following Course Objectives (C.O.):

CO1: Explain and evaluate the core areas of finance and accounting in sports business.

CO2: Describe the practical application of sport income and expenditures.

CO3: Investigate the issues regarding public/private financing of stadiums and sports facilities.

CO4: Discuss the economic impact of stadiums and facilities on local communities and hosting sport events and franchise valuation.

CO5: Analyze the sport manager’s position and the environment in which they must perform.

Volatility is the amount of fluctuation that occurs in a series of investment returns and the degree to which those returns deviate from the average. Most volatility translates into greater risk. Time is a factor in risk. Cash today is worth more to an investor than the same case in the future. How is risk measured? Risk is measured according to the level of risk and through the risk of time.

With the COVID-19 pandemic, volatility high been high in most industries, including the sports industry. Sports came to a halt in March of 2020. Having fans in the stands of the stadiums and arenas has been very difficult in 2020 and leagues are searching for alternative methods to recuperate revenue.

Types of Bankruptcy

 

Depending upon the overall health of a company, business bankruptcies can help struggling businesses in one of two ways. Here is a quick explanation of the options under specific chapters:

· When there is no chance of salvaging the business, this chapter allows the business to close in a transparent manner. While any business can use this chapter, it isn’t always the best choice.

· These chapters help businesses stay open by allowing them to make smaller monthly payments to creditors. The type of business determines which chapter the business can file.

The Sole Proprietor

As a sole proprietor, you and your business are one-in-the same, which, in a nutshell, means that you are responsible for all of the business debts. Because of this, both your personal and business finances are part of the bankruptcy and you must include all your assets and debts — both personal and business – when you file. You cannot exclude anything.

The Partnership

Partnerships are trickier, and often bankruptcy doesn’t provide much relief. In fact, a business bankruptcy can be financially harmful to individual partners if not careful.

The Corporation or LLC

Corporate bankruptcies have additional hurdles to scale before any filing can take place. For example:

· A corporation or limited liability company (LLC) must retain an attorney to file on its behalf.

· The bankruptcy can only be authorized by someone with authority to do so (which may be difficult if officers have abandoned the corporation).

Instructions

The final project for this class is a multimedia presentation to the mayor and city council of a city that is trying to entice a National Football League (NFL), Major League Baseball (MLB), National Basketball Association (NBA), National Hockey League (NHL), or Major League Soccer (MLS) team to move to their city. You are the vice president of finance for a consulting firm that has been hired by the mayor and city council to give them a detailed analysis of what it would take to entice a team to move to their city. You are a member of the five person team that will conduct the analysis and make a presentation to the mayor and city council. Your responsibility is to provide the financial analysis for the project which includes the construction of a sports venue to accommodate the team.

For this assignment you will develop a thorough proposal and outline for your presentation. Remember that your presentation must be at least 15 slides. Your proposal and outline must encompass the financial concepts that are covered in this course. Begin your proposal and outline by developing the thesis of your presentation. Describe the thesis then outline it. The outline must contain at least three levels of detail for each major element in the outline. End the outline by writing a brief conclusion which summarizes your presentation. The proposal and outline should also have a reference page with five or more references formatted in APA writing style. The proposal and outline will guide you through developing your presentation.

Bob Stewart. (2007). Sport Funding and Finance. In Sport Funding and Finance. Taylor and Francis.

https://doi.org/10.4324/9780080467023

Mason, D., Sant, S., & Soebbing, B. (2017). The peculiar economics of sports team ownership: Pursuing urban development in north american cities. Sport, Business and Management, 7(4), 358-374. doi:http://dx.doi.org.ezproxy2.apus.edu/10.1108/SBM-10-2016-0067

Marques, A. I., Soares, P., Soares-Miranda, L., Moreira, C., Oliveira-Tavares, A., Clara-Santos, P., . . . Carvalho, J. (2011). Evaluation of physical activity programmes for the elderly – exploring the lessons from other sectors and examining the general characteristics of the programmes. BMC Research Notes, 4, 368. doi:http://dx.doi.org.ezproxy2.apus.edu/10.1186/1756-0500-4-368

Devarajooh, C., & Chinna, K. (2017). Depression, distress and self-efficacy: The impact on diabetes self-care practices. PLoS One, 12(3) doi:http://dx.doi.org.ezproxy2.apus.edu/10.1371/journal.pone.0175096

The peculiar economics
of sports team ownership

Pursuing urban development
in North American cities

Daniel Mason
Faculty of Physical Education and Recreation,
University of Alberta, Edmonton, Canada

Stacy-Lynn Sant
School of Kinesiology, University of Michigan, Ann Arbor, Michigan, USA, and

Brian Soebbing
Faculty of Physical Education and Recreation,
University of Alberta, Edmonton, Canada

Abstract
Purpose – The purpose of this paper is to examine how North American professional team owners are
engaging in broader urban development projects that have their teams as anchor tenants in new sports
facilities, by examining the case of Rogers Arena in Edmonton, Canada.
Design/methodology/approach – Approached from a constructionist perspective, the study employed an
instrumental case study strategy as it facilitates understanding and description of a particular phenomenon
and allows researchers to use the case as a comparative point across other settings (with similar conditions) in
which the phenomenon might be present.
Findings – Using urban regime theory as a framework, the authors found that in Edmonton, the team owner
was able to align his interests with other political and business interests by engaging in a development
strategy that increased the vibrancy of Edmonton’s downtown core. As a result, the owner was able to garner
support for both the arena and the surrounding development.
Research limitations/implications – The authors argue that this new model of team owner as developer has
several implications: on-field performance may only be important insofar as it drives demand for the development;
the owner’s focus is on driving revenues and profits from interests outside of the sports facility itself; and the team
(and the threat of relocation) is leveraged to gain master developer status for the ownership group.
Originality/value – This paper adds to the understanding of owner interests and how franchise profitability
and solvency can be tied to other related business interests controlled by team owners.
Keywords Urban development, Sports franchises, Team ownership
Paper type Research paper

Professional sports leagues in North America provide an interesting context through which
the motivations of ownership can be explored, stemming from unique characteristics that
distinguish leagues from other business models. First, each of the four major
North American professional sports leagues – Major League Baseball, the National
Football League, National Basketball Association, and National Hockey League (NHL) –
acts as a de facto monopoly which allows it to restrict the number of available franchises in
its respective league. One consequence of this structure is the ability of individual team
owners to threaten to relocate in order to gain concessions from their host communities,
which take the form of subsidies and reduced facility rents (Rosentraub, 1999).
This behavior by clubs and cities spawned a wealth of research contesting the value of
professional sports teams and facilities to the communities that host them (e.g. Coates and
Humphreys, 2008; Propheter, 2012). As this paper will show, owners are in a unique

Sport, Business and Management:
An International Journal
Vol. 7 No. 4, 2017
pp. 358-

374

© Emerald Publishing Limited
2042-678X
DOI 10.1108/SBM-10-2016-0067

The current issue and full text archive of this journal is available on Emerald Insight at:
www.emeraldinsight.com/2042-678X.htm

This research was supported by the Social Sciences and Humanities Research Council of Canada.

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negotiating position where they can control the infrastructure development that may occur
in the area surrounding the team’s home facility (Mason, 2016).

Second, the production of the league product requires two separate organizations
(franchises) to combine to play a game, and a series of franchises to play a league schedule
and determine a league championship (Mason, 1999). As a result, a significant body of
research has explored the uncertainty of game outcomes, competitive balance, and the
implications of these core principles for attendance and team profitability. Seminal research
by Rottenberg (1956), Neale (1964), Sloane (1971), El Hodiri and Quirk (1971), and Quirk and
El Hodiri (1974) provided the groundwork for understanding these issues in professional
sports leagues around the world. More recent research expanded on these early foundational
studies while also providing insights using empirical evidence (e.g. Borland and MacDonald,
2003; Coates et al., 2014; Fort and Quirk, 1995; Vrooman, 2009, 2015).

Third, it is apparent the owners of these franchises are often motivated by varying degrees
of profit and utility maximization. Quirk and El Hodiri (1974) argued the assumption that:

[…] the actions of franchise owners are motivated solely by profits from operation of their franchise is
admittedly somewhat unrealistic. Owning a major-league franchise carries with it prestige and
publicity, and a wealthy owner might view it simply as a type of consumption; for such a
“sportsman”-owner, winning games rather than making money might be the motivating factor (p. 42).

Fort (2000) further noted that while North American professional sports owners are generally
considered profit maximizers and European sports owners are generally utility (win)
maximizers, there are examples where this does not hold true. For example, some owners may
want to win within a certain threshold of profitability, or others may enjoy ownership because
of the public profile that team ownership engenders (Zimbalist, 2003). Thus, research
examined the extent to which owner motivation effects on- and off-field behaviors such as
winning, ticket pricing, and talent acquisition (e.g. Késenne and Pauwels, 2006; Yilmaz and
Chatterjee, 2003). Finally, changes to the nature of the industry have made leagues and their
clubs more reliant on media revenues, resulting in research looking at how media companies
influence league operations and use sporting content as a platform to further the interests of
media companies (Mills and Winfree, 2016; Winfree and Rosentraub, 2012).

However, with some notable exceptions (see Greenberg, 2004; Rosentraub 2010), the
aforementioned research has disregarded how team owners are now leveraging franchise
ownership for another purpose: to leverage the on-field and brand value of the franchise to
further a broader facility-anchored real estate development. Unlike other solutions to
addressing differing owner motivations (which involves aligning owner interests within a
league or creating league-wide rules to curtail certain team behaviors) (Mason, 1997), this
process involves aligning the interests of team owners and local political and business elites,
who control access to resources and development opportunities in a given city. This paper
explores the issue, using a recent arena-anchored urban development project as a case study.
To do so, we borrow from urban regime theory (URT) (Stone, 1989), which examines the
manner through which local elites develop the capacity to allocate resources in order to reach
common goals. The paper is organized as follows. First, an overview of URT is provided,
along with a brief discussion of our method. The case is Edmonton, AB, Canada, is then
examined, and discussed in terms of URT in order to help to explain how and why team
owners are now exploring large-scale urban development projects. Based on this analysis, we
discuss the implications for team ownership in the North American context; we argue that:
on-field performance may only be important insofar as it drives demand for the development;
a focus is placed on driving revenues and profits on interests outside the sports facility
itself; and the team (and the threat of relocation) is leveraged to gain “master developer” status
for the ownership group. In doing so, we reveal a new context through which team ownership
may be pursued and how this may impact ongoing league operations.

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Urban regimes and sports franchise ownership
URT has emerged as a useful tool to understand how cities are “managed.” Developed in a
North American urban context, early regime theorists sought to understand and articulate
how public officials and local business leaders were able to come together in order to
foster an economic growth agenda that met the interests of both groups (Elkin, 1987).
Thus, regime theory can be viewed as a theory of networking; however a key to
understanding the relationships within regimes relates to the informal nature of those
relationships (Davies, 2002b). Research has focused on how regimes are able to form and
how governing coalitions are able to function over time (DiGaetano and Klemanski, 1993),
and regime theory has emerged as a dominant theory within the urban affairs field; its
intuitive appeal lies in how it enables one to understand how cities can be governed,
particularly over extended periods of time. The theory helps to explain how seemingly
disparate groups (such as local community organizations, political leaders, and the business
community, including team owners) are able to develop the capacity to work together in a
governing capacity (Tretter, 2008). In this way, URT can be viewed as a combination of
several theoretical approaches, including urban political economy and a community power
structure paradigm (DiGaetano and Klemanski, 1993; Davies, 2002a).

It is important to note that the presence of certain actors within an urban setting does not
guarantee the presence of a regime. Further, regimes do not form themselves; they must be
developed, managed, and sustained by their members (Davies, 2002b). As a result, there is
an important strategic element to urban governance. Clarence Stone (1989), widely
considered a founder of regime theory, first developed his notion of regimes in his seminal
study of the City of Atlanta. He proposed that regimes featured three elements: a capacity to
do something, a set of actors to do it, and a relationship among the actors that enables them
to work together (Stone, 1989).

As the theory gained traction within the urban affairs literature, he later suggested that
five elements were required for regimes to exist (Stone, 2002). The first was what he
described as an identifying agenda. An identifying agenda is the common interest that links
the seemingly disparate groups that form the regime in a given city. The second element
relates to stability. What distinguishes a regime from other forms of urban governance and
control – such as Logan and Molotch’s (1987) growth coalition – is the enduring and ongoing
persistence of a regime joined together by an identifying agenda. A third element is that
regimes are cross-sectoral. In other words, regimes cannot be described simply as groups of
wealthy, powerful, and influential elites – regime members share an identifying agenda but
may represent many different groups within a community. A fourth and key element relates
to the nature of regime interactions. According to Stone (2002), “no power of command
directs the overall arrangements – hence some form of cooperation plays an important role”
(p. 21). Thus, regime members may not always be distinguished by their levels of formal
interaction – regimes by nature represent informal arrangements amongst their
membership. Finally, the arrangements that exist between members have a productive
character. In other words, regime members will allocate resources that serve to support and
enable the identifying agenda that would not necessarily occur in the absence of the regime.

