RESEARCH ARTICLE
Older Adults’ Perceptions of Physical Activity: A Qualitative Study Sclinda L. Janssen*† & Jan E. Stube1 Department of Occupational Therapy, School of Medicine and Health Sciences, University of North Dakota, 210 2nd Ave North, Grand Forks, ND 50201, USA
Abstract The purpose of this study was to explore older adults’ perceptions of participation in physical activity (PA) as it impacts productive ageing and informs occupational therapy (OT) practice. In this phenomenological study, 15 community-dwelling older adults were recruited using purposive and snowball sampling at community locations. Data collection methods included two interviews and an observation. The primary finding was that older adults continue individual patterns of meaningful PA across their lifespan when they have support to adapt to age-associated limitations, with a gradual decline in intensity during older years. Although this study’s qualitative methodology limits broad generalizability, the findings provide applicability when situated in the context of community-living older adults interested in health maintenance through PA participation. OT practitioners have an important role with community-dwelling older adults to impact productive ageing by designing and promoting meaningful PA with adaptations that address unique, age-associated concerns. There is a need for further experimental research taking an occupational performance and health perspective to enhance the contribution of OT for this population’s health-related quality of life through meaningful PA. Copyright © 2013 John Wiley & Sons, Ltd. Received 30 May 2013; Revised 13 September 2013; Accepted 15 October 2013
Keywords older adults; qualitative research; purposeful exercise; health promotion; geriatric occupational therapy *Correspondence Sclinda L. Janssen, Department of Occupational Therapy, School of Medicine and Health Sciences, University of North Dakota, 210 Hyslop 2nd Ave North, Grand Forks, ND 58201–7126, USA. †
Email: [email protected]
Published online 3 December 2013 in Wiley Online Library (wileyonlinelibrary.com) DOI: 10.1002/oti.1361
Introduction People who are at least 65 years of age make up about 18% of the US population (Administration on Aging, 2010). Many of these older adults will experience impaired health conditions and increased chance of mortality related to a lifestyle of physical inactivity (Mokdad et al., 2004; Center for Disease Control [CDC], 2009). According to Kruger et al. (2007), only 8.2% of older adults in the United States participate in regular physical activity (PA). When Occup. Ther. Int. 21 (2014) 53–62 © 2013 John Wiley & Sons, Ltd.
comparing all age groups throughout the world, older adults have the lowest rate of participation in recommended PA that is “150 minutes of moderate-intensity aerobic PA throughout the week or do at least 75 minutes of vigorous-intensity aerobic PA throughout the week or an equivalent combination of moderate- and vigorous-intensity activity” (WHO, 2010, p. 31). Several descriptions of PA are available for the purposes of this study. The World Health Organization defined PA as “any bodily movement produced by skeletal muscles 53
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that requires energy expenditure” (2010, p, 53). Within this definition are several types of PA. The first is exercise, which is “planned, structured, repetitive, and purposeful” and is carried out to improve physical fitness (WHO, 2010, p. 52). Leisure time PA is another subset of PA, which includes participation in valuable leisure activities such as games, dancing, gardening and walking (WHO, 2010). Participation in leisure time PA is valuable for health and wellness as evidenced by correlations with longer life expectancy (Moore et al., 2012). Participation in PA is associated with functional independence in basic occupations, whereas lack of participation in PA is associated with functional disability (Arbesman and Lieberman, 2012; Shah et al., 2012). In addition, participation in PA can control weight; reduce risk for diabetes, cardiovascular disease and some types of cancer; regulate blood glucose; promote bone health (WHO, 2010) and decrease risk of falls (Painter et al., 2012; Schepens et al., 2012). Despite the many documented benefits, several barriers prevent older adults from participating in PA. External barriers include inconvenient destinations (King et al., 2003; Korkiakangas et al., 2009; Reitz, 2010), affordability (Korkiakangas et al., 2009), transportation (De Bourdeaudhuij et al., 2003; Korkiakangas et al., 2009; Reitz, 2010), weather, cultural barriers and lack of social support (Korkiakangas et al., 2009). Researchers also described internal barriers such as physical limitations, depressive symptoms, physical and emotional discomfort, loss of motivation (Korkiakangas et al., 2009), fear of falling (Painter et al., 2012; Schepens et al., 2012) and ageism (Butler, 2005). To overcome barriers to participation, researchers have found that people are more likely to sustain participation in activities that are meaningful and enjoyable (Csikszentmihalyi, 1990; Larson and von Eye, 2010). Csikszentmihalyi (1990) addressed meaningfulness and enjoyment in his flow theory, a theory that formed the basis for the present study. Csikszentmihalyi’s research found people are most happy when they engage in a meaningful and enjoyable activity that inspires personal growth and is so rewarding that they lose track of their surroundings and time. In the field of occupational therapy (OT), Larson and von Eye (2010) included flow theory in their study about participation and found that adults of all ages perceive time to go by faster when engaged in novel, complex and skill-requiring activities. When promoting participation and sustainability of PA among older adults, OTs need to understand how 54
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PA becomes meaningful and sustainable to this population. Ultimately, this understanding becomes valuable for OT practitioners who are promoting productive ageing as a component of the American OT Association’s (AOTA, 2007) Centennial Vision to promote occupation, participation and health. The purpose of this study was to explore older adults’ perception about participation in PA. To further understand participation in PA, this phenomenological study focused on the following research questions: • How does PA become a meaningful occupation to older adults? • How does PA become sustainable (i.e. weekly participation for more than 1 year) in community-dwelling older adults?
Method Research design Although evidence indicates PA and wellness programmes are effective in helping older adults experience productive ageing, most community-dwelling older adults choose not to participate in PA (Kruger, Carlson, and Buchner, 2007). To learn how to promote more participation, phenomenological qualitative research methodology was selected to explore older adult perceptions and experiences with PA in order to promote both meaningful participation and sustainability. Turpin (2007) supported use of phenomenological knowledge to balance art and science in research, which is consistent with the pluralistic nature of OT. Csikszentmihalyi’s (1990) flow theory, which he described as a phenomenological model, provided a useful underpinning to the exploration of meaning and sustainability of participation in PA with the older adult participants of this study. Concepts of flow theory, such as temporality and enjoyment, were utilized to construct several of the research questions (Table I). It should be noted that there were other interview questions also used that targeted varying aspects of PA related to experience, changes, socialization, preferences, sustainment and routines (Appendix A). Participants and sites Following approval of this study from the university’s Institutional Review Board, 15 community-dwelling older adults were recruited through purposive and snowball sampling. Criteria for study inclusion focused Occup. Ther. Int. 21 (2014) 53–62 © 2013 John Wiley & Sons, Ltd.
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Table I. Use of flow theory concepts to construct interview questions Flow concept Temporality Frustration Boredom Novelty Control
Interview question Think about a time when you did a PA and the time just flew by. How enjoyable was that experience and what made it enjoyable? Tell me about a time when you became frustrated with PA. What made it frustrating to you? How challenging was the PA? Tell me about a time when you became bored with PA. What made it boring to you? How challenging was the PA? Think about a time when you initiated new PA. What was the experience like? How much control do you like to have over deciding which types of PA you do and how you like to do it?
PA = physical activity. This table describes how specific concepts from flow theory were utilized within several interview questions. It should be noted that there were other interview questions also used in the study that targeted varying aspects of physical activity-related experience, changes, socialization, preferences, sustainment and routines.
on community-dwelling older adults who had engaged in PA over a year, had initiated PA in their older adult years or were currently participating in relatively little to no PA. Broad inclusion criteria of a variety of PA participation levels were allowed to foster a wide range of perspectives among older adults. Types of PA participants engaged in were varied; some did exercise PA, whereas others did more leisure PA. The researchers selected 15 participants because it was within the range of sample sizes that typically generate rigorous data in phenomenological studies (Creswell, 2007). Gatekeepers who were employed in programme director roles at the research sites helped to identify processes for recruitment of older adult participants. The gatekeepers knew each participant (except one); therefore, they were able to ascertain the participant’s ability to communicate and understand the consent form upon referral to the study. Potential participants were provided with a description of the study and the informed consent form (written in larger font to accommodate for possible age-related visual changes). They were informed verbally and in writing that their participation was voluntary, and they could withdraw at any time. They were also provided with support resources in case they experienced any injury or emotional distress during their participation in the study. Snowball sampling, through participant referral, allowed for enrolment of one additional participant who met the inclusion criteria. This person was an instructor in higher education, therefore, would likely understand the consent form as well. All participants acknowledged they were over the age of 65 years; some participants did not share their specific age but indicated their age category (refer to Table II for participant descriptions). Occup. Ther. Int. 21 (2014) 53–62 © 2013 John Wiley & Sons, Ltd.
