Principal barriers to health promotion program participation by older adults.
Abstract: The aim of this study was to determine the principal barriers to participation in health promotion programs for older adults using three samples of subjects: program participants, non-participants, and administrators of retirement facilities and senior centers. Results showed that the main barriers to program participation for older adults were health issues, time constraints, and fear of exercise. The main reason for not participating was lack of confidence in, and unfamiliarity with program personnel. Suggestions for improving recruitment included enhanced advertising of the program and the provision of substantive and relevant program descriptions including clear and complete credentials of the program providers.
Subject: Physical fitness
Aged
Physical fitness for the aged
Authors: Wright, Tim J.
Hyaner, Gerald C.
Pub Date: 01/01/2009
Publication: Name: American Journal of Health Studies Publisher: American Journal of Health Studies Audience: Professional Format: Magazine/Journal Subject: Health Copyright: COPYRIGHT 2009 American Journal of Health Studies ISSN: 1090-0500
Issue: Date: Wntr, 2009 Source Volume: 24 Source Issue: 1
Topic: Event Code: 242 Advertising Advertising Code: 52 Advertising Activity
Accession Number: 308743749
Full Text: INTRODUCTION

The identification of barriers to participation in health promotion, disease prevention programs has been a significant topic of research in recent years. Rimmer et al. (2002) determined that perceived barriers could influence a substantial number of potential subjects from participating in health promotion programs. They found that up to 72.5% of African American women with Type 2 diabetes would comply with a 12-week health promotion program that addressed nutrition and health behavior. However, this was only possible if the perceived barriers of 1) lack of transportation, 2) cost, and 3) lack of motivation to commit were mitigated. Additional research in the areas of HIV support group participation (Walch, Roetzer, & Minnett, 2006), participation in clinical trials (Gaul et al., 2006; Nguyen et al., 2005; Mills et al., 2006), participation in physical activity programs (Chinn et al., 2006; Dwyer et al., 2006; Allison et al., 2005), participation in food stamp programs (Algert, Reibel, & Renvall, 2006), and compliance with self-management for chronic pain (Austrian, Kerns, & Reid, 2005) have all identified perceived barriers and their effects on the levels of participation.

Among older adults, barriers have been examined in populations of older Koreans (Han et al., 2007), and Chinese subjects (Kwong & Kwan, 2007). The barrier research has involved acute care settings (Penney & Wellard, 2007), and those with cchronic disease (Rothman et al., 2007). Barriers to compliance with prescription drug therapies was also a topic of research in older adults (Rothman et al., 2007; Wilson et al., 2007; Abughosh et al., 2004; Ellis et al., 2004; Eagle et al., 2004; Avorn et al., 1998).

In older adults, barriers to participation in health promotion programs (Kwong & Kwan, 2007), and health promoting behaviors (Padula & Sullivan, 2006; Belza et al., 2004; Lucas et al., 2000) have been delineated. To date, researchers have found a variety of barriers unique to older adults. The majority of the barrier research in older adults involved only those subjects who elected not to participate or comply with a protocol.

PURPOSE

The qualitative study described herein sought to discover barriers to an educational health promotion program that specifically aimed to reduce cardiovascular disease (CVD) risk in a population of older adults (aged 65 to 88). The program that was developed was used to differentiate between program participants and non-participants so that the reasons for participating, and the perceived barriers to participation, could be explored.

This study implemented a novel program that was free of financial cost to participants and specifically addressed the barriers previously cited in the literature. The program utilized a unique educational process called the Swedish Study Circles (SSC). SSC uses a progressive format where individuals are free to share their own knowledge and thoughts on a topic over a period of four hour-long sessions. After the program was implemented, we were able to assess the perceived barriers to participation by interviewing those subjects who participated, non-participants, and a cohort of residential administrators who typically implement similar programs for the older adults in their care.

