Older adults’ social network and support and its association with physical activity

Abstract

The purpose of this study was to describe older adults’ social network and support during a physical activity intervention and its association with physical activity. Mixed methods were used for this secondary analysis of existing data from a physical activity intervention. Seventy-three participants who completed a session by telephone on using support comprised the sample. Participants reported on average approximately eight individuals in their social network. Half reported support for physical activity from a spouse/partner, adult child, or friend. Those who perceived support for self-reported physical activity tended to have greater improvements on average from baseline for mean daily minutes of physical activity than those with no perceived support. Four-fifths developed a plan for a spouse/partner, friend, adult child, or sibling to provide physical activity support. Participants reported that the session was helpful and increased their confidence in using support; over one-quarter intended to use support after the intervention ended.

Introduction

Approximately 14 million Americans have symptomatic knee osteoarthritis,¹ a chronic condition associated with functional limitations and recurrent knee pain that diminish health-related quality of life.^2,3 The functional limitations and knee pain associated with knee osteoarthritis impede physical activity and prevent initiation and maintenance of regular physical activity.⁴ Approximately half of those with knee osteoarthritis have hypertension,⁵ a prevalent cardiovascular risk factor. While physical activity is recommended for both conditions,^6,7 only 13% with knee osteoarthritis⁸ and 28% with hypertension⁹ meet physical activity recommendations.

Antonucci’s convoy model of social relations provides a framework to examine social relations in older adults.^10,11 The convoy model suggests that people are surrounded by supportive others who travel with them during their lifetime. The convoy model encompasses the social network and support. The social network has structural features, e.g., size, frequency of contact, proximity, and composition (spouse/partner, children, siblings, other relatives, friends, neighbors, and coworkers). Social support has functional features, e.g., types of support provided and received (emotional and instrumental) and perceived quality of support (positive and negative). According to the convoy model, support is reciprocal and can be perceived (support thought to be available if an event happens) or enacted (support actually provided if an event happens). Perceived support entails feeling supported, able to share concerns, encouraged in whatever is done, able to get sick care if needed, understood, and appreciated for things done. Enacted emotional support involves intangible actions such as listening and comforting, whereas enacted instrumental support includes tangible assistance such as giving advice, helping to take action, and helping with practical things.^12,13 In addition, personal (age, gender, race/ethnicity, and socioeconomic status) and situational (roles, norms, values, groups, and communities) features can change over time and affect the social network and support, which then affect health and well-being.

A convoy assessment involves identifying and placing important members into concentric circles based on three levels of closeness: close, closer, and closest. A recent analysis of older adults found that convoy size was on average about 7.4 with members being 51.8 years of age and 58.2% female. Members were known for a mean of 38.3 years with 71.2% living within a one hour drive and having contact at least weekly with the older adult. Convoy composition on average consisted of 34.4% adult children, 19.2% friends, 18.2% siblings, 18.2% other family members, and 10.0% spouse.¹⁴

The convoy model of social relations can be integrated with self-efficacy theory¹⁵ to examine use of support from convoy members to promote physical activity, a common recommendation in health care regimens. Positive support from others can increase self-efficacy to perform a specific behavior, such as physical activity, through modeling (e.g., being an exercise partner) and verbal persuasion (e.g., reminding, encouraging, and reinforcing). Modeling is effective as studies of dyads have shown that when individuals make healthy lifestyle changes, partners are likely to make the same changes.^16–21 Modeling of physical activity has the advantage of benefiting both members of the dyad, in particular with collaborative implementation intentions.²²

Two additional theories are essential for understanding perceived support for physical activity. Self-determination²³ and social control²⁴ theories specify the communication strategies of autonomy support and pressure control, respectively, that affect self-management of health care regimens. Autonomy support is demonstrated by endorsing personal preferences and providing options for making healthy lifestyle changes.²⁵ Spouse/partner support for patient autonomy in self-management of health care regimens was shown to promote physical activity and self-efficacy in those with knee or hip osteoarthritis.^21,26 Pressure control occurs when others attempt to compel self-management of health care regimens by inducing guilt and nagging.²⁷ Older men with knee osteoarthritis were less adherent to physical activity regimens on days when spouses/partners exerted pressure control to be active.²¹

