Randomized controlled trials (RCTs) have demonstrated the benefits of physical activity participation for older adults across numerous health outcomes, including all-cause mortality, cognitive health, functional independence, balance, and many more (Izquierdo et al., 2021; Pahor et al., 2014; Singh, 2002; Taylor, 2014). Despite the value and growing number of physical activity RCTs for older adults, little attention has been directed to ensuring that the outcomes measured in these trials are of high importance to older adults themselves (Mackey et al., 2023; Singh, 2002). For instance, our team recently published an inventory of outcomes reported in high-quality physical activity RCTs for older adults and in an unpublished secondary analysis of the 67 included articles, we found that noneexplicitly mentioned including older adult priorities or involvingpatient partners in outcome selection (Mackey et al., 2023). Neglecting the perspective of older adults in the selection of outcomes for such RCTs has negative consequences. It leads to research waste as results may lack relevance for the target population (Heneghan et al., 2017; Kersting et al., 2020; Maurer et al., 2022; Sacristán, 2013; Williamson et al., 2017). In addition, failure to incorporate patient perspectives also perpetuates an “ivory tower” divide wherein researchers maintain sole power and control in knowledge creation (den Houting et al., 2022).
Conversely, incorporating older adult perspectives during outcome selection for RCTs aligns with a growing shift in scientific discourse toward patient-oriented research and the use of patient-relevant outcomes. Patient-oriented research seeks to involve patients as partners in the design and conduct of research (Canadian Institutes of Health Research [CIHR], 2014). In turn, patient-oriented research aims to reposition knowledge creation within active and productive collaborations with patients (CIHR, 2014). Patient-relevant outcomes—those derived from the desires, interests, and curiosities of the research target population—are a critical aspect of conducting patient-oriented research (Kersting et al., 2020). Identifying and adopting patient-relevant outcomes promotes more relevant and practical results from clinical trials, empowers patients, and strengthens the connection between research and those whom it hopes to positively impact (Heneghan et al., 2017; Kersting et al., 2020; Maurer et al., 2022; Sacristán, 2013). Understanding patient-relevant outcomes may also reveal “blind spots” or novel outcomes that have not been adequately explored by previous research that can drive scientific discovery and ultimately improve patient health (Heneghan et al., 2017; Kersting et al., 2020; Kirkham et al., 2017; Maurer et al., 2022; Sacristán, 2013; Williamson et al., 2017). Finally, it is essential that core outcome sets—standard and minimum sets of outcomes to include in all trials in a particular clinical area—include outcomes that are meaningful to patients.
The purpose of this study was to support patient-relevant outcome selection in future RCTs of physical activity with older adults, including ongoing efforts to develop a core outcome set (Mackey et al., 2023). Our specific objective was to determine what outcomes related to their physical activity participation older adults find important.
Methods
Overview
To address our objective, we adopted qualitative methods to promote an in-depth exploration into the perspectives of older adults. Qualitative methods are effective in maintaining the complexities of the human experience while emphasizing the voices of marginalized populations (Phoenix, 2018). Likewise, leading models for guiding the development of behavioral interventions, such as obesity-related behavioral intervention trials (ORBIT), explicitly include qualitative research as an essential component in the development, refinement, and optimization of interventions (Czajkowski et al., 2015).
We conducted semistructured individual interviews with older adults. Our reporting for this study was guided by the consolidated criteria for reporting qualitative health research checklist (Tong et al., 2007). We obtained ethics approval for this study from Simon Fraser University (REB# 30000827), and all participants provided written informed consent.
Theoretical Perspective and Positionality
We adopted a critical realist perspective for this study. Critical realism is ontologically realist and epistemologically subjectivist; it contends that “there is a real world that exists independently of our perceptions ... [however] our understanding of this world is inevitably a construction from our own [standpoint]” (Maxwell, 2012, p. 5). With this perspective, we were “access[ing] ... [the] participants’ perception of (their) reality, shaped by and embedded within their cultural context, language and so on” (Braun & Clarke, 2021, p. 171). Adopting a critical realist perspective allowed us to explore causal mechanisms (Maxwell, 2012), such as the processes and beliefs that influenced which outcomes older adults valued. The subjectivist epistemology of critical realism also extended to our research team as we were not presenting a universal truth but, instead, an interpretation of the data that were inseparable from the group that produced them (Braun & Clarke, 2021; Maxwell, 2012). Specifically, this study was directed through the lens of the first author, Young: a master’s student who was 28 years of age, White, able bodied, male (sex), and a man (gender). Young had an extensive personal and professional history with physical activity, which included several years of personal training work primarily with older adults. Despite not having prior academic interviewing experience, he frequently discussed physical activity with his older adult clientele.
