1 The Culture of Physical ActivityRosaly Correa-de-Araujo, MD, MSc, PhD Senior Scientific Advisor to the Director Division of Geriatrics and Clinical Gerontology National Institute on Aging, National Institutes of Health Annual Meeting, American Geriatrics Society Grapevine, Texas May 2-5, 2013

2 Source: President’s Council on Fitness, Sports & Nutrition Report, 2010

3 INDICATOR 28 Use of Time

4 Healthy People Leisure Time Physical Activity, Older Adults with Reduced Physical or Cognitive Function, 2011 Source: NHIS

5 Physical Activity Participation, Health Perceptions, and CVD Mortality- The Dallas Heart Study, 2012Source: Mathieu et al, 2012

6 Why Physical Activity Differs Among Racial and Ethnic Groups?Everyone has a cultural identity and values. The complexity of culture is the interplay of its components and influencing factors. Race/ethnicity and multiple factors including external forces shape or influence culture. Acculturation may change cultural practices. Factors determining physical activity participation are part of the cultural environment.

7 RCTs Home-Based Interventions Targeting All Older AdultsRCT Study Purpose Intervention Outcomes Fries et al, 1993 Senior Healthtrac ↓ health risks/medical costs. Individual education. Retired Bank of America employees. Short term: ↓ cost by $350 ($100 control). Long term: improved risk score, exercise minutes/week Jette et al, 1999 Strong for Life Program Improving health of older adults with disabilities Individual strength exercise Support relationships. Campaigns & promotions. Short term: ↑ adherence rates. Lower extremity improvements Improved tandem gait. ↓ physical and overall disability. Castro et al, 2001 Improving PA in Older Adults Improve physical activity maintenance through phone and mail-medicated interventions Individual education, support relationships. Healthy older adults years Short term: Both phone or mail effective. Higher adherence rates for those prescribed high intensity exercise by mail intervention in maintenance year. Brassington et al, 2002 Telephone Counseling for Older Adults ↑ exercise adherence in older adults through cognitive or social mediators Support relationships, group education. Healthy and sedentary older adults. Short term: High adherence for both groups “moderate intensity & strengthening and stretching & strengthening exercises Source:

8 RCTs Community/Health Care Setting InterventionsRCT Study Purpose/Setting Intervention Outcomes Kriska et al Walking Groups Achieve/maintain walking of 7 miles/week. Parks/shopping malls, community-based Support relationships Campaigns/promotions Women, 50-65ys. Long-term: significant ↑, 80% walking at least 5 miles/week Minor et al, 1989 Physical Conditioning Exercise ↑ conditioning exercise for those traditionally excluded from vigorous activity due to health problems. Outpatient rheumatoid clinics. Group education: aerobic walking, aerobic aquatics, nonaerobic range of motion exercises. Older adults with rheumatoid arthritis or osteoarthritis. Short term: ↑aerobic conditioning: aerobic capacity, 50-foot walking time, self reported activity, anxiety, depression after 12 weeks. Nonaerobic group: ↑ exercise endurance, grip strength, flexibility. Long term: aerobic walking maintained activity after intervention. Mayer et al, 1994 San Diego Medicare Prevention Improve health through health promotion component of a preventive services intervention for Medicare beneficiaries. San Diego communities. Individual & group education, support relationships. Long term: ↑ aerobic activity, stretching and strength exercises Ettinger et al, 1997 Exercise + Education Effects of structured exercise programs. Community and home-based . Group education: aerobic activity. Health education. Knee osteoarthritis & physical disability Long term: consistent modest improvement in the aerobic and resistance programs, pain and disability reduction. Jarvis et al, 1997 TLC-ACT Encourage 60-minute walk per week. Primary care, academia Individual education: print materials, phone counsel. Computer tracking. Women Long term: TLC-ACT significant effect. Source:

9 Adaptation of Physical Activities Interventions to Meet the Needs of Ethnic MinoritiesSystematic review – 48,740 studies, 173 included, 12 theoretical paper, 7 systematic reviews, 107 empirical investigations. Majority conducted in the United States, primarily assessing adapted interventions in African Americas. Little evidence in relation to other ethnic groups. Research questions. Source: Liu et al, 2012