There is a small body of research on the influence of convoy members on older adults’ physical activity through modeling and communication strategies.^28,29 In one trial in older adults, mean physical activity and support for physical activity were significantly higher in those whose partner participated in the intervention compared to singles or those with a non-participating partner. Support for physical activity was positively related to physical activity in those whose partner participated in the intervention, indicating joint physical activity or mutual support for physical activity. Support for physical activity was negatively related to physical activity in singles or those with a non-participating partner, indicating misguided support that was perceived as pressure control.²⁸ In another trial in older adults, those in the group-based intervention had significantly increased support for physical activity from family and friends and were significantly more likely to participate in regular physical activity after the intervention compared to those in the control group.²⁹ However, little is known about who currently provides various types of support for physical activity to older adults with comorbid conditions. Further, there is limited knowledge about the convoy members and types of support that older adults select to promote their physical activity program.

The specific aims of this secondary analysis were to:

1. Describe older adults’ experiences with their social network providing support for physical activity and their short- and long-term intentions to use their social network to provide support for physical activity.

2. Examine the association between older adults’ perceived support for physical activity and mean daily minutes of lower extremity exercise and fitness walking as recorded in an electronic diary. The hypothesis was that older adults’ perceived support for physical activity will be associated with mean daily minutes of lower extremity exercise and fitness walking as recorded in an electronic diary.

3. Describe the impact of an intervention session about social network and support on older adults’ confidence to use support and beliefs about helpfulness of the session in promoting physical activity. The hypothesis was that an intervention session about social network and support will affect older adults’ confidence to use support and their beliefs about helpfulness of the session in promoting physical activity.

Material and methods

Design

A mixed methods design was used for this secondary analysis of existing data from a 24-week randomized controlled trial with older adults comparing a self-efficacy based physical activity intervention and an attention control intervention of health education on physical activity and clinical outcomes.³⁰ Assessments in the parent study were performed at baseline, immediate post-intervention, and six months post-intervention. Quantitative physical activity data from the key study time points and qualitative data from the intervention session on using support from others were integrated for this study.

Setting and sample

The parent study recruited a convenience sample of community-dwelling adults from a large mid-Atlantic city and the surrounding suburbs using registries, public domain mailing lists, and self-referral. Recruitment occurred from January 2012 to November 2013 with follow-up ending November 2014. Potential participants were age 50 years or older with knee osteoarthritis and hypertension treated with anti-hypertensive medication. The minimum age of 50 years was based on the American College of Rheumatology clinical criteria for knee osteoarthritis used in the parent study.³¹ Potential participants who regularly engaged in physical activity (lower extremity exercise ≥ 2 times/week and fitness walking ≥ 90 min/week) or had medical conditions that restricted physical activity were excluded. Potential participants underwent preliminary telephone screening followed by screening and enrollment visits before being randomized to the intervention group or attention control group. The sample for this study was comprised of 73 participants randomized to the intervention group of the parent study who completed a session on using support from others to promote adoption and maintenance of physical activity.

Procedures

Approval for this study was granted by the Institutional Review Board at the University of Pittsburgh (STUDY19010054). The parent study’s procedures are described elsewhere³⁰ with a brief description of the physical activity intervention group provided here. Participants in the intervention group received six weekly 60-minute sessions with a physical therapist conducted in a clinical research area at the School of Nursing followed by nine biweekly 20-minute telephone sessions with a registered nurse, set graduated goals for lower extremity exercise (flexibility, strengthening, and standing balance) and fitness walking, and used a daily electronic diary during the intervention for self-monitoring minutes of lower extremity exercise and fitness walking. The session schedule and topics for the intervention group are presented in Table 1. Self-efficacy strategies (mastery, modeling, social persuasion, and physiological feedback) were woven into the content of the sessions. An interactive-style intervention manual was used with the session content and goals customized to the participant.

Table 1.