METHODS

Qualitative methods were adapted for this study in order to learn as much as possible from a small sample size by soliciting in-depth commentary. Meetings with administrators at the various research sites led the researchers to determine that there would be few older adults willing to commit to the interview procedures. The projected number of subjects would not provide the statistical power to analyze quantitative data. Also, the qualitative methods allowed researchers to probe for barriers that have not been described in the literature. The study involved structured person-to-person interviews with administrators, non-participants and program participants from 3 residential housing facilities and a community Senior Center. Criterion-based sampling was used in the selection of the subjects for the three above mentioned groups. The subjects in the administrator group were involved with program promotion or direction in the residential facilities specifically designed for older adults. Administrators were deemed to be experts in interacting with older adults. Administrative positions for the participants included activities directors, educational directors, and wellness coordinators. Despite the broad range of job descriptions, the subjects in the administrative group would have a substantial influence on the implementation of the health promotion program.

Subjects in the participant and non-participant groups for this study were older adults over 60 years of age living in housing facilities or utilizing Senior Center or other older adult focused services in a Midwestern city surrounded by farmland communities. The non-participants were subjects that were invited, but did not participate in the initial program. Participants completed the entire initial program.

DATA COLLECTION

This study employed a person-to-person structured method of data collection. The structure refers to the fact that the questions that were asked of the subjects were predetermined and they were asked in the same order to each of the subjects.

The participants were recruited via e-mail and convenient meeting times were established. The participants were informed of the entire process and that the sessions would be recorded. All procedures were approved by a university institutional review board.

The interview questions included:

1 What, in your opinion are some personal issues that would keep an older person from participating in the Healthy Heart Program or other programs of this nature?

2 What are some facility regulations/operations that would limit an older person from participating?

3 Why, if at all, would you choose not to promote a program of this nature in this facility?

4 What are some program qualities that would lead you to not promote a program?

5 What are some positive qualities that would make a program more attractive?

6 What could we as researchers do differently to make participant recruitment more effective in this facility?

The study subjects were then contacted by email and/or follow-up telephone calls. Participants were asked if they would be willing to participate in an interview that would take no longer than 30 minutes. They were also informed of the procedures for data collection, the fact that the interview would be audio-taped, and the general purpose of the research. The recorded sessions were then transcribed and analyzed for emergent themes.

DATA ANALYSIS

The process of data analysis that was used for this study was verified at each step by an expert in qualitative methodology in order to ensure accuracy. All interviews were transcribed using the Microsoft Word software so that the answers to the interview questions could be written, verbatim, into three separate documents for the purpose of the data analysis. Each of the three documents would represent either the Participants, the Non-participants, or the Administrators. The three separate documents would serve as the raw data for the study.

The raw data were entered into the INVIVO 7 software package that is specifically designed for the organization and analysis of qualitative data. The three documents that were entered into the program were treated as separate projects and thus were not analyzed as components of a larger dataset. The purpose of this type of data entry was to treat each group of participants as a separate study group for the purpose of comparison.

After each of the documents was entered into INVIVO 7, the process of open coding commenced. The raw data were examined and any statements unrelated to the research questions were expunged. Pertinent information was then organized by placing statements into categories or nodes. The nodes served as the thematic categories that would later comprise the basis for the study results. Each of the nodes had specific inclusion criteria that would allow the researcher to decide whether or not to include a pertinent statement in that particular node.

After the initial open coding was completed by the lead author, data verification was performed by an external reader in order to ensure the trustworthiness and credibility of the data (internal validity). The external reader was not involved with the data collection process or the study as a whole. The external reader was given a list of nodes which included the inclusion criteria for each node and a brief explanation of each node's significance. The external reader was also given the complete transcripts of all three subject groups with the pertinent statements highlighted. The external reader was able to take the pertinent statements and categorize them in the nodes that were deemed appropriate independent of the categorization conducted by the researcher. The categorized statements were then compared to the researcher's categorization. An acceptable percentage of agreement between the researcher and the external reader was set at 80 percent.