10 Adaptation of Physical Activities Interventions to Meet the Needs of Ethnic Minorities: Summary of Systematic Reviews on Physical Activity in African-Americans Review Health Issue Intervention Results Whitt-Glover & Kumanyika, 2009 29 studies, from , in adults & children ↑ PA for all Interventions to increase PA & fitness Mixed results on effectiveness. Adult studies were more effective than those in children. Studies with cultural adaptations did not appear to result in significantly better outcomes. Banks-Wallace, 2002 18 studies from , in women Any Culturally relevant strategies are effective for promoting PA and dietary changes among African American women. No firm conclusions on effectiveness of particular components of adaptation. Source: Liu et al, 2012

11 Adaptation of Physical Activities Interventions to Meet the Needs of Ethnic Minorities: Direct Comparison of Adapted with Non-Adapted Interventions Study Intervention Results Newton & Perri, 2004 90 African-American adults RCT comparing 3 home-based exercise promotion interventions: Standard behavior exercise counseling. Culturally sensitive exercise counseling. Physician advice group. At 6-mo follow-up all three streams reported increases in physical activity, but no statistically significant differences were noted in: improvements in cardiovascular fitness reported physical activity between culturally sensitive and standard. Acculturation did not moderate relationship between group assignment and outcomes. Participants were “bicultural.” Source: Liu et al, 2012

12 Older American Indians & Alaska Natives’ Perceptions About Physical ActivityOppression, poverty, low self-esteem: Lower motivation for self-care. Providing care to other older adults in the community. Isolation. Uncomfortable around non-Indians. Fitness facilities: “people do not look like me.” Living with diabetes raised awareness about physical activity. Getting together to discuss health and help each other. Cultural and community connection are very important as motivator for participation. Source: Belza et al, 2004

13 Older African –Americans’ Perceptions About Physical ActivityThe role of friends to encourage activities. Social programs as key to physical activities. Group activities, but with individuality. Walking: stress relief, time for meditation, opportunity to be in contact with nature. Having determination, habit-forming, self-sustaining. Rain may aggravate physical conditions but should not prevent physical activity. Social aspects of programs are very important. Source: Belza et al, 2004

14 Barriers to Physical Activity in Older African-AmericansIndividual Socio-Environmental Monetary-socioeconomic issues Unsafe neighborhood Stray/dangerous dogs Adverse weather/climate conditions Heavy traffic Lack of public transportation Lack of parks and open space Lack of facilities Lack of time Lack of motivation Physical disability/disease Fatigue Lack of knowledge or prior experience Source: Siddiqi et al, 2011

15 Enabling Factors to Physical Activity in Older African-AmericansIndividual Socio-Environmental Doctor’s advice Social support Presence of children in the household Structured/group exercise program availability at church/community Easy access to parks Positive health benefits Mental health/stress Personal enjoyment Sense of wellbeing Weight loss Source: Siddiqi et al, 2011

16 Older Latinos’ Perceptions About Physical ActivityFaith as an integral part of daily activities. Music, singing and dancing as ways to remain physically active. Socializing, avoiding depression and being outdoors as motivators. Dizzy spells and lack of energy are barriers. Visual and hearing impairments are barriers. Unavailability of friends is a barrier. Faith is an integral part of daily activities including physical activities. Source: Belza et al, 2004

17 Barriers to Physical Activity in Older Hispanics/LatinosIndividual Socio-Environmental Monetary-socioeconomic issues Little or no time for social interactions Perceived neighborhood safety Perceived access to facilities Advancing age Lack of time Lack of motivation Overweight or obesity Perception of poor health Source: Ickes & Sharma, 2012

18 Enabling Factors to Physical Activity in Older Hispanics/LatinosIndividual Socio-Environmental Greater acculturation Culturally-focused strategies Dancing Walking Gardening Family-oriented Sense of Community, Social support Supportive friend Knowing/seeing people exercising Involvement in group exercise Greater acculturation Desire to be healthy for the family Anticipated health benefits Anticipated psychological benefits Self-efficacy Source: Ickes & Sharma, 2012

