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Development of a physical literacy model for older adults – a consensus process by the collaborative… Jones, Gareth R; Stathokostas, Liza; Young, Bradley W; Wister, Andrew V; Chau, Shirley; Clark, Patricia; Duggan, Mary; Mitchell, Drew; Nordland, Peter Jan 16, 2018

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RESEARCH ARTICLE Open AccessDevelopment of a physical literacy modelfor older adults – a consensus process bythe collaborative working group onphysical literacy for older CanadiansGareth R. Jones1*, Liza Stathokostas2, Bradley W. Young3, Andrew V. Wister4, Shirley Chau5, Patricia Clark6,Mary Duggan7, Drew Mitchell8 and Peter Nordland9AbstractBackground: Arguably the uptake and usability of the physical activity (PA) guidelines for older adults has notbeen effective with only 12% of this population meeting the minimum guidelines to maintain health. Healthpromoters must consider innovative ways to increase PA adoption and long-term sustainability. Physicalliteracy (PL) is emerging as a promising strategy to increase lifelong PA participation in younger age-groups,yet there is relatively little evidence of PL being used to support older adults in achieving the PA guidelines.Methods: An iterative and mixed-methods consensus development process was utilized over a series of sixinformed processes and meetings to develop a model of physical literacy for adults aged 65 years and older.Results: A multi-disciplinary collaborative working group (n = 9) from diverse practice settings across Canada,and representative and reflective of the full range of key elements of PL, was assembled. Three consensusmeetings and two Delphi surveys, using an international cohort of 65 expert researchers, practitioners, non-governmentorganizations and older adults, was conducted. 45% responded on the first round and consensus was achieved;however, we elected to run a second survey to support our results. With 79% response rate, there was consensusto support the new PL model for older adults.Conclusion: Older adults are a unique group who have yet to be exposed to PL as a means to promote long-term PAparticipation. This new PL model uses an ecological approach to integrate PL into the lifestyles of most older adults.Understanding the interactions between components and elements that facilitate PL will ultimately provide a new andeffective tool to target PA promotion and adherence for all older Canadians.Keywords: Physical activity, Aging, Physical literacy, Mixed-methods, Delphi surveyBackgroundThere currently exists a physical inactivity crisis amongolder adults who are the most inactive segment of theCanadian population [1]. Although the health benefits ofphysical activity (PA) for an aging population are wellestablished [2–4], the majority of older adults do notaccumulate enough PA to receive some level ofprotection from chronic disease and disability [5]. In noother age-segment of the population is the role of PA forpromotion of health and physical independence moreapplicable and crucial than for older adults. The firstwave of the Baby Boomer cohort reached 65 years of agein 2011, and coupled with increasing life expectancy,one in four Canadians will be an older adult over thenext 20 years. This population wave of older adults isalready being experienced throughout most Europeancountries; where PA levels vary depending upon factorssuch as income and the availability of formalized socialsupport networks [6]. Physical activity guidelines have* Correspondence: gareth.jones@ubc.ca1School of Health and Exercise Sciences, Faculty of Health and SocialDevelopment, University of British Columbia Okanagan Campus, Kelowna, BCV1V 1V7, CanadaFull list of author information is available at the end of the article© The Author(s). 2018 Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, andreproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link tothe Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver(http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.Jones et al. BMC Geriatrics  (2018) 18:13 DOI 10.1186/s12877-017-0687-xbeen developed to provide older adults with valuable in-formation on what they must do in order to maintainand/or improve health. However, the uptake and usabilityof these guidelines, globally, have not yet to any large de-gree been effective in increasing PA participation by olderadults, which should be of concern to health promotionspecialists [7]. Therefore, addressing a change in PA levelsis critical if policy makers and health promoters are goingto effectively influence the PA behaviours of older Cana-dians and older adults across the globe.The promotion of physical literacy (PL) is emerging asa promising strategy to increase lifelong PA participationin younger age-groups of the population [8]; however,there is relatively little evidence of PL being used to sup-port older adults in achieving the PA guidelines. Physicalliteracy is defined as “the motivation, confidence, physicalcompetence, knowledge and understanding to value andtake responsibility for engagement in physical activitiesfor life” [8]. Physical literacy is highlighted as the basis ofthe Canadian Sport for Life Long-term Athlete Develop-ment Model [9] which seeks to increase the involvementand enjoyment of sport for all Canadians. In the olderadult population, the ability and confidence of an indi-vidual to participate in various physical activities is astrong predictor of life-long participation in healthy sus-taining PA opportunities [10, 11]. This is of great im-portance as recent national surveys suggest that only12% of older Canadians (60–79 years) actually achieveminimum levels of PA required to maintain health [12].Increased participation in PA and the subsequent main-tenance of physiological function can help to alleviatenegative attitudes towards the aging process [13, 14]. Inaddition, having PA opportunities that match the olderadult’s physiological capacity will also help to reduceself-reported barriers to PA participation [12]. Thesecomponents are already included within existing PLmodels; developed for athlete development and for chil-dren and youth only [9, 15]. Thus, we proposed that aPL model be developed and used for older adults to sus-tain lifelong PA participation and as a strategy for PAadvocates, promoters and facilitators to support PAguidelines. Physical literacy could be the elusive factorthat will make a successful and