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Physical activity determinants of older women: what influences activity? (CE Series).

The number of persons over age 65 in the United States will increase by 7% to 20% in the next 30 years (U.S. Census Bureau, 1996). This demographic shift is occurring disproportionately; there is a higher percentage of older women. These women experience unique social and personal factors that influence their health behaviors and make them particularly in need of targeted health promotion.

Ninety percent of older adults have at least one chronic illness (Huffman, Rice, & Sung, 1996). An increase in functional impairments also occurs with age (Maddox & Clark, 1992). Notwithstanding these conditions, older adults report themselves to be generally well. Although physical health generally declines with age, mental health measures improve (Laforge et al., 1999).

Overall, older women experience poorer health than older men (Booth, Bauman, Owen, & Gore, 1997). Women live longer than men, have higher morbidity rates, and experience more years with disability than their male counterparts (Katz et al., 1983). Their disabilities may also be more debilitating, and they may require more health care in older age, creating an increased personal and financial burden because they also have a four-times greater likelihood of living alone (Arber & Ginn, 1994).

Cardiovascular Disease

Cardiovascular disease (CVD) causes more deaths than any other disorder in the United States and is the major cause of morbidity and mortality in older women (Centers for Disease Control and Prevention [CDC], 2002). Approximately 50,000 more women than men die from CVD each year (Fuster, 1999), even though women follow the male pattern of disease development by 10 years (Holm & Penckofer, 1992). The decreased CVD mortality rate over the past 2 decades has favored men disproportionately (Sahyoun, Lentzner, Hoyert, & Robinson, 2001). The postmenopausal loss of the protective effects of estrogen is believed to play a role in these CVD risks (Writing Group for PEPI, 1995).

In addition to their increased risk for morbidity and mortality from CVD, women face increased barriers to health care treatment (Sullinger, 2000). Previous studies have also excluded women; hence less is known about CVD in this group (Deaton, Kunik, Hachamovitch, Redberg, & Shaw, 2001). Further barriers to health include low social support in women, which is associated with an increased rate of CVD (Brezinka & Kittel, 1995) and higher CVD mortality (Kaplan, Seeman, Cohen, Knudsen, & Guralnik, 1987). Specific areas within the United States demonstrate various CVD mortality rates, indicative of heterogeneous risk factors for women (CDC, 2002). Barriers of cost, access, and acceptability of health care providers and health promotion information are factors likely related to these differences.

The Heritage Family Study found that high body fat and low cardiovascular fitness level are significant predictors of CVD risk (Katzmarzyk et al., 2001). Higher body weight often is found in individuals with less physical activity (PA) (Sternfeld, Ainsworth, & Quesenberry, 1999), but weight loss can occur with regular PA even if accumulated in short bouts throughout the day (DeBusk, Stenestrand, Sheehan, & Haskell, 1990; Jakicic & Wing, 1997; Jakicic, Wing, Butler, & Robertson, 1995). In older adults, mild-to-moderate amounts of excess weight have been considered longevity promoting; however, obesity is not considered beneficial (Andres, 1981).

Successfully managed hypertension in an older adult population reduces morbidity and mortality from CVD (Kane, Ouslander, & Abrass, 1994). Women experience elevated blood pressure (BP) more often than men (Jenkins et al., 1994), and hypertension is a stronger correlate of CVD in woman over 75 years than in men of that age (Douglas & Ginsburg, 1996). Improvements in both systolic and diastolic BP readings have been found following PA interventions in sedentary adults (Dunn et al., 1999). Moreover, even in adults with mild hypertension, the combination of PA with weight reduction can reduce systolic and diastolic BP readings (Blumenthal et al., 2000). For any age group, CVD risk-factor reduction leads to improved health and longevity (Anderson, Schnohr, Schroll, & Hein, 2000; Blair et al., 1995).

