Transcript Slide 1

Exercise for falls prevention in
Caucasian and South Asian
older adults: Are focus groups
a useful data collection tool?
Dr Maria Horne
[email protected]
Combining the strengths of UMIST and
The Victoria University of Manchester
Background
• Strategies to prevent falls often recommend regular exercise
(Gillespie et al. 2001)
• 40% of over 50s in UK report less physical activity than
recommended (Skelton et al. 1999)
• Higher rates of sedentary behaviour are reported among
South Asian older adults (Erens et al. 2001; Hayes et al.
2002; Gill et al. 2002)
• Half of those who commence a structured exercise programme
relapse within six months (Schmidt et al. 2000; Jancey et al. 2007)
Combining the strengths of UMIST and
The Victoria University of Manchester
Falls
• 30-40% of people over 65 fall each year (O’Loughlin et
al. 1993; Gillespie et al. 2001)
• Falling and fear of falling create a vicious circle of
psychological distress that seems to restrict activity and
independence, and increase social isolation (Bruce et al.
2002; Yardley & Smith 2003)
• Exercise reduces risk of falls (Gillespie et al. 2001)
• Evidence base is very strong for strength and balance
training reducing falls (Gillespie et al. 2001)
Combining the strengths of UMIST and
The Victoria University of Manchester
Aims
• To investigate cultural influences
• To identify salient beliefs to uptake and
adherence of exercise for fall prevention among
community dwelling Caucasian and South Asian
60-70 year olds
Combining the strengths of UMIST and
The Victoria University of Manchester
Research Design, Methods of
Data Collection and Analysis
• Ethnographic approach (Atkinson & Hammersley 1994;
Hammersley & Atkinson 1995)
• Data collection:Polyphonic interviews
 informal
 formal interviewing:
14 focus groups (n = 87; mean age = 65.74)
9 with Caucasian, 5 with South Asian
40 individual semi-structured (mean age = 64.83)
• Framework analysis (Ritchie & Spencer 1994)
Combining the strengths of UMIST and
The Victoria University of Manchester
Sample
Interview type
Focus groups
In-depth
interviews
No.
Gender
Caucasian
58
44 female
14 male
65.4
Active: 24 (41.4%)
Less active: 26 (44.8%)
Sedentary: 8 (13.8%)
South Asian
29
13 female
16 male
66.1
Active: 14 (48.3%)
Less active: 12 (41.4%)
Sedentary: 3 (10.3%)
Caucasian
23
14 female
9 male
64.8
Active: 10 (43.5%)
Less active: 9 (39.1%)
Sedentary: 4 (17.4%)
South Asian
17
10 female
7 male
65.2
Active: 8 (47.1%)
Less active: 4 (23.5%)
Sedentary: 5 (29.4%)
Combining the strengths of UMIST and
The Victoria University of Manchester
Mean age
Reported activity levels*
The need for focus groups
• Initial observation - many views, attitudes and beliefs expressed
about exercise, physical activity and the motivation and barriers
to performing these activities were expressed
• Discussion on fall prevention issues was never encountered
directly and was a topic that would be difficult to observe
• In certain areas it was difficult to observe individuals and groups
from South Asian backgrounds at leisure or in exercise classes
• Several focus groups conducted to highlight consensus and
disagreement in the area of
– exercise and physical activity in general
– in relation to fall prevention
Combining the strengths of UMIST and
The Victoria University of Manchester
Suitability of using focus groups with
older adults 
• Used successfully in other research studies with older adults:
– to identify issues that are more salient to older people
themselves (Horne & Costello 2001; Raynes et al. 2001; Loeb
et al. 2003;Hupcey et al. 2004) and
– To explore older peoples’ exercise motivations and influential
circumstances (Stead et al. 1997)
• Good for exploring salient attitudes and beliefs - provides a
practical way to access peoples’ experiences, attitudes, views,
knowledge, feelings and motives about various health and social
issues as well as their actions
• As a method of interacting with older adults, the method ideal as
it is not anxiety provoking (Gray-Vickrey 1993)
Combining the strengths of UMIST and
The Victoria University of Manchester
Suitability of using focus groups with
older adults 
• Facilitate access to the cultural and social norms of groups by
providing insight into cultural and social processes of both belief
formation and the role of expression of beliefs in peer groups
(Morgan 1997; Green & Hart 1999)
• Represent a culturally sensitive method suited to reproducing
community attitudes (Saint-German et al. 1993)
• Facilitates the disclosure and validation of group attitudes and
thinking (Fallon & Brown 2002)
• An excellent way to identify the needs of under researched
populations (Esposito 2001)
Combining the strengths of UMIST and
The Victoria University of Manchester
Suitability of the focus group method
to the research process 
• Open response format of the focus group schedule provided much
more information in the respondents own words than that from
questionnaires (Stewart & Shamdasani 1990)
