Exercise for falls prevention in Caucasian and South Asian older adults: Are focus groups a useful data collection tool?

1. Exercise for falls prevention in Caucasian and South Asian older adults: Are focus groups a useful data collection tool? Dr Maria Horne Maria.Horne@manchester.ac.uk

2. Background • Strategies to prevent falls often recommend regular exercise (Gillespie et al. 2001) • 40% of over 50s in UK report less physical activity than recommended (Skelton et al. 1999) • Higher rates of sedentary behaviour are reported among South Asian older adults (Erens et al. 2001; Hayes et al. 2002; Gill et al. 2002) • Half of those who commence a structured exercise programme relapse within six months (Schmidt et al. 2000; Jancey et al. 2007)

3. Falls • 30-40% of people over 65 fall each year (O’Loughlin et al. 1993; Gillespie et al. 2001) • Falling and fear of falling create a vicious circle of psychological distress that seems to restrict activity and independence, and increase social isolation (Bruce et al. 2002; Yardley & Smith 2003) • Exercise reduces risk of falls (Gillespie et al. 2001) • Evidence base is very strong for strength and balance training reducing falls (Gillespie et al. 2001)

4. Aims • To investigate cultural influences • To identify salient beliefs to uptake and adherence of exercise for fall prevention among community dwelling Caucasian and South Asian 60-70 year olds

5. Research Design, Methods of Data Collection and Analysis • Ethnographic approach (Atkinson & Hammersley 1994; Hammersley & Atkinson 1995) • Data collection:Polyphonic interviews  informal  formal interviewing: 14 focus groups (n = 87; mean age = 65.74) 9 with Caucasian, 5 with South Asian 40 individual semi-structured (mean age = 64.83) • Framework analysis (Ritchie & Spencer 1994)

6. Sample

7. The need for focus groups • Initial observation - many views, attitudes and beliefs expressed about exercise, physical activity and the motivation and barriers to performing these activities were expressed • Discussion on fall prevention issues was never encountered directly and was a topic that would be difficult to observe • In certain areas it was difficult to observe individuals and groups from South Asian backgrounds at leisure or in exercise classes • Several focus groups conducted to highlight consensus and disagreement in the area of • exercise and physical activity in general • in relation to fall prevention

8. Suitability of using focus groups with older adults  • Used successfully in other research studies with older adults: • to identify issues that are more salient to older people themselves (Horne & Costello 2001; Raynes et al. 2001; Loeb et al. 2003;Hupcey et al. 2004) and • To explore older peoples’ exercise motivations and influential circumstances (Stead et al. 1997) • Good for exploring salient attitudes and beliefs - provides a practical way to access peoples’ experiences, attitudes, views, knowledge, feelings and motives about various health and social issues as well as their actions • As a method of interacting with older adults, the method ideal as it is not anxiety provoking (Gray-Vickrey 1993)

9. Suitability of using focus groups with older adults  • Facilitate access to the cultural and social norms of groups by providing insight into cultural and social processes of both belief formation and the role of expression of beliefs in peer groups (Morgan 1997; Green & Hart 1999) • Represent a culturally sensitive method suited to reproducing community attitudes (Saint-German et al. 1993) • Facilitates the disclosure and validation of group attitudes and thinking (Fallon & Brown 2002) • An excellent way to identify the needs of under researched populations (Esposito 2001)

10. Suitability of the focus group method to the research process  • Open response format of the focus group schedule provided much more information in the respondents own words than that from questionnaires (Stewart & Shamdasani 1990) • Data is richer with emic responses being recorded (Stewart & Shamdasani 1990) • Able to check back replies directly with the informants (Stewart & Shamdasani 1990) - useful for clarifying issues that were not easy to do during observation or informal conversations • Participants’ interaction among themselves replaced their interaction with the facilitator leading to a greater emphasis on participants’ points of view

11. Suitability of the focus group method to the research process  • Does not discriminate against people who cannot read or write a particular language and those who have impaired vision (Kitzinger 1996) - ideally suited to older people and those from minority groups • Can encourage participation from those reluctant to be interviewed on their own (Kitzinger 1996) e.g. those intimidated by the formality and isolation of a one to one interview • Can facilitate and encourage contributions from people who believe they have nothing to say but who may engage in discussion generated by other group members (Kitzinger 1996)

12. Limitations • Some people may feel uncomfortable about discussing and expressing their views in front of a group • Potential for the researcher, as the group facilitator, to bias results by only seeking out those answers to preconceived notions or providing cues about the type of responses that are desirable (Stewart & Shamdasani 1990). • May become biased by a dominant figure within the group, whose opinions may unduly influence or inhibit passive participants (Stewart & Shamdasani 1990; Smithson 2000) • Can provide an unnatural setting for group interactions so that it must not be assumed that the technique provides access to ‘naturally occurring data’ as may be collected by participant observation (Kitzinger 1994)

