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Cultural barriers to exercise amongst the ethnic elderly

Michele V. Lewis, Rebecca A. Szabo, Karen R. Weiner, Louise McCall, Leon Piterman*

Abstract

Issue: The aim of this project was to determine the presence or absence of specific barriers to exercise amongst ethnic elderly in Australia.

Methods: Four sample groups used were; Indo-Chinese, Italian, Jewish and Greek. A qualitative study method was chosen, using focus groups to learn about attitudes and beliefs about exercise.

Results: Language is a major barrier to exercise promotion for ethnic elderly. Other barriers include "laziness" and fear of injury. All groups believed that exercise is beneficial as a curative therapy for medical conditions and emphasise the importance of doctor’s involvement. In addition they were aware of the social, physical and mental benefits of exercise. Exercise modalities may be culturally specific (eg. Tai Chi for the Indo-Chinese).

Conclusions: Barriers do exist to exercise but many are consistent cross-culturally and there is enormous individual variation within each cultural group.

So What? The results of this research are useful and relevant for future implementation of exercise promotion for ethnic elderly. Further research is need in this area.

Key words:

exercise, elderly, ethnic/culture, barriers, doctors

Introduction

Australia is a multi-cultural society with 22.7% of residents born overseas (4,063,000 persons) (1) and is an aging community. The number of elderly (over 65) in the population has increased by 78% between 1975 and 1995 (2). In 1994, the proportion of elderly in the population was 11.82%.

 Exercise improves an individual’s "total health", physically, mentally and socially. (3). A survey conducted in 1989-90 showed that 35.8% of adult Australians do not exercise (4). This lack of exercise is most prominent in the over 65 age group (4). This may contribute to a reduction in health status of sedentary elderly persons. Supporting this, 95% of persons aged over 65 suffer from a long term medical condition (4). Persons aged over 65 who did not exercise or engage in low levels of exercise had the most illnesses.

Given demonstrated improvements in both physical and psychological health a sound empirical basis exists for prescription of exercise for older adults (5) there is a need to promote exercise in the elderly. Evidence suggests that significant changes ascribed to the aging process are due to inactivity accompanying retirement. (3).

Aims

Through qualitative processes:

1. Explore attitudes and beliefs of cultural groups of ethnic elderly regarding exercise.

2. To identify barriers to exercise amongst these elderly

3. To examine ways of overcoming these barriers.

Methods

This study was a qualitative study utilising focus groups consisting of 15 to 25 participants targeting persons over 65 years within the Jewish, Italian, Greek and Indo-Chinese communities in Australia. Financial and logistical constraints required the use of local community groups to access participants and locations for the focus group settings. Participants were members of the National Council of Jewish Women, the Indo-Chinese Elderly Refugees Association, Preston Italian Senior Citizens Club and patients of a general practitioner who had a large Greek population. The first three focus groups were run at these organisations regular meeting time, thus ensuring attendance. The Greek focus group was conducted at the general practitioner’s surgery. Proponents of focus groups will often discourage familiarity between participants however in this case the group members knew one another and it was felt that this advantages outweighed the funding, time constraints and attendance issues associated with this project.(6,7)

The focus group began with some general discussion about healthy lifestyles and exercise. It then moved to more specific topics and concluded with participants responses on health promotion material. For each focus group, one member of the project team was a facilitator while another was the note taker and managed the dicta-phone but did not participate.

Results

Participants in each group found the topic relevant, interesting and important. This was demonstrated by the animated discussion and the enthusiastic involvement of group members. It was also found that the optimal discussion forum was a circle seating arrangement as evidenced in the Jewish group. Furthermore dicta-phone and note taker were effective means of data gathering.

The Italian and Jewish groups only had women which changed the validity of the data for the target population of elderly men and women.

What is exercise?

The Indo-Chinese focus group defined exercise in terms of activities that depend on age, that is active activities for the young and gentle forms such as Tai Chi, stretching and low impact martial arts for older people. House work was also considered exercise "because it tires you out". They considered that exercise "should not make you stressed". Therefore the Indo-Chinese considered playing with grandchildren was not exercise. The remaining groups defined exercise as a deliberate activity, something "you are putting your mind to" such as swimming, dancing, house work and yoga. Only half of the Italians thought that walking to the shops was exercise.

Benefits and disadvantages of exercise

All groups recognised mental, social and physical benefits including lowering blood pressure, assisting sleep, benefits for the heart, "bones and joints" in addition aiding recovery from illness and injury. These were evident by comments such as "healthy, happy and able to sleep well". The Indo-Chinese were the only group that did not mention weight loss as a reason to exercise. Psychological benefits such as "relieves boredom", happiness and promoting relaxation "it relaxes me and my worries disappear" were also identified.