We also adopted a patient-oriented research approach and collaborated with two patient partners throughout this study. As we aimed to elevate and prioritize the voices, lived experience, and expertise of older adults, it was imperative to involve older adults within the research team.
Setting and Context
As participant perceptions are inextricably linked to settings, both cultural and physical, it was prudent to understand the location in which these participants resided (Braun & Clarke, 2021). Metro Vancouver exhibits a level of physical activity comparable to that of British Columbia and higher than the national average of Canada (Statistics Canada, 2019). This could be attributed to several factors, including but not limited to climate (Aspvik et al., 2018), social attitudes (Yun et al., 2018), and urban design (Chaudhury et al., 2011). According to the 2021 census, 112,720 people aged 65 and older resided in Metro Vancouver, roughly 17% of the population (Statistics Canada, 2019). Within Metro Vancouver, we collected data for this study on the three main campuses of Simon Fraser University chosen at the discretion and convenience of each participant.
The temporal context of data collection is also of note. We collected data between July and August 2022 when most COVID-19 pandemic-related public health restrictions in British Columbia had been lifted; however, there was still significant societal caution (Government of British Columbia, 2022) . The COVID-19 pandemic and accompanying policy changes reshaped older adults’ access and ability to be physically active (Gray et al., 2022; Oliveira et al., 2021).
Participants and Recruitment
Eligible participants for this study were 65 years of age or older, were vaccinated against the COVID-19 virus (with two doses of Moderna or Pfizer vaccine or equivalent), were able to speak English, and had access to a telephone or email account and computer to arrange the interview. We used a variety of strategies to recruit participants, which included posting study advertisements on selected websites, Twitter accounts, and physical bulletin boards in high-traffic areas (e.g., community centers), physically distributing study advertisements near interview sites, and snowball sampling via enrolled participants.
Prospective participants contacted the first author by either email or phone call and then received a reply email with information about the study, a fillable portable document format (PDF) consent form, and a link to a short online demographic questionnaire. After returning the consent form and completing the demographic questionnaire, an interview meeting time and location were scheduled. If needed, participants could opt to review the consent form and perform the demographic questionnaire in person on the day of the interview. No participants refused to participate or dropped out of the interview.
We used convenience sampling to enroll the first four participants. As demographic similarities began to emerge across recruited participants, we shifted the sampling approach to stratified purposeful sampling, which aimed to create heterogeneity within recorded demographic characteristics (Palinkas et al., 2015).
Data Collection
Demographic characteristics were self-reported by participants either verbally at the start of the interview or in advance of their interview through an online survey. Sex, gender, and ethnicity were reported via open-ended text boxes. Ethnicity was categorized post hoc (South Asian; White [North American born]; White [European born]) for consistency of reporting.
All other data were collected via a single semistructured individual interview conducted by a single interviewer (Young). Interviews lasted between 40 and 75 min, with a mean of 53 min, depending on the responsiveness of the participant. All interviews were audio recorded with a Sony ICD-UX570 digital voice recorder. We denaturalized the transcripts in Microsoft Word to eliminate inconsequential components of speech (e.g., umm and ahh) while prioritizing the intellectual substance of the interview (Oliver et al., 2005). Transcripts were printed into hard copy for early analysis and also uploaded to computer-assisted qualitative analysis software (NVivo, Lumivero) for subsequent analysis. Young transcribed all of the interviews to encourage reflexivity within his role as an interviewer and promote early familiarity with the transcripts. During the transcription process, pseudonyms were assigned to all participants.