The sites included a community housing complex (three participants), a senior centre (nine participants) and a fitness centre (three participants). The researcher initially met with potential participants at the sites to verbally describe the research study, to provide written explanation, to obtain informed consent and to schedule subsequent interview and observation sessions.
Data collection An occupational therapist experienced in clinical practice and qualitative research methodology and first author of this article conducted one initial interview session and one other session that included both interview and observation with each of the 15 participants at the participants’ preferred locations. Each session lasted approximately 1 hour over a period of 2 months. Some examples of preferred locations were the library at the senior citizen centre, fitness centres and participants’ yards or gardens as participants demonstrated PA in their natural environments. The interview style consisted of primary and followup questions designed to answer the research questions using open-ended, exploratory strategies. The researcher encouraged participants to select their own pseudonym for the study to establish participants’ sense of control and rapport. Interviews were recorded and transcribed verbatim following consent from participants to assure accuracy of documentation for interpretation. During the second session that included both interview and observation, the researcher frequently performed the PA with the participant. For example, the researcher helped a participant rake the lawn and plant the grass seed. 55
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Table II. Description of participants Pseudonym Mary Willie Nelson Dudley Do Right Jane Wyman Katie Mac Pete Anna Mae Ring Archibald Patrick Lola Priscilla Donna Kathryn
Sex
Age
PA preference
F F M F F M M F M M M F F F F
Oldest old Older old Older old Younger old Young old Older old Oldest old Oldest old Older old Younger old Younger old Older old Younger old Older old Older old
Leisure PA and group exercise Leisure PA and group exercise Leisure PA (sports) and exercise Leisure PA (walking) and group exercise Leisure PA (gardening) Leisure PA that is sociable (billiards, walking) Exercise (machine equipment) Exercise (walks)* does not like it but likes results Leisure PA (yard work) and exercise (swimming) Leisure PA (woodcarving, lawn care, recreation) Leisure PA (yard work) Exercise (in groups) Leisure PA (yard work, biking, golf) and exercise Exercise (in groups) Leisure PA (walking alone) and exercise (in groups)
PA = physical activity. *This table describes participants and their preferences for PA. The age categories are younger old (ages 65–75 years), older old (ages 75–85 years) and oldest old (ages 85+ years). Age categories were derived from He et al. (2005).
She also played billiards with another participant. This persistent observation allowed the researcher to write field notes that reflected the kinaesthetic experience described during interviews.
in a concept map. Once data were saturated with no new meaning units and categories found between participants, textural descriptions (thematic statements) were created with an overarching assertion that encapsulated the experiences of all 15 participants (Moustakas, 1994).
Data analysis The researcher completed data analysis with guidance from Creswell (2007) and Moustakas (1994). Transcripts of interview and observation notes were organized according to participant pseudonyms. Open coding began with reflexive journaling initially during the analysis process. An audit trail was drafted with detailed notes following each interview and observation. The researcher retained documentation of original field notes for later review and comparison as well as notes related to decision-making and data analysis procedures. Memo writing was also used for ethical reasons to enhance transparency of decisions made with a supporting rationale. Data analyses steps included horizontalizing, developing meaning units, clustering and developing textural descriptions (Moustakas, 1994). The researcher overlapped steps between horizontalizing (highlighting statements) and developing meaning units (coding). While horizontalizing, significant statements from transcripts, field notes and reflexive journaling were highlighted to develop meaning units. Reflectively, the horizons (meaningful statements from the text), and the meaning units were listed in a key to cluster them into categories, which were then reflected 56
Trustworthiness Persistent observation and triangulation via multiple sources of data supported validity of this study. Methods to assess validity included literature comparisons, theoretical comparisons, audit trail, expert review and member checking with randomly selected participants. The expert reviewer was a professor and researcher in the field of exercise science. To verify the overarching assertion and themes, member checking was carried out with five randomly selected participants: two were from the housing complex, one was from the fitness centre and two were from the senior centre. According to Creswell (2008), member checking is carried out with one or more participants; therefore, selection of five participants further supported validity. Each participant agreed with the final themes presented; there were no suggestions for changes in findings. In addition, the researcher compared categories of the results from this study to the main domains of the OT practice framework (AOTA, 2008) and found congruence. The framework was considered credible for data comparison because it is an official comprehensive document of the American OT Occup. Ther. Int. 21 (2014) 53–62 © 2013 John Wiley & Sons, Ltd.
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Association that aides in the understanding of participation in occupations.
Results Participant perceptions of their experiences with PA were reflected in results through an overarching assertion with two main themes. Answering the research questions related to meaningfulness and sustainability of PA, the overarching assertion is that older adults continue individual patterns of meaningful PA across their lifespan when they have support to adapt to ageassociated limitations, with a gradual decline in intensity during older years. This overarching assertion and the two main themes found are discussed further in the following paragraphs (refer to Figure 1 for a concept map representing these findings). Overarching assertion: tendency toward lifespan continuity of meaningful physical activity Despite experiencing a gradual decline in PA intensity noted in older adult years, all participants had a tendency to continue their patterns of meaningful PA over their lifespan. Reflecting back to childhood, the participants described socialized leisure playful PA such as running games, tag, biking, walking, skating and work-related PA such as gardening and farming. As they aged, they
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transformed and adapted PA into adult styles that involved physical exercise (e.g. aerobics, swimming, weight lifting and walking) and leisure PA (e.g. wood-carving, gardening and playing billiards). The PA participation during their older adult years was more consistent with older adult roles and values; however, they had an overall tendency to continue similar patterns over the lifespan even though the intensity was lessened. For example, Mac indicated that he has always enjoyed PA that involved socialization with friends and family, but instead of playing high impact sports, he now enjoys lower impact PA such as walking and playing billiards with friends to avoid risk of injury or fatigue. As a participant observer, the researcher experienced the enjoyment associated with the social aspect of PA as well when playing billiards with Mac and his friends; there was much laughter, playful teasing, with an innate sense of support between players. Mac’s roles and values were related to social connectedness. Participants’ perceptions of PA over the lifespan suggested that PA became a meaningful occupation when they were able to attach the activity to their roles and values.