In the non-participant dataset, there was a total of 251 statements supporting 26 nodes with a 90.8% agreement. In the participant dataset there were 257 statements accompanied by 29 nodes and a 92.6% agreement. The administrator dataset had 363 statements and 31 nodes with a 95.2% agreement.

After the open coding and the verification was complete and the initial nodes were established, the statements with their corresponding nodes were examined and categorized into groups or hierarchies that would serve to address the research questions. The pertinent statements were tabulated for each of the hierarchies and the consistent themes were identified.

After the tabulation of the pertinent statements and the initial categorization into hierarchies was complete, flow charts were constructed to arrange the data into a more understandable and usable format. The flow charts were constructed to address each of the research questions and each of the individual charts included data for Participants, Non-participants, and Administrators.

RESULTS

ADMINISTRATORS

Administrators were asked the same questions, however, the word "participate" was changed to "promote." Eleven total subjects comprised the administrative group. There were 4 males and 7 females. The mean age of the administrative sample group was 48.4 years (range = 24 to 84).

NON-PARTICIPANTS

Thirteen total subjects comprised the non-participant group. The non-participant group had a mean age of 77.0 (range = 73 to 88).

PARTICIPANTS

Thirteen total subjects comprised the participant group. The non-participant group had a mean age of 80.7 (range = 65 to 88).

For the results, the consistent themes in all three datasets were identified for the purpose of triangulation.

BARRIERS

Several of the themes identified by the administrators agreed with themes that emerged from the older adults. All three groups identified health issues, time issues, and fear of exercise as barriers to health promotion program participation. The main areas of health concerns were general fatigue, lack of mobility, and the presence of other chronic diseases such as Type 2 diabetes and arthritis.

Administrator: Um, health issues of their own, you know they get up, I just don't feel good today, it's just too much of an effort.

Non-participant: Well, yeah, if they're not up to it, if they're already got to a point where they need it so bad that they can't get there, you know, that's a problem.

Participant: I benefit from you know feeling pretty good, I don't have pain with my disabilities. But people who have pain, you know, wouldn't be motivated to go and sit for an hour.

Timing issues included the time of day, scheduling issues, and the lack of desire to learn new information or inability to make a time commitment.

Administrator: And you know, the timing of the day, I mean, I know our seniors come in fairly early in the day like 8:30, 9:00, 9:30, you know right around that hour is when a lot of our seniors come in to the center, usually if you come around 2:30, they're gone, they've gone home for the day.

Non-Participant: I, I would say that if it involved a lot of time, I would not be interested, my plate is full. Let's see, well, time would be the biggest thing.

Participant: The only reason that I can think of that people wouldn't participate is time, because I'm not from this area, I have lots of time, but people who are not from this area still have their old activities plus all of the new activities that we get when we come here and so they're overwhelmed with choices of things to do.

REASONS FOR NOT PROMOTING/PARTICIPATING

Administrators were not asked to participate in a health promotion program but they were asked to promote the CVD risk reduction intervention. The investigators' request for reasons why a program would not be promoted by administrators corresponded with the question that asked the older adults for reasons why they would not participate. The consistent theme for not participating/promoting between the three groups was the hesitation to trust the program planning and implementation personnel. The reasons for the issues were different for each of the groups. Participants did not want unfamiliar people implementing these programs.

Participant: Well, if I didn't know who was doing it, um if I didn't know if it was going to be done well and be worthwhile.

Non-participants wanted to feel that they could have confidence in, and trust the health promotion program personnel.

Non-participant: I would want to be able to trust the people that I was working with and feel that what was being done was important. Anything that made me feel like that was not the case then that would tend to make me say "don't bother me, that it's not worth the time."

Administrators felt that they would not want to associate with personnel that had a separate agenda such as sales or other motive inconsistent with the goals of the health promotion program.

Administrator: If I thought that the person, like if I thought that you came in and you had an agenda that was not going to benefit the residents, that's what would keep me from supporting it.