Interviews covered a range of topics surrounding physical activity. The interview guide (Supplementary Material S1 [available online]) was designed with a variety of question styles to accommodate participants’ preferences (Green & Thorogood, 2018). All interview questions were piloted and critiqued by two patient partners and one older adult acquaintance. From pilot interviewee feedback, we made various language changes and clarifications. For example, the original interview guide did not define physical activity and had intentionally left it open to the interpretation of the participant. The pilot interviewees recommended clarifying what exactly was meant by physical activity, which was then added to the interview preamble. We concluded data collection upon reaching data saturation—when continued data collection would beget replication and redundancy in themes (Saunders et al., 2018; Vasileiou et al., 2018).
As personal biography and position of the interviewer can shape power dynamics, and therefore findings, we aimed to establish the interview as a place of trust where all conversation would be free of judgment (Pachana & Laidlaw, 2014). We used specific strategies to mitigate any perceived power differentials (Anyan, 2013; Broom et al., 2009; Davis et al., 2010). These included asking open-ended questions with room for participants to explore and discuss their perspectives and ideas, and alotting enough time to understand each participant’s unique background, empowering them to share about their lives (Rubinstein, 2001).
Data Analysis
We analyzed raw data using a reflexive thematic analysis following the six-phase approach provided by Braun and Clarke (2021; Byrne, 2022; Table 1). The flexibility of reflexive thematic analysis allowed us to integrate our chosen theoretical perspective (critical realism) with our chosen analytic orientation (inductive–deductive and semantic; Braun & Clarke, 2021). In addition, reflexive thematic analysis is a process directed by guidelines with room for individual interpretation and design choice as opposed to a methodology with a more rigid “package of theory, method, and other design elements” (Braun & Clarke, 2021, p. 4); this allowed us to tailor our analysis to best fit our research objective. Thus, we could implement strategies like open coding and multiple coders within our analysis. Finally, reflexive thematic analysis is notably accessible, and this was critical as we had a diverse coding team, which included patient partners and trainees who were new to qualitative analysis (Braun & Clarke, 2021). The study’s ethics approval allowed patient partners to review interview transcripts after participant names had been replaced by pseudonyms and any directly identifying information, such as family member names, had been removed.
Braun and Clarke’s (2021) Six Steps of Reflexive Thematic Analysis With Lead Researcher and Research Team Roles and Responsibilities
Six-phase approach (Braun and Clarke) | Actions taken by Young | Actions taken by supporting research team |
---|---|---|
Preanalysis | • Hosted a coding training meeting to discuss the underlying philosophy, end goals, and method of the reflexive thematic analysis coding strategy • Defined transcript nomenclature and shorthand (e.g., R = respondent) • Provided example excerpts from the transcripts and described potential approaches to coding | • Attended coding training • Brought forth underlying questions about the future of the coding process |
Reflexivity | • Kept a reflexive-writing journal throughout the study • Journal entries covered personal, intrapersonal, methodological, and contextual considerations | • Contributed to research meetings where ideas were discussed, challenged, and alternatives presented. Reflexivity across the entire research team was encouraged |
Phase 1: Familiarization with transcripts | • Conducted interviews and generated transcripts • Read through transcripts multiple times, making short notations of ideas and highlighting areas of rich data | • Read through transcripts multiple times, making short notations of ideas and highlighting areas of rich data |
Phase 2: Coding | • Systematically read through transcripts, attaching codes to important sections of text which related to the research objective • Hosted first research meeting after coding two transcripts. Goals were to troubleshoot early issues held by coding members and to discuss interesting segments of transcripts • Hosted second and third research meetings after coding seven and 12 transcripts. Same goals as the aforementioned • Recoded all transcripts | • Systematically read through transcripts, attaching codes to important sections of text which related to the research questions • Attended coding meetings and provided insight and perspective to specific sections of text • Provided reflexive insights on their interpretations of the transcripts |
Phase 3: Generating initial themes | • Began to group codes into meaningful groups, which were clustered around an idea • Deductively consulted with published literature for established names of outcome domains • Inductively defined names for themes that were novel to this study | |
Phase 4: Developing and reviewing themes | • Interrogated early themes with reference to transcripts to ensure that they captured the ideas presented by participants • Developed a conceptual model for visualizing the interrelation of themes | • Provided critical feedback on the creation of themes |
