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Psychosocial barriers must be considered when designing wellness programs for older adults

This is an excerpt from Exercise and Wellness for Older Adults, Second Edition, by Kay A. Van Norman


Identifying Psychosocial Barriers to Exercise

Health promotion specialists have made significant progress identifying and addressing common barriers to physical activity participation, such as transportation, accessibility, cost, environment, and quality programming and staff. However, in retirement communities where none of these identified barriers exist, the majority of residents (often as high as 80%) still remain inactive. Nationwide, 28% of U.S. adults older than 65 report being completely inactive, and 65% fail to meet the U.S. Centers for Disease Control and Prevention physical activity recommendations (Umstattd & Hallam, 2007). I believe that consistently low participation rates in both community-based and senior-living-based venues result from a failure to address psychosocial aspects of physical activity participation (discussed above) and failure to apply behavior change concepts to program design.

Stages of Change

Prochaska’s well-documented stages of change theory offers insight into behavior change. He stated that people go through five distinct stages of change when adopting a new behavior: precontemplation, contemplation, preparation, action, and maintenance. Research by Prochaska and Marcus (1994) shows that only about 20% of people with a less-than-ideal behavior are prepared to change (take action) at any one time. In senior-living facilities, the average rate of participation in physical activity classes hovers around 20% to 25%. An even smaller percentage of community-living older adults regularly participate in physical activity classes.

Applying the stages of change theory to physical activity participation demonstrates that standard health promotion strategies have made progress removing barriers for adults in the action stage of change (those who are ready to take action by attending a class) but have done little to move people from precontemplation, contemplation, and preparation into action. Page 33 outlines the five stages of change and also offers programming suggestions to match each stage of change. See chapter 7 for more specific programming ideas.

Personal Belief Factors

To move people through the first three stages of change into action (becoming more physically active), we must consider factors that contribute to personal beliefs about aging and physical activity. Generational bias, gender bias, and media images of aging and fitness can form unseen barriers to participation and thus prevent a person from moving from sedentary behavior to a physically active lifestyle. Understanding these factors can help us address and remove them.

Generational Bias

Life-course theory, which posits that the historical times and places people experience over their lifetimes have an influence on their lives (Bradley and Longino, 2001), provides an important perspective on generational bias. This life course shapes a person’s personal beliefs, and although vast differences exist among people depending on their personal experiences, important similarities emerge with regard to physical activity.

To effectively deliver the message of wellness to adults at each stage of change, we must understand similarities in the life course of adults older than 60 and how the resulting personal beliefs create the lens through which these people view physical activity programs and program messages.

For example, before today’s labor-saving technology, life was much more physically demanding, forging a strong association (for the 60+ generation) between physical activity and the hard physical work necessary both on the job and at home. Time spent in sedentary relaxation was often considered the reward for a hard day’s work. I have heard many older adults express a belief in their “earned right” to rest and relax, so, for some, age is the ultimate “pass” from exercise. Unfortunately, few recognize the high price (in functional decline) they will pay for prolonged sedentary behavior.

In addition, adults older than 60 grew up during the era of the industrial revolution, when a good portion of time and energy was devoted to conceiving of ways to remove the burden of physical exertion. Therefore, the perception that physical exertion is undesirable and happily avoidable lingers for many adults. Furthermore, automation and labor-saving devices brought a dramatic and welcome change of lifestyle, but only for those who could afford it.

Automation was new and expensive, forging a strong link between financial success and reduced physical exertion. There was a clear distinction between laborers and “gentlemen” who did little physical work and between housewives and “ladies of the house” who had domestic help. This generation started with the push lawnmower, traded up to the power lawnmower, and moved up further to the riding lawnmower, and when they had really “made it” they could hire someone else to mow the lawn. When filtered through generational bias, the message of physical activity as a positive aspiration is a hard sell to many adults.

Gender Bias

Our cultural climate encourages both males and females to be physically active, including engaging in vigorous sports and other physically challenging activities. However, that has not always been the case. Traditional gender roles and gender bias created both active and passive barriers to physical activity for many adults.

