http://informahealthcare.com/dre ISSN 0963-8288 print/ISSN 1464-5165 online Disabil Rehabil, Early Online: 1–9 ! 2015 Informa UK Ltd. DOI: 10.3109/09638288.2015.1061606

REVIEW ARTICLE

Cultural influences on exercise participation and fall prevention: a systematic review and narrative synthesis Haeyoung Jang1, Lindy Clemson1, Meryl Lovarini1, Karen Willis2, Stephen R. Lord3, and Catherine Sherrington4

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1

Faculty of Health Sciences, The University of Sydney, Sydney, Australia, 2Faculty of Health Sciences, Australian Catholic University, Melbourne, Australia, 3Neuroscience Research Australia, University of New South Wales, Sydney, Australia, and 4The George Institute for Global Health, The University of Sydney, Sydney, Australia Abstract

Keywords

Purpose: We aim to provide a systematic review of qualitative research evidence relevant to the experiences and perceptions of program providers and participants from culturally and linguistically diverse (CALD) backgrounds regarding (i) exercise and (ii) fall prevention programs for older people. Method: Using a narrative synthesis approach, we reviewed published journal articles reporting qualitative data. Electronic and manual literature searches were conducted to identify 19 publications that met the inclusion criteria. Of these, 16 discussed exercise and three focused on broader fall prevention programs. However, no studies were identified that explored the perspective of the program providers. Results: An overarching theme emerged identifying the influence of cultural values and perceptions on program participation. Also, identified were motivational, social and environmental influences. Conclusion: Exercise and fall prevention interventions need to be culturally appropriate and utilise the positive influences of social support, especially from physicians and family. While these findings can be used to inform the delivery of programs to these population groups, future studies should focus specifically on experiences and perceptions of older CALD people of fall prevention programs as well as the perspectives of program providers.

Culturally and linguistically diverse groups, exercise, fall prevention, older people, participation, qualitative data History Received 21 October 2014 Revised 18 May 2015 Accepted 9 June 2015 Published online 29 June 2015

ä Implications for Rehabilitation    

Program participation is influenced by cultural values and motivational, social and environmental factors. The meaning and importance of exercise can vary between and within cultures. Exercise and fall prevention interventions need to be culturally appropriate and utilise the positive influences of social support, especially from physicians and family. Providing information that falls can be prevented and the reasons why behaviours need to change will be more likely to encourage older people from CALD backgrounds to contemplate participation.

Introduction Falls are a major and growing health issue for older people. One in three older people aged 65 years and over experience at least one fall each year, contributing to high costs and poor health outcomes [1]. While generating serious consequences, falls are preventable. Evidence shows that fall prevention interventions including exercise effectively reduce falls among older people living in the community [2,3]. In multicultural societies like Australia, older people from culturally and linguistically diverse (CALD) backgrounds account for a significant and growing proportion of the older population. In Australia in 2006, 35% of older people aged 65 years and over were born overseas, with 61% of these coming from non-English Address for correspondence: Haeyoung Jang, Faculty of Health Sciences, The University of Sydney, Sydney, Australia. Tel: +61 2 9351 9494. Fax: +61 2 9351 9672. E-mail: [email protected]

speaking countries [4]. The number of older people from nonEnglish speaking backgrounds is projected to form a greater proportion of the older population in Australia over the next decade, posing significant implications for the delivery and planning of health services and programs [4]. It is not clear whether fall prevention and exercise programs effectively reach older people from CALD backgrounds and how such programs are perceived by people from CALD backgrounds. Older these people are often underrepresented in exercise and fall prevention programs and research projects [5,6]. Therefore, the results of such projects are usually most relevant to Englishspeaking homogenous groups. Research has shown that participation in exercise in CALD groups are often constrained by a range of factors, including cultural and religious beliefs, language barriers, circumstances of migration, acculturation, socio-economic characteristics and perceptional and environmental factors [7,8]. A wide range of factors should be considered in the quest for greater understanding of issues specific to the CALD older

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population, who may have more diverse and complex health needs, but probably experience more difficulties accessing health care, including cultural and religious beliefs, perceptions and experiences of migration as well as older age. Evidence from qualitative research can be beneficial for an indepth understanding of various experiences and perspectives of participants in, and providers of, exercise or fall prevention programs for older people from CALD groups. This knowledge is critical to ensuring available intervention programs are effective, relevant and acceptable, but, to the best of our knowledge, have not yet been addressed in systematic reviews. To address this gap, we conducted a narrative systematic review of qualitative studies. This review aimed to provide a comprehensive account of research evidence relevant to the experiences and perceptions of program providers and older people from CALD backgrounds with regard to (i) exercise and (ii) fall prevention programs for older people.

