Physical Activity Programming for Older Adults in Assisted Living: Residents’ Perspectives

Abstract

Decreasing sedentary behavior and increasing light physical activity could promote maintenance of functional abilities for older adults in assisted living. The purpose of this qualitative study was to gather residents’ recommendations about a proposed self-efficacy enhancing intervention to replace sedentary behavior with light physical activity. We interviewed 20 residents (mean age 83.1; 60% women). Topics included their current activities and thoughts about physical activity. We presented the intervention and asked questions to inform its modification. Data were analyzed with content and thematic analysis. Specific recommendations included shorter one-hour sessions and framing the intervention as increasing light physical activity rather than decreasing sedentary behavior. The thematic analysis identified multiple factors that could influence intervention implementation, including motivation to be active, safety concerns, ageist attitudes about physical activity, varying abilities of residents, social influences, and limited opportunities for physical activity. These results will inform physical activity intervention implementation for assisted living residents.

Older adults in assisted living (AL) tend to be highly sedentary, which may adversely impact their cognitive and mental health and increase their risk for frailty, decline in physical function, and mortality (Grgic et al., 2018; Manãs et al., 2019; Park et al., 2017; Rojer et al., 2021). Sedentary behavior is any waking behavior characterized by an energy expenditure ≤ 1.5 metabolic equivalents while in a sitting, reclining, or lying position (Tremblay et al., 2017). In contrast, physical activity is any body movement generated by the contraction of skeletal muscles that raises energy expenditure above resting metabolic rate (Thivel et al., 2018). Physical activity does not need to be moderate or vigorous intensity to produce health benefits; light intensity physical activity can replace sedentary behavior and may positively impact physical function, cognitive function, and life expectancy (Del Pozo Cruz et al., 2021; Erlenbach et al., 2021; Fanning et al., 2020). Maintaining physical function will help AL residents remain as independent as possible and prevent or delay the need for higher levels of assistance, including transfer to higher level care facilities such as nursing homes (Giuliani et al., 2008). Therefore, interventions to replace sedentary behavior with light physical activities could have important implications for quality of life in this population.

Physical Activity and Sedentary Behavior in Assisted Living

Assisted living facilities provide 24-hour supportive care (including meals, personal care, housekeeping, and assistance with activities of daily living), primarily for older adults who have functional limitations but do not need the level of medical supervision provided by nursing homes (Mollica et al., 2012). Assisted living staff may perform some household tasks for residents, even if residents have the ability to perform them (Resnick et al., 2011). While AL facilities often provide chair exercise classes, these classes are not evidence-based and do not address sedentary behavior.

There has been limited research focused on interventions to decrease sedentary behavior of AL residents; we are aware of only four previous pilot interventions (Dillon & Prapavessis, 2020; Giné-Garriga et al., 2020; Naber et al., 2020; Voss, Pope, Larouche, et al., 2020). The Voss et al. intervention utilized strategies at various levels of the ecological model and was found to be feasible with a trend toward decreased self-reported sedentary behavior, but did not decrease device-measured sedentary time (Voss, Pope, Larouche, et al., 2020). Naber et al. conducted an occupational therapy intervention to decrease sedentary behavior through individualized goal setting (Naber et al., 2020). Residents in that study had a non-significant increase in daily step counts, but did not decrease self-reported sedentary behavior. A pilot intervention by Dillon & Prapavessis aimed to decrease sedentary behavior through prompting 10 minutes of light physical activity three times per day in residents with cognitive impairment (Dillon & Prapavessis, 2020). They found that intervention participants increased their physical activity, but it is unknown whether the intervention impacted sedentary time as it was not reported. Finally, Giné-Garriga et al. tested an intervention to reduce sedentary behavior that was co-created with care home residents, staff, family members, and policymakers (Giné-Garriga et al., 2020). This pilot study found that the intervention did reduce device-measured sedentary time, but the one-on-one intervention delivery may be labor intensive.

There have been several other interventions focused on exercise or physical activity in the assisted living setting (Alvarez et al., 2015; Beato et al., 2018; Chen et al., 2021; Greene et al., 2017; Hummer et al., 2015; Johnson et al., 2013; Lauze et al., 2017; Resnick et al., 2011; Stanmore et al., 2019; Sung, 2009; Van Roie et al., 2017; Vanroy et al., 2019). Most of these studies had small sample sizes and only one measured light physical activity (Van Roie et al., 2017). There are no well-established interventions designed to increase light physical activity and decrease sedentary behavior in the assisted living setting.

