The Gerontologist Advance Access published March 17, 2014 The Gerontologist, 2014, Vol. 00, No. 00, 1–15 doi:10.1093/geront/gnu014 Research Article

Older Adults’ Perceptions of Mobility: A Metasynthesis of Qualitative Studies R. Turner Goins, PhD,*,1,2Jacqueline Jones, PhD, RN, FRCNA,3 Marc Schure, PhD,4 Dori E.  Rosenberg, PhD, MPH,5 Elizabeth A.  Phelan, MD, MS,6 Sherry Dodson, MLS,7 and Dina L. Jones, PT, PhD8 Department of Social Work, College of Health and Human Sciences, Western Carolina University, Cullowhee, North Carolina. 2 Center for Healthy Aging, Mountain Area Health Education Center, Asheville, NC. 3 Division of Informatics, Health Systems & Leadership, College of Nursing, University of Colorado, Aurora. 4 Puget Sound Veterans Affairs, Health Services Research and Development, Seattle, WA. 5 Group Health Research Institute, Seattle, Washington. 6 Medicine/Gerontology and Geriatric Medicine, University of Washington, Seattle. 7 Health Sciences Library, University of Washington, Seattle. 8 Department of Orthopaedics and Division of Physical Therapy, West Virginia University, Morgantown. 1

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*Address correspondence to R. Turner Goins, PhD, Department of Social Work, College of Health and Human Sciences, Western Carolina University, 4121 Little Savannah Road, Cullowhee, NC 28723. E-mail: [email protected] Received October 26 2013; Accepted February 5 2014

Decision Editor: Barbara J. Bowers, PhD

Purpose of the Study:  Optimal mobility is an important element of healthy aging. Yet, older adults’ perceptions of mobility and mobility preservation are not well understood. The purposes of our study were to (a) identify studies that report older adults’ perceptions of mobility, (b) conduct a standardized methodological quality assessment, and (c) conduct a metasynthesis of the identified studies. Design and Methods: We included studies with community-dwelling adults aged ≥65 years, focused on perceptions of mobility pertaining to everyday functioning, used qualitative methods, and were cited in PubMed, Embase, CINAHLPlus, or Geobase databases. Study quality was appraised using the McMaster University Tool. Results:  Out of 748 studies identified, 12 met inclusion criteria. Overall quality of the studies was variable. Metasynthesis produced 3 overarching themes: (a) mobility is part of sense of self and feeling whole, (b) assisted mobility is fundamental to living, and (c) adaptability is key to moving forward. Implications:  Older adults’ perceptions of mobility can inform interventions that would involve actively planning for future mobility needs and enhance the acceptance of the changes, both to the older adult and the perceived response to changes by those around them. Key words:  Mobility, Self-identity, Independence, Environment, Adaptation, Social connection

Due to the frequent occurrence of mobility impairment with aging and the expected surge in the numbers of older

individuals over upcoming decades (Federal Interagency Forum on Aging-Related Statistics, 2012), there has been

© The Author 2014. Published by Oxford University Press on behalf of The Gerontological Society of America. All rights reserved. For permissions, please e-mail: [email protected].

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Bowling, & Ebrahim, 2006; Cumming, Salkeld, Thomas, & Szonyi, 2000; McAuley et al., 2006; Tinetti, Mendes De Leon, Doucette, & Baker, 1994). This research has consistently suggested that subjective measures, such as perceived self-efficacy, play an important role in mobility-related choices. Yet, few studies have elicited older adults’ perceptions, beliefs, and values related to mobility. Thus, the purposes of our study were to (a) identify studies that report older adults’ perceptions of mobility, (b) conduct a standardized methodological quality assessment, and (c) conduct a metasynthesis to provide an interpretive analysis of perceptions of mobility among older adults grounded in existing qualitative research evidence. The research question for this review is “How do older adults perceive mobility?”

Methods Search Strategy One of us (S. Dodson), a health sciences librarian, conducted the literature searches. Studies were identified by searching four electronic databases, including PubMed, Embase, CINAHLPlus, and Geobase. We defined mobility by using the National Library of Medicine’s Medical Subject Headings (MeSH) in PubMed and appropriate corresponding subject headings in the other three databases. These MeSH terms for mobility and perception are presented in the Box. We also supplemented the database searches with searching by author, reviewing reference lists of published studies and review articles, repeating the search strategy prior to finalizing the study, and subjected the article list to expert review among the Centers for Disease Control and Prevention’s Healthy Aging Research Network members. We then combined the mobility and perception terms and limited them to English language and human studies in the aged, or those aged ≥65 years, excluding articles indexed to “Residential Facilities”[MeSH] or clinical trials as a publication type. Our final step was to limit the search to qualitative studies. We used an existing filter of search terms to identify qualitative studies (Marks & Wilczynski, 2009). EndNote version 14 software was used to remove duplicate citations (Thompson Reuters, 2000) and we stored the studies electronically in RefWorks version 2.0 (ProQuest, 2009).

