Journal of Physical Activity and Health, 2014, 11, 1420 -1429 http://dx.doi.org/10.1123/jpah.2012-0096 © 2014 Human Kinetics, Inc.
Official Journal of ISPAH www.JPAH-Journal.com ORIGINAL RESEARCH
Barriers and Enablers to Physical Activity Among Older Australians Who Want to Increase Their Physical Activity Levels Rona Macniven, Victoria Pye, Dafna Merom, Andrew Milat, Claire Monger, Adrian Bauman, and Hidde van der Ploeg Background: Physical activity interventions targeting older adults are optimized if barriers and enablers are better understood. This study identified barriers and enablers of physical activity and examined whether these were associated with meeting physical activity recommendations. Methods: 2225 adults aged 65 years and above who perceived themselves to be insufficiently active but would like to be more physically active self-reported their barriers and enablers to physical activity in the 2009 New South Wales Falls Prevention Survey. Binary logistic regression analyses examined associations between barriers and enablers and meeting the physical activity recommendation. Results: After adjusting for gender, age, BMI, and education, people who listed ill health (52%; OR = 0.56, 95% CI 0.45 to 0.70) as a barrier or who listed people to exercise with (4%; OR = 0.49, 95% CI 0.27 to 0.88) as an enabler had significantly lower odds of meeting recommendations. Those citing too expensive (3%) as a barrier (OR = 2.07, 95% CI 1.11 to 3.87) or who listed nothing will help (29%; OR = 1.40, 95% CI 1.10 to 1.77) and making time to be active (9%; OR = 1.78, 95% CI 1.23 to 2.58) as enablers had significantly higher odds of meeting physical activity recommendations. Conclusions: These findings give insights into older adults’ perceptions of factors that influence their physical activity, which could assist physical activity program planning in this population. Keywords: older adults, guidelines and recommendations, public health Physical inactivity has been identified as the fourth leading cause of mortality worldwide.1 Participation in regular physical activity confers numerous physical health benefits. Among older adults in particular, physical activity is essential for the prevention and treatment of numerous cardiovascular, metabolic and bone diseases.2 For both adults (18–64 years) and older adults (65 years and older), physical activity recommendations specify ‘at least 150 minutes of moderate-intensity aerobic physical activity throughout the week.’ Strength and balance activities are particularly recommended for older adults3 to prevent falls.4 However, the proportion of Australian adults meeting the aerobic guidelines is relatively low and this is particularly evident in community dwelling older adults. In NSW, only 54.7% of males and 41.2% of females aged 65 to 74 years achieve these recommendations and in adults aged 75+, rates are even lower at 41.8% and 26.6% for males and females respectively.5 Worldwide, populations are aging and life expectancy increasing. Currently, 11% of the worlds’ population is aged 60 years and older, and this is predicted to increase to 22% in 2050.6 This is occurring concomitantly with increases in the worlds’ population overall.7 Action by health and other sectors to increase population levels of physical activity across the lifespan is important for Macniven ([email protected]), Bauman, and van der Ploeg are with the School of Public Health, University of Sydney, Camperdown, NSW, Australia. Pye, Milat, and Monger are with the NSW Ministry of Health, Centre for Epidemiology and Research, Sydney, NSW, Australia. Merom is with the School of Biomedical and Health Sciences, University of Western Sydney, Campbelltown, NSW, Australia. 1420
reducing the burden of disease experienced as populations’ age and thus a better understanding of determinants will assist in this goal. The social-ecological model8 can be used to describe how participation in physical activity is influenced by broader intercultural, community, organizational, and interpersonal as well as individual factors. A review of correlates of adults’ participation in physical activity featured a number of barriers such as lack of time, fear of falling, too tiring, too weak and bad weather.9 In contrast, enabling factors like social support and having people to exercise with and safe and pleasant environments were found to be associated with regular participation in physical activity.10 In the context of this model, individuals’ barriers and enablers should be considered in light of these societal influences. Numerous studies examining barriers to physical activity in adults exist but those which focus on adults aged 65 years and over with generalizable samples are somewhat rarer. A recent review examined barriers (and motivators) for physical activity among adults aged 80 years and above identified 59 barriers across 44 studies.11 Physical health conditions, fear of falling, lack of social support and weather were common barriers. Mathews et al examined both barriers and enablers to physical activity in older adults finding often cited barriers were health problems, fear of falling, and inconvenience.12 Poor health, lack of company and lack of interest were commonly reported barriers in another recent study.13 Often mentioned enablers were positive outcome expectations, social support, and access to physical activity programs. Previous research in older adult populations has identified perceived level of exertion to be inversely related to coronary heart disease (CHD) prospectively, regardless of whether an individual met the physical guidelines.14 Self-perceptions of physical activity participation can therefore indicate target groups who might
Barriers and Enablers to PA in Older Australians 1421
benefit the most from health interventions. Perceived motivation is also a critical determinant of lifestyle behavior adoption and motivated individuals are likely to be particularly responsive to programs to increase physical activity and such a targeted approach to intervention development and delivery has been recommended for optimizing success.15,16 The development of policies and programs to increase physical activity in older adults can be further optimized if barriers and associated enablers to physical activity are better understood and incorporated into the planning of targeted interventions. The aims of this study were to examine 1) barriers and enablers to physical activity participation among older adults perceived to be insufficiently active but who would like to be more physically active; 2) whether associations differ by demographic and health characteristics; and 3) which barriers and enablers were independently associated with meeting physical activity recommendations, according to health status.