In general, older adults prefer physical activity programs that are group-based, age-appropriate, and incorporate physical activity into everyday activities (Beauchamp et al., 2007; Burton et al., 2015; Contrady, 2020), but there is little known about the preferences of AL residents related to physical activity programs. Tailoring of physical activity interventions can be enhanced by engaging stakeholders from the population of interest. This will help to ensure the intervention will be acceptable and will address their needs (Fernandez et al., 2019).

The Active for Life intervention is a physical activity-specific self-efficacy enhancing intervention designed to promote light physical activity and reduce sedentary behavior. It has been tested through multiple randomized controlled trials and was effective in other older adult populations for breaking up sedentary time, increasing light physical activity, and improving physical function (Fanning et al., 2016; Larson et al., 2014; McAuley et al., 2013). We modified the Active for Life intervention to be more appropriate for the AL population. The purpose of this study was to gather responses from AL residents on the proposed intervention, Active for Life in Assisted Living. A secondary aim was to explore contextual factors that may influence implementation of the intervention with this population.

Methods

This study was reviewed by the appropriate institutional review board and determined to be exempt from oversight. Participants gave verbal informed consent. We recruited participants from four AL facilities. At three of the facilities, we advertised an informational meeting about the study to the residents through flyers and/or posted signs with the assistance of the life enrichment director at each facility. At the informational meetings, residents were given details about the nature of the study and had an opportunity to ask questions. If residents wished to participate in the study or meet with the researcher to ask additional questions, they could provide their contact information. At one AL facility, staff preferred that informational flyers with the researcher’s contact information be distributed to each resident individually, rather than conducting an informational meeting. The sample size was determined by data saturation.

Inclusion criteria were age ≥65, being able to engage in activity without a wheelchair or motorized scooter, not currently meeting physical activity guidelines (<150 minutes of moderate physical activity per week) (Physical activity guidelines for Americans, 2018), and score ≥3 on the Mini-Cog screening. Scores on the Mini-Cog range from 0–5 and a score <3 indicates cognitive impairment (Milian et al., 2012).

One-on-one semi-structured interviews were conducted using a two-part interview guide. In part one, residents were asked questions about their daily lives in the AL facility, their current activities, and their general thoughts about physical activity. In part two, we presented the Active for Life in Assisted Living intervention to participants and requested feedback on each component of the intervention, their overall interest in participating, and any general suggestions for modifying the intervention. We also asked practical questions that could influence how intervention sessions are structured, such as how long they are able to stand and how far they are able to walk.

The interview included demographic data, length of stay in AL, use of assistive device, and completion of the Functional Comorbidity Index. The 18-item Functional Comorbidity Index is a stronger predictor of physical function than other comorbidity indices (Groll et al., 2005). Participants’ scores can range 0–18 and are based on the number of comorbidities that they report. Reliability is supported by intraclass correlations of 0.90 for intra-rater reliability and 0.61 for inter-rater reliability (Kabboord et al., 2019).

Data Analysis

Interviews were recorded and transcribed verbatim. Interview transcripts were analyzed by the first author using Atlas.ti software (ATLAS.ti, 2018). We performed content analysis to address the primary aim of the study, which was to gather feedback from assisted living residents on the Active for Life in Assisted Living intervention components. Content analysis allowed us to summarize and count responses to interview questions from the second part of the interview guide (specific to the Active for Life intervention) (Elo & Kyngäs, 2008). We performed thematic analysis according to the steps outlined by Braun & Clarke (Braun & Clarke, 2006) as a secondary approach to gain a broader understanding of factors that may influence intervention implementation. We reviewed all transcripts again for this secondary analysis and analyzed data from both parts of the interviews. Briefly, this process included generating initial codes, searching for themes, reviewing themes, and defining/naming themes. To check the validity of the findings, another researcher (N.G.) audited five interview transcripts and verified that the content and thematic analysis results were a good fit with the data.

Proposed Intervention

The proposed intervention utilizes theory-based strategies from social cognitive theory to enhance self-efficacy for performing light physical activity, thereby replacing sedentary behaviors. It consists of 16 weeks of physical activity sessions held twice per week in the facility, each lasting one and a half to two hours. Each session consists of 5–10 minutes of walking where participants are encouraged to walk at their own pace and take breaks as needed; 20–30 minutes of behavioral activities such as setting goals for increasing physical activity and education/discussion on topics such as the benefits of light physical activity, the negative effects of sedentary behavior, strategies for being active and breaking up sedentary time, and overcoming barriers to being active; and 30–45 minutes of functional circuit training with various exercise stations focusing on strength and balance, followed by stretching. The group exercises are designed to improve strength and endurance in order to facilitate the overall intervention goal of replacing sedentary behavior with light physical activity through regular daily activities.