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Methods We used systematic review methods for synthesising qualitative research using available guidance from the Cochrane Collaboration [9]. Our review sought to investigate experiences and perception of both program providers and participants. More specifically, the review was guided by two questions: (1) What are the experiences, needs and challenges of program providers in relation to the provision of exercise or fall prevention programs for older people from CALD groups? (2) What are the experiences and perceptions of older people from CALD groups concerning participation in exercise or fall prevention programs? Eligibility criteria Studies were included if they contained qualitative data (a) reporting the perspectives of older people aged 60 years and over from CALD groups living in the community or the perspectives of program providers working with such groups; and (b) were concerned with the experiences or perceptions of participation in exercise or fall prevention programs. We defined CALD groups as comprising persons born in a country where English was not the main language spoken and who had migrated to an Englishspeaking country [10]. Included studies were restricted to empirical studies published in peer-reviewed journals in the English language using a qualitative research methodology or data collection methods such as in-depth interviews, focus groups or observation. Studies using mixed methods were included if qualitative data relevant to our review questions were reported. We excluded studies relating to specific disease-defined population groups for which we envisaged that participant perspectives may differ from the general older population, such as cancer patients, but included studies among participants with other medical and physiological risk factors for falls including depression, history of stroke, Parkinson disease, gait problems and vision impairment [11]. Studies referring to mixed populations such as older and younger people or CALD and non-CALD groups or a mix of settings such as community and hospital were also excluded unless data for each group or setting were clearly distinguishable. In addition, studies for which the full text was not available were excluded. Search strategy We searched electronic databases and manually searched reference lists of the included studies, relevant texts (e.g. existing literature review papers) [7,8,12–14] and relevant journals (e.g. Journal of Aging & Physical Activity). We also liaised with researchers with subject expertise or interest including the authors. We searched Ageline, CINAHL, Embase, Medline,

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PsycINFO and Web of Science. Keywords for the search included terms relevant to essential concepts: older people, qualitative data collection methods and fall prevention (Supplemental Table S1). Search terms for fall prevention were selected drawing on findings from a Cochrane systematic review [2] to include terms relevant to effective interventions in reducing falls in community-dwelling older people. They included fall prevention, balance and strength training, exercise, Tai Chi, home safety/modification, footwear, vision impairment or vitamin D. To capture ‘‘exercise’’ studies, in particular, we used a broader range of search terms which included exercise, balance and strength training, Tai Chi, gait, physical activity, physical fitness and physical training. As people from different cultures define exercise differently [15], we wanted to understand the meaning of exercise among older people from CALD backgrounds. The search strategy was first piloted and then refined for each database. No search terms were used to identify CALD population groups as our pilot searches revealed that using such terms led to the exclusion of potentially relevant studies. No study publication date limit was imposed. The search was completed in March 2015. Study selection and quality assessment The selection of the studies followed a three-stage process of initial search and screening, preliminary categorisation, and retrieval and final selection. First, full details of studies yielded from the initial search were downloaded into Endnote. After duplicates were removed, each title was reviewed and screened against the screening checklist (Supplemental Table S2) by one author to identify potentially eligible studies. Then abstracts of all the potentially eligible studies identified were screened and classified into ‘‘Yes (relevant)’’, ‘‘Maybe (potentially relevant)’’ or ‘‘No (not relevant)’’ folders based on the screening checklist. Finally, the full texts of ‘‘Yes’’ and ‘‘Maybe’’ studies were assessed independently for eligibility by two authors. This was conferred with and verified by another two authors. Final inclusion of studies was based on an assessment of methodological quality of each relevant study to ensure that we only synthesised findings from methodologically rigorous studies. To assess study quality, we used a modified version of the Critical Appraisal Skills Programme (CASP) [16]. We assigned a score for each item on the checklist, as adopted by Horne and Tierney [12]. The first two questions of the checklist were marked out of two (yes ¼ 1/no ¼ 2) and the remaining questions were marked out of three (yes ¼ 3/somewhat ¼ 2/no ¼ 1) for a maximum score of 28. Studies that scored less than 14 out of 28 on this checklist were excluded from the review. The quality assessment was conducted independently by three authors, all experienced qualitative researchers. Disagreements were resolved through team discussion. Data extraction and synthesis We used a narrative synthesis approach guided by Popay et al. [17] to analyse and synthesise the findings from each included study. By ‘‘telling the story’’ of the findings, this method allowed us to focus on a wide range of factors relating to program participation among older people from CALD groups and develop a new conceptual framework about how to improve their participation. First, all the included studies were read and reread by one author to establish familiarity with the findings, generate initial codes and extract the data, which were carried out at the same time. A list of initial codes was developed from themes identified from the data, such as ‘‘facilitators to participation’’ and ‘‘barriers’’. Data extraction was based on inclusive approaches as per the review questions, in which all relevant data

