Assisted living (AL) residents engage in very low levels of physical activity (PA) (Krol-Zielinska, Kusy, Zielinski, & Osinski, 2010), and this is a problem. Most activities revolve around participation in self-care, such as bathing and dressing (Resnick, Galik, Gruber-Baldini, & Zimmerman, 2011). Despite the recommendation that they engage in 150 min of moderate PA per week (U.S. Department of Health and Human Services, 2018), older adults in AL spend less than one minute a day in moderate-intensity PA over a 24-hr period (Resnick et al., 2011).
Assisted living residents are at a higher risk for metabolic and musculoskeletal problems and frailty due to spending too much time in sedentary behavior (Krol-Zielinska et al., 2010; Matthews et al., 2008; Song et al., 2015). Sedentary behavior is defined by the Sedentary Behavior Research Network (2017) as any behavior characterized by an energy expenditure of ≤1.5 metabolic equivalents while in a sitting or lying-down position. PA is defined as all bodily movement that engages skeletal muscles and results in energy expenditure (U.S. Department of Health and Human Services, 2018).
Optimizing health and well-being through regular PA is essential for older adults in AL facilities (Niles-Yokum & Wagner, 2011), but a majority say they have no plan to increase daily PA levels (Schutzer & Graves, 2004). In addition, sedentary behavior may be unintentionally encouraged in AL residents due to the nature and number of supportive services offered to individuals. Shopping, meal preparation, and housekeeping services provided by most AL facilities may contribute to low levels of PA and increased disability and frailty (Mihalko & Wickley, 2003; Stefanacci, 2010). Although AL residents value PA as a means to maximize physical function, provide a sense of well-being, and promote health (Koltyn, 2001; Phillips & Flesner, 2013), little is known about how PA is experienced and what the meaning and perception of PA are for residents in the context of the AL environment. This is a gap in the research.
Personal, environmental, and social factors will influence the PA of residents in AL. Personal factors that contribute to PA include a past history of exercise participation, self-efficacy for exercise, and better physical and mental functioning (Chen, Li, & Yen, 2016). Environmental factors known to influence PA include having adequate space for activity (Phillips & Flesner, 2013) and the walkability of paths inside and outside the AL facility (Lu, Rodiek, Shepley, & Duffy, 2010; Rodiek, Lee, & Nejati, 2014). The social dimensions of the congregate environment of AL could influence PA, but little research has been conducted in this area.A better understanding of this complex interplay among variables would be useful in designing interventions that promote healthy levels of PA.
The purpose of this study was to explore AL residents’ past and current experiences of PA and the meaning and perceptions of PA in AL residents to answer two research questions:
- 1.What is the experience, meaning, and perception of PA in AL residents?
- 2.What are the factors associated with the experience of PA in AL residents?
Methods
Design, Sample, and Setting
We employed a qualitative, exploratory design and used phenomenological methods to analyze participant responses to questions. In phenomenology, the researcher seeks to understand a phenomenon, such as PA, at a deeper level, distinct from any theoretical framework (Colaizzi, 1978). The process first involves the researcher setting aside personal experiences, meanings, and perceptions of the phenomenon prior to participant interviews. This allows the researcher to better understand how participants view the phenomenon from their perspective. AL residents’ experiences, meaning, and perceptions of PA were explored to provide deeper insight and new information about what might influence PA engagement. Personal, environmental, and social factors associated with the experience of PA in AL residents were examined to provide an in-depth contextual understanding.
The institutional review board at the University of Michigan approved the study. The primary investigator (PI) conducted one-on-one interviews with a convenience sample of 20 AL residents recruited from four licensed AL facilities in the state of Michigan. Participants were required to meet the following eligibility criteria: (a) ≥55 years old, full-time resident in an AL facility for a minimum of three consecutive months; (b) ability to read, write, and/or speak the English language; (c) ability to engage freely in PA throughout the day without the aid of a wheelchair or motorized cart, and (d) Mini-Mental State Exam (MMSE) score of 24 or greater on a scale of 0–30. Individuals are considered to be cognitively impaired below an MMSE score of 24, and adequate cognitive function was required to carry out the activities of this study (Folstein, Folstein, McHugh, & Fanjiang, 2001). The MMSE has 22 items comprised of questions and paper-and-pencil activities that take approximately 10 min to complete. The MMSE is designed to screen for cognitive impairment in adults aged 18–100 years. Test–retest reliability has been established with Cronbach’s alpha coefficient of .79–.98 and interrater reliability of 0.83–0.95. Inclusion criteria ensured a sample of older adults, acclimated to the AL setting, who could answer the interview questions about the phenomenon and who were unencumbered in their ability to engage in PA throughout the day. Data were collected from May to September of 2015.
