According to the Healthy People 2010 report, regular participation in physical activity is associated with many health-related benefits. Some of these benefits include lower death rates; decreased risk of diabetes, colon cancer, hypertension, and depression; increased muscle and bone strength; enhanced psychological well being; and reduced depression and anxiety symptoms (U.S. Department of Health and Human Services [U.S. DHHS], 2000). Convincing evidence shows that physically fit individuals live approximately 2 to 3 years longer because of a reduction in all causes of mortality (Butler, Davis, Lewis, Nelson, & Strauss, 1998a, 1998b; Sallis & Owen, 1999).
The loss of functional abilities previously attributed to a normal aging process is actually related to inactivity (Sallis & Owen, 1999). For older adults, regular exercise is critical for maintaining the ability to perform various tasks, such as walking, climbing stairs, reaching, bending, and lifting - all of which are a part of daily living. Even more important, Green and Crouse (1995) concluded that participation in exercise can actually improve older adults' ability to perform various activities of daily living, based on a meta-analysis of exercise research data. Specifically, regular exercise can lead to maintained and improved strength, agility, and bone density. Maintaining bone density reduces the incidence of falls, which can devastate an independent lifestyle (Sallis & Owen, 1999; U.S. DHHS, 2000). Regular participation in moderate-intensity exercise was also associated with improved sleep quality (King, Oman, Brassington, Bliwise, & Haskell, 1997)- certainly, the fatigue resulting from inadequate sleep can lead to decreased functional ability.
To reduce the risk of disease, diminish chronic disease symptoms, and maintain or improve functional abilities, the following goal for improving health has been included in the Healthy People 2010 report, "Improve health, fitness, and quality of life through daily physical activity" (Section 22-7). Fifteen physical activity and fitness objectives are outlined as part of this goal statement. Two of these objectives are (U.S. DHHS, 2000):
* "Reduce the proportion of adults who engage in no leisure-time physical activity" (Objective 22-1).
* "Increase the proportion of adults who engage regularly, preferably daily, in moderate physical activity for at least 30 minutes per day" (Objective 22-2).
Even though most people know regular exercise is an important aspect of a healthy lifestyle, many do not exercise at all. When adults do engage in some exercise, often the physical activity is insufficient to realize health benefits (American Heart Association, 1997; Ulbrich, 1999). The incidence of inactivity increases with age, and 51% of adults ages 65 to 74 and 65% of adults ages 75 and older participate in no leisure-time physical activity.
Furthermore, only 16% of adults ages 65 to 74 and 12% of adults ages 75 and older participate in 30 minutes of physical activity at least 5 days a week (U.S. DHHS, 2000). Unfortunately, very few adults ages 65 and older are even close to meeting the physical activity and fitness goal for daily physical activity. Because ongoing adherence to an exercise routine is related to health status and the ability to maintain an independent lifestyle, inactivity is a major health concern for older adults.
In a review of more than 300 exercise adherence studies, self-efficacy was repeatedly and positively associated with participation in both supervised and overall physical exercise activities (Sallis & Owen, 1999). Self-efficacy is defined as individuals' confidence in their ability to perform a certain behavior under specific circumstances. Individuals with high self-efficacy or high confidence in their ability to perform a healthrelated behavior, such as walking for exercise, have a positive or "I think I can do this" attitude. When individuals are confident they can participate in a walking-for-exercise routine under a given set of circumstances, the likelihood of actual participation is great. Individuals with low self-efficacy or low confidence in their ability to perform a healthrelated behavior have a negative or "I don't think I can do this" attitude. When individuals have little confidence in their ability to participate in a walking-for-exercise routine, the likelihood of actual participation is minimal (Bandura, 1986; Hofstetter, Hovell, & Sallis, 1990).
The Walking Confidence Survey (WCS) was modeled after the SelfEfficacy for Exercise Behavior Scales (Sallis, Pinski, Grossman, Patterson, & Nader, 1988) and is a measure of walking for exercise self-efficacy (Konradi & Lyon, 2000). Because perceptions of self-efficacy are very dependent on the target behavior, an individual can have a high degree of self-efficacy for participating in a walking-for-exercise routine, but a low degree of self-efficacy for participating in a vigorous exercise program. Theoretically, limiting the scope of the self-efficacy measure to walking should result in a more precise assessment of walking for exercise self-efficacy, and a greater ability to predict walking for exercise behaviors in individuals.
