Key Strategies for Physical Activity Interventions Among Older Women: Process Evaluation of a Clinical Trial

Abstract

Purpose:

To describe strategies salient to physical activity (PA) initiation and maintenance among older women who participated in a clinical trial that tested a PA intervention.

Design:

A descriptive phenomenological, qualitative design for a process evaluation of a successful clinical trial.

Setting:

Senior primary care clinics associated with a large medical center in a southern state.

Participants:

A total of 20 older women at least 60 years without advanced frailty.

Method:

Purposive sampling using maximum variation technique was used to select participants. A semi-structured interview guide facilitated individual, in-depth interviews lasting 45 to 90 minutes. Narratives were analyzed using content analysis with constant comparison technique to summarize the data.

Results:

Eight African American and 12 white older women with a mean age of 68 from control and intervention arms participated. Five central themes described salient strategies to promote and maintain PA: sensed benefits, motivation, and self-efficacy were central to success, while a reduction in barriers was essential before maintaining PA. The last theme, a life-changing awareness indicated that PA had become a shared value. An explanatory model describing interrelationships is presented.

Conclusions:

This study suggests key strategies to include in PA interventions with older women. An unexpected finding was that PA became a shared value, an action promoted by the Culture of Health initiative to improve population health and well-being.

Keywords

physical activity culture of health fitness older adults women process evaluation

Cardiovascular disease is the leading cause of death in women in the United States, killing 1 in every 4 women, especially after the age of 65. There is substantial evidence that lifestyle modifications, such as increasing participation in regular physical activity (PA), could substantially reduce the incidence of heart disease and stroke.^1
-3 However, rates of habitual or lifelong PA in the United States are low, with essentially no increase in levels of PA among older adults in the past decade.⁴ The Centers for Disease Control report through the National Health Interview Survey that only 21% of all adults meet national PA guidelines, declining with age to 16% if 65 to 74 years and 8% if 75 years or older and with women at any age participating less than men.⁵

There are major challenges in the United States in determining how to propagate interventions to increase PA. National coalitions have recently come together to advocate for PA promotion at a population level in addition to an individual level.^6

-9 The consensus is that policies are needed to improve physical and social environments in communities, at work, or at schools to encourage PA.^9

-13 Accordingly, the Robert Wood Johnson Foundation (RWJF) and allies are championing a Culture of Health movement or a population-based strategy toward health promotion that reflects individual beliefs as well as cultural customs, community values, and equity.⁹ Improving health in the United States by increasing health promotion activities such as PA is an essential goal of this movement. At an individual level and despite a plethora of research on PA promotion, evidence regarding optimal strategies to encourage PA in adults, and especially older adults, vary widely. Conclusions about the effectiveness of individual components of interventions are lacking because of the heterogeneity of interventions, measures, outcomes, or populations sampled, thus limiting dissemination of interventions.^14

-17

Among the factors hindering our understanding of optimal strategies is that studies of PA interventions often lack adequate descriptions of methodology, the PA-promoting interventions used, and context of the interventions.^17,18 For example, articles often do not describe how complex PA interventions were delivered nor do they often test or specify which individual components were essential to the success of the intervention(s). However, it is fundamental that we understand the process of intervention delivery, which aspects of the intervention were most/least appealing, which aspects motivated participants to engage in sustained PA over time, and how those factors may differ across population subgroups (eg, by age, gender, health status) if we are to better understand differences in outcomes and to design better programs.

A Cochrane review of 19 studies with 7598 adult participants (over the age of 16 years) found that professional advice and guidance combined with ongoing support from health-care providers were associated with an increase in self-reported PA in the short term or within a year.¹⁷ A second Cochrane review of 14 trials with 648 participants that assessed interventions to promote exercise after cancer concluded that goal setting, exercise practice, and self-monitoring were common behavioral aspects of successful interventions to increase PA. The meta-analysis of Conn et al¹⁶ containing 359 studies of 99 011 participants found that behavioral approaches such as goal setting, contracting, self-monitoring, and rewards were more effective than cognitive approaches (changing knowledge, attitudes, and beliefs) in increasing PA; however, it did not support theoretically derived interventions, motivational interviewing counseling, group exercises, or barrier management, which are common methods used by many successful interventions. A review by Ashworth et al¹⁹ compared the effectiveness of home-based PA versus center-based PA programs for older adults and concluded that center-based programs are more effective in the short term, but home-based programs appear to be more effective when it comes to PA maintenance in older adults.

