Barriers and facilitators to older adults’ engagement in healthy aging initiatives
Objectives. To identify the facilitators and barriers to older adults’ participation in healthy aging or cardiovascular rehabilitation programs.
Methods. We conducted a scoping review to identify healthy aging program evaluations which identified participant barriers and facilitators. We developed a search strategy in the following databases: MEDLINE, Embase, APA PsycInfo, and Cochrane CENTRAL, all on the Ovid platform and Ebsco CINAHL.
Results. We included 17 articles in this review. Our team categorized the barriers and facilitators of older adults’ participation in healthy aging programs into seven themes: attitudes, organizational structure, accessibility, social structure, knowledge, demographics, and program specifics.
Conclusions. Understanding the facilitators and barriers that older adults face when deciding whether or not to participate or to continue participating in, healthy aging programs to promote in, cardiovascular health can help healthcare professionals provide optimal guidance for their patients and clients.
The demographics of Canada’s population is shifting. In the 2016 Census, people 65 years and older outnumbered children 14 years and under for the first time 1. As Canadians age, their risk of developing chronic diseases also increases. Currently, over one million Canadians are medically frail, meaning they are in “precarious health, have significant multiple health impairments, and are at higher risk of dying” 2. The Canadian Frailty Network predicts that the number of medically frail Canadians will double in the next decade 3. The cost associated with an unhealthy aging population is an even higher consumption of healthcare resources 3. According to the Government of Canada, 44% of adults over the age of 20 have at least one of 10 common chronic conditions. One of them is cardiovascular disease (CVD) 4.
According to the World Health Organization (WHO), CVD is the most widespread noncommunicable disease (NCD) worldwide, contributing to 17.9 million deaths annually (44% of NCD deaths), and CVD accounts for 10% of the global disease burden 5. The high prevalence of CVD, in turn, results in a high economic burden 6. By 2030, it is predicted that 23 million people per year will die from CVD 6. The primary load is attributed to either ischemic heart disease or cerebrovascular disease 7. Individuals with CVD may also be at risk for deteriorating cognition, including memory functions, independent of age-related decline 8. Our single-illness model healthcare systems are now scrambling to “meet the needs of older people with multiple, simultaneous, and often interrelated health and social issues that threaten their independence” 2.
Many factors can impact healthy aging, including malnutrition, risk of disease, socioeconomic inequalities, social environments, and negative attitudes about aging 9-11. Healthy, active aging at any age can contribute to continued participation in social, economic, cultural, spiritual, and civic life as well as social, mental, and physical wellbeing, autonomy, and independence 12-14. While there is ample evidence for the benefits of healthy aging initiatives for older adults with cardiovascular diseases, less is known about the motivations that people have for participating, or not, in healthy aging programs.
To better understand why older adults choose to participate in healthy aging initiatives, we conducted a scoping review of the attitudes, barriers and facilitators towards ongoing participation in healthy aging initiatives.
We followed the guidelines of Arksey and O’Malley (2005) for the reporting of scoping reviews 15.
A search strategy was developed by team members (AHT, JT, ACB) in consultation with a health librarian in Medline (Ovid MEDLINE(R) Daily and Epub Ahead of Print, In-Process & Other Non-Indexed Citations 1946 to Present) (see Appendix I). The search strategy was then translated into two additional databases EMBASE (Ovid, Embase Classic+Embase 1947 to present) and CINAHL (EBSCO, from inception).
We included studies that reported on healthy aging and/or cardiovascular rehabilitation community or home-based programs for older adults (65+) with cardiovascular disease. Studies included in this review focused on participants’ attitudes towards participation in healthy aging and/or cardiovascular rehabilitation programs, and the barriers and facilitators they experience to participating in these programs. We focused on the evaluations of these programs to understand the participant experience. As our focus was on older adults with cardiovascular disease, we limited our inclusion to studies where at least 50% of the study population was 65 years of age or older. We also included community-based cardiovascular rehabilitation programs within our definition of healthy aging programs. We included all quantitative, qualitative, and mixed methods study designs. We excluded studies if no data were available for extraction, they were not full publications, they did not report primary research (e.g., case reports, reviews, opinion pieces, editorials) or if the full manuscripts were not available in English. We also excluded studies in which participants were post-transplant recipients, used medical devices (pacemaker, implantable defibrillator, etc.), had primary congestive heart failure, pulmonary disease, or progressive neurological disorders. We did not include hospital-based healthy aging programs in this review as our focus was on community-based programming.