Theme 1: factors that support sustainability of physical activity Sustainability of ongoing participation in PA is influenced by many factors, all of which contributed to a sense of
Figure 1 Concept map for older adults’ perceptions of physical activity (PA)
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meaningfulness with the occupation of PA. The main factors were implicated in the data by participant perceptions of their experiences. Adapting to limitations Of all limitations, 13 participants described physical limitations most frequently with a need to adapt the PA to avoid pain, injury, fatigue or falls. For example, Katie created raised garden beds in extra-large rubber tubs to adapt to limitations in bending, strength and endurance. Mary holds onto stable physical objects within her apartment to adapt to balance limitations. Participants reflected upon emotional limitations to PA participation, such as ageism (negative bias toward older adults) and social rejection. Willie suggested that ageism limits her participation in PA. She said with tears in her eyes, “Just thinking that because of my age, I am not able to do it”. She also added that she is not interested in joining an exercise group because she has a fear of “not being accepted…It’s the idea of going in there and not knowing anybody and not being accepted…”. To adapt to these emotional limitations, Willie selects her environment for PA carefully. By doing PA within her apartment complex, she feels more confident because of the familiarity of people. Of all 15 participants, six of them found that impaired accessibility to community resources, poor transportation services and financial concerns limit their participation in PA. Each participant has found ways to adapt to these limitations but indicated a need for support to further adapt to personal limitations and environmental limitations. Independence and control The majority of participants suggested that retaining independence and control was important for sustainability of PA. Mary said she does not want any physical help from anyone because it makes her feel out of control; however, holding onto a stable physical object facilitates her sense of control with PA. Lola and Dudley also acknowledged the need to be in control of their own PA choices including the type of PA, place and timing. Lola said, “I guess nobody controls me; I control myself. [Laughs]…I wouldn’t want anybody telling me what I can and can’t do”. Personable and skilful leadership of a physical activity educator The importance of having a personable and skilful PA leader emerged from the data. Donna likes a leader who 58
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can “make it fun” and be an “excitable person with good ideas and a likable person”. She also said she does not like it when a leader is too sharp and authoritarian but does appreciate knowledgeable direction. Ring said that a PA leader from the health care field caused him to have “just about the worst pain in my life”. With a sudden transition to a serious affect with direct eye contact, he said deliberately, “It angered me… [pause]”. He followed with some profanity, which was a noteworthy contrast to the rest of the interview and observation where his demeanour appeared happy and enthusiastic. All participants agreed that it is essential for PA leaders to be personable and skilful when working with older adults. Using one’s individual learning style Participants appreciated the opportunity to learn about PA, and they were quite descriptive about their individual learning styles. Mary said she “learns it, writes it down, and then repeats it to someone”. For example, she learned during a wellness educational session that she can improve her balance with diagonal body movements, which she has since incorporated into daily activities such as folding laundry. Mary suggested that learning about PA helps her to sustain participation in PA. Participants described preferred learning styles such as observation, instruction, doing, slowing down and using their own experience to make helpful associations. Match between ability and the physical activity challenge The majority of participants suggested that a positive, healthy match between ability and challenge of the PA promotes continued participation in PA. To prevent boredom, Archibald likes a “challenge, to try to be a little more creative within, to try to change it a little bit”. In contrast, participants also said they become frustrated with PA that is too hard. Katie expressed frustration as she recalled her experience with stroke rehabilitation when she said, I had one [health professional] who made me so mad because he pushed me and pushed me and I’d say, “I can’t, I can’t do it” and he’d say, “Yes, you can and you will.” Now do it…I got mad (lower, short, abruptness in voice. Eyelids a bit lower). Occup. Ther. Int. 21 (2014) 53–62 © 2013 John Wiley & Sons, Ltd.
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Physical activity that is too easy or too challenging for participants’ ability often resulted in frustration and cessation of the PA. Enjoyment and motivation Enjoyment promoted sustained participation in PA, whether it was the enjoyment of the actual participation itself or the results of the participation. The researcher asked participants to describe an enjoyable PA experience when time seemed to pass quickly. Willie acknowledged enjoyment with wellness sessions provided in her apartment complex and responded, “Because you go at 1:30 and the next thing you know, it’s 2:15…It’s because of the people and keeping yourself active”. In contrast, Anna Mae, who was 90 years old, stated frankly that she does not like her PA of walking “briskly” but enjoys the results evident in maintenance of her weight and mobility, which enables her to go out in public and participate in other meaningful activities. Enjoyment fostered motivation as participants presented unique perceptions about specific motivation related to outcomes or goals that offer particular rewards. Ring is motivated to be productive when he does lawn care because he enjoys a nicer environment. In addition, he also enjoys a sense of physical well-being. For example, he is motivated to swim, “to keep in shape”. Archibald, Donna and Ring all stated that a physician recommendation to exercise for health is a powerful motivational tool. Participants described multiple motivational factors such as a desire for physical, social, environmental and emotional wellness.
Theme 2: intrapersonal and interpersonal differences in their perceptions about physical activity There were many intrapersonal and interpersonal differences among participants as they described concepts such as socialization, routine and preferences for physical environment. Kathryn prefers both social and solitary PA; she enjoys the social aspect of group exercise class but wants to walk alone because “it’s been good therapy for me”. Participants had varied perceptions about routines for PA. Dudley and Pete stated routines were “very important”, and they both described daily schedules for PA and specific workout routines they follow for exercise. In contrast, Priscilla said she used to have a morning walking date with her friend and said, “I used Occup. Ther. Int. 21 (2014) 53–62 © 2013 John Wiley & Sons, Ltd.
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to walk at six o’clock every morning. It was so hard to get up…I found the routine irritating”. Environment was an important consideration for eight participants. Mary and Anna Mae will not walk outside where there are uneven surfaces in the sidewalks because of their fear of falling. Donna was also concerned about falling when she said she likes the big gym because “you get around and you don’t have to be careful…about bumping into each other and knocking each other over”. Participant responses suggested that fear of falling is common among several participants, and it was important to them to have an environment that is free of falling hazards. Other participants suggested the environment was not important for PA participation.
Discussion All participants did perceive that they participated in some type of PA related to either leisure or exercise PA; however, the intensity varied significantly between participants. Multiple factors supported participation in PA for older adults, holding many implications for effective, client-centred PA programming delivered by OT practitioners. A blending of intrinsic factors (e.g. adaptation to limitations, maintaining sense of control and enjoyment of learning) with extrinsic factors (e.g. effective health educators, physician referral and suitable level of PA demand) are key to understanding this study’s 15 older adults’ participation experiences in PA. Additionally, participants reflected interpersonal and intrapersonal differences in their perceptions of PA. Meaningfulness and sustainability were found to be interconnected in that the factors contributing to meaningfulness of PA also enhanced sustainability. PA became a meaningful occupation, addressing the first research question, when participants were able to attach PA to their values – such as desires for wellness, social connectedness and productivity. Similar to the research evidence, participants in this study highlighted the need for control over PA (Cskiszentmihalyi, 1990; Eklund, 2007). In addition, fear of falling further elicited a need for control over PA. A collaborative approach from a personable and skilful OT will help older adults feel a sense of control to identify an appropriate challenge level for PA with recommendations for adaptations related to limitations. Sustainability of PA, as the second research question, was addressed through the finding that participants perceived they sustained participation in PA over a year 59
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when they were able to adapt to age-related limitations in performance skills and patterns. Most participants created strategies to adapt to their changing limitations and acknowledged a need for support to further adapt. Because of the dynamic influence ageing has on ability, there is a need for OTs to conduct frequent re-assessments and intervention, as needed, with older adults to promote sustainable participation in PA. Finally, sustainability and meaningfulness of PA were associated with the flow experience participants felt during PA and while reflecting upon the results of the PA (Csikszentmihalyi, 1990). Participants validated the importance of several flow theory concepts, such as temporality, having control over PA, having appropriate level of challenge to avoid boredom and frustration and creating novelty by changing certain aspects of PA. This finding emphasizes the importance for OT practitioners to consciously include these concepts of flow theory into their interventions when promoting PA.
Implications for occupational therapy practice The identification of themes from older adults’ perceptions of their experiences with PA has important implications for OT practitioners who are planning health promotion programmes: • Partner with community agencies such as fitness and senior centres. • Work with doctors to refer patients to OT for PA programming. • Provide individual evaluations and reassess as indicated. • Organize peer groups for PA. • Address accessibility limitations and offer community resources. To promote PA more effectively, OT practitioners should incorporate the following principles into specific PA interventions:
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• Use temporality to assess enjoyment with PA by asking participant about how fast time is going by during PA participation.
Study limitations Although inclusion of 15 participants is considered a fairly robust sample size in phenomenological research, there are limitations. First, there were two interviews and an observation carried out with each participant; three interviews would have supported rigour. Despite this limitation, rich data were collected beyond interview through the researcher observation and participation in many of the PAs to generate depth of understanding. Another limitation is that there may be unreported views and uncovered themes that participants did not think of during the interview or observation.