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Methods Population and Sampling The methods for the 2009 NSW Falls Prevention Baseline Survey are reported elsewhere.17 The target population for the Survey was all New South Wales (NSW) residents aged 65 years and over living in households with private telephones. Households were contacted using random digit dialing and 1 eligible person from the household was selected for interview. Interviews were carried out between March and July 2009. The survey instrument was translated into the 5 most prevalent languages among older adults in NSW: Arabic, Chinese, Greek, Italian, and Vietnamese. A shorter version of the instrument was administered to the main caretakers of participants unable to answer on their own behalf. In total, 5,681 interviews were conducted with NSW residents aged 65 years and over. The overall response rate was 60.8%, with 4.9% of interviews conducted in a language other than English. The majority of participants answered questions on their own behalf; proxy respondents were required for 361 participants (6.4%), who were unable to answer on their own behalf due to communication difficulties or cognitive impairment. The sample for this study was determined by 2 screening questions relating to participant’s perception of doing enough physical activity and their motivation to do more physical activity: ‘Do you think you are doing enough physical activity?’ (yes/no) and ‘Would you like to be more physically active?’ (yes.no). Respondents who answered both ‘no’ to the first question and ‘yes’ to the second question (1822; 32.1%) were further asked about barriers and enablers and hence, included in this study. The conduct of the Survey was approved by NSW Health’s Population and Health Services Research Ethics Committee (2008/12/114; HREC/08/CIPHS/55).
Measures Demographic and Health Factors. A selection of relevant demographic variables from the Survey were used in this study. These variables were: sex, age, and education. Self rated health status was recorded on a 6-point scale (excellent, very good, fair, poor, very poor) and dichotomized (good or better and fair or worse). The Socio-Economic Indexes for Areas (SEIFA) assigned respondents to 1 of 5 quintiles based on their postcode of residence with quintile 1 being the least disadvantaged and quintile 5 being
the most disadvantaged. Self-reported height and weight was used to calculate body mass index (BMI; underweight < 18.5 kg·m–2; Normal: 18 to 25 kg·m–2; Overweight: 25 to 29kg·m–2; Obese: ≥ 30 kg·m–2). Additional variables were participant-reported and doctordiagnosed morbidities of osteoporosis and arthritis and whether the respondent was afraid of falling (yes/no). Aerobic Physical Activity, Strength, and Balance Activities.
