Introduction

Regular physical activity (PA) in older adults, those aged ≥65 years old, is robustly promoted by the World Health Organisation (WHO) [1]. Plethora of research have shown physical activity leads to risk reduction in a wide variety of co-morbidities such as type 2 diabetes mellitus [2], breast [3, 4] and colon cancer [3], and hypertension [5]. The range of PA advocated includes muscle strengthening, improving balance and 150 minutes of moderate intensity aerobic activity throughout the week. The updated UK Chief Medical Officer’s Physical Activity Guidelines published in 2019 echoes very similar messages to those of WHO [6]. However, given the emergence of new data indicating that a small amount of PA can show beneficial health effects [7, 8], the 2019 UK guideline has shifted away from recommending a minimum amount of time to exercise. In the section dedicated to people ≥65 years old, it emphasises “some physical activity is better than none: even light activity brings some health benefits compared to being sedentary” [6]. This shift in message may have a significant impact on how older adults view PA.

The level of PA participation in older adults is low; in 2016 the Health Survey for England reported that 67% of adults aged 19–64 years met the aerobic activity guidelines (71% of men; 63% of women) whereas only 44% of adults aged ≥65 years (48% of men; 41% of women) met the target [9]. Therefore, it is paramount to understand older adults’ perspectives on participation in PA which then can aid us to develop interventions to promote PA, thus translating its benefits into practice. Previous qualitative research into older adults’ perceptions of PA have tended to focus on structured PA, such as resistance training, balance and strength, and falls prevention programmes [10, 11] and has highlighted a number of influencing factors that can be largely categorised as: physical, social, environmental and psychological [10, 11]. Common facilitators include both physical and mental health benefits deriving from being physically active, and encouragement from peers, family and support networks [10, 11]. Frequently cited barriers to exercise include physical limitations due to pain or existing medical conditions [12, 13], and lack of motivation [13, 14]. A number of psychological factors have been strongly linked with higher levels of general PA and exercises in the older adult population, including high self-efficacy, positive thinking, and motivational internal thoughts [15–17]. In their review, Cavill and Foster focused on qualitative studies and previous reviews that investigated the barriers and facilitators to participation in strength and balance activities, having found specific motivators including reducing the risk or fear of falling, and preventing deteriorating and disability, and specific barriers including the perceived risk of a heart attack/stroke or death and fear of looking too muscular [10].

A UK qualitative study looked into older adults’ experiences of successful PA interventions and what would influence exercise adherence at a population level and found PA being “enjoyable, sociable, affordable, accessible, flexible and seasonal were more important than the health benefits” [18]. Other qualitative studies on PA in community living older adults have focused on various influences such as the impact of neighbourhood deprivation in New Zealand including environmental influences, such as the local community and levels of traffic [19], or cultural influences in older Mexican women living in the US, for example in terms of gender expectations [20]. There have been some studies on older adults’ perceptions of general PA, which can incorporate a wide spectrum of activities such as household chores, non-structured PA including walking, and hobbies [21–23]. In a recent systematic review of qualitative studies on older adults and PA, the principle finding suggests the biggest drive for PA is how it contributes to a purposeful and fulfilling life [24], rather than the health benefits. We had unique access to a group of UK community-dwelling older adults, i.e. older adults who were living in their own homes. The objective of this focus group study was to increase our understanding of factors that can affect older adults’ general participation in all types of PA and to identify potential opportunities for effective intervention to promote PA in this age group; a secondary aim was to explore any gender differences in factors affecting PA participation.

Methods

Results

Focus group characteristics

Eleven focus group (FG) discussions were conducted with 92 participants, 47% were women, their mean age was 78 years, all were white British and living in their own homes. Table 1 shows the descriptive characteristics of the study participants, as assessed in 2011. Discussions lasted between 75–99 minutes (mean = 90 minutes).