As recently as the 1970s, girls and women were actively discouraged from engaging in recreational exercise. School policies required dresses for girls (unsuited to active play), recognized very few sports as appropriate for girls and women, and failed to fund any female teams, effectively relegating girls to a passive role watching boys play. I personally recall that when girls were first allowed to play basketball they were required to play only half-court. The full-court game was considered too vigorous, and vigorous exercise was considered unladylike at best and harmful at worst (to the “weaker” sex). Many women now aged 60+ were, as girls, counseled by physicians and parents to avoid hard physical exertion for fear of damaging reproductive organs.

The perception of exercise as potentially harmful to anyone “delicate” can be pervasive for many adults, even those who believe in the benefits of exercise. This perception can pose a significant barrier to physically frail people or those living with multiple chronic conditions. Current research identifies health problems, fear, and pain as the most commonly perceived barriers to exercise (Cohen-Mansfield et al., 2003; Rasinaho et al., 2007). Benjamin and colleagues (2005) found that physically frail older adults considering exercise were significantly influenced by subjective norms (i.e., the perceived social pressure to perform or not perform a given behavior). For many people, motivation to increase physical activity requires a belief that such a change is desirable, doable, and socially acceptable in light of health status.

Men aged 60+ can also have negative associations related to physical activity. Although boys were encouraged to be more physically active than girls, after a certain age physical activity just for fun was considered a frivolous use of time. A prevailing attitude was that a man with so much time and energy should be doing something productive (Van Norman, 2004). In addition, consider the media images of the 1950s and 1960s showing men coming home from work to be greeted at the door by their wives (with snacks and a newspaper) and encouraged to relax in the easy chair as a reward for a hard day’s work.

Many older men also relate fitness to the tough, grueling, and painful exercise they did in military boot camp, concluding that they don’t want any part of it, that they can’t be successful, that any less vigorous exercise really couldn’t do much good anyway, or some combination of these.

Media Images and Expectations

Helping adults change perceptions of exercise is made more difficult by media portrayals of fitness as an extreme. In addition, media images that reinforce negative expectations of aging, or portray a narrow view of successful aging, also make it difficult for many adults to believe in their ability to retain health and vitality throughout the life span.

The media often portrays fitness as exclusive to the “body beautiful” set, portraying an extreme ideal that is completely unrealistic and therefore personally irrelevant to the majority of the population (regardless of exercise habits or diet). Fitness is placed out of reach of the average person, regardless of age, and the consumer culture’s preoccupation with perfect bodies and youthful images is especially demeaning to older adults. It creates negative associations with age-related changes and aggressively promotes a belief that these changes are highly undesirable (Bradley & Longino, 2001). This image prevents many people from perceiving themselves as capable of being fit.

The prevailing media image of aging is largely dominated by extremes, effectively reducing older adults to caricatures and leaving them both seriously underrepresented and marginalized by the media (Krueger, 2001). One extreme is characterized by frailty and dependence, spawning endless jokes about aging as well as commercials and sitcoms that portray older adults as nonvigorous, sexless, confused, and a collective drag on social programs and the economy. To complicate matters, much aging research done in the past used subjects who were nursing home residents rather than those who lived independently or even a cross-section of the older adult population. This skewed research sample significantly contributed to the overemphasis of the negative aspects of aging and forged the expectation that most older adults will end up frail and dependent. These portrayals are a cornerstone of ageism, which can reduce older people’s opportunities for life satisfaction and dignity (Chodzko-Zajko, 2005).

The other extreme showcases “woofies” (well-off older folks), marketed as slender, healthy, financially secure, and at leisure in some fabulous resort community. They are portrayed as the lucky minority who through remarkable genes and large amounts of money and leisure time have escaped the usual consequences of aging. These extremes dominate the media and our perceptions even though it is clear that the majority of older adults exist in the broad range between these extremes. Both negative stereotypes and limited views of successful aging can have a significant impact on the self-esteem, body image, and self-efficacy of older adults. Setting the bar so high or low has significant implications for the perceived range of available and acceptable lifestyle options for adults to relate or aspire to (Bradley and Longino, 2001).

All of the psychosocial elements discussed ultimately determine a person’s health beliefs, choices, and behaviors, which in turn affect health outcomes. Wellness specialists who understand and apply the psychosocial elements of exercise behavior to program development can help clients activate the power of the mind–body connection to improve well-being.

This is an excerpt from Exercise and Wellness for Older Adults: Practical Programming Strategies, Second Edition.



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