The 10 items on the WCS represented two self-efficacy themes. Seven items were used to measure the "making time for exercise" theme and three items were used to measure the "resisting relapse" theme. Scoring for each WCS item was based on a 5-point Likert scale with response options ranging from 1 ("I know I cannot") to 5 ("I know I can"). Testing the WCS was completed using a sample of adults actively participating in a non-medically supervised exercise walking routine (N = 94). Scores for this sample ranged from 2.6 to 5 (M = 4.28, SD = .68, a = .9), indicating the study participants had a high degree of fitness walking self-efficacy. Because the sample was limited to individuals already participating in a fitness walking routine, high scoring on the WCS was anticipated.
A significant correlation between WCS scores and ongoing walking routine adherence was noted for participants younger than 65 (n = 51, r = .34, p = .01). However, a significant correlation was not found for participants 65 and older. Specifically, a correlation between exercise behaviors and the self-efficacy themes making time for exercise and resisting relapse was not found for adults 65 and older.
Because the rate of relapse is high for exercisers of all ages (U.S. DHHS, 2000), it was hypothesized that the theme with questionable application for older adults was "making time for exercise." Prior to the age of retirement, many adults balance multiple time consuming obligations. Because multiple obligations (e.g., raising children, working) compete for time, selfefficacy is influenced by how an activity fits into an already busy schedule. With retirement usually occurring approximately at age 65, employment-related demands decrease, and individuals might have more time for exercise and other activities. Perhaps with more time available, making time for exercise might become less of an issue. According to Cousins (1998):
study is needed to understand how paid work facilitates or undermines active leisure patterns, and how retirement from employment encourages or discourages future participation (p. 164).
Because little is known about how exercise walkers 65 and older develop their self-efficacy for exercise adherence appraisals, a qualitative focus group methodology was selected for this study. The purpose of this study was to describe the themes adults 65 and older use to construct self -efficacy (i.e., self-confidence) appraisals for adhering to their walking routines.
Following Committee for the Use of Human Subjects approval, adults age 65 and older (N = 19) were recruited for participation in a focus group study. The methodology for this study was based on Krueger's (1994) focus group guidelines. A variety of cost-effective recruitment methods were used to secure the study sample, including:
* Advertisements placed in sections of the regional newspaper with high 65-and-older demographic readership.
* Public service radio announcements on stations with a large 65and-older audience.
* A scheduled radio morning show interview to describe and discuss the project.
* Direct recruiting at a community services booth during early morning pre-shopping hours at the mall.
To place an effective and cost limiting newspaper advertisement, the following four factors were considered: cost, prospective sample audience, newspaper readership (by section of the paper and day of the week), and physical size of the advertisement. Taking all four factors into consideration, a 1-inch by 3 -inch recruitment advertisement was placed in the Features Section of the Thursday paper because:
* Monday through Friday advertisement rates were less expensive than weekend rates.
* The Thursday newspaper had the highest Monday through Friday circulation rate because grocery advertisements were printed on Thursday.
* The demographics for the readership of the Features Section included the desired population for the study.
A telephone number for contacting the researcher was included in all methods of recruitment. During the initial phone contact, callers meeting the study inclusion criteria were given a description of the project and the anticipated time commitment required for focus group participation. Callers interested in participating in the study were given focus group scheduling information and were mailed study materials including a Data Profile Sheet and Statement of Informed Consent. The completed Data Profile Sheet and the signed Statement of Informed Consent were collected prior to beginning each focus group session.
To ensure construct validity, three self-efficacy concept experts critiqued a draft of the initial focus group interview guide. Their suggestions were incorporated into the final focus group interview guide. Question categories were opening (2 questions), introductory (2 questions), transition (2 questions), key (6 questions), and ending (2 questions) for a total of 14 questions. Four focus group sessions were held to accommodate the participants' schedules and to maximize the opportunity for all to share ideas. All focus group sessions were audio recorded and written notes were kept. The number of participants per session ranged from four to six.