Stone (1989) described the set of actors that possess the capacity to make governing
decisions as the governing coalition; these are the various groups and individuals that are
brought together in order to govern a city. Thus, regime theorists argue that the politics of
urban growth is not simply the process of powerful business elites manipulating public
officials; a key here is the mutuality of interests shared by groups within the city
(Elkin, 1987). As a result, regime analyses have focused on how informal arrangements
occur and coalition building develops in order for regimes to develop the capacity to engage
in strategic behaviors that further the regime’s identifying agenda (Kilburn, 2004).
Research on urban regimes focused on US-based contexts, and evolved to include cross-case

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analyses and cities in other contexts[1]. Much of the early work on regimes in the USA falls
within three themes: the process through which regimes are formed, how and why regimes
form and/or fail, and the characteristics or regimes (Ward, 1996). Research on the latter
focused on the identification of ideal types. Research using URT to examine sport has
examined cities hosting sporting events (e.g. Henry and Paramio-Salcines, 1999; Misener
and Mason, 2008, 2009; Pelissero et al., 1991; Sack and Johnson, 1996; Schimmel, 2001).
For example, Misener and Mason (2008, 2009) demonstrated the existence of symbolic urban
regimes in the cities of Edmonton, Melbourne, and Manchester.

In order to explain how resources are allocated in the process of civic cooperation Stone
(1989) introduced the notion of “small opportunities”: “Urban regimes and civic cooperation
are less shaped by ideology than by the ability to allocate small opportunities.
These opportunities include selective material benefits that are important in solving the
free-rider problem in collective action and in providing a means to apply discipline” ( p. 232).
In other words, small opportunities represent the point where resources are allocated and
regimes are able to engage in actions that both support the broader identifying agenda,
but also serve to engage different regime members and/or signal to others the identifying
agenda and the support of specific groups.

When examining cities, there is perhaps no clearer example of how networks of political
and business elites converge and align their interests than with the construction of a new
sports facility (Friedman and Mason, 2004). Few North American professional sports team
owners today are limited in their business interests to franchise operations; many have
amassed wealth in other industries, or see teams as opportunities to leverage their other
interests in areas that align with operations, such as media ownership (Cousens and Slack,
2005; Harvey et al., 2001; Winfree and Rosentraub, 2012). Harvey et al. (2001), for example,
found that close to one-third of professional sport owners were from the entertainment
industry sector as defined by the North American Industry Classification System.
As a result, owners who are from the same cities that their teams perform in are already
embedded in the network of business and political elites that constitute the local
regime. Thus, the issue of new sports facility construction provides regimes within cities
with the “small opportunity” to align their interests and further the regime’s broader
identifying agenda.

So who does one expect to be part of this regime? First, land developers benefit, even if
they are not directly involved in the project. This benefit derives from the increasing real
estate values due to gentrification in the surrounding area, and they may be able to create
ancillary developments linked to the project. Others include public officials, who hope that
land values (and taxes) are increased due to the infrastructure development. Political leaders
also hope to benefit from the political capital associated with the ribbon cutting
opportunities tied to these types of projects. The local media also support the opportunity,
as the newspapers benefit from growth of the economy through an increase circulation rates
and advertising revenues (Buist and Mason, 2010). Thus, one can see how different
stakeholders benefit in different ways while in support of a singular identifying agenda.
However, the issue becomes whether the regime can agree upon the choice of small
opportunity. As we discuss below, the decision to build a new arena in Edmonton provided
one such occasion.

Methodology
The current study was based on part of a larger research project investigating the fit
between isolated sports infrastructure development projects, specifically NHL arenas, and
broader urban development initiatives. Approached from a constructionist perspective
(Guba and Lincoln, 2004), our study employed an instrumental case study strategy.
This case design was chosen as it facilitates understanding and description of a particular

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phenomenon and allows researchers to use the case as a comparative point across other
settings (with similar conditions) in which the phenomenon might be present (Stake, 1995).
Accordingly, we use this case to examine how political and business elites’ interests aligned
with a team owner to further a regime’s agenda. For the purpose of this paper, the
“small opportunity” is identified as the construction of a new sport and entertainment
complex in Edmonton, Canada. We provide a description of our research context and
explain our data collection and analysis in the following sections.

Research context
In Edmonton, construction was recently completed on Rogers Place arena. Developer/team
owner, Daryl Katz, is a Canadian businessman, investor, and founder of the Katz Group of
companies. The privately owned company has operations in sports and entertainment, film,
and real estate development. The Katz Group formed the Oilers Entertainment Group (OEG)
which owns Edmonton’s NHL franchise – the Edmonton Oilers – the Edmonton Oil Kings of
the Western Hockey League, and the Bakersfield Condors of the American Hockey League.
The OEG also operates Rogers Place, the new home of the Edmonton Oilers, which opened
in September, 2016.

In 2005, the previous Oilers’ ownership group expressed a desire for a new facility on the
grounds that the franchise’s revenue-generating capability was severely hindered by the
out-of-date facility it was occupying. Its existing arena – Rexall Place – was one of the oldest
in use by an NHL team, and considered antiquated in terms of its revenue-generating
amenities. The team was eventually sold in 2008 to the Katz Group. Shortly thereafter,
the City of Edmonton and the Katz Group entered into talks regarding a proposed new
arena. After a prolonged negotiation that included a relocation threat, the parties reached an
agreement in early 2013.

The new arena cost an estimated CAD$480 million, CAD$604.5 million when including
associated infrastructure. The City of Edmonton contributed $200 million to the facility and
$279 million in total, of which $199 million would be repaid through a Community
Revitalization Levy (CRL), whereby increased tax revenues generated from the area
surrounding the facility would be used to service the debt (a similar funding model to
Tax Increment Financing). The CRL would be in place for 20 years. Additional
infrastructure included land, a pedestrian walkway, a connection for the local light rail
transit system, a community ice rink, and a pedestrian overpass that would serve as a meeting
area and entrance to the new arena. The Katz Group contributed $130 million in cash and
future lease payments for the facility plus an additional $31.5 million in additional cash
and lease payments for other infrastructure. Finally, $125 million is to be repaid through the
implementation of a tax on event tickets, making the total contribution from the team owner
$286.5 million. The remaining $39 million would come other forms of government, including
$25 million from a regional collaboration funding allocation, and $7 million each provided by
the provincial and federal governments toward the community rink.

According to the website (www.icedistrictproperties.com), the ICE District will be
anchored by Rogers Place and will be Canada’s largest mixed-use sports and entertainment
destination. It is a 25+ acre development combining 1.3 million square feet of office space,
approximately 1,300 multi-family residential units, a public plaza, sports, entertainment, and
300,000 square feet of retail space in one location. The ICE District is located in the heart of
Edmonton and will link the four quadrants of the city to the downtown area. It is estimated
that there is $2.5 billion in development projects planned or scheduled within the ICE
District as well as additional projects in the downtown core, including: Edmonton Tower,
a 27-storey building that will house more than 65 percent of the City of Edmonton’s
downtown employees; Stantec Tower, a 60-story commercial and residential tower; and
Grand Villa Casino, a $32 million, 60,000 square foot facility attached to Rogers Place.

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www.icedistrictproperties.com

Data collection
The data were collected from two main sources – newspaper articles and documents – to
increase the reliability and validity of the findings (Creswell, 2007; Yin, 2013). In order
to explore how team owners seeking broader real estate development opportunities are able
to leverage their franchise and align their interests with business and political elites,
we opted to examine local newspaper articles. Since public officials, politicians, and business
leaders are the most cited and greatest suppliers of news items (Gans, 1979; Hess, 2000),
these articles would identify members of the regime as well as provide insight into their
broader agenda. Thus, newspaper articles were collected from the Edmonton Journal.
Owned by Postmedia Network Inc., the Edmonton Journal is consistently the highest
circulating daily newspaper in the city. In 2015, the paper had an average daily print and
digital circulation of 92,542 and a weekly total circulation of 555,252 (Newspapers Canada,
2016). Articles were sourced for the period 2005-2016, which encompassed a time frame
spanning the emergence of the new arena in local newspaper coverage to the year the
facility (Rogers Place) became operational. Using the Canadian Newsstand and LexisNexis
databases, articles were collected and identified through a search for keywords related to
the construction of the downtown arena. We limited our results to articles appearing in the
following sections: News; Citiplus; Opinions; Sports; and Business. This search yielded
346 articles and after each was read, 306 were deemed relevant for analysis.

Documents were also collected and included: the City of Edmonton’s Strategic Plan; the
Master Agreement between the City of Edmonton and the Edmonton Arena Corporation
(EAC); sponsorship agreements; and the tax agreement between the city and the EAC.
These documents provided information relating to the city’s strategies and plans,
the network of local actors involved in establishing the agreements, and evidence of the
city’s broader agenda as it related to the new arena. In order to supplement our media and
documentation data, a 90-minute, semi-structured interview was conducted with the
executive director of the Downtown Arena Project on January 5, 2017.

Data analysis
Qualitative content analysis was used to analyze the data. This method of analysis involves a
systematic, theory-driven approach to texts and examines both manifest and latent content of
the materials (Mayring, 2000). We adapted our process of analysis from guidelines provided
by both Mayring (2000) and Denis et al. (2001) who incorporated both deductive and inductive
approaches to coding. The first phase of analysis began with coding each newspaper article
for basic characteristics such as: date, staff reporter, and section. We then developed a set of
deductive coding categories which were based on URT (Stone, 1989, 2002) as well as prior
research which employed the theory to examine sport (Misener and Mason, 2008, 2009;
Henry and Paramio-Salcines, 1999). For example, categories were developed for the
identification of stakeholders/regime members, their interests, and motivations for
involvement in the project. We assigned definitions, examples, and coding rules for each
deductive category, in order to determine exactly under what circumstances a text passage
could be coded with a category. In the final stage of analysis, we employed inductive coding to
identify an initial set of themes in the data related to the decision to build a new arena in the
city. The data were analyzed to identify words, phrases, and ideas that repeated as patterns
(Fink, 2009). Patterns which emerged were analyzed in the context of the paper’s purpose and
theoretical and conceptual framework. The themes were then grouped together and used to
develop inductive coding categories (Mayring, 2000).

Aligning interests in Edmonton: results and discussion
The issue of building (and funding) a new hockey arena for the Edmonton Oilers presented a
“small opportunity” (Stone, 1989) for key stakeholders to align their interests. In this section,

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we identify the key stakeholders who coalesced around the arena development, highlight
the broader identifying agenda and the expected benefits of the project, and discuss how
these stakeholders communicated their agenda to the general public.

Key stakeholders
Examination of the newspaper articles and documents identified a set of actors (see Table I)
involved in the discourse surrounding the new hockey arena. Although this list is not
exhaustive, it highlights those local stakeholders who featured most prominently in the
newspaper coverage.

The stakeholders identified comprise a variety of local political and business elites, as
well as several organizations who championed the project. Notably, the city’s then-Mayor,
Stephen Mandel, as well as executives from the Oilers organization, were involved from the
onset in discussions regarding an arena-anchored real estate development. As plans for
the project progressed and the City Council vote drew near, real estate developers, city
councilors, and the team owner began to feature prominently in the news coverage.
In addition, the Downtown Vibrancy Task Force was established as an extension of
ONEdmonton Leaders Forum – a group of local leaders whose aim was to make Edmonton
one of the world’s top 5 mid-sized cities – after the organization decided that the city’s urban
core was a top priority. The Downtown Vibrancy Task Force was made up of business
executives, members of community organizations, and other city officials (see Table II).
Several members of this task force were frequently quoted in the newspaper coverage of the
issue as the group’s main task was to lobby the City Council (and by extension the public) in
favor of the arena project.

As evidenced by prominent stakeholders in the discourse, supporters of the development
came from a variety of groups within the community. In URT terms, when viewing the
arena project in Edmonton as a small opportunity, one can see how supporters cross many
different sectors and represent varying interests in the city, confirming the presence of a
regime in the city (Misener and Mason, 2008, 2009).

Name Role
Date emerged in
arena discourse

Stephen Mandel Mayor of Edmonton (2004-2013)

October 2005

Patrick LaForge Former CEO, Edmonton Oilers; Former President and COO, Oilers

Entertainment Group
October 2005

Cal Nichols Former Chairman, Edmonton Investors Group (previous owner/s of
the Edmonton Oilers)

October 2005

Jim Taylor Executive Director, Downtown Business Association April 2007
Bryan Anderson City Councilor December 2007
Kim Krushell City Councilor December 2007
Daryl Katz Chairman, Katz Group of Companies; current Owner, Edmonton Oilers July 2007
Don Iveson Former City Councilor (2007-2013); Mayor of Edmonton (2013-Present) March 2008
Ken Cantor Former Commercial Manager, Qualico (Real Estate Development company) March 2008
Bob Black Executive Vice President, Katz Group of Companies and Edmonton

Arena Corporation; Spokesman for WAM Developments (local developer
and Katz Group partner)

December 2009

Simon Farbrother City Manager July 2010
Simon O’Byrne Stantec Consulting, Managing Principal, Practice Leader – Urban

Planning; Chairman Downtown Vibrancy Task Force
January 2011

Terry Paranych Local Realtor/Developer January 2011
Rick Daviss Executive Director, Downtown Arena Project January 2012

Table I.
Prominent
stakeholders identified
in newspaper
coverage

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Edmonton’s regime and downtown development
Our analysis of the data revealed several key terms and phrases which were repeated as
patterns. From a regime perspective, this signals the underlying identifying agenda for the
regime in Edmonton, and the role of the development project as an opportunity to further
regime interests. Early media coverage of the issue focused on funding for the project,
in that the city was effectively subsidizing a new arena for a team that was owned by a local
billionaire; the arena was often referred to by proponents as a ‘catalyst project’ aimed at
achieving downtown development. For example, Mayor Mandel stated that “People see this
as a great opportunity for additional rejuvenation of downtown, that the city can put an icon
downtown” (Kent, 2007). Oilers’ owner Daryl Katz was quoted as saying, “I don’t know
if I would have had the same enthusiasm for the transaction but for the opportunity to build
a new arena and to revitalize downtown” (Staples, 2009). Further, the master agreement
between the City of Edmonton and the EAC emphasized that “the construction and
successful ongoing operations of the Arena Area Facilities will provide a catalyst for further
development” (City of Edmonton, 2013, p. 18). This commentary provides evidence that the
broader identifying agenda was not the prospect of a new sport facility for the city,
but rather, the “revitalization” associated with an arena-anchored real estate development.
In other words, the arena development was the small opportunity that could further the
regime’s interests in developing the downtown core of Edmonton.