Phase 5: Refining, defining, and naming themes | • Hosted a fourth research meeting to discuss the current interpretation of themes • Flagged themes and subthemes where there was room to improve naming • Created working definitions for themes and subthemes with reference to deductively incorporated themes | • Attended research meetings to provide critical feedback on the status of themes • Suggested alterations and considerations to theme and subtheme names and definitions |
Phase 6: Write-up | • Flagged powerful and relevant transcript quotations for each theme and subtheme • Drafted manuscript • Incorporated feedback of the research team | • Provided feedback on the strength of quotations and order of theme presentation • Reviewed manuscript and provided feedback |
Initial open coding of transcripts was done inductively, building up from the raw interview data. Four coders performed open coding independently, which allowed us to incorporate differing perspectives, assumptions, and interpretations of data into the analysis. We held coding meetings after reviewing two, seven, and all 12 transcripts to discuss issues with coding and understand the differentiation between coders; we did not search for consensus among coders. Next, we looked deductively at published outcome domain frameworks (Dodd et al., 2018) and our lab’s previous rapid review (Mackey et al., 2023) to categorize the initial coding into themes. Codes that did not fit into any predefined outcome domains were inductively sorted into novel themes. As we aimed to leverage older adults’ opinions, knowledge, and curiosity, it was imperative that we expressed their ideas as semantically as possible based on information presented within the interviews.
Results
We recruited 12 participants with varied histories of physical activity (Table 2) and demographic characteristics (Table 3). From the 12 interviews we conducted, we conceptualized five themes and 19 subthemes to summarize the outcomes of physical activity participation that mattered to older adults (Figure 1). A complete list of themes and subthemes, code labels, and representative quotations is available in Supplementary Material S2 (available online).
Physical Activity History of Participants (N = 12)
Pseudonym | Age | Gender | Lifetime/current engagement in physical activity |
---|---|---|---|
Linda | 67 | Woman | Low level of physical activity throughout life Started with weight room exercise recently |
Priya | 79 | Woman | Highly physically active across life with walking, hiking, and youth sport Current physical activity is primarily walking |
Erika | 75 | Woman | Low levels of physical activity during childhood attributed to gender norms. Adulthood prioritized raising children Became involved in organized physical activity with group fitness recently |
Cynthia | 72 | Woman | Moderately physically active across life with unstructured walking and swimming Currently walking and performing light home exercises |
Alice | 81 | Woman | Moderately physically active youth with sport. Activity slowed while raising children Currently walking and performing weight room exercise |
Margaret | 88 | Woman | Moderate physically activity level across life with walking and sport Current physical activity is primarily walking |
Roger | 77 | Man | Highly physically active childhood. Activity dropped during 20s due to life demands Currently involved with group fitness and golf |
Joseph | 95 | Man | Moderately physically active across life with walking and home exercise routine Continues the same routine today |
David | 65 | Man | Highly physically active across life with team and individual sport Currently engaging in running and hiking |
Thomas | 90 | Man | Moderate levels of unstructured physical activity throughout life Added structured physical activity with group fitness recently |
Richard | 83 | Man | Highly physically active childhood and young adulthood. Activity dropped across professional life Physical activity restarted during retirement with group fitness and cycling |
Raymond | 90 | Man | Highly physically active across life with sport Currently involved in group fitness and walking |
Demographic Characteristics of Participants (N = 12)
Variable | |
---|---|
Age (years), mean (SD), range | 80.1 (9.5), 67–95 |
Gender, n | |
Women | 6 |
Men | 6 |
Sex, n | |
Female | 6 |
Male | 6 |
LGBTQIA/2S identification, n | |
No | 12 |
Ethnicity, n | |
South Asian | 2 |
White (North American born) | 7 |
White (European born) | 3 |
Education level, n | |
Some high school | 1 |
Some postsecondary | 8 |
Some postgraduate | 3 |
Self-reported disability, n | |
Yes | 1 |
No | 11 |
Marital status, n | |
Widowed | 3 |
Single never married | 2 |
Separated or divorced | 2 |
Married or common law | 5 |
Employment status, n | |
Retired and not volunteering | 3 |
Retired and volunteering | 9 |
Days per week with 30 or more minutes of physical activity, mean (SD), range | 4.2 (2.6), 0–7 |
Theme: Physical Outcomes
Physical outcomes, or those to do with the structure, function, and movement of the physical body, were important to older adults. Although these physical outcomes were often top of mind for participants when they were asked about physical activity, being mentioned first did not imply that these outcomes were of higher importance than those mentioned subsequently; rather, they seemed to be mentioned first out of convenience of association.