The PI identified a convenience sample of four AL facilities. The facilities had a combined capacity of 176 residents: site one had 66 residents, site two 46, site three 34, and site four 30. The facilities were all one-story buildings with a central dining room to which residents walked for three daily meals. All facilities had an activities director available during daytime hours three to five days a week. All facilities offered weekday in-house activities, such as seated exercises; craft classes, such as sewing and painting; and social events, like piano recitals and sing-alongs. Depending on resident interest, outside trips to restaurants, shopping centers, and other destinations were offered weekly or monthly. All facilities provided housekeeping and laundry services, medication administration, and assistance with activities of daily living as needed.
Interviews
Semistructured interviews were designed to elicit in-depth descriptions of the experience of PA—how PA was experienced and in what context the experience took place—and to better understand the meaning and perception of PA. The questions were also designed to discover what personal, environmental, or social factors might influence PA. Interviews were organized around the completion of two tasks: (a) a calendar of current weekly activities and (b) a lifeline of PA over the lifespan (Gramling & Carr, 2004).
Calendar of weekly activities
Participants described their weekly activities by listing usual daily physical activities on a calendar. They were instructed to list all activities typically performed each day in the morning and in the afternoon, and they were not prompted by suggestions or descriptions of PA. The following questions and probes were used to guide this portion of the interview.
Describe the things you do during a typical week, specifically the physical activities you engage in. Tell me about your chart.
- 1.Describe how your usual physical activities change from day to day during the week.
- 2.Tell me about where your weekly physical activities take place.
- 3.Is there anything about the week’s physical activities that stands out for you?
- 4.Is there anything that influences your physical activities during the week?
- 5.Are there any physical activities that involve other people that stand out for you?
- 6.How do you feel about your weekly physical activities? How do your physical activities make you feel?
- 7.Is there anything else you would like to say about your usual weekly physical activities? What does physical activity mean to you?
- 8.What does it mean to you when you are unable to be as active as you would like?
- 9.What physical activities are the most important to you?
- 10.What physical activities would you like to continue to do in the future?
Lifeline
Participants completed a lifeline that described the highs and lows in PA throughout their life. Participants were given a paper with a straight, horizontal line representing the span of their life and instructed by the PI to place an X on the line to indicate when they moved to the AL facility and to write down the year. They were given 5 min to draw a continuous line representing the ups and downs of PA throughout their life. Individuals with visual or fine motor difficulties verbally described their lifetime PA levels as the PI recorded it on the lifeline. Participants explored the experience of PA in their lifetime by responding to the following questions and probes.
Tell me about your drawing and about physical activity in general in your lifetime.
- 1.Is there anything about physical activity in your lifetime that stands out for you?
- 2.Tell me what was happening, where you were, and who you were with that influenced your physical activity.
- 3.Tell me what caused physical activity to change over your lifetime.
- 4.How did your physical activity affect others in your lifetime?
- 5.How do you feel about physical activity in your lifetime?
What has physical activity meant to you during your lifetime?
- 1.What do the changes in physical activity in your lifetime mean to you?
- 2.Have you shared everything that is significant about physical activity?
- 3.Is there anything else you would like to say about physical activity?
Life histories are a qualitative approach to revealing how experiences and events link to action and behaviors. This approach has been used to study adaptation to disability and life changes in select populations (Gramling & Carr, 2004). In this study, the lifeline helped participants describe the PA experience, reflect on the meaning and perceptions of PA over the course of their lifetime, and reflect on the factors associated with PA.
Procedure
Facility contact information was accessed through the Michigan State Department of Human Services online list-serve. Following institutional review board approval, the PI contacted authorized representatives at the AL facilities for permission to recruit participants at each facility. The PI met with potential participants individually and explained the research, performed cognitive screening with the MMSE, and obtained informed consent and demographic data.