The key conclusions of these reviews and others^17,19
-21 are that levels of PA in older adults, especially women, remain low despite the undisputed health benefits of PA. Further, there is a great need to better understand successful components of interventions and why some people improve PA and become active, while others do not. Data are needed to better understand how individual factors, such as decision-making, motivators, personal accountability, or health, can promote PA and to identify effective delivery systems to promote lifelong PA in the United States.^10,22

Purpose

Because of the heterogeneity of findings within the body of PA research and the scarcity of studies which describe intricacies of interventions, we conducted a process evaluation study with older women participants who were involved in a clinical trial in which an intervention to increase PA was tested. We specifically aimed to describe the experiences of older women regarding uptake and maintenance of the PA intervention, salience of intervention components, acceptability of procedures, and the barriers and facilitators of PA to support effective implementation of future PA programs.

Overview of Lifestyle Physical Activity for Older Women Trial

The Lifestyle Physical Activity for Older Women (LPAW) study was a single-blinded, randomized controlled trial of a tailored, motivational intervention to increase lifestyle PA among older women who did not routinely engage in PA. Complete information about methods and results is presented elsewhere (Lefler, 2016).²³ Lifestyle PA was defined as a daily accumulation of self-selected PA to include leisure, occupational, and household activities.²⁴ Older women were recruited from primary care clinics affiliated with an academic medical center in a rural, southern state. Potential participants were selected if they were ≥60 years of age and were not frail or demented. Women were excluded if they reported regular participation in PA or had an acute illness. The mean age of the participants was 69 years; 64% of the 144 enrolled participants were non-Hispanic whites and 35% were non-Hispanic African American women.

For the experimental condition, a health-care counselor used a PA educational booklet from the National Institute on Aging ²⁵ with motivational interviewing counseling to tailor the PA intervention to individual participants’ preferences and needs. Motivational interviewing is an established behavior change technique in which a counselor helps the participant to identify and mobilize intrinsic values to stimulate behavior change.²⁶ Initial in-person meetings were followed by telephone counseling sessions over the 6-month duration of the trial, during which the counselor used the same motivational interviewing technique. For the control condition, we used the PA booklet to endorse lifestyle PA in addition to monthly phone calls, where we contacted the participants to match attention but without counseling. Outcome measures were administered at baseline, 3 months, and 6 months, and included PA accelerometer measures, a PA diary, the Exercise Stage of Change Assessment,²⁷ the Self-Efficacy for Exercise Scale,²⁸ and the Medical Outcomes Study Short Form-36 quality-of-life measure.²⁹ Results of the study confirmed that the intervention was effective in increasing PA among the sedentary older women at 3 and 6 months.

Design

This process evaluation study used a descriptive phenomenological, qualitative design informed by the Medical Research Council procedure.³⁰ We conducted in-depth, face-to-face individual interviews to explore the experiences of the women who had participated in LPAW trial. Phenomenology emphasizes the participant’s perception as the basis for knowledge and is often used to explore and describe phenomena critical to the understanding of a lived experience, yet is a research method that is rigorous, critical, and systematic in the investigation of phenomena.³¹ The study was approved and conducted in accordance with the local institutional review board.

Participants

Participants were a subsample of women from the LPAW trial recruited after 9 months of trial completion. They were purposively selected using maximum variation sampling, that is, we selected a diverse set of participants with varied experiences in order to capture the full range of participant perceptions.³² We invited women from each of the following 4 experience groups to participate: (1) women in the control group who dropped out of the study, (2) women in the experimental group who dropped out, (3) women in the control group who completed the study, and (4) women in the intervention group who completed the study. We recruited a total of 20 women based on the phenomenological design³¹ and criteria for theoretical saturation,³² a process of determining how many interviews are sufficient when considerable repetition of narrative occurs and no new ideas emerge.

