Abstract
Introduction
Currently, physical activity (PA) is the only intervention that consistently demonstrates the slowing of age-related declines in physical function (Buford et al., 2014). Habitual PA, defined as physical activity participation on a weekly basis, has multiple health risk reducing dimensions that include positive influences on obesity, stroke, and high blood pressure and type 2 diabetes (Australian Institute of Health and Welfare, 2010; Gillespie et al., 2009). In Canada, the major health risks are heart disease, cancer, stroke, respiratory disease, and diabetes and are the leading causes of death in the general population (Health Canada, 2008). In a report by Statistics Canada in 2012, Canadian adults aged 50 or older rarely made positive changes in lifestyle behaviors after being diagnosed with these and other chronic conditions with only modest changes made in behavior relating to diabetes (Newson et al., 2012). Not only does the aging population have more exposure to increased chronic conditions, but they also have increased activities of daily living (ADL) limitations brought on either by these chronic conditions or from the negative influences of physical inactivity, or a combination of both (Wrosch, Schulz, Miller, Lupien, & Dunne, 2007).
Habitual PA can be used as a management strategy for improving physical health (i.e., chronic condition treatment and physical function increase) while increasing an older adult’s independence as a consequence of an increased functional ability (Cress et al., 2005). Unfortunately, evidence has shown that older adults are the least physically active groups in the Canadian and U.S. populations (Craig, Brownson, Cragg, & Dunn, 2002).
Although the importance of PA programs is acknowledged, health promoters are challenged to recruit older adults into these PA programs (Hildebrand & Neufeld, 2009). Challenges to recruitment of older adults include their lack of time, ill health, changing health status, fear of injury, environmental considerations (convenience/access), safety, cost, lack of knowledge (understanding the benefits), and lack of self-discipline or motivation (Costello, Kafchinski, Vrazel, & Sullivan, 2011). This, therefore, highlights the need for research on recruitment and enrollment of community-dwelling older adults into PA programs. Previous research has examined approaches that looked at recruitment strategies for two American older adult activity programs one being the Active Living Every Day (ALED) program (Dunn et al., 1999) and the other program, the Naturally Occurring Retirement Community (NORC; Callahan & Lanspery, 1997). These programs employed a variety of recruitment strategies using local media, such as newspapers and radio shows as well as flyers in stores, churches, seniors centers, and similar locations in the area. To understand what works and does not work in activity programs, with respect to recruitment, data can be collected using semistructured interviews to examine the successful elements of recruitment drives (Hildebrand & Neufeld, 2009).
As it is apparent that there exist means and opportunities for Canadians and specifically older adults to become more physically active, the question becomes how to best get these “at risk or vulnerable” populations into activity programs. As shown in the Hildebrand and Neufeld research of 2009, one potential pathway is by collecting and analyzing information directly from older adults themselves by examining barriers and promoters to enrollment in PA programs through semistructured focus groups. Building on this idea, King et al. (1992) classified the influential factors that could affect enrollment into the following three categories: person-based variables, environmental factors, and intervention factors. Person-based variables included individual characteristics such as age, lifestyle, physical and mental health, and attitudes and beliefs (Mills et al., 1996). Environmental factors include the setting in which the program occurs, as well as interpersonal factors, such as the support and encouragement of family, friends, and physicians (Dishman, Sallies, & Orenstein, 1985). Intervention factors include program components (targeted behaviors, program aims, and length of program), recruitment strategies (content, credibility, and means of conveying recruitment message), and exclusion criteria (such as age, gender, current health status; Mills et al., 1996).
Tai Chi (TC) has been shown to be a successful PA tool for reduction in falls and improvements in health-related cardiovascular and musculoskeletal fitness, arthritis, and psychosocial behavior (Taylor-Piliae, & Froelicher, 2004). In TC, the body is comfortably moved and relaxed, the mind is focused on the moment, and body movements are slow, smooth, and well-coordinated as the various forms are undertaken (Hong & Xian, 2007). TC exercise has the ability to produce balanced movements between natural physical and metabolic processes in the body in a slow, meditative, and relaxed way. These sequential graceful movements emphasize the smooth integration of trunk rotation, weight shifting, and coordination, along with a progressive narrowing of one’s stance or base of support. As powerful as TC is, it is important to emphasize the social benefits as part of the PA participation structure that helps keep the mind engaged, as well as evidence that being physically active with people of similar age, ability, and outlook highly influences the social rewards that are a significant influence on adherence to long-term practice (Chen, Snyder, & Krichbaum, 2001).
