Participants' Attitudes, Opinions, and Beliefs of a Physical Activity Program in West Virginia

Background

Increasing physical activity levels is a major public health priority in the United States. A large proportion of West Virginia residents may be at risk for being physically inactive given the state's unique demographic profile. West Virginia has the third oldest population in the country along with the highest rates of disability (42.3%) and arthritis (35.5%) (U.S. Census Bureau, 2008; U.S. Census Bureau Population Division, 2005; Centers for Disease Control and Prevention & The Merck Company Foundation, 2007). Thirty-two percent of West Virginia residents report no leisure-time physical activity (Centers for Disease Control and Prevention & The Merck Company Foundation, 2007). Thus, West Virginia is in great need of physical activity programs, especially for its older adult population.

There are over 1,000 community-based, physical activity programs; however, few have been formally evaluated (Sheppard et al., 2003). Quantitative studies have identified the health benefits associated with regular exercise in older adults, including improvements in cardiovascular health, fitness, mood, strength, and quality of life (Slack, 2006). Qualitative research on exercise programs for older adults, however, is sparse (Melillo et al., 1996).

Extension can be a "collaborative partner" in addressing issues of improving health and inactivity (Morgan, 2006), and two such programs have been previously described (Morgan; Rice, 2007). One local program, the Active for Life Program (AfLP), was developed for older adults by the West Virginia University Extension Service. One-hour classes are held three times per week by volunteer instructors and consist of low- to moderate-intensity exercises designed to increase strength, flexibility, and balance. Although originated in 1993, there are no data to support the AfLP. The purpose of the study reported here was to assess the participants' attitudes, opinions, and beliefs of the AfLP using a qualitative approach. The results of the study will be used as part of a broader program evaluation of the AfLP.

Methods

The qualitative study reported here used focus group discussions to explore participants' attitudes, opinions, and beliefs concerning the AfLP. Within the group discussions, the foci included: 1) perceived positive and negative life impact, 2) positive and negative aspects of the Program, and 3) suggestions for improvement of the AfLP.

Participants were recruited from a local church that sponsored an AfLP class in Monongalia County, West Virginia. The study was approved by the West Virginia University Institutional Review Board, and all participants provided written informed consent.

Three 1-hour focus groups consisting of up to eight participants were moderated by two (of three) trained facilitators. Information on demographic characteristics, program attendance, and presence of physician-diagnosed arthritis were collected from each participant by questionnaire. Group discussions were conducted based on an open-ended, semi-structured, 10-item focus group interview guide constructed by the researchers and refined through a series of role-playing interviews with other research team members. Discussions were audiotape to ensure accuracy, and a facilitator took detailed field notes of the participants' comments during the discussion. The focus group questions were as follows.

1. How did you hear about the AfLP?


2. What made you decide to participate in the AfLP?


3. What positive impact has the AfLP had on your life?


4. What negative impact has the AfLP had on your life?


5. Would you recommend the AfLP to your friends or family? Why or why not?


6. Describe your favorite aspect of the AfLP.


7. What barriers did you experience with participation in the AfLP?


8. Describe any changes you would make in the AfLP.


9. What do you think an ideal exercise program should be like?


10. Is there anything else anyone would like to add?

Data analysis was performed using a systematic text analysis of the focus group transcripts and field notes. The text was coded according to specific responses provided by the participants, and a coding dictionary was constructed. Data were clustered into a conceptual diagram to provide context for specific participant responses and to demonstrate a relationship between codes. The main headings in the conceptual diagram represent the key themes identified in the focus groups. Key themes were then divided into major and minor sub-themes.

Data were verified using two types of triangulation. First, each facilitator independently identified codes in the transcripts and field notes. Only codes identified by all three of the facilitators were included in the coding dictionary. In addition, qualitative data source triangulation was conducted through use of the three separate focus groups. Only responses, or codes, appearing in all three focus groups were placed into the conceptual diagram as major sub-themes. The minor sub-themes were codes that were present in only one or two of the focus group discussions.

Results

Of the 24 older adults who were recruited and enrolled in the study, 19 (79%) participated in a focus group discussion. Five (21%) participants withdrew from the study due to illness or inclement weather.

The participants were predominantly white (95%) females (95%) with a mean ± standard deviation age of 78 ± 7.3 years (range, 67 to 92 years). The prevalence of self-reported doctor diagnosed arthritis was 63%.