Download:

• PPT
  PowerPoint slide
• PNG
  larger image
• TIFF
  original image

Table 1. Descriptive characteristics of focus group participants (n = 92) (data collected in 2011).

https://doi.org/10.1371/journal.pone.0263050.t001

Thematic analysis

Six overarching themes were identified through the process of thematic analysis: (1) past life experiences, (2) significant life events, (3) getting older, (4) physical activity environment, (5) psychological/personal factors and (6) social capital.

These themes are described below, with quotations offered as illustrative examples in Table 2. Quotations are labelled with the number of the focus group and M or W to indicate whether the speaker was a man or woman. We present the findings as they address the primary objective of the study which was to explore what influences physical activity (PA) participation among community-dwelling older people, and where applicable note differences between men and women.

Download:

• PPT
  PowerPoint slide
• PNG
  larger image
• TIFF
  original image

Table 2. Quotations illustrating each of the six themes.

https://doi.org/10.1371/journal.pone.0263050.t002

1. Past life experiences.

Many participants spoke of PA habits or routines from previous life stages, e.g. early life or working life, continuing into older age (quotations 1 and 2). Others had stopped being active in the past for a variety of reasons such as busy lifestyles (e.g. work or raising a family), a new medical condition or event that impeded PA participation, and had not resumed their activity later in life, or because of they had aged (quotation 3).

2. Significant life events.

This theme includes major events that are common in later life, which may present particular challenges to older people’s daily routines and habits.

2.1. Retirement. In this cohort of older adults, men were more likely to mention retirement, than the women. This perhaps reflects the generation where the men tend to be the main earner for the family than the women. Therefore, it was noted the men were more likely to mention having more free time or freedom since retirement to participate in pursuits, take up new hobbies, join new organisations, or volunteer. They spoke of the importance of keeping going after retirement and maintaining a routine (quotation 4). Although some enjoyed a busy schedule after having made a complete break from their working life (quotation 5), others had difficulty adapting to the lack of structure post-retirement (quotation 6).

2.2. Bereavement. For both men and women, adjusting to losing a partner included taking up activities that they previously had not done. There were some gender differences in this regard. Men spoke of doing new activities such as housework. For women, losing their husband led to more walking if they did not drive, or less if they used to walk together. Loss of a partner, pet, friend or family member also led to feelings of isolation and loneliness, with some suffering a loss of confidence, or depression (quotation 7); participants spoke of these aspects in the context of discussion around their views on a ‘healthy lifestyle’ and their PA habits, so it appeared likely that they affected their PA, even if in an indirect manner. Women highlighted the importance of having a supportive network, for example someone going through similar experiences (quotation 8).

3. Getting older.

Debilitating health conditions, e.g. joint or heart problems, and the resultant medical events, e.g. hip or chest operations, impacted on activities, physical condition and loss of abilities such as driving or walking (quotation 9). Additionally, some medications caused side-effects like drowsiness. The decline in capability or ability to do certain activities, slowing down due to the natural ageing process and deconditioning of musculoskeletal health were important constraining influences on physical activity (quotation 10).

While some felt physically limited due to a heart condition, for instance, or a major medical event, others were determined to get back to their original capacity and not be prevented from doing the PA they wanted to do. In some cases, a medical condition or event had led them to do specific exercises or to adapt types of PA to suit their current condition (e.g. rehabilitation exercises). Pain and discomfort were barriers to doing PA, with some determined to ‘walk through it’ (quotation 11). Many spoke of maintaining activities despite being stiff and suffering general decline, of slowing down the pace but still continuing to complete the task (quotation 12). Interactions with medical professionals encouraged PA, including some wanting to prove medical professionals wrong (quotations 13 and 14).

4. Physical activity environment.

4.1. Availability of local services and facilities. The discussions revealed varying knowledge with regards to availability of local facilities and activities, for example, some took advantage of regular activities such as walks, some had never heard of U3A (University of the Third Age) and for others it was an important part of their lives (quotations 15 and 16). The U3A is an organisation of locally-run interest groups around the UK that provide opportunities for members, usually individuals who are no longer in full-time work, to engage with others to undertake a broad range of activities together. Some women spoke of a lack of publicising of local organisations and facilities, and women were more likely than men to speak of reduced opportunities suitable for older people, as illustrated in quotation 17, where some felt there was a lack of certain facilities suitable for older people.