Physically, TC is highly appropriate for an aging population because it can be practiced by participants with one or more chronic conditions due to its appropriate intensity, steady rhythm, and low physical and mental demands. Moreover, it specifically influences balance and motor control, variables that might reduce falls in this more vulnerable population (Y. Li, Devault, & Van Oteghen, 2007). To date, there has been no research around promoters and barriers to enrollment to TC programs in Canada and this, therefore, highlights the importance of looking at this information as TC programs increase throughout the country.
The goal of the present study was to examine the barriers to, and promoters of, enrollment to a community-based TC program in older ethnically diverse low-income adults. The findings from this research have the potential to elucidate the facilitators and challenges this vulnerable population has with respect to enrolling in PA programs within their community. This knowledge could also be used to better design community-based PA programs to help facilitate stronger registration rates that could therefore lead to better participation rates.
Method
Participants
Eligible participants were 50 years or older and were community members of various ethnicities in two locations in the Greater Toronto Area of Ontario, Canada—Jane and Finch as well as Dundas and Spadina. These two locations were chosen for their multiple ethnic groups and their low socioeconomic status (SES) with both the Dundas and Spadina and Jane and Finch area having a population average income of about Can$26,771.00 (Social Planning Toronto, 2009) with low income defined through low-income cutoffs (LICOs) where a family has to spend 20 % more of its income on food, shelter, and clothing than the average family (Statistics Canada, 2010). Dundas and Spadina was specifically targeted because it is an area that is particularly dense in adults of Chinese origin (a purposeful decision to explore influences of ethnic origin affiliations with TC) as well as being socioeconomically similar to the Jane-Finch community (Profile of Low Income in the City of Toronto, 2010).
The research goal was to have three cohorts for the TC program from 2010 to 2012. There would be two focus groups for each cohort (1 male and 1 female) facilitated 2 to 3 months before each TC program. Participants for the focus groups were recruited using flyers/posters, in-person interviews, and word of mouth, from community hubs such as grocery stores, shopping malls, community groups, and living complexes. In total, 87 participants took part in six focus groups (53 participants for the female focus groups and 34 participants for the male focus groups) and ranged in age from 50 to 84 years.
Materials and Measures
Participants were briefed on the study and were informed that they would be asked a series of questions that they could answer freely and honestly based on their likes and dislikes with respect to enrolling in the TC program. The questions explored were as follows:
What are some of the key promoters that you see for enrolling in a TC program? Possible probes used were physical and mental activity, improvement of physical and mental status, social networking, enjoyment, current knowledge of TC.
What are some of the key challenges that you see for enrolling in a TC program? Possible probes used were day/time of session, numbers of sessions per week, location of program, language, gender, age range, transportation, lack of knowledge of TC or past history with TC, current health status, and weather conditions.
A digital voice recorder was used to record each focus group and these recordings were subsequently transcribed verbatim. The experimental protocol conformed to the standards set by the Declaration of Helsinki and is approved by the Research Ethics Board at the local University.
Focus Groups
There were three cohorts in the overall study so six focus groups were conducted (one male and one female per cohort) and each group was made up of seven or more participants with the goal of equal numbers between males and females. Participants were contacted by phone or in-person and asked to participate 3 days prior to the scheduled focus group session.
A contributing researcher (Focus Groups 1 and 2) and the first author (Focus Groups 3, 4, 5, and 6) worked with three research assistants to facilitate the focus groups. Attendees seated themselves around two digital voice recorders, which were stationary on a table or chair. Participants were read each question, with probes used when needed, and were allowed to answer freely as well as discuss their perceptions among themselves. The duration of each focus group session was 45 to 60 min. Focus groups were conducted at or close to the locations of the proposed TC program. Focus group participants were provided snacks and beverages post focus group participation and were given a Can$10 gift card for a local grocery store as a thank you for participating. The focus groups held at the Spadina and Dundas location were provided with a translator that spoke both Mandarin and Cantonese for any participants who did not speak English. Discussions ended with the opportunity for participants to make final comments before the recorders were switched off.