STUDY SELECTION PROCESS
All titles and abstracts were screened for full-text review by two independent reviewers from a pool of three reviewers (SHT, JT, ACB) to determine if they met the inclusion and exclusion criteria outlined above. The reviewers discussed any differences in the inclusion decisions, with a third reviewer brought in if they could not reach an agreement. Two reviewers (AHT, BL) then independently reviewed all articles included in the full-text review for inclusion in data extraction, with discussion to resolve conflicts.
We developed a data extraction form to obtain consistent and comparable evidence from each study and assist in the synthesis of collected evidence. Extracted information included: study characteristics (title, authors, objective, and study design), participant characteristics, details of the healthy aging program (e.g., length of program, exercise, nutrition, lifestyle, frequency of meetings, etc.), and barriers and facilitators to participation. Extraction was conducted by two reviewers independently using the consensus tool in Covidence 16.
A thematic approach was taken to categorize the facilitators and barriers to participation. In the data extraction phase, the barriers and facilitators described within each study were extracted (AHT, JT). Team members (AHT, ACB) then met to discuss these results and categorize them into themes. A narrative discussion is provided relating to barriers and facilitators. Seven themes were identified: attitudes, organizational structure, accessibility, social structure, knowledge, demographics, and program-specific barriers.
Our initial searches identified 10,734 titles. After removing duplicates, 7,810 titles remained. These remaining titles abstracts were then screened for relevance to inclusion and exclusion criteria, resulting in the selection of 121 articles for full text review. We selected 17 articles to be included in this review (see Figure 1). Reasons for exclusion at the full-text stage included: studies that did not have a mean age of participants 65 years of age or older (n = 43), interventions that did not include an evaluation of its barriers and facilitators to participation (n = 20), wrong patient populations (n = 18), in-hospital interventions (n = 6), studies without an healthy aging intervention (n = 5), full text was not found (n = 5), conference abstracts (n = 4), intervention protocols (n = 3), and studies exclusively on medication adherence (n = 1).
The majority of the programs included in this review were a mixture of cardiac rehabilitation programs and community-based exercise, diet, smoking cessation, and drug adherence programs, and community-based health check programs. The majority of the programs were group-based and provided a combination of exercise program and support for behavioural changes for a healthier lifestyle. Program length varied from two to 12 weeks.
We have provided an overview of the studies included in the review in Appendix I. Our team categorized the barriers and facilitators of older adults’ participation in healthy aging programs into seven themes: attitudes, organizational structure, accessibility, social structure, knowledge, demographics, and program specifics.
Theme 1. Attitudes
Attitudes describe the beliefs, feelings, and attitudes participants expressed towards cardiac disease, cardiac rehabilitation, lifestyle consequences to health, and perceived susceptibility to future illness. Participants’ attitudes towards healthy aging programs and lifestyle changes in general were found to both hinder and facilitate participation. Attitudinal barriers included participants viewing their recovery as a process outside their control 17, minimizing the severity of a myocardial infarction (MI) in their own minds 17, or feeling that attending the program would be too stressful 17 or painful 18 and, therefore, they avoided participation.
Other participants lacked motivation to change their lifestyle 19-21, or had negative feelings towards exercise 22,23. Still other participants believed that their disease was the result of stress, rather than lifestyle factors like smoking and/or exercise 24. Of the 10 studies that included an exercise component, participants from four of the studies worried that exercise could induce further health issues 18,20,25. Some participants did not feel that healthy aging programs would improve their health 22,23,26. Finally, some participants were worried that asking their family members/caregivers to help them to participate would be a burden 27.
Participants’ attitudes were also found to facilitate their participation in healthy aging programs. These included the feeling of being personally responsible for their recovery 17, capable of managing the disease 24, having a personal desire to change their lifestyle 17,21, and viewing MI as a serious medical event that required action 17. Other participants valued healthy aging programs and being active, noting an increased sense of well-being, and increased physical health 19,20,23,26. Additionally, there were some gender differences with men perceiving that their recovery would be faster if they participated, while women were fearful of a reoccurrence of their illness if they did not participate 18.