The average length of participation in the AfLP ranged from two to nine years. Although 74% of the participants reported attending classes three times per week on average, less than one-third (31.6%) reported meeting the national physical activity recommendation of at least 150 minutes a week of moderate intensity activity (Physical Activity Guidelines Advisory Committee, 2008).

Positive aspects of the AfLP structure were expressed in each of the focus groups. Participants agreed that the AfLP was an ideal and appropriate program designed for people their age. All participants would recommend the AfLP to others. Additionally, participants were supportive of the AfLP because of its donation-only fee scale, convenient location, and group atmosphere.

Key themes that emerged from the discussions served as the main headings in the conceptual diagram (Figure 1). Key themes included: 1) motivating factors to participate, 2) factors inhibiting participation, and 3) recommendations for change. The quotations that follow have been extracted from the focus group discussions in order to support the key themes identified.

Figure 1.
Conceptual Diagram: Themes Evolving from Active for Life Program Focus Groups

Motivating Factors

Of the three key themes, the motivating factors far outweighed the others. Motivating factors included socialization and companionship, perceived health benefits, an overall feeling better, and the opportunity to "get up, get out, and get going" (Focus group questions 1, 2, 3, 5, 6, 9).

Social Support/Companionship

One major motivational factor that was consistent throughout all three focus groups was the social connections that were developed through the program. Participants also expressed a need for the companionship and motivation that they experienced in group exercise.

I have no motivation to do it on my own, I need the group session...it's hard to exercise alone and its fun in a group...I won't do it by myself... I don't do it at home, it's too dull (Focus Group 2)

...it gets me out amongst a supportive group of people...being together, it's good to be with people...I need the motivation of the group (Focus Group 3)

I look forward to being around familiar people....broadens my social contacts... I have met new people (Focus Group 1)

Perceived Health/Medical Benefits

Many participants reported that after several months of participation, they had experienced health benefits that motivated them to continue the program. Some of the health benefits mentioned included improved flexibility, agility, and stamina, and decreased stress levels.

...exercise helped with my headaches...it is prevention to not lose flexibility... (Focus Group 1)

It is keeping me active... my body needed it! (Focus Group 2)

...wanted to decrease high blood pressure....improve my balance...I could no longer do the activities I was used to doing. It was a doctor recommendation due to health problems...it helped after surgery on my knee... (Focus Group 3)

Feeling Better

Participants also expressed an overall perception of simply "feeling better" with participation in the Program.

...I always feel better after I leave... (Focus Groups 1 & 3)

... I wanted the good feeling gained when exercising... (Focus Group 2)

...there is a good feeling gained...I wanted to feel good... (Focus Group 2)

Getting Up, Out, and Going

The group structure and class schedule acted as a motivating factor and provided participants with a common activity to look forward to and a reason to leave home on a regular basis.

It is a reason to get out of the house...it gives me structure and keeps me from sleeping in (Focus Group 1)

I have a purpose for getting up and a place to go...it makes me get up and get going with my day (Focus Group 2)

It got me out of the house after retirement...it gets me out in the winter...I don't get out much otherwise (Focus Group 3)

Inhibiting Factors

There were few negative aspects of the program mentioned. Two major sub-themes were discovered following the discussions, time and transportation (Focus group questions 4, 8).

Lack of Time

Time was mentioned as an inhibiting factor in all three focus groups and mostly related to scheduling conflicts with other appointments.

...time consuming but worth it...have to schedule around it... (Focus Group 1)

...conflicts with other activities, including doctor appointments... (Focus Group 2)

It's a time commitment...I'm unable to come on certain days, but it is time well spent when I do come... (Focus Group 3)

Transportation

Transportation was reported as another inhibiting factor. Several participants did not have their own vehicles and had to rely on other members to carpool. Participants affected by inflated gas prices also took advantage of carpooling. Due to the location of the class site, traffic congestion was also an issue at the busy intersection.

...traffic...roads and weather... (Focus Group 1)

...price of gas... (Focus Group 2)

...transportation would be an issue, if we didn't help each other get here... (Focus Group 3)

Another factor inhibiting participation was weather, although it appeared in only two of the focus group discussions. Though inclement weather and poor road conditions were cited as a barrier to attendance, the AfLP sessions were canceled if the local school system canceled school due to weather.