The PI guided the participant to first complete the activity calendar and associated interview, followed by the lifeline and associated interview. At the end of the second interview, participants were asked if they had shared everything of importance about their PA. The interviews lasted from 40 min to 1.5 hr. The mean duration for the interviews was 50 min.
Data Analysis
Colaizzi’s (1978) phenomenological approach was used to analyze the qualitative data. First, the PI engaged in the process of bracketing prior to data collection. Bracketing is the review of the personal understanding and experiences of a phenomenon by the PI or interviewer, and it assists in setting aside any prejudgments about the phenomenon. This allows for a new and unbiased focus on participant experiences and the meaning of the phenomenon (Moustakas, 1994). The PI also engaged in bracketing prior to each individual interview to recognize attitudes and knowledge about PA that developed in the course of data collection, so it could be set aside.
Interviews were audiotaped and transcribed verbatim. Recorded interviews were listened to several times to get an overall feeling for the quality of the content. The PI transcribed field notes during and immediately following each interview. Transcribed interviews were read several times and compared with the audio interview to check for accuracy before they were entered into the NVivo 11© (QSR International, Doncaster Victoria, Australia) software (QSR International, Doncaster Victoria, Australia). The PI analyzed data by identifying all significant, nonoverlapping statements related to the experience of PA. Statements were combined to form meaning units, and meaning units were examined and clustered into themes common to all participants. The themes were used to write a description of what the participants experienced and answer the research questions. The PI and a second researcher (J. L. Larson) compared the themes to the transcripts and field notes to determine if they matched the content.
Methodological rigor was achieved through verification and validation (Creswell, 2007; Meadows & Morse, 2001). Verification was accomplished through a literature review that examined what is known about the phenomenon and where the gap in literature exists. Field notes enhanced the understanding of the context and quality of the responses. Data collection and analysis were completed concurrently to identify what was known and not yet known about the phenomenon as the study went on (Morse, Barrett, Mayan, Olsen, & Spiers, 2002). Sample size and composition ensured that data saturation was achieved (Safman & Sobal, 2004; Ulin, Robinson, & Tolley, 2005). Contrary cases were reviewed to identify aspects of the analysis that were not readily obvious, thereby contributing to saturation (Creswell, 2007; Meadows & Morse, 2001). Validation was accomplished through the bracketing process, which identified researcher biases that might influence the data collection and analysis and cause premature closure. The organization of meaning units into themes was checked throughout the analysis by a second researcher (J. L. Larson), yielding more trustworthy results (Creswell, 2007).
Results
The sample consisted of 20 adults from four AL facilities. The age range was 57–96 years (M = 77.4, SD = 10.6) and included 16 (80%) females and four (20%) males. Fifty percent (N = 10) had some college education or a college degree. Two (10%) reported being employed. Thirteen (65%) reported using a walker occasionally, and seven (35%) reported never using a walker. The range for the length of stay in the AL facility ranged from 3 to 89 months (M = 27.6, SD = 26.0). MMSE scores ranged from 24 to 30 (M = 27.65, SD = 2.03). Table 1 describes the sample characteristics.
Sample Characteristics
| Variable | N = 20 | Percentage |
|---|---|---|
| Gender | ||
| female | 16 | 80 |
| male | 4 | 20 |
| Ethnicity | ||
| White | 19 | 95 |
| African American | 1 | 5 |
| Marital Status | ||
| widowed | 11 | 55 |
| single | 5 | 25 |
| divorced | 4 | 20 |
| Education | ||
| less than high school degree | 2 | 10 |
| high school degree | 8 | 40 |
| some college | 3 | 15 |
| college degree | 7 | 35 |
| Employment status | ||
| part time ≤ 20 hr per week | 1 | 5 |
| full time ≥ 40 hr per week | 1 | 5 |
| Walker use | ||
| yes | 13 | 65 |
| never | 7 | 35 |
| Range | M ± SD | |
| Age | 57–96 | 77.4 ± 10.6 |
| Length of stay (months) | 3–89 | 27.6 ± 26 |
| MMSE score (0–30) | 24–30 | 27.6 ± 2.0 |
Note. MMSE = Mini-Mental State Exam (Folstein et al., 2001). Psychological Assessment Resources, Inc., 2010.