Study Selection and Appraisal Inclusion and Exclusion Criteria For the purposes of our study, we defined mobility as movement within a space, or from space to space, for accomplishing daily living tasks (Prohaska et  al., 2011). The inclusion criteria for this study were published studies that (a) included community-dwelling adults aged ≥65 years, (b) focused on perceptions of mobility pertaining to everyday

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increased interest in understanding mobility’s relative role in the health and well-being of this population (Prohaska, Anderson, Hooker, Hughes, & Belza, 2011). The construct of mobility refers to all types of movement such as walking, biking, and driving within and between environments to accomplish daily living tasks (Prohaska et al., 2011). Optimal mobility, or one’s capacity to safely and reliably transport one’s self via desired means to chosen locations, is an important component of healthy aging (Satariano et  al., 2012). For example, studies support a strong positive association between mobility and well-being (Banister & Bowling, 2004; Cvitkovich & Wister, 2001; Mollenkopf, 2005; Spinney, Scott, & Newbold, 2009). Yet, with the increased burden of comorbidities and functional limitations in older adults, loss of mobility becomes inevitable for many. Research has provided evidence that mobility loss can negatively affect well-being (Freeman, Gange, Muñoz, & West, 2006; Groessl et al., 2007; von Bonsdorff, Rantanen, Laukkanen, Suutama, & Heikkinen, 2006; Yeom, Fleury, & Keller, 2008). Such evidence underscores the need for increased collaborative research across multiple disciplines to better understand the spectrum of biological, cognitive, behavioral, psychosocial, and environmental factors affecting mobility in older adults. In turn, results from this interdisciplinary work would inform future research as well as the development and/ or improvement of interventions designed to enhance and maintain optimal mobility (Prohaska et al., 2006; Satariano et al., 2012; Webber, Porter, & Menec, 2010). Despite recent calls for a more comprehensive theoretical framework around mobility research (Prohaska et al., 2011), most mobility research and mobility-related interventions and policies have been discipline (e.g., physical therapy, transportation, engineering) and domain specific (e.g., walking, driving, assistive device use; Prohaska et al., 2011; Satariano et  al., 2012; von Bonsdorff et  al., 2006; Webber et  al., 2010). Webber and colleagues (2010) proposed an ecological framework for mobility that captures the diversity of theoretical perspectives across mobility domains. This framework suggests that a range of biological, cognitive, psychosocial, and environmental factors interact to influence mobility and the adaptations that are made to maintain mobility. Webber and colleagues posit that as one’s life space or mobility in and outside of one’s home expands, the number of factors influencing mobility increases. This framework also accounts for other factors, such as gender, culture, and personal life experiences that may indirectly affect mobility. Consistent with this framework, a number of mobilityrelated studies with older adults have expanded the range of influential factors to include personal beliefs, perceptions, and experiences of mobility and mobility-related adaptive responses to functional decline (Ayis, Gooberman-Hill,

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functioning, (c) used qualitative methods, and (d) were published since the electronic databases inception date through October 2012. The exclusion criteria were published studies that (a) had no primary data collection, (b) focused on measurement of mobility or mobility for leisure physical activity, (c) dealt with an uncommon disease or condition and/or in a specific clinical setting, (d) were non-English, or (e) were dissertations.

Methodological Critical Review We considered seven possible methodological rating tools for qualitative studies (e.g., CASP, 2007; Letts et  al., 2007; NICE, 2009; Paterson, Throne, Canam, & Jillings, 2001; Pluye, Gagnon, Griffiths, & Johnson-Lafleur, 2009; Sandelowski & Barroso, 2002; Walsh & Downe, 2006). Of these tools, the Critical Skills Appraisal Skills Programme (CASP) is the most widely used, which we did not select due to its brevity. Ultimately, we selected the McMaster University Tool (Letts et al., 2007) due to its more comprehensive set of criteria particularly around rigor. Using this tool, each article was subjected to an objective assessment of whether the article reported 17 critical components of the study that we rated as either present or not present. At least two of the research team members independently rated each study who then met via telephone to review the ratings. Any differences were then resolved through group discussion until a consensus was achieved. The tool evaluated study reporting quality with regard to the study purpose, literature reviewed, study design, sampling, data collection, descriptive clarity, analytic rigor, auditability, and overall rigor. Overall rigor includes assessing the study based on the four components of trustworthiness determined by credibility, transferability, dependability, and confirmability. Credibility is related to capturing the true picture of the phenomenon. Transferability refers to whether the results can be transferred to other situations and is ensured through adequate descriptions of the study sample and setting. Dependability is determined by the congruence of the data and the results with a clear description of data collection, analyses, and interpretation.