POSITIVE PROGRAM QUALITIES

There was a consistent theme in the three groups concerning positive program qualities. The ideal program had honest, trustworthy, familiar personnel with no obvious agenda to sell products to the older adults.

Non-participant: Well, I think that any program that I participate in I'd like to feel that there are really competent people doing it so I'm not wasting my time or even getting erroneous information and I would want to have the perception that they're being honest with me.

Participant: I would certainly like to feel that the people putting on the program were credible and I'd like to feel that they were well prepared when they come to do whatever it is that they are going to do and um, yeah I would feel like that is a big factor.

In this area, the administrators added the qualities of a university affiliation, and the level of involvement of the personnel with the older adult participants. The administrators wanted to feel as though the program personnel were highly involved in the entire program process. They did not want the program to be the responsibility of the facility staff. The administrators also felt more comfortable knowing that the program had a university's formal "stamp of approval."

Administrator: Program that has a teacher that builds some rapport with the participants, because I think that's important also that they want to come to work with that specific person, um, probably, kind of with [the University] connection, I think that people like to know that there are researchers that are thinking or looking at the effects of a larger program.

IMPROVEMENTS

There were themes that were consistent for all of the groups regarding suggestions for program improvements. All three groups felt that there was a need for more informative advertising.

Administrator: Um, one on one, you know, go you know I mean, a lot of seniors some will listen to the radio, some will read the paper and some watch TV news and stuff like that. Um, if you've thought of going on TV and talking, they are usually very happy to have people to come on and talk, I don't know if you've thought about that.

Non-participant: I've wondered about the advertising, somebody was doing studies at [the University] and they were looking for post menopausal women and they were looking at how do you advertise this, I know they were passing out flyers and things.

Participant: Well, you could do some kind of advertising you know, have some kind of pamphlet saying we would like to have people meet and discuss whatever it is and get their ideas and give them ideas of perhaps how we could help them.

The need for more information was also an important theme.

Non-participant: Well, making the information available and getting the information to them I think would be imperative.

Participant: I think as long as you explain why you're doing it, what you're doing and why you're doing it, most people would be willing to participate.

But just make known why you're doing it and what you're looking for.

The administrators believed that advertisements should include reminders about the program and its important dates, coupled with the additional personal contact of the presenter with the population-s of-interest. The information that is needed should be simple and age appropriate for the older adults.

Administrator: If you want to provide something in a written way that could be distributed we could do that. Um, posting it on the bulletin board if it is several pages long won't get it the attention that it needs. Almost need to have it a brief as possible and enough pages that we could circulate it to all of the apartments, we have 80 some residents.

DISCUSSION

REDUCTION OF BARRIERS

Researchers and program developers must mitigate perceived barriers in order to increase program participation. In previous studies there have been efforts to decrease perceived barriers reported by older adults. The majority of barrier reduction efforts focused on increasing awareness of the possibility of modifying morbidity or mortality related to a particular health risk. Using the Health Belief Model (HBM) as a framework, an awareness of the health risk might influence an older adult's perceptions of the susceptibility and severity of a disease outcome. Folta et al. (2008) found that women were somewhat aware of their risk of CVD, but they thought that it was something that they could overcome themselves without help from others. They reported that interventions should be implemented as awareness of a health issue increases. Without awareness, there may be no interest in the topic of the intervention. Cataldo (2007) examined the perceptions of smoking behavior in older smokers and the nurses who cared for them. Cataldo (2007) found that there were myths associated with tobacco use accepted by older smokers as well as the nurses. Nurses and older smokers believed that smoking could improve cognition and mood for the older adults and that the benefits of smoking cessation would not exceed the risks for the older smokers. Yardley et al. (2006) found that older adults were unaware of the fact that they were at a higher risk of falling and were therefore less likely to participate in fall prevention interventions.

Using the HBM as a framework, detailed information must precede program implementation in order to increase an older person's perception of program benefits and decrease the perception of program barriers. The increase in information on the program topic may also serve to increase perceptions of program value as well.