It is this agenda that seemed to bring together support from disparate groups of
stakeholders. In one article, Reporter David Staples (2016) referred to Daryl Katz and the
City as “Edmonton’s Odd Couple,” highlighting the reason for their cooperation as a
common goal of “a desperate need for a win on this career-and downtown-defining project”
(p. A6). Although current Mayor Don Iverson initially opposed the arena project as a
City Councilor, prior to declaring his candidacy for Mayor in June 2013, he voted in favor of
the arena, citing that it would be beneficial for the city’s downtown (Stolte, 2013).
Key stakeholders agreed that Edmonton suffered from an image problem which was
directly attributed to its “long-neglected city centre” (MacKinnon, 2011, p. C1).

Name Company/title

Paul Allard DIA Holdings Ltd, Project Manager
Bob Black Katz Group, Executive Vice President, sports and entertainment
Carolyn Campbell University of Alberta, Associate Dean, Executive Education
Simon Farbrother City of Edmonton, City Manager
Brad Ferguson Edmonton Economic Development Corporation, President and CEO
Randy Ferguson (Vice-Chair) Strategic Group, Chief Operating Officer
Alyson Hodson ZAG Creative Group, Partner
Kim Irving ATB Financial, Vice President
Terry Kilburn Avison Young, Partner
David Majeski RBC, Vice President, real estate and construction
Mack Male Paramagnus Developments, Owner
Doug McConnell Dialog, Principal
Hon Anne McLellan Bennett Jones, Corporate Counsel
Simon O’Byrne (Chair) Stantec Consulting, Managing Principal, Practice Leader – Urban Planning
Ian O’Donnell Downtown Edmonton Community League, Development Chair
Darin Rayburn Melcor Developments, Executive Vice President
Andrew Ross Clark Builders, Executive Vice President
Keith Shillington Stantec Consulting, Vice President
Michael Smith WAM Development Group, Senior Vice President, Multi-Family
Jim Taylor Downtown Business Association, Executive Director
Sheila Weatherill EPCOR Board of Directors, Vice-Chair
Source: www.edmonton.ca/documents/PDF/Downtown_Vibrancy_Task_Force

Table II.
Downtown vibrancy
task force committee

members (as of
July 2013)

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Thus, a vibrant downtown core was a key feature in the arena discourse. For example,
Former CEO and President of the Edmonton Oilers, Patrick LaForge, stated that
“[Edmonton needs] a city centre that’s alive and vibrant and entertaining and good enough
to attract the best in the world and entertain them and keep them here” (Staples, 2008, p. A1).
Executive Vice President of Sports and Entertainment for the Katz Group, Bob Black,
reiterated this sentiment by stating that “The Edmonton arena district will be a vibrant,
walkable and environmentally sustainable mixed use development that will create a hub of
commercial, social and cultural activity in the heart of our downtown” (Sands and Gordon,
2012, p. A4). The importance of a vibrant downtown was also reflected in the City’s Tax
Agreement with the EAC which highlighted that the city wished to encourage Edmonton’s
economic growth and a vibrant downtown community. This would be achieved by
supporting public-private partnerships and embracing new sports and entertainment
concepts in the downtown core (City of Edmonton, 2014).

Team owner motivations and the Regime
As evidenced by the discourse in local media coverage of the project, the development
(or revitalization) of Edmonton’s downtown core was central to the interests of key
stakeholders. After Edmonton City Council declared approval of the arena in 2013, a series
of real estate projects were announced for the Edmonton Arena District (see section on
Research Context). The arena district was expected to attract over CAD$2.5 billion worth of
real estate development in the downtown core. This estimate reemphasized the
stakeholders’ claims that the project would indeed generate development and revenue for
the city in the form of property taxes which would in turn pay back the CRL introduced to
fund the arena. Katz stated that “we planned this before we bought the team […] we were
active in the real-estate market, relative to where we saw the arena (being built)”
(MacKinnon, 2014, p. D2). Thus, the prospect of being the developer provided the impetus
for purchasing the Edmonton Oilers and ultimately solidified the relationship between the
team (owner) and the city.

The team and the facility were, therefore, considered valuable assets as they both
increase the attractiveness of the district, and provided the opportunity for the Oilers’ owner
to insert himself into the real estate development opportunity. Executive Director of the
Downtown Arena Project, Rick Daviss, reiterated this point by stating “if you’ve got the
same owner with the same real estate development opportunity […] chances are that it will
[…]. Because he sees that there are mutual advantages there, like the real estate will flourish
because of the arena and the arena will flourish because of the development” (Executive
Director, Downtown Arena Project, personal communication). Moreover, Daviss believed
“the real estate play is big […] [Katz] is so much bigger than hockey, getting out of the
drugstore business and into the entertainment business” (personal communication). In this
case, Katz leveraged his ownership of the Oilers and its need for a new facility to pursue
control of the development, along with partner WAM Developments. Commenting on
Katz’s arrangement with the City, Rick Daviss stated that “[the project] turned out to be a
very, very profitable deal for the private sector and the city” (Staples, 2015, p. A4).

To review, the case of Rogers Place in Edmonton reveals a clear desire for political and
business elites in Edmonton to align their interests to engage in a large-scale, real estate
development project in downtown Edmonton. From an URT perspective, the broader
identifying agenda was to further develop the city’s downtown core in order to make
Edmonton a more attractive place to live, work, and visit. In the discourse surrounding the
arena project, the construction of Rogers Place functioned as a “catalyst” providing an
opportunity for further real estate development that would benefit the city. The owner of
the Edmonton Oilers, Daryl Katz, was able to leverage his ownership of the team by aligning
his own interests in real estate development with that of other key stakeholders

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in the community. In regime theory parlance, the small opportunity of arena development
became a key point through which a regime in Edmonton was able to further its identifying
agenda by making the downtown core more vibrant. As owner of the team, Katz furthered
his own interests along with the interests of broader regime.

Implications
The Edmonton case reviewed above reveals the significant investment by the franchise
owner into real estate surrounding the arena the team plays in. While the use of public funds
to finance the arena was a contentious issue in Edmonton (and remains one in cities
considering similar projects), there are several key outcomes that benefit both the team
owner and the city itself. First, the scarcity of franchises often results in team owners
threatening to relocate should their demands for subsidies not be met (Foster et al., 2015).
However, once the surrounding development occurs and the owner has a substantive
financial stake in it, the likelihood of relocation diminishes considerably. Even if the owner
sells the team and maintains a financial interest in the development, there is still an incentive
to keep the team as an anchor tenant to make the surrounding area more attractive to
residents and visitors. Second, having the ownership stake in the development provides a
key means to align the interests of the city and team. In Edmonton, the city’s interest was to
increase (relocate) economic activity to the downtown core. With the team owner’s
investment in the surrounding district, the owner benefits from any increase in activity in
the area (over and above those attending events at the arena itself). Thus, the interests of the
team and the regime in the community align. We feel this new model of operations has some
important implications for the operations of professional sports leagues as a whole, and
introduces another rationale for ownership that builds on the existing arguments for team
ownership (win vs wealth maximization). These implications are discussed below.

On-field performance is important insofar as it drives demand for the development
A unique dynamic emerges when considering the competitiveness of teams and franchise
revenues. All things being equal, the more competitive a team is, the more likely it is to draw
fans to the stadium (e.g. Coates et al., 2014), television viewers (Tainsky, 2010; Tainsky et al.,
2014), and increases revenues and profits (e.g. Gustafson and Hadley, 2007). However,
the likelihood of winning also should increase when additional resources are spent on player
and non-player inputs (Scully, 1974). Thus, franchises are always interested in winning,
albeit profit maximizing owners will want to win insofar as it maximizes their profits
(El Hodiri and Quirk, 1971).

Research presented evidence that a new facility may influence revenues and the need to
win (e.g. Brown et al., 2004; Rascher et al., 2012). Brown et al. (2004) looked at NFL team
revenues between old and new facilities. Results from their analysis found significant
differences in a variety of revenue streams such as ticket sales, luxury seating, advertising/
parking/other, and total local revenue. They also found new NFL venues increased the
league’s gross operating revenues. Later research by Rascher et al. (2012) found new NFL
stadiums lessen the impact of winning on attendance and revenue and this decreasing
reliance on winning provides teams with a better ability to accurately forecast attendance
and revenues, thus providing increasing financial certainty in an industry setting that relies
on the uncertainty of game outcomes and, by extension, the uncertainty of the race to crown
a league champion. With this in mind, owners may be able to focus more on making the
district more attractive as a destination than worrying about fielding a competitive team to
ensure that facility revenues are maximized.

For those teams in leagues that play a series of playoff rounds and where owners are
wealth maximizers, there may also be less of an incentive for the team to make the playoffs.
For example, setting aside dates for playoff games in the venue may preclude other popular

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entertainment acts from being hosted in the facility; one cannot assume that the facility
would be empty in lieu of the playoff games played. Where the team owner only controls
revenues from the team itself, there is strong incentive to play these games. In contrast, as
long as there are other entertainment acts that can use the facility (and drive traffic to other
team-owned amenities in the district), the owner can still profit from the overall
development. As a result, there is now less incentive for owners to have teams make the
playoffs to access lucrative playoff dates, if the facility and surrounding area will continue
to see a number of events that ensure that area will be busy.

This suggestion does not undermine the value of the team to the overall development; in
many cases it will be clear that the team is the anchor tenant and will factor heavily in
residents’ willingness to live near the venue and access the other amenities in the vicinity.
However, teams will not necessarily need to win in order to ensure the success of the
development, the demand for events, or the profitability of the team owner/developer.
Quinn et al. (2003) examined the impact of new venues on team on-field performance for
North American professional sports leagues. Comparing on-field performance in the old and
new venue, they found no real difference in team winning percentages. In fact, they conclude
that conditions exist within new facilities that “[…] apparently impede a poor team’s
improvement” (Quinn et al., 2003, p. 180). Research by Clapp and Hakes (2005) supported
earlier findings by Quinn et al. (2003). Furthermore, they concluded that team owners who
are profit maximizing do not use the increased revenues from the new stadium to improve
team quality (i.e. team performance). Rather, these increased revenues are used by the owner
to either pay off debt or retain for profits. Depken (2006) found that franchise values
increased substantially in the first ten years of a new facility. In addition, Depken (2006)
concluded that teams “artificially increase operating expenses in order to downplay their
profitability” (p. 468). Thus, one cannot expect the team to improve or the owner to use
additional revenues to improve the team’s performance. However, revenues should increase
and there should be less sensitivity to team performance on revenues, which should
ultimately benefit the success of the broader development (where fans/consumers continue
to use other amenities in the stadium or arena district).

Owner focus on driving revenues and profits from interests outside of the sports facility itself
There is a tendency to evaluate teams and the facilities they play in on an isolated basis, rather
than in terms of their contributions to a broader bundle of amenities that a given city might
possess (Clark, 2004). While research on amenities and amenity theory examined the role of
the arena in the broader development from the perspective of the public funds provided to
finance facilities (Rosentraub, 2010), where team owners own or control the surrounding
development, the key to the owner’s interests is not the profitability of the team or the
competitiveness of it, it is the extent to which the team contributes to the overall capacity of
the development to generate revenues for the owners’ business holdings (Mason, 2016).

Thus, owners invested in the surrounding development will be interested in putting a
team on the court, field, or ice that maximizes overall revenues. As a result, winning and
profit maximization for the franchise itself will be secondary to the attractiveness and
revenues of the entire development. We argue that there are several key implications for
this. First, a competitive team will be useful, but an exciting (competitive) team may be even
more important. The desire for an exciting, competitive team may lead to franchises
assembling rosters that not only are meant to win, but to do so in an entertaining fashion.
This behavior may result in attempts to acquire “marquee” players who are attractive to
fans. The second is that owners can sometimes take advantage of the league’s revenue
sharing agreements (e.g. Mason, 1997) for their own self-interest. In most North American
professional sports leagues, teams share other teams’ and overall league revenues under the
auspices of maintaining competitive balance (Vrooman, 2015). For example,

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all North American professional sports leagues equally share national broadcast media
rights. Local revenues, however, are shared differently (see Peeters, 2015; Vrooman, 2015 for
an overview). Within each league, certain revenue streams are excluded from revenue
sharing agreements. The revenue streams that are excluded may be revenue streams that
directly correspond to new stadiums and surrounding development. For example, the NFL
excluded luxury box revenues from the football-related revenue that is shared amongst the
clubs (Larsen et al., 2006). Thus, not only do team owners not have to share the revenues
from the surrounding district, certain revenue streams from the sports facility itself may not
have to be shared with other league clubs. Seen in this manner, the value for the team will be
to drive revenues outside of the facility (that are not under the purview of current league
revenue sharing agreements) where the owner will profit but not have to share with other
league clubs. It is important to note here that this phenomenon will benefit the regime,
as there is a greater likelihood that other stakeholders (including the City) will benefit from
ancillary consumption in the nearby area.

Team leveraged to gain “master” developer status for ownership group
Due to some historically unique circumstances, North American professional sports
teams have been able to operate largely free from the antitrust and anti-competition
scrutiny that other industries face. This freedom allowed leagues to limit the availability
of franchises, which in turn created a competitive market for cities seeking to host
major league franchises. Although cities and their residents are becoming more
sophisticated in their understanding of the benefits (or lack thereof) that teams and
facilities provide, there appears to be no end in sight to the use of public subsidies to
lure or retain teams through the construction of new or substantively renovated venues
to host them.