The true costs of CVD to older women and their families are significant. Women with CVD, while adapting to the disease and symptoms, are faced with lifestyle modifications, diagnostic testing, and medications (Mosca et al., 1999). Furthermore, women are the primary care providers in a family. From 7% to 15% of grandparents provide extensive childcare to their grandchildren, and the majority of these care providers are the grandmothers (Fuller-Thomson & Minkler, 2001). In addition to these personal and family costs, the financial burden of CVD to society was estimated to be nearly $300 billion for 2001 (American Heart Association, 2000).

Physical Activity

The distinction between PA and exercise is significant for this review. Physical activity is the broader of the two terms, indicating any activity that moves the body and thereby increases energy expenditure. Exercise is the subgroup of PA that is planned, structured, and repetitious for the intention of increasing some parameter of physical fitness (Bouchard & Shephard, 1994; Caspersen, Powell, & Christenson, 1985; U.S. Department of Health and Human Services [DHHS], 1996). Because exercise is too narrow a term to capture the intent of PA (reduction of cardiovascular risk factors [King, 1994]), PA is the term used in this article.

A sedentary lifestyle has been implicated as a major risk factor for CVD mortality (American College of Sports Medicine [ACSM], 2000). Physically active persons tend to develop less CVD, and disease in active people tends to develop later than for inactive persons (ACSM, 2000).

In addition to the cardiovascular benefits, regular PA prevents or treats many causes of morbidity and mortality such as diabetes, hypercholesterolemia, and osteoporosis (DHHS, 1996). Additionally, regular PA improves physical parameters of body habitus, fitness, endurance, strength, and flexibility (ACSM, 2000). Evidence from Alemeda County, Framingham, and other long-term studies demonstrates that PA is associated with better health as well as longer life. Those who are physically active have lower mortality than sedentary individuals (Fried et al., 1998; Kaplan et al., 1987; Kaplan, 1997; Kushi et al., 1997; Paffenbarger et al., 1993; Sherman, D'Agostino, Cobb, & Kannel, 1994) and have higher physical functioning (Guralnik & Kaplan, 1989; Judge, Schechtman, Cress, & the FICSIT Group, 1996; Kaplan, Strawbridge, Camacho, & Cohen, 1993) despite the usual decline in functioning seen with increasing age (Maddox & Clark, 1992). Regular PA is also associated with a decrease in falls in this population (Buchner et al., 1997), while increased functional capacity is associated with maintenance in the community, rather than nursing home placement (Greene, Ondrich, & Laditka, 1998).

Despite the fact that benefits of regular PA outweigh the risks, participation rates are low (DHHS, 1996). Although nearly every older adult can successfully perform cost-effective PA, the rate of its performance decreases with age (Caspersen & Merritt, 1995; CDC, 1995; DHHS, 1996). Women continue to have higher rates of inactivity than men throughout all ages of adulthood (Caspersen, Pereira, & Curran, 2000).

Many determinants of PA are susceptible to interventions (Wilcox & King, 1998). Determinants of personal and environmental factors should be prioritized in high-risk groups such as the elderly and isolated (Dishman, 1994).

Consideration of all physical activities is particularly applicable for women, because PA in this group is otherwise underestimated if housework and occupational energy expenditure are not considered (Dan, Wilbur, Hedricks, O'Connor, & Holm, 1990). Two new categories of PA, volunteer work and religious activities, were recently added to a compendium of energy expenditure (Ainsworth et al., 2000). These activities are particularly important with older adults and minority older adults, respectively. This inclusion reflects the broad range of lifestyle physical activities within community life (Dunn, Andersen, & Jakicic, 1998).

Conceptual Framework

The Model of Physical Activity Behavior (MPAB), a modification of the Interaction Model of Client Health Behavior (IMCHB) (Cox, 1982; Cox & Roghmann, 1984; Cox & Wachs, 1985), demonstrates the relationship among the determinants of PA and PA behavior. The IMCHB has been modified previously for a physical activity intervention study (Wilbur, Miller, & Chandler, 2003). The MPAB (see Figure 1) frames the relationship between background determinants (demographic characteristics, environmental resources, social influence, and current health), which are not readily susceptible to interventions, and the intrapersonal determinants (motivation, cognitive appraisal, and affective response), which may be responsive to interventions. The three intrapersonal determinants are key components of the MPAB, mediating the background variables and subsequent behavior. Health outcomes include the PA behavior and the resultant reduction in CV risks.