DOI: 10.3109/09638288.2015.1061606

presented in a study were extracted from the sections of results, discussion and conclusion including participant quotes of each study. Data extracted from each study were summarised into evidence tables in accordance with the initial categories, which were entered into Nvivo (version 10 produced by QSR International, Melbourne, VIC, Australia) for line-by-line coding, comparison of similarities and differences between studies, categorisation and the preliminary synthesis of the findings. The preliminary synthesis was then reviewed independently by another three authors for focused coding, leading to the development of key themes and sub-themes through team discussion. Diagrams were used to identify links and interrelationships between themes. The final thematic framework was refined through team discussion and consensus.

Results

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Description of included studies The initial searches yielded a total of 59 638 records including duplicates (Figure 1). Of those, after the three-stage process of screening, 20 studies were selected for the assessment of study quality. The reasons for exclusion of 207 relevant study reports for which the full text was examined are listed in Supplemental Table S3. After quality assessment, one further study was excluded due to poor quality, leaving 19 publications included in the synthesis. Of 19 included studies, 16 studies focused on physical activity or exercise, two related to fall prevention in general [18,19] while one focused on the use of mobility aids for fall prevention [20] (Figure 1). Exercise is generally considered to be a type of physical activity that is planned and structured [21]. In most of the included studies, the terms physical activity (PA) and exercise

Figure 1. Flow chart summarizing the study selection process.

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were not clearly defined, but used interchangeably to refer to a broad range of activities undertaken in various domains, making it not possible for us to identify the types of exercise or PA and to focus only on exercise for fall prevention. For example, sometimes Tai Chi was referred to as PA while walking or dancing was perceived as exercise. Only one study examined one type of program and this was a walking group [22]. Prior evidence suggests that the use and understanding of the terms PA and exercise can vary with different languages and cultures and they should be explored in ‘‘culturally bound ways’’ [15]. Therefore, throughout our results and discussion we used the term exercise to mean exercise, physical activity or physical fitness. We found no studies exploring the perceptions or experiences of service providers in providing programs for older people from CALD backgrounds (review question 1). All included studies related to the perceptions or experiences of older people from CALD groups (review question 2). Key characteristics of each study including author, study aim, location, population, type of intervention program, sampling method and data collection and analysis methods are provided in Supplemental Table S4. Of 19 included studies, 18 were qualitative and one study [23] used a mixed methods approach. Studies were conducted in the US (n ¼ 10), Australia (n ¼ 3), Canada (n ¼ 3), UK (n ¼ 2) and New Zealand (n ¼ 1). Three studies were conducted with multicultural population groups while most focused on specific cultural groups including Chinese (n ¼ 6), Latino (n ¼ 4), South Asian (n ¼ 2), Filipino (n ¼ 1), Indian (n ¼ 1), Slavic (n ¼ 1) and Tongan (n ¼ 1). Both fall prevention studies were conducted with Chinese older immigrants and the study on mobility aids included Italian immigrants. Quality assessment scores ranged from 17 to 28 (Supplemental Table S5).

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Synthesis of findings Two key themes were identified: (1) the role of culture in shaping perceptions, values and beliefs, and (2) motivational, social and environmental influences. For each theme and subtheme, we first describe the findings for exercise and then follow with further discussion if the theme was also reported in relation to any fall prevention intervention. Supplemental Table S6 provides a summary of themes and subthemes identified and supporting interview quotations. Theme 1: the cultural shaping of experiences, values and beliefs Cultural values and beliefs clearly shaped the experiences and perceptions of older people and their participation in exercise or fall prevention programs.