13. Conduct of focus groups with Caucasian participants  • 9 focus groups (3-9 participants); 60 to 90 minutes; 8 mixed; 1 female only group • Consent to audiotape focus group was sought from all participants • Focus group schedule was piloted with the first Caucasian focus group. No alterations were required and, therefore, the data from this were included in the final analysis • Moderator - ensured participants felt welcomed and relaxed; seating was arranged in a circle and tea, coffee, fruit juice, fruit and biscuits were provided in order to establish a relaxing, comfortable environment; explained the purpose of the meeting, encouraged participants to talk to each other

14. Conduct of focus groups with Caucasian participants  • Support person - Check tape recorder, record the layout of the group, recorded the general flow of discussion points, highlight the main discussion points, record non verbal communications and note ‘silent voices’ • Invited participants to introduce themselves: • introductions acted as an icebreaker by helping people to relax and become comfortable with the group set up • useful approach for transcribing purposes to help identify who was speaking and when • For the purpose of group comparability and coverage of theoretical issues a standardised FG schedule was used (schedule contained general open ended questions to generate discussion, but also served to maintain control of the topics to be discussed)

15. Conduct of focus groups  • managing group dynamics, controlling the way participants interact, for example trying to get everyone to participate equally to the discussion • As the focus group progressed a balancing out of the participants and my interests tended to occur (resulted in the focus group becoming less structured ) • This process allowed unexpected issues to arise, providing the opportunity to probe deeper • Concluded the focus group with a summary of the discussion and sought verification of the discussion from the participants

16. The conduct of focus groups with South Asian participants • 5 focus groups (2-9 participants); 45 to 70 minutes; 3 female only groups and two male only groups • Focus group schedule was given to a registered interpreter to check for cultural sensitivity and translation. No issues were raised • Focus group schedule was subsequently piloted with the first South Asian women’s group. No alterations were required and the data from this were included in the final analysis • Bridging the language barrier - three local interpreters used to interpret, translate and assist with facilitation of the focus group discussions, one female who could speak and translate Mirpuri Punjabi, one male who could speak and translate Mirpuri Punjabi and another who could speak and translate in both Punjabi and in Gujarati.

17. The conduct of focus groups with South Asian participants • Real-time translation (Esposito 2001) validates the data during the focus group; provides opportunity to redirect questions to focus group participants to clarify understanding of responses • Interpreters acted as co facilitators/moderators; did not expect them to be an expert in the topic as not a necessary requirement to moderate a focus group (Kreuger 1998; Baker & Hinton 1999) • Beneficial that they were not experts in the topic area as they would be less likely to add their opinions to the discussion (Kreuger 1998; Baker & Hinton 1999) • Acted as assistant - Check tape recorder, record the layout of the group, the general flow of discussion points once translated to me by the interpreter, ask probing questions to be translated and interpreted by the facilitator, highlight the main discussion points, record non verbal communications and direct interpreter to ask a question to ‘silent voices’ to encourage a response

18. Post focus group • Interpreter would transcribe the tape into an English language transcript. • The tape and transcription were then given to another native speaker, a multilingual link worker, to assess the accuracy of transcription provided by the original interpreter and agree a ‘correct’ version of the text • Analysis

19. Findings • Confusion about exercise and physical activity • Lack of awareness • Too young to fall • The potential of exercise to prevent falls • Fall prevention exercises unnecessary • Fatalism

20. Confusion about exercise and physical activity • Considerable similarities between the Caucasian and South Asians in the way they talked about falls, exercise and fall prevention • Majority of participants used the phrases interchangeably and even used the phrase ‘physical exercise’: ‘Well going on the allotment and digging over patches to plant things…so that is what you see as physical exercise’(LC2: Caucasian female, 62 yrs: Sedentary)

21. Lack of awareness • limited general awareness that exercise could help in fall prevention but this did not motivate the majority of either Caucasian or South Asian participants to undertake exercise: ‘I walk and I went to do exercise and now I understand exercise does stop you from falling but I didn’t before?’ (BS 3: South Asian female, 63 years: Active)

22. Lack of awareness • Caucasian and South Asian’s poor awareness of benefits of exercise • strength, balance and mobility • Small minority aware of benefits of exercise in fall prevention • unable to exercise because of existing health issues and limited mobility: ‘I can’t [exercise] because of my arthritis, you know, I think I might fall’ (AB40: South Asian female, 62 years: Sedentary)