[FIGURE 1 OMITTED]

The Literature

An important critique of regular PA research concluded that determinants that best facilitate PA are not known (Dishman, 1994). The purpose of this literature review was to identify the background and intrapersonal determinants of PA in women older than 65 years of age. Once these determinants are identified, interventions can be developed to increase the PA levels of older women and subsequently reduce CVD risks.

To evaluate the progress in the science since the Dishman critique (1994), Medline, CINAHL, and PsychoInfo were searched for the years 1994-2001 for the terms exercise or PA and women with the limitation in population to those 65 years and over.

Sixteen papers met inclusion criteria (see Table 1). Seven of the studies either offered no theoretical basis or listed the concept of self-efficacy as the theoretical underpinning.

Background Determinants

Demographic characteristics. Age, gender, socioeconomic status indicators of income and education, marital status, and race are often used in PA determinant studies. Physical activity rates are consistently found to decrease with age (Ebrahim & Rowland, 1996; MacLeod & Stewart, 1994). Additionally, socioeconomic indicators of home ownership (Ebrahim & Rowland, 1996), higher income (Conn, 1997), and higher education (MacLeod & Stewart, 1994) correspond to higher rates of PA participation. Marital status demonstrates equivocal results in older women. One study found more physically active older adults in the nonmarried group (Scharff, Homan, Kreuter, & Brennan, 1999), while another found more PA in the married group (Van Den Hombergh, Schouten, Van Staveren, & Kok, 1995).

Three studies specified the population by race. Two studies explored differences in determinants of PA in older adult women across races (Clark, 1999; Fitzgerald, Singleton, Neale, Prasad, & Hess, 1994). The population in the remaining study was older, urban African-American women (Jones & Nies, 1996). A positive relationship between exercise beliefs and exercise activity was found in one study that compared African-American and Caucasian rates of exercise (Fitzgerald et al., 1994). Older Caucasian women, when compared to their African-American counterparts, experienced higher rates of PA. In all three of the studies that presented information on African Americans, exercise was measured as the outcome variable. The emphasis on exercise, rather than PA, in these studies likely under-represents the energy expenditure of both groups of older women and may confound the results.

One of these studies found that both groups cited weather as a barrier, but the Caucasian group added location access and availability as well as cost to their list of barriers (Clark, 1999). Older women of different races from the same city experience distinct barriers to exercise. The explanation of these differences was not explored; however, it is likely that the physical and social environments in which the women reside were quite different.

Environmental resources. Environment is consistent across age groups as an influence upon PA (Sundquist, Malmstrom, & Johansson, 1999). Socioeconomic status likely represents environmental barriers or facilitators of regular PA performance (Clark, 1995). For example, poor neighborhood safety had a negative relationship with PA performance for older adults (CDC, 1999).

Environmental barriers identified by studies in this literature review, which correspond to less PA, include poor or no sidewalks or benches, fear of crime, and weather (Clark, 1999). General fear of neighborhood safety was a barrier cited by some urban older women (Jones & Nies, 1996), whereas stairs in the home may have promoted PA (Van Den Hombergh et al., 1995).

All but two studies were located in urban or undeclared population areas. The influence of population density was evaluated by these two studies (Scharff et al., 1999; Wilcox, Castro, King, Housemann, & Brownson, 2000). Wilcox et al. (2000) compared rural and urban determinants as part of a larger study of women over 40 years. The only finding concerning older women was that urban women over 70 years of age were more active than their rural counterparts.

Scharff et al. (1999) compared residents in small towns and farm areas in the nonurban Midwest on determinants of PA, with no differences found by location. Identified trends included increased PA in the rural older women population, with more frequent reporting of exercise activities in the towns. A minority of both groups, however, met the standards set by the Surgeon General. As with many urban-based studies, more education, married status, and younger age were associated with increased PA.

