Physical exercise: An enigma for elderly - A qualitativeassessment of percieved motivators and barriers amongelderly using focus group discussion in urban slums ofBengaluru.

Introduction

Physical Exercise (PE) is planned, organized, repetitive movements carried out to sustain or improve health and fitness¹. It reduces the chances of developing cardiovascular diseases, cerebrovascular diseases, diabetes and other lifestyle disorders, especially in those who fall in older age groups. It helps to promote and maintain good health. Physical exercise aids in mental wellbeing and regular exercise also helps to shield from depressive episodes which are very commonly observed in the older population. It improves strength and immunity, develops self-confidence and is an excellent stress buster. In addition, PEv also helps to reduce chances of fall by improving flexibility and building up endurance. However, despite its many benefits, the elderlydo not partake in physical exercise, as much as is actually required. Globally, 1 in 4 adults is not active enough² . In this regard, elderly presents a unique problem. The lack of regular PE leads to reduced bone density and deteriorating physical strength which in turns leads to inability to exercise, leading to a vicious cycle. Many factors can be attributed to the lack of engagement of the elderly like frailty, dependency and lack of knowledge and facilities.³ This problem is further compounded in urban slums where there is a dearth of facilities and spaces for PE and where illiteracy and poverty is highly prevalent. So it is imperative to assess the factors which inhibit and motivate the elderly to indulge in PE in the urban slums of Bengaluru. Therefore this study was conducted to assess the perceived motivators and barriers for physical exercise in elderly among urban slums in Bengaluru

Materials and methods

It was a Qualitative study with 6 sessions of focus group discussions (FGD) conducted among the elderly (more than 60 years of age) of the urban slums in the field practice area of Bengaluru Medical College and Research Institute, Bengaluru in the months of September and November 2019. Each FGD consisted of 8-10 members. A total of 63 elderly subjects were included in the study. The setting of the FGD was discussed and fixed prior to the discussion. The FGD was conducted with the assistance of a facilitator, mediator and a note taker in the local language that the study subjects were familiar with (Kannada). The first 10 minutes of the discussion involved building a rapport with the participants, obtaining informed consent and assuring confidentiality and privacy. The discussion incorporated questions which explored the broad themes of understanding the concept of PE, the measurement of adequacy of exercise, the advantages of participation in exercise, the factors that motivate to engage in PE and the perceived barriers that prohibit them from carrying out PE. The sessions were audiotaped with the participants’ consent. Each FGD lasted for 30-45 minutes, with equal time and opportunity for each subject. Open ended questions were asked and diversions from the topic at hand were avoided. The discussions were recorded by the note takerverbatim. The socioeconomic data was collected and analyzed. Transcripts were prepared from the translated notes and analyzed using Atlas ti software. Ethical approval was obtained from the Institutional Ethics Committee.

Inclusion criteria

Participants who are more than 60 years of age, willing to give informed consent

Exclusion criteria

Bed-ridden patients, Elderly with major psychiatric illnesses

Data analysis

Transcripts were made of the FGD and common themes identified. The transcripts were analyzed using Atlas ti software. Results were expressed in network of codes.

Results

The mean age of the participants was 69.3 years. 41.26 % (26) of participants belonged to the age group 61-70. 91.30% (57) of participants were female.86.96% (54) of participant were Hindus.69.57% (43) of the participants were widowed, 91.30% (57) were illiterate.

The major themes identified in the FGD were the concept of physical exercise, adequacy of exercise, benefits of physical exercise, motivators and barriers to physical exercise.

Concept of physical exercise among the elderly:

The elderly people were of the opinion that any activity which causes tiredness can be regarded as physical exercise.

“Something that makes tired, makes sweat”

They discussed walking and stretching to be acceptable forms of physical exercise.

“Walking….. Exercise is walking”

“when I at home, for good health I stretch”

Regular household chores were included as forms of physical exercise by most of the participants.

“I have house work……. Cleaning, looking after children, cooking. That sufficient”

The elderly participants also opined that physical exercise was an activity which was intended for younger individuals with better stamina and physical condition and not something to be pursued at an older age.

