In order for complex health issues to be appropriately understood, multiple levels of influence must be examined. Strategic planning involving critical analysis of the multifaceted factors that influence health and behaviour are necessary for health promotion programs to be effective. Relevant models and theories can provide a framework to better understand the intricacies of behaviour change. The Social Ecological Model, see Figure 1, is a multi-level approach which recognizes individuals as part of larger social systems and interactions between individuals and environments as essential drivers of health events (Garcia, Diez Roux, Martins, Yang, & Florindo, 2017). When using the Social Ecological Model to approach health issues, five levels of influence are considered – Intrapersonal, Interpersonal, Organizational, Community, and Public Policy (Simpson, 2013). I will use this model as a framework to examine factors influencing physical activity levels in older adults, recognizing the dynamic interrelations between multiple levels of influence between a person and their environment. As our population ages, we recognize that physical activity will contribute to reducing the burden of disease, disability, and the cost of health care. The video "Get Fit for Active Living" below from the Canadian Centre for Activity and Aging (2015) further explains the role of physical activity to maximize our quality of life and healthy aging potential.
Lack of physical activity is a prevalent public health issue, despite our knowledge of the well-documented health benefits of physical activity to combat chronic disease and improve well-being. In Canada, recommended physical activity levels to achieve health benefits for older adults are still far below daily guidelines. Only 14% of older adults aged 65-79 are meeting the Canadian Physical Activity Guidelines of 150 minutes of moderate to vigorous physical activity per week in bouts of 10 minutes or more (Public Health Agency of Canada, 2018). I believe most older adults are not aware of these guidelines and require support at multiple levels to achieve higher rates of physical activity. In the Figure 2 below, the many reasons to support physical activity for improved health are shared.
Our behaviour and lifestyle choices are what come to mind when we think of the major influences on our individual health. Individual behaviour and lifestyle interventions have typically been the main approach for tackling the inactivity levels of Canadians. By only focusing on this individual level of influence, we miss key influences on a broader scale which have a significant impact on determining our health and engagement in physical activity. Now, more than ever, physical activity has been designed out of our lives and the barriers to easily participate in physical activity are steep. In my professional practice, I provide direct support to increase older adults’ physical activity levels to improve functional ability and independence. I often hear these barriers to participate in physical activity from my older adult home care clients: limiting health conditions, chronic pain, fear of falling, dislike of using mobility aids, and lack of assistance, support, or resources. Many clients have difficulty with stairs or have very low endurance which restrict their ability to safely walk in their community or outside of their home. With my involvement, a key goal is for my clients is to increase their confidence and skills to navigate their home environment safely. As a qualified exercise professional, I can assist clients to reach these goals to impact their health and optimize their strength.
Sedentary behaviour increases with age. Older adults spend 10.1 hours/waking day sedentary. Active transportation decreases with age. Older adults aged 65-79 spend 1.5 hours/week using active ways to get places, significantly lower than the general adult population. Adults aged 80+ spend even less time; less than 1 hour/week.
(Public Health Agency of Canada, 2018).
Many of the barriers I presented are at the individual level, however the negative view of aging and the physical environment can hold strong, compounding influences. Boulton, Horne, and Todd (2018), illustrated their findings on what impacted older adults in West Yorkshire, United Kingdom to engage in physical activities from a Social Ecological Model approach, see Figure 3 below. Each level is interrelated and can influence and impact each other. I believe these results would be similar for older adults in Canada.
Below, I will present the influences of physical activity engagement for older adults in Canada at each level of the Social Ecological Model, beginning with the Intrapersonal Level, where individual beliefs, attitudes, and skills are of influence.
Intrapersonal Level:
At this level, multiple influences include one’s personal beliefs, knowledge, skills, health status, and health literacy. The level at which they were previously active in childhood and adulthood will influence how active they are as they age. Motivation at an individual level is complex and, for an older adult, often powered by the intent of preventing ill health or decline. Frequently, a limiting factor can be mobility restrictions or fear of falling which restrict engagement in physical activity, especially if there is no access to appropriate exercise training. Something as simple as owning a dog and the responsibility of dog walking can be of influence to older adults, as seen in the study by Boulton et al. (2018).
One’s perceptions on aging will influence their physical activity levels, as some believe that decreasing physical activity is a normal part of aging. The physical activity type, intensity, or frequency can be modified to remain safe and appropriate for an older adult. The confidence to overcome barriers and then to make and sustain feasible changes are key factors in the likelihood of making lifestyle changes among older adults (Jones et al., 2018). The focus of physical activity promotion programs should prioritize sustaining engagement from older adults and to provide appropriate adaptations to accommodate mobility limitations. Groups at risk for lower physical activity levels include older adults with low income, low education, living with disabilities and/or chronic health conditions, living in institutions or in isolation (Jones et al., 2018).
The next Interpersonal Level of the Social Ecological Model expands to include family, friends, and social networks and their impact on physical activity engagement.
Interpersonal Level:
The people whom one directly socializes with (family, spouse, friends, peers) and receives support from (health providers) will influence their physical activity levels. It is beneficial to form close relationships with people who encourage engagement in physical activity. Group settings for supportive physical activity can promote companionship and socialization for older adults. Physical activity in an atmosphere which is friendly, welcoming, and enjoyable is important to older adults (Boulton et al., 2018). If one is around others who do not participate often in physical activity, motivation to stay active will likely decrease.
