The Surgeon General, in Healthy People 2000 (U.S. Department of Health and Human Services [USDHHS], 1991), has identified the most important goal of health promotion among individuals age 65 and older - to maintain health and functional independence. Healthy People 2000 stresses the importance of physical activity and exercise for the achievement of this goal. The American College of Sports Medicine (ACSM, 1998) has concluded that participation in a regular exercise program is an effective strategy for prevention or reduction of many of the functional declines associated with aging.
Endurance training can help maintain and improve cardiovascular function, reduce risk factors for illness, improve health status, and contribute to an increase in life expectancy. Strength training helps offset loss in muscle mass and strength typically associated with normal aging. Additional benefits include improved bone health and postural stability, thus reducing risks for osteoporosis and falls. Evidence also suggests that regular exercise can provide a number of psychological benefits, including preserved cognitive status, alleviation of depressive symptoms, and improved self-concept (ACSM, 1998).
Health promotion involving physical activity and exercise is one means to improve functional status of Americans. Bortz (1992) concludes there is no drug in current or prospective use that holds as much promise for sustained health as a lifetime program of physical exercise (p. 1203).
Despite the anticipated benefits of physical exercise, more than 60% of American adults are not regularly physically active. Physical inactivity is even more prevalent among women than men, among Black and Latino individuals than White individuals, among less affluent than the more affluent, and among older than younger adults (USDHHS, 1996).
While benefits of exercise for older adults have been extensively documented, only recently has research been conducted on the perceptions of older adults toward physical activity and exercise (Melillo, et al., 1996; Melillo, Futrell, Williamson, & Chamberlain, 1997). Research on the perceptions of older Latino adults about this topic has not been a focus of published studies. Knowledge about the motivators and barriers to physical activity and exercise for older Latino adults is necessary to effectively prescribe exercises to improve their functioning. This study examined the perceptions of older Latino adults regarding physical fitness, physical activity, and exercise.
BACKGROUND AND SIGNIFICANCE
This section addresses the salient sociodemographic characteristics of the older Latino population and the prevalence of health problems in Latino adults that are particularly amenable to exercise interventions. The limited information related to older Latino adult perceptions about physical activity and exercise is also discussed. The terms Latino and Hispanic are often (but not universally) accepted as interchangeable ethnic descriptors of families originating in Spanish-speaking countries. Latino is used throughout this article, because it is the preferred term in the area in which this research was conducted (Garcia & Marotta, 1997).
Latinos are the fastest growing minority in the United States. Census data from 1990 (U.S. Census Bureau, 1999) indicate that Hispanics (the term used by the U.S. Census Bureau) constitute 8.8% of the total general population. In 1997, individuals of Hispanic origin (who may be of any race) represented 4.9% of the population of 65 years or older (American Association of Retired Persons, 1997). The proportion of Latino older adults, like the aging population of America in general, is expected to grow. Between 1990 and 2030, the White, non-Latino population 65 and older is projected to increase by 93%, with the older minority population expected to grow by 328%. The Latino elderly population is expected to grow by an astounding 570% (American Association of Retired Persons, 1997). The largest Latino subgroups are Mexican Americans (60%), Puerto Ricans (12%), and Cubans (5%) (U.S. Census Bureau, 1990).
Sociodemographic characteristics may predispose older Latinos to health deviations. Nationwide, Latinos are twice as likely to be below the poverty level than the general population. Only half of Latinos older than age 25 have completed high school, compared to 80% of the general population. Latinos have less access to health care, higher dependence on emergency services for care, and significantly less coverage by health insurance (Garcia Si Maretta, 1997). Additionally, little is known about health care needs of different Latino subgroups, despite known greater health risk factors due to lower educational attainment, skill levels, income, and health insurance coverage (Bell & Alcalay, 1997).
Heart disease and stroke are the leading causes of mortality among Latinos, accounting for 26.9% of deaths in men and 33.3% of deaths in women (American Heart Association [AHA], 1999). The prevalence of overweight individuals among Latinos is higher than for non-Latino White individuals, particularly among women (AHA, 1999). Harris (1991) reported an increased incidence of diabetes among Cubans, Mexican Americans, and Puerto Ricans living in the United States, compared to nonLatino White individuals.
Chronic illness is also impacted by diet, exercise, and lifestyle issues. The AHA (1999) reports that 61.5% of Latino men and 61.9% of Latino women have a sedentary lifestyle. There has been a paucity of research to explain the prevalence of inactivity with respect to older Latinos.