Session Schedule and Topics in the Intervention Group

Week Number/Study Staff	Session Number	Topic
1 / PT	1	Learning more about knee osteoarthritis and hypertension
2 / PT	2	Getting started with lower extremity exercise
3 / PT	3	Getting started with walking
4 / PT	4	Being physically active when you have pain
5 / PT	5	Using heat and cold to promote physical activity
6 / PT	6	Telling the difference between normal body signals and warning signs
8 / RN	7	Scheduling physical activity
10 / RN	8	Dealing with unpleasant sensations
12 / RN	9	Managing setbacks to physical activity
14 / RN	10	Avoiding risks of physical activity
16 / RN	11	Using support from others
18 / RN	12	Using self-talk to motivate and persist
20 / RN	13	Building self-confidence through persuasion
22 / RN	14	Trying other types of physical activity
24 / RN	15	Reviewing and closing

Notes. PT=physical therapist; RN=registered nurse.

Procedures specific for this study pertain to the intervention session delivered by the study nurse on using support from others. The session opened with a review of the lower extremity exercise and fitness walking recorded in the participants’ electronic diary over the last two weeks to determine adherence to goals and guide new goal setting. Next, the participants’ social network was constructed using a diagram in the participants’ project packet. A hierarchical mapping technique developed by Antonucci³² was used to determine network size and emotional closeness. Using a diagram with four concentric circles with “You” in the innermost circle, participants were asked to place the first names or initials of person(s) who are so close to them that they cannot imagine life without them in the circle immediately surrounding them. Next, they were asked to place the first names or initials of person(s) who are not quite as close but still very important in the next circle. Then, they were asked to place the first names or initials of person(s) who are not quite as close but still important in the outermost circle. Lastly, they were asked to show the relationship to them for the people in their social network by noting it next to their name or initial, e.g., spouse, child, neighbor, sister, etc. The number of persons in the three circles were summed for the size of the social network.

After constructing the social network, evidence-based patient education about support from convoy members to manage physical activity was interspersed with a series of open-ended questions (Table 2) to guide development of an individualized support plan according to participants’ current support and new support that they intend to implement during the intervention. At the next session two weeks later, the study nurse followed up with the participants about their confidence in using support to manage physical activity. At the end of the intervention, the study nurse asked the participants to rate all of the intervention strategies that they learned and practiced, including using support, and to develop a long-term physical activity plan using these strategies after the intervention ends.

Table 2.

Open-ended Questions on Using Support from Others

Who helps you now with your physical activity program and what do they do to help?

Who could help you with your physical activity?

What types of help could you use?

What can you do to let your support persons help you most effectively?

What is your support strategy for the next two weeks?

What is your long-term physical activity plan and what strategies will you use?

The sessions were audio-recorded and the responses to the open-ended questions were transcribed for content analysis and coded by EAS. Coding was aided by types of convoy members often reported in the social network^12,14 and evidence-based examples of types of support⁴ and techniques for effective support.^21,26 Additional types of support and techniques for effective support reported by participants were identified, categorized, and described as needed.

Measures

Experiences with their social network and support and intentions to use their social network and support.

Participants were asked the following open-ended questions (Table 2): Who helps you now with your physical activity program and what do they do to help? Who could help you with your physical activity? What types of help could you use? What can you do to let your support person help you most effectively? What is your support strategy for the next two weeks? What is your long-term physical activity plan and what strategies will you use?

Lower extremity exercise and fitness walking.

All participants recorded their physical activity of lower extremity exercise and fitness walking on a daily basis in an electronic diary. Data on the minutes of lower extremity exercise and fitness walking were each summarized as a daily average yielding the mean daily minutes over a seven-day period at each of the key study time points (baseline, immediate post-intervention, and six months post-intervention).

Confidence to use support and helpfulness of the session in promoting physical activity.

Participants were asked the following yes-or-no question: Did the session increase your confidence in using support to manage physical activity? Participants were asked to rate the helpfulness of the session on a 5-point Likert scale with 1 being “not helpful” to 5 being “very helpful.”

Demographic data.

Demographic data collected in the parent study at baseline was used to describe this sample in terms of age, sex, race, marital status, employment status, educational level, and household income.

Validity and reliability of qualitative coding.