Six themes common to all participants were identified: (a) PA includes planned exercise, activities of daily living, and social activities dependent on a schedule or routine; (b) PA means independence and confidence in the future; (c) residents perceived themselves as being active; (d) social comparisons influenced the perceptions of PA; (e) personal health and functioning influenced PA; and (f) motivations and preferences influenced PA. Themes a, b, and c answered the first research question about the experience, meaning, and perception of PA. Themes d, e, and f answered the second research question, about the factors associated with PA. The two cases were contrary to general findings.
PA is Dependent on a Schedule or Routine
”There are activities in the afternoon and sometimes the evening. Monday through Friday they offer those activities. And they let you know, they announce it, come to this or come to that. Monday through Friday they offer activities. Devotions at 9:00, sewing every Tuesday at 3:00, girl comes with her guitar every Wednesday. We take a trip every month.”
PA Means Independence and Confidence in the Future
”I like what I do and it means I’m not relying on somebody else to do stuff for me. I’d feel like an invalid; it would make me feel like a cripple if I couldn’t walk by myself.
I’d feel bad about it [not doing PA] ‘cause I like to keep busy. If I couldn’t walk, I wouldn’t like that at all. I would miss that, yeah. I’d hate to end up in a wheelchair, that would be really hard, difficult.”
“I got a future, I want to get there. But being here and being able to do what I’m doing, it keeps you alive and it makes you worthwhile. I have a plan, just ask me what I’m doing tomorrow.”
Residents Perceived Themselves as Being Active
“I was always really active as a little kid. My goodness, we kept going all the time.”
“I was a tinsmith; sheet metal work. Put siding up, put partitions in, made all the duct work for fresh air exhaust.”
“I did a lot of secretarial work.”
”In the afternoon, I go to craft or we play jeopardy or trivia which I love. At seven we play bingo and then I go back to my room and watch TV until about eleven and then I go to bed. That’s my day.”
Lifelines demonstrated a consistent pattern with higher levels of PA during childhood and young adulthood, compared with later life. Most residents drew lifelines that remained above the neutral horizontal line throughout life with dips in PA related to specific events or illnesses, such as a car accident, stroke, fall, or hospitalization. The lifeline data indicated that PA was currently at an all-time low. One contrary case demonstrated an increase in present PA compared with past PA. For this participant, sedentary behavior was prominent during most of childhood and into young adulthood due to functional disability. PA increased in frequency and intensity in older age because opportunities became available and functional ability had improved since childhood. Current PA for this participant, however, included similar activities engaged in by all the residents and involved mainly seated recreational and social activities. A second contrary case demonstrated that not all residents viewed themselves as active. This participant said that the AL facility was not a place where one engaged in PA but rather rested from life’s labors.
Social Comparisons Influenced PA
“I keep busy here; I’m not just sitting here twiddling my thumbs. It worries me that I’m sitting more than I ever did in my life. I’m well aware I’ve got to keep moving in some way. But I think I do more than most around here.”
“My daughter says, ‘What are you doing out there pulling weeds? You shouldn’t be doing that.’ But I like it!”
Perceived Health and Functioning Influenced PA
“I cough a lot and that worries me, my whole body shakes cause I cough so hard. And that affects your ability to do stuff. But I want to do as much as I can. It means a lot. Because then I’m not just sitting there with my face down.”
Motivations and Preferences Influenced PA
“If I didn’t move, then everything would freeze up, and I would end up in a wheelchair. I do it because I want to keep at least somewhat fit. It makes me feel good. It helps me keep my strength.”
“If there wasn’t anybody there [exercise class], then it wouldn’t be any fun.”
“Well, it’s [delivering mail] extra money. It pays for the extras, you know, like my vitamins.”
“As I say, my day is a little quieter because I tend not to participate in everything. I tried everything just to see what it was. But I love to read, but I don’t go to the book club because I want to enjoy reading for myself, and to sit and pick it apart has never appealed to me. So, I don’t do that. It makes it sound like ‘Well, aren’t you a snob?’ But it just doesn’t appeal to me.”