Subthemes: Physical Function and Mobility Outcomes
As I get older I don’t have the same balance that I had, I don’t have the same strength that I had, so I mean, it’s all the more important that I do ... the exercise. Y’know, one of the things you lose as you get older, is gradually your balance, and so ... I make an exercise out of, stupid as it sounds, putting on my underwear, and taking off my underwear, or shorts, or socks. Y’know, I try to stand on one foot, and not lean against the wall.—Roger (age 77 years)
Closely related to physical functioning were mobility outcomes—those to do with the capacity for movement as well as actual daily movement. Margaret, a frequent walker, described the importance of mobility and her appreciation of being mobile: “I know so many people [and] they’re either with walkers, or canes, or troubles physically, and I figure as long as I can walk, I should walk. It’s good for the body”—Margaret (age 88 years).
Subthemes: Physical Structure and Cognitive Outcomes
Participants also stressed the importance of physical activity in making structural changes, for instance, to bones, joints, and body composition. Linda described how she hoped that physical activity might result in improvement in outcomes of her physical structure: “I was getting some health problems and I thought maybe if I lost some weight and got my knee [better, that] ... I would feel better”—Linda (age 67 years).
The structure and function of the brain were also cited as a desired outcome of physical activity participation. David, an older adult in his own right but also a caregiver to a family member, commented on why he has incorporated physical activity into his caregiving: “She has advanced dementia, so cognitively we are not sure what is going on in that little brain of hers but ... the idea is to mentally stimulate her”—David (age 65 years).
Theme: Clinical Outcomes
The clinical outcomes theme was also related to the physical body; however, it differed from physical outcomes as it centered on changes in health and physiology. Participants presented clinical outcomes that were often tied to the prevention and management of disease and adverse health events.
Subthemes: Falls and Injury Outcomes
Falls posed a major concern for participants. Whether the participant had personally experienced a fall, knew someone who had fallen, or simply understood the risk of falls, they were frequently discussed as something to avoid. Alice, who had personally endured a fall, commented on her perspective: “I want to very much improve my balance because I think that so often elderly people if they fall, then it’s curtains, and I don’t wanna fall again”—Alice (age 81 years).
Physical activity was also believed to help mitigate the potential severity of an injury, as seen with Roger: “I would think that the fact that I didn’t break my neck when I fell down ... was because, y’know I grabbed, I was able to hold on for a certain amount of time to reduce the impact”—Roger (age 77 years).
Subthemes: Disease and Physiological Outcomes
When my wife had Alzheimer’s, I did nothing [but] associate with old people, and [I] realize[d] what it’s like to be old and “holy who’s looking forward to this?” and you better get fit for it. Like the fear being old and not being fit, and my fear that I am going to be old.—Thomas (age 90 years)
Physiological outcomes were relevant to some participants. Often the importance of these outcomes seemed to be linked to some interaction with a health professional, as seen with Alice: “Your conversations with your doctor, does she feel that you’re doing better with the resulting blood work that they do or, y’know potassium levels, or I don’t know!”—Alice (age 81 years).
Subtheme: Health and Longevity Outcomes
Participants were interested in outcomes related to maintaining overall health and promoting longevity. Erika described how exercise might impact the length of her life: “Older people think oh, y’know my end is near I don’t have to do anything just wait, but you could actually extend your life and have more enjoyable old age by exercising. I really believe that”—Erika (age 75 years).
Theme: Social Outcomes
Social outcomes or those to do with the relation and interaction with others were a consistent talking point for men and women. The theme of social outcomes was the most homogeneous theme of outcomes, meaning that there was limited differentiation between code labels.
Subthemes: Social Interaction and Connectedness Outcomes
Participants often wanted their engagement in physical activity to double as an opportunity for social exchange. This came in two forms; the first, social interaction, was the more casual type of socialization that happened organically. For example, Linda described getting out of the house and the opportunities it provided: “Oh it will be fun, it will make you feel good, let’s get out of the house and go for a walk ... who knows what’s out there, might be able to meet your neighbours”—Linda (age 67 years).