Individual perceptions of barriers to and benefits of exercise and physical activity have been shown to be significant correlates of exercise behavior in older Black women (Jones & Nies, 1996), healthy middleclass Latinos (Hovell, et al., 1991), and a mixed-ethnicity sample of adults age 65 to 100 years (Conn, 1998). Barriers and incentives to exercise exist in all populations, but the relative importance of these is likely to vary between and within subgroups and is poorly understood at the present time (Melillo, et al., 1996; Melillo, et al., 1997).
In the United States, older Latinos' strong preference for speaking Spanish rather than English may pose a significant barrier to familiarity with exercise or other health-related programs. In fact, 77% of Latinos speak Spanish at home (Garcia & Maretta, 1997), and Hyde (1990) found that five of six Spanish-speaking individuals older than age 65 in the United States report some degree of difficulty with the English language.
Kriska and Rexroad (1998) identified community, family, and friend support and the existence of a safe, convenient space as being of particular importance to exercise participation rates among Latinos. After adjustment for socioeconomic and other historical variables, correlates of walking for a sample of healthy middle-class Latinos included friends' support, normative beliefs, and decreased perceived barriers to exercise (Hovell et al., 1991). In the same study, vigorous exercise was found to be related to self-efficacy, friends' support, and physical activity as a child. Sennot-Miller (1994) found that the perceived difficulty of the health-promotion activity significantly influenced the likelihood of its adoption by older Hispanic and nonHispanic White women, and suggested that interventions should focus on decreasing the individual's perception of the difficulty of the behavior.
Physical activity and exercise are documented to be effective in the prevention and treatment of some chronic diseases. Latinos have an increased prevalence of some chronic diseases, and their physical activity and exercise participation is considered inadequate. Little is known about their perceptions related to physical activity and exercise participation. It is anticipated that this study will contribute to the body of knowledge related to physical activity and exercise in older Latinos.
The focus group design was selected as the methodology for this study for several reasons. Focus groups facilitate exploration and understanding of participants' beliefs, experiences, thoughts, and intentions underlying behavior (Goss, 1998). Focus groups are ideal for older adults who can share their thoughts and feelings in a safe environment (Gray-Vickrey, 1993), while providing a greater understanding of a population subgroup with respect to a specific topic (Saint-Germain, Bassford & Montano, 1993). Of particular relevance for this study, focus groups are considered especially appropriate for research with older Latino women because they draw on oral tradition, norms of helping, and existing social networks (Saint- Germain et al., 1993).
Sampling was purposive. Inclusion criteria included individuals age 60 and older, self-identification as Latino, and willingness to attend focus group discussion. The first two groups were held in Lowell, Massachusetts, where 12.2% of the population in 1995 was Latino; the third group was held in Lawrence, Massachusetts, where 48.4% of the population in the same year was Latino (Torres and Chavez, 1998). The demographic characteristics of the sample are shown in the Table.
Participants ranged in age from 59 to 76, and the majority were women who had lived in the United States for an average of 25.6 years. Five of the eighteen reported 12 years of education, and four were currently employed. Forty-four percent (n = 8) reported that their income was inadequate to meet their needs. The group size ranged from four to eight (six, four, eight, respectively). All were fluent in Spanish and had come from Puerto Rico (33%, n = 6), the Dominican Republic (33%, n = 6), Colombia (17%, n = 3), Portugal (11%, n = 2), and Guatemala (6%, n = 1). Two participants in the second focus group identified themselves as being of Latino ethnicity, although they were originally from Portugal. These individuals participated in Latino community organizations.
Data were collected through a series of three focus group interviews, which were conducted during a 4-month period at two different urban senior centers in northeastern Massachusetts. Recruitment for the focus group was performed by a team, which included a research assistant and key outreach staff representing the two senior center community agencies. The initial contact was through English and Spanish announcements posted at these community sites, but additional efforts included one-on-one contact by outreach staff. Followup telephone contacts were also made to ensure attendance on the scheduled day.
DEMOGRAPHIC CHARACTERISTICS OF OLDER LATINO FOCUS GROUP PARTICIPANTS
A team of university-based researchers planned and implemented the sessions. Each group was facilitated by a bilingual, bicultural, and master's-prepared gerontological nurse practitioner who had substantial experience working with Latinos in the two communities. All three focus groups followed the same format, and occurred during the daytime hours to encourage attendance by older adults.
