A Qualitative Exploration of Factors Associated with Walking and Physical Activity in Community-Dwelling Older Latino Adults

Abstract

BACKGROUND

Ethnic/racial minorities often live in neighborhoods that are not conducive to physical activity (PA) participation. We examined perceived factors related to walking/PA among Spanish- and English-speaking older Latinos in a low-income, multi-ethnic neighborhood.

METHODS

Exploratory focus group study with Latinos stratified by preferred language and gender: English speaking women (n=7, M age=74.6); English speaking men (n=3, M age=69.3); Spanish speaking women (n=5, M age=66.4); Spanish speaking men (n=5, M age=74.0). Focus group audio files were transcribed, and qualitative research software was used to code and analyze documents.

RESULTS

At the individual-level, reasons for exercising (improved health) and positive health outcome expectancies (weight loss and decreased knee pain) were discussed. Neighborhood/environmental factors of safety (fear of crime), neighborhood changes (lack of jobs and decreased social networks), weather, and destination walking were discussed.

DISCUSSION

Individual and environmental factors influence physical activity of older, urban Latinos, and should be taken into consideration in health promotion efforts.

The Latino population aged 65 years and older will increase 224% by 2030, compared to a 65% increase for the older non-Latino white population (Greenberg, 2009). Physical activity (PA) plays a significant role in primordial prevention of chronic disease and accompanying disability (Chodzko-Zajko et al., 2009), yet older adults are the least active age group (CDC, 2005). Walking is the most prevalent form of PA in older adults (Eyler, Brownson, Bacak, & Housemann, 2003) and walking among older adults is associated with positive health outcomes (Weuve et al., 2004).

Understanding the influence of individual, structural, and social features of the neighborhood environment and PA participation is important for creating healthy communities (King, 2008). Social-ecological approaches stress the importance of these multiple levels of influence on health behaviors (Sallis & Owen, 2002). At the individual-level, many older Latinos are knowledgeable of the health promoting benefits of exercise (Belza et al., 2004), however, this understanding has not led to widespread adoption and maintenance of PA. The residential neighborhood is the most common location for walking among older adults (Eyler et al., 2003). Unfortunately, environmental barriers to neighborhood-based PA may be accentuated among older adults as a result of a combination of declines in physical and cognitive functioning, increased discomfort with driving, and fewer social network members (Yen, Scherzer, Cubbin, Gonzalez, & Winkleby, 2007).

On the southeast side of Chicago there is a “convergence of disadvantage” (Gills, 2001) including low socioeconomic status (Bensman & Lynch, 1987) and documented health disparities (CDPH, 1999), similar to many urban areas across the United States (Giachello et al., 2003). These additional factors/barriers can make it even more difficult for older adults from disadvantaged neighborhoods to adopt and maintain PA. Learning about such factors can inform the design of interventions and influence urban designs that promote activity among at-risk populations (Michael, Green, & Farquhar, 2006). To date, however, very little is known about individual and environmental-level factors that influence older Latino adult participation in walking. The purpose of this exploratory qualitative study was to examine individual-level and neighborhood/environmental factors related to walking/PA among Spanish- and English-speaking older Latinos living in a low income, multi-ethnic neighborhood.

METHODS

Participants

Approval for the study was obtained through the Institutional Review Board (IRB) at the BLINDED. A purposive sampling technique was used to recruit participants with the assistance of community agencies. Inclusion criteria were: 1) age ≥ 50 years old; 2) Hispanic/Latino self-identification; 3) fluency in Spanish or English; and 4) residing in Block Group 4 of Census Tract 4610.

Data Collection and Measures

After obtaining informed consent, a survey was administered. A semi-structured focus group guide was developed that included questions aimed at eliciting detailed narratives on the predetermined topics (Table 1), which were identified from the literature and the team’s previous research in the neighborhood. Four focus groups were conducted, stratified by preferred language and gender: English speaking Latina women; English speaking Latino men; Spanish speaking Latina women; and Spanish speaking Latino men. Focus groups were facilitated by a trained female bilingual, bicultural Latina moderator. An additional note taker was responsible for recording session details. Focus groups ranged from 35 to 75 minutes in length and all were recorded and transcribed. Participants were financially compensated with $20 for participation. Group discussions conducted in Spanish were transcribed in Spanish and then translated into English. English translations were for purposes of content review by non-Spanish-speaking research staff, but not for purposes of data analysis.

Table 1.