Theme 2. Organizational structure
Organizational structure describes the referral and/or buy-in (or lack of referral and buy-in) by healthcare professionals (HCPs) regarding rehabilitation programs. An important barrier specific to organizational structure occurred when patients did not receive a referral from an HCP or when there was no buy-in from HCPs regarding these programs 17,18,22,23,26,28,29.
Referral to a healthy aging program, as well as support from HCPs, were notable facilitators to participants’ decisions to attend a program across a range of studies 17-21,23,26,29,30. Additionally, men described receiving written material about a program as facilitating their participation, while women described the opportunity to discuss health aging programs with their HCP as a facilitator 28.
Theme 3. Accessibility
Accessibility refers to the means and ability to be able to access programs. Across studies, participants described their ability to access a program, including transportation difficulties 18,19,21,23,25,28,29, an accessible location of a program 19,27, and the cost of a program (including lack of insurance) 18,20,21,25 as barriers to participation. Participants also described how time constraints because of work and family responsibilities prevented participation in healthy aging programs 20,23.
Having access to independent or private transportation was described as a facilitator to participation 29. Additionally, participants’ ability to change their work schedules also supported their increased attendance 20, as did having the financial means to attend 20,30.
Theme 4. Social structure
Social structure describes the social network and support as well as family and/or work responsibilities that contribute to participation. A few social barriers were described across a small number of studies. Some participants described a lack of social support as impacting their ability to participate 21,28,30,31. Participants across several studies also described how the social support they received from family and peers supported their participation in healthy aging programs 18,19,21,26,27,30. Some participants also described worry over having to meet new people at a new venue 25.
Theme 5. Knowledge
Knowledge refers to the understanding or lack of understanding of cardiac rehabilitation’s role in healthy aging. A few knowledge barriers were identified by participants, including a lack of understanding of what a healthy aging program involves and how participation can positively impact their cardiovascular health 17,18,22,25,26,29. Additionally, one study found that some participants lacked an understanding of their own health status and risks factors 26, while another study suggested that exercise could be adapted to meet participants’ physical impairments 19. Finally, some prospective participants identified that being overloaded with paper information from HCPs results in a loss of knowledge retention, which in turn impacted their participation 19. Analogously, patients in two studies identified that learning about healthy aging programs supported their decision to participate in a program 21,26.
Theme 6. Demographics
Demographics describes non-modifiable barriers and facilitators to participation, including age, gender, comorbidities, and education level. Several demographic metrics across different studies were identified as barriers to participation. These included advancing age (over 80 years) 28,29,31, being a woman* 28, living alone 28,31,32, and lower education levels 21. Additionally, certain comorbidities such as pain and fatigue 19,20,27, addiction (e.g., smoking) 20, the psychological influence of a cardiac event (e.g., irritation, depression) 27, having had valve surgery 23, or simply the number and type of comorbidities 19,20,22,23,29,31-33 posed a barrier to participation.
Individuals who did participate in healthy aging programs were more likely to be younger (64 +/- 12 years) 29,33, married or living with a partner 29,31, living close to the location of the program 19,21,31, and having obtained education levels beyond high school 21,33. The results were mixed when it came to sex, with one study indicating males were more likely to participate 29, and another suggesting females were more likely to participate 23. Having had an MI 31, cardiac surgery 23,33, a lower BMI and smaller waist circumference 21, and overall higher levels of health and functioning 21,26 were all noted more often in individuals who opted to participate.
Theme 7. Program specifics
Program-specifics refers to environmental or implementation specific aspects of programs which encourage or discourage participation. Some studies examined the barriers to participation in specific healthy aging programs. These barriers included classes being too large, a lack of opportunities to arrive a few minutes late or stay late to talk with staff 19,26,27,30, a lack of support from program staff and fellow participants 18,30, being tired after exercising 18, and feeling that recovery was too slow 18. Additionally, participants described barriers related to the scheduling of the program, e.g., occurring too long after a cardiac event 27 and too few sessions 19,27,30. Finally, participants described barriers pertaining to staffing including a lack of relationship with staff 26, lack of a physician present at sessions 27, and worries that staff were not suitably trained to care for them if something happened to them during a session 26.