The health promotion program in this study addressed the physical and intellectual dimensions of health because it was educational and the topic was chronic disease prevention. The novel format also contributed to the social or interpersonal dimension of health because of the interaction with peers. If older adults did not value these dimensions of their health, then they may have been less likely to participate.

Helping older adults to realize that they are in much greater control of their health than they perceive may elevate their internal locus of control (ILOC). Frieswijik et al. (2006) used written information to increase moderately frail older adult's self-management ability. They reported that simple in formational interventions may be useful additions to other, more complex interventions for older adults. Increasing the ability to care for one's self would imply an increase in ILOC which would also be related to increases in self efficacy.

Increasing ILOC and self-efficacy may involve renaming terms that invoke fear in older adults. For instance, administrators stated that exercise programs had to be "disguised" to make them less fear-invoking. Participation in dance, for example, would support physical activity, but would likely not be associated with the term "exercise" which was viewed negatively. Older adults may have low ILOC and self-efficacy associated with exercise, but they may have high ILOC and self-efficacy for dancing because they have higher confidence in their ability to engage in the activity without risk.

Participation in games was very attractive to the older adults in this study. Taking the educational components and modifying them to present as a quiz game may improve participation because older adults may have higher perceptions of control and confidence associated with playing games. Team games also contribute to enhanced social support and the interpersonal dimension of health.

IMPROVEMENTS FOR INTERVENTIONS

The topic for the initial program for this study, CVD risk reduction, was chosen by the researchers. This topic was a logical selection as CVD was the leading cause of morbidity and mortality in our population-of-interest. Regardless of the importance and impact of CVD in older adults, if there is minimal interest in the topic, there will likely be little participation. Paquet et al. (2005) examined the differences between the needs expressed by patients in cardiac rehabilitation programs and the actual care that they received. Through qualitative methodology, they found that there were considerable differences in the needs expressed by patients and the actions of the hospital staff. Programs needed to shift their focus from exclusively promoting healthier behaviors to addressing the patient's perceived needs. Effective planning requires active input from the population-of-interest preceding program implementation.

PRECEDE MODEL

Planning health promotion programs for older adults would benefit from the use of the 5-step Predisposing, Reinforcing, Enabling Constructs in Educational/Environmental Diagnosis and Evaluation (PRECEDE) model of intervention planning as described by Green & Kreuter (1991). This model has been used in older adult populations in evaluating programs for fall prevention (Bonner et al., 2007), implementing health education programs (Imamura, 2002), and predicting screening behavior (Black et al., 2001). Not all of the steps of this model were adopted for the planning of the health promotion program for this study. The first step in the process is the social assessment which examines the older adult's perceptions of their own needs. This can be done through interviews with a sample of the population-of-interest. A comprehensive social assessment was not conducted for this study which may have influenced the non-participants.

The planning for the initial program study began with the second step of the PRECEDE model which was the epidemiological assessment. Epidemiological data on the prevalence and incidence of CVD in the U.S. older adult population was used to determine the topic for the program and was the basis for the topic selected for the older adults.

The third step, a behavioral and environmental assessment, insures that the intervention is appropriate for older adults. The health promotion program for this study sought to influence the behavior of the population of interest by increasing knowledge of risk, however, an assessment of the health behaviors of the population before implementation may have allowed the program to be more focused on the perceived needs of the older adults and therefore increased participation.

The identification of the predisposing, reinforcing, and enabling factors that act to increase the chances of behavioral changes is the fourth step of the model. Assessing issues such as motivation, attitudes, knowledge, beliefs and rewards would give a program a baseline of variables for post-intervention evaluation.

Step 5 of the PRECEDE model, the administrative and policy assessment was used in the planning of the health promotion program. Meetings and interviews with facility administrators established the plan for the program. The program plan, access to the older adults, and suggestions for effective implementation were all discussed with each individual administrator before the implementation.