Social influence. Because women have not traditionally been socialized to exercise (Vertinsky, 1998), it was not unexpected to find that social influences or social supports were positively related to PA with older women (O'Brien Cousins, 1996). Specific influences such as socializing, having a companion (Ebrahim & Rowland, 1996), and family support (Paxton, Browning, & O'Connell, 1997) were associated with an increase in PA in older women. However, in the one study that evaluated medical advice, this form of support did not demonstrate a significant association with PA (Paxton et al., 1997).

Previous health. Better overall health was consistently related to increased PA in this literature review (Ali & Twibell, 1995; Conn, 1997; Dornelas, Swencionis, & Wylie-Rosett, 1994; Ebrahim & Rowland, 1996; Van Den Hombergh et al., 1995). Positive health behaviors such as diet and stress management (Conn, 1997), cancer screening (Ebrahim & Rowland, 1996), and nonsmoking (Conn, 1997; Dornelas et al., 1994) corresponded with current PA. Health determinants of PA included physical components of health and functional status (Ebrahim & Rowland, 1996; Van Den Hombergh et al., 1995), as well as symptom control (Paxton et al., 1997; Schneider, 1999). African-American women reported barriers of fatigue (Clark, 1999; Jones & Nies, 1996) that were not reported by their Caucasian counterparts. The African-American women in one study reported more symptoms identified as health barriers, such as joint pain, leg swelling, and fear of falls, while their Caucasian counterparts listed lack of motivation, energy, and confidence as barriers (Clark, 1999). Across races, health-related barriers for older women included fear of chest pain, symptoms of shortness of breath (Clark, 1999), and fear of myocardial infarction (Scharff et al., 1999). More frequent illness-related symptoms in groups of older women corresponded with higher rates of inactivity in that population.

Intrapersonal Determinants

Intrinsic motivation. In all of the studies that measured self-efficacy, a concept related to an individual's beliefs in personal ability to perform an activity, a positive relationship was found with PA (Ali & Twibell, 1995; Dornelas et al., 1994; O'Brien Cousins, 1996; Paxton et al., 1997). In addition, self-efficacy regarding exercise behaviors, self-efficacy for stress management, and self-efficacy for diet behaviors correspond with PA (Conn, 1997) and indicated a possible relationship between self-efficacy and a variety of health behaviors. A similar positive relationship was found in a study that used the motivation component of competence (MacLeod & Stewart, 1994). Additionally, health was identified as the single most significant motivator for PA behavior for older women (Scharff et al., 1999).

Affective health. In addition to physical health, affective health or mental well-being was a significant indicator of regular PA in the elderly. Enjoyment (Jones & Nies, 1996; Paxton et al., 1997) and positive mental well-being (Dornelas et al., 1994; Jones & Nies, 1996; Schneider, 1999; Van Den Hombergh et al., 1995) were related to increased PA in the studies from this review.

Cognitive appraisal. Few perceived barriers and frequent perceived benefits of PA corresponded with activity performance (Ali & Twibell, 1995). The cognitive appraisal of perceived barriers negatively influenced PA performance (Fitzgerald et al., 1994; Paxton et al., 1997). Whereas younger groups of women reported barriers of parenting obligations and obesity more frequently than the older group (Scharff et al., 1999), older women were less active.

Summary of determinants. As outlined by the MPAB, background and intrapersonal determinants significantly influenced PA performance in older women. Increased age, decreased income, lower educational attainment, and female gender were the demographic characteristics that consistently had a negative association with PA. Environmental determinants that negatively influenced PA included rurality, limited access to a facility, fear of crime, bad weather, and the lack of sidewalks. In contrast, positive social influences by friends or family were positively related to PA with older women. Good physical health and a lack of physical symptoms were significant motivators of PA. Intrapersonal determinants of motivation, cognitive appraisal, and self-efficacy were consistently seen with increased PA. The identification of specific determinants of PA for various populations indicated a clear need for interventions to be tailored to groups for improved adoption and maintenance of PA behaviors.