• Data is richer with emic responses being recorded (Stewart &
Shamdasani 1990)
• Able to check back replies directly with the informants (Stewart &
Shamdasani 1990) - useful for clarifying issues that were not easy
to do during observation or informal conversations
• Participants’ interaction among themselves replaced their
interaction with the facilitator leading to a greater emphasis on
participants’ points of view
Combining the strengths of UMIST and
The Victoria University of Manchester
Suitability of the focus group method
to the research process 
• Does not discriminate against people who cannot read or write a
particular language and those who have impaired vision (Kitzinger
1996) - ideally suited to older people and those from minority
groups
• Can encourage participation from those reluctant to be
interviewed on their own (Kitzinger 1996) e.g. those intimidated
by the formality and isolation of a one to one interview
• Can facilitate and encourage contributions from people who
believe they have nothing to say but who may engage in
discussion generated by other group members (Kitzinger 1996)
Combining the strengths of UMIST and
The Victoria University of Manchester
Limitations
•
Some people may feel uncomfortable about discussing and expressing
their views in front of a group
•
Potential for the researcher, as the group facilitator, to bias results by only
seeking out those answers to preconceived notions or providing cues
about the type of responses that are desirable (Stewart & Shamdasani
1990).
•
May become biased by a dominant figure within the group, whose opinions
may unduly influence or inhibit passive participants (Stewart &
Shamdasani 1990; Smithson 2000)
•
Can provide an unnatural setting for group interactions so that it must not
be assumed that the technique provides access to ‘naturally occurring
data’ as may be collected by participant observation (Kitzinger 1994)
Combining the strengths of UMIST and
The Victoria University of Manchester
Conduct of focus groups with
Caucasian participants 
• 9 focus groups (3-9 participants); 60 to 90 minutes; 8 mixed; 1
female only group
• Consent to audiotape focus group was sought from all participants
• Focus group schedule was piloted with the first Caucasian focus
group. No alterations were required and, therefore, the data from
this were included in the final analysis
•
Moderator - ensured participants felt welcomed and relaxed;
seating was arranged in a circle and tea, coffee, fruit juice, fruit
and biscuits were provided in order to establish a relaxing,
comfortable environment; explained the purpose of the meeting,
encouraged participants to talk to each other
Combining the strengths of UMIST and
The Victoria University of Manchester
Conduct of focus groups with
Caucasian participants 
• Support person - Check tape recorder, record the layout of the
group, recorded the general flow of discussion points, highlight the
main discussion points, record non verbal communications and note
‘silent voices’
• Invited participants to introduce themselves:
– introductions acted as an icebreaker by helping people to relax
and become comfortable with the group set up
– useful approach for transcribing purposes to help identify who
was speaking and when
– For the purpose of group comparability and coverage of
theoretical issues a standardised FG schedule was used
(schedule contained general open ended questions to generate
discussion, but also served to maintain control of the topics to
be discussed)
Combining the strengths of UMIST and
The Victoria University of Manchester
Conduct of focus groups 
• managing group dynamics, controlling the way participants
interact, for example trying to get everyone to participate equally
to the discussion
• As the focus group progressed a balancing out of the participants
and my interests tended to occur (resulted in the focus group
becoming less structured )
• This process allowed unexpected issues to arise, providing the
opportunity to probe deeper
• Concluded the focus group with a summary of the discussion and
sought verification of the discussion from the participants
Combining the strengths of UMIST and
The Victoria University of Manchester
The conduct of focus groups with
South Asian participants
•
5 focus groups (2-9 participants); 45 to 70 minutes; 3 female only groups
and two male only groups
•
Focus group schedule was given to a registered interpreter to check for
cultural sensitivity and translation. No issues were raised
•
Focus group schedule was subsequently piloted with the first South Asian
women’s group. No alterations were required and the data from this were
included in the final analysis
•
Bridging the language barrier - three local interpreters used to interpret,
translate and assist with facilitation of the focus group discussions, one
female who could speak and translate Mirpuri Punjabi, one male who could
speak and translate Mirpuri Punjabi and another who could speak and
translate in both Punjabi and in Gujarati.