Having access to a suitable environment at home or nearby was a motivator for PA, e.g. having access to a garden, parks, and allotments. Some localities had greater availability of facilities than others, and there was mention of a loss of green spaces.

4.2. Accessibility. Availability of transport and having a bus pass offered freedom and pleasurable experiences. While some were reliant on a bus pass, others rarely used it. Some mentioned a lack of local transport, and how not being able to drive was restrictive. Affordability of activities and transport was an issue for some and could mean reduced participation in activities (quotation 18).

5. Psychological/personal factors.

5.1. Mental state. For some participants, their mental well-being, low mood/depression and self-esteem appeared to be important aspects relating to the activities that they felt able to do. Participants also spoke widely of the enjoyment of activities, and the importance of keeping not only physically but mentally and socially active.

5.2. Motivation and maintaining independence. Discussions highlighted the importance of determination, discipline, positive thinking, motivation, independence, and self-efficacy (a belief in one’s ability to undertake an action). There was a strong desire in some not to be restricted, and to keep going in order to remain independent; there was an awareness of ageing, with a fear of stopping being active as it might then be harder to restart (quotations 19, 20 and 21).

5.3. Beliefs and self-awareness. Many were determined to take part in things, to ’not feel old’, and did not want to be perceived as incapable purely due to chronological age, and the importance of interacting with people of all ages as ’that keeps you young’ (quotation 22). Some demonstrated ‘outcome expectancy’ (anticipation of future outcomes as a result of current actions) regarding PA being beneficial for long-term health or longevity (quotation 23). Some mentioned a lack of motivation, perceived as laziness, as a barrier to PA, acknowledging that they ‘should’ do more (quotation 24).

Personal preferences affected engagement with certain types of PA, such as disliking group settings or organised activities, and some suggested alternatives that they would prefer (quotations 25 and 26). Some men said they felt unworthy in some way of joining group activities (quotation 27).

6. Social capital.

Many participants were involved in local or community groups and organisations (e.g. village committees, volunteering, U3A), although some of these were more mentally stimulating than physically challenging. Social aspects of PA and lifestyle more generally were important. Social comparisons were made with peers’ health and PA behaviour. It appeared that behaviours were sometimes motivated by fear resulting from others’ experiences or feeling fortunate to have relatively good health compared to others (quotations 28 and 29). Having a dog was an important motivator for some participants to do PA, particularly as it appeared to function as an incentive to go for walks on a regular basis (quotation 30); moreover, the social aspects of dog walking, including meeting other dog walkers and walking and talking together, appeared to be an important factor for engagement in this activity. Family, friends, and partners were important motivators (quotations 31 and 32) and as a source of social support. However, in some cases they could have a negative impact on PA due, for example, because their role as carers constrained their time. For both men and women, living alone was a potential barrier to social interaction and PA. Women were more likely than men to mention the importance of having helpful or supportive neighbours and community (quotation 33). For some this aligned with a desire to avoid being a burden on family which appeared to be a motivation to keep fit (quotation 34). The role of friends appeared to be particularly important for those who had lost their partner or lived alone, and there was suggestion that activities that are not just couple-oriented might be of importance (quotation 35).