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Cultural perceptions of ageing and the ageing body The perceptions of older people from CALD groups, especially the attitudes, expectations and values of the society in which they grew up in, had an important impact on program participation. Positive impacts related to the belief that health and physical independence increased in importance with age, which facilitated participation in exercise. Evident in many studies were negative attitudes or stigma towards ageing and the ageing body, such as a fear of dependency, where the effects on exercise participation were detrimental rather than beneficial. In many studies, the value of exercising in older age was questioned with participation considered by some as inappropriate, incompatible or useless [23–27]. Many Latino older people, for example, perceived exercise not ‘‘fitting’’ for older people and expressed ‘‘shame’’, ‘‘acting foolish’’ or ‘‘a waste of time’’ of doing exercise in old age [27]. In addition, the concept of old age as a time to rest or relax was widespread among Asian Indian, Chinese and Latino immigrant older peoples [23,25–27]. Perceptions about participation specifically in fall prevention programs were influenced by negative cultural perceptions associated with a fear of frailty, lost function and becoming an embarrassment or burden in old age [18–20]. In two fall prevention studies [18,19], fear of falling was common among Chinese older immigrants, who were inclined to hide falls from their adult children in order to avoid worrying them or becoming a burden to them. Similarly, the use of mobility aids, especially walking canes, among Italian older immigrants was hampered by strong socio-cultural stigma towards ageing and falls and the identification of these devices as symbols of frailty and lost function [20]. The role of health beliefs and health status Health beliefs were a strong influence, both facilitating and impeding participation in exercise. In many studies, there was a widespread belief that exercise had beneficial effects related to physical health, well-being and independence in old age, which translated to participation in exercise [24,26–34]. In some, however, traditional health beliefs impeded the perceived need for exercise among older people. For example, many Chinese older immigrants believed that proper care of the body and mind or ying and yang was possible through the use of (traditional Chinese) medicine and dietary practices more than through exercise [18,24,26]. High levels of fatalism were also commonly reported among Chinese older immigrants. With an acceptance of illness and physical decline in old age, many Chinese older people understood health by the concept of ‘‘luck’’ [25,26] such that: ‘‘Good health means good luck’’ [26]. For them, there was little

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sense in trying to change the processes of ageing by engaging in exercise. Alongside these cultural health beliefs, health status also influenced exercise participation. For some, health problems and chronic conditions served as a key motivator for the initiation or continuation of exercise [23–26,28,32,33]. Conversely, not being sick or having no health problems was an indication of no need for exercise [25,26]. For many others, however, physical health limitations and poor health served as a barrier to exercise [23– 26,28,31,32,34–36]. The fear of detrimental effects (e.g. worsening pain or health problems) often outweighed the potential benefits of exercise [23,24,27,28,36]. In the study on the use of mobility aids, perceived health benefits (e.g. functional and safety gains) did not necessarily enhance perceived need among Italian older immigrants [20]. Perceived risks, however, were associated with not using mobility aids as one study participant said: ‘‘I wouldn’t feel secure with a cane’’ [20]. Fatalistic health beliefs had important implications for Chinese older immigrants’ understanding and experience of falls and fall prevention [18,19]. Similarly with the findings regarding exercise, having a fall and finding suitable fall prevention programs was also explained by the concept of luck. Chinese older people with fatalistic beliefs were less likely to view falls as preventable, interventions as effective or worth participating in, or to change behaviours to improve their health as reflected in the following statement: ‘‘There is no prevention for falls as falls always happen suddenly’’ [19]. Chinese older people demonstrated some understanding on the impacts of some specific health conditions (e.g. poor vision and Parkinson’s disease) on falls risk, but this was not explored in relation to their participation in fall prevention [19]. The need for culturally appropriate programs There was a strong preference for programs that were culturally relevant and appropriate. The need for programs that catered to specific rather than mixed cultures was highlighted as well as programs conducted in culture-specific languages [24–31,33–35]. The promotion of cultural unity was also seen as important. Having a place ‘‘to exercise and congregate in’’ with people of the same cultural background, same language or similar age motivated participation in exercise [22,27,28,30,36] and helped immigrant older people to mediate not just language, but most importantly, the cultural barriers they experienced within their adopted country [28]. There was a recognition that this may rest on an organisation’s ability to secure sufficient funds to deliver and maintain such programs over time [28]. Older people from certain CALD groups faced various religious or cultural expectations in relation to their social and physical behaviours such as clothing, which limited their exercise participation and choices throughout their life. Cultural barriers to participation were a particular concern of older women [24,25,29,37], with many older women expressing a preference for gender-segregated activities [25,29] and feelings of embarrassment or concerns about mixed-gender programs [24,25,35,37]. Expectations in appropriate exercise attire also were of concern. In addition, limited English and a lack of program information in their own language were reported as barriers to exercise [25,29]. Hence, older people often lacked information about the necessities and benefits of exercise [25,35] and some were dependent on ethnic organisations or ethnic media as a source of health information [34]. The importance of health education interventions was commonly emphasised as an effective way to positively influence perceptions and uptake of exercise among older people from CALD groups [25,28,30,31,34,36].