At the beginning of each 90minute focus group session, the researcher read the following statement to the participants to share the purpose of the study:
The purpose of this study is to learn more about how personal perceptions influence walking for exercise behaviors. Specifically, I am interested in learning about how you weigh different factors and come up with a decision to either exercise or not exercise on a daily basis.
Next, the following two opening questions were asked, "How long have you been participating in a walking-for-exercise routine?" and "Tell me about your walking-for-exercise routine. How often, how long, how far, how fast?" The purpose of the opening questions was to get each participant to share a piece of "nonthreatening" factual information and to help each participant develop a sense of comfort while sharing information in a group setting.
Introductory questions were next asked to allow participants the opportunity to reflect on their "walking for exercise" experiences. Consistent with Krueger's (1994) guidelines, the primary purpose of the introductory questions was to foster communication and interaction among the group participants. One of the introductory questions was, "What led you to begin a walking-for-exercise routine?" Transition items were developed to establish a link between the introductory questions and the key questions. To provide variability in the type of questions asked, the transition items were constructed using a sentence completion strategy. After hearing the first part of a sentence, participants completed the idea on a sheet of paper. After a few minutes, participants shared and discussed what they had written. One of the transition items was, "On the days that I do walk, the things that make me decide to walk UnClUdC..."
SAMPLE DEMOGRAPHICS: AGE, MARITAL STATUS, WALKING LOCATIONS, AND EDUATION (N = 19)
Because the rate of illiteracy varies, focus group facilitators should consider the attributes of the study population and sample (if known) prior to using this sentence completion strategy. Also, as the participants are working on the sentence completion task, the facilitator must carefully assess for verbal and nonverbal responses. If participants seem uncomfortable or frustrated, the facilitator should change to a different data collection strategy. Prior to this study's focus group sessions, the Data Profile Sheets were reviewed. The decision to use the sentence completion strategy was influenced by the participants' reported level of education (Table 1). By assessing participants' nonverbal communication and participation level during the sessions, the facilitator concluded participants were able to complete the sentence completion items with minimal difficulty.
Six key questions were designed to determine participants' self-efficacy perceptions specifically related to the performance of walking-for-exercise activities. Information was also elicited about relationships between the level of self-confidence for exercise and:
* Previous experience with exercise.
* Knowledge about walking for exercise.
* Daily scheduling of exercise sessions.
* Personal health.
Two of the key questions were, "How do you fit your walking-for-exercise routine into your daily schedule?" and "In what way does your personal health influence your decision to walk on any given day?" Participants were also asked about friends, family, and health professionals who may have influenced their walking-for-exercise confidence levels.
Finally, each session concluded with two ending questions. The purpose of these questions was to bring closure to the discussion and provide an opportunity for reflecting on previous comments. The following ending questions were asked, "What advice would you give to others who are having a hard time sticking with their walking routine?" and "Is there anything else you would like to add?" According to Krueger (1994), a typical focus group session consists of approximately 12 questions. Because all of the focus group sessions included fewer than 12 participants, it was not difficult to complete the entire interview in the 90minute time frame.
Incentives for participating in focus group sessions are appropriate to compensate participants for their time and effort (Krueger, 1994). Following the focus group session, each participant received coupons from a local restaurant that offered heart-healthy menu items, discount coupons from a store specializing in exercise footwear, a wrist pocket pouch for carrying a key or identification card, and $10 in cash.
Participants (N = 19) recorded information about themselves and their walking-for-exercise routines using the Data Profile Sheet The study sample included 11 women and 8 men ages 65 to 86 (M = 70.78). Based on age, height, and weight information, 17 (89.5%) of the participants were within a "normal weight range" and 2 (10.5%) of the participants were obese.
A wide range of walking-forexercise experience was reported. Three participants reported starting their routine less than a year prior, and 9 participants reported they had been walking for 10 years or longer (M = 7.58, SD = 5.57). One 74-yearold participant reported he had been walking for exercise for approximately 74 years - this response was not included in the quantitative analysis. Participants reported completing their routines an average of 5.32 times per week (SD = 1.61).