Participants were asked about the past week frequency and total time spent in doing the following 11 prompted activities: walking for recreation, exercise, or to go to places for at least 10 minutes continuously; any strength and resistance exercise; tai chi; yoga; tennis; golf; lawn bowls; balance training; group based exercise; dancing; team sport; and an option to report on other activities that were not prompted. Prevalent activities in the ‘other’ category were assigned to 6 new categories: gardening, cycling, swimming, gym workout, fishing, and using an exercise machine. All the prompted and the new categories mentioned were included toward meeting the aerobic recommendations given that each is considered as at least moderate-intensity (≥ 3 METs) in the Compendium of Physical Activities.18 While the Compendium is intended for use in adults 18 to 65 years only, there is no equivalent for older adults therefore this version is a valid means of classifying physical activities for inclusion in this study. Participants who accumulated 150 minutes a week were considered as meeting the minimum aerobic physical activity recommendations.2 Barriers and Enablers to Physical Activity. The question ‘Is there
anything that stops you from participating in physical activity?’ was used to elicit details of barriers to physical activity. Answers were both pre- and postcoded. Participant responses were initially coded into the following unprompted categories (n = 10): ill health; not interested; no appropriate activities in my area; activities which exist are too expensive; no transport to reach activities; no access to appropriate childcare; too busy; caring for a family member; other; and nothing. These 10 categories were developed in light of the physical activity determinants literature19 and pilot testing. Respondents could mention multiple barriers. Responses originally coded as other (4.5%) were independently recategorized by 2 members of the research team with any differences in opinion discussed until a consensus was reached. Two new categories were created from the original other category—weather and mental health—and many of the answers placed in the other category were able to be placed into an already existing category. A small number (n = 10) of responses could not be categorized into a new or existing category and remained in the other category such as equipment for physical activity needing repair and lack of confidence and these were not included in the analyses. The open-ended question ‘is there anything that would make it easier for you to be more physically active?’ was used to determine physical activity enablers. The unprompted responses were initially coded into 7 categories: improved health; availability of sports or gym facilities; transport to exercise facilities; affordability of exercise activities; people to exercise with; motivation; and nothing will help. These categories were again developed in light of the physical activity determinants literature19 and pilot testing. Respondents could mention multiple enablers. The answers assigned to 2 categories, other and nothing will help, were independently recategorized by 2 authors with any differences in opinion discussed until a consensus was reached. Two new categories were created: weather and improved environment. The other category was retained for 201 responses which could not be categorized elsewhere and were
1422 Macniven et al
excluded from further analyses due to heterogeneity of responses and the majority being responses of a humorous nature.
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Statistical Analyses The data were weighted by age and sex to reflect that of the overall residential population of NSW aged 65 and over and adjust for differences in the probabilities of selection among subjects.20 Descriptive statistics were used to calculate frequencies of responses for demographic and health factors; physical activity participation; and barriers and enablers to physical activity. Chisquare analyses were used to test differences in the relationships between categorical demographic and health variables in relation to meeting the physical activity recommendations. Tests for correlations between 7 potentially related barriers and enablers were also conducted. A series of binary logistic regression analyses examined associations between individual barriers and enablers of physical activity and meeting the physical activity recommendation, while adjusted for gender, age, BMI, Socio-Economic Indexes for Areas (SEIFA), and education. Barriers and enablers reported by less than 2% of respondents—no access to appropriate childcare and mental health (as barriers) and transport to exercise facilities and improved environment (as enablers)—and the other category (4%) were excluded from subsequent analyses due to the low number of respondents and heterogeneity of responses, respectively. Subsequently, a further model was developed on factors associated with meeting the physical activity recommendation. In the prediction model nonsignificant barriers and enablers were removed via backward elimination, until only significant barriers and enablers remained in the model. The prediction model was also adjusted for gender, age, BMI, and education. Results were reported as odds ratios with 95% confidence intervals for the whole group and stratified dichotomously by health status, as this has been found to be associated with physical activity participation.21 Analyses were conducted using SAS software (version 9.2, SAS Institute, Cary, NC, USA). Statistical significance was set at P < .05.
Results Participant Characteristics The characteristics of the (unweighted) sample are described in Table 1. The majority were female (58%) and under 75 years of age (62%). Forty-seven percent of the 32.1% of the total sample surveyed who did not think they were doing enough physical activity were in fact found to be meeting the guidelines.
Meeting Physical Activity Recommendations Table 1 displays how males were significantly more likely than females to meet the physical activity recommendations (53% vs. 42%). Those aged under 75 were significantly more likely to meet guidelines than respondents aged over 75 (53% vs. 36%). Education, BMI category, SEIFA, and self rated health status were all significantly related to meeting recommendations.