Questions were asked according to an interview guide (Sidebar on page 42). This guide was developed from a tool previously used by the researchers in a qualitative study of communitydwelling, non-Latino older adults (Melillo, et al., 1996; MeKlJo, et al., 1997), and subsequently adapted and translated into Spanish. Direct translation, which assesses language correctness, may not be culturally or linguistically appropriate for lowincome ethnic populations. To ensure correct colloquial words, symbolic meaning, and word structure, Zambrana (as cited in Burnett, 1999) recommends bilingual individuals of the same ethnic origin as the study population and who are experienced in the community translate the instrument. An experienced Latina translator thus translated the interview guide into Spanish. All members of the research team, in reviewing each of the translated transcripts from the three focus groups, agreed the responses to English were appropriate in relation to the original questions.
An additional member of the research team served as an observer, took field notes, and audiotaped the sessions. Prior to starting the discussion, the facilitator and the other member of the research team obtained informed consent and demographic data. The groups began with a brief introduction, including a description of the questions to be asked. Participants were actively involved in the discussion and demonstrated a great deal of respect for each other and for the moderator. They interacted cordially and were attentive.
Overall, the physical spaces for the focus groups were comfortable, conducive to small group interaction, and satisfactory for audiotaping. At one center, there were several interruptions due to the multipurpose nature of the room. However, this did not impede the flow of the discussion. Refreshments were offered at all focus groups to promote participation and comfort, and smoking was not permitted. Each session lasted from 1 hour to 1 hour and 15 minutes. The sessions were conducted in Spanish, in accordance with the wishes of the participants. Each participant received a $15 grocery store gift certificate.
Participants expressed their enjoyment related to participating in the group, appreciation of being able to voice their opinions, and satisfaction in contributing to the research effort. Following the focus group, the facilitator and observer held a debriefing session to discuss and clarify communications and behaviors occurring throughout the sessions.
Analysis of Data
The research team collected the tapes and contracted with two bicultural/bilingual transcriptionists not associated with the project who transcribed verbatim the focus groups discussions. Transcribing the focus group tapes recorded in Spanish required approximately 3 to 4 hours for each 1hour focus group. Each transcript was reviewed with the focus group facilitator to confirm that the transcript accurately reflected what the group said.
A combination of open, axial, and selective coding procedures was used to analyze each transcript. Transcripts were read several times during data analysis. As each transcript became available, it was open-coded sentence-by-sentence or word-by-word to identify categories and themes and the meaning of what was being said. Members of the research team analyzed each transcript separately. Following this analysis, the group, as a whole, reviewed the individual coding to further assess the interrater reliability. All researchers identified similar categories within each transcript examined.
Common categories in the transcripts began to emerge. Axial coding was then used, along with open-coding procedures. Previously identified categories were used in subsequent transcripts. Comparisons were continually made between the first transcript being coded and later ones. A master list was made which identified all coded categories from the transcripts. The process of selective coding was then employed where subcategories were identified and named. The original master list was continually refined until all members of the research team were in agreement that the categories developed reflected the intent of the participants' responses. As lists of coded information developed, broad themes began to emerge.
Data were also entered in a PCbased qualitative software package called Ethnograph™ (Scolari, Sage Publications Software, Thousand Oaks, California), by a researcher not involved with the identification of coding categories (Seidel, 1 998). This program allowed for organization of the three focus groups transcripts, using the coding scheme devised by the research team. This strategy provided verification of the categories and themes in the data based on the frequency of occurrence.
The data elicited during the focus groups included older Latinos' perceptions of physical fitness, physical activity and exercise, benefits of physical activity and exercise, and barriers and facilitators to physical activity and exercise participation.
The focus group participants viewed physical fitness in the following ways:
* Being able to do anything.
* The mind and body working together.
* Feeling "light," being healthy.
Data across all three focus groups showed that participants agreed that most older Latinos are not physically fit, and that exercise is important for physical fitness. The value of functional independence was expressed across all groups as being "able to do anything," being "capable of anything," and "not depending on anyone." The importance of physical fitness was reflected in such participant statements as feeling healthy and being able to "do normal activities with ease." Participants described physical fitness as "cleaning your mind," promoting "your optimistic self," and "improving mental health." The positive impact of physical fitness on health was described as being not tired, sleeping well, taking medications as prescribed, having self-control, and eating well.
Another theme common to all three focus groups was the importance of the mind-body connection. There were frequent references to the positive effect of physical activity and exercise on the mind, as well as references to the negative effects of the lack of activity on the mind and body. References were made related to the importance of how one feels mentally, and that feeling "peace" is an indication of good physical condition. Mental attitude was identified as contributing to how one feels physically. The links between exercise, the mind, and the body may best be described by the comment from one participant, who stated exercise "takes out of your mind the thoughts that you are ill."