Conclusion A valid, descriptive qualitative study was undertaken to understand and, ultimately, impact PA programming to promote older adults’ occupation, participation and health. The data collected from these participants was rigorously and ethically conducted to achieve authentic and plausible findings. This will allow OT to begin an experimental research agenda to examine the benefits of occupation-based PA to enhance older adults’ health-related quality of life. This study provides insight into older adults’ perceptions of PA, which is useful for OT in promotion of PA among community-dwelling older adults. When older adults are able to adapt to age-related limitations in performance skills and patterns, they tend to continue similar patterns of meaningful PA throughout their life. The need for adaptation implies the field of OT has a substantial role in promotion of PA with communitydwelling older adults to help them experience productive ageing during their golden years.
Acknowledgments • Match performance skill level to PA demands to avoid frustration and boredom. • Collaborate and foster participant control while adapting PA to limitations. • Help older adults connect PA to personal values when selecting types of PA. • Continually create novelty by modifying approaches and style of PA. 60
We acknowledge significant support and input for this study by Dr. Gail Ingwalson, Dr. Jodie Bergland Holen, and Dr. Lars Helgeson who served on the dissertation committee for the first author of this article in partial fulfillment of the philosopy degree in Education at the University of North Dakota. We also express gratitude to Steve Finney from the University of North Dakota Writing Center for his writing expertise. Occup. Ther. Int. 21 (2014) 53–62 © 2013 John Wiley & Sons, Ltd.
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REFERENCES Administration on Aging (2010). US Population by age: July 1, 2010. http://www.aoa.gov/AoARoot/Aging_Statistics/Census_ Population/census2010/Index.aspx [13 September 2013] American Occupational Therapy Association (2007). AOTA’s centennial vision and executive summary. The American Journal of Occupational Therapy 6: 613–614. American Occupational Therapy Association (2008). Occupational therapy practice framework: domain and process. The American Journal of Occupational Therapy 6: 625–683. Arbesman M, Lieberman D (2012). Methodology for the systematic reviews on occupation- and activity-based intervention related to productive aging. The American Journal of Occupational Therapy 3: 271–276. Butler RN (2005). Ageism: looking back over my shoulder. Generations 3: 84-86. Center for Disease Control and Prevention [CDC] (2009). Web-base inquiry statistics query and reporting system (WISQARS). National Center for Injury Prevention and Control. http://www.cdc.gov/injury/wisqars/LeadingCauses. html [13 September 2013]. Creswell JW (2007). Qualitative Inquiry and Research Design. Thousand Oaks, CA: Sage Publications, Inc. Creswell JW (2008). Analyzing and interpreting qualitative data. In JW Creswell (Ed.), Educational Research: Planning, Conducting, and Evaluating Quantitative and Qualitative Research. Upper Saddle Creek, NJ: Pearson Education, Inc. Csikszentmihalyi M (1990). Flow: The Psychology of Optimal Experience. NY: Harper and Row. De Bourdeaudhuij I, Sallis JF, Saelens BE (2003). Environmental correlates of physical activity in a sample of Belgian adults. American Journal of Health Promotion 1: 83–92. Eklund M (2007). Perceived control: how is it related to daily occupation in patients with mental illness living in the community? The American Journal of Occupational Therapy 5: 535–542. He W, Sengupta M, Velkoff VA, DeBarros KA (2005). 65+ in the United States: 2005. US Census Bureau, Current Population Reports (23–209). Washington, DC: U. S. Government Printing Office. King WC, Brach JS, Belle S, Killingsworth R, Fento M, Kriska AM (2003). The relationship between convenience of destinations and walking levels in older women. The American Journal of Health Promotion 1: 74–82. Korkiakangas EE, Alahuhta MA, Laitinen JH (2009). Barriers to regular exercise among adults at high risk or diagnosed with type 2 diabetes: a systematic review. Health Promotion International 4: 416–427.
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Kruger J, Carlson SA, Buchner D (2007). How active are older Americans? Preventing Chronic Disease: Public Health Research, Practice, and Policy 3: 1–12. Larson E, von Eye A (2010). Beyond flow: temporality and participation in everyday activities. The American Journal of Occupational Therapy 1: 152-163. Mokdad SH, Marks JS, Stroup DF, Gerberding JL (2004). Actual causes of death in the United States, 2000. Journal of the American Medical Association 10: 1238–45. Moore SC, Patel AV, Matthews CE, Berrington de Gonzalez A, Park Y, Katki HA, Linet MS, Weiderapass E, Visvanathan K, Helzlsouer KJ, Thun M, Gapstur SM, Hartge P, Lee IM (2012). Leisure time physical activity of moderate to vigorous intensity and mortality: a large pooled cohort analysis. PLOS Medicine 11: 1–14. Moustakas C (1994). Phenomenological Research Methods. Thousand Oaks, CA: Sage Publications, Inc. Painter JA, Allison L, Dhingra P, Daughtery J, Cogdill K, Trujillo LG (2012). Fear of falling and its relationship with anxiety, depression, and activity engagement among community-dwelling older adults. The American Journal of Occupational Therapy 2: 169–176. Reitz SM (2010). Promoting exercise and physical activity. In ME Scaffa, SM Reitz, MA Pizzi (Eds.), Occupational Therapy in the Promotion of Health and Wellness (225–252). Philadelphia, PA: FA Davis Company. Schepens S, Sen A, Painter JA, Murphy SL (2012). Relationship between fall-related efficacy and activity engagement in community-dwelling older adults: a meta-analytic review. The American Journal of Occupational Therapy 2: 137–148. Shah RC, Buchman AS, Leurgans S, Boyle PA, Bennett DA (2012). Association of total daily physical activity with disability in community-dwelling older persons: a prospective cohort study. BioMed Central Geriatrics 63: 1–8. Turpin M (2007). Recovery of our phenomenological knowledge in occupational therapy. The American Journal of Occupational Therapy 4: 460–473. World Health Organization (2010). Global recommendations on physical activity for health. http://whqlibdoc. who.int/publications/2010/9789421599979_eng.pdf [2 September 2013].
Appendix A Interview questions During introductions, ask the participant to select a pseudonym for themselves which I will use in the study. 1. People refer to physical activity in a variety of ways such as exercise, work-out, etc. What word do you use to name physical activity?
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2. Tell me about your experience with PA as a child, adult, and now. How has your participation in PA changed over the years? 3. Think about a time when you did a PA and the time just flew by. How enjoyable was that experience and what made it enjoyable? 4. Some people like to do PA alone, while others like to do it in groups with other people. How do you like to do PA? 5. Tell me about a time when you became frustrated with PA. What made it frustrating to you? How challenging was the PA? 6. Tell me about a time when you became bored with PA. What made it boring to you? How challenging was the PA? 7. What is your favourite type of PA. What is it about this type of PA that makes it your favourite? 8. Some people like to have a leader or trainer when doing PA. What kind of leadership, if any, do you like to have for PA? 9. Tell me a little about yourself as you think of how you participate in PA. What is your personality like during PA? 10. Think about a time when you initiated new PA. What was the experience like? 11. Think about a time when you were able to sustain participation in PA over a long period of time. What was it like? What do you think helped you to sustain the PA?
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12. What do you think about establishing a routine for PA? How does this help or hinder your ability to sustain the PA? 13. How much control do you like to have over deciding which types of PA you do and how you like to do it? 14. What concerns do you have about doing PA? How do you address these concerns during PA? 15. Tell me about how the physical environment affects your enjoyment of PA, for example, the building, noise, music, amount of people, etc. 16. Some people find that learning new ideas related to PA helps them participate in PA. People have different styles of learning. Some like to listen and watch and then try. Some people learn by doing. Some people like to talk about ideas in order to gain more understanding before trying. How do you like to learn about new ideas? 17. Could you please describe what your main motivation is for participating in PA. 18. In the field of occupational therapy, we describe any activity one does as an occupation. An occupation can include meaningful activities like cooking a meal, doing self-care like washing, and participating in a favourite hobby. What make PA meaningful to you? 19. What do you think you need to be able to do PA on a regular basis?