Because franchises are scarce, the leverage that the team owner possesses may allow
him/her to become the primary developer in the area surrounding the arena. This will
allow the owner to profit from more than the operations of the team itself. In attaining
“master developer” status, the owner is able to leverage the key asset – the team – which is
the anchor tenant of the centerpiece of the development (the sports facility) in order to gain
control over the development of the surrounding district (Rosentraub, 2010). For this reason,
real estate developers may view franchises simply as assets to access development
opportunities they might otherwise not have the opportunity to pursue.

A repercussion of this is that the team will be viewed by the owner/developer as
secondary to the facility itself; it is the fact that the venue can drive attendance and
visitors to the area that is a key; it matters less what these people are coming to see
as long as they are coming. In Columbus, OH, Nationwide Realty did not even bother to
become a team owner; instead they used Nationwide Arena as an anchor for the
development project in that city. The fact that it is a NHL team (the Blue Jackets) that
serves as the major tenant is secondary to the overall development and revitalization of
that city’s downtown.

Conclusion
While having a stake in the broader development represents an important and potentially
lucrative business opportunity for the franchise owner, there are several issues that may
arise that can complicate issues facing North American professional sports leagues. As
mentioned earlier, team owners have traditionally operated clubs with the
complementary and, at times, conflicting aims of winning and maximizing wealth.
With team owners like those in Edmonton investing more financial resources in the
district surrounding the new arena than in the team itself, a question now arises at as to

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whether or not such owners will distinguish between maximizing revenues from the club
itself, or the overall development.

Historically, the need to implement restrictions on player mobility and salaries has
been rationalized by leagues in the context of maintaining competitive balance and
protecting smaller markets that may not be able to generate revenues comparable to
larger ones. However, team owners may be able to generate substantial revenues from the
surrounding development in such a way as to buffer smaller markets from a lack of
revenues from the team itself. This may allow teams in smaller markets to remain more
viable in the long run, and also reduce the expectations team owners have for the public’s
financial contributions to the facility.

Conversely, win maximizing owners who control the surrounding development may
overspend on playing talent and drive down team profitability, knowing that losses can be
recouped by the profits from the surrounding district. This would have the opposite effect of
making it more difficult for other league clubs seeking to build their own competitive
rosters. This may result in changes to collective bargaining and intra-league revenue
sharing policies between league clubs. This paper has revealed that team ownership in
North American professional sports leagues continues to be a complex phenomenon; future
research should explore the implications of this ownership model on overall league profits
and competitive balance.

Note

1. Debate over the applicability of regime theory to non-US contexts has been waged in the urban
affairs literature. This has focused on the degree of influence that the business community has in
the policy process in other cities in other countries, and the degree of autonomy that local regime
arrangements have to govern. However, we feel that this debate is not central to our use of the
tenets of regime theory as developed by Stone’s work.

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RESEARCH ARTICLE Open Access

Evaluation of physical activity programmes for
the elderly – exploring the lessons from other
sectors and examining the general characteristics
of the programmes
Ana I Marques1*, Pedro Soares2†, Luísa Soares-Miranda1†, Carla Moreira1†, António Oliveira-Tavares1†,
Paula Clara-Santos1,3†, Susana Vale1†, Rute Santos1,4† and Joana Carvalho1†

Abstract

Background

: In Portugal, there are several physical activity (PA) programmes for elderly people developed by the
local government. The importance of these programmes has been increasing since the evidence has shown that
this type of health promotion interventions may reduce the deleterious effects of the ageing process. However, no
study has already identified the general characteristics of these programmes nor if they use any scheme to assess
the quality of the service provided. A widely-used scheme is the EFQM Excellence Model, which will be in the core
of our present work. Thus, the main aims of this preliminary study were 1) to identify the general characteristics of
the PA programmes developed by the Portuguese Local Public Administration 2) to determine the extent of
implementation of quality initiatives in these programmes.

Methods

: Data were collected by an on-line questionnaire sent to all Continental Municipalities (n = 278).
Categorical data were expressed as absolute counts and percentages. Continuous data were expressed as the
mean and SD. An open-ended question was analysed using qualitative content analysis with QSR NVivo software.
Associations between categorical variables were tested by the use of contingency tables and the calculation of chi-
square tests. Significance level was set at p ≤ 0.05.

Results: Results showed: i) a total of 125 PA programmes were identified in the 18 districts of the Portugal
mainland; ii) the main goal of the majority (95.2%) was the participants’ health promotion; iii) different
characteristics of the programmes were found according to different regions of the country; iv) certain
characteristics of the programmes were associated to the existence of other features; v) only one PA programme
developed quality initiatives.

Conclusion

s: In conclusion, although there are many PA programmes for elderly people spread throughout the
country, aiming at improving the health of participants, the overwhelming majority does not adopt quality control
initiatives. Considering that the quality of a service increases customer satisfaction, the continuous quality
improvement of the PA programmes for elderly people should therefore be implemented since they can be useful
and critical for elderly satisfaction and adherence.

Keywords: physical activity, elderly people, quality, assessment, EFQM

* Correspondence: anavalente@netvisao.pt
† Contributed equally
1Research Centre in Physical Activity, Health and Leisure, Faculty of Sport,
University of Porto, Porto, Portugal
Full list of author information is available at the end of the article

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© 2011 Marques et al; licensee BioMed Central Ltd. This is an open access article distributed under the terms of the Creative Commons
Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction in
any medium, provided the original work is properly cited.

mailto:anavalente@netvisao.pt

http://creativecommons.org/licenses/by/2.0

Background
Biopsychosocial changes arising from the ageing pro-
cess can negatively affect the quality of life of the
elderly by limiting their ability to carry out everyday
activities and exposing them to a greater vulnerability
to health problems [1]. Evidence provided by several
studies highlights that physical activity (PA) can play a
major role on global health promotion [2,3], in large
part by epidemiological evidence of the positive effect
of an active lifestyle and involvement of individuals in
PA programmes [4,5]. Indeed, these programmes are
particularly important to prevent and minimize the
deleterious effects of the ageing process [6,7] and to
improve quality of life [1,6-8]. Nevertheless, a substan-
tial proportion of European elderly adults – with parti-
cular relevance to the Portuguese population – have
lower PA levels than those recommended for good
health [9,10]. Therefore, increasing adherence to PA
among elderly people is actually an important public
health challenge. Several authors suggest that higher
attendance in PA programmes is influenced by degrees
of enjoyment and satisfaction [11-14]. Therefore, con-
tinuous quality improvement of the PA programmes
for elderly people can be crucial for elderly satisfaction
and adherence, since one of the most important factors
for customer satisfaction is providing a quality service
[15-17].
The National Center for Chronic Disease Prevention’s

Division of Nutrition and Physical Activity described a
set of recommendations and strategies to improve pro-
grammes, developing new approaches and highlighting
the need for effective programme evaluation [18,19].
Furthermore, programme evaluation is a useful tool for
continuous quality improvement [20] and the WHO
guidelines for the evaluation of health promotion
emphasize the need to evaluate and propose the alloca-
tion of adequate resources for this action [21].

In Portugal, Public Administration is the sector that
offers the largest supply of goods and services, and as
such, should be the sector that must devote most atten-
tion to Quality and to the definition of quality stan-
dards. In this way, a quality management model is
essential in order to improve the public service delivery
to citizens and better allocate scarce public resources.
With the objective of helping organizations to improve

their performance, the European Foundation for Quality
Management (EFQM) introduced in 1991 the Excellence
Model, which is currently used by thousands of organi-
zations throughout Europe, such as companies, health
institutions, schools, public safety services and govern-
mental institutions, among others. The model also pro-
vides organizations with a common management
vocabulary and tools, thus facilitating the sharing of best
practices between organizations of different sectors [22].
The EFQM Excellence Model (Figure 1) is a non-

prescriptive framework, based on nine criteria divided
into thirty-two sub-criteria. Of these nine criteria, five
are ‘Enablers’ – what an organization does to achieve
excellence – and four are ‘Results’ – what an organiza-
tion achieves, that is, the results achieved on the path
to Excellence. ‘Results’ are caused by ‘Enablers’ and the
feedback from ‘Results’ help to improve ‘Enablers’. The
arrows presented in the model show the dynamic nat-
ure of the model; the issues related to ‘Innovation and
Learning’, while horizontal vectors essential for the
model’s architecture, emerge as cross-sectional ele-
ments in all the criteria. They show innovation and
learning to improve enablers that in turn lead to
improved results.
The model recognizes that there are many approaches

to achieving sustainable Excellence in all aspects of per-
formance, based on the premise that: “Excellent results
with respect to Performance, Customers, People and
Society are achieved through Leadership driving Policy

Figure 1 EFQM Excellence Model (EFQM, 2003a).

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and Strategy that is delivered through People, Partner-
ships and Resources, and Processes” [17]. Definitions of
the Model criteria are given below, in Table 1.
It is around these nine criteria and the thirty-two sub-

criteria that an organization’s progress towards excel-
lence is assessed. Self-assessment will shed light on the
areas requiring improvement and how to conduct
improvement actions, acting on the process.
The implementation of the EFQM Excellence Model

within the Public Administration has been principally
publicised within the healthcare sector, with its inherent
benefits largely discussed by Jackson [23]. Several
authors [24-30] have also discussed the implementation
of the excellence model within health and social care
environments.
Furthermore, many approaches have been made in

education institutions, especially in the higher education
system. Models based on quality awards such as the
EFQM Excellence Model or models created for self-
assessment in academia, have become an important
instrument to implement self-assessment methodology
for quality improvement in higher education institutions
[31,32].
In the last years, particular attention has been devoted

to this framework by the local governance sector. In
order to achieve the quality plan goals, Bologna Munici-
pality top managers chose to employ the EFQM Excel-
lence Model in 1997 [33] and this action was followed
by many other cities of Europe [34,35].
Additionally, there has been a growing concern about

quality and quality management within the public lei-
sure services, which has resulted in the introduction of

quality programmes and its associated techniques, such
as EFQM Excellence Model, to facilitate leisure manage-
ment [36-38]. Robinson highlighted the significant role
played by quality management as an appropriate strategy
for the management of public leisure facilities in bring-
ing about a customer-focused approach to service deliv-
ery and the evidence of its assignment in improving
service quality [36]. The research carried out by the
same author [37] indicated that nearly one third of pub-
lic leisure facilities use the EFQM Excellence Model for
the reason that its use led to improvements in service,
primarily through clearer procedures and continuous
improvement.
Taking into account that, in Portugal, there are several

PA programmes for elderly people developed by the
local government, involving many employees and activ-
ities that reach thousands of participants and also
expend considerable public fees, it seems appropriate a
quality assessment of these PA programmes. However,
to our knowledge, there is no specific tool to assess the
quality of the service provided. Thus, the main aims of
this preliminary study were 1) to identify the general
characteristics of the PA programmes developed by the
Portuguese Local Public Administration and 2) to deter-
mine the extent of implementation of quality initiatives
in these programmes.

Methods
An on-line questionnaire was sent out to all Portuguese
Continental Municipalities (n = 278) in May, 2008. This
questionnaire has provided the following information:
geographic localization, number of programmes to

Table 1 Definitions of the Model criteria (adapted from EFQM, 2003a)

MODEL CRITERIA DEFINITION

Leadership Excellent Leaders develop and facilitate the achievement of the mission and vision. They develop organisational values and
systems required for sustainable success and implement these via their actions and behaviours. During periods of change
they retain a constancy of purpose. Where required, such leaders are able to change the direction of the organisation and
inspire others to follow.

Policy & Strategy Excellent Organisations implement their mission and vision by developing a stakeholder focused strategy that takes account
of the market and sector in which it operates. Policies, plans, objectives, and processes are developed and deployed to
deliver the strategy.

People Excellent organisations manage, develop and release the full potential of their people at an individual, team-based and
organisational level. They promote fairness and equality and involve and empower their people. They care for,
communicate, reward and recognise, in a way that motivates staff and builds commitment to using their skills and
knowledge for the benefit of the organisation.

Partnerships &
Resources

Excellent organisations plan and manage external partnerships, suppliers and internal resources in order to support policy
and strategy and the effective operation of processes. During planning and whilst managing partnerships and resources
they balance the current and future needs of the organisation, the community and the environment.

Processes Excellent organisations design, manage and improve processes in order to fully satisfy, and generate increasing value for,
customers and other stakeholders.

Customer Results Excellent organisations comprehensively measure and achieve outstanding results with respect to their customers.

People Results Excellent organisations comprehensively measure and achieve outstanding results with respect to their people.

Society Results Excellent organisations comprehensively measure and achieve outstanding results with respect to society.

Key
PerformanceResults

Excellent organisations comprehensively measure and achieve outstanding results with respect to the key elements of their
policy and strategy.

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enhance quality of life for elderly people (name and
objectives), age of the PA programme [39], characteris-
tics of age groups and participants’ average age [40,41],
number of activities offered in the PA programme
[42,43], frequency of the programme (days/week) [1,39],
quality initiatives [20,44-47], name of the organization
that delivers the programme, and identification details
of the PA programme’s coordinator (Additional file 1).
Question format ranged from closed questions with
multiple choices and dichotomous type to open-ended
question. Categorical data were expressed as absolute
counts and percentages. Continuous data were
expressed as the mean and SD.
An open-ended question which addressed the objec-

tives of the programme was analysed using qualitative
content analysis with QSR NVivo software. Contingency
tables and chi-square tests were used to analyse associa-
tions between categorical variables, performed with the
Statistical Package SPSS, version 17.0. Significance level
was set at p ≤ 0.05.