Results

Twenty-six AL residents expressed interest in participating and 20 were subsequently enrolled and interviewed. Of the residents who expressed interest but did not participate, two later decided they were not interested, two could not be contacted to schedule the interview, one was unavailable due to hospitalization, and one was ineligible due to age. Five participants were recruited from each facility. The number of apartment units at each facility ranged from 80–130.

The mean age of study participants was 83.1 (SD 9.8; range 65–99) with 60% (n=12) women, 85% (n=17) non-Hispanic White, and 15% (n=3) non-Hispanic Black. The mean length of stay in AL was 41.4 months (SD 35.2) and participants had a mean score of 4.5 (SD 2.3) on the Functional Comorbidity Scale. All residents scored between 3–5 on the Mini-Cog screening. Forty percent (n=8) used a walker, 20% (n=4) used a cane, 15% (n=3) used both a cane and walker, and 25% (n=5) did not use an assistive device. The mean interview length was 48 minutes (range 18–81 minutes).

Content analysis

Assisted living residents provided reactions to several components of the proposed Active for Life intervention. Full results of the content analysis are presented in Table 1. Residents generally thought the three main intervention components (walking, educational/behavioral activities, and circuit training) sounded reasonable and helpful. Some residents remarked that the walking and circuit training would be appropriate for themselves, but might be challenging for other residents. Many residents thought a 16-week intervention was too long of a commitment and the length of 12 week presented to the final 5 participants was better received. However, four residents additionally commented that regardless of the length, residents will not be accustomed to a program where they are asked to regularly attend, as activities in their facility are typically optional. Residents generally thought 1.5–2-hour sessions were too long, with three residents mentioning that they are accustomed to activities in their facility lasting ≤1 hour.

Table 1.

Content analysis results on participants’ preferences and suggestions related to the proposed intervention.