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Older Adults’ Perceptions of Physical Activity: A Qualitative Study Sclinda L. Janssen*† & Jan E. Stube1 Department of Occupational Therapy, School of Medicine and Health Sciences, University of North Dakota, 210 2nd Ave North, Grand Forks, ND 50201, USA
Abstract The purpose of this study was to explore older adults’ perceptions of participation in physical activity (PA) as it impacts productive ageing and informs occupational therapy (OT) practice. In this phenomenological study, 15 community-dwelling older adults were recruited using purposive and snowball sampling at community locations. Data collection methods included two interviews and an observation. The primary finding was that older adults continue individual patterns of meaningful PA across their lifespan when they have support to adapt to age-associated limitations, with a gradual decline in intensity during older years. Although this study’s qualitative methodology limits broad generalizability, the findings provide applicability when situated in the context of community-living older adults interested in health maintenance through PA participation. OT practitioners have an important role with community-dwelling older adults to impact productive ageing by designing and promoting meaningful PA with adaptations that address unique, age-associated concerns. There is a need for further experimental research taking an occupational performance and health perspective to enhance the contribution of OT for this population’s health-related quality of life through meaningful PA. Copyright © 2013 John Wiley & Sons, Ltd. Received 30 May 2013; Revised 13 September 2013; Accepted 15 October 2013
Keywords older adults; qualitative research; purposeful exercise; health promotion; geriatric occupational therapy *Correspondence Sclinda L. Janssen, Department of Occupational Therapy, School of Medicine and Health Sciences, University of North Dakota, 210 Hyslop 2nd Ave North, Grand Forks, ND 58201–7126, USA. †
Email: [email protected]
Published online 3 December 2013 in Wiley Online Library (wileyonlinelibrary.com) DOI: 10.1002/oti.1361
Introduction People who are at least 65 years of age make up about 18% of the US population (Administration on Aging, 2010). Many of these older adults will experience impaired health conditions and increased chance of mortality related to a lifestyle of physical inactivity (Mokdad et al., 2004; Center for Disease Control [CDC], 2009). According to Kruger et al. (2007), only 8.2% of older adults in the United States participate in regular physical activity (PA). When Occup. Ther. Int. 21 (2014) 53–62 © 2013 John Wiley & Sons, Ltd.
comparing all age groups throughout the world, older adults have the lowest rate of participation in recommended PA that is “150 minutes of moderate-intensity aerobic PA throughout the week or do at least 75 minutes of vigorous-intensity aerobic PA throughout the week or an equivalent combination of moderate- and vigorous-intensity activity” (WHO, 2010, p. 31). Several descriptions of PA are available for the purposes of this study. The World Health Organization defined PA as “any bodily movement produced by skeletal muscles 53
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that requires energy expenditure” (2010, p, 53). Within this definition are several types of PA. The first is exercise, which is “planned, structured, repetitive, and purposeful” and is carried out to improve physical fitness (WHO, 2010, p. 52). Leisure time PA is another subset of PA, which includes participation in valuable leisure activities such as games, dancing, gardening and walking (WHO, 2010). Participation in leisure time PA is valuable for health and wellness as evidenced by correlations with longer life expectancy (Moore et al., 2012). Participation in PA is associated with functional independence in basic occupations, whereas lack of participation in PA is associated with functional disability (Arbesman and Lieberman, 2012; Shah et al., 2012). In addition, participation in PA can control weight; reduce risk for diabetes, cardiovascular disease and some types of cancer; regulate blood glucose; promote bone health (WHO, 2010) and decrease risk of falls (Painter et al., 2012; Schepens et al., 2012). Despite the many documented benefits, several barriers prevent older adults from participating in PA. External barriers include inconvenient destinations (King et al., 2003; Korkiakangas et al., 2009; Reitz, 2010), affordability (Korkiakangas et al., 2009), transportation (De Bourdeaudhuij et al., 2003; Korkiakangas et al., 2009; Reitz, 2010), weather, cultural barriers and lack of social support (Korkiakangas et al., 2009). Researchers also described internal barriers such as physical limitations, depressive symptoms, physical and emotional discomfort, loss of motivation (Korkiakangas et al., 2009), fear of falling (Painter et al., 2012; Schepens et al., 2012) and ageism (Butler, 2005). To overcome barriers to participation, researchers have found that people are more likely to sustain participation in activities that are meaningful and enjoyable (Csikszentmihalyi, 1990; Larson and von Eye, 2010). Csikszentmihalyi (1990) addressed meaningfulness and enjoyment in his flow theory, a theory that formed the basis for the present study. Csikszentmihalyi’s research found people are most happy when they engage in a meaningful and enjoyable activity that inspires personal growth and is so rewarding that they lose track of their surroundings and time. In the field of occupational therapy (OT), Larson and von Eye (2010) included flow theory in their study about participation and found that adults of all ages perceive time to go by faster when engaged in novel, complex and skill-requiring activities. When promoting participation and sustainability of PA among older adults, OTs need to understand how 54
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PA becomes meaningful and sustainable to this population. Ultimately, this understanding becomes valuable for OT practitioners who are promoting productive ageing as a component of the American OT Association’s (AOTA, 2007) Centennial Vision to promote occupation, participation and health. The purpose of this study was to explore older adults’ perception about participation in PA. To further understand participation in PA, this phenomenological study focused on the following research questions: • How does PA become a meaningful occupation to older adults? • How does PA become sustainable (i.e. weekly participation for more than 1 year) in community-dwelling older adults?
Method Research design Although evidence indicates PA and wellness programmes are effective in helping older adults experience productive ageing, most community-dwelling older adults choose not to participate in PA (Kruger, Carlson, and Buchner, 2007). To learn how to promote more participation, phenomenological qualitative research methodology was selected to explore older adult perceptions and experiences with PA in order to promote both meaningful participation and sustainability. Turpin (2007) supported use of phenomenological knowledge to balance art and science in research, which is consistent with the pluralistic nature of OT. Csikszentmihalyi’s (1990) flow theory, which he described as a phenomenological model, provided a useful underpinning to the exploration of meaning and sustainability of participation in PA with the older adult participants of this study. Concepts of flow theory, such as temporality and enjoyment, were utilized to construct several of the research questions (Table I). It should be noted that there were other interview questions also used that targeted varying aspects of PA related to experience, changes, socialization, preferences, sustainment and routines (Appendix A). Participants and sites Following approval of this study from the university’s Institutional Review Board, 15 community-dwelling older adults were recruited through purposive and snowball sampling. Criteria for study inclusion focused Occup. Ther. Int. 21 (2014) 53–62 © 2013 John Wiley & Sons, Ltd.
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Table I. Use of flow theory concepts to construct interview questions Flow concept Temporality Frustration Boredom Novelty Control
Interview question Think about a time when you did a PA and the time just flew by. How enjoyable was that experience and what made it enjoyable? Tell me about a time when you became frustrated with PA. What made it frustrating to you? How challenging was the PA? Tell me about a time when you became bored with PA. What made it boring to you? How challenging was the PA? Think about a time when you initiated new PA. What was the experience like? How much control do you like to have over deciding which types of PA you do and how you like to do it?
PA = physical activity. This table describes how specific concepts from flow theory were utilized within several interview questions. It should be noted that there were other interview questions also used in the study that targeted varying aspects of physical activity-related experience, changes, socialization, preferences, sustainment and routines.
on community-dwelling older adults who had engaged in PA over a year, had initiated PA in their older adult years or were currently participating in relatively little to no PA. Broad inclusion criteria of a variety of PA participation levels were allowed to foster a wide range of perspectives among older adults. Types of PA participants engaged in were varied; some did exercise PA, whereas others did more leisure PA. The researchers selected 15 participants because it was within the range of sample sizes that typically generate rigorous data in phenomenological studies (Creswell, 2007). Gatekeepers who were employed in programme director roles at the research sites helped to identify processes for recruitment of older adult participants. The gatekeepers knew each participant (except one); therefore, they were able to ascertain the participant’s ability to communicate and understand the consent form upon referral to the study. Potential participants were provided with a description of the study and the informed consent form (written in larger font to accommodate for possible age-related visual changes). They were informed verbally and in writing that their participation was voluntary, and they could withdraw at any time. They were also provided with support resources in case they experienced any injury or emotional distress during their participation in the study. Snowball sampling, through participant referral, allowed for enrolment of one additional participant who met the inclusion criteria. This person was an instructor in higher education, therefore, would likely understand the consent form as well. All participants acknowledged they were over the age of 65 years; some participants did not share their specific age but indicated their age category (refer to Table II for participant descriptions). Occup. Ther. Int. 21 (2014) 53–62 © 2013 John Wiley & Sons, Ltd.