Results and Discussion

Number of PA programmes and geographic localization
Of the 278 municipalities, 97 questionnaires were totally
answered. Since some municipalities provided more
than a single programme, 174 programmes intended to
enhance the quality of life for elderly people were identi-
fied. Of these, 125 were PA programmes. Figure 2 repre-
sents the geographical distribution of the 125 PA
programmes in the 18 districts of the Portugal mainland
and it also represents the 5 regions (NUT_II). The lar-
gest percentage of programmes was located in the lit-
toral districts of the Continent (58.9%) where there is
the greatest number of residents and more percentage
of individuals aged 65 or more, i.e., 69.4% [48], as
revealed in Figure 3 and Figure 4.

Objectives of the PA programme
The major objective focused was “to promote health”
(95.2%) remotely followed by “to improve physical func-
tion” (28.8%), “to create socialization opportunities”
(25.6%) and “to prevent disease” (18.4%), as reflected in
Table 2. Chi-square analysis showed a higher than
expected number of programmes that aim “to create
socialization opportunities” in the Alentejo region, possi-
bly due to the fact that this places are separated by vast
plains of uninhabited territory, with a poor transport
network and a lack of opportunities for socialization
[49], which are generally located in more urbanized
localities. On the contrary, the programmes belonging
to the North are those that give less value to this objec-
tive (p = .017). Instead, it is in the North of the country
that the programmes pay more attention to the objective
“to promote physical activity” (p = .04). When analyzing

the national territory according to the coastland areas
and inland areas, we found that the programmes from
the coastland give more importance to the objective “to
improve self-esteem/self-confidence” (p = .023). In line
with this diversity of objectives found in the PA pro-
grammes of the present study, scientific evidence sup-
ports that regular PA has several physical, psychological
and social beneficial effects on a variety of health out-
comes [1,6,50-54].

Age of the PA programme
The results (Figure 5) indicate that the most common
age of the PA programme was “one year of age and less

Figure 2 Distribution of PA programmes by district;
representation of NUT_II.

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than five”, representing 55.2% and “five years of age and
less than ten”, representing 26.4%. Programmes with 10
or more years (8%) are located mainly in the Lisbon
region, possibly due to the fact that there is a greater
concentration of population aged 65 years or more (p ≤
.000) [48]. This may have led Lisbon region’s politicians
to be sooner concerned than their peers regarding the
design of programmes that meet the elderly people’

needs. This has been made easier possibly because of
the presence of town halls’ organizational structures
necessary for the development of programmes, such as
sports divisions, and qualified people with a degree in
physical education or sport [55]. In addition, pro-
grammes that are located on the coastland (also with
the highest concentration of elderly population) are
those that are established for longer (p ≤ .000). The fact
that many programmes have emerged in recent years
may suggest that local government has made an effort
to create initiatives aimed at increasing PA in elderly
adults, integrating issues of ageing into social and local
health policies. It will also be noted that since the late
nineties, the Municipal enterprises of sport have
expanded with increasing impact [56], providing favour-
able conditions for the development of these pro-
grammes. Moreover, the global tendency toward the
decentralization of policies, which also includes those
concerning the promotion of PA and the implementa-
tion of effective health-promotion strategies with regard
to the distribution and administration of resources,
highlights the key role that must be played by local
authorities [57].

Characteristics of age groups and participant’s average
age
Table 3 provides the characteristics of age groups, i.e.
minimum and maximum age required to enrol in the
PA programme, and the average age of participants.
While the maximum age intended is, in most cases,

“not limited” (64%) and the minimum age is 55 years
(85%), the average age of participants is 72.23 ± 1.54
years. The majority of programmes have a minimum
age of 55 years as a pre-requisite for admission (68%),
followed by those who require 60 years as the mini-
mum age (16.8%). Some authors [58-60] advocate that
the benefits of sufficient aerobic exercise, even if
started as late as age 60 years, is associated with a 1-
to-2 year increase in life expectancy as well as
improved functional independence and quality of life
benefits. According to a six-year study carried out by

Figure 3 Population density by municipality and by NUT_II
(INE 2009).

Figure 4 Distribution of resident population according to age
groups, by NUT_II (INE 2009).

Table 2 Objectives of the PA programmes for elderly
people

% n

To promote health 95.2 119

To prevent disease 18.4 23

To improve physical function 28.8 36

To create socialization opportunities 25.6 32

To promote social recognition 9.6 12

To improve self-esteem/self-confidence 11.2 24

To promote leisure occupation 15.2 19

To promote physical activity 16.8 21

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researchers at the US National Institute on Aging,
elderly people who are physically active are much
more likely to live longer than elderly people who are
not physically active [61]. However, there are still 19
programmes (15.2%) that have higher minimum ages
(65 and 70 years old). The available data from the
Contemporary Portugal Database [40] indicates that
the oldest age group (75+) increased at the fastest pace
(from 1991 to 2001, their number increased 32.8%
from 527948 to 701366). Actually, people’s life expec-
tancy in developed countries has increased greatly over
the last 25 years, leading to an increase in the retire-
ment age [41]. Shephard argues that in early old age
(65-75 years), there may be a modest increase of PA,
in an attempt to fill free time resulting from retire-
ment [62]. In this way, the minimum age required to
enrol in some PA programmes, although high, respond
to demographic and social trends.

Number of activities offered in the PA programme
Figure 5 gives an overview of the number of activities
offered in PA programmes. The majority number of
activities was “4 or more”, representing 46.4%, followed
by the PA programmes with “two activities”, which
reached 28%. Programmes with 10 or more years are
those that offer more activities, while programmes with
1-5 years offer two activities (p = .003). These results sug-
gest that older programmes are more aware of recom-
mendations concerning this issue. Roberts and Brodie
suggest that such programmes should offer a wide range
of activities, while allowing individuals to focus on those
gradually that they identify as more likely to engage in
regularly [42]. Among other considerations, the AHA
scientific statement [43] also stated that these pro-
grammes should fulfil the demands of different needs
between women and men, embrace occupational and lei-
sure activities and simple tasks of daily living, incorporate
the importance of socialization and include a diversity of
exercise activities to enhance PA participation of the
elderly. Simultaneously, our data suggest that more
recent programmes seem to be more cautious regarding
the inclusion of different activities, preferring initially to
get a deeper understanding of customer needs.

Frequency of the programme (days/week)
The usual frequency with which individuals participate
in the overall programme are two times per week (Fig-
ure 5), representing 54.4%. Moreover, 28% of the

Figure 5 Characteristics of PA programmes’ age, number of activities and frequency/week.

Table 3 Characteristics of age groups and participant’s
average age

minimum age intended maximum age intended

55 60 65 70 75 80 85 90 95 n.l.

% 68 16.8 14.4 0.8 4.8 11.2 2.4 16 1.6 64

n 85 21 18 1 6 14 3 20 2 80

mean ± SD participants’ age 72.23 ± 1.54

n.l.: not limited

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programmes allow seniors to sessions for three or more
times per week, offering them organized opportunities to
be physically active. Programmes of 6 to 10 years of age
are those that can be attended a greater number of days
per week (p = .034). Consequently, the international
recommendations [6] to increase the level of PA among
older people in order to reach at least 30 minutes or
more of moderate-intensity PA on most – preferably all
– days of the week are more easily achieved. The Lisbon
region presents a larger than expected number of pro-
grammes with a weekly frequency of three times, while
the Centro region presents a greater number of pro-
grammes that could be frequented only once per week (p
= .006). When compared the number of activities offered
by the programme with the weekly frequency, it was
observed that the greater the number of activities, the
greater the number of days per week that an individual
can participate in the programme (p = .003).

Quality initiatives
Just one PA programme for elderly people (0.8%) has
quality initiatives, in this particular case, a quality man-
agement system certification. Beyond certification, the
certifying institution provides customized solutions to
increase the quality and efficiency of the programme.
The use of quality schemes in public leisure services in
Portugal [38] is widely divergent from use in other coun-
tries [37,63-65], where their governments act directly in
this matter. In this respect, several studies [37,44-46]
found that the quality initiatives may improve process
and outcomes. The Healthy Ageing – A Challenge for Eur-
ope Report [47] suggests a systematic application of qual-
ity management/assurance methods to increase project’s
quality; these indicate that Quality is an important issue
for PA programmes for older people. Simultaneously, the
Benchmark 3 from Physical Activity and Health Branch
at the CDC [20] advocate a complete programme evalua-
tion in order to improve their continuous quality
improvement. This reinforcement is given by the CDC
with the following statement: ’the evaluation is the sys-
tematic examination and assessment of features of an
initiative and its effects, in order to produce information
that can be used by those who have an interest in its
improvement or effectiveness’ (CDC 2002 [19], p.5). So, in
opposition to what was found in the present study, it
seems that PA programmes for elderly people must be
assessed to make informed decisions when planning new
initiatives or examining existing services, in order to
improve them. It also reveals commitment to delivering
the highest quality service viable with available resources.

Organization that delivers the programme
The main organization that owns the programme was
the “municipal government” (85.6%) distantly followed

by “other” (7.2%) and “municipal enterprises of sport”
(4.8%), as reflected on Table 4. The municipal govern-
ments are responsible for developing programmes in the
Lisbon region, whereas in the Alentejo region, the Local
City Centre or other local organizations develop them
(p = .005). These results suggest that in regions where
there is greater dispersion of the population, such as
Alentejo [48], governments and other organizations clo-
ser to the population are responsible for developing
these programmes, revealing a greater involvement of
different partners. The development and sustainment of
the community partnerships is the first public health
benchmarks for PA Programmes established by the Phy-
sical Activity and Health Branch at the CDC [20].

Conclusion
In conclusion, data showed that the majority of the 125
PA programmes identified in the present study set the
goal of promoting the health of participants, which
reflect the current recommendations. Furthermore, the
majority of programmes have a minimum age of 55
years as a pre-requisite for admission. However, there
are still some programmes that have higher minimum
ages. It was also observed that the greater the number
of activities, the greater the number of days per week
that an individual can participate in the programme,
with most of the programmes offering two activities and
having a frequency of two times per week. The “munici-
pal government” was the main organization responsible
for developing the PA programmes.
Moreover, in spite of an eminent preoccupation with

health, quality of life and autonomy of older subjects
inherent to the PA programmes studied, there is no
effective use of quality initiatives, seen as an important
process to improve programmes. Indeed, our results
showed that only one PA programme develops quality
initiatives. In summary, the results of the present study
highlight the need of continuous quality improvement
of the Portuguese PA programmes for elderly people,
since it can be critical for elderly satisfaction and
adherence.
In closing, although these findings provide some clues,

future research may be needed to characterise the qual-
ity management models of the PA programmes devel-
oped by the Portuguese Local Administration, using the
EFQM’ criteria or other tool considered applicable.

Table 4 Organization name

% n

Municipal Government 85.6 107

Municipal enterprises of sport 4.8 6

Local City Centre 2.4 3

Other 7.2 9

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Strengths and Limitations

To our knowledge, this was the first study exploring the
general characteristics of the Portuguese PA pro-
grammes for elderly people, as well as identifying which
organizations were developing quality initiatives. The
relevance of this investigation is that it offers a direction
for further research into quality management in an area
that has not previously been extensively examined.
However, a major limitation is worthy of comment.

Taking into account that the invitations to participate in
the study were done online, so the answer to the ques-
tionnaire was voluntary, care should be taken in extra-
polating our findings, since our sample is, probably, not
representative of all PA programmes developed in
Portugal.

Additional material

Additional file 1: On-line questionnaire. Explanation of the structure
and content of the on-line questionnaire

Acknowledgements

This study was supported by FCT – SFRH/BD/36796/2007

Author details

1Research Centre in Physical Activity, Health and Leisure, Faculty of Sport,
University of Porto, Porto, Portugal. 2Department of Physical Education, José
Estêvão High School, Aveiro, Portugal. 3School of Health Technology of
Porto, Polytechnic Institute of Porto, Porto, Portugal. 4Research Centre in
Sports, Health Sciences and Human Development, Higher Institute of Maia,
Maia, Portugal.

Authors’ contributions
AIM participated in the acquisition and analysis of data and participated in
drafting and editing the manuscript. PS supervised the drafting and editing
of manuscript. LSM and CM managed the data collection and analysis. AOT
provided technical support on the data collection and analysis. PCS and SV
helped design the questionnaire and managing the online process. RC and
JC participated in the coordination of the study and supervised the drafting
and editing of manuscript.
All authors read and approved the final manuscript.

Competing interests

The authors declare that they have no competing interests.

Received: 27 June 2011 Accepted: 26 September 2011
Published: 26 September 2011

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doi:10.1186/1756-0500-4-368
Cite this article as: Marques et al.: Evaluation of physical activity
programmes for the elderly – exploring the lessons from other sectors
and examining the general characteristics of the programmes. BMC
Research Notes 2011 4:368.

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Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.

Abstract
Background
Methods
Results
Conclusions
Background
Methods
Results and Discussion
Number of PA programmes and geographic localization
Objectives of the PA programme
Age of the PA programme
Characteristics of age groups and participant’s average age
Number of activities offered in the PA programme
Frequency of the programme (days/week)
Quality initiatives
Organization that delivers the programme
Conclusion
Strengths and Limitations
Acknowledgements
Author details
• Authors’ contributions

Competing interests
References

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OFF THE PRESS

Journal of Sport Management, 2012, 27,

84

-85
© 2012 Hunaan Kinetics, Inc.

Sports Finance and Management:
Real Estate, Entertainment, and the
Remaking of the Business (1st Ed.)

By Jason A. Winfree and Mark S. Rosentraub. Published
in 2012 by Taylor & Francis Group, Boca Raton, FL.
(481 pp., $69.95).