EAS transcribed the audio-recordings and coded the first eight transcripts to develop the codebook. XS independently coded one transcript to ensure validity of the codes, which clarified the meaning of one code. As EAS continued coding, the codebook was refined as new codes were added, in particular combinations of the original codes when multiple convoy members and multiple types of support were reported. The inter-rater reliability of the coded qualitative data was assessed by dual-coding 10% of the audio-records and computing a Cohen’s Kappa of 0.973, where a Kappa ≥0.60 is considered acceptable.³³ Confirmability was achieved by use of an audit trail to document ideas about coding, reasons for merging codes, and notes about the meaning of themes.

Data analysis

To address specific aim one, the participants’ responses to open-ended questions on using support from others were analyzed within a content analysis framework.³⁴ EAS analyzed the transcripts and identified the key points, which were categorized to form initial classes used to code the transcripts. The initial classes were refined to identify main themes. IBM SPSS version 25 (IBM Corp., Armonk, NY) was used for the descriptive analysis of social network size and the codes produced from the qualitative analysis. Frequencies and percentages of codes were used to describe the following data: (a) convoy members currently supporting older adults with their physical activity program and types of support they provide; (b) convoy members who could provide support; (c) types of support older adults could use with their physical activity program; (d) techniques older adults could use to help convoy members in being most effective; (e) convoy members and types of support older adults intend to implement during the intervention; and (f) convoy members and types of support older adults intend to implement after the physical activity intervention ends.

To address specific aim two, SAS version 9.4 (SAS Institute, Inc., Cary, NC) was used for linear mixed modeling to investigate the relations between perceived support for physical activity and the dependent variables of mean daily minutes of lower extremity exercise and fitness walking over time (baseline, immediate post-intervention, and six months post-intervention). To summarize these relations, the standardized mean difference (d) of the change in the mean daily minutes of lower extremity exercise and fitness walking at immediate post-intervention and six months post-intervention relative to baseline values between those reporting perceived support for physical activity and those reporting no perceived support for physical activity were computed.

To address specific aim three, measures of central tendency (mean, standard deviation, and range) were employed to describe confidence to use support and helpfulness of the session in promoting physical activity. The sample was described using frequencies and percentages for categorical demographic characteristics and measures of central tendency (mean, standard deviation, and range) for continuous demographic characteristics. Participants reporting perceived support for physical activity were compared to participants reporting no perceived support for physical activity using Chi Square tests for categorical demographic characteristics and independent sample t-tests for continuous demographic characteristics.

Results

Participants

The 73 participants were on average 65.0 years of age (SD=8.5, range, 51–86), 75.3% (n=55) female, 74.0% (n=54) white, 46.6% (n=34) married, 50.0% (n=36) employed, with greater than high school education (79.4%, n=58), and a household income <$50,000 (45.3%, n=29). Older adults reported having an average of 8.4 (SD=3.7, range 3–21) convoy members in their social network. There were no significant demographic differences between participants who reported perceived physical activity support and participants who reporting no perceived physical activity support except for marital status; a greater percentage of those who were married reported having support for physical activity (p=.002).

Description of older adults’ social network and support and intentions to use their social network and support

Content analysis yielded 165 codes for individual convoy members or combinations of convoy members who were currently providing physical activity support to older adults and who could provide support to them. The theme that emerged was that a variety of family members and friends currently provide or could provide physical activity support to older adults. For example, “My wife walks with me.” Also, “My buddy, ___, helps me schedule. We talk together on the phone, you know, to find what time is good for you.”

Fifty-two codes were generated for types of physical activity support currently being provided to older adults and types of physical activity support that they could use. The theme that materialized was that older adults perceive an array of physical activity support currently being provided and that they could use. For example, “___ will remind me in a nice way, it’s time to walk, go ahead, it is nice outside, it is not raining.” Also, “Well, my husband is supportive. He is supportive, if I need to walk or something, he can do dinner…he can do other things, like I said, he took care of our grandchild when I walked.”

Fifteen codes were created for techniques older adults could use to help a convoy member in being most effective. The theme that appeared was perceived physical activity support can be negative and can be managed by older adults using specific techniques. For example, “___ gets to be a little more pushy, and the one time I just explained to her, you know, you don’t understand, sometimes because it hurts so bad I can’t move as easily. I have to take a lot of things into consideration. I just can’t go lifting weights and joining all kind of gyms and having people that don’t understand my condition make me do things that can harm me more than help me”.

About half (n=37, 50.7%) of older adults reported that someone currently supports them with their physical activity. Among those who perceive support, the convoy members who most frequently support them are a spouse/partner (n=14, 37.8%), adult child (n=4, 10.8%), friend (n=4, 10.8%), trainer (n=2, 5.4%), grandchild (n=1, 2.7%), or other (n=1, 2.7%). Eleven (29.7%) participants reported that more than one convoy member supports them with their physical activity; in addition to those listed above, the combinations also included a sibling.

Among those who perceive support, the types of support most often provided include the following: be a physical activity partner (n=12, 32.4%), take over some responsibilities so physical activity can be done (n=3, 8.1%), give exercise advice (n=2, 5.4%), ask if physical activity was done (n=2, 5.4%), remind to do physical activity (n=2, 5.4%), give encouragement or praise (n=2, 5.4%), or drive to a track or gym (n=1, 2.7%). Thirteen (35.1%) participants reported receiving multiple types of support; in addition to the types of support listed above, the combinations also included get exercise information or equipment, rearrange schedules for physical activity, and discuss eating habits in conjunction with physical activity.

Nearly all (n=68, 93.2%) participants identified one or more potential convoy members who could help them with their physical activity. The following convoy members were most frequently identified as a potential source of support: friend (n=11, 16.2%), spouse/partner (n=9, 13.2%), adult child (n=8, 11.8%), sibling (n=5, 7.4%), neighbor (n=3, 4.4%), grandchild (n=1, 1.5%), cousin (n=1, 1.5%), nephew (n=1, 1.5%), or other (n=1, 1.5%). Twenty-eight (41.2%) participants identified multiple potential convoy members, which included a variety of in-laws, parents, housemates, and co-workers in addition to the convoy members listed above.

While about one quarter (n=20, 27.4%) of participants reported that they did not need support, the remaining 53 (72.6%) participants identified one or more potential types of support that they could use to promote physical activity. The following single types of support were identified: give encouragement or praise (n=8, 15.1%), remind to do physical activity (n=7, 13.2%), be a physical activity partner (n=7, 13.2%), take over some responsibilities so physical activity can be done (n=4, 7.5%), rearrange schedules for physical activity (n=4, 7.5%), ask if physical activity was done (n=2, 3.8%), drive to a track or gym (n=1, 1.9%), discuss eating habits (n=1, 1.9%), record physical activity (n=1, 1.9%), or have a trainer (n=1, 1.9%). Seventeen (32.1%) participants reported that they could use multiple potential types of support; in addition to the types of support listed above, the combinations also included get exercise information or equipment, and give exercise advice.

Twenty-two (30.1%) participants reported experiencing pressure control, e.g., nagging, in the past related to their physical activity. They identified techniques that they could use if encountering pressure control in the future. The most common technique was to inform the individual of specific types of support that would be helpful (n=11, 50.0%). Other techniques were to inform the individual of functional limitations (n=4, 18.2%), tell the individual that “nagging” is not helpful (n=4, 18.2%), praise the individual when autonomy support was provided that was helpful (n=2, 9.1%), or ignore the comment (n=1, 4.5%).

While about one-fifth (n=15, 20.5%) chose not to implement a support plan over the subsequent two weeks, 58 (79.5%) participants selected one or more convoy members from their social network to ask for support with their physical activity (see Table 3) and identified the types of support that they would request (see Table 4). The following persons were most frequently selected in the support plans: spouse/partner, friend, adult child and/or their partner, or sibling. The following types of support were most frequently identified in the support plans: remind to do physical activity, be a physical activity partner, take over some responsibilities, give encouragement or praise, rearrange schedules for physical activity, or ask if physical activity was done.

Table 3.

Convoy Members Selected to Promote Physical Activity (n=58)

Convoy Member	n (%)
Spouse/partner	16 (27.6%)
Friend	14 (24.1%)
Adult child and/or their partner	10 (17.2%)
Sibling	5 (8.6%)
Neighbor	2 (3.4%)
Grandchild	2 (3.4%)
Co-worker	2 (3.4%)
Cousin	1 (1.7%)
Nephew	1 (1.7%)
Other	1 (1.7%)
Husband and daughter	1 (1.7%)
Daughter and friend	1 (1.7%)
Sister and cousin	1 (1.7%)
Grandson and neighbor	1 (1.7%)

Table 4.

Types of Support Selected to Promote Physical Activity (n=58)

Type of Support	n (%)
Remind to do physical activity	19 (32.8%)
Be a physical activity partner	16 (27.6%)
Take over some responsibilities	4 (6.9%)
Give encouragement or praise	3 (5.2%)
Rearrange schedules for physical activity	3 (5.2%)
Ask if physical activity was done	3 (5.2%)
Remind to do physical activity and give encouragement or praise	3 (5.2%)
Drive to a track or gym	2 (3.4%)
Get exercise information or equipment	2 (3.4%)
Be a physical activity partner and give encouragement or praise	1 (1.7%)
Rearrange schedules for physical activity and get exercise information or equipment	1 (1.7%)
Remind to do physical activity and be a physical activity partner	1 (1.7%)

Over one-quarter (n=18, 27.3%) of participants reported that they intended to use support from convoy members to maintain their physical activity after the intervention ends. Spouse/partner (n=7, 38.9%), adult child (n=3, 16.7%), friend (n=3, 16.7%), or co-worker (n=2, 11.1%) were most frequently reported with each of the following convoy members selected once: grandchild, partner and sister, and other. Be a physical activity partner (n=12, 66.7%) or remind to do physical activity (n=2, 11.1%) were most often reported with each of the following types of support selected once: give encouragement or praise, remind to do physical activity and give encouragement or praise, rearrange schedules for physical activity and be a physical activity partner, and get exercise information or equipment.

Association of social network and support and physical activity

Although not statistically significant (p≥.05), participants who reported perceived support for physical activity tended to have greater improvements on average from baseline for the minutes of lower extremity exercise per day at immediate post-intervention (10.40 versus 6.47, d=0.518) and to a lesser extent at six months post-intervention (6.83 versus 4.89, d=0.252) than participants reporting no perceived physical activity support. More modest improvements were observed for mean daily minutes of fitness walking, with those participants reporting perceived support for physical activity showing slightly greater improvements from baseline for fitness walking at immediate post-intervention (10.55 versus 8.92, d=0.172) and six months post-intervention (10.36 versus 7.39, d=0.204) than participants reporting no perceived physical activity support.

Responses to an intervention session on social network and support

Seventy-two participants were asked if the session on using support from others increased their confidence to implement this strategy. Sixty (83.3%) participants reported that their confidence was increased, while 12 (16.7%) participants reported that their confidence did not increase. Some of the reasons given for no increase in confidence were that they already had support, they were self-motivated and do not ask for support, or support was not readily available. At the end of the intervention, 66 participants rated the session on using support from others as 3.82 (SD=1.11) on a scale from 1 to 5, where 5 was very helpful.

Discussion

On average, older adults have 8.4 convoy members in their social network. Similarly, a study of a national sample of adults 50 years of age and older reported that their social network included a mean of 8.9 convoy members.¹² This finding was replicated in a more recent regional sample of adults 50 years of age and older, showing a mean of 7.4 convoy members.¹⁴ The relationship composition of the participants’ social network was consistent with the literature.^12,14 About half reported currently receiving support for physical activity from one or more convoy members, primarily a spouse/partner, adult child, and friend. While be a physical activity partner was most often identified, a variety of other types of support was provided as well. These findings extend knowledge about convoy members and types of support for physical activity among older adults as cross-sectional studies tend to focus on marital status and spousal physical activity as correlates of physical activity participation.^35,36 Participants who perceived support for self-reported lower extremity exercise and fitness walking tended to have greater improvements on average from baseline for mean daily minutes of lower extremity exercise and fitness walking than those with no perceived support.

