4.7 Discussion 90
4.7.2 Connecting exercise and self-care to context and characteristics 92
The research setting, participant demographics and shared values, beliefs and behaviours demonstrated possible influences on older adults’ perceptions and experiences of exercise as self-care. Bjornsdottir, Arnadottir, and Halldorsdottir45 concluded that physiotherapists needed to be keenly aware of the impact of social and physical environmental influences
when promoting exercise as a means to self-care. Furthermore, examining older adults’ values, beliefs, and behaviours related to exercise as self-care, is thought to provide important insights for efficacy of therapeutic exercise interventions prescribed by physiotherapists. 58 The following sections integrate the findings of this study with previously cited work on behaviours, barriers, values and beliefs to demonstrate the influences of these factors on exercise participation.
4.7.2.1
Influence of the setting on exercise and self-care
The centrally located community centre held a gym and ran programs specifically marketed to older adults residing in the community. Participants spoke to the importance of having sidewalks, trails, and relatively flat terrain, as making it easier for them to walk around town. These elements of the setting could be considered motivators or facilitators of exercise participation, where these findings are comparable to literature on older adults’ perceived barriers to exercise participation. Specifically, the lack of available or accessible sidewalks, parks, and fitness/recreation centres or programming are considered barriers to exercise participation for older adults. 26, 45, 47, 51 Unfortunately, there were elements of this setting that echoed published perceived exercise barriers for older adults including the lack of public transportation. 26, 30, 45, 47, 49, 51 The lack of public
transportation was a frequently cited barrier for participants who could not access local services due to impaired mobility (unable to walk the distance) or were unable to drive. Given there was no local, publicly funded, medical walk-in clinic, and the nearest hospitals were in the neighbouring towns, some participants might not have received regular exercise counselling or feedback on their health status.
The lack of exercise counselling from a physician is another commonly cited perceived barrier to exercise participation for older adults. 26 With the exception of two participants who indicated their physician as the individual who spurred them onto exercise in
response to their health events, it was not possible to know whether participants received regular exercise counselling from physicians, because it did not come up in the interviews or participant observations. The community centre hosted regular educational lectures with local experts, and served as a meeting place for festival organizers, and members of a meditation group. However, participants did not speak to programming offered by the
community centre as a source of information concerning the link between chronic disease symptoms and exercise. The local pharmacist, chiropractor, and family physicians could have been potential resources for exercise counselling as well, but participants did not mention these resources as sources for exercise counselling either. Sufficient exercise counselling within the context of chronic disease self-management is an important consideration given Canadian researchers Smith and colleagues52 reported that older adults did not relate their chronic disease symptoms to their perception of their own health status even though their chronic disease was determined to be a significant barrier to exercise participation. 52 Future research could examine potential partnering
opportunities between the community centre and health care practitioners, such as the local pharmacists, family physicians, and chiropractor with respect to provide exercise counselling.
4.7.2.2
Influence of demographics on exercise and self-care
When compared to existing literature, it is reasonable to believe that the participants’ ages, number of chronic diseases, and level of education could have had an impact on participant’s shared values, beliefs, and behaviours, and what they perceive and enact as exercise and self-care. The majority of participants were in their seventies. Therefore, participants lived and grew up in this or another rural community may have shared an upbringing similar to other rural-residing older Canadians of the same age group. Specifically, participants may have grown up in a sociocultural context that strongly valued work activity, with diminished priority for leisure-time physical activity following retirement; 26, 37-39 in a place where exercise participation was not considered a common practice, 45 or with no experience of regular exercise. 26, 40-42 Although all participants were living in the rural community at the time of study, some grew up in other areas of the province or even out-of province and in urban settings. All participants engaged in some form of regular physical activity, from walking in apartment hallways with a walker to walking 13 km daily along a wooded trail. The fact that so many of this sample
reported having regularly participated in exercise implied there was motivation among this group to engage in exercise. Findings from the interview transcripts revealed that this motivation or rationale was not necessarily self-care given the previously stated
disconnect between an understanding of exercise and self-care for chronic disease. The majority of participants were living with two chronic diseases, but had few mobility impairments. Similarly, 70% of older Canadians are reported to have at least one chronic disease,and 49% of older Canadians were found to live with two or more. 1 However, a physiotherapy study on therapeutic exercise program participation among older adults with systemic diseases, trauma and postoperative conditions, or back, neck or shoulder pain57 found that type and number of chronic illnesses were not significantly related to exercise participation. However, the authors did note that older adults with greater disability due to illness were more likely to participate in the therapeutic exercise
program than those with less disability. The same article demonstrated that a higher level of education was significantly related to lower exercise participation among women, but not among men. 57 The majority of participants from this study completed at least some post-secondary education. Future research could explore correlations between
perceptions of exercise and self-care, and exercise participation among this group.