Interview topic	Main Responses	Other responses
Walking 5–10 minutes of walking at their own pace	● Walking is reasonable n=9 ● Reasonable for others, I could do more n=4 ● Reasonable for me, may be challenging for others n=3 ● Walking time could be longer n=2	● Walking should be progressive in nature (build up the time) n=3 ● Residents will have varying abilities n=3 ● We (researchers) should consider residents’ attention spans n=2 ● We need to consider the space available for walking n=2 ● “I’m more capable than most” n=2
Behavioral/Educational Component 20–30 minutes of education including the benefits of light physical activity, discussions about overcoming barriers to being active, and goal setting	● Good/helpful n=19	● We should shorten the time of this component n=5 ● Need to address their confidence and motivation n=2 ● Need to get to know the people n=2 ● This is the less exciting component of the program n=2 ● We should consider residents’ attention spans n=1 ● Not sure if most residents are interested in PA n=1 ● Likes the idea of group discussions n=1 ● We should phase out education over time n=1 ● This component should not be between walking and circuit training n=1
Circuit Training 30–45 minutes with exercise stations focusing on strength and balance	● Good/helpful n=19   (but might be too challenging for some n=2) ● Not interested n=1	● Residents will have varying abilities n=4 ● Circuit training will be a helpful opportunity for things I can’t or don’t do on own n=3 ● Supervision will be important n=3 ● Some already exercise on their own (will they want to do more?) n=2 ● Circuit training should be progressive in nature n=2 ● Circuit training time should be shortened n=2 ● We should stretch first n=2 ● May need two groups with different levels (such as a sitting exercise group and a standing exercise group) n=2 ● We will need to figure out space where this would take place n=1 ● Sounds good if people will join n=1 ● Some residents may need modifications n=1 ● Should not be mandatory (program in general) n=1 ● Will need balance support n=1 ● Have plan in place for if someone wanders off during exercise n=1
Program Length 16 weeks (n=15) 12 weeks (presented to final n=5)	Presented 16 week ● Good length n=7 ● Too long n=4 ● Good for me, might be too long for others n=3 Presented 12 week ● Good if…n=3   ‐ we have the option to drop out   ‐ people interested enough to attend regularly (they are used to optional activities)   ‐ framed as “we’re available to help you for 12 weeks”, not that you must attend for 12 weeks ● Good length n=1 ● Too long n=1	● It may take some time for people to ease into the program/they may join gradually n=4 ● People are not used to programs where they would be expected to attend every session n=4 ● Whether length is appropriate will depend on resident interest n=3 ● Consider weather (some residents have to walk to main building) n=1 ● Greater frequency for fewer weeks would be better n=1 ● Most programs in assisted living are ongoing n=1 ● Needs to be long enough to demonstrate value n=1
Session Lengtha 1.5–2 hours (n=15) 1–1.5 hours (n=5)	● 1.5–2 hours is too long n=8 (n=3 said sessions should be 1 hour only) ● 1.5–2 hours is appropriate n=2 ● 1.5–2 hours okay for some, not all n=1 ● 1–1.5 hours is appropriate n=2 (n=1 said sessions should be 1 hour only) ● In general, program takes too much time n=1	● We need to consider residents’ attention spans n=2 ● Program should be more repetitive with less time per session n=2 ● We should build up to longer sessions n=1 ● Residents will have varying abilities n=1
Session Frequency 2 sessions/week	● Good n=13   (n=1 said this frequency would be good if they end up liking the program) ● Could have >2 sessions/week (usually suggested 3 sessions/week) n=4 ● In general, program takes too much time n=1 ● Residents may choose to only attend 1 session/week n=1	● We could hold one session on the weekend n=1 ● Will take time to get the program going and get people involved n=1 ● Will need to alternate days with yoga classes n=1
Other activities they would suggest adding	● Nothing they would want to add to the program n=5 ● Game-like/enjoyable activities n=4 ● Would like their facility to add exercise machines n=2 ● Functional activities n=1 ● Mental/hand-eye coordination n=1 ● Training in proper techniques n=1 ● Stairs n=1 ● Swimming n=1 ● Yoga n=1 ● Liked that current program in their facility includes a massage after working upper extremity muscles n=1
How interested would you be in participating?	● Interested n=13 ● Would give it a try n=5   ‐ thinks it might be designed for those with decreased abilities n=1   ‐ depends on time of year (less likely in winter to walk over) n=1   ‐ depends on health n=1   ‐ depends on motivation n=1   ‐ depends on ability to do the program (with poor balance) n=1 ● Not interested in PA n=1 ● Don’t need n=1		● Factors mentioned influencing participation   ‐ Health n=2   ‐ Wanting to help the program n=1   ‐ Whether they like it n=1   ‐ Seeing progress n=1   ‐ Commitment level n=1   ‐ Time of day (not morning) n=1 ● It will be helpful to learn to do exercises on their own n=1
How interested would other residents be?	● Interest will vary (some will, some won’t) n=8 ● It will be a challenge to recruit n=3 ● Not many will be interested n=2 ● Will really like it if…   ‐ it is enjoyable n=1   ‐ they can see benefits n=1 ● We will need something catchy, incentives n=2 ● Unsure n=2 ● Residents may join later (after they have seen others participate) n=1		● Residents may not be interested in PA n=3 ● Some residents may not have focus or ability to participate n=3 ● The program would be helpful for residents n=2 ● Some may not stick with it n=2 ● The program is more than they typically do on their own n=1
Session Time of Day	● Morning n=10   ‐ mornings less busy n=5   ‐ morning person n=1   ‐ more alert n=2   ‐ people fall apart in the afternoon n=1   ‐ get it done right away n=1   ‐ people nap in the afternoon n=1 ● Either morning or afternoon n=5 ● Afternoon n=4   ‐ don’t always get up in time n=1   ‐ more time in afternoon n=1   ‐ wouldn’t participate in am n=1		● Will need to schedule around other activities at the facility n=6
Equipment Preferences (Hand weights vs. exercise bands)	● Either/try both n=8 ● Weights n=5 ● Not sure/no experience with one or other n=2 ● Exercise bands n=1 ● May depend on individual abilities n=1		● Consider if weights are safe n=1 ● Consider ease of transporting equipment (weights might be more difficult) n=1
How long are you able to stand?	● <30 minutes (several said 10 minutes) n=8 ● Not limited n=6 ● Not sure, never stands still n=3 ● 45–60 minutes n=2		● Standing can cause pain or dizziness n=3 ● Depends on how they’re feeling n=1 ● Can stand longer with assistive device n=1
How far are you able to walk?	● Not too limited n=10 ● Limited n=9   ‐ across parking lot to other building   ‐ affected by foot pain   ‐ only walks to meals   ‐ difficulty walking uphill   -10 minutes   -1-2 blocks, then hip, knee problems   ‐ gets out of breath   −1/2 mile with walker and stopping to rest   ‐ limited by hip arthritis		● Can walk longer with assistive device n=2 ● It is easier when there is less traffic in the hallways n=1
Wearing Garmin (wrist-worn pedometer)a In some interviews, the participants were shown the device to see how well they could read the screen	● Yes, would be willing to wear n=11 ● Able to read screen n=8   ‐ but might be too small for others n=2 ● Difficult to read screen n=1		● Could be used as incentive n=1 ● There is a risk of residents losing the device n=1
Study Measuresa	● Willing to complete n=13		● Those who have completed can speak to how easy it is n=1 ● Will be interested in seeing study outcomes n=1
Framing Program Goal Increasing light physical activity vs. decreasing sedentary time	● Increase activity n=12   ‐ positive n=5   ‐ promote something vs. telling not to do something n=1   ‐ telling to decrease sitting sounds like accusing of laziness n=1   ‐ lift into something better n=1   ‐ easier to track n=1   ‐ they won’t like a decrease sitting message n=1 ● Decrease sitting n=5   ‐ more motivating because less opportunities to be active in small apartment n=1   ‐ recognizes sitting problem n=3   ‐ people may not realize how long they sit n=1 ● Both (could frame it both ways) n=2 ● Not interested n=1		● Frame it as starting small and building to the goal (don’t have to start with 30 min.) n=1
General suggestions	● Residents will have a range of abilities n=5 ● Some will be limited n=4 ● Should we stretch before walking? n=4 ● Recruitment may be challenging (unsure if people will join) n=3 ● Important for residents to know their limits n=2 ● Kudos to us for planning the program n=2 ● We should address their interest in maintaining PA and abilities (many become discouraged with aging) n=1 ● Need to define our target population n=1 ● Need to find the right activities to include in the program n=1 ● Include music n=1 ● Need to get with the people (see if they like it, get them onboard) n=1 ● They need to see the benefits and see how others like the program (might take some time) n=1 ● Opportunity to work on thing can’t do on own (balance) n=1 ● Program is necessary n=1 ● Safety, monitoring is important n=1 ● Two groups may be needed for residents of different abilities n=1 ● Consider planning an intervention for those who are more active and able (could be in conjunction with staff interested in exercise) n=1