 Only a few items were identified as disadvantages of exercising; these being time commitment and injury if exercise is not done correctly as illustrated by the comment "you move your bones in the wrong way you might hurt yourself". Over exertion was another disadvantage identified as it "may do more harm than good".

Why or why not exercise?

Why or why not exercise was discussed and the main reasons given by all groups for not exercising was "laziness" however all said they would exercise if the doctor told them to. Changing routine and lack of importance were singled out by the Italian groups as barriers, evidenced by comments such as "it takes me all day to do the house work". The Indo-Chinese and Greeks wanted to see health benefits, the Jewish perceived exercise as inconvenient and expressed concern about bad experiences such as falling.

Ideal setting

The Indo-Chinese preferred instruction in Vietnamese in a park or on grass involving gentle exercises such as walking. Likewise the Italian group preferred exercise outdoors in areas such as parks as "concrete is bad for your calves" and it "is nice to walk in the fresh air with trees and oxygen". This group also preferred group activities led by an Italian speaking instructor. Likewise the Greek group liked walking, gardening and being active at home, while they preferred exercising individually they also acknowledged that a group is good for "encouraging and socialising".

Relevance of Exercise

The relevance of exercise was discussed and there was a trend in the responses of the Jewish and Greek groups that "exercise is for everyone, all people, no matter what age". The Indo-Chinese and Italians recognised exercise was necessary for a healthy lifestyle as "exercise is important for people recovering from health problems".

Services

When asked about the availability and usage of services all groups could list services in their areas, however one reason given by the Indo-Chinese and Italian groups for not using these services were language barriers.

Health Promotion

The results of the discussion of health promotion techniques in promoting exercise in the elderly are found in Table 1. These results indicate that health promotion is effective for all cultural groups included in this study when it is recommended by health professionals. This message is reinforced by pamphlets, written in native languages, that can be taken home as a reminder.

Table 1. Promotional techniques most relevant for each ethnic group

Participants in each group found the topic relevant, interesting and important. This was demonstrated by the animated discussion and the enthusiastic involvement of group members. It was also found that the optimal discussion forum was a circle seating arrangement as evidenced in the Jewish group. Furthermore dicta-phone and note taker were effective means of data gathering.

The Italian and Jewish groups only had women which changed the validity of the data for the target population of elderly men and women.

Discussion

As Italy and Greece are the third and fourth most common birthplaces for the overseas born population in Australia, these were chosen for this study. In addition an Indo-Chinese group was selected because the number of Southeast, Southern and North east Asian born Australian residents increased from 1.8% in 1976 to 4.6% in 1994 (6). Jewish elderly were included as this was the group that the program was piloted on initially.

Members of focus groups knew each other so were quite relaxed, comfortable and able to freely express their opinions. Language barrier was a problem in all groups and an interpreter was required for the Indo-Chinese group which increased the chances of introducing errors during translation. The Italian and Jewish groups only included females, thus limits the generalisability of this study.

What is exercise?

The general meaning of exercise, that is "activity" was the same for all groups. However the Indo-Chinese distinguished between exercise for the young and old. The Italian group defined exercise as a deliberate activity and did not consider manual labour as a form of exercise. This was considered part of the lifestyle. This is in contrast to the Jewish and Greek groups which did consider manual labour and housework to be exercise. For the Indo-Chinese, exercise should not be mentally or physically stressful. Therefore their examples of exercise differed for the other groups, particularly they did not consider playing with grandchildren exercise whereas the other groups did.

Advantages of exercise

Each group acknowledged the benefits of exercise including physical, psychological and social advantages. All mentioned benefits for the heart, "bones and joint" and for recovery from illness and injury although the Italian and Greek groups recognised that exercise may be harmful particularly if done incorrectly. While the Jewish group did not provide specific examples they were generally negative about exercise for themselves.

Why or why not exercise?

All groups recognised "laziness" as an obstacle to exercise and that a major influence on exercising was the recommendation by doctors and other health professionals. All believed a group environment encouraged regular participation and that it is easier to find excuses when exercising alone.

 Both the Indo-Chinese and Greek groups felt exercise was not necessary if already healthy but generally the Italian and Jewish groups disagreed. This variation is derived from how the groups defined "activity". Some of the Italian, Jewish and Greek participants felt housework and regular activities were enough as they did not have time or energy to do more. The Indo-Chinese, Italian and Greek groups all needed to see health benefits of doing exercise in order to continue and believed that one reason for exercise was rehabilitation particularly for recovery from illness or injury. The Indo-Chinese, Jewish and Italians believed that certain physical factors prevented them from exercising especially lack of strength and agility. Both the Indo-Chinese and Jewish participants were afraid of falling thus limiting their choice of exercise. Inclement weather was considered a deterrent to outdoor exercise for both Greek and Jewish participants. Some Italians did not exercise because they recognised that the manual labour they performed had been an integral part of their daily activity, however this was not defined as exercise.