I got to know [a] lot of other people my age group and ... at this age, there is no shame, we share everything, y’know whether it is money, or whether it’s health, or relatives, or our anger or whatever it is.—Priya (age 79 years)
I think that we had [several] guys that have experienced the prostate [cancer], but the interesting part of it is that y’know, they can share it, if a guy is facing it, you talk to any one of the others and they compare notes, as to what’s the procedure, you know what’s the best, what are the plusses and minuses of the surgery, and so it’s great sharing. It’s great rapport, and you know there is a photo gallery that they have one guy that takes pictures of everybody and that’s sent out, I guess every year or so they update it, and so you have the faces and names of all the guys that are around you.—Raymond (age 90 years)
Subtheme: Social Solitude Outcomes
So, I really really appreciate when it’s just me, or just me and my partner, and we are out in the middle of nowhere, and the phone will not ring, cause it can’t ring, and I just absolutely love it.—David (age 65 years)
Theme: Psychological Outcomes
The theme of psychological outcomes, those to do with mental processes, emotions, and perceptions, was the most heterogeneous theme derived from the transcripts. Participants presented several interpretations of the psychological outcomes they wished to see from their engagement in physical activity.
Subthemes: Control and Identity Outcomes
It was a directional shift, it was like, now I am walking toward health, now I am walking toward my goals. Instead of sitting around moaning about—wondering y’know “will I ever get to these?” Instead of wondering well “I’m getting older every day, will I ever get to this” now I’m walking towards it.—Cynthia (age 72 years)
Mental is a big part of it, like I’m in charge you know, and I do this exercise everyday at a certain time, I could not go through the day without having done it, it’s strenuous, especially climbing the stairs, and doing some mental exercises as well, but I feel good once it’s done, I’m in charge.—Joseph (age 95 years)
Joseph was also a participant who viewed activity as a fulfillment or reproduction of their identity. This was not unanimous among participants, but those who had been consistently active for long durations of their lives seemed to create an element of their identity, which was that of being physically active. Therefore, engaging in physical activity became an activity of self-expression and in alignment with their identity. Joseph alluded to this component of identity: “I want to maintain that, I find that rewarding. And, it’s the discipline I’ve done it my whole life, morning exercise is hardly ever missed ... I must do it”—Joseph (age 95 years).
Subthemes: Confidence and Mental Well-Being Outcomes
I really need to both develop better balance and more confidence so that if I need to step over something I don’t have to look for something to grab to do it. And that’s coming, the balancing leg exercises are really helping, getting way better at them.—Alice (age 81 years)
Similarly, Erika recalled how physical activity has helped her social confidence: “I am not outgoing, I will not go out of my way to meet people, but at least going to the fitness classes I had a reason to—I actually look forward to it”—Erika (age 75 years).
Aside from confidence, participants looked toward physical activity for a range of mental well-being-related outcomes. Richard found acute enjoyment through engaging in his activities of choice: “Well, I love movement as I said, I love moving”—Richard (age 83 years).
I imagine other people, like old people being isolated at home, y’know, I don’t feel that, depressed that way. I am grateful that I have a reason to get up in the morning and I have a activity that I enjoy and [is] useful to me. That I feel that I am doing the right thing.—Erika (age 75 years)
Subthemes: Environmental Outcomes
The greenery and the pheromones from the trees, [it] definitely gives a benefit of nature around you. And seeing the birds, not just from photography, but seeing the birds and seeing the plants, these days particularly. Picking up berries and eating them, stealing berries from the bears, making each other feel guilty “hey that’s for a bear!” There is no difference you know, you think at eighty people are old, the jokes haven’t changed they [are] still like teenagers.—Priya (age 79 years)
Theme: Overarching Outcomes
Overarching outcomes were those that encompassed or were comprised of the other outcomes. These outcomes were located at a more general and holistic level than the outcomes found in the other themes. For example, to maintain independence, an older adult would need to have some physical function and social support and actively manage clinical considerations.