Methods

Measures

A semi-structured interview guide was developed for the process evaluation in the context of the LPAW trial goals. The interview guide facilitated an open, in-depth interview with women about the acceptability of the interventions (control and experimental), their engagement in the processes of the interventions, and the barriers and facilitators to regular PA. The global question that started the interview was: “Describe for me your experiences with the PA research study.” If needed, probes were used to encourage elaboration of particular dimensions of the topic under discussion. Please see Interview Guide in Table 1.

Table 1.

Semi-Structured Interview Guide With Probes.

Describe for me your experiences with the physical activity research study

What processes or activities helped you stay active in the study? OR

What processes or activities caused you to drop out of the study? Which were most important to you?

Tell me about maintaining physical activity over the course of the study

Tell me about the things you liked. Tell me about the things you did not like. What about the procedures?

Tell me about what your doctor or health-care provider said to you about needing to exercise or about this study

Tell me about your physical activity now. How do you keep it going? OR How do you plan to start again? What do you need most?

What else do you think would be helpful to know about this study or your participation in physical activity?

Data Collection

Potential participants were contacted via telephone by a graduate student in public health (B.H.) who was not involved with the original study. She was trained in interview techniques with coursework and by the principal investigator (PI, L.L.L.), an experienced qualitative researcher. The graduate student conducted all interviews in a private study office, which lasted 30 to 90 minutes on average. Interviews were digitally recorded and transcribed verbatim. The participants received a $25 grocery gift card in appreciation.

Analysis Strategies

Qualitative data

The graduate student entered each transcript into Ethnograph (v 6.0; Qualis Research, Denver, Colorado), a text-based data management program. This program numbered each line and allowed data to be organized and sorted by designated labels or codes. The interview data were initially coded using content analysis,³³ and a systematic, objective analysis was designed to identify keywords, phrases, and topics. This was followed by constant comparison, an iterative process designed to identify common themes by comparing one interview to another.³⁴

Using these standard methods, the PI and graduate student read narratives independently and developed codes for each idea expressed in the narratives and developed definitions for each. We discussed and fine-tuned these codes and definitions, reaching consensus on each. We repeated this process with all interview narratives, comparing one to the next, and coded the remaining interviews. Second-level analysis ensued, in which we aggregated similar codes to form categories, and developed central themes by combining similar categories that illuminated collective experiences. We then selected exemplary and common narratives for each thematic category to illustrate and explicate the experiences and beliefs of the participants.

Quantitative data

The Statistical Package for Social Sciences (SPSS) 11.5 for Windows program was used for descriptive analysis of the sample characteristics.

Results

Sample Description

Table 2 summarizes the demographic and clinical characteristics of the 20 women who took part in this study. Participants had a mean age of 68 years (range: 60-94 years); 8 were non-Hispanic African American women, 11 were non-Hispanic white women, and 1 was Native American. Eleven of the participants were part of the intervention group, and 9 were in the control group. The 4 participants who agreed to participate in this study and who did not complete the clinical trial had dropped out for health reasons (specifically, self-reported depression, shortness of breath, heart problems, and an ankle injury). As can be seen from Table 2, participants varied in their demographic profiles, and self-reported cardiovascular risk factors were highly prevalent in this sample. Of note, 40% already had a history of cardiovascular disease and 35% had a diagnosis of type 2 diabetes mellitus. Collectively, the sample would be considered at high risk for cardiovascular disease according to the American Heart Association.³⁵

Table 2.

Demographics, Cardiovascular Risk Factors, and Comorbid Conditions.^a

Characteristic	n (%)
Age (range)	68 (60-94)
Race/ethnicity
Non-Hispanic black	8 (40)
Non-Hispanic white	11 (55)
Educational level
High school graduate with some college, vocational, or trade school	10 (50)
College graduate	3 (15)
Graduate school	7 (35)
Income
Less than $10 000/year	1 (5)
$10 000 to $29 999/year	8 (40)
$30 000 to $39 999/year	3 (15)
>$40 000/year	7 (35)
Refused	1 (5)
Living alone
Yes	9 (45)
No	11 (55)
Risk factors/comorbid conditions
History of cardiovascular disease (CAD, PAD, AAA, and CVA)	8 (40)
Hypertension	17 (85)
Diabetes	7 (35)
Tobacco use
Current smoker	1 (5)
Past smoker	7 (35)
Nonsmoker, with second-hand exposure	10 (50)
Nonsmoker, without second-hand exposure	2 (10)
BMI (mean)	32.2
Hyperlipidemia	14 (70)
Family history: heart attack or stroke	11 (55)
Follows heart-healthy or low-fat/-sodium diet	4 (20)

Abbreviations: AAA, abdominal aortic aneurysm; CAD, coronary artery disease; CVA, cerebrovascular accident; PAD, peripheral arterial disease.