Analysis
All focus group data were transcribed and participants were designated with unique gender identifiers (i.e., F-1 for female 1, M-1 for male 1, etc.). Transcripts were analyzed based on multiple readings of the focus groups; broad themes/categories were established for the responses. In accordance with hierarchical content analysis outlined by Côté and colleagues (Côté, Salmela, Baria, & Russell, 1993; Côté, Salmela, & Russell, 1995), “meaning units” were identified from comments and quotes. From these meaning units, similarities were identified and grouped into “categories” of similar meaning units with common features such as repetitive words and phrases (Côté et al., 1993; Tesch, 2013). Six different documents (two for each cohort) were created (three female and three male in total) from which categories with similar meaning units were grouped together. This approach to qualitative analysis is often referred to as the constant comparative method (Glaser, Strauss & Strutzel 1968) and uses a technique of contrasting the data until saturation is achieved. Saturation refers to the process of defining encompassing categories at a level that demonstrates no new concepts from the data (Côté et al., 1993).
The data were analyzed via the use of guidelines that, although systematic, are endowed with maximum flexibility (Glaser & Strauss, 1967). In the first stage, quotes from the transcripts were initially coded into thematic clusters. Themes were identified and promoters and barriers to enrollment categories were created. All categories identified at all three stages of analysis were checked by a second coder to ensure they were grounded in the data (Charmaz, 2006).
Trustworthiness
Interpreter reliability was established through the categorization of a random sample of participants’ response (approximately 10% of meaning units) by an individual familiar with this method of qualitative analysis. There was complete agreement in the categorization of the data.
Results and Discussion
Baseline sociodemographic characteristics of the prestudy focus group participants can be seen in Table 1. The majority of the participants were female with almost 80% of the entire focus group members being 65 years of age or older and of mixed ethnicity that is not culturally connected to TC (ethnicity connected to TC being East Asian). Most of the participants had a high school education or less, were single, and had an income of Can$14,000 or less. Within the two broad themes (Promoters and Barriers to Enrollment to a TC program), six categories of clustered meaning unites emerged (Table 2). There were minimal differences found between males and females in these themes and no differences between cohort groups with no perceived ethnocultural barriers to enrollment. These categories and themes are described in further detail with quotations from participants.
Baseline Sociodemographic Characteristics of Prestudy Focus Group Participants.
Note. Focus groups for each cohort divided by gender, therefore three cohorts had six focus groups.
Themes, Categories, and Subcategories to Enrollment Resulting From the Qualitative Analysis.
Note. Numbers refer to number of people. TC = Tai Chi.
Promoters to Enrollment
Health improvement
Although a health focus priority is pervasive throughout society, it becomes an even higher priority in populations that can see a personal decline in their health status, such as older adults. Older adults embrace physical, functional, psychological, and social health in their definition of successful aging (Phelan, Anderson, Lacroix, & Larson, 2004). In our focus groups, several participants mentioned multiple times that, even though they had minimal knowledge of TC, they perceived TC as good PA to improve their health and, as such, it was a draw for enrollment. Many statements reflected this such as “. . . we know it is good for health, seniors become more flexible” (M-19), and “to strengthen the body, to help regulate it . . . health” (F-22), as well as, “good for seniors health condition because the actions/practices are slow” (M-20). However, the focus was not just on physical health improvement but on mental/emotional health improvement as well. This was shown by such phrases as, “we will be more optimistic and open-minded [from participating]” (F-23), and “health mentally is maintained [with exercise]” (M-15).
Research has shown that health status is consistently a significant individual facilitator (and potential barrier) to PA participation because people understand the need to exercise to improve health (or not exercise because health was too poor; Boehm et al., 2013). It is therefore important to not only have PA programs that demonstrate evidence-based health improvement but also health improvement when participants are already dealing with chronic conditions. This information then needs to be clearly presented to potential PA program participants to facilitate enrollment.