The fourth component of trustworthiness, confirmability, relates to the use of strategies that limit bias in the research including data neutrality. Metasynthesis A metasynthesis is a rigorous systematic interpretive study of a body of qualitative research literature (Bondas & Hall, 2007; Sandelowski & Barroso, 2007) with the aim of producing new knowledge beyond the original studies. The process involves interpretations of interpretations (McCormick, Rodney, & Varcoe, 2003) and an interpretive integrative synthesis (Thorne, Jensen, Kearney, Noblit, & Sandelowski, 2004). Combined with a general inductive approach (Thomas, 2006) to qualitative analysis, the metasynthesis technique of reciprocal translation (Paterson et al., 2001; Thomas & Harden 2007) allows for synthesis of data that is expressed as metaphor, concepts, cases, conceptual models, phrases, contradictions, and themes of similarities and differences. It extends analysis to going beyond the original studies to more abstract level theme development. In our study, we were not attempting to produce a metaethnography, an interpretive comparison (meta-study), nor a meta-summary but rather an interpretive integration (Sandelowski & Barroso, 2007; Thorne et  al., 2004). We aligned with Noblit and Hare’s (1988) contention that when the studies are about similar things, they can be “added together.” In this way, individual studies added together can be understood for a larger and different interpretive meaning. Reciprocal translation adapted from Noblit and Hare’s original work, and Noblit’s more recent writing with other qualitative metasynthesis scholars (Thorne et al., 2004), is fitting and congruent with this type of metasynthesis. Our approach was that the whole of the published papers provided the context of interpretations (Sandelowski & Barroso, 2007; Thorne et  al., 2004). These contexts provided the foreground of assumption we drew upon to interpret the findings and the sense or interpretations made of them. Our unit of analysis was interpretation. We used a parts and whole movement as a team within and across each study, each team member, and at each team analysis discussion. We paid particular attention to language and its context, relationships, and dissonance, deconstructing and reconstructing along the way. This provided an interpretive end product that is more than the singular end product of each study or anyone individual team member. In this way, we built a multilayered interpretation that was reconstructed through contemporary knowledge of older adults and mobility, refined and defined by ongoing discussions and clarifications. The primary studies were read as a whole by six team members. We had iterative team discussions wherein

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Article Adjudication Five members of our research team reviewed each of the titles identified in the literature search for relevance, applying the inclusion and exclusion criteria. Articles identified as potentially relevant based on title by any of the reviewers were subjected to abstract review. Four members of the research team reviewed the abstracts. Articles that were selected by at least three of those four reviewers were deemed relevant for full article review. After full article review, we chose studies by consensus where all four reviewers agreed to be relevant for inclusion.

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Identification

Results Search Results Figure 1 shows our article selection process with the number of articles rejected at each step. The search produced a total of 748 citations across the four databases. When we removed duplicate citations (n  =  148), the final result was 600. We rejected 426 studies after a title screen and an additional 152 after an abstract screening, yielding 22 studies for a full article review. After full article review, 12 were chosen as relevant for study inclusion. The majority of articles were not included in this review because they did not focus on perceptions of mobility as it pertained to everyday functioning.

Study and Participant Characteristics Table  1 summarizes each of the 12 articles including authors, publication year, purpose, country, study design, methods, participants, and findings. The majority of the studies were conducted in North America (n = 8) with one study each in Australia, Germany, United Kingdom, and Sweden. The studies were conducted between February

Records identified through database searching (n = 748)

PubMed (n = 474) Embase (n =195) CINAHLPlus (n = 36) Geobase (n = 43)

Included

Eligibility

Screening

Records after duplicates removed (n = 600)

Figure 1.  Article selection process.

Records screened (n = 600)

Records excluded (n = 578)

Full-text articles assessed for eligibility (n = 22)

Full-text articles excluded (n = 10)

Studies included in metasynthesis (n = 12)

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themes and subthemes in each study were identified, and each member created a taxonomic structure that described themes, concepts, and conceptual relationships interpreted within and across the findings of each study (Sandelowski & Barroso, 2007). Team members also independently identified participant quotes from the reviewed studies to support the themes and subthemes. Agreement was reached among the team members through consensus regarding how each of the study findings related to one another and how conceptual linkages were reframed as a result. An audit trail of discussions and decision integrity was maintained through audio recordings and note taking (Schoenberg, Miller, & Pruchno, 2011). These were revisited throughout the iterative analytic team process. New derived themes at a higher level of abstraction emerged that were then linked back to each primary study to ground the context of new (re)interpretations through iterative group reflection, interpretation, and theorizing (Bondas & Hall, 2007; McCormick et  al., 2003; Sandelowski & Barroso, 2007; Sandelowski, Docherty, & Emden, 1997). This produced a new thematic understanding of mobility as perceived by older adults.

Exploratory descriptive qualitative

Qualitative descriptive

Secondary analysis qualitative descriptive

Grounded theory

Exploratory, descriptive qualitative

Qualitative descriptive

Canada

United States

United States

United States

United States

United States

To examine the views of elderly persons regarding the use of assistive devices in fall prevention

To ascertain older adults’ subjective perceptions about “life domains,” and provide a preliminary typology of adaptive strategies used to obtain salient goals within each domain To examine the decision-making and problem-solving process toward use of or intention to use mobility devices among older African American adults with emerging or present chronic disabilities To ascertain how older drivers change driving patterns and behaviors (“selfregulation”) to continue driving without compromising their perceived safety, independence, and quality of life To ascertain how certain minority women define health and well-being and to determine what environmental, social, and cultural factors contribute to healthy aging To explore the range of mobility-related personal perceptions, meanings, and emotions regarding participants’ anticipation of, or experiences with, mobility changes

Aminzadeh and Edwards (1998) (#2)

Clark et al. (1996) (#9)

King et al. (2011) (#8)

Hopkins, Kwachka, Lardon, and Mohatt (2007) (#5)

Donorfio et al. (2008) (#6)

Copolillo, Collins, Randall, and Cash (2002) (#1)

Study design

Country

Study purpose

A typology of adaptive strategies was developed based on 10 life domains.

Older adults use their past experiences, observations of others, and heuristic rules for making decisions regarding mobility device use.