The sites included a community housing complex (three participants), a senior centre (nine participants) and a fitness centre (three participants). The researcher initially met with potential participants at the sites to verbally describe the research study, to provide written explanation, to obtain informed consent and to schedule subsequent interview and observation sessions.
Data collection An occupational therapist experienced in clinical practice and qualitative research methodology and first author of this article conducted one initial interview session and one other session that included both interview and observation with each of the 15 participants at the participants’ preferred locations. Each session lasted approximately 1 hour over a period of 2 months. Some examples of preferred locations were the library at the senior citizen centre, fitness centres and participants’ yards or gardens as participants demonstrated PA in their natural environments. The interview style consisted of primary and followup questions designed to answer the research questions using open-ended, exploratory strategies. The researcher encouraged participants to select their own pseudonym for the study to establish participants’ sense of control and rapport. Interviews were recorded and transcribed verbatim following consent from participants to assure accuracy of documentation for interpretation. During the second session that included both interview and observation, the researcher frequently performed the PA with the participant. For example, the researcher helped a participant rake the lawn and plant the grass seed. 55
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Table II. Description of participants Pseudonym Mary Willie Nelson Dudley Do Right Jane Wyman Katie Mac Pete Anna Mae Ring Archibald Patrick Lola Priscilla Donna Kathryn
Sex
Age
PA preference
F F M F F M M F M M M F F F F
Oldest old Older old Older old Younger old Young old Older old Oldest old Oldest old Older old Younger old Younger old Older old Younger old Older old Older old
Leisure PA and group exercise Leisure PA and group exercise Leisure PA (sports) and exercise Leisure PA (walking) and group exercise Leisure PA (gardening) Leisure PA that is sociable (billiards, walking) Exercise (machine equipment) Exercise (walks)* does not like it but likes results Leisure PA (yard work) and exercise (swimming) Leisure PA (woodcarving, lawn care, recreation) Leisure PA (yard work) Exercise (in groups) Leisure PA (yard work, biking, golf) and exercise Exercise (in groups) Leisure PA (walking alone) and exercise (in groups)
PA = physical activity. *This table describes participants and their preferences for PA. The age categories are younger old (ages 65–75 years), older old (ages 75–85 years) and oldest old (ages 85+ years). Age categories were derived from He et al. (2005).
She also played billiards with another participant. This persistent observation allowed the researcher to write field notes that reflected the kinaesthetic experience described during interviews.
in a concept map. Once data were saturated with no new meaning units and categories found between participants, textural descriptions (thematic statements) were created with an overarching assertion that encapsulated the experiences of all 15 participants (Moustakas, 1994).
Data analysis The researcher completed data analysis with guidance from Creswell (2007) and Moustakas (1994). Transcripts of interview and observation notes were organized according to participant pseudonyms. Open coding began with reflexive journaling initially during the analysis process. An audit trail was drafted with detailed notes following each interview and observation. The researcher retained documentation of original field notes for later review and comparison as well as notes related to decision-making and data analysis procedures. Memo writing was also used for ethical reasons to enhance transparency of decisions made with a supporting rationale. Data analyses steps included horizontalizing, developing meaning units, clustering and developing textural descriptions (Moustakas, 1994). The researcher overlapped steps between horizontalizing (highlighting statements) and developing meaning units (coding). While horizontalizing, significant statements from transcripts, field notes and reflexive journaling were highlighted to develop meaning units. Reflectively, the horizons (meaningful statements from the text), and the meaning units were listed in a key to cluster them into categories, which were then reflected 56
Trustworthiness Persistent observation and triangulation via multiple sources of data supported validity of this study. Methods to assess validity included literature comparisons, theoretical comparisons, audit trail, expert review and member checking with randomly selected participants. The expert reviewer was a professor and researcher in the field of exercise science. To verify the overarching assertion and themes, member checking was carried out with five randomly selected participants: two were from the housing complex, one was from the fitness centre and two were from the senior centre. According to Creswell (2008), member checking is carried out with one or more participants; therefore, selection of five participants further supported validity. Each participant agreed with the final themes presented; there were no suggestions for changes in findings. In addition, the researcher compared categories of the results from this study to the main domains of the OT practice framework (AOTA, 2008) and found congruence. The framework was considered credible for data comparison because it is an official comprehensive document of the American OT Occup. Ther. Int. 21 (2014) 53–62 © 2013 John Wiley & Sons, Ltd.
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Association that aides in the understanding of participation in occupations.
Results Participant perceptions of their experiences with PA were reflected in results through an overarching assertion with two main themes. Answering the research questions related to meaningfulness and sustainability of PA, the overarching assertion is that older adults continue individual patterns of meaningful PA across their lifespan when they have support to adapt to ageassociated limitations, with a gradual decline in intensity during older years. This overarching assertion and the two main themes found are discussed further in the following paragraphs (refer to Figure 1 for a concept map representing these findings). Overarching assertion: tendency toward lifespan continuity of meaningful physical activity Despite experiencing a gradual decline in PA intensity noted in older adult years, all participants had a tendency to continue their patterns of meaningful PA over their lifespan. Reflecting back to childhood, the participants described socialized leisure playful PA such as running games, tag, biking, walking, skating and work-related PA such as gardening and farming. As they aged, they
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transformed and adapted PA into adult styles that involved physical exercise (e.g. aerobics, swimming, weight lifting and walking) and leisure PA (e.g. wood-carving, gardening and playing billiards). The PA participation during their older adult years was more consistent with older adult roles and values; however, they had an overall tendency to continue similar patterns over the lifespan even though the intensity was lessened. For example, Mac indicated that he has always enjoyed PA that involved socialization with friends and family, but instead of playing high impact sports, he now enjoys lower impact PA such as walking and playing billiards with friends to avoid risk of injury or fatigue. As a participant observer, the researcher experienced the enjoyment associated with the social aspect of PA as well when playing billiards with Mac and his friends; there was much laughter, playful teasing, with an innate sense of support between players. Mac’s roles and values were related to social connectedness. Participants’ perceptions of PA over the lifespan suggested that PA became a meaningful occupation when they were able to attach the activity to their roles and values.