Combining the strengths of UMIST and
The Victoria University of Manchester
The conduct of focus groups with
South Asian participants
•
Real-time translation (Esposito 2001) validates the data during the focus
group; provides opportunity to redirect questions to focus group
participants to clarify understanding of responses
•
Interpreters acted as co facilitators/moderators; did not expect them to be
an expert in the topic as not a necessary requirement to moderate a focus
group (Kreuger 1998; Baker & Hinton 1999)
•
Beneficial that they were not experts in the topic area as they would be
less likely to add their opinions to the discussion (Kreuger 1998; Baker &
Hinton 1999)
•
Acted as assistant - Check tape recorder, record the layout of the group,
the general flow of discussion points once translated to me by the
interpreter, ask probing questions to be translated and interpreted by the
facilitator, highlight the main discussion points, record non verbal
communications and direct interpreter to ask a question to ‘silent voices’
to encourage a response
Combining the strengths of UMIST and
The Victoria University of Manchester
Post focus group
• Interpreter would transcribe the tape into an English language
transcript.
• The tape and transcription were then given to another native
speaker, a multilingual link worker, to assess the accuracy of
transcription provided by the original interpreter and agree a
‘correct’ version of the text
• Analysis
Combining the strengths of UMIST and
The Victoria University of Manchester
Findings
• Confusion about exercise and physical
activity
• Lack of awareness
• Too young to fall
• The potential of exercise to prevent falls
• Fall prevention exercises unnecessary
• Fatalism
Combining the strengths of UMIST and
The Victoria University of Manchester
Confusion about exercise and
physical activity
• Considerable similarities between the Caucasian and South
Asians in the way they talked about falls, exercise and fall
prevention
• Majority of participants used the phrases interchangeably
and even used the phrase ‘physical exercise’:
‘Well going on the allotment and digging over patches to
plant things…so that is what you see as physical exercise’
(LC2: Caucasian female, 62 yrs: Sedentary)
Combining the strengths of UMIST and
The Victoria University of Manchester
Lack of awareness
• limited general awareness that exercise could
help in fall prevention but this did not
motivate the majority of either Caucasian or
South Asian participants to undertake
exercise:
‘I walk and I went to do exercise and now I
understand exercise does stop you from falling
but I didn’t before?’ (BS 3: South Asian female,
63 years: Active)
Combining the strengths of UMIST and
The Victoria University of Manchester
Lack of awareness
• Caucasian and South Asian’s poor awareness of
benefits of exercise
– strength, balance and mobility
• Small minority aware of benefits of exercise in fall
prevention
– unable to exercise because of existing health
issues and limited mobility:
‘I can’t [exercise] because of my arthritis, you know, I think I
might fall’ (AB40: South Asian female, 62 years: Sedentary)
Combining the strengths of UMIST and
The Victoria University of Manchester
Too young to fall
• Too young to fall
• Falls happened to older people:
‘I think that’s after 80s [having a fall], when people are
getting older. There is no place for thinking about it now’
(I33: South Asian male, 63yrs: Less Active)
Combining the strengths of UMIST and
The Victoria University of Manchester
The potential of exercise to
prevent falls
• Those who had fallen
• more likely to acknowledge risk, and may heed
advice to exercise but
• fear activity would expose them to further risk
‘Yes it would motivate me [to perform exercise for fall
prevention] …by falling it has frightened me and that
prevented me going to do exercise because I thought I
might fall again’ (I31: South Asian female, 62 yrs:
Sedentary)
Combining the strengths of UMIST and
The Victoria University of Manchester
Fall prevention exercises
unnecessary 
• Those who perceived themselves to be fit and
healthy, believed fall prevention exercises were
not necessary for them personally:
‘…I just feel I’m not in a position…that I’m very lucky in
that I don’t need to [exercise to prevent falls]. I’m not in a
position that I feel I need to do any more than I do. Maybe
if I was struggling with something, I’d say, “well yeah, I’ll
go and see if I can get a wee bit of exercise”, but there
again, I might say “I’ll go to the physio, they might move
those bones for me”, rather than go to a sports or leisure
centre’ (I7: Caucasian female, 65yrs: Active)
Combining the strengths of UMIST and
The Victoria University of Manchester
Fall prevention exercises
unnecessary 
• Young older adults with no fall history did not
acknowledge their risk of falling:
‘I wouldn’t think about things like that, to be honest, when
I’m going to fall...’ (I16: Caucasian male, 68 yrs: Active)
• Others simply did not perceive falling to be a
serious issue:
‘I’m not bothered if I fall…everyone falls so it doesn’t really
matter. As long as I have the strength I’ll carry on walking’
(I32: South Asian female, 70 years: Less active).