Discussion

Literature since 1994 has contained a great deal of information regarding determinants of PA in the population of older women. However, several gaps remain. Studies often evaluated small numbers of determinants, preventing a comprehensive, holistic view of the individual and the process of behavior adoption and maintenance. Theoretically based studies which include the multiple determinants of PA are needed to advance the field, as well as to allow a comparison of results across studies.

A second identified gap in the literature is the use of exercise as the study outcome. It is less likely that older, ill, socially isolated individuals, or women with extensive family and household obligations will participate in traditional exercise behaviors. However, measures that capture the extent of PA in these groups may find that some groups such as rural women are actually quite physically active, despite traditional findings to the contrary. PA, rather than exercise, is therefore recommended as the outcome measure because it meets the goal of improved health, function, and life expectancy while encompassing all the energy expended in daily life.

A final gap noted in the literature is that few studies differentiate among subgroups of older women. For example, studies are lacking between age groups of older women or between groups of differing population densities. An older woman of 65 years would presumably have differing determinants of PA than a neighbor 20 years her senior. Social access, health status, income, exercise cognition, and motivation are all presumably different in these age subgroups. In addition, increased population densities with their concurrent amenities such as sidewalks, inside facilities for PA, health care access, and frequency of social interactions would presumably provide fewer barriers to PA. What isn't known is how these barriers are overcome in rural areas, or for that matter, how older women in urban areas become or remain physically active. These determinants are not established, so more complexities in study populations are needed.

The MPAB was useful in framing the results from the literature review. The background and intrapersonal categories differentiated those determinants that may or may not be responsive to interventions. Once each of the determinants is identified in relation to one another, interventions can be developed to facilitate the progression within the MPAB toward increasing PA behavior with the associated reduction in CV risk.

Those persons with greater motivation, self-efficacy, income, education, and socioeconomic status, as well as those who are young males with better mental and physical health, and reside within safe, urban environments enjoy the benefits of regular PA. Findings indicate that older African-American women, with limited income, social isolation, and poor health, infrequently enjoy the benefits of regular PA and thus the CVD risk reduction associated with PA performance. Only after understanding these determinants will specific interventions be developed to meet their unique needs.
Table 1.
Determinants of Physical Activity in Women

                   Theory, Design, N,
Author/Year          Location, Race        PA or Ex

Ali & Twibell      HPM, CS, N=100, Not     Ex
(1995)             by location or race

Clark (1999)       Stages of change, CS,   Ex
                   N=17, Urban, AA and
                   Cauc

Clark & Nothwehr   SE, CS, N=440, Urban,   Ex
(1999)             Not by race

Conn (1997)        SCT, CS, N=225, Not     Ex
                   by location or race

Dornelas et al.    SE, Long, N=65,         PA--walk
(1994)             Urban, Not by race

Ebrahim &          No stated theory, CS,   PA
Rowland (1996)     N=704, No stated
                   location or race,
                   Great Britain

Fitzgerald         No stated theory, CS,   Ex
et al. (1994)      N=99, Urban, AA and
                   Cauc

Jones & Nies       HPM, CS, N=30,          Ex
(1996)             Urban, AA, Southern
                   U.S.

MacLeod &          IMCHB, CS, N=75, Not    Ex
Stewart (1994)     by location or race

O'Brien Cousins    SCT, HLC, CS, N=327,    PA
(1996)             Urban, Not by race

O'Brien Cousins    SCT, HPM, CS, N=327,    PA
(2000)             Urban, Not by race

Paxton et al.      SE, CS, N=105, Urban,    Ex
(1997)             Not by race

Scharff et al.     Stages of change, CS,    PA
(1999)             N=186, Nonurban
                   Midwest, Not by race

Schneider          Self-regulation model,   PA
(1999)             CS, N=364, Urban
                   Midwest, Not by race

Van Den            No stated theory, CS     PA
Hombergh et al.    N=503, Urban Dutch,
(1995)             Not by race

Wilcox et al.      No stated theory, CS,    PA
(2000)             N=35, Urban and rural,
                   Not by race