Physical Activity and Exercise
The participants in all three groups viewed physical activity and exercise as interchangeable terms. Responses describing physical activity and exercise included walking - the most frequently mentioned activity; performing home duties and home cleaning; shopping; going up and down stairs; "running behind kids;" working out at a gym; performing specific exercises; bicycling; dancing; moving rhythmically with limbs; swimming; and using at-home exercise machines. Most of the comments related to physical activity and exercise described positive effects. One description offered of exercise was "physical activity to achieve good health." Participants also described exercise as being "healthy... to keep going despite age and personal problems'* and "giving you more energy to do more things."
Concerns were voiced, however, that the Latino community, in general, views exercise as "for the young," with one participant offering, "when you're over 60, it's time to rest." Some were "afraid to exercise" for fear a health problem could be made worse, and others were concerned that exercising more than necessary may lead to death.
It was noted when analyzing the transcripts that a difference existed between the participants' perceptions of physical activity and exercise and what they perceived other older Latinos thought about physical activity and exercise. Group members described the value of physical activity and exercise, but stated that many older Latinos do not exercise because they do not value it and are "afraid to exercise." Comments related to how other older Latinos think exercise is a waste of time and for younger people were found in all three focus groups. However, these comments were not evident when participants described their own perceptions. The participants overwhelmingly described the positive benefits of exercise. The reason for the differences is unclear, but may be caused by participants recognizing the social acceptability of being involved in exercise and recognizing the positive benefits of exercise.
Perceived Facilitators and Benefits
In all three groups, participants described physical and psychological benefits of physical activity and exercise. One description that emerged across all three groups was "feeling new, light, and happy" as a result of physical activity and exercise. Participants defined "feeling light" as taking weight off, living longer and better, feeling relaxed, feeling less stressed, having a clean mind, feeling free, feeling deeply moved, feeling strong, and having less discomfort. One participant noted the benefits of physical activity and exercise by responding, "you feel capable, despite age."
"Support" and "motivation" emerged as participants discussed what would facilitate physical activity and exercise. Support included community resources, group support, cultural unity, and health providers. Community resources included access to transportation and having a "place." Participants put particular emphasis on the notion of having a "place of our own," stating that they needed a "gym" or a place to walk. Some participants feit that older Latinos need a place of their own to "exercise and congregate in." Focus groups also expressed a need for the community to provide transportation for easier access to exercise programs.
Group support was another area that emerged in the discussions, and is evident in statements such as, "It is good to go with a group," "we don't like to be alone," "getting together and helping each other." The notion of having cultural unity was discussed in all groups and seemed to merge the sentiments of group support and needing a place. Participants believed that it could help to "get together as Latinos, to speak our own language and to be taught the importance of exercise in our own language."
Another aspect of perceived needed support was for health provider support. Nurses and physicians were identified as helping to motivate Latinos to initiate exercise programs. Nurses were identified as key players in supporting Latinos throughout an exercise program by teaching how to perform the exercises, offering guidance and advice, monitoring health, and being there in case of a problem. The role of the nurse was identified as a supportive role, compensating for some of the insecurities Latinos expressed. These insecurities included fears of the potential adverse effects of exercise on existing health problems.
The importance of one's motivation or willpower in initiating and maintaining an exercise program was expressed in all three focus groups. It was unclear what elements underlie the willpower for exercise. The support of health care providers or the support of family may have a role in maintaining adequate willpower. "Having someone to give you a push" and "pushing yourself" were used to describe one's success in an exercise program. "How you were brought up" was an important influence on exercise for older Latinos and emphasizes the value one's culture and family place on exercise. If there is little value placed on exercise at a younger age, the same values may affect willpower across the life span.
Support and motivation were stressed repeatedly as necessary preconditions for older Latinos to initiate and sustain a regular program of physical activity. However, participants also stressed that those preconditions were glaringly absent in the Latino community. The participants requested that the research staff develop these supports in their communities.
Two themes emerged as elements that impede Latinos' physical activity participation - fear and a feeling of inappropriateness. Participants identified the fear of physical activity, so prevalent among older Latinos, as having a negative effect on their health. One participant said, "Older Latinos are afraid to exercise, afraid it will deteriorate them." Participants expressed concern that physical activity can hurt if you have asthma or heart disease. Monitoring exercise activity was considered an important role for health providers, who could "tell you what to do and not to do so you would not injure yourself." Some participants identified physician-initiated limitations on the type of exercise older Latinos can perform because of poor health status.
Perhaps one of the most striking findings in the study was the prevailing sentiment that exercise and physical activity are considered inappropriate in older age within the Latino culture. Inappropriateness was expressed as "shame" at doing exercises, reflecting a belief that to exercise in old age is to act foolish by not accepting that "the teen years are over." Other comments include the following:
* "Older Latinos don't like to try to exercise because they think it is for younger people."