Barriers and Enablers to Physical Activity No barriers and enablers were found to be correlated with 0 of the 7 potentially related variables found to have a phi coefficient greater than 0.39. The number (n) and weighted percent of 10 barriers to physical activity are presented in Table 2. The most common barrier was ill health (52%) and after adjusting for gender, age, BMI, SEIFA
and education this was the only barrier significantly associated with a reduced odds of meeting physical activity recommendations (OR = 0.50, 95% CI 0.40 to 0.61). Six other barriers were significantly associated with an increased likelihood of meeting physical activity recommendations: activities which exist are too expensive (OR = 2.16, 95% CI 1.18 to 3.98); no transport to reach activities (OR = 1.88, 95% CI 1.08 to 3.27); too busy (OR = 1.42, 95% CI 1.07 to 1.88); caring for a family member (OR = 1.62, 95% CI 1.00 to 2.62); nothing (OR = 1.33, 95% CI 1.00 to 1.76); and weather (OR = 2.22, 95% CI 1.18 to 4.20). Among respondents with self-rated good health, all relationships were in the same direction but 2; ill health (OR = 0.66, 95% CI 0.52 to 0.85) and activities which exist are too expensive (OR = 4.58, 95% CI 1.83 to 11.45), remained significant. Among those with self-rated poor health, 4 barriers remained significant in this group: ill health (OR = 0.35, 95% CI (0.22 to 0.57)); no transport to reach activities (OR = 3.24, 95% CI 1.05 to 9.98); too busy (OR = 2.56, 95% CI 1.17 to 5.59); and caring for a family member (OR = 3.23, 95% CI 1.16 to 8.96); while 1 barrier was found to be significantly associated with meeting the recommendations in this group only: not interested (OR = 1.73, 95% CI 1.01 to 3.00). The number (n) and weighted percent of 8 physical activity enablers to physical activity are presented in Table 2. Twenty-nine percent of participants reported there was nothing that would make it easier for them to be more active, followed by improved health (21%). Among the whole sample, nothing will help (OR = 1.38, 95% CI 1.10 to 1.72) and making time to be active (OR = 1.95, 95% CI 1.37 to 2.77) were significantly associated with an increased likelihood of meeting physical activity recommendations. Improved health (OR = 0.71, 95% CI 0.55 to 0.92), and people to exercise with (OR = 0.51, 95% CI 0.30 to 0.88) were significantly associated with a reduced likelihood of meeting recommendations When the sample was divided into the 2 groups of self-rated health status, all relationships were in the same direction but fewer remained significant. Among those with good health, only respondents who cited making time to be active had significantly higher odds of meeting physical activity recommendations (OR = 1.77, 95% CI 1.20 to 2.62) and respondents who cited improved health (OR = 0.75, 95% CI 0.49 to 0.89) and people to exercise with (OR = 0.43, 95% CI 0.23 to 0.82) had significantly lower odds of meeting recommendations. In the good health group only, affordability of exercise activities was associated with an increased likelihood of meeting recommendations (OR = 1.98, 95% CI 1.02 to 3.84). Among those with poor health, the only enabler which remained significant was the response that nothing will help (OR = 1.52, 95% CI 0.97 to 2.38). In the prediction model (Table 3), in the whole sample, those who listed ill health were significantly less likely to meet recommendations than those who did not (OR = 0.56, 95% CI 0.45 to 0.70). Respondents citing too expensive as a barrier were significantly more likely to meet the recommendation than those who did not (OR = 2.07, 95% CI 1.11 to 3.87). The ill health barrier was also significantly associated with a reduced likelihood of meeting the recommendation in both the good and poor health groups (OR = 0.74, 95% CI 0.57 to 0.97 and OR = 0.28, 95% CI 0.16 to 0.48, respectively). In the good health category, a positive association for the barrier too expensive was evident (OR = 4.47, 95% CI 1.78 to 11.22) but in the poor health category, an inverse association between citing the barrier and meeting the recommendation existed (OR = 0.24, 95% CI 0.06 to 0.91). Participants who listed nothing will help (OR = 1.40, 95% CI 1.10 to 1.77) and making time to be active (OR = 1.78, 95% CI 1.23 to 2.58) were more likely to meet the physical activity recommendation than those who did not. Respondents who listed people to
Barriers and Enablers to PA in Older Australians 1423
Table 1 Demographic, Behavioral, and Health Characteristics of Participants (n = 1822) Variable Sex Meet PA guidelines* Age group Education
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Self rated health status
n (%)
Meet PA guidelines (%)
Male
769 (42)
53*
Female
1053 (58)
42
Yes
848 (47)
x
No
974 (53)
x
≤ 74
1123 (62)
53*
≥ 75
699 (38)
36
Tertiary
763 (38)
53*
High school
837 (47)
45
Less than year 10
270 (15)
36
Excellent
179 (10)
55*
Very good
485 (27)
57
Good
596 (33)
48
Fair
365 (20)
38
Poor
136 (8)
23
Very poor
51 (3)
22
31 (2)
54*
546 (32)
49
Underweight
BMI categorya
Normal
Suffers from osteoporosis
Overweight
652 (38)
50
Obese
502 (29)
42
Yes
354 (19)
42*
No
1468 (81)
48
Suffers from any form of arthritis
Yes
1020 (56)
44*
No
802 (44)
50
Level of socioeconomic disadvantage (SEIFA)
1 (least disadvantaged)
266 (15)
47
2
288 (16)
54
3
370 (21)
45
4
473 (27)
49
5 (most disadvantaged)
373 (21)
42
Abbreviations: PA, physical activity. a Underweight:
Official Journal of ISPAH www.JPAH-Journal.com ORIGINAL RESEARCH