In a 2004 study, older adult participants frequently mentioned both health and social benefits as motivating factors for being physically active (Belza et al., 2004). Several times during the focus groups, participants mentioned that they had heard that TC was appropriate for older adults, and thus they were motivated to enroll. This can be seen in statements such as “[TC] is used in retirement and good for health” (M-23) and “have heard Tai Chi is good for [seniors] blood pressure” (M-25).
In light of this information, it is therefore important to increase health literacy with older adult communities on the benefits of PA programs both for physical health and mental health (Nutbeam, 2000). It is also important to emphasize in lighter intensity PA programs, such as TC, that chronic conditions do not need to be an exclusion consideration for participation and, in fact, TC can positively influence health in participants with multiple conditions (G. Li, Yuan, & Zhang, 2014).
Time of day
Of equal importance to health, in our focus groups, was time of day. When exploring this area many focus group participants were not shy in voicing what time worked for them. Some research has shown that PA programs can be inaccessible due to older adults’ schedules around self-care, volunteer work, and family obligations (Hildebrand & Neufeld, 2009). There were multiple motivators around time of day and possible enrollment with respect to our focus group participants reflected in statements such as “afternoons good, can come with wife” (M24) and “do not want noon, time to eat” (F-21). There were also time of day motivators specifically relating to older adults, “a lot of older people don’t sleep very well, so not too early” (F-31) and as many older adults take public transit, they need to factor this into their schedule reflected by the statement, “. . . and then the subway then another bus to get here . . .” (F-34).
It is important to understand that many participants in our focus groups acted as support systems for their children and grandchildren. Therefore participants ability to attend sessions was influenced by their family commitments. Such commitments and time choices were reflected in the statements, “not as good in morning since grandkids sleeping” (F-25), and “[if in same building as kids program] . . . when the kids settled, then they can do it [Tai Chi]. (F-28). So with multiple desires for times and various reasons for timing, this potentially demonstrates the importance, where possible, for older adult programs to be offered throughout the week at different times. Our results were consistent with previous findings that have shown that these patterns were strongest during the day, especially mid to late morning, with much less activity in the evenings (Davis & Fox, 2007).
Socializing/networking
Although we found minimal differences between males and females in our categories, the socializing/networking category had a slightly higher female focus compared with males. However, it is important to note that there were a high percentage of female participants in our focus groups (60.9), which potentially could have influences over gender differences. That being said, current research knowledge has shown that the social environment is one of the elements that influences the “determinants of health” (World Health Organization [WHO], 2014). Research has shown that social participation for older adults is part of a productive and healthy aging paradigm, and social support system facilitated through friends and family therefore has a strong protective effect on healthy aging (BC Ministry of Health, 2004). Based on this evidence, it is important then to create older adult programs that not only enhance physical health but also increase a positive social environment regardless of gender.
Multiple participants in our focus groups mentioned the draw to participate through social interaction. Even though many mentioned the social aspects there were different motivators for them socially, one participant stated simply, “OK to do classes with the men” (F-22), whereas another woman stated, “I would like the men to participate, to get these men out and exercising” (F-10). Some participants just liked the basic social aspect stated as, “also to socialize as well” (F-26) and “group activity can be a great draw especially if alone” (M-30). However, it was interesting to note that many participants felt the desire to enroll to have people support them. This is seen in statements such as “people looking out for you and asking where you were” (M-31) and “just knowing people will miss you” (F-28), and some participants were motivated by potential follow-up if they missed class in statements such as “checking in on you, to make sure you are OK” (F-32) and “things like get well cards, or missed you cards [when they are absent]” (F-31).
Making programs highly interactive has been shown to be a strong variable for recruitment and retention for PA interventions and shows the strong force that social needs can influence on enrollment (Beech et al., 2003; Robinson et al., 2003). Although social motivation has long been recognized as a draw to participation from our focus groups, there could be seen multiple levels at work within this social arena. Some research has focused on different levels of social support, be it from family and friends all the way to program leadership (Bunn, Dickinson, Barnett-Page, Mcinnes, & Horton, 2008), and so it is important, when looking at proven enrollment variables, to leverage as many of these variables as possible.