Some participants walked as few as 3 days per week, and others walked as often as every day. The average length of time for each walking-for-exercise session was 50.58 minutes, and exercise sessions ranged from 20 minutes to 120 minutes (SD = 24.11) Demographic information for study participants is reported in Tables 1 and Table 2.
The audio recording for each focus group session was transcribed using a word processing program and saved as an ASCII file. The Scolari (1998) software program ATLAS.ti for Windows was used to facilitate qualitative data analysis. Additionally, computer-based systems provided features to help the researcher record annotations and retrieve previously completed work. Unlike other software packages, ATLAS.ti also includes a concept map feature, which is useful in the process of theory building. For this project, the concept mapping feature was used to create a diagram depicting the relationship between walking-for-exercise adherence and the concepts identified during the process of qualitative data analysis (Figure). A detailed description of the software package, a demonstration version, and brief descriptions of user projects can be found at the ATLAS.ti home page (http://www.atlasti.de/).
ACE OF PARTICIPANTS, EXPERIENCE WITH THE WALKING ROUTINE, AND DESCRIPTION OF THE WALKING-FOREXERCISE ROUTINE
The original data-analysis plan was broken into three steps:
* Work together to learn how to use the ATLAS.ti software.
* Individually code the transcript data.
* Compare data and discuss similarities and differences.
During the process of working together to learn the software, the authors realized their collective ability to sort, code, and analyze data exceeded the sum of their independent efforts. Therefore, the authors changed the initial data-analysis plan and coded all the transcript data as a team. A total of 308 quotations were coded into 17 concept categories. Each concept category represented a unique self-efficacy for exercise adherence theme expressed by focus group participants. Log notes were recorded for each session, and included a summary of completed work and objectives for the next session.
Habit and Routine. The concept category with the greatest number of supporting quotations was labeled "Habit and routine." A total of 90 quotations (29.2%) were coded into this concept category. One participant noted, "She [friend] just wouldn't give it [walking] up," and another stated, "and I've been walking 5 years." Another participant said, Tm walking every day." Scheduling seemed to be an important consideration for maintaining the habit and routine. "But it is part of your day. You get up, you get dressed, you go to the mall, and you come back," said one participant. Another one noted, "we changed the time that we go over because we would have missed several times if we hadn't. We just scheduled it around what we had to do." Commitment was also associated with maintaining the habit. One participant stated, "I feel guilty if I don't get out and walk. If I don't get out, I feel like I've done something against myself." Another participant expressed a high level of commitment stating:
You do not make appointments that interfere with your walking. If you make doctors' appointments, you make them for later in the day and anything that comes along where you designate a time interval; you do it later because your habit is that you're going to go walking. That's the way it works out.
The participants' faithfulness to their walking routines was very strong. "It's just like a habit. Part of things that I do because it's habit and I want to, I guess," said one participant. Another one said, "I've been very faithful when I've been home, of showing up three times a week." Advice for maintaining the habit and routine was given by one participant who stated, "I'd say, if you really want to do this, pick a time and be consistent and follow that every day." This participant also said time and place helped maintain consistency and the walking habit.
Healthy Body. The second most frequently coded concept category was labeled "Healthy body." A total of 34 (11%) quotations were coded into this category. Working to maintain or achieve a healthy body was a clear motivation for many participants. Some participants stated they adhered to their walking-for-exercise routine to enhance their health. Others said they adhered to their walking routine to reduce unpleasant physical symptoms or avoid future health problems. One participant expressed a goal to avoid future health problems stating, "and I don't have any health problems and I don't want to have any health problems." Another participant also wanting to avoid future problems stated:
I started because I didn't like the effects of the blood pressure medicine, and I asked if there wasn't some other way we could do this. The doctor said, "well, maybe if you walked" so I began walking... It's working, it's better than medication.