Recommendations for Changing the Program

The only major sub-theme to emerge in each of the three focus groups was to increase the amount of walking during the class sessions. Minor sub-themes included the addition of: 1) more vigorous activities, 2) more variety or different activities, and 3) different intensities of exercise offered on alternative days. Additional suggestions for improvement mentioned in only one focus group included incorporating more balance exercises, music, and dance or rhythmic exercise (Focus group questions 7, 8, 9, 10).

Discussion

Numerous community-based exercise programs promoting physical activity among older adults have been designed and evaluated; however, the AfLP has never undergone a formal evaluation of this kind. In order to determine if the program should be expanded and marketed as an effective and feasible public health strategy for achieving physical activity-related health benefits in the growing older population, a comprehensive program evaluation was necessary. This aspect of the program evaluation served to elicit the participants' attitudes, opinions, and beliefs. With the qualitative evaluation, we verified the positive influence of the AfLP on the community-dwelling adults who participated in the program. The focus group discussions enabled us to hear directly from the participants about their experience in the Program.

The focus groups elicited data on factors that motivated and inhibited participation and provided recommendations for program change. One of the most motivating factors was the amount of socialization and companionship available to participants. Social support from friends, relatives, and physicians has been rated as a significant motivator to join and continue with exercise (Damush, Perkins, Mikesky, Roberts, & O'Dea, 2005). Previous studies have also conclusively shown that when people exercise in groups that are cohesive, their levels of compliance are greater than exercising alone (Burke, Carron, Eys, Ntoumanis, & Estabrooks, 2006; Carron, Hausenblas, & Mack, 1996; Dishman & Buckworth, 1996).

A common inhibiting factor was a lack of time, which was consistent with the few qualitative studies that exist on community-based exercise programs (Melillo et al., 1996; Schoster, Callahan, Meier, Mielenz, & DiMartino, 2005). Jancey et al. (2007) also indicated time as a barrier to physical activity and reported competing priorities such as other social activities, doctor's appointments, and family responsibilities.

Unavailable transportation was also identified as a common barrier to participation in exercise (Damush et al., 2005; Eurenius, Biguet, & Stenstrom, 2003; Melillo et al., 1996). Eyler et al. (1998) divided the external barriers to physical activity into two categories. Environmental barriers, such as lack of transportation, were mentioned less often; in fact, personal barriers to exercise, such as a lack of time, were mentioned twice as frequently (Eyler et al., 1998).

A suggestion for Extension professionals is to conduct regular process evaluations of existing programs. This would be done to identify barriers to participation and suggestions for program change. Program changes made to adapt to participant needs may prevent individuals from dropping out. In the event participants do drop out, it may benefit agents to follow up with these individuals to find out their reasons for discontinuing.

There were some limitations to the study. The results may be vulnerable to biases associated with subjective studies (Belza et al., 2006). For example, only current members were recruited for participation in the focus groups. Due to the cross-sectional nature of the study, we did not have access to former participants. Former participants may have been able to identify additional barriers. In addition, the opinions reported by some participants may have influenced others to either speak up more or to withhold their own opinions. Also, the exercise leaders participated in the focus groups and may have inadvertently influenced the discussion. Another limitation is the lack of generalizability of the results to older adults participating in other exercise programs outside of West Virginia.

In conclusion, AfLP participants felt that the Program had a positive influence on their lives. Other Extension Services may be able to use this information to adopt and initiate the AfLP and ultimately increase access to physical activity programs for older adults. Gerrior and Crocoll (2008) reported on the increasing need for these programs at state, regional, and community levels due to the aging Baby Boomer generation. Although recent studies have established efficacy in group exercise as a way to promote physical activity, these programs are highly underutilized (Boutaugh, 2003).

However, resolution to this problem can be facilitated by physicians and other healthcare providers who can be powerful influencers of physical activity. Individuals are more likely to adopt healthier lifestyles when advised to do so by medical professionals (International Council on Active Aging [ICAA], 2005). However, according to the ICAA, physicians are unaware and lack knowledge about evidence-based exercise programs. Therefore, studies of the sort reported here are crucial to the expansion of programs like the AfLP as well as the education of not only community-dwelling adults, but healthcare professionals as well (ICAA, 2005).

Acknowledgment

This project was supported by a West Virginia University Public Service Grant.

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