^aQuestion on this topic was added later to the interview guide and was not posed to all participants.

Note: The “Main Responses” column contains mutually exclusive categories, and each resident is only represented by one response in that column. “Other responses” are responses that residents gave in addition to their main response and residents could be represented in more than one category.

Most residents were interested in participating in the proposed intervention (n=13) or expressed that they would try it (n=5), although one resident thought her physical activity was sufficient without the program and another was not at all interested in physical activity. They expressed that interest in participating will likely vary among residents (n=8), with two residents commenting that others will probably like the intervention if it is enjoyable and they can see its benefits. Others suggested that recruitment will be challenging (n=5), but that participation could be improved with incentives and something “catchy” to get them interested (n=2). For framing the goals of the intervention, twelve residents felt that emphasizing increasing light physical activity by 30 minutes would be more motivating than focusing on decreasing sedentary behavior, mainly because it sounds more positive.

Thematic analysis

We identified seven themes and nine sub-themes related to factors that could be important in implementation of an intervention to promote physical activity with the AL population.

Attitudes and Beliefs about Physical Activity.

The first theme, attitudes and beliefs about physical activity includes three sub-themes.

Significance of Physical Activity.

Assisted living residents predominantly believed that physical activity is very important and has several potential benefits for them. As one resident commented, “It’s very important. Extremely. Because I don’t want people have to take care of me. It maintains my independence…and I know how important it is because I’m not as strong as I once was, and I know it’s from sitting (02).” In addition to the ability to move and maintain independence, residents associated physical activity with beneficial outcomes such as weight loss, pain reduction, and maintenance of mental capabilities and mental health. Contrary to most AL residents, one resident did not believe physical activity was valuable at his age.

Motivation and Confidence for Physical Activity.

Assisted living residents described that low motivation or self-described “laziness” could hinder their activity levels, even if they wanted to be active. One resident described a conversation with herself about her motivation to be active: “I says, ‘Self, get up and go for a walk…’ But I haven’t done it yet (02).” Residents expressed that confidence in their ability to be physically active was important and that other residents may need help building their confidence for physical activity: “They need the encouragement to get their confidence, because they’re capable of doing it. They just have been told so long that, ‘You’re old’ (10).”

Safety Concerns.

Residents expressed safety concerns about balance, falls, and injury risks during physical activity. Some had fallen in the past and wanted to avoid future falls, like one resident who said, “So I don’t want to fall No. So it’s…You’ve got to think safety all the time. (06)” Concerns about levels of supervision and monitoring while they perform physical activity were common. In thinking about physical activity sessions, one resident was concerned for other residents in her facility and said, “You don’t want anybody to have an accident and get hurt…they’re going to need people helping so that nobody gets into trouble (05).”

Attitudes and Beliefs about Aging.

This theme represented how AL residents think and feel about aging and the relationship between aging and physical activity. Two sub-themes are described.

Perspectives on Aging.