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DOI: 10.3109/09638288.2015.1061606

In fall prevention studies, the need for language-specific programs was also reported. For older Chinese people, it was vital that these programs were conducted in Chinese as stated by one study participant: ‘‘It is good that we have it [the Tai Chi class] in Chinese. I will not attend if it’s not in Chinese’’ [18]. Language problems included not just limited English but also a lack of literacy in their first language [18]. Therefore, there was a preference to also receive information via visual media such as TV or DVD [18,19]. The lack of information was an even more common issue. Older people from CALD groups received little reliable information on fall risk factors and consequences or fall prevention interventions [18–20]. Their understanding of falls and fall prevention was often reliant on sources such as family members or friends [19] and strongly affected by traditional cultural views of health and illness [18]. Many Chinese older people, for example, were aware of Tai Chi as a beneficial exercise, but not necessarily as a fall prevention intervention [19]. The lack of information contributed to reduced understanding of the necessities or benefits of fall prevention interventions; the lack of interest or motivation for them; the lack of awareness of the potential impact of medication use on falls risk; preference for seeing a doctor and taking medications over doing exercise even after having an injurious fall [18–20]; and the need for education interventions for preventing falls [20]. The importance of family roles and responsibilities Older people from CALD groups commonly placed great importance on their family roles and responsibilities but had divergent views about how this would influence their engagement in exercise. For example, some people perceived grandparenting as an important motivation for increased exercise in old age as indicated by one study participant: ‘‘Do everything that children doðwalk, run, play’’ [31]. Others, however, considered a lack of time stemming from housework as a key barrier to exercise, which was particularly apparent amongst older women from Asian Indian [23], Chinese [25], Filipino [28,32], Mexican [33], Vietnamese [30] and Tongan [35] backgrounds. Many older women echoed comments like the following; ‘‘My full day goes in housework. So, I have no time for anything else’’ [23]. A lack of established routines for exercise due to work or family obligations during adulthood often led to a lack of exercise later in life [23,24,26,29]. For some, traditional gender role expectations lessened after migration as a result of acculturation to western society [34] or individual older women learned to effectively ‘‘go against tradition’’ [37] and use social, cultural and environmental resources available to structure their choice of exercise and continue their engagement in it [24,26,27,29,31,33,37]. One Mexican woman explained: ‘‘I can give up running for something that I have to do, but if there is a tense situation, I will give up what I have to do to tend to that situation. But if I can go run well just let me out the door you know just to get that relief’’ [37]. Various personal strategies were used by older people to balance their duties and need for exercise in everyday life including: doing exercises along with their sick mother [37]; practicing Tai Chi at home guided by a DVD while taking care of a sick husband [24]; or walking to the local shops, taking grandchildren to and from school, performing prayer as exercise [29]. No study explored how cultural beliefs regarding family responsibilities influenced participation in fall prevention programs. Cultural perceptions of PA, exercise and fall preventions The meaning of PA or exercise varied within and across cultures, which exerted an important influence on an individual’s participation in these activities. For example, in Chinese and Latino