29 older adults living in a federally subsidized housing project in Los Angeles Nine older African Americans

Participant observation, in-person semistructured interviews, and descriptive field notes Theme analysis Focus groups Grounded theory analysis of themes

Focus groups Grounded theory theme analysis

30 community-dwelling older adults

Older adults equated mobility with driving a vehicle, attitudes regarding mobility status and preparedness for change were dependent on both personal experience and disability level, and mobility loss spurred fear of dependence.

81 community-dwelling Older adults are aware of agerelated changes to driving and older adults in Florida self-regulation behaviors, and and Illinois that transportation alternatives are limited. 15 midlife and older The women define healthy Yup’ik/Cup’ik women aging within a framework of sustenance living and respect for elders.

Interviews documented the diversity of personal experiences and meanings of falls, aging, and assistive device use among older adults.

30 communitydwelling older adults from Italian and British Canadian backgrounds

Four audiotaped 60- to 90-min focus group interviews, 6–8 persons per group, notes taken immediately following Theme analysis Audiotaped, in-person individual semistructured interviews Life domain analysis Individual in-person interviews and focus group, line-by-line hand coding Theme analysis

Summary of findings

Participants

Methods

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Authors & year

Table 1.  Description of Reviewed Studies

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Qualitative descriptive

Sweden To examine how frail elderly persons experience becoming assistive device users and how these devices affect their independence in daily activities

Skymne, DahlinIvanoff, Claesson, and Eklund (2012) (#12)

Focus groups Theme analysis

Focus groups theme, constant Comparative analysis

Exploratory qualitative

Canada

To examine the experiences and perspectives on driving among well elderly persons

Rudman et al. (2006) (#11)

The meaning of mobility remained stable over time. Respondents’ perceptions included losses in mobility, decreased satisfaction in mobility experiences, and increased satisfaction with public transport. 79 community-dwelling, Four main themes emerged: older adult drivers (a) the value of driving, (b) mechanisms of self-monitoring and self-regulation, (c) people influencing decision making, and (d) opinions regarding licensing regulations. Two main themes emerged: (a) 18 adults aged confidence in knowledge and ≥80 years residing at experience and (b) getting a geriatric rehabilitaused to assistive devices in tion unit daily activities. Mailed survey and semistructured interviews Content analysis

QUANT → qual (mixed methods)

Germany

To examine the subjective meaning of mobility over time, trends in satisfaction with various mobility domains, and interindividual variation in mobility-related satisfaction

Mollenkopf, Hieber, and Wahl (2011) (#10)

81 (66 survey participants, 15 focus group participants) older adults who used scooters and/or were members of a scooter support group 82 older communitydwelling adults (35 of which participated in the semistructured interviews)

Mailed survey and audiotaped focus group interviews Theme analysis

Descriptive exploratory qualitative

Australia

To investigate the meaning that older people attribute to having an electric mobility scooter and to identify factors that influence and affect their purchase and use

May, Garrett, and Ballantyne (2010) (#7)

Five themes of living with knee OA emerged: (a) experiencing knee pain is central to daily living, (b) experiencing mobility limitations devalues self-worth, (c) sharing the experience, (d) assessing one’s own health, and (e) managing chronic pain. Three main themes were generated: (a) factors for obtaining a scooter, (b) the meaning of mobility, and (c) issues around sharing spaces.

Three older adults diagnosed with OA of the knee

In-person open-ended interviews (n = 3 interviews over time) Theme analysis

Descriptive phenomenology

Canada

To understand the experience of living with knee osteoarthritis (OA) in older adults

Maly and Krupa (2007) (#3)

Summary of findings

Methods

Participants

Study design

Country

Study purpose

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Authors & year

Table 1.  Continued

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Three main themes were generated: (a) one’s willingness to connect with the world drives the relation between mobility and well-being, (b) while loss of physical mobility can affect one’s sense of well-being, and other types of mobility can compensate for this loss, and (c) well-being is enhanced by physical mobility because it enables independence and inter-dependence. 128 community-dwelling older adults United Descriptive Kingdom qualitative To examine the interrelations between spatial mobility, aging, and well-being in rural persons aged ≥60 years Ziegler and Schwanen (2011) (#4)

Focus groups, in-person semistructured interviews, open axial coding Theme analysis

Summary of findings Methods Study design Country Study purpose Authors & year

Table 1.  Continued

1996 and March 2012, with sample sizes ranging from 3 to 128 participants. The predominant study design was descriptive qualitative research. The qualitative data from the 12 studies represented a total of 472 older adults. Five of the 12 studies used more than one method for collecting data; 2 of which used a combination of quantitative (i.e., surveys) and qualitative data collection approaches. The most frequently used qualitative methods were focus groups (n = 8), followed by interviews (n = 6) and observation (n = 1). Although gender, race, and ethnicity were not reported in all articles, the studies appeared to be comprised predominantly white female participants with the exception of several studies that focused exclusively on certain racial and ethnic groups including African American women, Italian and British Canadians, or Alaska Natives.