Barriers and Enablers to Physical Activity Among Older Australians Who Want to Increase Their Physical Activity Levels Rona Macniven, Victoria Pye, Dafna Merom, Andrew Milat, Claire Monger, Adrian Bauman, and Hidde van der Ploeg Background: Physical activity interventions targeting older adults are optimized if barriers and enablers are better understood. This study identified barriers and enablers of physical activity and examined whether these were associated with meeting physical activity recommendations. Methods: 2225 adults aged 65 years and above who perceived themselves to be insufficiently active but would like to be more physically active self-reported their barriers and enablers to physical activity in the 2009 New South Wales Falls Prevention Survey. Binary logistic regression analyses examined associations between barriers and enablers and meeting the physical activity recommendation. Results: After adjusting for gender, age, BMI, and education, people who listed ill health (52%; OR = 0.56, 95% CI 0.45 to 0.70) as a barrier or who listed people to exercise with (4%; OR = 0.49, 95% CI 0.27 to 0.88) as an enabler had significantly lower odds of meeting recommendations. Those citing too expensive (3%) as a barrier (OR = 2.07, 95% CI 1.11 to 3.87) or who listed nothing will help (29%; OR = 1.40, 95% CI 1.10 to 1.77) and making time to be active (9%; OR = 1.78, 95% CI 1.23 to 2.58) as enablers had significantly higher odds of meeting physical activity recommendations. Conclusions: These findings give insights into older adults’ perceptions of factors that influence their physical activity, which could assist physical activity program planning in this population. Keywords: older adults, guidelines and recommendations, public health Physical inactivity has been identified as the fourth leading cause of mortality worldwide.1 Participation in regular physical activity confers numerous physical health benefits. Among older adults in particular, physical activity is essential for the prevention and treatment of numerous cardiovascular, metabolic and bone diseases.2 For both adults (18–64 years) and older adults (65 years and older), physical activity recommendations specify ‘at least 150 minutes of moderate-intensity aerobic physical activity throughout the week.’ Strength and balance activities are particularly recommended for older adults3 to prevent falls.4 However, the proportion of Australian adults meeting the aerobic guidelines is relatively low and this is particularly evident in community dwelling older adults. In NSW, only 54.7% of males and 41.2% of females aged 65 to 74 years achieve these recommendations and in adults aged 75+, rates are even lower at 41.8% and 26.6% for males and females respectively.5 Worldwide, populations are aging and life expectancy increasing. Currently, 11% of the worlds’ population is aged 60 years and older, and this is predicted to increase to 22% in 2050.6 This is occurring concomitantly with increases in the worlds’ population overall.7 Action by health and other sectors to increase population levels of physical activity across the lifespan is important for Macniven ([email protected]), Bauman, and van der Ploeg are with the School of Public Health, University of Sydney, Camperdown, NSW, Australia. Pye, Milat, and Monger are with the NSW Ministry of Health, Centre for Epidemiology and Research, Sydney, NSW, Australia. Merom is with the School of Biomedical and Health Sciences, University of Western Sydney, Campbelltown, NSW, Australia. 1420
reducing the burden of disease experienced as populations’ age and thus a better understanding of determinants will assist in this goal. The social-ecological model8 can be used to describe how participation in physical activity is influenced by broader intercultural, community, organizational, and interpersonal as well as individual factors. A review of correlates of adults’ participation in physical activity featured a number of barriers such as lack of time, fear of falling, too tiring, too weak and bad weather.9 In contrast, enabling factors like social support and having people to exercise with and safe and pleasant environments were found to be associated with regular participation in physical activity.10 In the context of this model, individuals’ barriers and enablers should be considered in light of these societal influences. Numerous studies examining barriers to physical activity in adults exist but those which focus on adults aged 65 years and over with generalizable samples are somewhat rarer. A recent review examined barriers (and motivators) for physical activity among adults aged 80 years and above identified 59 barriers across 44 studies.11 Physical health conditions, fear of falling, lack of social support and weather were common barriers. Mathews et al examined both barriers and enablers to physical activity in older adults finding often cited barriers were health problems, fear of falling, and inconvenience.12 Poor health, lack of company and lack of interest were commonly reported barriers in another recent study.13 Often mentioned enablers were positive outcome expectations, social support, and access to physical activity programs. Previous research in older adult populations has identified perceived level of exertion to be inversely related to coronary heart disease (CHD) prospectively, regardless of whether an individual met the physical guidelines.14 Self-perceptions of physical activity participation can therefore indicate target groups who might
Barriers and Enablers to PA in Older Australians 1421
benefit the most from health interventions. Perceived motivation is also a critical determinant of lifestyle behavior adoption and motivated individuals are likely to be particularly responsive to programs to increase physical activity and such a targeted approach to intervention development and delivery has been recommended for optimizing success.15,16 The development of policies and programs to increase physical activity in older adults can be further optimized if barriers and associated enablers to physical activity are better understood and incorporated into the planning of targeted interventions. The aims of this study were to examine 1) barriers and enablers to physical activity participation among older adults perceived to be insufficiently active but who would like to be more physically active; 2) whether associations differ by demographic and health characteristics; and 3) which barriers and enablers were independently associated with meeting physical activity recommendations, according to health status.