Subtheme: Independence Outcomes
Not being dependent on others, I want to be able to dress myself, I want to be able to get my groceries, I want to be able to pay my bills, I want to be able to—if I decide I would like to go somewhere I would like to be able to go somewhere and not have to worry about, y’know, does it have access for people who have mobility issues, is it too far away. I just want to grow old where there is as few restrictions on what I can do physically as possible.—David (age 65 years)
Not physically fit to like [run] a marathon but physically fit that you can ... live a normal life as best you can, that to me is the goal of being physically fit. I’ve never planned to run a marathon, but I do plan to be able to walk around downtown without having to stop every five minutes and sit down.—Linda (age 67 years)
Subtheme: Quality of Life Outcomes
Quality of life outcomes were perhaps the most general or holistic desired outcome of engaging in physical activity. Despite more specific considerations, it was obvious that the participants believed that being active would improve their quality of life. Cynthia encapsulated maintenance of her body within quality of life when she said: “I want to live a quality life and to do everything I can do [to] prevent deterioration [of] my physical apparatus, and I believe that is perfectly possible”—Cynthia (age 72 years).
Quality of life that is left to them, I mean if you’re in your eighties, who knows how much life is left to you, but the quality of it is something that you can influence, as long as you’re reasonably healthy.—Margaret (age 88 years)
Discussion
The findings of this study display that older adults desire broad and diverse outcomes from their physical activity participation, ranging from specific (e.g., leg strength) to generic (e.g., quality of life). Across the five outcome themes, a dichotomy was noted between participants’ views of outcomes related to the physical body (i.e., physical and clinical outcomes) and those that were mentally perceived and unlinked to the body (i.e., social and psychological outcomes). Participants often assumed a reserved outlook while discussing bodily outcomes, hoping to maintain their current status or limit decline. Personal and vicarious experiences in combination with an overarching social narrative of physical decline with advancing age (de Beauvoir, 1972; Gullette, 2015) appeared to shape how participants thought about outcomes connected to the body. This understanding of aging did not discourage participants from attempting to exert some control over their physical aging journey, and despite the surface modesty, such goals are still positively linked to multiple health outcomes (Robinson & Lachman, 2017). In contrast, mentally perceived outcomes that were unbound by a physical body elicited a more ambitious set of desires from participants. For example, participants wanted to improve their social connectedness or mental well-being above that of their current status. The narrative shifted from maintenance and mitigating decline to improvements above baseline. As Simone de Beauvoir beautifully wrote, “Our private, inward experience does not tell us the number of our years” (1972).
Frequently, outcomes that mattered to participants were nested within one another, forming successive contingencies (Shell, 2023; Skinner, 1996). For example, an older adult might value improving their balance to maintain their independence, and thus live a higher quality of life. This means–ends orientation of outcomes, which has been previously demonstrated in pedagogical research (Shell, 2023), was prevalent across interviews, with outcomes seldom being mentioned in strict isolation. Within this orientation, and building upon research on formation of outcome expectancies in other fields (Shell, 2023), we theorized that participants’ level of depth or specificity when discussing their relevant outcomes was predicated on the individual’s knowledge and experience. For example, an individual may value something specific, such as blood pressure regulation, as an outcome if their physician had previously spoken to them about that specific outcome. Likewise, embodied experiences, such as experiencing a fall, could shift a participant toward other specific outcomes, such as balance, leg strength, or body composition (Griffin, 2017). Moreover, across all themes, outcomes could typically be built up successively to the idea of improving one’s overall quality of life. As such, quality of life improvements seemed to be the root of all outcomes.
The findings of this study are consistent with contemporary research examining older adults’ motivators of, and beliefs about, physical activity. Recent systematic reviews (Baert et al., 2011; Burton et al., 2017; Yarmohammadi et al., 2019) have shown that older adults are motivated by four of the themes conceptualized in our study—physical, clinical, social, and psychological benefits. Complementary research on older adults’ beliefs and perceived behavioral expectancies of engaging in physical activity has similarly reported that older adults expect benefits from physical activity across the themes of this study (Huffman & Amireault, 2021; Stehr et al., 2021). The current study adds to this literature in important ways. Both motivators and beliefs are large and broadly encompassing concepts, and past studies did not reach the same level of specificity (e.g., subthemes) about desired outcomes as we were able to achieve in the current study. Moreover, our analysis revealed a deeper understanding of why particular outcomes were important to older adults, and how these outcomes were interrelated and nested among one another.