Theme 1: factors that support sustainability of physical activity Sustainability of ongoing participation in PA is influenced by many factors, all of which contributed to a sense of
Figure 1 Concept map for older adults’ perceptions of physical activity (PA)
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meaningfulness with the occupation of PA. The main factors were implicated in the data by participant perceptions of their experiences. Adapting to limitations Of all limitations, 13 participants described physical limitations most frequently with a need to adapt the PA to avoid pain, injury, fatigue or falls. For example, Katie created raised garden beds in extra-large rubber tubs to adapt to limitations in bending, strength and endurance. Mary holds onto stable physical objects within her apartment to adapt to balance limitations. Participants reflected upon emotional limitations to PA participation, such as ageism (negative bias toward older adults) and social rejection. Willie suggested that ageism limits her participation in PA. She said with tears in her eyes, “Just thinking that because of my age, I am not able to do it”. She also added that she is not interested in joining an exercise group because she has a fear of “not being accepted…It’s the idea of going in there and not knowing anybody and not being accepted…”. To adapt to these emotional limitations, Willie selects her environment for PA carefully. By doing PA within her apartment complex, she feels more confident because of the familiarity of people. Of all 15 participants, six of them found that impaired accessibility to community resources, poor transportation services and financial concerns limit their participation in PA. Each participant has found ways to adapt to these limitations but indicated a need for support to further adapt to personal limitations and environmental limitations. Independence and control The majority of participants suggested that retaining independence and control was important for sustainability of PA. Mary said she does not want any physical help from anyone because it makes her feel out of control; however, holding onto a stable physical object facilitates her sense of control with PA. Lola and Dudley also acknowledged the need to be in control of their own PA choices including the type of PA, place and timing. Lola said, “I guess nobody controls me; I control myself. [Laughs]…I wouldn’t want anybody telling me what I can and can’t do”. Personable and skilful leadership of a physical activity educator The importance of having a personable and skilful PA leader emerged from the data. Donna likes a leader who 58
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can “make it fun” and be an “excitable person with good ideas and a likable person”. She also said she does not like it when a leader is too sharp and authoritarian but does appreciate knowledgeable direction. Ring said that a PA leader from the health care field caused him to have “just about the worst pain in my life”. With a sudden transition to a serious affect with direct eye contact, he said deliberately, “It angered me… [pause]”. He followed with some profanity, which was a noteworthy contrast to the rest of the interview and observation where his demeanour appeared happy and enthusiastic. All participants agreed that it is essential for PA leaders to be personable and skilful when working with older adults. Using one’s individual learning style Participants appreciated the opportunity to learn about PA, and they were quite descriptive about their individual learning styles. Mary said she “learns it, writes it down, and then repeats it to someone”. For example, she learned during a wellness educational session that she can improve her balance with diagonal body movements, which she has since incorporated into daily activities such as folding laundry. Mary suggested that learning about PA helps her to sustain participation in PA. Participants described preferred learning styles such as observation, instruction, doing, slowing down and using their own experience to make helpful associations. Match between ability and the physical activity challenge The majority of participants suggested that a positive, healthy match between ability and challenge of the PA promotes continued participation in PA. To prevent boredom, Archibald likes a “challenge, to try to be a little more creative within, to try to change it a little bit”. In contrast, participants also said they become frustrated with PA that is too hard. Katie expressed frustration as she recalled her experience with stroke rehabilitation when she said, I had one [health professional] who made me so mad because he pushed me and pushed me and I’d say, “I can’t, I can’t do it” and he’d say, “Yes, you can and you will.” Now do it…I got mad (lower, short, abruptness in voice. Eyelids a bit lower). Occup. Ther. Int. 21 (2014) 53–62 © 2013 John Wiley & Sons, Ltd.
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Physical activity that is too easy or too challenging for participants’ ability often resulted in frustration and cessation of the PA. Enjoyment and motivation Enjoyment promoted sustained participation in PA, whether it was the enjoyment of the actual participation itself or the results of the participation. The researcher asked participants to describe an enjoyable PA experience when time seemed to pass quickly. Willie acknowledged enjoyment with wellness sessions provided in her apartment complex and responded, “Because you go at 1:30 and the next thing you know, it’s 2:15…It’s because of the people and keeping yourself active”. In contrast, Anna Mae, who was 90 years old, stated frankly that she does not like her PA of walking “briskly” but enjoys the results evident in maintenance of her weight and mobility, which enables her to go out in public and participate in other meaningful activities. Enjoyment fostered motivation as participants presented unique perceptions about specific motivation related to outcomes or goals that offer particular rewards. Ring is motivated to be productive when he does lawn care because he enjoys a nicer environment. In addition, he also enjoys a sense of physical well-being. For example, he is motivated to swim, “to keep in shape”. Archibald, Donna and Ring all stated that a physician recommendation to exercise for health is a powerful motivational tool. Participants described multiple motivational factors such as a desire for physical, social, environmental and emotional wellness.
Theme 2: intrapersonal and interpersonal differences in their perceptions about physical activity There were many intrapersonal and interpersonal differences among participants as they described concepts such as socialization, routine and preferences for physical environment. Kathryn prefers both social and solitary PA; she enjoys the social aspect of group exercise class but wants to walk alone because “it’s been good therapy for me”. Participants had varied perceptions about routines for PA. Dudley and Pete stated routines were “very important”, and they both described daily schedules for PA and specific workout routines they follow for exercise. In contrast, Priscilla said she used to have a morning walking date with her friend and said, “I used Occup. Ther. Int. 21 (2014) 53–62 © 2013 John Wiley & Sons, Ltd.
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to walk at six o’clock every morning. It was so hard to get up…I found the routine irritating”. Environment was an important consideration for eight participants. Mary and Anna Mae will not walk outside where there are uneven surfaces in the sidewalks because of their fear of falling. Donna was also concerned about falling when she said she likes the big gym because “you get around and you don’t have to be careful…about bumping into each other and knocking each other over”. Participant responses suggested that fear of falling is common among several participants, and it was important to them to have an environment that is free of falling hazards. Other participants suggested the environment was not important for PA participation.
Discussion All participants did perceive that they participated in some type of PA related to either leisure or exercise PA; however, the intensity varied significantly between participants. Multiple factors supported participation in PA for older adults, holding many implications for effective, client-centred PA programming delivered by OT practitioners. A blending of intrinsic factors (e.g. adaptation to limitations, maintaining sense of control and enjoyment of learning) with extrinsic factors (e.g. effective health educators, physician referral and suitable level of PA demand) are key to understanding this study’s 15 older adults’ participation experiences in PA. Additionally, participants reflected interpersonal and intrapersonal differences in their perceptions of PA. Meaningfulness and sustainability were found to be interconnected in that the factors contributing to meaningfulness of PA also enhanced sustainability. PA became a meaningful occupation, addressing the first research question, when participants were able to attach PA to their values – such as desires for wellness, social connectedness and productivity. Similar to the research evidence, participants in this study highlighted the need for control over PA (Cskiszentmihalyi, 1990; Eklund, 2007). In addition, fear of falling further elicited a need for control over PA. A collaborative approach from a personable and skilful OT will help older adults feel a sense of control to identify an appropriate challenge level for PA with recommendations for adaptations related to limitations. Sustainability of PA, as the second research question, was addressed through the finding that participants perceived they sustained participation in PA over a year 59
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when they were able to adapt to age-related limitations in performance skills and patterns. Most participants created strategies to adapt to their changing limitations and acknowledged a need for support to further adapt. Because of the dynamic influence ageing has on ability, there is a need for OTs to conduct frequent re-assessments and intervention, as needed, with older adults to promote sustainable participation in PA. Finally, sustainability and meaningfulness of PA were associated with the flow experience participants felt during PA and while reflecting upon the results of the PA (Csikszentmihalyi, 1990). Participants validated the importance of several flow theory concepts, such as temporality, having control over PA, having appropriate level of challenge to avoid boredom and frustration and creating novelty by changing certain aspects of PA. This finding emphasizes the importance for OT practitioners to consciously include these concepts of flow theory into their interventions when promoting PA.
Implications for occupational therapy practice The identification of themes from older adults’ perceptions of their experiences with PA has important implications for OT practitioners who are planning health promotion programmes: • Partner with community agencies such as fitness and senior centres. • Work with doctors to refer patients to OT for PA programming. • Provide individual evaluations and reassess as indicated. • Organize peer groups for PA. • Address accessibility limitations and offer community resources. To promote PA more effectively, OT practitioners should incorporate the following principles into specific PA interventions:
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• Use temporality to assess enjoyment with PA by asking participant about how fast time is going by during PA participation.
Study limitations Although inclusion of 15 participants is considered a fairly robust sample size in phenomenological research, there are limitations. First, there were two interviews and an observation carried out with each participant; three interviews would have supported rigour. Despite this limitation, rich data were collected beyond interview through the researcher observation and participation in many of the PAs to generate depth of understanding. Another limitation is that there may be unreported views and uncovered themes that participants did not think of during the interview or observation.