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groups, PA or exercise was often considered an age-based activity, defined as a leisure activity during young-adulthood and a way to achieve physical and mental health in older age [24–28]. In Indian and Tongan cultures, activities such as dancing, fishing, cooking, art-making or yoga were an integrated part of everyday life, but not necessarily related to promoting health [23,29,35,36]. In addition, PA or exercise as an activity was typically viewed in terms of gender appropriateness. That is, older men typically participated in leisure activities, while older women typically participated in household activities [25,31,36]. Accordingly, the importance of having a daily physical activity routine rather than organised or structured exercise was emphasised in various CALD groups [27]. Often with limited choices, daily activities like housework or gardening were regarded as forms of exercise [23,25–27,31,32,34–36]. Low- to moderate-intense exercises were preferred and walking was often the most frequent or preferred form of exercise reported [22,25,27,28,31,32,34,36]. Reasons to walk or preferences to walk, although closely linked to health incentives in a few studies [22,31], involved varied social, cultural or economic motives including: (a) being accessible, familiar and convenient [25,36]; (b) the only transport option both in home and host countries [31,34,36]; (c) a form of leisure or socialisation [31,36]; (d) a way to maintain independence and to help others [31]; (f) an integrated part of daily lives [32]; and/or (g) no cost [31,36]. In line with these findings, participation in formal exercise was viewed as a low priority or even unnecessary as was participation in fall prevention programs [19,20,23,25,29]. Participation in exercise was not understood as a fall preventive measure, rather, the use of personal strategies to prevent falls such as being careful, wearing appropriate shoes or using assistive devices such as a walking stick were emphasised [18,19]. In two studies on PA or exercise [28,31], fear of falling was discussed as a barrier to exercise. Theme 2: motivational, social and environmental influences Program participation among older people from CALD groups was also influenced by motivational, social and environmental factors, on which post-migration experiences had a profound effect. Motivation and intent Motivational factors including self-motivation, personal determination, enjoyment, interests and self-efficacy were important factors encouraging initiation and continuation of exercise [22,23,25–29,34,36,37]. One older person said: ‘‘Even though my doctor recommended doing so, I still need to be determined. But the limitation is your motivation. If you are lazy and unmotivated, you cannot do it’’ [28]. Self-motivation and selfefficacy were often contingent on the cultural and family values placed on exercise in old age. They were strengthened through various resources and experiences such as a sense of achievement (e.g. from mastering a specific activity), encouragement from others, parenting or work experiences [22,25–27,30,37]. Education and an emphasis on self-monitoring of health also increased motivation [24,31]. On the other hand, a lack of motivation, interest or desire to participate, fear of making a commitment or certain personality traits, such as being introverted or having a sense of inferiority, were reported as barriers to participation in exercise and the use of mobility aids [20,23,25–28,31,32,35]. A lack of motivation, desire or need for these interventions was often prompted or exacerbated by language barriers, a lack of information and knowledge, social isolation and/or other socio-cultural disadvantages

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faced by older people from CALD groups [20,24,25,28,33] as explained by one Chinese woman: ‘‘I am very introverted. I don’t know English. I don’t know how to communicate with other people. I’m afraid of saying something wrong. I enjoy staying at home and doing indoor activities’’ [25]. However, no study explored how motivation or lack of motivation influenced participation in fall prevention programs.

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The importance of social support Physicians or health professionals played an important role in supporting, encouraging and recommending exercise in a range of CALD groups [22–24,27,29,35]. Receiving advice and support from health care providers of the same cultural or language background was reported to be crucial [27,29,35]. Many Chinese older immigrants chose traditional body exercise (e.g. Tai Chi or Luk Tung Kuen) in accordance with physicians’ recommendations [24–26]. For some however, advice was not supportive. Some Korean older immigrants did not walk for exercise because their health care providers recommended against this due to their age or health condition [28]. Families were also an important influence on participation in exercise. Older people were encouraged by their families to participate in exercise as a way of maintaining health [23,25,28,29,34]. For Chinese older immigrants, the family was more important than friends in this regard, often due to an increased emphasis on looking after oneself after migration and lack of friends or relatives in a new country [34]. The Chinese cultural emphasis on graceful interaction (not causing trouble) with others or cultural embarrassment of requesting help was also identified as a significant factor [25]. Familial influence also had adverse effects. In some studies, the influence of family was an important reason for not exercising [23,25,35] as explained in the following: ‘‘Last week I asked my son to buy me a bike for my exercise, but my son was very scared that I might have an accident. Our children sometimes prevent us from doing exercise or physical activity’’ [35]. Support from the community such as community resources and group support also played an important role. Religious organisations and leaders were influential in organising appropriate exercise programs and promoting them among various CALD communities [28,31,35,36]. Government was also seen as an important provider of such programs [30,35]. Friends or the peer group were important sources of support [29,34,37] or role models for exercise [23]. Exercising in a group was particularly influential, providing a sense of commitment and belonging; companionship, opportunities to share knowledge or experiences resulting in improvements in self-confidence or self-efficacy [22,27,29–31,34,36,37]. Participation in group-based exercise resulted in social benefits such as a socially active life, social recognition and a sense of community as well individual benefits such as a sense of achievement and personal accomplishment, which were important facilitators for participation [28,29,36]. A lack of social support, including having no one to provide encouragement or to exercise with, was closely related to low levels of exercise participation among a number of CALD groups including Indian, Latino and Chinese [23,25–28,33]. In fall prevention studies, the role of social support was also noteworthy. A physician’s recommendation was the most important factor influencing the decision to use mobility aids among Italian older immigrants in contrast to their British counterparts who tended to make their own decisions [20]. In addition, physicians were the most important and influential source of information on fall prevention among Chinese older immigrants in Australia, who reported low awareness of the problem of falls and utilisation of other health services and professionals [19].