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Methods Population and Sampling The methods for the 2009 NSW Falls Prevention Baseline Survey are reported elsewhere.17 The target population for the Survey was all New South Wales (NSW) residents aged 65 years and over living in households with private telephones. Households were contacted using random digit dialing and 1 eligible person from the household was selected for interview. Interviews were carried out between March and July 2009. The survey instrument was translated into the 5 most prevalent languages among older adults in NSW: Arabic, Chinese, Greek, Italian, and Vietnamese. A shorter version of the instrument was administered to the main caretakers of participants unable to answer on their own behalf. In total, 5,681 interviews were conducted with NSW residents aged 65 years and over. The overall response rate was 60.8%, with 4.9% of interviews conducted in a language other than English. The majority of participants answered questions on their own behalf; proxy respondents were required for 361 participants (6.4%), who were unable to answer on their own behalf due to communication difficulties or cognitive impairment. The sample for this study was determined by 2 screening questions relating to participant’s perception of doing enough physical activity and their motivation to do more physical activity: ‘Do you think you are doing enough physical activity?’ (yes/no) and ‘Would you like to be more physically active?’ (yes.no). Respondents who answered both ‘no’ to the first question and ‘yes’ to the second question (1822; 32.1%) were further asked about barriers and enablers and hence, included in this study. The conduct of the Survey was approved by NSW Health’s Population and Health Services Research Ethics Committee (2008/12/114; HREC/08/CIPHS/55).
Measures Demographic and Health Factors. A selection of relevant demographic variables from the Survey were used in this study. These variables were: sex, age, and education. Self rated health status was recorded on a 6-point scale (excellent, very good, fair, poor, very poor) and dichotomized (good or better and fair or worse). The Socio-Economic Indexes for Areas (SEIFA) assigned respondents to 1 of 5 quintiles based on their postcode of residence with quintile 1 being the least disadvantaged and quintile 5 being
the most disadvantaged. Self-reported height and weight was used to calculate body mass index (BMI; underweight < 18.5 kg·m–2; Normal: 18 to 25 kg·m–2; Overweight: 25 to 29kg·m–2; Obese: ≥ 30 kg·m–2). Additional variables were participant-reported and doctordiagnosed morbidities of osteoporosis and arthritis and whether the respondent was afraid of falling (yes/no). Aerobic Physical Activity, Strength, and Balance Activities.
Participants were asked about the past week frequency and total time spent in doing the following 11 prompted activities: walking for recreation, exercise, or to go to places for at least 10 minutes continuously; any strength and resistance exercise; tai chi; yoga; tennis; golf; lawn bowls; balance training; group based exercise; dancing; team sport; and an option to report on other activities that were not prompted. Prevalent activities in the ‘other’ category were assigned to 6 new categories: gardening, cycling, swimming, gym workout, fishing, and using an exercise machine. All the prompted and the new categories mentioned were included toward meeting the aerobic recommendations given that each is considered as at least moderate-intensity (≥ 3 METs) in the Compendium of Physical Activities.18 While the Compendium is intended for use in adults 18 to 65 years only, there is no equivalent for older adults therefore this version is a valid means of classifying physical activities for inclusion in this study. Participants who accumulated 150 minutes a week were considered as meeting the minimum aerobic physical activity recommendations.2 Barriers and Enablers to Physical Activity. The question ‘Is there
anything that stops you from participating in physical activity?’ was used to elicit details of barriers to physical activity. Answers were both pre- and postcoded. Participant responses were initially coded into the following unprompted categories (n = 10): ill health; not interested; no appropriate activities in my area; activities which exist are too expensive; no transport to reach activities; no access to appropriate childcare; too busy; caring for a family member; other; and nothing. These 10 categories were developed in light of the physical activity determinants literature19 and pilot testing. Respondents could mention multiple barriers. Responses originally coded as other (4.5%) were independently recategorized by 2 members of the research team with any differences in opinion discussed until a consensus was reached. Two new categories were created from the original other category—weather and mental health—and many of the answers placed in the other category were able to be placed into an already existing category. A small number (n = 10) of responses could not be categorized into a new or existing category and remained in the other category such as equipment for physical activity needing repair and lack of confidence and these were not included in the analyses. The open-ended question ‘is there anything that would make it easier for you to be more physically active?’ was used to determine physical activity enablers. The unprompted responses were initially coded into 7 categories: improved health; availability of sports or gym facilities; transport to exercise facilities; affordability of exercise activities; people to exercise with; motivation; and nothing will help. These categories were again developed in light of the physical activity determinants literature19 and pilot testing. Respondents could mention multiple enablers. The answers assigned to 2 categories, other and nothing will help, were independently recategorized by 2 authors with any differences in opinion discussed until a consensus was reached. Two new categories were created: weather and improved environment. The other category was retained for 201 responses which could not be categorized elsewhere and were
1422 Macniven et al
excluded from further analyses due to heterogeneity of responses and the majority being responses of a humorous nature.