Methodological Critical Review Table  2 summarizes the results of the critical review for each article per the McMaster University tool (Letts et al., 2007). All of the studies clearly stated the purpose and/ or research question with a relevant review of the literature. Three studies identified a theoretical perspective, including the Transtheoretical Model (King et  al., 2011); the International Classification of Functioning, Disability, and Health (Rudman, Friedland, Chipman, & Sciortino, 2006); and the “mobility turn” in social and cultural theory (Ziegler & Schwanen, 2011). In all 12 studies, the sampling methods appeared to capture the intended populations and therefore provided sufficient variation in qualitative data. However, only one study made an explicit connection between data saturation and the sample size chosen (Donorfio, Mohyde, Coughlin, & D’Ambrosio, 2008). With respect to analytic rigor, data analyses were inductive in all instances. Few studies described an audit trail that tracked the decision-making process during the analysis (e.g., how codes, categories, and themes were identified). Findings were consistent with the data and a meaningful picture of the phenomenon under study emerged in all reviewed studies. Some, but not all components, of overall rigor were present in the reviewed studies. With respect to transferability, for example, all but one study described the participants and setting sufficiently to permit for comparisons including specific information of number of men and women participants. Overall, we found that more than one half of the studies were deemed credible and transferable with dependability and confirmability less frequent.

Metasynthesis Table  3 shows the three analytic themes and subthemes that emerged from our metasynthesis of the literature.

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Participants

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Study purpose: Was the purpose and/or research question stated clearly? Literature: Was relevant background literature reviewed? Study design Was a theoretical perspective identified? Sampling Were the sampling methods appropriate? Was sampling done until redundancy in data was reached? Data collection: Was procedural rigor used? Descriptive clarity Clear and complete description of participants Role of researcher and relationship with participants Analytical rigor Were data analyses inductive? Were findings consistent with and reflective of data? Auditablity Was a decision trail developed? Was the process of analyzing the data described adequately? Theoretical connections: Did a meaningful picture of the phenomenon under study emerge? Overall rigor Credibility: Do the descriptions and interpretations of the participants appear to capture the phenomenon? Transferability: Can the findings be transferred to other situations? Dependability: Was there consistency between the data and findings? Confirmability: Were strategies employed to minimize bias?

Yes Yes

No Yes No Yes Yes No

Yes Yes

Yes Yes Yes

Yes

Yes Yes Yes

Yes

No Yes No Yes Yes Yes

Yes Yes

No Yes Yes

Yes

Yes No No

Clark et al.

Yes

Aminzadeh & Edwards

Yes

Yes

Yes

Yes

Yes

No Yes

Yes Yes

Yes No

No

Yes No

No

Yes

Yes

Copolillo et al.

No

No

No

No

Yes

No No

Yes Yes

Yes Yes

Yes

Yes Yes

No

Yes

Yes

Donorfio et al.

No

No

Yes

Yes

Yes

No No

Yes Yes

Yes Yes

Yes

Yes No

No

No

Yes

Hopkins et al.

No

Yes

Yes

Yes

Yes

No No

Yes Yes

Yes No

No

Yes No

Yes

Yes

Yes

King et al.

No

Yes

Yes

Yes

Yes

Yes Yes

Yes Yes

Yes No

Yes

Yes No

No

Yes

Yes

Maly & Krupa

Mollenkopf et al. Yes Yes

No Yes No No No No

Yes Yes

No No Yes

Yes

Yes No No

May et al. Yes Yes

No Yes No Yes Yes Yes

Yes Yes

No No Yes

Yes

Yes No No

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Table 2.  Critical Review of the Identified Studies

No

No

Yes

No

Yes

Yes No

Yes Yes

Yes No

Yes

Yes No

Yes

Yes

Yes

Rudman et al.

No

No

Yes

No

Yes

No No

Yes Yes

Yes No

Yes

Yes No

No

Yes

Yes

Skymne et al.

Yes

Yes

Yes

Yes

Yes

Yes Yes

Yes Yes

Yes No

Yes

Yes No

Yes

Yes

Yes

Ziegler & Schwanen

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Using a process of identifying meaning units, or common and unique features aggregated and interpreted within and across studies, we identified from the 12 studies that mobility is “part of the fabric of the older adult and their lifetime story.” Themes that inform this new synthesized understanding are (a) mobility is an integral part of sense of self and feeling whole, (b) assisted mobility is fundamental to living, and (c) adaptability is key to moving forward. Primary studies were linked to these themes through reciprocal translation and identified by a number (defined in Table 1) in the following narrative with illustrative participant quotes for emphasis.

Theme 2: Assisted Mobility Is Fundamental to Living Mobility is essential to life and indicative of life (#10, pp.  782–783). This theme speaks to how assisted mobility keeps older adults living as before, sometimes even better, brought about by renewed access or interests and supported social interaction. One participant identified mobility as “a journey but also…there is more to mobility than the end destination as travel is pleasurable itself” (#10, p.  796). Independence mediates the link between mobility and well-being (#4, p. 772) and its impact is bidirectional: “you impact your mobility and your mobility impacts you” (#4, p.  769). When faced with a mobility limitation, older adults felt that there were few alternatives, especially related to transportation. They spoke of feeling “imprisoned without a car” (#11, p.  69) isolated (#7, p.  1224), and assistive devices being almost a substitute for legs, “a magic carpet” (#2, p. 301; #11, p. 69). With respect to using assistive devices, they described the benefits (e.g., improved function, reduced pain, stability, psychological security) and barriers (e.g., embarrassment, fear of dependence). Using assistive devices was sometimes seen as a “last resort” (#1, p. 65) and delayed use for as long as possible. Others felt that they were “not yet old enough” (#1, p. 68; #7, p. 1225) to use devices. The decision on how and when to change behavior in the event