Conclusion A valid, descriptive qualitative study was undertaken to understand and, ultimately, impact PA programming to promote older adults’ occupation, participation and health. The data collected from these participants was rigorously and ethically conducted to achieve authentic and plausible findings. This will allow OT to begin an experimental research agenda to examine the benefits of occupation-based PA to enhance older adults’ health-related quality of life. This study provides insight into older adults’ perceptions of PA, which is useful for OT in promotion of PA among community-dwelling older adults. When older adults are able to adapt to age-related limitations in performance skills and patterns, they tend to continue similar patterns of meaningful PA throughout their life. The need for adaptation implies the field of OT has a substantial role in promotion of PA with communitydwelling older adults to help them experience productive ageing during their golden years.
Acknowledgments • Match performance skill level to PA demands to avoid frustration and boredom. • Collaborate and foster participant control while adapting PA to limitations. • Help older adults connect PA to personal values when selecting types of PA. • Continually create novelty by modifying approaches and style of PA. 60
We acknowledge significant support and input for this study by Dr. Gail Ingwalson, Dr. Jodie Bergland Holen, and Dr. Lars Helgeson who served on the dissertation committee for the first author of this article in partial fulfillment of the philosopy degree in Education at the University of North Dakota. We also express gratitude to Steve Finney from the University of North Dakota Writing Center for his writing expertise. Occup. Ther. Int. 21 (2014) 53–62 © 2013 John Wiley & Sons, Ltd.
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REFERENCES Administration on Aging (2010). US Population by age: July 1, 2010. http://www.aoa.gov/AoARoot/Aging_Statistics/Census_ Population/census2010/Index.aspx [13 September 2013] American Occupational Therapy Association (2007). AOTA’s centennial vision and executive summary. The American Journal of Occupational Therapy 6: 613–614. American Occupational Therapy Association (2008). Occupational therapy practice framework: domain and process. The American Journal of Occupational Therapy 6: 625–683. Arbesman M, Lieberman D (2012). Methodology for the systematic reviews on occupation- and activity-based intervention related to productive aging. The American Journal of Occupational Therapy 3: 271–276. Butler RN (2005). Ageism: looking back over my shoulder. Generations 3: 84-86. Center for Disease Control and Prevention [CDC] (2009). Web-base inquiry statistics query and reporting system (WISQARS). National Center for Injury Prevention and Control. http://www.cdc.gov/injury/wisqars/LeadingCauses. html [13 September 2013]. Creswell JW (2007). Qualitative Inquiry and Research Design. Thousand Oaks, CA: Sage Publications, Inc. Creswell JW (2008). Analyzing and interpreting qualitative data. In JW Creswell (Ed.), Educational Research: Planning, Conducting, and Evaluating Quantitative and Qualitative Research. Upper Saddle Creek, NJ: Pearson Education, Inc. Csikszentmihalyi M (1990). Flow: The Psychology of Optimal Experience. NY: Harper and Row. De Bourdeaudhuij I, Sallis JF, Saelens BE (2003). Environmental correlates of physical activity in a sample of Belgian adults. American Journal of Health Promotion 1: 83–92. Eklund M (2007). Perceived control: how is it related to daily occupation in patients with mental illness living in the community? The American Journal of Occupational Therapy 5: 535–542. He W, Sengupta M, Velkoff VA, DeBarros KA (2005). 65+ in the United States: 2005. US Census Bureau, Current Population Reports (23–209). Washington, DC: U. S. Government Printing Office. King WC, Brach JS, Belle S, Killingsworth R, Fento M, Kriska AM (2003). The relationship between convenience of destinations and walking levels in older women. The American Journal of Health Promotion 1: 74–82. Korkiakangas EE, Alahuhta MA, Laitinen JH (2009). Barriers to regular exercise among adults at high risk or diagnosed with type 2 diabetes: a systematic review. Health Promotion International 4: 416–427.
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Kruger J, Carlson SA, Buchner D (2007). How active are older Americans? Preventing Chronic Disease: Public Health Research, Practice, and Policy 3: 1–12. Larson E, von Eye A (2010). Beyond flow: temporality and participation in everyday activities. The American Journal of Occupational Therapy 1: 152-163. Mokdad SH, Marks JS, Stroup DF, Gerberding JL (2004). Actual causes of death in the United States, 2000. Journal of the American Medical Association 10: 1238–45. Moore SC, Patel AV, Matthews CE, Berrington de Gonzalez A, Park Y, Katki HA, Linet MS, Weiderapass E, Visvanathan K, Helzlsouer KJ, Thun M, Gapstur SM, Hartge P, Lee IM (2012). Leisure time physical activity of moderate to vigorous intensity and mortality: a large pooled cohort analysis. PLOS Medicine 11: 1–14. Moustakas C (1994). Phenomenological Research Methods. Thousand Oaks, CA: Sage Publications, Inc. Painter JA, Allison L, Dhingra P, Daughtery J, Cogdill K, Trujillo LG (2012). Fear of falling and its relationship with anxiety, depression, and activity engagement among community-dwelling older adults. The American Journal of Occupational Therapy 2: 169–176. Reitz SM (2010). Promoting exercise and physical activity. In ME Scaffa, SM Reitz, MA Pizzi (Eds.), Occupational Therapy in the Promotion of Health and Wellness (225–252). Philadelphia, PA: FA Davis Company. Schepens S, Sen A, Painter JA, Murphy SL (2012). Relationship between fall-related efficacy and activity engagement in community-dwelling older adults: a meta-analytic review. The American Journal of Occupational Therapy 2: 137–148. Shah RC, Buchman AS, Leurgans S, Boyle PA, Bennett DA (2012). Association of total daily physical activity with disability in community-dwelling older persons: a prospective cohort study. BioMed Central Geriatrics 63: 1–8. Turpin M (2007). Recovery of our phenomenological knowledge in occupational therapy. The American Journal of Occupational Therapy 4: 460–473. World Health Organization (2010). Global recommendations on physical activity for health. http://whqlibdoc. who.int/publications/2010/9789421599979_eng.pdf [2 September 2013].
Appendix A Interview questions During introductions, ask the participant to select a pseudonym for themselves which I will use in the study. 1. People refer to physical activity in a variety of ways such as exercise, work-out, etc. What word do you use to name physical activity?
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2. Tell me about your experience with PA as a child, adult, and now. How has your participation in PA changed over the years? 3. Think about a time when you did a PA and the time just flew by. How enjoyable was that experience and what made it enjoyable? 4. Some people like to do PA alone, while others like to do it in groups with other people. How do you like to do PA? 5. Tell me about a time when you became frustrated with PA. What made it frustrating to you? How challenging was the PA? 6. Tell me about a time when you became bored with PA. What made it boring to you? How challenging was the PA? 7. What is your favourite type of PA. What is it about this type of PA that makes it your favourite? 8. Some people like to have a leader or trainer when doing PA. What kind of leadership, if any, do you like to have for PA? 9. Tell me a little about yourself as you think of how you participate in PA. What is your personality like during PA? 10. Think about a time when you initiated new PA. What was the experience like? 11. Think about a time when you were able to sustain participation in PA over a long period of time. What was it like? What do you think helped you to sustain the PA?
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12. What do you think about establishing a routine for PA? How does this help or hinder your ability to sustain the PA? 13. How much control do you like to have over deciding which types of PA you do and how you like to do it? 14. What concerns do you have about doing PA? How do you address these concerns during PA? 15. Tell me about how the physical environment affects your enjoyment of PA, for example, the building, noise, music, amount of people, etc. 16. Some people find that learning new ideas related to PA helps them participate in PA. People have different styles of learning. Some like to listen and watch and then try. Some people learn by doing. Some people like to talk about ideas in order to gain more understanding before trying. How do you like to learn about new ideas? 17. Could you please describe what your main motivation is for participating in PA. 18. In the field of occupational therapy, we describe any activity one does as an occupation. An occupation can include meaningful activities like cooking a meal, doing self-care like washing, and participating in a favourite hobby. What make PA meaningful to you? 19. What do you think you need to be able to do PA on a regular basis?
Occup. Ther. Int. 21 (2014) 53–62 © 2013 John Wiley & Sons, Ltd.