Reviewed by Jason D. Reese, PhD, Assistant Professor,
University of Mary Hardin-Baylor

How has the business of sport changed over the last
two decades? The answer to this question is somewhat
obvious; a lot! However, when researchers and practi-
tioners take a closer look at these changes, they realize
the changes vary based on the discipline within spori
business. Sport Finance and Management takes a closer
look at the changes affecting tbe financial aspect of
spori business. It is an excellent comprehensive text that
focuses on topics such as the financing of sport facilities,
ownership stmctures, pricing strategies, investments, and
more. This book differs from most spori finance texts due
to its underlying theme: sport, entertainment, and real
estate development. As we have seen in many sport man-
agement higher education programs around the world,
sport business is often partnered with entertainment; in
both theory and practice. Therefore, this text would be
exceptional for those students wishing to experience the
foundational theories in sport finance, with an emphasis
on enteriainment and real estate development.

While not formally organized, the text can be divided
into five sections: a) introduction to sport business and
finance, b) facilities and real estate finance, c) media
and team valuation, d) customer demand and pricing
strategies, and e) investments, league policies, and taxes.

Chapters 1-3 provide an introduction to the field
of sport business, how it has changed over the past two
decades, its ownership structure, and an introduction
to financial statements. Chapter 1 begins with an intro-
duction to how rapidly the sport industry has become
increasingly dynamic. This discussion is broken down
into four changes in the industry that have directly
challenged sport finance practitioners and researchers:
ownership structure, media, real estate investments,
and league policies. This chapter does a great job of
providing longitudinal data across multiple leagues and
facilities to suppori their assertions. Following discus-
sion on the changes affecting sport finance practitioners,
the authors present various changes in ownership struc-
ture in Chapter 2. This is an important discussion as it
serves as a foundation to the development of subjects
in future chapters. This chapter is focused on the his-
tory of team sporis and how they were developed with

the purpose of supporting industrial growth, meeting
the needs and wants of a growing population, captur-
ing increased wealth and discretionary spending, and
creating a socializing foundation to support egalitarian
ideals. The chapter also explores the current pattems of
ownership in today’s sport industry. This includes the
positives and negatives of various ownership structures
along with discussion on the varied business interests
of majority owners. Finally, the chapter concludes with
how sport teams are integrating their business models
both horizontally and vertically.

Chapter 3 is developed around four types of financial
statements (balance sheets, income statements, statements
of retained eamings, and statements of cash flows), and
how these statements are examined through ratio analysis.
This chapter is essential for understanding how financial
principles should be applied to a unique industry. This
chapter uses financial data from publically traded com-
panies, including those from major league teams and
multinational sport retail and apparel corporations. The
chapter concludes with an analysis of specific revenue
sources such as sponsorship, media, and in-stadium
revenue in various leagues.

Chapters 4-6 shift the discussion to sport facilities
and real estate. These chapters primarily focus on how
facilities are designed and financed, and how the real
estate development industry has merged with the spori
industry. A new term is introduced to the reader in chapter
4, “Disneyfication”. This term refers to the design of a
facility that includes activities related to entertainment
and retail offerings that surround the event being held.
This chapter uncovers the various financial concerns
related to facility design, size, and location. The discus-
sion related to facilities continues into chapter 5. This
chapter primarily focuses on the two main tools used to
finance facilities: equity and debt financing. An examina-
tion of bonds is also included. In addition, the chapter
includes an appendix that examines the mathematics
behind the time value of money. This appendix would
be well suited for a more advanced student population.
For example, graduate education is probably the best fit
for using this information. The chapter then concludes
with an overview of facility financing from the public
sector, specifically taxes. The last chapter in this section
shifts its focus from facility design and financing to the
idea that sports teams can become real estate develop-
ment companies.

Chapter 6 discusses the value of land in downtown
versus suburban areas, tbe advantages of developing
facilities in residential and entertainment districts, and
horizontal integration toward “Disneyfication.” The book
describes “Disneyfication” as the entertainment beyond
the sport event. This chapter is beneficial to curriculum
that wishes to focus on the effects of marketing on the

84

Off the Press 85

financial viability of a sport organization. The chapter
includes an in-depth discussion of real estate inside the
facility. Real estate inside the facility includes, but is not
limited to: luxury seating, price tiers and the seating deck,
signage on scoreboards, electronic and other displays,
playing surfaces, facility naming rights, and uniforms
or “kits”. The chapter concludes with two case studies
of sport teams where cities, San Diego and Los Angeles,
used facilities to increase profits. These case studies give
instructors the ability to shift their focus from interpreta-
tion of financial theories to practical application.

Chapters 7 and 8 deal with the introduction of media
to the sport industry, as well as how teams derive their
value. These chapters are of particular relevance for
researchers and practitioners who are interested in the
vertical integration of sport teams and how it has affected
team valuation. Chapter 7 is organized around the idea
that the media-team relationship has gone through an
evolution which includes 3 phases: a) media as advertis-
ing for teams and leagues, to b) media as a major revenue
source, and finally c) media vertically integrating with
teams. The chapter includes discussion on the changes
in the media-team relationship due to consumer inter-
ests, the need for competitive balance, and the role of
the internet on sports media consumption. The chapter
does a good job of acknowledging the changes in how
sport coverage is consumed. Specifically, netcasts and
advanced media are addressed; relatively new topics in
the sport management discipline.

Chapter 8 shifts the focus to how teams are valued.
The chapter addresses issues related to ownership struc-
ture such as controlling interests and vertical integration
with media. Furthermore, various types of valuation
models such as multiple earnings, zero growth, constant
growth, capital asset pricing, and the free cash flow model
are addressed. The authors do a good job in engaging
readers by offering an in-depth analysis of the value of
franchises in the North American “Big Four” (NFL, MLB,
NBA, & NHL), as well as college athletics.

Chapters 9 and 10 focus on customer demand and
actions that sport teams have taken to change demand
in the short and long run. The discussion of demand is
introduced in chapter 9 with an overview of the law of
demand and its effect of quality and price. This section is
essential to those readers with limited experience in the
economic theories of supply and demand. The chapter
then divides demand in two broad categories: a) long-
run and b) short-run demand. In the long-run section
there are investigations into the trends in the market,
market penetration, substitutes associated with economic
competition, and the honeymoon effect of new facilities.
The short-run section focuses on demand for tickets.
Examples of short-run changes in ticket demand include
the effect of winning, superstars, intemational markets,
game specific determinants, and television’s effect on
attendance. This discussion on short-run demand is a
great transition into chapter 10.

In chapter 10, the authors focus on the various
pricing mechanisms used in the sport industry. Much
of the discussion relates to the pricing of event tickets

and includes foundational concepts on the elasticity of
price. In addition to these foundational theories, the
case for many traditional promotional pricing tactics is
presented. For example, personal seat licenses, bundling,
price discrimination, and group discounts are examples
of traditional promotional pricing tactics. In addition to
these traditional methods, the chapter addresses innova-
tive strategies being introduced into today’s sport event
ticket industry. They pay significant attention to innova-
tive practices such as variable ticket pricing, dynamic
pricing, and “pay what you want” pricing.

The last two chapters (11 & 12) conclude the text
by evaluating the various types of investments made
by sport organizations and how these investments
are affected by league policies and taxes. Chapter 11
defines capital budgeting and reviews the various types
of team investments. The discussion of investments is
continued with an overview of the various types of risk,
and the differences between risk and uncertainty in an
investment. Finally, an overview of the various types
of investments that teams make in areas such as player
contracts and facility improvements is presented. The
last chapter in the text focuses primarily on the various
league policies that affect sport organizations. These
policies include player drafts, revenue sharing, luxury
taxes, salary caps, collective bargaining, and league
specific policies. The chapter then concludes with an
overview of the various taxation methods used by sport
organizations to maximize profit.

The major strength this text brings to the current
sport finance landscape is the application of financial prin-
ciples to sport, entertainment, and real estate. This is not
to say that other sport finance texts do not concentrate on
the unique aspects of sport finance. However, Sport and
Finance Management spends a great deal of time discuss-
ing unique combinations of sport and entertainment seen
in today’s sport industry, in addition to sport teams and
their investment in real estate. A second strength of this
text is the authors’ use of current financial statements and
data. While many sport organizations keep their financial
information private, the book uses data from organization
that must release their financial information such as Nike
and the Green Bay Packers to explain theoretical material
covered in the chapters.

One of the limitations to this text is that while each
chapter relates to one another well, the text is not seg-
mented into broad categories. However, the chapters are
presented in a logical and well-organized manner; the
book begins with an introduction and walks the reader
through various issues that sport finance professionals
encounter in today’s dynamic industry.

While there may be some issues to be worked out in
future editions, this first edition is an exceptional tool for
instructors of sport finance courses at the undergraduate
level. In addition, due to its excellent overview of issues
facing the sport manager in today’s industry, this text
could be used as a supplement for introductory or survey
courses in sport management. Likewise, this text would
be well-suited as a supplement for graduate level sport
finance courses.

Copyright of Journal of Sport Management is the property of Human Kinetics Publishers, Inc. and its content

may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder’s express

written permission. However, users may print, download, or email articles for individual use.

RESEARCH ARTICLE

Depression, distress and self-efficacy: The

impact on diabetes self-care practices

Cassidy Devarajooh
☯*, Karuthan Chinna☯

Department of Social and Preventive Medicine, Faculty of Medicine, University of Malaya, Jalan Universiti,

Wilayah Persekutuan, Kuala Lumpur, Malaysia

☯ These authors contributed equally to this work.
* cassdeva@hotmail.com

Abstract

The prevalence of type 2 diabetes is increasing in Malaysia, and people with diabetes have

been reported to suffer from depression and diabetes distress which influences their self-

efficacy in performing diabetes self-care practices. This interviewer administered, cross sec-

tional study, conducted in the district of Hulu Selangor, Malaysia, involving 371 randomly

selected patients with type 2 diabetes, recruited from 6 health clinics, aimed to examine a

conceptual model regarding the association between depression, diabetes distress and

self-efficacy with diabetes self-care practices using the partial least square approach of

structural equation modeling. In this study, diabetes self-care practices were similar regard-

less of sex, age group, ethnicity, education level, diabetes complications or type of diabetes

medication. This study found that self-efficacy had a direct effect on diabetes self-care prac-

tice (path coefficient = 0.438, p<0.001). Self-care was not directly affected by depression and diabetes distress, but indirectly by depression (path coefficient = -0.115, p<0.01) and diabetes distress (path coefficient = -0.122, p<0.001) via self-efficacy. In conclusion, to improve self-care practices, effort must be focused on enhancing self-efficacy levels, while

not forgetting to deal with depression and diabetes distress, especially among those with

poorer levels of self-efficacy.

Introduction

Diabetes mellitus is a common chronic disease in Malaysia. According to national studies, the

prevalence of diabetes has increased from 11.6% in 2006 to 15.2% in 2011 [1]. People with dia-

betes suffer from a higher burden of psychosocial problems and psychological disorders [2].

The prevalence of depression is higher among people with diabetes, and is partly attributed by

vascular damage which may induce cerebral pathology that constitutes vulnerability for

depression [3]. Depression adds to the burden of managing diabetes, as those with depression

perform poorer diabetes self-care [4].

Diabetes distress, an affective disorder, is a syndrome comprised of a multidimensional

component, such as worry, conflict, frustration, and discouragement that can accompany liv-

ing with diabetes, and is closely related to depression [5]. Majority of people with diabetes who

PLOS ONE | https://doi.org/10.1371/journal.pone.0175096 March 31, 2017 1 / 16

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OPEN ACCESS

Citation: Devarajooh C, Chinna K (2017)

Depression, distress and self-efficacy: The impact

on diabetes self-care practices. PLoS ONE 12(3):

e0175096. https://doi.org/10.1371/journal.

pone.0175096

Editor: Mohammad Ebrahim Khamseh, Institute of

Endocrinology and Metabolism, ISLAMIC

REPUBLIC OF IRAN

Received: January 9, 2017

Accepted: March 20, 2017

Published: March 31, 2017

Copyright: © 2017 Devarajooh, Chinna. This is an
open access article distributed under the terms of

the Creative Commons Attribution License, which

permits unrestricted use, distribution, and

reproduction in any medium, provided the original

author and source are credited.

Data Availability Statement: All relevant data are

within the paper and its Supporting Information

files.

Funding: The authors received no specific funding

for this work.

Competing interests: The authors have declared

that no competing interests exist.

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were depressed experienced diabetes distress, however, most of those experiencing diabetes

distress were not depressed [6]. Diabetes distress effects an individual’s problem solving skill

which is required to carry out diabetes self-care and this may result in poorer self-care prac-

tices, and ultimately poorer glycemic control [7].

Both depression [8]and diabetes distress [9] influences self-efficacy. A high level of self-effi-

cacy is needed to manage the daily challenges associated with caring for diabetes. Individuals

with higher levels of self-efficacy perform better diabetes self-care practices [10, 11].

This study aims to explore the relationship between depression, diabetes distress and self-

efficacy with diabetes self-care practices. Up to date, there has been no study in Malaysia

which assessed the structural relationship between depression, diabetes distress and self-effi-

cacy with diabetes self-care practices. Based on the available literature, it is hypothesized that

self-efficacy affects diabetes self-care directly, while depression and diabetes distress both have

direct and indirect effects via self-efficacy on diabetes self-care. Diabetes distress is hypothe-

sized to affect depression directly. Fig 1 illustrates the relationship between self-care with

depression, self-efficacy and distress.