Table 3.  Team Synthesis and Reciprocal Translation: Mobility Is Part of the Fabric of Older Adults and Their Lifetime Story Derived analytic theme & subthemes

In paper # (as listed in Table 1)

Primary study themes

1. Mobility is part of sense of self and feeling whole: This theme speaks to the understanding that mobility is vital to health Parts of me were missing, grieving and loss 1, 3, 8, 9 Perception of self-related to mobility, image, devalues selfworth, life domains Partial person 2, 3 Meaning of falls, devalues self-worth Can decrease confidence 1, 3 Devalues self-worth Indicative of life 3, 5, 8, 10, 11 Keeping busy, attitudes and feelings about mobility loss, practical and symbolic meaning of driving, devalues self-worth, basic human need, life force Self-sufficiency, autonomy, freedom 3, 4 Everyday living, devalues self-worth Capable, robust 1, 5, 10 Walking, control, zest for life It is in the moving that keeps you going 5 Keeping busy, walking Independence 2, 3, 6, 7, 8 Meaning of falls, social norms, devalues self-worth, life domains, meaning of mobility, personal transportation, mobility independence 3, 10 Sharing the experience, changes out of home mobility over Being a caregiver restricts opportunities for time mobility; role and identity change impacts sense of mobility

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Theme 1: Mobility Is an Integral Part of Sense of Self and Feeling Whole For older adults, the meaning(s) of mobility, and the value they place on it, are diverse and rooted in personal experience. This theme speaks to the understanding that for older adults mobility was perceived to be vital to health. Mobility is a basic human need that signifies independence, well-being, and freedom. There was a general awareness of the decline in mobility that occurs with age, with some viewing the decline as inevitable and a universal age-related occurrence. Older adults often perceived “parts of me were missing when I was…unable to do things…” (#3, p. 1427) and “I was like a partial person, I  was a half of myself.” (#3, p. 1427) when mobility was lost, reduced, or limited. When the latter occurred, older adults felt a decreased selfconfidence and a diminished sense of self. One participant said a “loss of control [over mobility] deprives you of your identity” (#4, p. 773). Participants associated mobility with

being robust and capable and asserted it is in the “moving that kept [them] going” (#5, p. 46). They experienced grieving and a sense of loss over time that related to who they were when they had greater mobility and the limitations now imposed on their self-identity (#1, p. 67).

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Table 3.  Continued Derived analytic theme & subthemes

In paper # (as listed in Table 1)

Primary study themes

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2. Assisted mobility is fundamental to living: This theme speaks to how assisted mobility keeps them living as before, sometimes better Imprisoned without a car 6, 11 Transportation and mobility independence, practical and symbolic meaning of driving Driving is fundamental 1, 11 Practical and symbolic meaning of driving, last resort Drive for as long as possible 1, 11 Practical and symbolic meaning of driving, last resort Freedom 7, 10, 11 Practical and symbolic meaning of driving, personal transportation and mobility independence, meaning of mobility, autonomy, freedom Safety, security 2, 6, 7, 11 Safety, self-regulation, meaning of mobility, monitoring and regulating self, perception of need, meaning of falls Social interaction keeps you connected 1, 3, 6, 7, 10 Social norms, cultural values, meaning of mobility, sharing experience, personal transportation, satisfaction with key areas of mobility Community engagement 2, 7 Meaning of mobility Substitute for legs 6 Personal transportation and mobility independence Psychological and physical enabling 4, 5, 7, 9, 10, 11 Well-being, keeping busy, meaning of mobility, life domains, zest for life, practical and symbolic meaning of driving Scooters important in life 7 Obtaining a scooter Devices can keep you going 12 Confidence in knowledge and experience 4, 11 Well-being, practical, symbolic meaning of driving It is a journey but also…there is more to mobility than end destination as travel is pleasurable in itself Too young for devices 1, 2, 8, 10 Image, perception of need, attitudes and feelings as about mobility loss, monitoring and regulating self Perceptions of others not always congruent 1, 2, 6, 11 Perception of need, self-regulation behaviors, control, whose opinion is worth listening to? 3. Adaptability is key to moving forward: This theme speaks to how older adults navigate decline over time Cannot always control such as built 1, 2, 3, 7, 10 Control, issues sharing spaces, perceived changes barriers environment or transportation access to cane use, sharing the experience Cognitive flexibility to reframe limits 4, 11 Well-being, monitoring, regulating self Unwanted attention, fear, negative 1, 2 Image, social norms, social referents stereotypes Mobility changes involves difficult decisions, 6, 7, 9, 11 Self-regulation, men and women differ, social norms, complex whose opinion is worth listening to? 2, 6, 8, 11 Awareness of driving strategies, perception of need, Major event can trigger the need for managing mobility loss and change, monitoring self adaptability or a major event be a consequence of decline Decisions influenced by others, social 2, 7, 10, 11, 12 Meaning of mobility, perceptions of need, perceived impact, counseling and planning ahead changes over time, monitoring self, getting used to, whose opinion is worth listening to? Pain can influence 3, 12 Getting used to, managing chronic pain Perceptions of mobility and adaptability 3, 4, 5, 6, 9, 10 Perceived changes over time, assessing own health, ability changes over time, with age keeping busy, respect for elders, self-regulation, adaptive strategies, satisfaction with key areas over time Stuck in grieving and loss, not move forward 8, 11 Symbolic meaning, monitoring self, attitudes and feelings 4, 7 Issues sharing spaces, mobility Built environment; can rediscover environment but can also hinder travel/ access; can be own home, local, or community Partner can compensate for mobility chal1, 6, 7 Alternatives, self-regulation, issues sharing spaces lenge leading to positive experiences