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Similar to the findings regarding exercise participation, the impact of family on participation in fall prevention interventions was significant, but not always favourable. For example, an older person’s decision to use a walking cane was disapproved by family members who had negative perceptions about the use of such devices [20]. The group environment also had a positive impact on participation in fall prevention programs. Chinese older immigrants attending Tai Chi classes in the UK highly valued the social aspects of the program such as ‘‘making friends’’ and ‘‘having the Chinese food together after’’ [18]. Changes in the living environments and life circumstances Participation in exercise among older people from CALD groups was also affected by changes in the living environment between their country of origin and their current location. Differences or changes in the physical environment which could affect program participation related to weather conditions [23,28,31,35,36]; transport availability [23,25,27,28,31,35]; community safety concerns [23,28,35,36]; availability of facilities [24,35]; geographical isolation [28]; or community design [30]. Changes in life circumstances in the new country also made it difficult to find the time or resources needed for exercise. Such changes often involved negative life experiences including: (i) a less active or sedentary lifestyle in the new country; (ii) social isolation; (iii) cultural disconnection with exercise available in the new country (e.g. older South Asians’ unfamiliarity with Canadian winter sports); (iv) personal safety concerns experienced as an old minority in the new country; (v) limited housing options for large immigrant families in the new country, restricting indoor exercise; (vi) frequent visits to the home country; (vii) financial difficulties stemming from lower socio-economic status in the new country and/or (viii) resettlement disruptions, family separation and long work hours [23,26,28,30,33,35,36]. Given these post-migration experiences, older people were less likely to perceive exercise as convenient or to fit into their new lifestyles after migration [30] and also more likely to lose motivation for exercise and pay less attention to it in the new country [26]. The effects of lifestyle changes were more detrimental for recent immigrants with low levels of English-proficiency, education and income [30]. Cost or the expenses associated with program participation was regarded as an issue not only to exercise [24,28] but also to fall prevention programs and the use of mobility aids [18,20] as suggested in the following statement: ‘‘I wouldn’t mind paying the odd pound but I guess it can mount up if you come twice a week, every week in the month’’ [18].

Discussion Our systematic review revealed limited qualitative research on the perspectives of the key stakeholders in fall prevention programs for older people from CALD backgrounds, finding no study exploring the perceptions or experiences of service providers. The majority examined perceptions and experiences of older people from CALD groups relating to participation in exercise. Only three studies focused on fall prevention approaches, with one of these exploring the use of mobility aids. Despite the limits posed by the shortage of primary qualitative studies on effective knowledge generation and synthesis, our review had some important findings. Our review, in particular, highlights the impacts of culture and other life circumstances and experiences, often related to post-migration experiences, as important factors that could have detrimental rather than beneficial effects on participation in exercise and fall prevention among older people from CALD groups. Similar with the general older population, attitudes, expectations and values play an important role among these older populations. Noticeable was the

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DOI: 10.3109/09638288.2015.1061606