Materials and methods

This was a cross sectional study with patients recruited from all 6 primary health clinics in the

district of Hulu Selangor. Hulu Selangor is the biggest district in the state of Selangor, measur-

ing about 174,047 hectares. In the district of Hulu Selangor, there were 6,396 patients with

type 2 diabetes receiving treatment in 6 government health clinics. The fees for each visit inclu-

sive of consultation, investigation and medication is only 1 Ringgit Malaysia (1 US Dollar = 4.40

Ringgit Malaysia, average exchange rate in December 2016). Eligibility criteria as a participant

in this study was being a Malaysian older than 18 years old, having a diagnosis of type 2 diabe-

tes and can at least understand the Malay language. The exclusion criteria were pregnancy and

cognitive impairment such as dementia or mental retardation. Eligible patients were

approached for written consent for the study.

Fig 1. Hypothesized model of the relationship between depression, diabetes distress and self –

efficacy with self-care

practices.

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Sample size

To perform a partial least square structural equation modeling, Henseler et al. [12] recom-

mended a 10 to 1 ratio of sample size to model parameter. The theoretical model in this study

had 6 model parameter. Thus with a ratio of 10 to 1, the sample size required was 60. For a reli-

able analysis, a minimal sample size of 200 is considered good. To determine diabetes self-care

practice, the sample size was calculated using the Open Epi software version 3.01. With a type

2 diabetic population of 6,396, power of 80%, confidence interval of 95% and an anticipated

frequency of good self-care at 52% [13], the required sample size was 361. The sample size was

increased by 30% after considering non-responders. The final sample size was 480 patients. A

proportionate number of patients were selected from all 6 clinics based on the number of

patient attendees. Every 10th patient on the follow-up list was approached to participate in this

study. The purpose and relevance of the study was explained to all the potential participants.

Data management and statistical analysis

This was an interviewer-based study. Data was double entered and cleaned before analysis.

The Statistical Package for the Social Science (SPSS) version 20 was used for descriptive and

inferential analysis and subsequently for factor analysis of the diabetes distress scale.

Categorical variables were presented as frequency (n) and percentages (%), and numerical

variables were presented as mean and standard deviation (SD). ANOVA and t test were used

to determine differences in continuous data.

For factor analysis, a good factor analytical model must have several properties. The guide-

lines provided by Hair et al (2010) were used [14]. The item correlation must be between 0.3–

0.9, the Kaiser-Meyer-Olkin (KMO)>0.6 and the factor loading ideally >0.7 but not less than

0.5 is acceptable. The preferred Average variance extracted (AVE) is >50%, but may be less if

some factor loading are <0.7. The correlation between subdomains of the diabetes

distress

scale should be<0.85 to have discriminant validity.

The Smart PLS3 software was used for the structural equation modeling. The path coeffi-

cients were calculated between variables and the significance level was set as p<0.05.

Ethical issue

Ethical approval for this study was obtained from Malaysian Institute of Public Health, regis-

tration number NMRR-13-93-15292 and from the University of Malaya Ethical Committee.

Permission to conduct the study was also obtained from the State Health Director, District

Heath Offices and the respective Medical Officers.

Self-care. Diabetes self-care was assessed using the Malay version of the Summary of Dia-

betes Self Care Activities scale. The Malay version of the Summary of Diabetes Self Care Activi-

ties scale has 12 items and measures levels of diabetes self-care in 5 major areas; diet, exercise,

adherence to medication, blood glucose testing and foot care. Every item measures the number

of days each diabetes self-care activities were practiced in the last seven days, and is scored

between 0 to 7. To assess overall diabetes self-care, the score of all items was divided with the

total number of items. Similarly, to assess self-are for individual areas of diabetes care, the

score of all items within the respective area of diabetes care was divided with the correspond-

ing number of items. From a possible score of between 0 to 7, a score of 4 and above was con-

sidered as good practice [15, 16].

Self-efficacy. Self-efficacy was assessed using the Malay version of the Diabetes Manage-

ment Self Efficacy scale [15]. This questionnaire has 14 items and measures self-efficacy in 4

major areas; diet, exercise, medication adherence and blood glucose control. Each item was

scored between 0 to 10. The scoring of this scale was based on the total score of all items, with

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higher score indicating better self-efficacy. There was no scoring for individual areas of self-

efficacy. The possible score for this scale was between 0 to 140.

Depression. Depression was assessed using the Malay version of the PHQ (Patient

Health Questionnaire)– 9 item questionnaire. The Patient Health Questionnaire-9 (PHQ-9)

is a self-report measure to screen for depression, consisting of nine questions with each item

being scored from 0 to 3. The PHQ-9 is scored by calculating the total score of all 9 items.

The total PHQ-9 scores ranges from 0 to 27 with the scores of 10 or more categorized as

depression [17].

Diabetes distress. Diabetes distress was assessed using the Diabetes Distress Scale (DDS),

a 17 item questionnaire, measuring 4 domains of distress; [18] emotional burden, physician

related distress, regimen related distress and interpersonal distress. Each item was measured

on a Likert Scale of 1–6, where higher values indicate distress. The DDS allows overall distress

or the individual domain to be measured. The score for the scale was based on the average

score of all the items, with a possible score of between 1 to 6. A score of 3 or more was catego-

rized as distress. This questionnaire was not available in the Malay language. Originally in the

English language, it was translated and validated in this study

Data collection tools and measurements

The consented eligible patients were required to complete the survey. A face-to-face interview

was conducted. Self reported data regarding socio-demographics, diabetes self-care practices,

self-efficacy, depression and diabetes distress were collected by trained interviewers.

Translation, pre-test and pilot test

Originally in English and not available in the Malay language, the Diabetes Distress Scale was

translated and validated prior being used. The scale has 17 items, measuring distress in four

domains; emotional burden, physician related distress, regiment related distress and interper-

sonal distress. As the scale was not available in the Malay language, it underwent a translation

process. The forward translation was performed by 3 individuals while the backwards transla-

tion by 2 individuals. All translators were familiar and fluent with the original language and

target language. A panel decided on the best translation that suited the target population. The

translated version underwent pre-testing involving 16 patients with diabetes and pilot testing

involving 40 patients with diabetes recruited from the same study setting. All the domains had

good internal consistency with Cronbach Alpha >0.7.

Results

Four hundred and eighty eligible patients were approached, 391 agreed to participate in this

study, giving a response rate of 81.5%. The sex, age, duration of diabetes and HbAc1 values

were comparable between responder and non-responder (Refer Table 1)

After data cleaning, only 371 participants were included for analysis. The mean age of the

participants was 55.33 ± 10.09 years. Among the 371 study participants, 141 (38.0%) were
males, 215(58.0%) were of Malay ethnicity followed by Indians at 110 (29.6%) and Chinese at

46 (12.4%).

Majority of the study participants, n = 189 (50.9%) attained primary education (�6 years of

formal education), followed by secondary education (7–11 years of formal education), n = 149

(40.2%) and lastly tertiary education (�12 years of formal education) n = 33 (8.9%). The most

prescribed oral hypoglycemic agent was biguanide, n = 340 (91.6%), followed by sulphonyurea,

n = 251 (67.7%), acarbose n = 18 (4.9%) and lastly glitazones, n = 9 (2.4%). One hundred and

three (27.8%) study participants were prescribed insulin injections. Among the study

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participants, 41 (11.4%) had retinopathy, 21 (5.8%) had ischemic heart disease, 4 (1.1%) had

stroke while 2 (0.6%) had nephropathy.

The mean diabetes self-care score was 3.87 ± 0.82, with 170 (45.8%%) categorized as prac-
ticing overall good diabetes self-care. For the individual self-care domains, medication adher-

ence had the highest score, followed by foot care, diet, exercise and lastly self-monitoring of

blood glucose, with the respective scores being 6.01 ± 1.98, 5.63 ± 1.84, 4.70 ± 1.56, 2.77 ± 1.78
and 1.38 ± 1.59. Among the 371 study participants, 303 (81.7%) practiced good medication
adherence, 290 (78.2%) practiced good foot care, 266 (71.7%) practiced good diet, 112 (30.2%)

had good exercise practices and lastly 32 (8.6%) had good self-monitoring of blood glucose

practices.

The mean depression score was 4.58 ± 2.57, with 16(4.3%) categorized as depressed. The
mean diabetes distress score was 1.54 ± 0.66, with 20 (5.4%) categorized as distressed. The
mean self-efficacy score was 104.08 ± 23.20, from a possible score of between 0 to 140. (Refer
Table 2)

The self-care practices were similar regardless of sex, age, ethnicity, education level, diabetes

complications and diabetes medication. Similarly, depression was not influenced by sex, age,

ethnicity, education level, diabetes complication or diabetes medication. Self-efficacy level was

significantly higher among those with secondary education level when compared to those with

primary education level. Self-efficacy was similar between sex, age group, ethnicity, complica-

tion status and diabetes medication. Diabetes distress was significantly higher among the

Malays when compared to the Indians and among those with tertiary education when com-

pared to those with primary education. Diabetes distress level was similar between sex, age

group, complication status and diabetes medication. (Refer Table 3).

To assess the relationship between self-care with self-efficacy, depression and diabetes dis-

tress as illustrated in Fig 1, a partial least square structural equation modeling analysis was per-

formed using the SmartPLS 3 software. As indicated in Fig 2, there was a significant direct

positive effect from self-efficacy (path coefficient = 0.438, p<0.001) to diabetes self-care. There

were also significant direct negative effects from depression (path coefficient = -0.263,

p<0.001) and from diabetes distress (path coefficient = -0.230, p<0.001) to diabetes self-effi-

cacy. There was a significant positive effect from diabetes distress (path coefficient = 0.268,

p<0.001) to depression. Both depression and diabetes distress had no significant direct associ-

ation with self-care, but had significant negative indirect effect on self-care, via self-efficacy.

The indirect effect of depression (path coefficient = -0.115, p<0.001) and distress (path coeffi-

cient = -0.122, p<0.001) indicate that depressed and distressed individuals had lower self-effi-

cacy and performed poorer self-care. This model explained 22% of variation in self-care.

(Refer Table 4)

Table 1. Comparison of baseline characteristics between responder and non-responder.

Variables Mean ± SD p—value
Responder (391) Non–Responder (89)

Sex* Male(145)
Female(246)

Male(40)

Female(49)

0.169

Age (years) 55.33 ± 10.09 55.71 ± 12.63 0.762
Duration of diabetes (years) 6.02 ± 4.60 5.26 ±4.04 0.153
HbA1c (%) 8.77 ±2.29 8.50 ± 1.96 0.308

t-test was performed for continuous data

* Chi-square performed with a significance level set at <0.05.

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Table 2. Participants demographics, self-care and psychosocial factors.

Characteristics Mean ± SD N (%)
Age (years) 55.33 ± 10.09
Sex

Male 141 (38.0%)

Female 230 (62.0%)

Race

Malay 215(58.0%)

Chinese 46 (12.4%)

Indian 110 (29.6%)

Education level

Primary education (1–6 yrs) 189 (50.9%)

Secondary education (7–11 yrs) 149 (40.2%)

Tertiary education (�12 yrs) 33 (8.9%)

Medication type

Biguanide 340 (91.6%)

Sulphonyurea 251 (67.7%)

Acarbose 18 (4.9%)

Glitazone 9 (2.4%)

Insulin 103 (27.8%)

Complications of diabetes

Ischemic Heart Disease 21 (5.8%)

Stroke 4 (1.1%)

Nephropathy 2 (0.6%)

Retinopathy 41 (11.4%)

SDSCA score (self-care) 3.87 ± 0.82
Good practice 170 (45.8%)

Poor practice 201 (54.2%)

Diet score 4.70 ± 1.56
Good practice 266 (71.7%)

Poor practice 105 (28.3%)

Exercise score 2.77 ± 1.78
Good practice 112 (30.2%)

Poor practice 259 (69.8%)

Medication adherence score 6.01 ± 1.84
Good practice 303 (81.7%)

Poor practice 68 (18.3%)

SMBG score 1.38 ± 1.59
Good practice 32 (8.6%)

Poor practice 339 (91.4%)

Foot care score 5.63 ± 1.98
Good practice 290 (78.2%)

Poor practice 81 (21.8%)

PHQ score (depression) 4.58 ± 2.57
Depressed 16(4.3%)

Non-Depressed 355 (95.7%)

DDS score (distress) 1.54 ± 0.66
Distressed 20 (5.4%)

Non-Distressed 350 (94.6%)

DMSE score (self-efficacy) 104.08 ± 23.20

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Factors influencing diabetes self-care

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Table 3. Socio-demographic characteristics and its associated factors among the study participants.