A few AL residents expressed that they don’t feel society values older people. As one resident said, “Nobody is positive about senior citizens except senior citizens…People throw away, have a tendency to throw away, old folks, and we still got some life in us, so they need to stop throwing us away (10).” Some residents described personal discouragement related to aging and not being able to do as much as they used to do. As one resident said, “People don’t realize, I don’t think, how devastating getting old is (18).” On the other hand, many residents were thankful that they maintained certain abilities at their age: “And I just feel very fortunate. When I look around I think I’m 80 years old and I’m still walking, thank God (07).”

Appropriate Level of Physical Activity in Older Age.

Residents discussed how much physical activity they should be doing in their older age. They acknowledged that their activities had changed as they aged: “I’m getting old and I can’t do what I did before. But I had fun doing it (07).” Several talked about the tendency they have to “baby” themselves or not push themselves in their physical activity as they get older. There seemed to be some uncertainty about how much physical activity they should be doing and whether too much could be harmful, as evidenced by one resident who shared, “I’m concerned that I will decondition. I feel I have already and I want to maintain as much endurance but I don’t know what reality is because my age is progressing. I’ve here lived a year longer, and so how much would I have deconditioned even if I was working really hard at home with a lot of outside work? Maybe I could be worse because I would be wearing my body out. I don’t know (05).”

Abilities of Assisted Living Residents.

Another theme was related to how AL resident view their own physical and mental limitations and limitations of other residents. We identified two sub-themes.

Physical and Mental Limitations.

Assisted living residents described several physical symptoms they experienced, including worsening eyesight, joint and back pain, fatigue, shortness of breath, dizziness, and balance issues. At times, these issues interfered with their ability to perform physical activities. Many of the residents interviewed also observed mobility limitations in other residents that they felt would limit those residents’ abilities to exercise. As one said, “Surprisingly, there is not too many in here that can get up and walk around in the place (12).” They also recognized that different types of conditions might have different effects on physical activity: “And so I guess the person themselves would have to decide if it’s something they can do if they try because some things are temporary, and some are permanent disabilities (06).” In addition to physical limitations, AL residents mentioned that many residents in their facility had some level of cognitive decline and that cognitive issues could be a barrier to participation in physical activity programs. In speaking about physical activity, on resident said, “I just don’t think most of them can stay focused on it (14).”

Wide Range of Abilities.

Related to physical and mental abilities, residents emphasized that there is a wide range of abilities among the residents in their facilities and that everyone is different. One resident described the different walking abilities: “We have the walk—people that can walk real good and people that can walk a little bit and those that have the walkers (6).” As a result of these varying abilities, residents expressed that it may be challenging to plan a single program that would be an appropriate level of difficulty for all residents: “You’re not going to get all of them in the same program. So you’re going to have to pick…You’re going to have people maybe like me that sit down this end. Then you’re going to have people in electric carts up at this end, and they’re not all going to fit your program (9).” They also thought the program would need to be adjusted on an individual basis.

Social influences for physical activity.

Two sub-themes were identified related to social factors that may be important to consider in planning a physical activity intervention.

Encouragement to be Physically Active.

Some residents had family members who encouraged them to be more active. One said, “My daughter…she totally encourages me to get active here constantly. ‘Dad, you know, don’t just sit in your room doing nothing. Get active and do things,’ which I do (04).” In some cases, family members discouraged them from doing certain activities due to safety concerns, like one resident’s family who discouraged her from taking walks in the park due to her history of falls. Generally, the only form of encouragement from AL staff was to encourage them to attend chair exercise classes. Some said that physical activity was a conversation topic among residents and that they checked in with one another to see if they have done their walking. For example, one resident shared, “Well, we all talk about, ‘Did you take your walk today?’…and it’s easy to walk when you’ve got other people that are interested, and those that aren’t interested, you don’t talk about it (09).” They also invited one another to go for walks or encouraged one another to attend chair exercise classes. Some were inspired when they saw other residents being active. One resident described a conversation with herself: “I say, ‘If that man who recently had a stroke and he’s walk—’ I said, ‘Now if he can do it, you can do it.’ (02)” On the other hand, some residents who felt they were the most active did not find encouragement from other residents.

Group Exercise Preference.

When talking about their experiences in exercise classes, many residents commented that they really enjoyed group exercise settings. They liked the interaction, camaraderie, and encouragement found in group exercise. One described her experience with group exercise within the facility: “Activity’s more fun if you’re doing it with people than—and see, I was alone in [US state] and didn’t do as much as I am here, so it’s fun to do it with other people (10).” Another resident described why she liked group exercise classes based on experiences outside of the facility: “Because you can encourage one another, and that type of stuff. And especially if you’re having one of those achy days, and you really don’t want to, but you see other people doing it, it kind of makes you do it too (19).”

Space for being active.