Other program pairing
As seen in the promoter influence around “time of day,” older adults sometimes are limited due to their schedules. Many older adults who are managing multiple chronic conditions must schedule and travel to various appointments that can take an entire day to complete. Combined with a self-care schedule are also considerations of volunteer work that many older adults partake in to remain vital as well as support for their adult children in various roles of day care and baby-sitting. These multiple scheduling variables influence older adults to desire more efficiency with their scheduling by looking at enrolling in programs that are paired with other programs. Our focus groups uncovered different pairings that related to the different needs and obligations that some older adults have. Some participants wanted to pair activities relating to their grandchildren as can be seen in the statements, “Because our [children’s] program starts at 1 . . . So we think 1:30 [for Tai Chi] when we settle the kids, then we can do it.” (F-22) also, “if you want to leave them [children] alone, you have to have the kids program on” (F-23). Other potential participants had other programs at locations where the TC program could potentially take place. They articulated how it would be easier for them to attend multiple programs demonstrated by, “Monday mornings good because right after is another program, bingo” (F-29) and “we can also have another class Friday right after another function” (F-30) also, “[we] are already here so good time for another [TC] class” (F-31). Evidence shows that one important variable, among several, is convenience (Gavin & Myers, 2003) demonstrating the need for easier pathways for activity accessibility.
Older adults living independently have been shown to be successfully recruited to PA programs through partnerships with neighborhood organizations, that although are not exactly pairing, demonstrate that other programs (participator or informative) are facilitators to enrollment (Hildebrand & Neufeld, 2009). When examining research focused around enrollment/recruitment, there can be seen a pattern of partnerships that have been associated with successful campaigns showing the importance of pairing, be it programs within participator centers or through community partnerships (Carroll et al., 2011).
Barriers to Enrollment
Accessibility (travel and weather)
Although older adults may have challenges around having enough PA programs to address their needs, there is actually a twofold challenge in older adult programming. One, of course, is having enough programs to support older populations, but consideration is also needed for any given program to make sure it is accessible to the community it serves. Many of the participants in our focus groups articulated their desire to attend but were faced with the realities of big city living, which involve travel distances, public transport schedules and cost, time of day issues such as rush hour, and the physical health resources needed to use transportation services. On top of all this are the ever-changing Canadian weather patterns. Weather challenges were shown in statements such as “Will come in bad weather, but too much snow though cannot walk” (F-23) and direct statements such as “storms can be a barrier” (F-25) and “heavy snow a barrier, we cannot come here” (F-26). Even when highly motivated, the reality of the weather was always there in this statement, “Weather not a problem when living close, although the very cold weather can be difficult” (M-22) and “summer, spring and fall more accessible” (M-28).
Canadian research has shown that walking challenges due to the environment can be a barrier to both active transport and PA participation (Lockett, Willis, & Edwards, 2005). However, our focus groups also uncovered barriers to enrollment through transportation limitations relating to time and walking versus public transportation. One potential participant stated, “A 30 minute walk is [my] limit” (F-22) and, “[I can come if] do not have to make another trip” (M-27) and echoing the 30-min limitation was, “[can come if] locations not too far” (F-29). Neighborhoods that have shown limitations to active transport have demonstrated poorer older adult health outcomes (King et al., 2011). These poorer health outcomes around lower active transport neighborhoods lead directly to less walking, which can manifest not only in a decline in health but a much lower chance of these older adults walking to activity programs. It is therefore important to guard against the oversimplified notion that “if we build it they will come” in light of the challenges and limitations older adults face around accessibility to activity programs. Many programs have been created to help older adults maintain/improve health but initiation of these programs needs to be done in areas and community centers that take into account the limitations around accessibility/travel and weather challenges.
Teacher/leadership appropriateness
The proposed TC program was aimed at community-dwelling older adults based in a neighborhood that has had increased access to PA programs from the adjacent universities research initiatives. As there has been an increase to research funded PA programs, there was a higher percentage of focus group attendees that had historically attended other PA programs. Through this experience, some of the focus group participants understood exactly what they liked in a teacher or PA group leader. They knew what qualities would make it more attractive to enroll, and those qualities that they felt were a barrier for enrollment. Such basic statements as, “also hard to find a [good] teacher” (F-24) and “communicate clearly with participants important” (M-22) to more precise statements as “the [Tai Chi] masters have to be very organized because the students may not follow it [Tai Chi]” (M-23) and “[Tai Chi] needs to be accessible both through facility and through teacher” (M-25).