Participants across different studies described key aspects of specific programs that encouraged their continued participation. Participants described the peer support they received as a facilitator to their continued participation 19,20,24,30 as well as the importance of a program being culturally inclusive 28. The program structure also contributed to participation, including small group sizes 27, and the time of day of a program (afternoon) 27. Finally, participants highlighted the importance of well-qualified, friendly, and reassuring staff 18,24,27,30.
Understanding the facilitators and barriers that older adults face when deciding whether or not to participate, or to continue participating in a healthy aging or cardiovascular rehabilitation program can help HCPs provide the best guidance for their patients and clients. Barriers that participants face are not limited to those affecting their health; rather, this review identified themes relating to individual attitudes, the organizational structures which individuals encounter, the social structures in which individuals operate, their ability to access programs, as well as their knowledge about their own health conditions. Additionally, individual demographics such as sex and marital status can influence individual participation, as well as the specific contextual elements that relate to the way programs are designed or implemented.
An individual’s attitude was one factor to participation (or not) that was described in several studies. Individuals who felt responsible for their own recovery, who felt capable of managing their recovery, and who felt that attending a program was an effective way of obtaining information they needed to assist in their recovery were more likely to attend and to remain engaged in a program. Dechaine et al. 34 found that both men and women were intrinsically motivated by desires such as gaining strength and speed, losing weight, ‘feeling better’ and improving their mental health. Women, however, were more likely to also attribute their sense of motivation to an external desire not to let down program staff, while men were more likely to see the program as a task they could accomplish 34. When individuals viewed their recovery as someone else’s responsibility (e.g., HCPs), when they had negative perceptions of exercise (e.g., stress or pain), or if they were fearful that engagement in a program may cause a setback in their health, then they were less likely to participate. These findings align with findings from Bennett et. al. 35 who suggest that when cardiac patients attribute their health status to something that is within their control and that can be changed with behaviour, they are more likely to make adaptive changes than when they attribute their health status to non-modifiable factors such as biology.
Correspondingly, an individual’s knowledge about healthy aging programs impacted participation. Individuals who had learned about healthy aging programs were more likely to attend whereas, individuals who did not attend were more likely to lack an understanding of what a healthy aging program involves. Additionally, participants of healthy aging programs were more likely to report having received a referral and/or support from their HCPs regarding participation. Together, these important barriers and facilitators point to the important role HCPs play in educating, advocating and supporting their patients’ participation in healthy aging programs.
Participants also described many barriers and facilitators specific to the structure and management of healthy aging program themselves. Participants generally preferred smaller programs, with flexible schedules that were located in easily accessible locations and were run by competent, knowledgeable, and supportive staff. When participants experienced success, they reported increases in their confidence, motivation, and overall health which further facilitated their continued participation. The health benefits of healthy aging programs are well documented; however, encouraging participation is difficult and attrition is high. Developing programming that appeals to and supports its participants is critical to improving the health of older adults.
There are a number of steps that HCPs can take to facilitate increased engagement in healthy aging programs. These can include advocacy through a coordinated effort of politicians, HCPs and educators to address ageism, and the adoption of person-centred, interdisciplinary, community-based programs and interventions for healthy aging. Program designs should address not only the physical needs of healthy aging, but also the mental and social needs to promote both fitness and overall wellbeing.
Some of the studies included in this scoping review were limited by a small sample size, making it challenging to generalize the results. Additionally, we limited the included studies to those disseminated in English, due to the vast number of included studies. As such, our results are only generalizable to programs that were reported in English language journals. Most of the studies included in this review were also English language programs, which means that non-English speakers, such as recent immigrants, were excluded from these studies. The lack of studies reporting on multilingual programs suggests an additional participant barrier that was not captured in this review.
The diversity of facilitators and barriers for older adults with cardiovascular disease participating in healthy aging programs suggests that HCPs need to employ multiple strategies to help increase engagement by this group. Understanding how demographics, knowledge, attitudes, accessibility, organizational structures, and social structures impact an individual’s ability or motivation to participate in a healthy aging program can provide healthcare providers and allied health professionals insight into which types of healthy aging programs may best meet not only the health needs of their patients, but also best suit their personalities and lifestyles.
The Author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: We would like to thank the Pfizer Global Medical Grant program for funding this work [grant number 57505093].
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