Discussion

This study has highlighted six themes that might affect community-living older adults’ participation in PA: past life experiences; significant life events; getting older; PA environment; psychological/personal factors; and social capital. The first three are largely non-modifiable as they tend to be events that have already happened or over which there is potentially limited or no control, however how an individual responds to these events could be modifiable. The opportunity to optimise the PA environment is likely to require a broader intervention approach and involvement of a multitude of stakeholders, such as local authorities, in order to make meaningful changes. Our analysis proposes the remaining two factors–psychological/personal and social capital partly determine how people respond to largely non-modifiable factors. For instance, those with higher levels of self-efficacy or determination, might be more likely to respond positively to the consequences of ageing and medical events or conditions, by maintaining or increasing their PA. There was a gender difference in response to the loss or serious illness of a partner. Women who had access to and utilised their social network appeared to be more likely to remain engaged in PA. Whereas for men, the loss or serious illness, of a partner led to the need to carry out more household chores, but not to a specific interest in engaging with social activities. Despite approaching the PA data inductively, the same themes and relationships between the themes appeared to hold for the PA data as they did in the published diet findings in this group [27]. Unhealthy lifestyle behaviours including poor diet and low PA levels often co-occur in older adults [31, 32], and we can speculate that the motivations might be similar for both types of behaviour.

The role of psychological and social factors has been identified in previous quantitative studies that have shown leisure time PA to be significantly linked with self-efficacy [15] and improved social, physical, emotional and cognitional function [33]. Specifically, thinking more positively and having motivational internal thoughts have been extensively shown to be associated with increases in older adults’ leisure time PA [15–17]. In a systematic review of 63 studies with adults aged ≥60 years [17], motivation and self-efficacy were the two psychological characteristics that were consistently associated with higher level of routine PA [17]. In our focus groups of community-dwelling older adults we observed variability in psychological and social factors that can affect the response of an older person to an event. This poses an interesting avenue for intervention targets, with health coaching using elements of motivation and self-efficacy to promote healthy behaviours. There is great heterogeneity in what constitutes health coaching [34]. It commonly consists of patient-centred approaches based on a behavioural change model that is delivered by a trained professional. The process often involves patient-determined goals, self-discovery and accountability. The effects of health coaching on level of PA participation in those aged ≥60 years have been found to be small but significant, compared to controls, and it is effective in both older adults with and without chronic conditions [35]. The use of “positive framing” has also been used in older adults in the context of walking; in one intervention study those exposed to “positive framing”, where participants were informed of beneficial effects of walking, were found to walk more steps, after controlling for baseline number of steps walked, than those receiving “negative framing”, where participants were informed of negative effects of not walking [36]. In a weight-loss trial, a motivation-focused programme that specifically targeted motivational factors showed comparable weight loss to the traditional skills-based weight loss programme [37].

The presence of physical limitations or health-related conditions has been found to be closely related with older adults’ perceptions of being able to be physically active [11, 24]. Interestingly in our study we found polarising views on this matter. Some felt that their health-related issues were a barrier to being active, whereas others refused to let medical conditions be an impediment to their participation in PA, therefore making particular efforts to overcome obstacles. Halvarsson and colleagues interviewed older women (≥65 years), with a diagnosis of osteoporosis and either self-perceived fear of falling or who had experienced a fall within the past 12 months, after participating in a balance training programme [38]. The aim of the programme was to improve self-efficacy, balance and physical function [39]. The programme improved participants’ self-perceived empowerment and self-efficacy, therefore resulting in the ability to approach activities of daily living with confidence and to employ risk-reducing strategies to avoid falls. However, the participants’ assessment of risk still remained influenced by their own perception of fragility [38]. Aligning with our study findings, this reflects how some people’s perception of their health is a barrier to be overcome, whereas for others it is insurmountable.

Conclusion

In an ageing population, healthy living is becoming a key concept and this has thrown up new challenges, thus to facilitate the adoption and maintenance of PA the inclusion of the intended users’ perspectives is crucial. This study sought the viewpoints of a group of free-living community older adults who had not been recruited for specific PA related activities or programs. Consequently, PA in its broadest sense was discussed psychosocial factors emerged as key influences, suggesting that interventions that target factors such as self-efficacy and social engagement, might hold potential for promoting engagement in general PA. These findings would aid the development of future interventions and as well as local authority planning for the needs of older adults living in the community.

Supporting information

Acknowledgments

We would like to thank the participants of Hertfordshire Cohort Study who took part in this study.