Residents commented that there was space available for walking near or around their facilities, however, safety concerns such as unpaved and uneven outdoor paths or uncertainty about the safety of surrounding neighborhoods led some to prefer walking within the facility. At three of the facilities, residents described exercise or therapy rooms but generally felt they were underutilized. They described barriers to using exercise rooms such as being unsure of how to use equipment or whether they needed physician permission or supervision: “I didn’t know what was expected of us and what was readily available to us or what would be okay for us to just, can you just go over and use that or does somebody have to be there, too, to oversee it or whatever and where is it? (05).” At the facility without an exercise room, one resident commented on the space available for doing exercises: “Well, there really isn’t enough, and you do it in your room. And I got one of the smallest rooms here. (12).”

Current Exercise Classes Offered.

Residents described the types of exercise classes offered within their facilities, which were mainly chair exercises. Residents at a two facilities also mentioned a walking club. A few residents regularly attended the chair exercise classes and felt they were valuable and beneficial. One resident remarked about the classes, “I like that they keep us active. That they keep us not just doing nothing (04).” However, most residents interviewed did not feel the classes were beneficial for them and while some still attended for the social aspect, many did not participate. Residents’ descriptions of chair exercise classes included the following: “You know, wish we had more activities in terms of physical activities, but the ones they have are so childish that a lot of people just don’t participate because they are childish (14).” Many felt that these classes were boring and didn’t count as exercise: “If you’re sitting, that’s not activity (16).” Even at the facilities where a walking club was offered, the residents interviewed did not participate. As one resident described, “I’ve seen them walking, and I would walk with them if I was available, but they walk very slow. And a number of them are using walkers or scooters and I think it’s wonderful that they’re doing it but it wouldn’t provide me with the level of activity I felt like I was needing (03).” They recognized that the classes were designed to be inclusive for everyone within the facility, including those who used wheelchairs, and that the classes could be beneficial for some residents. Even so, some wished the facility would offer classes that were more “aggressive (04)” and focused on promoting activity for those who were not using wheelchairs.

Limited Opportunities for Physical Activity.

The AL environment and policies limited opportunities for both leisure and non-leisure physical activity. One example is staff completing housekeeping tasks automatically: “Don’t need to do any of those things. They do it all for us. They don’t even ask if we want to do it ourselves (04).” Residents typically had less space for being active than they did before moving into AL and some had to leave exercise equipment behind when they moved. As one resident commented, “When you leave a house that you’re living in and have much more to do and everything, you’re moving much more than what you are in any type of living, assisting living (03).” Some residents mentioned that their physical activity was influenced by which days exercise classes were offered and that no classes were offered on weekends. One resident described his struggles with finding good times to go walking outside of the facility: “But it always seems like if I go now I’m going to miss lunch. If I go now, I’m going to miss something, and there’s short of a draw to be here at the right times (09).” In some facilities, residents were bothered by the fact that there were no staircases to practice using the stairs in order to maintain that ability. Residents felt they had too much time for sedentary activities like watching television and wished more physical activities were available. One resident remarked that “I feel like I have more energy than I have activity to express it (05).”

Discussion

The results of both the content and thematic analyses are useful in planning an intervention to promote light physical activity and reduce sedentary behavior among AL residents. From the content analysis we found that residents preferred a shorter overall intervention length, shorter sessions, and framing the goals in terms of increasing light physical activity. Residents overall liked the plan for the three components of the intervention (walking, behavioral activities, and circuit training) and most were interested in participating. The thematic analysis drew attention to a number of factors that could influence the implementation of physical activity interventions with the AL population including motivation, safety, beliefs about aging, varying abilities, and social influences.

We received a lot of pragmatic suggestions from residents to inform the modification of the Active for Life in Assisted Living Intervention from previous versions to be appropriate for older adults in AL. Our findings are consistent with Voss’s results that encouraging AL residents to decrease sedentary time may not be the best approach because they perceive certain sedentary activities as beneficial; instead interventions could encourage light physical activity and breaks in sedentary time (Voss, Pope, & Copeland, 2020).

Attitudes and beliefs about physical activity identified in the thematic analysis were consistent with previous research. Other studies have reported that AL residents are aware that too much sedentary behavior or not enough physical activity can negatively affect physical and mental health (Kotlarczyk et al., 2020; Phillips & Flesner, 2013; Vos et al., 2019; Voss, Pope, & Copeland, 2020) and that lack of motivation (Phillips & Flesner, 2013; Voss, Pope, & Copeland, 2020), self-efficacy (Chen et al., 2015), and safety concerns are important (Kotlarczyk et al., 2020; Voss, Pope, & Copeland, 2020).