Support. The third most frequently coded concept category related to perceptions of self-efficacy for walking adherence was labeled "Support." A total of 32 (10.4%) quotations were coded into this category. Many of the participants in the focus group sessions noted that their self-confidence for walking adherence was related to support. After reviewing all of the quotations in the support concept category, four subcodes for support were identified:
* Need for companionship
* Perceived support
* Prescriptive support (i.e., giving and receiving exercise routine suggestions and recommendations).
* Actual support.
An example of the need for a walking companion was demonstrated by the following quotation:
The other thing would be to find a friend who wanted to walk with you at the same time and then it would be sort of leverage. If you had to meet a friend or pick up a friend, or whatever it was.
Perceived support, actual support, and the need for a walking companion was reflected in the following quotation:
But a lot of mornings someone will come along and start walking with you and so we have a group of men who all coffee together after walking and most of them are there for the same reason that I am. Out of the group, four of us have had open heart surgery.
Only a few participants discussed support from health care providers. One participant noted, "The doctor said you got to start walking and I started walking." A second participant stated:
I have three different doctors at [the clinic] who have been very supportive. They are all in the pulmonary field and commended me for doing it. My local doctors is [sic] also aware of it and endorses it.
The participants described no specific examples of a health care provider giving a specific walking routine prescription. One participant perceived that his family was supportive stating, "My son and daughter are real supportive."
Sources for receiving prescriptive support included physicians, exercise instructors, chiropractors, and friends. One participant stated, "The doctor said you've got to start walking, so he recommends exercise." Another participant noted that "our gal over there at the exercise class....I've gotten more [support] from her than I ever got." Finally, one participant suggested the following exercise prescription for sedentary older adults, "I think if they would get into a structured program like I am.. .that would help."
Control of relapse. The fourth most frequently coded concept category was labeled "Control of relapse." A total of 30 (9.7%) quotations were coded into this category. After reviewing all of the quotations in the control of relapse category, three subcodes were identified. The first subcode was used to describe situations of actual relapse related to scheduling conflicts or physical problems. Two examples of relapse included, "The things that have kept me from walking...she had a wedding coming up or getting ready for a trip or something" and "I have multiple problems and one of the them is a chronic back problem, when that goes out, that hobbles me sometimes." The second category of relapse was used to describe the participants' concerns about the potential for relapse. One participant noted:
I'm a little concerned about what will happen when my friend goes back to teaching in a few weeks. But I'm hoping I will be in a routine and will be able to do it myself.
The final category was the lack of a destination as a concern for relapse. One participant stated, "I think part of the inducement, as far as I am concerned, is if we stop at the store."
WALKING FOR EXERCISE SELF-EFFICACY THEMES
One participant's statement be used as an example of all four the main concept categories:
People often say to me that "well, yeah, but you've got Bob to walk with." I'm sure that at various times that he's been gone, like in the hospital or fishing, or something like that, and I walked once. But I don't think - I mean, I'd have to do a whole new mental - if we didn't walk together. That would be a deterrent.
Other Themes. Supporting quotations (n = 122) for the 12 additional themes collectively represented less than one-third of the coded data. A listing of all 16 theme categories and number of supporting quotations is reported on Table 3.
Lack of Time
According to an overview of previously published exercise adherence studies (Sallis & Owen, 1999), lack of time has been strongly correlated with physical activity participation. A limitation in applying this finding to older adults' participation in moderate intensity exercise is that most of the previously published studies focused on adult adherence to vigorous exercise. It was not surprising that during focus group discussions, different themes were identified by this sample of older adults. For example, only a few of the focus group participants mentioned a "Lack of time" theme in their responses. Even when participants were prompted with the question, "How do you fit your walking-forexercise routine into your daily schedule?" they typically did not mention lack-of-time concerns.
The self-efficacy for walking-forexercise themes most frequently mentioned by participants in this focus group study were:
* Habit and routine.
* Healthy body.
* Control of relapse.
However, all of the identified themes collectively provided a comprehensive description of the self-efficacy for walking appraisal process used by study participants. The importance of developing a walking-forexercise "habit" or "routine" was the theme most often mentioned and emphasized by the participants.
An insight gained from the data analysis was that many of the participants grew up in a culture that included walking as an important means of transportation. Participants discussed personal histories that included walking to work, walking to the store, and walking to friends' homes. For many participants in this group, current fitness walking activities were attributed, in part, to a history of walking experience established out of necessity many years ago.