In my experience, family support is crucial for high physical activity levels in older adults. Family can act as a powerful enabler of physical activity engagement and sustainment. In some cases, however, family or health care workers can be a hindrance to activity levels. Family may not provide physical activity support or encouragement out of fear of harming a loved one. Sedentary behaviour may be promoted by the family of older adults seen as a way of being helpful or with the intent to prevent a fall. This counter-intuitive thinking should be re-framed instead with providing empowerment to older adults to adopt and maintain healthy behaviours and incorporate physical activity in each day.
At the next level - Organizational Level, I examine how social structures and organizations influence the physical activity level in older adults.
Organizational Level:
As a diverse nation, culturally relevant programming is a fundamental factor to influence Canadians and physical activity levels. Jones et al. (2019) stresses the importance of community physical activity promotion programs to be integrated into settings that have the infrastructure, culturally competent staff, access to exercise specialists, and experience in providing outreach and delivering the program to diverse populations. Programs and resources should be accessible, affordable, and geared towards older adults. The perceived environment hosting the physical activities should provide flexible, variable, and adaptable options to suit the needs of older adults, as described by Boulton et al. (2018). Instructional leaders with the quality and knowledge to tailor interventions to older adult individuals is key at the organizational level to influencing physical activity.
Next, I will examine the relationships between organizations at the Community Level which includes social norms, cultural values, and the built environment.
Community Level:
This level represents how the individual is socially connected, influenced by socio-cultural norms and expectations, and their interaction with built and natural environments where they live (Jones et al., 2018). The social climate and perceptions of physical inactivity in Canada can be reshaped by the changing of societal norms and beliefs. Yun et al. (2018) found older adults meeting physical activity guidelines had higher odds of reporting seeing people walking or exercising, or kids playing actively outdoors in their neighborhood. The environment walkability, street connectivity, neighourhood safety, and access to green spaces all influence physical activity levels.
At the most expanded level, Public Policy, the corresponding initiatives, laws, and regulations will impact physical activity levels in older adults.
Public Policy:
This integral level will shape and support elements within the model that can facilitate improved physical activity levels in older adults. Initiatives across governments can enhance physical activity engagement through funding for quality, evidence-based programs and resources. Appropriate support and strategies at the policy level can impact the capacity for older adults to feel able to easily participate in physical activity. Some examples of policy developments for healthy aging include age-friendly community movements, social isolation reduction strategies, and particiPACTION. Canada has developed a national policy document “A Common Vision for increasing physical activity and reducing sedentary living in Canada: Let’s Get Moving” which acknowledges the interacting contributing factors at multiple levels, see Figure 4 below.
Conclusion:
It will take multiple, evidence-based strategies to affect beneficial change at multiple levels of the Social Ecological Model in order to improve physical activity levels of older adults in Canada. The formulation of an acknowledged physical literacy strategy targeted and developed for older adults and seniors would be of benefit to address the complexity of influences. In Figure 5 below, a proposed Physical Literacy Model for Older Adults, created with an Ecological Approach developed by Jones et al. (2018) is presented.
Physical literacy is defined as “the motivation, confidence, physical competency, knowledge and understanding to value and take responsibility for engagement in physical activities for life” (Jones et al, 2018). Ultimately, increased participation and competency in physical activity can help reduce negative attitudes towards aging and promote life-long sport, recreation, and physical activity engagement.
References:
Boulton, E. R., Horne, M., & Todd, C. (2018). Multiple influences on participating in physical activity in older age: Developing a social ecological approach. Health Expectations, 21(1), 239-248. Retrieved from https://doi.org/10.1111/hex.12608
Centre for Active Living. (n.d.). Centre Resources & Projects. Retrieved from https://www.centre4activeliving.ca/our-work/centre-resources/
Garcia, L. M. T., Diez Roux, A. V., Martins, A. C. R., Yang, Y., & Florindo, A. A. (2017). Development of a dynamic framework to explain population patterns of leisure-time physical activity through agent-based modeling. The International Journal of Behavioral Nutrition and Physical Activity, 14(1), 111. Retrieved from https://ijbnpa.biomedcentral.com/articles/10.1186/s12966-017-0553-4#Abs1
Jones, G. R., Stathokostas, L., Young, B. W., Wister, A. V., Chau, S., Clark, P., Duggan, M., Mitchell, D., … Nordland, P. (2018). Development of a physical literacy model for older adults - a consensus process by the collaborative working group on physical literacy for older Canadians. BMC geriatrics, 18(1), 13. Retrieved from https://bmcgeriatr.biomedcentral.com/articles/10.1186/s12877-017-0687-x
Paterson, D., & Stathokostas, L. (2015, January 30). Physical Activity and Aging in Canada Video Series. Retrieved from https://www.uwo.ca/ccaa/research/stories/aging_demographics.html
Public Health Agency of Canada. (2018, May 30). A Common Vision for increasing physical activity and reducing sedentary living in Canada: Let's Get Moving. Retrieved from https://www.canada.ca/en/public-health/services/publications/healthy-living/lets-get-moving.html
Simpson, V. (2015). Models and theories to support health behavior intervention and program planning. Health and Human Sciences. Retrieved February 20, 2019 from https://mdc.itap.purdue.edu/item.asp?itemID=21894
Yun, L., Vanderloo, L., Berry, T. R., Latimer-Cheung, A. E., O'Reilly, N., Rhodes, R. E., . . . Faulkner, G. (2018). Assessing the social climate of physical (in)activity in canada. BMC Public Health, 18(1), 1301. Retrieved from https://doi.org/10.1186/s12889-018-6166-2
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