Our results reflect ageism and negative stereotypes related to aging that are highly prevalent in Western cultures (Dionigi, 2015). Because these stereotypes may be internalized by older adults and influence how they view themselves and their behaviors, it is not surprising that AL residents may not feel valued by society and may experience discouragement related to aging (Dionigi, 2015). Previous studies have identified that AL residents may believe increased sedentary behavior is an inevitable part of aging (Kotlarczyk et al., 2020; Voss, Pope, & Copeland, 2020) and it is important to recognize that this belief is likely related to aging stereotypes of poor physical functioning and dependency (Dionigi, 2015). Interventions should promote positive views of aging by addressing ageist attitudes of inevitable decline and the perception that structured physical activities are inappropriate for older adults (Jeon et al., 2019; Menkin et al., 2022). Promoting positive views of aging may motivate older adults to participate in physical activity and improve their quality of life by helping them engage in meaningful activities (Jeon et al., 2019; Menkin et al., 2022).

The influence of AL residents’ abilities echoed the findings of earlier work; physical conditions such as fatigue, mobility, pain, impaired sight and hearing, musculoskeletal problems, neurological conditions, and poor balance can impact residents’ physical activity (Phillips & Flesner, 2013; Vos et al., 2019; Voss, Pope, & Copeland, 2020). We are not aware that previous qualitative studies in AL have identified themes related to the wide range of physical and mental abilities among AL residents discussed by participants in our study. The wide range may be due to facilities moving toward an aging in place approach where residents with more complex care needs are staying in AL longer before transferring to a higher level of care (Morgan et al., 2014).

Our results indicate that social influences on physical activity are meaningful to AL residents. Social engagement, such as through group physical activities, may motivate residents to reduce their sedentary behavior (Voss, Pope, & Copeland, 2020). Walking companions or walking groups may provide social support (Kotlarczyk et al., 2020), although residents in our study did not favor larger walking groups. Receiving encouragement from family or AL staff can motivate residents to reduce sedentary time and take walks (Phillips & Flesner, 2013; Voss, Pope, & Copeland, 2020). On the other hand, family members may discourage AL residents from performing certain activities they perceive as unsafe (Vos et al., 2019). Social comparisons may play an important role as participants framed their abilities and behaviors in comparison to other residents. These comparisons may provide a helpful point of reference and inspire physical activity behaviors, but could also result in feelings of discouragement or inadequacy (Halliwell, 2012).

Residents reinforced the fact that structural factors have a major impact, specifically environmental and policy factors. Space available for being active, such as walking areas and dedicated exercise space and equipment, influences the physical activity of AL residents and requirements for physician permission or supervision are a barrier to residents using exercise space (Kotlarczyk et al., 2020; Phillips & Flesner, 2013). Services provided in AL for activities of daily living and household activities give them fewer reasons to move (Kotlarczyk et al., 2020; Voss, Pope, & Copeland, 2020). Residents’ dissatisfaction with chair exercise classes and desire for more challenging programs are not surprising given that activities in AL are usually planned according to the “lowest common denominator” of physical and cognitive abilities (Morgan et al., 2014). Assisted living residents desire workouts tailored to their individual needs and abilities, including more vigorous exercises (Bender et al., 2021).

Our results have several implications for planning physical activity interventions in AL. Issues to be addressed include enhancing residents’ motivation and confidence for physical activity (such as the self-efficacy enhancing strategies in our proposed intervention), ensuring safety by providing adequate supervision and appropriate balance supports, and providing highly adaptable activities. Separate interventions for residents with different levels of ability may need to be considered. An intervention could address ageist attitudes about physical activity and help older adults in AL remain engaged and active as they age. Social support from family or other residents could be incorporated in intervention strategies. The dissatisfaction of many residents with chair exercise classes highlights a need for other types of physical activity programs in AL.

There were strengths and limitations to this study. This study uniquely asked for recommendations from AL residents on a proposed intervention to reduce sedentary behavior and this method of engaging the residents as stakeholders was a strength. In addition, residents provided rich data that allowed us to conduct a secondary analysis. Regarding limitations, the four AL facilities from which residents were recruited were similar in the types of support provided and activities offered. Based on comments made by several of the residents we interviewed, it is possible that the residents who volunteered for our study tended to be more active and have higher levels of physical function than others in their facilities.

In conclusion, AL residents recommended shorter sessions and emphasizing increasing light physical activity rather than decreasing sedentary behavior. Other important considerations in intervention planning included safety, accommodations for a wide range of abilities, the effect of social influences, and the unique AL environment. Residents could benefit from assistance in identifying opportunities for increasing physical activity, such as performing more household activities for themselves to the extent they are able to do so.