Researchers may develop interventions for older adults based on their professional experience, contemporary trends, or epidemiological evidence, but this does not necessarily insure participation by older adults. To properly plan a program or intervention all steps of a model like the PRECEDE model would help to insure that the perceived needs of the older adults were being addressed.

PEER EDUCATION

Peer education was the basis of the health promotion program for this study, but the methodology could also be used to assess need in the population-of-interest. Because of our findings that there was hesitation to trust the program personnel which seemed to hinder program participation, program improvements should be made using members of the population-of-interest during the planning process. Often, program personnel are unfamiliar to the population-of-interest, therefore planning efforts should utilize influential older adults. The Swedish Study Circles (SSC) format seemed to be an effective method of increasing knowledge, but also may have been effective in the planning of other, larger interventions. The SSC format, as described by Strombeck (1991), was intended to be an educational intervention in this study, but it seemed optimal for planning as well. Indeed, SSC could be used to identify quality of life variables, which is the first step in the PRECEDE model. This is because of the freedom to share ideas, beliefs, and thoughts on various health topics with other older adults. SSC facilitators could then take the ideas generated in the sessions to the researchers and program planners for their consideration in planning other interventions. In the SSC format, there is limited contact between older adults and researchers thus reducing this perceived barrier while at the same time, assessing the perceived needs of the population.

ADVERTISING

All three of the study groups stated that more advertising was needed to improve participation. New innovations in advertising such as e-mail and text messaging via cellular telephones may be used for current and future populations of older adults. The majority of older adults in this study had computer access and they used the computers mainly for the purpose of sending and receiving e-mail. Several of the facilities had computers located in common areas that were used by residents. Because of this, e-mail reminders may be a useful method of advertising to increase participation. Text messaging may be a future means of communication but the use of cellular telephones is not as prevalent as the use of computers in these facilities. As mentioned previously, the administrator group felt that advertisements should not simply be in the form of flyers in mailboxes. The flyers should be posted in high traffic areas for maximum exposure.

Regardless of the method of advertisement, all groups believed that the advertising needed to have specifically tailored information for the population-of-interest. Tailoring can follow the Transtheoretical Model by Prochaska (1979). The information needs to be tailored for both people who are ready to take health promoting action and those who are contemplating action. If the information is not tailored, the population-of-interest may not participate.

The major limitations of the study included the lack of random sampling, small sample size, and the homogenous nature of the group of subjects. Any older adult that was willing to be interviewed became a study subject. Participation in the study interviews, and the initial program was purely voluntary and therefore, one must be careful when making inferences to the general population of older adults based on the study findings. However, the small sample size accurately illustrated the presence of barriers in older adult populations. The sample that emerged was homogenous, but typical of older adult populations in small Midwestern urban and rural communities. The older adults lived in close proximity to one another and varied widely in socio economic status.

This study and its methods may provide helpful insight into the planning and development of health promotion programs for older adults. The use of qualitative methods allowed for the acquisition of in-depth commentary by the population-of-interest on barriers to participation in these types of programs. We concluded with suggestions from our findings and the literature on ways health professionals can plan effective health promotion programming for this rapidly growing segment of our population.

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Yardley, L. Bishop, F. L., Beyer, N., Hauer, K., Kempen, G. I., Piot-Ziegler, C., Todd, C. J., Cuttelod, T., Horne, M., Lanta, K., & Holt, A. R. (2006). Older people's views of falls-prevention interventions in six European countries. Gerontologist, 46, 650-60.

Tim J. Wright, PhD, is a Senior Lecturer in Health Education, University of Wisconsin-Stevens Point. Gerald C. Hyner, PhD, is Professor of Health Promotion; Director, Gerontology Program; Associate Director, Center on Aging and the Life Course, Purdue University. Please address all correspondence to: Tim Wright, Ph.D, Department of Health, Exercise Science, and Athletics, 2050 4th Ave. Stevens Point, WI, 54481, University of Wisconsin-Stevens Point. (TEL): 765-714-7042. Email: Tim.wright@uwsp.edu.
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