Wisdom gained throughout the project is important to share. Because qualitative software is different from other types of computer programs, it is important to include work sessions devoted to learning the software in the project time-line. Although learning to use the software requires investments of time and effort, computer-assisted software for qualitative data analysis is an invaluable tool for organizing, reorganizing, archiving, and presenting transcribed data.
Also, the process of finding and naming themes cannot be rushed. In this study, the team approach to theme identification was more productive than working individually. Talking through perceptual differences helped the authors see the data from another's perspective. Finally, using a Project Log to record discussion summaries and completed work was very helpful when it became necessary to review rationales for previously reached conclusions. On several occasions, the authors avoided repeating previous discussions by consulting the Project Log. Also, keeping a record of project goals and accomplishments in the Project Log helped the authors plot the project wisely and use their time effectively.
Development of the Walking Confidence Scale II (WCSII) is planned. The WCSII factor development will be based on the four most prevalent walking for exercise selfefficacy appraisal themes identified by participants in this focus group study. The authors anticipate that data collected using the WCSII will be used to determine the likelihood of someone 65 or older adhering to a previously established walking-forexercise routine.
Because self-efficacy appraisal is influenced by experience and personal history, two additional focus group studies are needed. The population for the second focus group study would include adults 65 and older contemplating initiating a new walking-forexercise routine. The population for the third focus group study would include adults 65 and older who have experienced a relapse in their walking for exercise. Because the self-efficacy appraisal themes may be different for each group, subsequent intervention strategies for promoting adherence may also be different.
Participation in exercise and physical activity is important for maintaining a healthy and satisfying life. For this reason, nurses must be actively involved in promoting exercise adoption and adherence to their patients. Four nursing responsibilities for promoting exercise follow.
First, nurses should keep informed about exercise guidelines appropriate for adults 65 and older. The Healthy People 2010 document, available on the Internet at http://www.health. gov/healthypeople/document, is a helpful information source.
Second, nurses should initiate a discussion about physical activity participation with their patients during the assessment process. Questions focusing on the self-efficacy concept categories of habit and routine, healthy body, support, and control of relapse can be included in this assessment. This information should be added to the patient's medical record. In addition to the medical value of this information, the nurse-initiated discussion communicates the importance and value of physical activity participation to the patient. Patients who exercise will benefit from the nurse's support, patients not exercising can be identified and assessed, and patients having difficulty with their exercise routines can be assisted.
Third, nurses should design intervention strategies for enhancing adherence to a walking routine. These interventions should be based on the self-efficacy concept categories identified as weak. For example, if the patient expresses a lack of support for exercise participation, nursing interventions should focus on strategies to increase support. Strategies might include getting the patient involved in a walking group at a shopping mall or health department, helping the patient find a walking partner, or providing the patient with regular opportunities to discuss walking progress over the telephone. If the patient expresses difficulty developing a walking-for-exercise routine, nursing interventions should focus on strategies to develop and maintain a routine. Strategies might include:
* Helping patients design an enjoyable routine that easily fits into their schedule.
* Helping patients develop alternate plans for times when typical conditions vary (e.g., vacation, company at home, occasional appointments, mild illness, poor weather).
* Helping patients balance personal preferences and physical factors when determining the time of day for exercise.
* Encouraging the patients to "protect" the time set aside for exercise. One focus group participant protected his exercise time by actually writing it in his schedule as a standing appointment.
Finally, nurses should be aware of exercise resources available in the community. Some community-based exercise programs may be available to senior citizens at either no cost or a very low cost. These programs can provide patients with information about exercise and support from professionals and peers.
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SAMPLE DEMOGRAPHICS: AGE, MARITAL STATUS, WALKING LOCATIONS, AND EDUATION (N = 19)
ACE OF PARTICIPANTS, EXPERIENCE WITH THE WALKING ROUTINE, AND DESCRIPTION OF THE WALKING-FOREXERCISE ROUTINE
WALKING FOR EXERCISE SELF-EFFICACY THEMES