* "They think that because of their age, exercise will make them worse, not well."
* "When they become 60, it is time to rest and let other people serve them."
* "It is a waste of time. I am too old and I am not supposed to be doing exercise."
Finances were not identified as a barrier, although 44% of the participants identified their income as inadequate. There seemed to be recognition that walking as a physical activity did not involve cost.
DISCUSSION/IMPLICATIONS FOR NURSING
Older Latinos in this study viewed physical fitness in a manner consistent with the World Health Organization's (WHO) 1948 definition that
health is a state of complete physical, mental, and social well-being and is not merely the absence of disease (as cited in Gochman, 1997, p. 10).
Fitness is viewed positively by older Latinos, but exercise is seen as potentially detrimental in some cases where specific health problems exist. The Latino participants also viewed physical fitness as depending on your mind and body working together and "being able to do what you want." These views seem to support the contention of Alford and Futrell (1998) that, in the next century, healthy independence for older people will relate to functional capability.
The participants expressed a need for four types of support - community resources, group support, cultural unity, and health provider support. This reflects Kriska and Rexroad's (1998) suggestion that the need for supportive surroundings becomes a theme when examining intervention efforts in Latino groups. Studies have consistently identified community, family, and friend support as important factors influencing activity participation rates (Kriska & Rexroad, 1998). The results of this study corroborate the findings of Delgado (1997) in that Latino providers and interpreters were essential for Latino participants in this study to feel comfortable in activity participation.
Findings in this study have broad implications for policy and nursing practice. Nurses can serve as cultural links for older Latinos in accessing community resources. The community, as a resource, was a major type of support needed by Latinos. Some participants expressed a need for services that were, in fact, already available to them in the community.
Sociocultural factors influencing Latino perceptions must be assessed if health promotion program planning is to be tailored to meet individual and group needs. The older Latinos expressed a strong interest in group versus individual activities and in developing a sense of "unity" with other older Latinos. The older Latinos did not express the wish to be "acculturated" with the dominant sociocultural group. In fact, having "a place to call our own" was strongly voiced. Thus, it is imperative for nurses to develop programs and policies to meet the identified needs of the population.
The findings of this study offer a basis for nursing intervention development. Fear and inappropriateness are limiting factors in physical activity and exercise behavior for some older Latinos, suggesting the perception that the negative consequences of physical activity and exercise could outweigh known benefits. Careful pre-exercise assessment and education by bicultural/bilingual nursing professionals could alter these perceptions. Positive role modeling, program planning, and mass media campaigns aimed specifically toward older Latinos could influence beliefs, values, and attitudes related to physical activity and exercise.
Determining an older Latino's readiness to undertake a physical activity and exercise program is a critical component of physical activity and exercise counseling by nursing professionals. The positive influence of support from family and friends within the Latino community could be maximized to promote physical activity and exercise participation. Also, the need of minorities for education related to health promotion regarding physical activity and exercise is evident.
Educational preparation in culturally competent care is critical to enable nurses to effectively serve this minority community. The Bureau of Health Professions, Health Resources and Services Administration (Klein, 1995) has recommended the following:
increasing the numbers of geriatric specialists such as nurses, social workers, occupational therapists, physical therapists, psychologists, physicians, and others who...are able to provide ethnically competent practice (p. 95).
Further, a nursing curriculum, including ethnogeriatrics must be part of the basic knowledge and skills preparation for all nurses.
Although the study was exploratory and the sample size small, it provides useful cultural knowledge and information for community health and gerontological nurses. The findings from this study also suggest a number of areas for future research. The influence of socioeconomic status in perceptions of health and related behaviors abounds in the literature. However, little discussion of this variable was evident in this study. Research examining and comparing perceptions of physical activity and exercise between different socioeconomic groups would provide further depth in analysis.
Longitudinal studies of exercise habits of Latinos as they evolve during a lifetime are recommended. Also, studies comparing the older Latino cohort with younger Latino cohorts are needed to determine what influence the preference for group activities and programs has when individuals consider participation in physical activity and exercise. Intervention studies addressing the barriers and motivators to physical activity and exercise identified in this study are important to develop strategies to increase the physical activity and exercise participation of older Latinos. Finally, experimental studies are needed to examine the effectiveness of interventions related to cost, acceptability, and accessibility to Latinos, as well as other underserved groups.
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DEMOGRAPHIC CHARACTERISTICS OF OLDER LATINO FOCUS GROUP PARTICIPANTS