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Theme 3: Adaptability Is Key to Moving Forward The third theme speaks to how older adults navigate declines in mobility over time. Decline is a nonlinear continuum ranging from optimum to restrictive (#8, pp. 46–47). Older adults were similar across studies in their perceptions of the physical (e.g., lack of transportation), social (e.g., isolation), and psychological (e.g., despair, grief, resentment) consequences that were associated with mobility limitations. Perceptions often centered on poor health status and a fear of dependence or becoming a burden to others. Older adults also illustrated cognitive flexibility in how to reframe their limitations, actively adapting to mobility with a positive attitude (#4, p. 679) or resigning to the change (#8, p. 39). Mobility change involved difficult decisions that were complex, emotional, and often influenced by others (#1, p. 64). There was concern regarding the social impact as well as the stigmatized views related to frailty and old age. The views of health professionals regarding the significance and place of mobility meaning, however, did not always correspond with the older adults’ self-image. As older adults age, their perceptions of mobility and their ability to adapt changed over time. Some were trapped in grieving and loss of who they perceived they were before mobility changes. They found that they do not move forward nor were they able to reframe this new assisted mobility existence. For others, navigating and adapting to mobility changes meant a rediscovery of the built environment and building new social interactions, especially when older adults developed new camaraderie with others of similar mobility status (#7, p. 1428). Yet for others, the existing built environment could hinder travel supported by a scooter, for example. A  major event can trigger a mobility change and the need for adaptability or a major event can be a consequence of decline (#2, p. 299). Partners (spouse) compensated for mobility challenges by

introducing new interactions or activities to the older adult, which led to new and positive experiences.

Discussion Mobility is often measured with quantitative techniques that assess physical function or activities of daily living. These measures do not include the more subjective aspects of mobility that are also important to older adults. For our metasynthesis, we examined how older adults perceived mobility and found three themes, including (a) mobility is an integral part of sense of self and feeling whole, (b) assisted mobility is fundamental to living, and (c) adaptability is key to moving forward. Our metasynthesis highlights the ways that mobility affects not only physical function but also mental health, emotional health, social health, and sense of self. We found that mobility was viewed as vital to older adults’ ability to continue participation in life as they have known it. Older adults’ resistance to assistive device use or to stop driving becomes clearer with a deeper understanding of the meaning older adults’ attribute to these changes (Betz, Jones, Petroff, & Schwartz, 2013). Device use and driving cessation affect the individual, friends, and family of the individual; the way an individual is viewed; the way they fit or do not fit into the group; and the individual’s ability to participate in a community. Despite the absence of a clear threshold to evoke such change, some older adults self-regulated their behavior in order to preserve safety and independence. Examples include restricting driving to only daylight hours, restricting activities to avoid use of an assistive device, and waiting for good weather to venture outside of the home. Ultimately, we found that mobility change is not viewed only as a physical event, but as a multidimensional construct with social and psychological implications. The findings generated from this study correspond with a study that examined the meaning of mobility among residents and staff of a long-term care facility (Bourret, Bernick, Cott, & Kontos, 2002). Through focus groups, the facility’s residents were asked about their perspectives of mobility. There were 20 residents, aged ≥60 years, who participated in the study. The dominant theme from their responses was that mobility was independence and not being reliant on others. The participants indicated that the lack of freedom from limited mobility was viewed negatively and that mobility independence was identified as critical to self-worth. Similar to our findings, the facility’s residents compared restricted mobility to being imprisoned. Identified dimensions of mobility included the ability to perform self-care activities and to get around the facility independently. Residents who were immobile would voluntary refrain from activities for fear of admitting their

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of a mobility limitation was based on a combination of environmental (e.g., access to community), intrapersonal (e.g., age, health, self-confidence, self-image), and interpersonal (e.g., maintaining friendships) factors. In some cases, having a car accident or experiencing a decline in health would serve as the impetus for behavior change and assistive devices could provide a sense of security. In other cases, however, older adults would not make the decision to change behavior (e.g., use an assistive device) even in the presence of safety (e.g., prior falls) or health issues (e.g., joint problems). Older adults perceived ageist stereotypes as a significant barrier to outwardly displaying their need for assisted mobility. There was incongruence in how others, such as spouse or caregiver, perceived assisted mobility (#2, p. 330; #3, p. 1429) and the importance of unassisted mobility as linked to the older adult’s identity.