“Exercise? At this age? See I am old. No…… For young… with more power and strength.”

Perceived benefits of physical exercise:

The participants opined that physical exercise has positive effects on the overall health and improves their strength.

“Exercise is good…. Makes strength”

Others were of the opinion that physical exercise improves the mental health and decreases tension and stress.  

“Exercise….. makes me happy. Free feeling”

The participants were also aware that regular physical exercise helps to reduce the risk of developing many non-communicable diseases. In addition, the subjects also have awareness that PE helps to manage and reduce the damage caused due to the NCD.

“BP, sugar is there…. Doctor told daily walking can BP sugar reduced. “

“I have leg pain……. Doctor said due to me being overweight…. Told me to walk, exercise”

In some cases, the subjects opined that doing PE helps them to sleep better.

”I sleep good afterwards….”

Perceived adequacy of physical exercise:

Most of the subjects were of the opinion that the household chores or their routine occupation is also to be considered as physical exercise and that it is adequate for their age.

“I walk here and there as part of work. That is exercise itself”

“I have house work……. Cleaning, looking after children, cooking. That sufficient”

“I clean temples. It is lots of hard work. That is enough for this age. Too tired to do more”

Percieved motivators for physical exercise

The most common motivation for engaging in physical exercise as cited by the participants was the availability of accessible facilities nearby.

“Lalbagh is so nearby. Only some 10-15 minutes walking distance. Free also.”

Another motivating factor to physical exercise is the appropriate weather condition for physical exercise.

“Good climate there in Bengaluru. Not much rain. So walking not disturbed”

“Not raining is good time for walking”

The next common motivation stated by the subjects was safety of the roads and paths in their area.

“Not much dogs. Traffic also less. Can walk without any fear.”

Advice by medical practitioners to engage in PE to reduce weight, manage their lifestyle illnesses or as general advice was also reported by subjects as a major

“My sugar… is high. So my doctor told if I walk it will reduce”

“I have such pain in my legs. Doctor told weight reduce then my pain will go”

“I go to doctor for cold and all…… sir sometimes tells to do exercise and walk”.

Some of the participants were of the opinion that the need for socialization motivates them to engage in PE.

“I walk around the street to talk to neighbours and everyone… I like to know what is happening around me…. So I walk….”

Alleviation of boredom and force of habit were also stated as motivators for PE.

“At home sitting idle, I don’t like. So I walk around sometimes”

“After Fajr prayers, we not supposed to sleep, no? So I walk around street till sun is up. Now, it is a habit”

Percieved barriers to physical exercise 

The subjects opine lack of interest as the most important barrier to physical exercise.

“I don’t like….,.. No interest to do”

The next most discussed barrier to PE was arthritic conditions which prevent them from taking part in PE.

“Such pain in my knees and legs. I can’t walk only, how I can exercise?”

Lack of knowledge was also reported to be a major barrier to indulging in PE.

”I am healthy. I don’t have any illness. Why I should do physical exercise?”

“I don’t know why we should walk…….. no one has told me why it is so important”

Visual impairment was also stated to prevent them from engaging in regular exercise.

“I can’t see. Even with glasses. I am afraid I may fall and get hurt.”

The subjects also stated that lack of peer and self-consciousness and time constraint to be major barriers to PE.

“Parks and all filled with young ones. So embarrassed to walk there. If someone else my age was there………..”

“I sell vegetables. I wake at 6o’clock to go to market. Evening I come back. Where is time?

Discussion

Physical exercise is a very efficient health promoting activity among adults, particularly among the elderly. Hence identifying the perceived motivators and barriers to PE is a very imperative task.The mean age of the participants was 69.3 years.41.26 % (26) of participants belonged to the age group 61-70. 91.30% (57) of participants were female.86.96% (54) of participant were Hindus.69.57% (43) of the participants were widowed, 91.30% (57) were illiterate. In a similar study conducted by Rasinaho et al, the mean age of the participants was 77.9 years. In a different study conducted by Shaikh et al, the mean age of the participants were 71.