Relevance of exercise

All groups believed exercise is very important to elderly persons recovering from medical conditions and recognised the relevance of exercise to a healthy elderly lifestyle. However the groups differed on the level of activity in their definition of exercise.

Ideal setting

Indo-Chinese and Greek participants liked outdoor activities however, Jewish participants wanted exercise to be conducted by an instructor indoors. Ideally the Indo-Chinese group required an instructor speaking their native language. Although both Italian and Greek participant spoke English, ideally they preferred instruction in their native language. For the Italian group this was important for cultural reasons, where as the Greeks this was for language concerns. Italian, Indo-Chinese and Jewish preferred a group setting compared with Greek participants who preferred exercising alone. Cultural issues (especially a family like atmosphere) were included as a major reason for group activities being ideal for the Italian participants.

Services

The Indo-Chinese and Italians groups knew of some local services such as Tai Chi and aqua aerobics at housing commission and local health centres, while individual knowledge and interest in their use varied. The Jewish and Greek groups had limited knowledge of local services and the Jewish participants had very low levels of interest, one reason given was lack of transport. Some Greek participants used these services and were more interested than the members of the other groups, however "everything is there if you want it.... but it all costs money".

Responses to health promotion techniques and material

As evidenced in Table 1. posters were considered sufficiently motivational by Indo-Chinese participants in contrast to the Italian, Jewish and Greek groups. The Italians who saw these as "just a picture and doesn’t show anything", whereas the Indo-Chinese and Greek groups also believed pamphlets to be influential in promoting exercise in the elderly although they felt these would have a better result in their own language as illustrated by comments such as "good to have some pamphlets in Greek - even if understand English if don’t know one word may not understand the whole thing." Both the Jewish and Greek groups wanted doctor’s involvement in exercise promotion as "everyone our age sees a doctor at least once a month" and they liked the idea of television and radio promotion. The Italian participants did not identify this as important. Due to language barriers the Indo-Chinese group did not believe television promotion would have a positive impact on promoting exercise in the elderly.

Conclusion

All groups considered exercise to be a vital part of a healthy lifestyle. However the Italian, Greek and Jewish participants considered exercise to be a range of energetic activities whereas the Indo-Chinese group considered gentler activities more appropriate for their age group. There were no apparent differences among these four cultural groups concerning their views of exercise benefits including socially, mentally and physically and they all agreed that exercise is essential as a therapy for medical conditions. They indicated that motivation to exercise is substantially increased when exercise is recommended by health professionals, particularly doctors.

Barriers do exist and vary cross-culturally, within individuals and each cultural group. Therefore barriers such as language, laziness, fear of injury, change in routine must be considered for future implementation of exercise promotion for the ethnic elderly. The ideal exercise setting for each individual cultural group also needs to be considered as illustrated by the Indo-Chinese, Jewish and Italians preference for group activities (with their respective cultural group) with a native speaking instructor. Ethnic persons should be involved in planning, marketing and implementing any exercise or other health promotion efforts. Health promotion methods and the services promoted also need to be taken into consideration when developing an exercise program for each cultural group to achieve maximum impact. Furthermore doctors and health professionals should realise the positive impact their influence has on positive health behaviours and that they are great motivators of health seeking behaviours.

References

1. McLennan W, Australian Bureau of Statistics. -. Migration, Australia. Canberra: Commonwealth of Australia, (Publication 3412.0) 1994

2. McLennan W, Australian Bureau of Statistics - Estimated Resident Population by sex and age: States and Territories Canberra: (Publication 3201.0) Commonwealth of Australia, 1993-4.

3. Office of Recreation Development, Department of the Environment, Sport and Territories. Active and Inactive Australians-assessing and understanding levels of Physical Activity. Canberra: Commonwealth of Australia. 1995.

4. Castles I. National Health Survey: Summary of Results Australian Bureau of Statistics Commonwealth of Australia. (Publication 4364.0) Canberra 1989-90.

5. Van Sickle TD, Hersen M. Effects of physical exercise in cognitive functioning in the elderly. International Journal of Rehabilitation and Health; 1996: 67-100.

6. Hawe P, Degeling D, Hall J. Evaluating Health Promotion, a health Workers' guide. Sydney: MacLennan & Petty, 1990; 178-179.

7. Schattner P, Shmerling A, Murphy B. Focus groups: a useful research method in general practice. Med J Aust 1993; 158

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