Sample focus group questions

Domain	Questions
Attitudes and personal views toward PA in old age	Is it ok (appropriate/inappropriate) for older adults to exercise? Do you ever feel that this time in life is a time to rest?
Enjoyment of Walking	What do you enjoy most about walking? What do you like least?
Barriers to walking/exercising	What things in your neighborhood make it difficult to walk? What aspects of your health influence if you walk? What aspects of your culture, if any, influence if you walk for exercise?
Facilitators and enablers of walking/exercising	Of all the things that would help you walk more, which ones are the most powerful?

Data Analysis

An iterative, hybrid-coding process combining a priori and emergent category derivation approaches was used for code development. Initial themes, used to structure the focus group guide (see Table 1), were coded for and then refined and supplemented with emergent codes that surfaced during data analysis as prescribed by the quasi-inductive descriptive approach. Bilingual/bicultural research assistants used Atlas.ti software to code the Spanish textual data directly from the Spanish transcripts (using English codes) rather than coding from the English translation. Coding from the original language for which data were collected ensured greater raw data immersion and familiarization (Caban, Walker, Sanchez, & Mera, 2008; Pope, Ziebland, & Mays, 2000). This was followed by discussions among the research assistants to resolve any disagreements. The percent agreement in coding was 62% among the two research assistants, with 100% agreement achieved through face-to-face discussion of the final codes assigned. The two research assistants did comparative, line-by-line reading for identification and organization of themes. Themes and sub-themes identified by the research assistants were discussed by the entire research group.

RESULTS

Background characteristics

Table 2 displays the demographic characteristics from survey data. On average participants were overweight/obese, and had lived in the U.S. for many years. Education level across groups was low. All participants were retired and had low-income. Overall, participants self-rated their health as “Fair” or better.

Table 2.

Characteristics of the Study Sample

Variable	English Women M (SD) or % N = 7	English Men M (SD) or % N = 3	Spanish Women M (SD) or % N = 5	Spanish Men M (SD) or % N = 5
Age	74.57 (4.47)	69.33 (5.86)	66.40 (6.69)	74.00 (6.48)
BMI	31.91 (7.49)	26.76 (1.93)	31.56 (3.41)	27.29 (2.38)
Number of children	2.86 (2.12)	3.33 (1.15)	3.60 (1.52)	3.20 (3.35)
Years in the US	66.86 (17.03)	69.33 (5.86)	38.20 (22.87)	43.00 (19.27)
Years of education	11.29 (3.09)	10.00 (2.00)	6.20 (3.42)	8.00 (5.79)
Married	14.3	33.3	40.0	20.0
Retired	100.0	100.0	100.0	100.0
Country of Origin
USA	85.7	100	20.0	20.0
Mexico	14.3	-	60.0	60.0
Puerto Rico	-	-	20.0	20.0
Income < 30,000	100.0	100.0	100.0	100.0
Health Status
Excellent/Very good	42.9	-	20.0	20.0
Good	57.1	100	20.0	20.0
Fair	-	-	60.0	60.0

Note: BMI = Body Mass Index

Themes identified

The participants generated several insights related to walking and PA. Emergent themes identified across focus group participants included individual-level factors and neighborhood/environmental factors (Table 3).

Table 3.