^aN = 20.

Narrative Results

Five central themes emerged from participants’ descriptions of their experiences regarding PA and their participation in the trial: barriers to PA, benefits to health, motivation, self-efficacy, and a life-changing awareness. Table 3 includes the themes, categories within each theme, and examples of raw data from the participants that illustrate each.

Table 3.

Central Themes, Categories, and Participant Narratives.

Central Themes	Categories of Each Theme	Participant Narratives
Barriers	Health incident	“I was excited about starting…it didn’t last long…it was mainly my not being able to breathe.” (Control group, dropped out^a) “I was doing great until I had another accident…a broken vertebra with severe pain.” (Control group, dropped out)
	Needed more help	“…hey I’m right on your side…you need to get up. That would compel them to do better. That’s what a lot of people need…I mean they got the willpower and the mind-set thing but when it comes to doing it, you need a little shove…” (Intervention group) “Keep behind the old people…just say ‘how you doing today? You making out ok with your exercises? Are the exercises helping you?’ Just to say that you’re interested, you know.” (Control group)
	Limited support from provider	[Did your Provider ever say anything to you about exercise?] “No…I guess it would help me if they would encourage me to do that.” (Intervention group)
Benefits in health	Mental	“And I find where my mind was being activated. I don’t know if that’s what the study supposed to be…I was able to remember things…it kept my mind alert.” (Control group)
	Physical	“It helped me. I lost like 7 pounds and that really got me going. I loved it. I felt better…I slept a lot better.” (Intervention group) “All this exercise actually helps…It helps with depression. Like I said, I feel better. My blood pressure is lower. I just love it. Great health benefits.” (Intervention group)
Becoming motivated	PA diary	“I felt it [PA diary] was very good because I knew I was going to be filling that out. So it made me aware. I’ve got to do something because I’m going to be recording this. It was a boost to keep going…encouragement.” (Intervention group)
	Accountability	“I think probably the most beneficial part was the accountability factor…having somebody to come back and report to. It gave me that inspiration knowing that you had to account for it [exercise].” (Intervention group)
	Tailored	“We were able to discuss things and lay out a plan that was best suited for me…It was like having an athletic trainer.” (Intervention group)
Self-efficacy		“So it gave me a better outlook on things as far as doing things for myself…You think about what you can do…It gave me a better way of thinking about myself and about life.” (Control group) “I have balance. I can do it…I didn’t walk as fast. I didn’t do things as strenuously as I do now. Now I really feel better. I felt empowered…Actually it’s choking me up a bit. It was exactly what I needed. I was very worried about myself.” (Intervention group)
Life-changing awareness		“I view exercise differently than I had in the past…it really does impact, you know, the way you view exercise and nutrition long after the study is over.” (Intervention group) “You just have to incorporate it in the way you live [PA], that’s just part of your days…It made me more aware of the need to be consistent about it.” (Intervention group)

^aIf participant dropped out of the trial, it is indicated following their narrative by “dropped”; all other participants remained in the study for 6 months.

Barriers to PA

Barriers to PA were identified as a central experience, mentioned by all of the participants in at least 145 different statements. In part, this was because all participants were queried on this point. As expected, many narratives reflected the daily struggles in attempting to participate in PA. Three categories of barriers to PA were common: (1) health incidents, (2) needed more help, and (3) limited support from provider.

A health incident was defined as any health problem that functioned as a barrier to engaging in PA. Our participants described multiple health conditions that served as barriers to PA, and overcoming barriers was key to maintenance of PA; for example, “I had let myself get out of doing any more movement that I had to, especially when my feet hurt, I do have a hard time; but I managed…I just keep telling myself I can.”