In the present study, participants identifies PE to be any activity that makes one tired or sweat. The elderly also cite walking and stretching to be appropriate forms of exercise for them. The study by Mathew et al also stated walking to be an apt form of PE.⁴

In the present study, most of the participants opined that the house chores and the routine occupation that they engage in was adequate as physical exercise for their age. This is in agreement with the results of the study by Mathews et al, where the subjects reported that daily house work were sufficient as PE. This demonstrates the lack of awareness among the elderly regarding the PE. Since, household chores and other routine work is carried out in a leisurely manner, it is not expected to expend much energy and hence cannot be strictly considered to be physical exercise. This result showcases the misunderstandings and myths prevalent among the urban poor, where literacy is low.⁵

The major motivating factor for the elderly to participate in PE was cited to be the presence of accessible, inexpensive facilities and appropriate weather for the same. Many subjects spoke of the convenience of having approachable parks (Lalbagh) and roads and how these facilities motivated them to be more regular in their physical exercise. The climate of Bengaluru was also noted by the subjects to be pleasant and appropriate for PE. This observation also concurs with the result obtained in the study by Mathews et al where the pleasant environment and good walking routes were regarded as motivators for regular exercise. A similar result was obtained in the study by Rasinaho, where good environmental factors facilitated PE. From this observation, the myth that the urban poor do not have any easily accessible facility for PE can be effectively debunked. Contrary to popular belief, the urban slums do have adequate facilities that encourage PE, but these are not utilised properly by the slum dwellers. Good exercising facilities are very much a motivating factor for PE.⁶

Safety was also cited as a major faciliatator for PE. The absence of dogs and heavy vehicle traffic in their walking routes was noted by many of the subjects and these motivated them to do regular exercise. The belief that an urban slum as a dangerous area for the elderly is also effectively contradicted by this observation.⁸ This is similar to the study by Mathews et al, where safety was not considered a problem that deters the participants from PE. However stray dogs were regarded as a dilemma that led to many participants not taking part in exercise.

Advice from medical practitioners were also stated to be a major motivator for PE. The doctors whom they had been consulting would often advise them to walk or exercise regularly to reduce risk of disease, reduce weight or manage any lifestyle disorder. As most of the elderly do have comorbidities, the advice from their doctors are avery strong motivator for PE. However, it is to be noted that even elderly with no comorbidities must exercise to maintain their health so it is advisable for doctors to prescribe PE as a health boosting tool for all the elderly individuals and not merely the ones that have health conditions. Similar results were obtained in the studies conducted by Rasinaho et al and Shaikh et al, where the preventive benefits of PE were regarded as major motivators.

Need for socialization, force of habit and alleviation of boredom were the other motivating factors identified in this study. Need for human contact is an overlooked factor that can definitively lead to increased levels of PE in the elderly. The geriatric population are often ignored at home, unable to do regular occupation and feel isolated from their younger counterparts. These factors often contribute to the development of depression in the elderly. Hence, if PE is promoted to the elderly as a way of socializing, they will take far more initiative for it. This is in concurrence with the study by Rasinaho where human social contact was described as a powerful motivator to PE. Shaikh et al also observed the result that the need for socialization can produce a great initiative among the elderly to conduct exercise. The study by Mathews also demonstrates that company can induce many to take up regular PE.

The major barrier to PE identified in this study is lack of interest. This shows the need for health promotion and appropriate health education in the urban slums. This issue can only be tackled by comprehensive behaviour change communication. Contrastingly the study by Rasinaho et al showed that lack of interest and knowledge was not regarded as a barrier, and in fact most of the participants had interest to participate in PE, but did not have the time or facilities for it.

Arthritic conditions and Visual impairment were another barrier that deterred the subjects from participating in PE. As the age increase, the effects of age also become evident in the form of various forms of arthritic and visual complaints. This result is similar to the results obtained in study by Rasinaho et al, and Shaikh et al, where medical illnesses were cited to be a major barrier to PE. Physical discomfort due to Arthritis was also reported as a barrier to PE in the study by Mathews.