prolonged impacts of cultural values and beliefs on the ways they perceived and defined ageing and health, their perspectives of cultural appropriateness, family duties and gender roles and the meanings they ascribed to exercise and fall prevention measures. We found that, despite an increased desire for autonomy and independence, a sense of inevitability about becoming frail, dependent or sedentary in old age was common and had significant negative effects on exercise participation as it weakened self-efficacy and motivation to undertake exercise. In addition, cultural norms attached to traditional family responsibilities were deeply embedded and reinforced even after migration. While these norms often posed a barrier to exercise, there was some evidence that they were renegotiated to facilitate changes among older people. We also found that participation in exercise or fall prevention differed not only between but also within CALD groups and in many studies it was complex and complicated due to diverse issues facing individual older immigrants. Physicians and family played an important role in encouraging or discouraging adaptation of exercise or fall prevention, which signified not only family centred culture among CALD groups but also the lack of social support and the interdependent nature of family relationships in CALD households. Difficulties in adapting to new living environments, circumstances and/or language contributed to the lack of information and knowledge of fall prevention programs and deterred participation in these programs or discouraged seeking social support outside the family. The detrimental effect of acculturation and language barriers has been also addressed in recent literature reviews on PA or exercise participation in CALD groups [7,8,12]. Although the impact on program adherence and retention was not included in major themes that we identified from our review, there were a few studies that explored factors promoting program adherence [26,29,37]. Findings from these studies suggest that factors promoting program adherence can be different from those influencing program initiation. In these studies, factors that were most significant in promoting adherence were having appropriate social support [29] and intrapersonal mechanisms (such as perseverance, personal interest and the development of selfconfidence, self-determination or self-efficacy) [26,37] while health-related factors played the biggest role in program initiation. We also found that cultural values and beliefs were often negotiated to incorporate people’s choice of exercise and continued engagement and adherence. Our findings support previous systematic review findings on participation [13] and implementation [14] of fall prevention interventions in the general population, adding to the understanding that program participation is complex and multifactorial. Similar findings have been made to suggest that older people’s participation in intervention programs are influenced not only by cultural and individual beliefs and perceptions but also by health, social, psychological, economic and environmental factors. For example, as in the general population, health status is one of the strongest predictors of engaging in exercise. With these influences impacting through the individual, a large number of the participants in the primary studies were not physically active, not involved in organised exercise or any fall prevention interventions, not informed or under-informed about the benefits of these programs and the consequences of not participating in them, and, more importantly, not motivated to participate in these. Many preferred walking and low- to moderately intense exercise, and were unaware of exercise regimes that are effective for fall prevention. Viewing behaviour change as a process occurring over time, the transtheoretical model (TTM) of health behaviour change recognises that individuals differ in their readiness to overcome barriers and change health behaviours and therefore that different interventions are needed for those at

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different stages [38]. The findings of this review support the notion that the majority of people are at an earlier stage of change and are not intending to take action in the foreseeable future. As such, approaches to engage older people must be tailored differently than if they are contemplating or ready for action. TTM may be a useful perspective in helping frame the messages relevant to their beliefs and stage of action as well as personal benefits and activities that provide a continued sense of mastery [39,40]. Although there is work to be done, the relationship between behaviour change and improvement in PA and exercise in different cultural groups has been demonstrated [41–44]. To promote uptake and maintenance of fall prevention programs or exercise programs effective for fall prevention among those who are not ready for immediate or long-term change, programs need to be designed to match individual and community needs, suggesting that there would be no ‘‘one-sizefits-all’’ solution. Our findings suggest that, without specific targeting, the reach of fall prevention programs to older people from CALD backgrounds is likely to be poor. Exercise and fall prevention interventions need to be culturally appropriate and maximise beneficial effects of educational interventions and the positive influence of social support, especially from physicians and family. More attention should be paid to education with regard to raising awareness of fall prevention and the important components of exercise effective for fall prevention (e.g. challenging balance and regular long-term participation [3]). Having some materials in the language and leadership from within the CALD community is preferred and makes sense as language, communication, meaning and acceptance are inextricably linked. Increased exposure to information and knowledge about the program and the program benefits will ease social isolation and encourage engagement in community-based programs. This highlights the important role of partnerships between CALD-specific and mainstream health care organisations in working together to reach older CALD people, providing culture-sensitive and relevant information and adapting programs and approaches. Healthcare professionals require an understanding of the community and its diversity. There are a range of strategies that can be used to enhance cultural appropriateness and relevance in addition to culturally appropriate materials. These include, for example, drawing directly on the experience of members of the CALD group and engaging them as advisors and volunteers, understanding the collective community shared practices for health beliefs, support and practices, building on strong familial and community ties and working within the broader social and cultural values when designing messages about participation and prevention, as well as tailoring to individual diversity [45,46]. The absence of literature on the perspectives of program providers and other stakeholders in fall prevention represents an important lack of knowledge. Also, the few studies on fall prevention and participation have limited our ability to identify and compare experiences and perceptions of older CALD people. In addition, we included only empirical studies published in peerreviewed journals, excluding the grey and non-English literature, which may have excluded some relevant studies. While these findings can be used to inform the delivery of programs to this population group, future studies should focus specifically on experiences and perceptions of older CALD people to fall prevention programs as well as the perspectives of program providers.

Declaration of interest The authors have no declaration of interest to report. This study was supported by a National Health and Medical Research Council (NHMRC) Partnership Projects Grant.

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Supplementary material available online Supplemental Tables S1–S6.

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Cultural influences on exercise participation and fall prevention: a systematic review and narrative synthesis.

We aim to provide a systematic review of qualitative research evidence relevant to the experiences and perceptions of program providers and participan...
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