Physical activity is recognized as a complex health behavior, intertwined with related constructs such as sedentary behavior, and influenced by personal, social, and environmental factors (Boulton et al., 2017; Gabriel et al., 2012; Thornton et al., 2017). This notion of complexity was reflected in the current study’s results through the quantity, breadth, and interrelated nuance of outcomes that participants presented as important. Although desired outcomes of physical activity engagement are shaped by multilevel influences described in social–ecological models (Shell, 2023; Thornton et al., 2017), the outcomes expressed by older adults in the current study primarily existed at the individual and interpersonal levels. For example, an older adult may engage in physical activity to remain independent, an outcome that is likely influenced by Western cultural expectations (Rubinstein et al., 2015); however, the outcome itself resides at the individual and interpersonal levels. The complex nature of physical activity behavior, in conjunction with the diversity of outcomes presented as important by older adults, suggests a rich opportunity and need for continued investment in interdisciplinary research examining older adult physical activity (Kivits et al., 2019). In particular, the results of this study suggest that evaluations of older adult physical activity interventions may benefit from examining a diverse set of outcomes spanning across disciplines.
The current study also makes an important contribution to the identification and adoption of patient-relevant outcomes for physical activity trials and related core outcome sets. As previously mentioned, none of the 67 articles included in a recent rapid review (Mackey et al., 2023) of RCTs of physical activity with older adults explicitly mentioned including older adult priorities within the selection of their outcomes. Some of the relevant outcomes for older adults identified in the current study are already being measured frequently in RCTs; for example, 76% of the trials within the rapid review incorporated some measure of physical outcomes (Mackey et al., 2023). However, emotional functioning outcomes (closely related to psychological outcomes of this study) were only used in 21% of previous trials, and social outcomes were only reported in 12% of the studies included in the rapid review. Furthermore, every capture of social outcomes in trials included in the rapid review was measured via a single question on a longer form questionnaire. Therefore, those who design RCTs of physical activity for older adults could not only do a more consistent job of including social outcomes, but there also appears to be an opportunity to develop and adopt improved instruments to measure social outcomes.
We recognize that there were certain limitations to this work. First, relying on a single individual interview may have limited the development of trust and rapport within interviews, which may have contributed to a social desirability bias of participants being overly positive regarding physical activity (Read, 2018). It is also possible that certain sensitive topics may have been missed through conducting only a single interview. For example, we anticipated that some outcomes related to sexual health would have arisen throughout the interviews. Their absence may be due to the single-interview structure and the sensitive nature of this topic. Nonetheless, we believe that most of the topics covered around physical activity outcomes were likely not sensitive in nature and not affected via a single-interview structure. There is also the possibility that the perspectives that we captured are not exhaustive due to homogeneity across certain participant characteristics (e.g., disability status, education, and ethnicity; Lewis & Ritchie, 2003). However, we believe that the themes and subthemes from this study are broadly representative for the target population (Lewis & Ritchie, 2003).
Conclusions
This study used interviews to explore the outcomes of physical activity participation that older adults find important. Relevant outcomes were plentiful but could often be related back to wanting to improve, maintain, or prevent decline in quality of life. To date, RCTs have been instrumental in showing the many health benefits of physical activity for older adults. To ensure that physical activity research continues to grow and improve, it is essential that researchers designing RCTs of physical activity for older adults consider patient perspectives and seek to incorporate patient-relevant outcomes. Doing so will promote research collaborations with patients and reduce the potential of research waste.
Acknowledgments
The authors would like to acknowledge the work of Bob Strain, a patient partner who assisted in the development of the interview materials and oversaw data analysis. We would also like to thank the participants of this study for their generosity in sharing their knowledge and time. This study was supported by a research grant from the Drummond Foundation to Mackey and by a Scholar Award from Michael Smith Health Research British Columbia to Mackey. Young was supported by a Canada Graduate Scholarship—Master’s from the Canadian Institutes of Health Research. The funding agencies had no role in the research.
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