Lack of knowledge was also cited as a barrier for PE. The participants were of the opinion that they were healthy and that physical exercise was not a necessity of them. This shows the need for extensive health education and the need to emphasize that PE is a form of health promotion that is essential for everyone irrespective of their health education.9 This is in contrast to the studies conducted by Rasinaho et l, Sheik et al and Mathews et al respectively, where the subjects are aware of the importance of PE and lack of knowledge was not a major barrier to PE.

Lack of peer support and self-consciousness is also a major barrier. Elders often feel embarrassed to frequent parks which are often filled with young individuals. Despite having interest to participate in PE, the fact that facilities they attend are almost devoid of other elderly is a great source of humiliation for the elderly. This further alienates them from exercise, thereby considering PE to be an activity purely for the younger generation. This result is also reflected in the study conducted by Mathews et al, where the participants were of the opinion that peer support could be great motivator for PE.

The present study also found that time constraint is a major barrier to PE. Indefinite daily schedules and daily occupation make it difficult for them to indulge in PE. This result showcases that the elderly do not place much importance to PE. They place their occupation and housework at higher rungs as compared to PE. The importance of regular exercise must be explained to the elderly and that making time to do activities that improve their health will be extremely beneficial for them in the long run. This is in accordance with the studies conducted by Mathews et al, Rasinaho et al.

In the present study, the most commonly cited benefit from PE was stated to be maintenance of good health, followed by sense of well being and management of chronic illnesses. The source for the information for PE was usually medical practitioners and family members. Since the elderly are at risk of many diseases and are constantly anxious about their own health, the promotion of PE as a health promoting activity can never be overemphasized. However, in the study by Shaikh et al, the most common benefit was improvement in functioning of the body. Exercise also had improved their stamina and strength. Another major benefit perceived by the elderly in this study was improved sleep and proper mental wellbeing. These results are in accordance with the study by Shaikh et al in which improved sleep and relieved stress were 2 benefits perceived by the elderly. In a study by Mathews et al, the major benefits as perceived by the participants were maintenance of function and disease prevention.⁵

According to WHO, the elderly must engage in at least, 150 minutes of moderate intensity physical activity per week, or in the case of elderly with decreased mobility, physical exercise must be done at least 3 times per week. However, in the current study, most of the participants did not participate in regular exercise. They were also of the opinion that household chores and routine work is adequate enough to be considered as PE.

Conclusion and recommendations

Most of the participants were of the opinion that house work and regular chores were physical exercise. The source of information regarding physical exercise were primarily from acquaintances and family members.The main motivators of physical exercise was safe, accessible facilities, advice by doctors and safety. Hence, these motivators must be encouraged as far as is possible.The medical practitioners who advise their elderly patients regarding the importance of PE must also extend the courtesy to their younger caretakers so that with the motivation of the entire family, the elderly can truly participate in PE. PE must be tailored to each individual according to their boundaries and limits. Field workers must make a concerted effort to educate the elderly individually in their homes about the importance and practices of PE. Safe facilities can also make the elderly feel at ease and participate whole heartedly in PE.

The main barriers were lack of interest, joint pains and lack of knowledge. Lack of interest is major barrier to PE which can be tackled by comprehensive behavior change communication strategies. Focus must be made on the various advantages of doing PE. It must be made clear that PE is not a ‘youth-specific” activity but an activity to be indulged in by all ages. Since pain and visual impairment are two major barriers, the type of exercise prescribed must be tailored. Rigid guidelines must be avoided. Lack of knowledge is also a major barrier that can be tackled by proper health education and health promotion.Peer support and socialization would facilitate better participation in physical exercise.The introduction of exclusive “seniors-only parks” which contain special exercise equipment tailored for the elderly can be very appealing and can motivate those who are too self-conscious to participate in PE without any fear or embarrassment. Rather than seeing PE as a chore, the elderly must be educated on how PE is actually a means to socialise and a great opportunity to make acquaintances who have common interests.Medical Practitioners have to advise physical exercise to the healthy elderly people as well to promote their health.