                   Positive Background          Positive Intrapersonal
Author/Year           Determinants                   Determinants

Ali & Twibell      Health status                SE; few Ex barriers,
(1995)                                          perceived Ex benefits

Clark (1999)       AA: knee/back pain, tired,   AA: weather; Cauc:
                   leg swell, fear falls; AA    motivation energy,
                   and Cauc: SOB, fear CP       confidence, location
                                                access and
                                                availability, money,
                                                weather

Clark & Nothwehr   Environmental barriers:      SE; barrier of weather
(1999)             poor/no sidewalks, lack
                   of benches, fear crime

Conn (1997)        Higher income; health        Stress management,
                   status, negative history     dietary behavior; SE:
                   of smoking; not with age     diet, exercise and
                                                stress management

Dornelas et al.    General health, nonsmoker    SE; psychological
(1994)                                          well-being

Ebrahim &          Mobility, health, younger    Exercise cognition;
Rowland (1996)     age, home-ownership,         few barriers: time,
                   previous sports activity,    fitness, health
                   low body mass index (BMI),
                   cancer screening,
                   socializing; few barriers
                   for sports: interest,
                   money, sport partner,
                   joint pain

Fitzgerald         Caucasians more active       Exercise cognition
et al. (1994)      when compared to AA

Jones & Nies       Neighborhood safety,         Enjoyment
(1996)             benefits of life
                   enhancement, low
                   barriers of: access or
                   availability, fatigue,
                   exercise apparel,
                   exercise belief
                   tiring/hard work

MacLeod &          Education, number of         Competence
Stewart (1994)     medications, younger
                   age, building location;
                   not with income or
                   marital status

O'Brien Cousins    Social support               SE
(1996)

O'Brien Cousins    Low barrier: fear of
(2000)             harm

Paxton et al.      Lack of pain with Ex,        SE, enjoyment, health
(1997)             site availability,           value of Ex, health
                   family support; not          belief that receiving
                   with exercise history        enough Ex
                   or medical advice

Scharff et al.     Education, younger age,      Most significant
(1999)             high cholesterol,            motivators to physical
                   marriage, high               activity: health
                   perceived risk MI; not       reasons
                   by location: rural vs.
                   small towns

Schneider          Muscle/joint comfort         Feeling of well-being,
(1999)                                          concentration on
                                                activity

Van Den            Mental status, younger
Hombergh et al.    age, functional ability,
(1995)             health, perceived health
                   home environment with
                   stairs

Wilcox et al.      Urbanicity for women >70
(2000)             years old

Note: Abbreviations: Ex = exercise; HPM = Health Promotion Model; SCT =
Social Cognitive Theory; SE = self-efficacy; CS = cross-sectional
study; Long = longitudinal study; AA = African American; Cauc =
Caucasian


Acknowledgment: The author wishes to thank Dr. JoEllen Wilbur for her support during the development of this manuscript.

For more information, contact the John A. Hartford Foundation Institute for Geriatric Nursing, New York University, The Steinhardt School of Education, Division of Nursing, 246 Greene Street, 5th Floor, New York, NY 10003, call (212) 998-9018, email hartford.ign@nyu.edu or access the Web site at www.hartfordign.org

Note: This investigation is supported in part by the National Institutes of Health, National Research Service Awards T2 NR0707508 and F31 NR8070-01 from the National Institute of Nursing Research.

Publisher's Note: Publication of this article was supported by a grant provided by Nurse Competence in Aging, a 5-year initiative funded by The Atlantic Philanthropies (USA) Inc., awarded to the American Nurses Association (ANA) through the American Nurses Foundation (ANF), and representing a strategic alliance between ANA, the American Nurses Credentialing Center (ANCC), and the John A. Hartford Foundation Institute for Geriatric Nursing, New York University, The Steinhardt School of Education, Division of Nursing.

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Donna J. Plonczynski, PhD, APN, FNP, RN, is a Family Nurse Practitioner, TriCounty Community Health Center, Malta, IL, and an Assistant Professor, Northern Illinois University, DeKalb, IL.
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