23. Too young to fall • Too young to fall • Falls happened to older people: ‘I think that’s after 80s [having a fall], when people are getting older. There is no place for thinking about it now’ (I33: South Asian male, 63yrs: Less Active)

24. The potential of exercise to prevent falls • Those who had fallen • more likely to acknowledge risk, and may heed advice to exercise but • fear activity would expose them to further risk ‘Yes it would motivate me [to perform exercise for fall prevention] …by falling it has frightened me and that prevented me going to do exercise because I thought I might fall again’ (I31: South Asian female, 62 yrs: Sedentary)

25. Fall prevention exercises unnecessary  • Those who perceived themselves to be fit and healthy, believed fall prevention exercises were not necessary for them personally: ‘…I just feel I’m not in a position…that I’m very lucky in that I don’t need to [exercise to prevent falls]. I’m not in a position that I feel I need to do any more than I do. Maybe if I was struggling with something, I’d say, “well yeah, I’ll go and see if I can get a wee bit of exercise”, but there again, I might say “I’ll go to the physio, they might move those bones for me”, rather than go to a sports or leisure centre’ (I7: Caucasian female, 65yrs: Active)

26. Fall prevention exercises unnecessary  • Young older adults with no fall history did not acknowledge their risk of falling: ‘I wouldn’t think about things like that, to be honest, when I’m going to fall...’ (I16: Caucasian male, 68 yrs: Active) • Others simply did not perceive falling to be a serious issue: ‘I’m not bothered if I fall…everyone falls so it doesn’t really matter. As long as I have the strength I’ll carry on walking’ (I32: South Asian female, 70 years: Less active).

27. Fall prevention exercises unnecessary  • Both Caucasian and South Asian perceive that a loss of physical strength would motivate them to perform exercise for fall prevention - were willing only to perform those pursuits they feel comfortable with doing, rather then specifically for fall prevention: ‘...if you haven’t got the strength [you would need to do exercise to prevent falls]. But I am willing to do walking to keep me going to help prevent the falls’ (I30: South Asian female, 67yrs: Less active).

28. Fall prevention exercises unnecessary  • Most people preferred physical activity for strength building because they felt it was included into everyday life: ‘But, with the physical activity its everyday. I know what I’m doing because I have to move to get stuff for the house, for the cooking and everything’ (I26: South Asian female, 63 yrs: Active) • Exercise related to activities of daily living seemed to be a motivator: ‘I combine physical activity with exercise…if you’re climbing stairs and, if I go in to Marks and Spencers or wherever I’ll invariably walk the stairs to the next floor, rather than take the escalator or a lift’ (I6: Caucasian male, 63 yrs: Active)

29. Fatalism  • Both Caucasian and South Asian believed falls were a natural consequence of ageing: ‘…but sometimes you can’t help it [fall] because of your age…If that person is old, it is that age….you need to try to maintain the ability to do something…but sometimes it’s beyond their physical ability...they are weak’ (I33: South Asian male, 63 yrs: Less active) • Fatalism: a biological inevitability? ‘It’s your bones; they still get old [in relation to falls]. I don’t feel it’s any kind of exercise, it’sjust your body ageing; you cannot do what you did when you were younger’ (K5: Caucasian female, 66 yrs: Less active)

30. Fatalism  • Falling was out of older people’s control – particularly strong among South Asian ‘…how can you avoid a fall? If it’s going to happen, it will happen’ (I25: South Asian female, 62 yrs: Active) • Amongst South Asians ‘inshallah’ or the idea of illness being down to God’s will was very apparent: ‘Anything can happen at any time. I can’t say I have any fears. Things can happen. God knows. God knows’ (I29: South Asian male 67 yrs: Active)

31. Conclusions  • More similarities then dissimilarities between Caucasian and South Asian older adults beliefs about take up of exercise for fall prevention • Falls prevention takes a very low priority • Little association between exercise and fall prevention • More motivated to participate in fall prevention exercises when explained that this could improve strength and balance (positive concept) as opposed to preventing falls (negative concept) • More likely to acknowledge risk, and may heed advice to exercise but fear activity would expose them to further risk

32. Conclusions  • Exercise for fall prevention is only believed to be necessary when you become older or weaker • Differences in beliefs between Caucasian and South Asians in the area of fatalism and the need for gendered exercise sessions • Falls prevention should not be the focus of health promotion strategies • The overall benefits of exercise and leading active healthy lifestyles should be promoted

33. Contact details If you would like more information about the study please do not hesitate to contact me: Email: Maria.Horne@manchester.ac.uk Tel: 0161 3067680