Participants often explained that they needed more help or support than what was provided in the LPAW trial and that they had unmet needs. This barrier was reported primarily by the 9 women in the control group because they did not receive as much support as those in the intervention group. “Nobody made me do anything. Nobody was standing over me. I looked at the pictures and the video…and I never looked at it again. There was no incentive.” Only 3 of the women in the intervention group reported that they needed more help; they suggested having an in-person demonstration of exercises, more frequent telephone calls, and/or a longer study duration.

The last category of reported barriers to PA was limited support from provider. Most participants did not recall their providers recommending participation in PA, while a few said their providers recommended it but did not provide specific instructions. Participants expressed the need for more support from their providers to participate in PA and to prescribe how: “I don’t want to hear you’re just overweight and you’re this or that…because I already know that…if they would talk to the patient.”

Benefits in health

Participants were asked what they liked about the LPAW study, and all but one participant praised the study. Unexpectedly, our participants had little to say about the study procedures, rather they reported benefits they experienced from engaging in PA. At least 57 different statements described perceived benefits of PA, including improvements in mental and physical health. For instance, “…exercise as the key to keep me mobile, to keep me moving. If it weren’t for that, I don’t know. I would probably be in that power chair by now.” This particular participant shared that she was using a cane and a power chair prior to the study and now she did not require assistive devices.

Motivation

Motivation/motivating participants to engage in PA was a key component of the LPAW intervention, so we were not surprised that those in the intervention group mentioned it as a benefit. However, all but one control group participant (n = 8/9) also reported that study participation increased motivation to sustain engagement in PA. The importance of study-induced motivation was mentioned by 18 of the 20 participants in approximately 105 different statements. Importantly, the interview guide did not reference motivation, so the participants were not cued to mentioning it as a benefit or a facilitator of sustained engagement. Motivation was discussed as both a method and a benefit of participating in PA. As a method, women used the motivation created by the study methods to prompt them to perform PA daily. Three aspects of study procedures were most often raised in relation to motivation: (1) the PA diary, (2) accountability, and (3) tailored counseling.

Participants in both arms of the trial were asked to keep a PA diary and record daily PA. Although 30% of the participants reported that they did not like to use the diary, all others indicated that the diary helped motivate them to continue PA: “I had to maintain it [PA] because of the phone calls and the diary. So that was a motivation.”

Participants said that the sense of accountability to trial personnel also motivated and facilitated continued PA. Overall, participants felt accountable to perform PA; they knew they would be receiving a phone call and did not want to disappoint the study team. The last category was tailored counseling, defined as the idea that the program felt personal to them; some even stated that they felt like they had a personal trainer. For example, “Helping people find what it is that lights them up and makes them want to move.”

Self-efficacy

Self-efficacy was defined as confidence in one’s ability to attain goals or perform PA, a feeling of mastery, ability, or empowerment. Self-efficacy was discussed by 50% of the participants in 37 different narratives. Participants felt that study participation increased feelings of control; improved ability, confidence, accomplishment, and positive self-image; and reduced fears of falling. The LPAW intervention included a motivational interviewing technique²⁶ designed in part to increase participants’ sense of self-efficacy, so it is not surprising that feelings of increased self-efficacy was identified as a promoter of PA by intervention group participants. Unexpectedly, some women in the control group also reported improved self-efficacy, although the mechanism by which this occurred is uncertain. A participant in the control group stated “You think about what you can do. You don’t really think about what you can’t do.”

Life-changing awareness

Women who reported increasing their PA stated that study participation had changed their thinking about health and healthy lifestyles. They experienced improved awareness and value of the need for PA and a reduction in sedentary time. Most talked about “moving more,” “doing more,” and integrating movement into daily life. An exemplary narrative that expresses this central theme is: “It’s just constantly in my mind…it’s affected my thinking. I can do that [PA] in my house. Just finding things that I can do to make it…incorporated in my life. It has made me more aware of what a difference that PA makes.”