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There remains a need to improve our understandings of the best ways to support older adult mobility transitions. Quantitative examinations as well as health promotion and clinical interventions designed to improve mobility may consider capturing these thematic elements that emerged in our study to promote a more complete contextual understanding of mobility. Such studies can build on our findings through the development of surveys measuring the gaps in the current quantitative literature such as the psychosocial impact of mobility loss, how people cope with mobility changes, and attributes that help cope with such changes. Also, most mobility interventions are aimed at improving functioning or exercise levels but do not measure or focus on improving mobility aspects such as how to better transport to desired locations. Older adults’ perceptions of mobility can inform interventions that would involve actively planning for future mobility needs to enhance the acceptance of the changes, both to the older adult and the perceived response to changes by those around them. For instance, a new clinical tool, Assessment of Readiness for Mobility Transitions, was developed to assist social service providers working with older adults in examining perceptions to age-related mobility changes (Berg-Weger, Meuser, & Stowe, 2013; Meuser, Berg-Weger, Chibnall, Harmon, & Stowe, 2013). In addition, greater attention by professionals on the meaning of mobility and its self-determined integration and reintegration into daily living a life would be beneficial as older adults adapt to mobility loss. Effective planning with older adults would identify their views related to devices and adaptations that may come in the future. This planning may benefit from the use of motivational interviewing or cognitive behavioral therapy. Understanding how older adults would like to plan for future mobility transitions can inform the development of a brief tool that would assist with conversations and monitor adaptations over time. Such efforts will need to be interdisciplinary as issues of mobility touch upon transportation, physical therapy, psychology, medicine, nursing, public health, gerontology, social work, and urban planning.

Box. Search Terms Used for Mobility and Perception The following search query was used for the PubMed, Embase, CINAHL Plus, and Geobase searches: Mobility Terms “Activities

of

Daily

“weight-bearing”[MeSH balance”[MeSH

Terms]

Living”[Major] Terms] OR

OR

OR

“postural

“walking”[MeSH

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dependence. This study suggests that older adults’ perceptions of mobility are similar between those residing in the community and long-term care facilities. Our study has several limitations worth acknowledgement. The scope, quantity, and quality of the qualitative studies included in the review are a limitation. Also, our review did not include the gray literature due to time and resource constraints, which limits the review to the portion of data available in published form (Conn, Valentine, Cooper, & Rantz, 2003). Despite these limitations, our use of a metasynthesis approach has several strengths. The investigators were a cross-disciplinary group, including gerontology, nursing, public health, medicine, clinical psychology, library science, and physical therapy. Having such a cross-disciplinary group facilitated the interpretation to be more interdisciplinary in nature (Paterson et al., 2009). Such interdisciplinary knowledge is often needed for public health or policy progression that also considers methodological, epistemological, and ontological orientations. Our study adds a missing perspective to the field of mobility as it articulates what has been previously discerned about community-dwelling older adults’ perceptions of mobility. This new perspective of “mobility as part of the fabric of older adults and their lifetime story” provides empirical support for the ecological framework for mobility (Webber et al., 2010). This framework can be used to guide future research of mobility, generate new hypotheses, and assist in the development of mobility assessment and screening for testing in large population-based research efforts. As a “collage of meaning” (Kinn, Holgersen, Ekeland, & Davidson, 2013), our results emerged from the synthesis of 12 discrete qualitative studies and a critical dialogue across disciplinary, sociopolitical, and contextual landscapes within our team and [Centers for Disease Control and Prevention’s Healthy Aging Research Network] to which we belong. The literature examining perceptions of mobility among older adults is relatively small and our synthesis can help point to needed research endeavors. We have identified a number of areas that are particularly in need of examination. Specifically, although there was diversity across the study populations in the 12 studies, we see a need for more descriptive studies on different race and ethnicities with larger samples. Such research would include the testing of the ecological framework for mobility across diverse populations. Also, this literature would benefit from similar research focusing on middle-aged adults. Although most of the work has examined mobility conceptualized primarily around fulfilling basic daily tasks, it needs to be complemented with research examining mobility for engagement in more leisure and social activities.

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Box . Continued Terms]

OR

“Gait”[MeSH]

Terms]

OR

“automobile

Topic]

OR

OR

Major

“Movement”[MeSH:noexp]

“Locomotion”[MeSH:noexp] Activity”[MeSH:noexp] “Dependent

“bicycling”[MeSH

driving”[MeSH

OR

OR

“Running”[MeSH]

Ambulation”[MeSH]

Limitation”[MeSH]

OR

OR “Motor

OR

OR

“Mobility

“Wheelchairs”[MeSH]

OR

“Self-Help Devices”[MeSH:noexp] OR “canes”[MeSH Terms] OR “mass transportation”[All Fields] OR “mass transit”[All Fields] OR “public transportation”[All Fields] OR “railroads”[MeSH Terms] OR “subways”[All Fields] OR “buses”[All Fields] OR “railroads”[All Fields] OR “subway”[All Fields]

“Perception”[MeSH:noexp] OR “Self Concept”[MeSH] OR

“Awareness”[MeSH]

OR

“Health

Knowledge,

Attitudes, Practice”[MeSH] Note: MeSH = Medical Subject Headings.

Funding The Center for Disease Control and Prevention (CDC) Healthy Aging Research Network is a Prevention Research Centers program funded by the CDC Healthy Aging Program. Efforts were supported, in part, by cooperative agreements from CDC’s Prevention Research Centers Program: U48-DP-001921, 001938, and 001911.

Acknowledgments This publication is the result of work conducted by the CDC Healthy Aging Research Network. The contents of this publication are solely the responsibility of the authors and do not necessarily represent the official views of the CDC.

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