Combining the strengths of UMIST and
The Victoria University of Manchester
Fall prevention exercises
unnecessary 
• Both Caucasian and South Asian perceive that a
loss of physical strength would motivate them to
perform exercise for fall prevention - were willing
only to perform those pursuits they feel
comfortable with doing, rather then specifically
for fall prevention:
‘...if you haven’t got the strength [you would need to do
exercise to prevent falls]. But I am willing to do walking to
keep me going to help prevent the falls’ (I30: South Asian
female, 67yrs: Less active).
Combining the strengths of UMIST and
The Victoria University of Manchester
Fall prevention exercises
unnecessary 
• Most people preferred physical activity for
strength building because they felt it was
included into everyday life:
‘But, with the physical activity its everyday. I know what
I’m doing because I have to move to get stuff for the
house, for the cooking and everything’ (I26: South Asian
female, 63 yrs: Active)
• Exercise related to activities of daily living
seemed to be a motivator:
‘I combine physical activity with exercise…if you’re climbing
stairs and, if I go in to Marks and Spencers or wherever I’ll
invariably walk the stairs to the next floor, rather than take
the escalator or a lift’ (I6: Caucasian male, 63 yrs: Active)
Combining the strengths of UMIST and
The Victoria University of Manchester
Fatalism 
• Both Caucasian and South Asian believed falls were a
natural consequence of ageing:
‘…but sometimes you can’t help it [fall] because of your age…If that
person is old, it is that age….you need to try to maintain the ability to
do something…but sometimes it’s beyond their physical ability...they
are weak’ (I33: South Asian male, 63 yrs: Less active)
• Fatalism: a biological inevitability?
‘It’s your bones; they still get old [in relation to falls]. I don’t
feel it’s any kind of exercise, it’s just your body ageing; you
cannot do what you did when you were younger’ (K5:
Caucasian female, 66 yrs: Less active)
Combining the strengths of UMIST and
The Victoria University of Manchester
Fatalism 
• Falling was out of older people’s control –
particularly strong among South Asian
‘…how can you avoid a fall? If it’s going to happen, it will
happen’ (I25: South Asian female, 62 yrs: Active)
• Amongst South Asians ‘inshallah’ or the idea of
illness being down to God’s will was very
apparent:
‘Anything can happen at any time. I can’t say I have any
fears. Things can happen. God knows. God knows’ (I29:
South Asian male 67 yrs: Active)
Combining the strengths of UMIST and
The Victoria University of Manchester
Conclusions 
• More similarities then dissimilarities between Caucasian and
South Asian older adults beliefs about take up of exercise for
fall prevention
• Falls prevention takes a very low priority
• Little association between exercise and fall prevention
• More motivated to participate in fall prevention exercises
when explained that this could improve strength and balance
(positive concept) as opposed to preventing falls (negative
concept)
• More likely to acknowledge risk, and may heed advice to
exercise but fear activity would expose them to further risk
Combining the strengths of UMIST and
The Victoria University of Manchester
Conclusions 
• Exercise for fall prevention is only believed to be necessary
when you become older or weaker
• Differences in beliefs between Caucasian and South Asians
in the area of fatalism and the need for gendered exercise
sessions
• Falls prevention should not be the focus of health promotion
strategies
• The overall benefits of exercise and leading active healthy
lifestyles should be promoted
Combining the strengths of UMIST and
The Victoria University of Manchester
Contact details
If you would like more information about the
study please do not hesitate to contact me:
Email: [email protected]
Tel: 0161 3067680
Combining the strengths of UMIST and
The Victoria University of Manchester