However, there were also qualities that participants mentioned that were not directly related to teaching such as “good connection with leader of the group [important]” (F-28) and one participant stated that they need to “like the instructor” as well. Relating to older adults was also a strong focus that could be a potential barrier to enrollment reflected in statements like, “instructors need to relate and vice versa” (F-29) and “sometimes young [age of instructor] is a barrier” (F-30). One participant was very clear in her desire to have an instructor that knows “what it feels like to be in an aging body” and also made the observation of a past instructor that “was injured and older, in pain, and participants knew that the instructor could relate to them” (F-28). Evidence reinforces the fact that it is important to have well-trained, matched, and tailored leadership specifically around recruitment as well as retention (Carroll et al., 2011). In a study done by Hildebrand and Neufeld (2009), participants articulated that one of the variables that made enrollment more attractive was trust in both the program organizations and the staff running those programs. This same study concluded the importance in enrolling and retaining participants by not running a “one-size-fits-all” recruitment approach for all age groups. It is therefore important to understand variables that have proven to work for adults below 50 years of age potentially do not work for older adults (Hildebrand & Neufeld, 2009).
Conclusion
In our focus group investigations, we discovered six categories, four relating to promotion and two relating to barriers of enrollment. Adding to this, we also found no specific barriers or promoters that related to gender and specific cultural limitations. Categories included physical and mental health, time of day, socialization, program pairing, accessibility, and appropriate leadership/teacher.
Although it is important for PA programs to focus on optimal methodology and adherence, it is equally important to focus on enrollment. In this period of increasing costs and lower funding, it is important to attract and enroll optimal numbers of participants to community PA programs. The target population for any study is a source of great knowledge with respect to key variables that can facilitate an optimal enrollment process. The study focus groups in this article were highly beneficial with respect to informing, directly and advising the important variables to focus on so as to achieve the highest enrollment numbers possible. In future research, where financially and temporally possible, further study in PA programming should aspire to hold focus groups both pre and post the actual research program to help facilitate enrollment and adherence. Not only is this process important for gathering valuable data, it is also important to hear directly from the population that these PA programs are intended to serve (Ory & Smith, 2015). Once again as we move into a future that has limited research funding, it is important that the voice of the stakeholders be a part of the research landscape (Stevens et al., 2015).
Based on the evidence presented here, combined with previous research reinforcing the same results, agencies/groups should look to prioritizing PA programming messages around health benefits to participants and making sure the time of day for their programs is optimal for the participants. As well these PA programs could potentially benefit from an increased influence of socializing and networking for the participants within the program itself. Also, where possible, aligning different program offerings (aimed at the same age groups) within centers concurrently could potentially allow participants to benefit from less travel frequency and therefore less limitation to access. However, it is important to place PA programs within communities that allow the greatest number of participants to travel the least distance and to have leaders of these programs a positive draw for the participants.
Although the evidence discovered from these focus groups was valid and clearly presented, there were some limitations. The first cohort focus groups (groups 1 & 2) were facilitated by a different researcher then cohorts two and three (groups 3 to 6) and thus the focus group information gathering process may have been slightly different. Every attempt was given to balance gender representation, but females represented a high percentage. Finally, Cohorts 1 and 3 were facilitated by English, but Cohort 2 was facilitated using translators and therefore some slight meaning changes could have developed in the probes around questions of enrollment barriers and promoters.
These focus groups within the themes of promoters and barriers to enrollment illuminated four categories around enrollment promotion and two categories around barriers to enrollment. Health improvement, time of day, opportunities for social engagement/networking, and program pairing were the promoters to enrollment, and accessibility relating to weather and travel and appropriate leader/teacher were the barriers to enrollment.
Footnotes
Declaration of Conflicting Interests
The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding
The authors received no financial support for the research, authorship, and/or publication of this article.