Participant demographics aside, shared values, beliefs, and behaviours can further explain participants’ perceptions and experiences of exercise and exercise as self-care, and
provide important insights for therapeutic exercise interventions prescribed by physiotherapists. 58
4.7.2.3
Influence of shared values, beliefs and behaviours on
exercise and self-care
Independence, a sense of community, and being with others were shared, important and defining group characteristics or values, beliefs, and behaviours. These group
characteristics are known to be defining features of older adults across rural Canada2 and in this study were found to influence self-care and exercise behaviours, as touched on throughout the Findings, summarized in Figure 1, and discussed further below. These shared characteristics align with findings from a large focus group study with
community-dwelling older adults who described ``being healthy” as including “functional independence, self-care, management of illness, positive outlook, and personal growth and social contribution”. 13(p.249) The participants from the present study valued independence as functional capacity and self-reliance or not needing help from
others. When compared to the findings from Miller and Iris 13 one can argue that the value of independence or functional independence is an important consideration with respect to understanding what this group perceives as health and exercise or even
exercise as self-care. In Miller and Iris13 functional independence was operationalized as taking responsibility for and carrying out one’s own usual activities while avoiding help from or dependence on others. Social contribution was described as giving of ‘oneself to others’ through sharing with peers their knowledge and skills pertaining to health and health behaviours. 13 Social contribution aligns with the sense of community found in the present study, where participants described a strong sense of community through their stated value and belief in the importance of helping others.
In the present study, being with others was a source of enjoyment, motivation, and safety while exercising. Given this explanation, being with others could also be referred to as social support or an important form of social influence. Drawing the link between being with others and social influences is important given that social influences are known to have important, positive effects on exercise. 77 For example, Hill and colleagues 53
demonstrated that older adults were more likely to engage in therapeutic exercise prescribed by a physiotherapist, if they lived with a partner. Participants from this study also described being with others as a source of safety while exercising. This is an important finding that could begin to explain how physiotherapists could help older adults navigate a commonly cited barrier to exercise participation among older adults, which is fear of falling or re-injury. 26, 30, 47-49, 51 Where being with others was also reported as a source of enjoyment and motivation, being with others could be described as a source of confidence or self-efficacy, as described in Social Cognitive Theory (SCT). Specifically, learning from peers through modeling behaviour (known at vicarious
experience) or encouragement from peers to go for a walk or to the gym (known as social persuasion) could have been the mechanisms for motivation, as described by participants. Being with others provided enjoyment, which could have positively influenced self- efficacy through positive physiological state. 24 Specifically, if an individual engages in exercise and has a pleasant experience, their confidence in their ability to perform that activity is increased. However, an individual may exude lower self-efficacy for exercise after s/he had an unpleasant exercise experience or had stayed home because they had no
one to walk with. Understanding confidence is important when designing therapeutic exercise programs.48Highlighting the link between confidence, being with others and enjoyment begins to explain how this study provides a contextual example of the importance of making therapeutic exercise programs enjoyable and familiar for older adults.