Discussion

We undertook this process evaluation to describe the experiences of older women regarding uptake and maintenance of the PA intervention, the salience of intervention components, the acceptability of procedures, and barriers and facilitators of PA. Unexpectedly, participants also provided explanations of why they succeeded or failed in integrating PA into their daily lives. This article adds to the science of PA interventions by suggesting central mechanisms for PA success and failure among sedentary and diverse older women with multiple comorbidities. From these data, we diagramed an explanatory model (Figure 1), grounded in the narratives of older women, that illustrates the salient components of the intervention that were expressed in this study.

Figure 1.

Physical activity (PA) explanatory model.

Description of Explanatory Model

Initially, women volunteered to participate in a study aimed at promoting PA and they enrolled with their own preconceived PA goals. The study team gave differing levels of support that included PA educational information, attention, and counseling (intervention group only). Women experienced benefits and barriers to performing PA, and often, both were simultaneously and continuously interacting with their ability to engage in PA. All 20 women in this study reported benefits from PA, which included physical and mental health improvement, motivation, and improved self-efficacy for PA, concomitantly promoting each other. Ultimately, if successful, participants reported a life-changing awareness of the need for regular and lifelong PA to maintain or improve health. On the left side of the model, primary barriers included health incidents, needed more help (unmet needs), and limited support from provider. If barriers were not overcome, women failed to progress in their PA and dropped out of the study; however, if participants overcame their barriers, goals for PA were again initiated, and they began the process again. For example, women who recovered from a health incident, had needs met and/or were provided support, were able to reengage in the PA process. This model suggests salient components of PA interventions and their role in facilitating PA; alternatively, it presents why older women failed to integrate PA into their lives. Thus, this simple model may be useful for other interventionists and clinicians aiming to start a PA program for older patients.

Benefits or Facilitators of PA

Perceived health improvement, including both improved mental acuity and physical strength, were key intrinsic motivators and benefits of PA in this study. According to other research describing motivators for PA in sedentary older adults, preventing declining health serves as a key motivator.^20,36,37 In a systematic review by Bauman et al of PA,²⁰ health status was found to have a consistent and direct role in promoting both initiation and maintenance of PA. Consistent with other work,^36,38 many of the women in our study reported that performing PA improved their mobility, flexibility, self-sufficiency, and mental stamina. Almost all of the women in this evaluation said that they “felt better” and could “do more than before,” which resulted in enjoying their PA and motivated them to keep performing PA. Such autonomous motivation has been found to be vital in the initiation and maintenance of long-term PA behavior in individuals with coronary heart disease.³⁹ A recent meta-analysis also supported that motivational interventions increase adherence, especially long term.⁴⁰ As expressed in these narratives, women who maintained this autonomous motivation were more successful in integrating daily PA into their lives.

Women who became self-efficacious were more successful in performing and incorporating PA into their daily lives. Research demonstrates that exercise-related self-efficacy predicts PA levels in older people in a dose–response relationship, that is, participants who report higher levels of exercise self-efficacy show greater increases in PA than those with lower levels.⁴¹ Other evidence suggests that self-efficacy serves as a mediator for PA adherence⁴² and can predict engagement in PA.⁴³ Important facilitators to PA supported by other work but not described by women in our study include affordability,^37,44 convenience of PA programs,^37,44 and social support.^38,45,46

Barriers to PA

The most common barrier that contributed to study attrition was a health incident or infirmity that inhibited participants from continuing PA. Recent research confirms that poor health and physical limitations are prominent barriers to participation in PA among older adults.^37,38,47,48 Health infirmities were identified as key barriers in a recent systematic review³⁸ of 45 articles (28 583 total participants) concerning motivators and barriers for PA in older adults. The most common health conditions described in the review were pain, overweight, poor balance, muscle weakness, and shortness of breath. In this review,³⁸ as in our study, these conditions can serve a dual purpose as initiators and motivators for PA. As per the narrative analysis, participants joined the LPAW study because they were overweight, had poor balance or weakness, and aimed to improve their fitness and health.