Focus Group Themes and Supporting Participant Quotations

Individual-level Factors Influencing Physical Activity
Purpose of exercise E.g., enjoyment, health, fitness	Spanish-speaking woman (translated): “I’m telling you, I like walking. How I like it.”
	Spanish-speaking man (translated): “The physical state is important to do (all) that.”
Health outcomes of physical activity E.g., favorable profiles for cardiovascular health (blood pressure, cholesterol, weight), mental health, and improved physical functioning (stiffness, knee pain)	English-speaking man: “Well, it’s good for your heart. It’s good for your whole body, your legs and breathing.”
	English-speaking woman: “The best of walking is for the high pressure, for your cholesterol, for headaches… and you lose weight.”
	Spanish-speaking woman (translated): “He [doctor] says that walking an hour daily will help you lose weight.”
Neighborhood/Environmental Factors Influencing Physical Activity
Safety E.g., criminal activity	English-speaking woman: “Just dodge the bullets that’s all.”
	English-speaking man: “Yep, after 8:00 o’clock, 7:00 o’clock, as soon as it gets dark forget it that’s it. I don’t even let my sister go out.”
	English-speaking man: “When you get old these kids that are running around they think they can take your wallet and run away.”
Potential solutions for criminal activity E.g., walking in groups, carrying a weapon, staying in after dark, not carrying valuables, surveillance/patrol system	English-speaking man: “I’m telling you now it’s bad…You’ve got to carry something with you and be looking over your damn shoulder”
	English-speaking woman: “More patrols. Well, the presence so that you can see them, and the rest of the kids would see them and the kids would know, hey the cops are going to be coming by any second now”
	English-speaking man: “they’ve been hitting a lot of senior ladies and get their jewelry, the gold…they can’t have nothing on.”
	Spanish-speaking woman (translated): “When both of us go (walking), I feel more secure, but this is the reason why one does not walk outside.”
Safety: Sidewalk cracks and uneven sidewalks E.g., Neighborhood walkability	Spanish-speaking woman (translated): “The quality is bad. They are cracked. I have to step down to the street.”
	English-speaking woman: “It took us I don’t know how many years to get a sign here [at senior center] for them to slow down.”
Neighborhood changes E.g., negative neighborhood transformation and modified family structure/values	Spanish-speaking woman (translated): “…there have always been problems from the moment I arrived here in South Chicago, there was much, much, much trouble. But now there are too many.”
	English-speaking man: “the main point is …you have no work for the people and it’s going bad. That’s why the (steel) mills here used to be a good thing.”
	Spanish-speaking woman (translated): “Because there are only people from the poorest neighborhood. Everything is pure danger - and the children take on the image of what they see. They have no respect for people.”
Weather E.g., inclement weather (too cold or heat waves)	Spanish-speaking man (translated): “I mean, to go out in extremely cold weather is difficult, right? Similarly, in extremely hot weather.”
	English-speaking woman: “…if the weather is bad, if it’s full of ice and snow you can’t walk and then you’re afraid of falling and breaking something.”
Destination walking E.g., walking for purposes of shopping, medical appointments, religious activities, and recreation	English-speaking woman: “I like to go out and see people and go into the stores. I can spend a lot of time in stores.”

Individual-level Factors

Purpose of exercise

Participants from all groups mentioned why people engage in PA (See Table 3 for quotations). A common comment was that walking is an enjoyable way to stay active. The Spanish-speaking participants cited health reasons for being active; the English-speaking participants talked about PA as a necessity for maintaining function.

Health outcomes

Many participants discussed how PA positively impacts various health outcomes. Weight loss and knee pain were most frequently discussed. Spanish-speaking men discussed weight loss most frequently. Of all groups, the English-speaking men were least likely to discuss the health outcomes of PA.

Neighborhood/Environmental Factors

Safety

Participants in all groups discussed a lack of safety as a factor that impacted their walking and PA in the neighborhood. Safety included subthemes such as crime (e.g., gangs, drugs), frequently mentioned by English-speaking men. Participants in most groups commented that increased risk of crime made it dangerous to be out in the neighborhood after dark. Potential solutions included carrying a weapon for safety; and an improved surveillance or patrol system. Lack of safety was also related to non-crime issues. For example, participants talked about how sidewalk cracks and uneven sidewalks influenced their walking behavior. English-speaking women suggested more “seniors present” signs to impact traffic safety.

Neighborhood changes

Participants perceived negative changes taking place in the neighborhood over time, notably the increase in crime. The male participants noted a lack of jobs and its negative impact on lives. English-speaking men talked about decreased social networks, and also about shifts in the demographic composition of the area to less Latinos and more African Americans, contributing to racial tension. Participants in the Spanish-speaking groups discussed the change in family structure, that the children’s parents now worked, and values were not taught anymore.

Weather

Weather was a factor in the walking behaviors of the older Latinos. Participants from all groups commented on the impact of cold/ice/snow on walking, but also the impact of extreme heat in the summer. Women discussed the negative conditions that the snow and ice created and how it increased their fear of falling.

Destination walking

Many older Latino adults walked with a destination in mind. Destination walking was very common among participants in the English-speaking groups. Common destinations included homes of family and friends; and shops and stores, often with the intent to visit with store owners and neighborhood shoppers.

DISCUSSION

Walking is the most prevalent form of PA in older adults (Eyler et al., 2003) and is appealing because it can be performed with limited resources and without companionship (Dawson, Hillsdon, Boller, & Foster, 2007). Unfortunately very little is known about factors that influence older Latinos’ participation in walking, especially among older Latinos who live in low income neighborhoods where the perception might be that walking is not low risk and walking cannot be done alone.

From the focus group discussions it appears that individual-level factors such as a lack of knowledge of physical activity play a small role in the PA of these older Latinos. Participants from all groups spoke about the benefits of engaging in a physically active lifestyle. A wide range of physical and mental health benefits were cited, consistent with other studies (de Melo, Menec, Porter, & Ready, 2010). Evidence-based programs such as EnhanceFitness, which can improve balance, muscle strength, flexibility, endurance, and dual-task walking performance (ability to perform two tasks simultaneously such as talking while walking) might be accepted by older Latinos, if such programs are available in their neighborhoods (Agmon, Kelly, Logsdon, Nguyen, & Belza, 2013).