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Statistical Analyses The data were weighted by age and sex to reflect that of the overall residential population of NSW aged 65 and over and adjust for differences in the probabilities of selection among subjects.20 Descriptive statistics were used to calculate frequencies of responses for demographic and health factors; physical activity participation; and barriers and enablers to physical activity. Chisquare analyses were used to test differences in the relationships between categorical demographic and health variables in relation to meeting the physical activity recommendations. Tests for correlations between 7 potentially related barriers and enablers were also conducted. A series of binary logistic regression analyses examined associations between individual barriers and enablers of physical activity and meeting the physical activity recommendation, while adjusted for gender, age, BMI, Socio-Economic Indexes for Areas (SEIFA), and education. Barriers and enablers reported by less than 2% of respondents—no access to appropriate childcare and mental health (as barriers) and transport to exercise facilities and improved environment (as enablers)—and the other category (4%) were excluded from subsequent analyses due to the low number of respondents and heterogeneity of responses, respectively. Subsequently, a further model was developed on factors associated with meeting the physical activity recommendation. In the prediction model nonsignificant barriers and enablers were removed via backward elimination, until only significant barriers and enablers remained in the model. The prediction model was also adjusted for gender, age, BMI, and education. Results were reported as odds ratios with 95% confidence intervals for the whole group and stratified dichotomously by health status, as this has been found to be associated with physical activity participation.21 Analyses were conducted using SAS software (version 9.2, SAS Institute, Cary, NC, USA). Statistical significance was set at P < .05.
Results Participant Characteristics The characteristics of the (unweighted) sample are described in Table 1. The majority were female (58%) and under 75 years of age (62%). Forty-seven percent of the 32.1% of the total sample surveyed who did not think they were doing enough physical activity were in fact found to be meeting the guidelines.
Meeting Physical Activity Recommendations Table 1 displays how males were significantly more likely than females to meet the physical activity recommendations (53% vs. 42%). Those aged under 75 were significantly more likely to meet guidelines than respondents aged over 75 (53% vs. 36%). Education, BMI category, SEIFA, and self rated health status were all significantly related to meeting recommendations.