Characteristics, n(%) Self-care Self-efficacy Diabetes distress

Depression

Mean ± SD P value Mean ± SD P value Mean ± SD P value Mean ± SD P value
Sex 0.645

Male, 141(38.0%) 3.79 ± 0.77 0.181 104.51 ± 21.34 0.777 1.62 ± 0.71 0.066 4.50 ± 2.54
Female, 230(62.0%) 3.91 ± 0.70 103.81 ± 24.30 1.49 ± 0.62 4.63 ± 2.60
Ethnicity 0.681

Malay, 215(58.0%) 3.82 ± 0.90 0.392 103.86 ± 25.29 0.535 1.63 ± 0.72 0.007b 4.67 ± 2.85
Chinese, 46(12.4%) 3.92 ± 0.67 101.21 ± 21.69 1.46 ± 0.67 4.35 ± 2.16
Indian, 110(29.6%) 3.94 ± 0.68 105.70 ± 19.22 1.39 ± 0.47 4.50 ± 2.12
Age 0.776

�60 years, 255(68.7%) 3.92 ± 0.70 0.071 105.25 ± 22.75 0.15 1.53 ± 0.66 0.970 4.61 ± 2.62
>60 years, 116(31.3%) 3.77 ± 0.70 101.51 ± 24.05 1.54 ± 0.66 4.46 ± 2.44
Education level 0.008

c
0.245

Primary, 189(50.9%) 3.78 ± 0.74 0.080 101.46 ± 23.53 0.012a 1.49 ± 0.62 4.74 ± 2.70
Secondary, 149(40.2%) 3.98 ± 0.85 108.05 ± 21.09 1.53 ± 0.65 4.32 ± 2.29
Tertiary, 33(8.9%) 3.90 ± 1.00 101.18 ± 28.06 1.88 ± 0.84 4.91 ± 2.98
Complication status 0.913 0.425 0.286 1.00

With at least one complication, 67(18.1%) 3.86 ± 0.78 102.03 ± 23.31 1.63 ± 0.77 4.58 ± 2.79
No complication, 304(81.9%) 3.87 ± 0.82 104.53 ± 23.18 1.52 ± 0.64 4.58 ± 2.52
Diabetes treatment 0.056 0.929 0.071 0.491

OHA only, 268(72.2%) 3.81 ± 0.81 104.32 ± 23.27 1.52 ± 0.62 4.60 ± 2.47
Insulin only, 18(4.9%) 4.21 ± 0.85 104.50 ± 20.95 1.89 ± 0.94 3.89 ± 2.76
OHA and Insulin, 85(22.9%) 3.97 ± 0.82 103.23 ± 23.64 1.54 ± 0.71 4.67 ± 2.83

a
secondary education—primary education = 6.59

b
Malays—Indians = 0.231

c
tertiary education—primary education = 0.384

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Fig 2. Relationship between depression, diabetes distress and self –efficacy with self-care practices.

**p<0.001.

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The response to the 17 items of diabetes distress scale was subjected to principal axis factor-

ing to test the dimensionality of the items in the construct [19]. Items which had poor conver-

gence (correlation <0.3) with the construct or poor discriminance (correlation >0.9) were

removed. Items with poor factor loading (<0.5) were also removed. In the final version of the

questionnaire, the emotional burden domain had 4 items (item number 4 removed due to

poor correlation), the physician related distress domain had 3 items (item number 9 removed

due to poor factor loading), the regimen related distress domain had 4 items (item number 14

removed due to poor factor loading) and the interpersonal domain had 3 items. The sample

size was adequate with as the KMO values were >0.6, and had good convergence validity as

the AVE were around or more than 50% (Refer Table 5). All pairwise correlations between the

constructs were less than 0.85. Hence, there is sufficient discriminant validity between the con-

struct (Refer Table 6).

Discussion

As has been shown from the pilot study and the factor analysis, the translated Diabetes distress

Scale was valid. Factor analysis was performed to ensure that the translated Diabetes distress

Scale measures what it was meant to while enabling the items to be reduced into a smaller set to

save time and facilitate easier interpretation [20]. The final translated Diabetes Distress scale has

14 items. All the items within the respective domains had item correlation of between 0.3–0.9,

which meant that all the items measured the same underlying theory. The KMO (Kaiser-

Meyer-Olkin) value for all domains of the translated Diabetes Distress scale were > 0.6, indicat-

ing that the sample size was sufficient to perform a factor analysis. Only one factor was extracted

from each domain, with the factor loading of all items being >0.5, indicating good relationship

between each item with the underlying factor[20]. All pairwise correlations between the con-

structs were less than 0.85, indicating that there was no sign of multicollinearity [21].

The baseline characteristics between responder and non-responder were the same, thus

reducing any possible responder bias.

Though there is limited information regarding diabetes self-care practices among Malay-

sians, the finding of this study was in agreement with the available studies which reported non

satisfactory diabetes self-care practices [13, 22]. Medication adherence was the most practiced

self-care and this was most likely because medication was provided for free by the healthcare

provider and unlike diet and exercise which requires lifestyle changes, it was easier to performed

[23]. Furthermore, the immediate effect or derangement of health outcome if medication

Table 4. Direct and indirect effects.

Outcome Direct effect Indirect effect Total effect

Self –care

Self-efficacy !self-care 0.438** 0.438

Depression ! self-care 0.036 -0.115** -0.079

Distress ! self-care -0.109 -0.122** -0.231

Self-efficacy

Depression ! self-efficacy -0.263** -0.263**

Distress ! self-efficacy -0.230** -0.070* -0.300**

Depression

Distress ! depression 0.268** 0.268*

*p<0.01, **p<0.001

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prescription was not followed may increase their compliance rate [24]. Unlike medications

which were provided for free, glucose testing machines and their test strips were not provided

by the health clinics and patients were required to purchase it themselves. Having to personally

finance the cost for self-monitoring of blood glucose may limit the practice [22, 25].

Table 5. Factor analysis of the diabetes distress scale.

Items Factor loading

Emotional

burden

Physician

related distress

Regimen

related

distress

Inter -personal

distress

1. Feeling that diabetes is taking up too much of my mental and physical energy every

day.

2. Feeling angry, scared, and/or depressed when I think about living with diabetes. 0.769

3. Feeling that diabetes controls my life. 0.634
a

4. Feeling that I will end up with serious long-term complications, no matter what I

do.

0.524

5. Feeling overwhelmed by the demands of living with diabetes. 0.749

6. Feeling that my doctor doesn’t know enough about diabetes and diabetes care. 0.796

7. Feeling that my doctor doesn’t give me clear enough directions on how to manage

my

diabetes.

0.722

8. Feeling that my doctor doesn’t take my concerns seriously enough. 0.723
b

9. Feeling that I don’t have a doctor who I can see regularly enough about my

diabetes.

0.488

10. Feeling that I am not testing my blood sugars frequently enough. 0.728

11. Feeling that I am often failing with my diabetes routine. 0.802

12. Not feeling confident in my day-to-day ability to manage diabetes. 0.654
c

13. Feeling that I am not sticking closely enough to a good meal plan. 0.469

14. Not feeling motivated to keep up my diabetes self-management. 0.771

15. Feeling that friends or family are not supportive enough of self-care efforts (e.g.

planning activities that conflict with my schedule, encouraging me to eat the “wrong”

foods).

0.657

16. Feeling that friends or family don’t appreciate how difficult living with diabetes can

be.

0.794

17. Feeling that friends or family don’t give me the emotional support that I would like. 0.816

Correlation matrix 0.325–0.587 0.527–0.571 0.405–0.708 0.520–0.648

KMO (Kaiser-Meyer-Olkin) value 0.741 0.705 0.742 0.696

AVE (Average variance extracted) 48% 56% 55% 58%

Initial items 5 4 5 3

Final items 4 3 4 3

a
removed (correlation = 0.272)

b,c
removed (Factor loading <0.5)

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Table 6. Correlation between domains of the translated diabetes distress scale.

Correlation between constructs

Construct Emotional Physician Regimen Interpersonal

Emotional –

Physician 0.619 –

Regimen 0.793 0.692 –

Interpersonal 0.677 0.617 0.816 –

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In this study, sex did not influence self-care. Reports regarding the association between sex

with self-care has not been consistent [26, 27], and is influenced by the local and traditional

sociocultural gender role [28]. The self-efficacy levels were similar between sex in this study.

Adebayo et al. [29] and Venkataraman et al. [30] reported that when controlled for social gen-

der role and sociodemographic factors, self-efficacy does not differ between sex. This study

found no association between sex with diabetes distress or depression. Previous studies have

reported that females were more likely to experience diabetes distress and depression [4, 31,

32] and this has been attributed to their biological nature, difference in mood and gender roles

[33, 34].

This study found no association between age with self-care, and similar findings have been

reported by other studies [35–38]. Age was not associated with self-efficacy, depression and

diabetes distress in this study. This finding was in agreement with previous studies which

reported that age was not associated with psychosocial factors, but instead other factors such

as sociodemographic level, social support, comorbidity and overall well-being were [39–42].

The self-care practices, self-efficacy and depression were similar between ethnicities. Diabe-

tes distress was lowest among the ethnic minority. This finding did not conform to previous

finding reported elsewhere. Though there is no specific information regarding Malaysian dia-

betics, study elsewhere have associated ethnic minorities as marginalized groups with issues

concerning access to healthcare services [43]. Ethnic minorities have also been reported to face

more socioeconomic constraints, poor education and perceived discrimination, thereby

increasing the levels of depression and diabetes distress [4, 44]. In this study, all the partici-

pants regardless of ethnicity or socioeconomic status had equal access to healthcare services.

The education level did not influence diabetes self-care practices. Previous studies reported

that those with higher education performed better self-care as they had better awareness [45].

In this study, all, the participants had equal access to healthcare services. Self-efficacy was

higher among those with higher education. This finding was in agreement with previous stud-

ies [46, 47]. This study found higher levels of diabetes distress among those with tertiary educa-

tion. The association between education level with diabetes distress has not been consistent as

other factors such as employment and income which are closely related to education influ-

ences distress as well [48, 49].

In this study, diabetes complications were not associated with diabetes self-care, self-effi-

cacy, distress or depression. Previous studies have reported that patients with diabetes

experiencing more or severe complications were associated with poorer self-care, lower self-

efficacy, depression and diabetes distress [31, 50]. In this study, the severity of the complica-

tions were not explored, which may have influenced the current finding.

This study found that the type of medication prescribed did not influence diabetes self-care,

self-efficacy, diabetes distress or depression. Other studies have reported that those on insulin

exercised lesser due to the fear of hypoglycemia [51] and were more likely to be non-compliant

to insulin injections as it causes discomfort and interferes with their daily activities [52]. The

complexity of insulin therapy has been reported to result in poorer self-efficacy [53] especially

concerning the proper timing and dosages, while the discomfort and interference of daily

activities associated with insulin injections has been regarded as burdening by some, resulting

in significant emotional distress [54] and a higher prevalence of depression among insulin

users [54, 55].

Using partial least square to assess structural relationship, this study found that self-efficacy

was a strong predictor of diabetes self-care. The positive association between self-efficacy and

diabetes self-care practices was in agreement with previous studies [56–58]. High levels of self-

efficacy is associated with better self-autonomy, more confidence, more initiative and persis-

tence in dealing with daily needs of diabetes care [59]. A higher level of self-efficacy also

Factors influencing diabetes self-care

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ensures the continuity of appropriate diabetes self-care practices [60]. A high sense of self-effi-

cacy amplifies and strengthens an individual’s well-being in many ways. Individuals with con-

fidence in their capabilities looks at difficult tasks as challenges to be overcome rather than a

problem to be avoided [61].

Contrary to what we expected, in this study, depression did not influence self-care practices.

This finding could have been due to the low prevalence of depression and difference in study

population [62]. Furthermore, the almost free health services among the participants of this

study could have served as a protective factor from depression [63]. Similarly, in this study,

diabetes distress did not influence self-care practices. This finding could have been due to the

low prevalence of distress among the study participants and the sociocultural background of

the participants. Previous studies have reported that socio-cultural norms influences ones per-

ception of disease. Studies have shown that Asians and Caucasians perceive disease differently

[64]. Though not having any direct association with self-care, both depression and diabetes

distress were indirectly associated with self-care via self-efficacy. Diabetics experiencing

depression and distress had lower levels of self-efficacy and later practiced poorer self-care.

Diabetics experiencing distress have been reported to have lower levels of self-efficacy [65],

while depression leads to problems such as apathy, hopelessness, fatigue, memory problems

and loss of confidence in performing daily activities which are all required in managing a

chronic disease like diabetes [66, 67].

The positive association between distress with depression was in agreement with previous

studies [68, 69]. Diabetes distress is caused by the difficulty in coping with diabetes in daily

life. A minimal amount of diabetes distress is part of living with diabetes. However, when

severe enough, or exacerbated by other environmental or personal factor, diabetes distress

maybe severe enough to lead to depression [68].

Overall, among the study population, self-efficacy was the most important factor in deter-

mining good diabetes self-care. Though depression and diabetes distress affected self-care

indirectly via self-efficacy, the prevalence of these conditions were low. Thus, to improve self-

care practices, effort must be focused on enhancing self-efficacy levels, while not forgetting to

deal with depression and diabetes distress, especially among those with poor self-efficacy.

Conclusion

This study is the first in our knowledge to explore the relationship between depression, diabe-

tes distress and self-efficacy with self-care practices among Malaysians with type 2 diabetes.

Having higher levels of self-efficacy was associated with better diabetes self-care practices. Fur-

thermore, managing depression and diabetes distress is important among diabetics as it may

lead to poor self-efficacy and subsequently poorer diabetes self-care. Based on the insights

gained from this study, future research should focus on the same topic, with more emphasis

on increasing patient’s self-efficacy level and to reduce depression and diabetes distress with

the ultimate aim of improving diabetes self-care practices.

Limitations

There are limitations to this study that should be acknowledged. Firstly, the result of this study

represents the population under study, which are people with type 2 diabetes who were being

cared for in government healthcare centers in the district of Hulu Selangor. Therefore, the

results should not be generalized and needs to be replicated in different patient groups. Sec-

ondly, the questionnaires utilized in this study were self-reported. Thirdly, this study was of a

cross sectional study design, thus no statement of causality can be made.

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Supporting information

S1 File. Raw data file.

(XLSX)

Acknowledgments

The authors would like to thank the doctors and nurses working in health clinics in the District

of Hulu Selangor for their help and hospitality.

Author Contributions

Conceptualization: CD.

Data curation: CD.

Formal analysis: KC.

Funding acquisition: CD.

Investigation: CD KC.

Methodology: KC.

Project administration: CD.

Resources: CD.

Software: KC.

Supervision: CD.

Validation: KC.

Visualization: CD KC.

Writing – original draft: CD.

Writing – review & editing: CD KC.

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