Discussion
The results of this study provide new insight into the experiences and perceptions of past and current PA, the meaning of PA, and factors associated with PA for AL residents. Six themes provided a description of what the participants experienced and in what context they experienced it. Their PA includes planned exercise, activities of daily living, and social activities largely scheduled with limited opportunities for spontaneous PA. Participants noted that PA is important; it means independence and having confidence and hope in the future. Participants perceived themselves as being physically active throughout their life, even though most of their current activities qualify as sedentary behavior (Sedentary Behavior Research Network, 2017). Perceptions of their current PA were influenced by social comparisons to other residents. They believed that PA is important for maintaining mental and physical health, but at the same time, health and functioning are factors that influence PA.
Although some findings of this study were consistent with community-dwelling older adults, others were unique to the congregate environment of AL. The residents in this study defined the experience of PA in broad terms that included all bodily movement and social engagement. These findings are consistent with the previous research of community-dwelling older adults who identified quilting, travel, card games, and sewing as being part of an active life when describing PA (Aronson & Omon, 2004).
In contrast with the PA of older adults living in the community, PA is scheduled in the AL environment. All participants in this study discussed a schedule of activities established by staff or family, around which most physical activities were performed. However, the interview guide used in this study, which included the weekly activity form, may have contributed to the residents’ description of PA as being tightly scheduled. Yet none of the participants deviated from discussing PA as being scheduled and none voiced dissatisfaction with the schedules or routines. The schedule of activities could contribute to a sense of consistency and comfort for residents, or it could limit autonomy due to set schedules.
The meaning of PA should not be underestimated for AL residents: it means independence and confidence in the future. After moving to AL, many residents experience a keener sense of loss in health and independence and begin to question their future, which can be very frightening (Bekhet, Zauszniewski, & Nakhla, 2009). They, therefore, have a sense of urgency to do everything possible to delay further disability. For this reason, PA is highly valued by residents, even though the types of PA in which they engage are mostly group-based chair activities.
All participants, with the exception of a contrary case, compared themselves to other residents and perceived they were engaged in more frequent and vigorous PA. This is a form of downward social comparison (Taylor & Lobel, 1989). Downward social comparisons make individuals feel better about themselves and can serve as a means of self-evaluation and self-enhancement to promote self-esteem. Downward social comparisons may have a negative effect on health behaviors, such as PA, by providing false assurance that PA levels are adequate. This could serve as a barrier to the adoption of higher levels of PA. Some work has been done in this area, but little is known about the effects of social comparisons on PA (Knight, 2016). Social comparisons are a novel finding in this study and could be an important consideration in the congregate environment of AL, potentially more important than for people living in the community setting.
Personal factors associated with PA emerged that were consistent with the findings from community-dwelling older adults. The residents acknowledged that PA was important for their overall health; in fact, maintaining mental and physical health were major motivators for them. They also recognized that problems with health and functioning had a negative influence on their PA, which is consistent with previous research in community-dwelling older adults (Conn, 1998; McPhee, Johnson, & Dietrich, 2004; Schroeder, Nau, Osness, & Potteiger, 1998). Phillips and Flesner (2013) found that older adults in long-term care settings were motivated to engage in PA by the prospect of delayed disability, improved health, better stamina, enhanced self-sufficiency, and improved mental health.
Residents expressed clear preferences for specific types of PA, some of which were very sedentary, yet consistent with their broad definition of PA. The impact of PA preferences as a personal factor associated with PA behaviors is also found in the literature. Herbert and Greene (2001) identified that participants engaged in PA for longer periods of time when they were allowed to participate in a preferred activity. Hence, offering preferred activities might lead to higher levels of PA (Hummer, Silva, Yap, Toles, & Anderson, 2015; Lihavainen et al., 2012; Peri et al., 2008).
Conclusion
In summary, AL residents defined the experience of PA broadly and viewed themselves as physically active even though most of their activities were sedentary. Residents perceived themselves as being active in part because they compared themselves to each other. PA meant independence and confidence in the future, and they saw it as important for healthy living. Factors influencing PA included personal health and motivations and preferences for PA. Further research is needed to examine the unique effects of the congregate setting and social comparisons on perceptions of PA and PA behavior. Ultimately, this will inform the development of interventions that promote higher levels of PA in AL residents.
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