Neighborhood/environmental factors were also discussed. Safety, or lack thereof, was the most commonly discussed theme related to walking, similar to studies with urban, older African Americans (Gallagher et al., 2010). Many older Latinos felt that once it became dark outside (late afternoon during winter in many parts of the United States), their safety was in jeopardy, which greatly diminished the opportunity to walk outside. However, lack of safety was not an absolute deterrent to walking. Strategies to overcome safety concerns included individual-level strategies such as walking during daylight hours and before children were released from school; and carrying a weapon (i.e., fire arm) as a means of protection. Some participants wanted more environmental-level intervention, including greater patrolling and a better surveillance system. Addressing safety concerns may need immediate attention in local neighborhoods in order to increase neighborhood walking.

Participant recommendations to increase walking included the presence of more “seniors present” signs, which would alert drivers that older, slower moving people would be walking and crossing in the area. Such signs could be of additional importance in Latino communities, since Latinos aged 65 and older have a pedestrian fatality rate that is 173% higher than that of same-aged non-Latino whites (Ernst, 2011). Environmental/policy recommendations also included improving the quality of the streets and sidewalks. A recent study found that sidewalk continuity and maintenance encouraged walking (Gallagher et al., 2010). Unfortunately, municipal services tend to be substandard in low-income racially or ethnically segregated neighborhoods (Hastings, 2009). Importantly, 73% of outdoor falls in older adults participating in LTPA are caused by environmental factors related to sidewalk maintenance (Li et al., 2006).

English-speaking older adults commented extensively on the changes seen in the neighborhood. Since the closing of steel mills in the 1970s, many South Chicago residents have incomes below poverty levels (Giachello et al., 2003), leading to higher crime rates and reductions in disposable income to spend on personal fitness. The changing neighborhood also meant that the English-speaking older adults walked to their family and friends’ houses less frequently because those people had died or moved away. A unique finding in this study included an element of racial tension that was present for participants in the Spanish-speaking groups. The rapid growth of the Latino population, the widespread gentrification of neighborhoods, and the demolition of public housing has led to increased co-habitation of African Americans and Latinos (Giachello et al., 2003). Older Latinos talked about this demographic transition, specifically in reference to African Americans, many of whom they felt did not teach values, leading to illegal behavior of the children. Thus, the older Latinos’ lack of comfort and familiarity that they once experienced might have lead to less PA participation in the neighborhood.

Inclement weather is a barrier that is frequently mentioned in the older adult literature (Henderson & Ainsworth, 2000). Although little can be done to prevent this barrier, participants did have environmental/policy suggestions. Recommendations included better work by the city’s streets and sanitation department to quickly and thoroughly clear snow and ice from sidewalks, making it more feasible to engage in walking behavior.

Destination walking is a prominent form of PA. For example, proximity of walking destinations was independently associated with increases in the level of walking among older adults (Nagel, Carlson, Bosworth, & Michael, 2008). Participants from the English-speaking groups, who had lived in the U.S. for most of their lives, talked about going to stores as a way of meeting people and seeing old friends. Unfortunately, given the paucity of destinations in the neighborhood due to the closing of businesses, and the comments that many friends had moved or passed away, this is less of a viable option. Finding ways to increase destination walking are imperative.

Despite our findings regarding older Latino adults’ perceptions of walking in their neighborhood, this study has limitations. Inherent to focus group methodology, the current study was comprised of a small sample of participants (N=20). Also, results may not be generalizable to recent immigrants.

This study highlighted the importance of neighborhood factors in promoting PA among older Latinos. Moving forward, the current data could be triangulated with an environmental audit in order to inform a safe passages walking intervention. The combination of neighborhood older adults’ perceptions reported here, along with details of the condition of sidewalks, lighting, aesthetics, etc. that are assets in the community or areas that need to be fixed, can provide a solid base for initiating positive health behavior change.

The present study underscores the need for the collaboration of various sectors of society serving older adults to improve the aging of the Latino population. Collaboration with city officials, who have decision-making power and a budget from which to allocate money for neighborhood changes, might be considered. Also, given the major role that lack of safety played in the participants’ PA, working with the police department might be a necessity. Finally, providers of health information and health care are essential for successful aging among older Latinos, to ensure that individual and environmental-level approaches are included.