19 Older Asian-Americans’ Perceptions About Physical Activity (1)Chinese Importance of daily activity routine. Physical activity is critical to maintaining health, more important than medications. Physical activity helps with digestion, blood circulation, relaxation, avoiding medications, preventing sickness and chronic pain, living longer and happier in overall good health. Weather- fear of falling Physical activity helps maintain friendships Social obligation may interrupt physical activity Source: Belza et al, 2004

20 Older Asian-Americans’ Perceptions About Physical Activity (2)Korean Importance of daily physical activity routine. Physical activity helps with joint pain, digestion, feeling relaxed and happy. Being tired or dizzy precludes physical activity. Should not walk because of age or health condition. Isolation from other Koreans is an issue. Source: Belza et al, 2004

21 Older Asian-Americans’ Perceptions About Physical Activity (3)Filipinos Importance of community, laughter and socializing with those of same age. Physical activity as part of bigger social picture. Physical activity is important to counteract American high fat diet: high blood pressure. Physical activity helps with digestion, blood circulation, stimulates appetite, sweating is beneficial Walking importance: stretching, tai-chi, household chores. Dancing makes you feel younger and never give up. Family, work obligations, feeling bad or sick may preclude physical activity. Vision impairment: Fear of tripping or falling. Dramatic fears: rape, robbery, kidnapping, terrorism. Filipino center: unity, equality, cooperation. Share exercises with those confined to home. Source: Belza et al, 2004; Ceria-Ulep et al, 2011

22 Older Asian-Americans’ Perceptions About Physical Activity (4)Vietnamese Consistent routine of daily exercise. Physical activity and massage: blood circulation, avoid medication use, help longevity. Stiff muscle: weak, sick. Mental activities should be integrated. Motivation is being afraid of early death. Personal determination, willpower critical for remaining active. Geographic isolation is a barrier, far from friends and places to walk. Cold weather problematic, difficult to breathe. Source: Belza et al, 2004

23 Older Asian-Americans’ Perceptions About Physical Activity (5)Cambodian Small stature of most Cambodians serves as a deterrent to physical activity, they think there is no health issue. Sweating is thought of as a benefit to physical activity, if you sweat a lot, toxins get out of your body and you have no diseases. Found to be beneficial for chronic diseases, to help breath better and prevent acute disease. Older adults emphasized exercise for being health and live long. Social engagement (seeing others exercise, having a supporter friend), community emphasis in the United States. Source: Coronado et al, 2011

24 General Recommendations for Physical Activity Interventions/Programs for Older AdultsPotential Strategies Foster relationships among physical activity participants Peer support or “buddy system” Group classes or individual instruction Information on benefits, location, program availability Informal phone tree networks Bring programs to where people live Classes at senior housing facilities Transportation to community programs from facilities Walking club at senior housing facilities Partner with other programs One-stop shopping program Transportation Provide a variety of options Programs to different levels of physical capability Options for both groups and individuals Offer culture-specific programs Classes & programs for similar culture, language Language proficient instructor, good communication, similar values Components of music, traditional dance Source: Belza et al, 2004

25 Issues Unique to South Asians Practice, Policy & Research on Physical ActivityThemes Practice/Policy Future Research Communication Culturally relevant advice Patient s’ preferences Community to advertise benefits Interpreters /workers Interactions between professionals and patients regarding benefits. How patients want info to be delivered & by whom. Relationships Use examples of performance Social support interventions Outreach Evaluate existing social support interventions Beliefs Cultural/religious values Use traditional activities Involve community in planning and delivery Group norms Importance of goal specificity Evaluate interventions working with fatalistic beliefs Explore PA inclusion around the day for sustainability Environment Identify programs likely to succeed, pre-existing communities Access for combined interventions Service provision in known community & networks Types of activities preferred by older South Asians and performance locations Source: Horne & Tierney, 2012

26 Community EnvironmentsPolicy Implications Health Care Systems Health Care Professionals Community Environments

27 Future Research Most effective study designs for whom and at what costs. Effectiveness of behavior change in clinical practice. Efficacy of different behavior interventions assessed in diverse settings with diverse populations. Translation and disseminations of evidence-based strategies into health practices.

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