Barriers and Enablers to Physical Activity No barriers and enablers were found to be correlated with 0 of the 7 potentially related variables found to have a phi coefficient greater than 0.39. The number (n) and weighted percent of 10 barriers to physical activity are presented in Table 2. The most common barrier was ill health (52%) and after adjusting for gender, age, BMI, SEIFA
and education this was the only barrier significantly associated with a reduced odds of meeting physical activity recommendations (OR = 0.50, 95% CI 0.40 to 0.61). Six other barriers were significantly associated with an increased likelihood of meeting physical activity recommendations: activities which exist are too expensive (OR = 2.16, 95% CI 1.18 to 3.98); no transport to reach activities (OR = 1.88, 95% CI 1.08 to 3.27); too busy (OR = 1.42, 95% CI 1.07 to 1.88); caring for a family member (OR = 1.62, 95% CI 1.00 to 2.62); nothing (OR = 1.33, 95% CI 1.00 to 1.76); and weather (OR = 2.22, 95% CI 1.18 to 4.20). Among respondents with self-rated good health, all relationships were in the same direction but 2; ill health (OR = 0.66, 95% CI 0.52 to 0.85) and activities which exist are too expensive (OR = 4.58, 95% CI 1.83 to 11.45), remained significant. Among those with self-rated poor health, 4 barriers remained significant in this group: ill health (OR = 0.35, 95% CI (0.22 to 0.57)); no transport to reach activities (OR = 3.24, 95% CI 1.05 to 9.98); too busy (OR = 2.56, 95% CI 1.17 to 5.59); and caring for a family member (OR = 3.23, 95% CI 1.16 to 8.96); while 1 barrier was found to be significantly associated with meeting the recommendations in this group only: not interested (OR = 1.73, 95% CI 1.01 to 3.00). The number (n) and weighted percent of 8 physical activity enablers to physical activity are presented in Table 2. Twenty-nine percent of participants reported there was nothing that would make it easier for them to be more active, followed by improved health (21%). Among the whole sample, nothing will help (OR = 1.38, 95% CI 1.10 to 1.72) and making time to be active (OR = 1.95, 95% CI 1.37 to 2.77) were significantly associated with an increased likelihood of meeting physical activity recommendations. Improved health (OR = 0.71, 95% CI 0.55 to 0.92), and people to exercise with (OR = 0.51, 95% CI 0.30 to 0.88) were significantly associated with a reduced likelihood of meeting recommendations When the sample was divided into the 2 groups of self-rated health status, all relationships were in the same direction but fewer remained significant. Among those with good health, only respondents who cited making time to be active had significantly higher odds of meeting physical activity recommendations (OR = 1.77, 95% CI 1.20 to 2.62) and respondents who cited improved health (OR = 0.75, 95% CI 0.49 to 0.89) and people to exercise with (OR = 0.43, 95% CI 0.23 to 0.82) had significantly lower odds of meeting recommendations. In the good health group only, affordability of exercise activities was associated with an increased likelihood of meeting recommendations (OR = 1.98, 95% CI 1.02 to 3.84). Among those with poor health, the only enabler which remained significant was the response that nothing will help (OR = 1.52, 95% CI 0.97 to 2.38). In the prediction model (Table 3), in the whole sample, those who listed ill health were significantly less likely to meet recommendations than those who did not (OR = 0.56, 95% CI 0.45 to 0.70). Respondents citing too expensive as a barrier were significantly more likely to meet the recommendation than those who did not (OR = 2.07, 95% CI 1.11 to 3.87). The ill health barrier was also significantly associated with a reduced likelihood of meeting the recommendation in both the good and poor health groups (OR = 0.74, 95% CI 0.57 to 0.97 and OR = 0.28, 95% CI 0.16 to 0.48, respectively). In the good health category, a positive association for the barrier too expensive was evident (OR = 4.47, 95% CI 1.78 to 11.22) but in the poor health category, an inverse association between citing the barrier and meeting the recommendation existed (OR = 0.24, 95% CI 0.06 to 0.91). Participants who listed nothing will help (OR = 1.40, 95% CI 1.10 to 1.77) and making time to be active (OR = 1.78, 95% CI 1.23 to 2.58) were more likely to meet the physical activity recommendation than those who did not. Respondents who listed people to
Barriers and Enablers to PA in Older Australians 1423
Table 1 Demographic, Behavioral, and Health Characteristics of Participants (n = 1822) Variable Sex Meet PA guidelines* Age group Education
Downloaded by Purdue Univ on 09/16/16, Volume 11, Article Number 7
Self rated health status
n (%)
Meet PA guidelines (%)
Male
769 (42)
53*
Female
1053 (58)
42
Yes
848 (47)
x
No
974 (53)
x
≤ 74
1123 (62)
53*
≥ 75
699 (38)
36
Tertiary
763 (38)
53*
High school
837 (47)
45
Less than year 10
270 (15)
36
Excellent
179 (10)
55*
Very good
485 (27)
57
Good
596 (33)
48
Fair
365 (20)
38
Poor
136 (8)
23
Very poor
51 (3)
22
31 (2)
54*
546 (32)
49
Underweight
BMI categorya
Normal
Suffers from osteoporosis
Overweight
652 (38)
50
Obese
502 (29)
42
Yes
354 (19)
42*
No
1468 (81)
48
Suffers from any form of arthritis
Yes
1020 (56)
44*
No
802 (44)
50
Level of socioeconomic disadvantage (SEIFA)
1 (least disadvantaged)
266 (15)
47
2
288 (16)
54
3
370 (21)
45
4
473 (27)
49
5 (most disadvantaged)
373 (21)
42
Abbreviations: PA, physical activity. a Underweight:
