Barriers to exercise participation among older Chinese adults attending a primary care clinic in Hong Kong

Olivia B Y Choi 蔡寶瑜，David K K Wong 王家祺，Man-kuen Cheung 張文娟

HK Pract 2021;43:21-32

Summary

Objective: To explore the level of physical activity (PA) and the barriers to exercise participation among the older adults attending a university primary care clinic in Hong Kong.
Design: Cross-sectional questionnaire survey
Subjects: Patients aged 60 or above attending a university primary care clinic in Hong Kong
Main outcome measures: Level of PA as measured by the validated short version of International Physical Activity Questionnaire (IPAQ), self-perceived internal and external barriers to PA
Results: Overall, 20% (47/235) of respondents had low level of PA. The three most common internal barriers to PA were found to be: “too tired” (59%, 139/235), “too lazy” (52%, 122/235), and “medical problem” (47%, 111/235). The most common external barriers were: “bad weather” (49%, 116/235), “lack of time” (37%, 87/235), and “no one to exercise with” (28%, 65/235)
Conclusions: The study has identified the most common barriers to exercise participation among the older adults attending a university primary care clinic. Healthcare providers can address these barriers and develop strategies for the implementation of exercise programmes in coming years.

Keywords: exercise barriers, physical activity, older adults, Hong Kong

摘要

目 標 : 探討在香港某所大學基層醫療診所就醫的老年患者 的身體活動(PA)情況和妨礙他們參加身體鍛煉的因素。 設計：橫斷面問卷調查
設計 ： 橫斷面問卷調查
對象 ： 在香港某所大學基層醫療診所就醫的60歲及以上 患者。
主要測量內容： 以經驗證的簡版《國際身體活動問卷》 (IPAQ)評估身體活動水準以及自我認為的妨礙鍛煉的 內、外部因素。
結果 ： 總體而言，20%(47/235)的應答者身體活動 水準較低。妨礙鍛煉的三個最常見內部因素為“太 累”(59%，139/235)、“太懶”(52%，122/235)、“醫療 問題”(47%，111/235)；三個最常見外部因素為“天氣不 好”(49%，116/235)、“沒時間”(37%，87/235)和“沒有 鍛煉夥伴”(28%，65/235)。
結論 ： 本研究指出了某所大學基層醫療診所妨礙老年患 者鍛煉的最常見因素，醫護人員可藉此而制定未來開展 身體鍛煉的更佳策略。

關鍵字： 妨礙鍛煉的因素、身體活動、老年人、香港

Introduction
Background

Life expectancy of Hong Kong people rank amongst the longest in the world. According to the health facts released by Department of Health in 2019¹ , the expectancy of life at birth for men and women in Hong Kong was 82.2 years and 87.6 years respectively. Because of the aging population, Hong Kong is facing more non-communicable diseases (NCD) such as heart disease, diabetes and cancer. This presents a serious public health concern. In 2018, the Department of Health and Food & the Hong Kong Health Bureau developed a strategic health framework to prevent and control NCD by 2025.² One of the targets is to reduce physical inactivity.

American College of Sports Medicine has launched a global initiative called “Exercise is Medicine”. The aim of this is to make both physical activity assessment and exercise promotion the standard of clinical care. Primary care physicians are encouraged to work with their patients to incorporate exercise into their lifestyles. In The University of Hong Kong (HKU), the University Health Service (UHS) and the Centre of Sports (CSE) have collaborated to support this initiative. In order to have successful implementation of this initiative, full understanding of the exercise barriers in our elderly population is crucial in order to modify their exercise behaviour. Although many studies have explored the barriers to PA, there are limited local studies on older adults in the Hong Kong primary care setting. Therefore, more local research in this field is warranted.

Objecttive

Our study aims to (1) assess the amount and intensity of physical activity of the older adults who attend a certain university primary care clinic; (2) identify the internal and external barriers that may hinder their participation in exercise.

Methods

Study design

This study was a cross-sectional, anonymous, helper-assisted questionnaire survey. UHS attendees who were Cantonese speaking and aged 60 or above were invited to participate in this study during the data collection period from November 2019 to January 2020.

The following groups of patients were excluded from the study: (1) those who declined to take part or would not give consent to the study; (2) those who could not understand Cantonese; (3) those who were cognitively impaired (as documented in their case notes); and (4) those who had completed the questionnaires before.

The questionnaires would be distributed by healthcare assistants or registered nurses to suitable candidates before their consultations. The patients would be asked to complete the questionnaire with the assistance of a helper at the clinic. Two retired registered nurses were recruited as voluntary helpers for this study. They were required to attend a briefing session before the start of the study in order to ensure that they had (1) clear understanding of the definition of moderate and vigorous activities; (2) full understanding of the questions; and (3) complete understanding of the data collection procedure.

Close supervision and support were provided by the principal investigator during the data collection period. The completed questionnaires were collected by the voluntary helpers and subsequently handed over to the principal investigator for analysis. The completion of the survey took approximately 10 minutes.

Study population and sampling

The participating clinic serves university students, staff, dependants and retirees. The study population was Cantonese-speaking clinic attendees aged 60 or above. There is no general agreement on the definition of “older adults” as aging is a dynamic process, and often the definition is linked to the retirement age. The cutoff of age 60 was chosen as it is the normal retirement age of university staff. The clinic population of those aged 60 or above is approximately 4715. For sample size estimation, the formula for cross-sectional studies was used, where sample size (SS) = Np(1-p)]/ [(d² / Z² 1-α/2*(N-1)+p*(1-p)] [9]. Given a population size (N) of 4715, a hypothesised proportion (p) of 0.2, and a margin of error (d) of 0.05, the sample size required was 234 with 95% confidence level.

Survey instrument

The short version of International Physical Activity Questionnaire (IPAQ) was used to assess the level of PA in the last 7 days. The validity and reliability of the IPAQ had been tested in 12 countries among adults aged 18 – 65¹⁰, as well as in Hong Kong.¹¹ Further studies^12-13 evaluated the validity and reliability of IPAQ used in the elderly, and it was concluded that the short version of IPAQ was a useful and valid tool for assessing PA among elderly adults.

The IPAQ used in our study was the short Chinese version (IPAQ-C) originally translated by Macfarlane et al¹¹ according to the procedures recommended by the International Consensus Group for the Development of the IPAQ and with cultural adaptations made. It involved translation and back translation from the original English version. The IPAQ-C was shown to be valid and reliable for assessment in older Chinese adults.¹⁴

The barriers to exercise were assessed with a list of items developed after review of previous studies, including the focus group discussion by Larkin et al. in 2005¹⁵, a Hong Kong study by Chou et al in 2008¹⁶ and a study by Justine et al. in 2013.¹⁷ The final questionnaire consisted of 18 questions that gave a comprehensive cover of the perceived exercise barriers in older adults. The barriers could be broadly divided into internal and external. External barriers were those one might not be able to control, and internal barriers were those which could be determined by one’s own decisions.^17-18 Participants were asked to rate the barriers on a 4-point Likert scale (1 = Not at all, 2 = Rarely, 3 = Occasionally, 4 = Always)

The content validity of each question was rated on a 4-point Likert scale (not relevant, somewhat relevant, quite relevant, and highly relevant). Based on the proportion of experts who rated a question as quite or highly relevant, the item-level content validity index (CVI) was computed.¹⁹ The item-level CVIs of all the questions were rated 1.00, thus the scale-level CVI computed was also 1.00. Some wordings of the questions were changed after review in order to make it more reader-friendly. Pilot testing was performed in 20 patients from different backgrounds before the questionnaire was finalised.

Statistical analysis

Data was analysed using the open source software “R” for statistical computing version 3.4.4 (2018- 03-15).²⁰ Frequency tables were computed to check for range and completeness. Descriptive statistics were computed to summarise and express the data in percentages, with calculated means and standard deviations where applicable.

A multiple logistic regression analysis explored the demographic predictors to low level of physical activity. Mann-Whitney U-test was used to compare the mean Likert score on the barriers between those with low level of PA and those with adequate level of PA. Mann-Whitney U-test is preferred over t-test because the variables in the two groups were not normally distributed. Statistical significance was established at P < .05 for all tests.

Ethical consideration

This was an anonymous study. Participation was voluntary and involved minimal risk. Those who agreed to participate were deemed to have given consent for their data to be used for research purposes. Refusal to participate would not incur any negative consequences and would have no impact on their medical care. Approval from the Human Research Ethics Committee of The University of Hong Kong was received before commencement of data collection (Reference: EA 1910031).

Result

A total of 252 questionnaires were distributed and 240 were returned, which yielded a response rate of 95.2%. Among the returned questionnaires, five were excluded from analysis due to grossly incomplete data (e.g. missing most demographic data or a whole section of the questionnaire). A total of 235 completed questionnaires were used for final analysis. This represented about 5% of the clinic population of those aged 60 and above (N=4715).

Socio-demographics

The characteristics of the respondents were shown in Table 1. 53.2% (125/235) of the respondents were female and 46.8% (110/235) were male. Approximately half of the respondents were in the age group 60-64 (48.1%, 113/235). This survey was taken in a university clinic setting. The respondents spanned all education levels but about half of them completed tertiary or even higher education (53.6%, 126/235). Majority of the respondents were retirees (63.8%, 150/235). Although 77% (181/235) suffered from chronic medical conditions requiring regular follow-up or treatment, more than half of the respondents rated their own health as good, very good or excellent (62.1%, 146/235), and only 3.4% (8/235) rated their health as poor.

Level of physical activity

The respondents’ level of PA was assessed using the short version of IPAQ. According to the IPAQ scoring protocol ²¹, the total metabolic equivalent (MET) score of each participant was calculated and the participants were then categorised into three groups according to their level of PA. The criteria of moderate and high level of PA required total activity of at least 600 and 3000 MET-minutes/week respectively. Anyone with a total activity below 600 MET-minutes/week was categorised as low level.

Table 2shows the types and level of PA of our study population. 20% (47/235) of the respondents had low level of PA. 64.7% (152/235) had moderate level of PA and 15.3% (36/235) had high level of PA. Walking was the most common form of activity in all groups. The percentage of contribution by walking in the low, moderate and high-level activity groups were 81.3%, 65.2% and 57.6% respectively.

Demographic predictors of low level of physical activity

Multiple logistic regression analysis (Table 3) was computed to explore the impact of various demographic data on the respondents’ level of PA. PA level below 600 METS/min per week was used as the target variable. After adjusting for other covariates, overall the demographic variables were not very strong predictors of low-level exercisers. They had minimal impact on the level of PA except for age group 70-74 which showed a significant P value of .034.

Barriers to exercise

Figure 1shows the ranking of the internal barriers to exercise participation among the respondents. The three most common internal barriers to exercise are “too tired” (59%), “too lazy” (52%), and “health problem” (47%). And the three most common external barriers are shown inFigure 2. They are “bad weather” (49%), “lack of time” (37%), and “no one to exercise with” (28%). Among all the barriers, the least likely ones are “feeling shy” (8%), “cost” (12%), “interfere with work” (13%), and “lack of transportation” (19%).

Comparison of impact of barriers between those with low and adequate level of PA

According to the IPAQ scoring protocol²¹, anyone with a total activity below 600 MET-minutes/week was categorised as low level of PA. Table 4 shows the result of the Mann-Whitney U-test comparing the mean Likert score on the barriers between those with low level of PA and those with adequate level of PA. Significant differences were found for the following barriers with P value < .05, which means that they are the important barriers to the low-level exercisers: (1) poor physical conditioning; (2) no motivation; (3) exercise is boring; (4) fear of injury; (5) causes too much pain; and (6) no one to exercise with.

Discussion

Principal findings

About 20% of the respondents were found to be underactive, defined as less than 600 MET-min/ week. This result is similar to the report published by the Hong Kong Department of Health in 2015.⁸ Among all the activities, it is worth noting that walking was found to be the most common physical activity and it contributed to about 63% of the total METS in our study population. This was also observed in the Deng et al.’s study¹⁴, in which the METS contributed by walking was around 75%. Walking is a common form of activity because it is simple and easily accessible. A Japanese Study²² on elderly men without critical illness found that walking for 2 or more hours per day could lower the all-cause mortality. Thus, walking should be promoted in the underactive elderly adults because it can easily be fitted into their daily routine. In addition, walking has a lower rate of injury.²³ However, multi-parameter exercise programme should also be considered, including muscle strengthening and balance exercise as advised by the World Health Organisation.24 studies showed that multi-component exercise intervention could improve the balance and mobility25; and help to prevent falls in older adults.^26-27

Our study also illustrated the most common internal and external exercise barriers.

The most common internal barriers were “too tired”, “too lazy”, and “medical problem”. In Justine et al’s study¹⁷, 51.7% respondents also considered “too tired” as an important barrier to participation in exercise among older adults. Therefore, the exercise programme introduced to older adults should be individualised. Introductory short sessions can be considered to avoid exhaustion of the participants and the intensity and duration of the exercise programme can be adjusted accordingly.

Feeling too tired or being too lazy may also reflect a lack of motivation, which is a significant determinant of exercise participation²⁸ and exercise adherence. ²⁹ Lack of motivation was considered as a barrier in 37% of our respondents. Motivation can certainly affect behaviour. The question is how we can motivate people to exercise. One study showed that participation in sports during adolescent was associated with a higher level of physical activity in later adulthood.30 Therefore, exercise programme should be promoted early in life.

Larkin et al¹⁵ performed a qualitative study on 86 adults aged 65 or above using in-depth interview to identify their perceived barriers to exercise. They found that the most prevalent perceived barrier to exercise among the respondents was "medical problem" (38%). Our study had similar findings. As it is common for those with chronic illness to believe that exercise may do more harm than good, effective management of their medical problems is essential. In addition to this, primary care physicians should also give clear and proper guidance on exercise programmes. The exercise prescription should be tailor-made for the individual and it should include the type, frequency, duration and intensity.³¹ This is particularly important for low-level exercisers. As shown in our study, these patients had more fears of injury and more doubts in their ability to undertake physical activity.

Among the external barriers, “bad weather”, “lack of time”, “no one to exercise with” were found to be significant barriers in our study. Studies other than ours had shown that “lack of facilities” was a significant external barrier^16-17 but not in ours. This could be related to the easy access to sports facilities at our University for staff and retirees. The free access introduced in 2018 has further encouraged more staff and retirees to participate in exercise and has made “cost” less of a concern. In fact, cost was found to be one of the least common barriers in our study.

In Chou et al’s study¹⁶, 38% of Chinese respondents agreed or strongly agreed that “too hot” or “too cold” was a barrier to do exercise. In our study, 49% of the respondents believed that weather was a barrier to exercise. Thus, indoor or home exercises programme should be promoted among the older adults so that their participation will be less likely to be affected by adverse weather.

“Lack of time” was another major barrier found in our study. This is consistent with previous research.^16-17 Some studies found that small bouts of exercise can be beneficial³² and improve adherence.³³ This can be an alternative for those who believe that they have little time for exercise.

“Lack of transportation” was not found to be a crucial barrier in our study. It makes sense as Hong Kong has a highly sophisticated transport network, and this makes most of the sporting facilities easily accessible. In addition, our study showed that the most common exercise was walking which can be performed anywhere.

By comparing between those with low level of PA and those with adequate PA, we found that certain exercise barriers had more significant impacts on the low-level exercisers. In order to overcome the barrier “no one to exercise with”, more group exercise classes can be planned. Ideally, the class should be led by an experienced fitness instructor, who can give proper advice to the participants on how to improve their fitness and how to prevent injury. That would help to attenuate the concerns of “poor physical conditioning” and “fear of injury”. Other benefits of group class include making new friends among the participants and making exercise less boring. Peer support may also improve the motivation and adherence to the exercise programme. In relation to the concern of “causing too much pain”, apart from proper advice on warm up and cool down, healthcare providers can explain to the participants that the pain is only temporary and the long-term benefits of exercise outweigh the pain.

Relevance to clinical setting

At HKU, the UHS has collaborated with the CSE to support the initiative “Exercise is Medicine”. In order for the implementation to be successful, our doctors and our sport coaches should acknowledge the concerns of the older adults and ensure that the prescriptions are practical and achievable. There is no one-size-fitsall approach, especially in those with chronic medical conditions. With the information obtained from this study, we can develop better strategies in exercise promotion among the older adults. The programmes organised should be accessible, inexpensive and enjoyable, e.g. easy trail walks. Proper guidance is essential and small bouts of exercise can be considered. If the above pilot programme is successful, it can then be extended to the community

Strengths and limitations

Although many overseas studies were performed to explore the barriers to PA or exercise, there are not many local studies involving older Chinese adults in Hong Kong, especially in the primary care setting. A high response rate of 95% was achieved in our study. Retired nurses were recruited to assist the completion of the questionnaires and supervision was also given to them in order to obtain high quality data.

As the study was taken in a university clinic, the data is skewed towards more educated and affluent patients, therefore the study’s external validity is reduced. As the physical activity level was self-reported, reporting bias was possible. More accurate level of PA can be obtained if pedometer or accelerometer are used for assessment of PA but it would require more resources. Our study only explored the exercise barriers, nevertheless it is also important to explore the motivators as they can be inter-related. Exercise behaviour can be affected by both. Therefore, further study such as a focus group discussion can be considered to explore the motivators of exercise.

Conclusion

Despite awareness of the various documented health benefits, some older adults still do not have adequate PA. This study highlighted the most common barriers which may hinder their participation in exercise. In the university setting, by acknowledging the above, the UHS can work with the CSE to develop better exercise programmes for their elderly staff and retirees. Physical activity assessment and exercise promotion should be part of the standard of primary care. In the community setting, the same practice should be applied but that will require collaboration between the government, nongovernment organisations, medical and non-medical professionals. More resources should be allocated to develop appropriate exercise programmes to promote healthy aging. These will benefit the general population in the long run and hence lessen the medical burden to the society.

Acknowledgement

We would like to thank Mr. Tommy Lai for his assistance in statistical analyses, and all the clinic staff for their assistance during the research period.