Over 90% of the participants identified one or more convoy members who could help them with their physical activity, which suggests that older adults’ social network is large enough to contain potential convoy members for physical activity that future support interventions can engage. Similar to findings in older rural women with arthritis,⁴ participants in this study reported potential types of support that they could use, such as give encouragement or praise, remind to do physical activity, be a physical activity partner, take over some responsibilities, rearrange schedules, and ask about physical activity.

Nearly one-third reported receiving pressure control to be physically active, which other studies found has adverse effects on self-management. Patients were less adherent to physical activity²¹ and dietary³⁷ regimens on days when spouses/partners applied pressure control for these self-management behaviors. Also, pressure control by spouses/partners had negative effects on medical adherence after total knee replacement surgery in knee osteoarthritis patients.³⁸ The participants in this study were able to generate techniques to use if encountering pressure control in the future, which suggests that future support interventions can include instruction on reducing pressure control for both members of the dyads.

Four-fifths developed a plan selecting a spouse/partner, friend, adult child, and sibling that included remind to do physical activity, be a physical activity partner, take over responsibilities, encourage or praise, rearrange schedules, and ask about physical activity. These behaviors are consistent with theoretically-derived, evidence-based strategies of modeling to promote healthy lifestyles^16–21 and autonomy support to promote weight loss, physical activity, and self-efficacy for osteoarthritis self-management.^21,26,39 However, one-fifth chose not to implement a support plan as a component of their physical activity program. Consistent with self-determination theory,^23,25 these participants may be more intrinsically motivated; thus, it is important for convoy members and nurses to support older adults’ autonomy and respect their preference to not engage convoy members in their physical activity program. The majority of participants reported that the intervention session was helpful and increased their confidence on using support with over one-quarter intending to use support after the intervention ends, which provides evidence for sustainability.

Nurse-led interventions based on self-efficacy theory have been used to promote physical activity in older adults⁴⁰ and could be integrated with the convoy model of social relations in future studies. Recommendations for future research include developing and testing a dyadic self-efficacy based physical activity intervention for older adults with comorbidities and convoy members of their choosing that systematically incorporates preferred types of support based on modeling, increasing autonomy support, and reducing pressure control.⁴¹ Intake interviews with the dyads could screen and educate them about their roles, activities, and possible benefits and challenges to participation to insure that they are informed and capable of engaging in the intervention.

Promotion of physical activity in older adults by nurses in primary care settings is imperative.⁴² Implications for nurses working with older adults who are prescribed a physical activity regimen include determining if they currently have one or more convoy members supporting them and what types of support are being provided. If older adults lack support, nurses can ascertain if they want support and have someone in their social network who could assist them in ways that would be most helpful. Nurses can assist older adults and their convoy members to strategize types of support to promote physical activity and ways to manage pressure to be physically active, if it should occur. When feasible, nurses can emphasize the benefits to both the older adult and convoy member of being an exercise partner, such as feeling, sleeping, and functioning better and reducing the risk for development and progression of many chronic disorders.⁴³

This study had a few limitations. The sample size of 73 was small, although saturation was reached with no new convoy members, types of support, and techniques for effective support being reported toward the end of qualitative coding. The small sample may have contributed to the lack of significant associations between perceived support and self-reported physical activity. The groups with support and with no support were not randomized and differed on marital status, which introduces selection bias. Since the participants were enrolled in an intervention study, they were a self-selected sample being engaged in health promoting activities so findings are not generalizable to the population of older adults with comorbidities. Further, the findings can only be generalized to community-dwelling, inactive, older, white, educated women with knee osteoarthritis and hypertension managed with antihypertensive medication.

Conclusions

Physical activity is recommended for older adults with the prevalent comorbidities of knee osteoarthritis and hypertension. Older adults with these comorbidities had a social network that includes a variety of family members and friends who can provide specific types of support for physical activity. Only half of older adults perceived support from convoy members to promote physical activity so there are opportunities to implement support interventions to help older adults achieve recommended levels of physical activity. While a small proportion of older adults did not want to establish support plans, an intervention session on support was rated highly and most older adults were able to select a convoy member, identify one or more types of support to request, and describe techniques to manage pressure control with many intending to use support from convoy members in the long term.