Another barrier, needing more help or unmet needs, has been a common theme found in other works aimed at identifying barriers to PA.^37,38 In our study, most of the control group participants and even a few of the intervention group participants desired more support such as specific recommendations and follow-up of PA progress during scheduled primary care appointments. Recent guidelines from the American Heart Association recommend that providers include regular assessment of and recommendations for PA during routine medical visits.^49,50 However, this practice is yet to be widespread,⁵¹ and studies find less than one third to 50% of providers advise regarding PA.^52,53 Other research finds that a lack of interest is a major barrier to PA,^38,47 although our study did not support this. We hypothesize this is likely due to selection bias as noninterested women probably would not have volunteered to participate.

Physical Activity as Supporting a Culture of Health

The RWJF recently coined the term Culture of Health to encourage all stakeholders to view health and health-care collaboratively.⁹ The Culture of Health initiative proposes that health is greatly influenced by complex social factors, such as individual and community perceptions and values, physical environments, socioeconomic status, opportunities, access, and equity. By shifting the values of individuals and communities so that health and healthy actions are the preferred choice, this initiative advocates that population health will improve now and for the future. The Culture of Health initiative proposes that population health will improve by changing mind-sets or values, such as a shared awareness of importance of habitual PA as an action to improve and promote lifelong health.

Reliability, Validity, and Limitations

We used several techniques to maximize the validity and reliability of this study, following the guidelines for data integrity and trustworthiness of qualitative work outlined by Lincoln and Guba⁵⁴ and the Consolidated Criteria for Reporting Qualitative research.⁵⁵ We report a full description of the analysis process to demonstrate results were created systematically to improve trustworthiness.^55,56 Bias was limited by having an uninvolved interviewer who had limited information about the initial study. Consistency was established by conducting all interviews using the interview guide. Interviews were transcribed verbatim and checked for accuracy. Coding was confirmed with a second reviewer; consensus was reached on coding decisions and a detailed audit trail of analyses decisions was recorded for confirmability and replicability. Results contain unedited narratives to explicate and substantiate findings.

Common limitations of qualitative technique are present in this study. For example, there is some degree of interpretation, generalizability is limited due to small sample size, and no formal path analysis testing of the model was performed. We also did not present the results to the participants for confirmation. However, presentation of the analyses techniques and the unedited narrative data improve authenticity and trustworthiness.^55,56

Conclusion

The personal experiences shared by our participants of their struggles and successes in integrating PA into their lives provide a further understanding of how to improve PA and promote a culture of health among our older patients. Principally, these women made it clear that they need more guidance and follow-up from health-care providers regarding PA. Particularly when experiencing a health incident, health-care providers need to provide direction regarding safe and effective PA practices. Encouragement and motivation to improve self-efficacy was also a key factor in overcoming barriers to begin again. Providers could promote self-efficacy by focusing on successes and using PA diaries and follow-ups to promote accountability for PA. The Culture of Health initiative espouses that promoting health is as important as treating illness and health-care providers play a key role in helping to establish health as a shared value and essential priority. This research challenges providers to improve our understanding of how to help build a culture of health by promoting PA.

So What?

What is already known on this topic?

Participation in regular PA reduces the incidence of the leading cause of death, cardiovascular disease; however, rates of PA have not increased over the last decade despite a plethora of research interventions to increase PA.

Evidence regarding optimal strategies to encourage PA in adults, and especially older women, vary widely. Conclusions about the effectiveness of individual components of interventions are lacking because of the heterogeneity of interventions, measures, outcomes, or populations sampled, thus limiting dissemination of interventions.

What does this article add?

This study adds to the science of PA by suggesting central mechanisms for success or failure of PA interventions among sedentary and diverse older women with multiple comorbidities.

What are the implications for health-promotion practice/research?

Findings from this study suggest that PA programs for older women should include interventions supporting motivation and self-efficacy, reduce barriers to PA, and focus on benefits to health in order to grow a life-changing awareness of the need for PA.

Changing mind-sets and values about PA, an action to cultivate a Culture of Health, may help propagate daily PA to improve lifelong health.

Footnotes

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This project was supported by grant 1R15NR012832 through the NIH National Institute of Nursing Research, by the Translational Research Institute (CTSA) and the Medical Research Endowment at the University of Arkansas for Medical Sciences, grant #UL1TR000039 from the National Center for Research Resources and National Center for Advancing Translational Sciences.

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