sustained increase in PAparticipation by older adults [16].The literature is most established in describing PL inchildren and youth. However, these models of PL forchildren and youth and the Canadian long-term athletedevelopment model may not be appropriate when ap-plied to older adult populations [17], as they are rootedin development of PL from childhood and do not con-sider topics of retention, loss and re-tuning of skills atlife stages by which individuals negotiate age-associatedphysiological decline. The current Canadian long-termathlete development model highlights the importance ofPA skill development and the use of these skills withinvarious environments. Within an inactive older adultpopulation, the primary interest may not be kicking orthrowing skills, but rather the re-training of functionalskills that will assist in maintaining physical independ-ence and preventing frailty [18]. There is a dearth ofresearch that has explored PL in older adults. A searchof pertinent literature databases by our librarian usingthe relevant keywords ‘physical literacy’ and ‘aging’,yielded no evidence-based citations that directly describethe concept of PL in the older adult population. Conse-quently, there currently does not exist an approach toframe PL for older adults.There have been parallel developments in the area ofhealth literacy, defined as “the degree to which individ-uals have the capacity to obtain, process, and understandbasic health information and services needed to makeappropriate health decisions” [19]. Applied to olderadults, lifelong educational and learning practices (self-study, computer/Internet and print resources, etc.) havebeen modelled as important enablers for positive healthbehaviours [20]. Such pedagogical development empha-sizes the importance of generic health literacy resourcesand highlights the methods used by older adults toaccess and learn positive health behaviours that fosteroptimal aging. Similarly, a PL model extends this healthliteracy work by uniquely specifying evidence-based PAbehaviours and practices for all older adults across thelatter stages of their life course.The purpose of this manuscript is to describe theprocess used to develop a model of PL in the context ofthe older adult population. Ideally, the model will repre-sent specific identified components that support PL inthe older adult because the role of PL in later life PAparticipation is currently unknown. Due to low PAlevels, attitudinal, societal, cultural, gender, and environ-mental factors, it is hypothesized that the current olderadult population likely possess little knowledge of orengagement with PL; contributing to their lack of PAparticipation. Thus, the specific objectives of this projectare to: (1) Assemble a collaborative working group of re-searchers and stakeholders whose expertise and reachcover a broad perspective of PA and aging; and (2) De-velop an evidence-based model of PL for older adults.The aim of this project is to develop a framework thatpromisingly captures integral aspects of PL that validlyorganizes and presents key facts in a manner that can beused to guide informational approaches that promote PLwith respect to knowledge exchange among older adults,knowledge use by practitioners, and knowledge creationby researchers. With this aim of moving towards a sem-inal model, we anticipate that a refined model could, inthe long run, be employed in efforts to increase aware-ness and provide education in the area of PL. As such,Jones et al. BMC Geriatrics  (2018) 18:13 Page 2 of 16this model would eventually become a meaningful re-source for increasing PA to appropriate levels and redu-cing the sedentary behaviours of older Canadians andeventually older adults across the globe.MethodsA collaborative working group (CWG) of expert re-searchers and knowledge users (2 were older adults 65+years) were identified and assembled to undertake thisinitiative. This CWG was a multi-disciplinary team fromdiverse practice settings across Canada and representa-tive and reflective of the full range of key elements of PLincluding affective, physical, cognitive and behaviouralfactors as outlined in the 2015 Canada’s Physical LiteracyConsensus Statement. Specifically, the CWG consistedof individuals with expertise in; exercise physiology andaging (GJ, LS), psychosocial and socio-cultural aspects ofexercise and aging (SC, AW, BY), professional develop-ment and promotion in the area of exercise (MD andGJ), sport pedagogy and older sportsmanship (BY),knowledge translation in the area of active aging (PC,GJ, and LS), older adult sport organization (PN),physical literacy (DM), and gerontology and policy(AW). All members of the CWG were involved in eachstep of the consensus development process. The numberof CWG members (n = 9) was based on 9-memberRAND panels [21]; large enough to permit diversity ofrepresentation while still small enough to allow everyoneto be involved in the group discussion.An iterative and mixed-methods consensus develop-ment process was utilized (Fig. 1), over a series of sixinformed processes and meetings. This method was usedto collate and consider the best available evidence usingthe collective judgement of these experts to yield a con-sensus for the purpose of developing the model. Thisstudy received ethical approval from the University ofBritish Columbia’s Behavioral Research Ethics Board[Ref# H17–00884] and was in compliance with theHelsinki Declaration. All interview participants gaveconsent to participate in the survey via email response.Pre-planningIn advance of our preliminary meetings, a systematic re-view of the literature was completed to identify, appraise,Fig. 1 Consensus Development ProcessJones et al. BMC Geriatrics  (2018) 18:13 Page 3 of 16and synthesize studies related to PL literature related toolder adults [21]. The results of this review revealed thatthere was a plethora of research available for youngerpopulations, but very limited, if any, research was avail-able on PL in older adults. Development of a PL modelfor older adults would assist health promotion experts inincreasing PA toward evidence-based recommendedlevels [2, 4].Pre-planning for the initial formal meeting was con-ducted in a teleconference format, organized by theworking-group leads (GJ and LS). The review of the lit-erature suggested that a PL model for older adults didnot exist and therefore the group was introduced tocurrent definitions and other models of PL for childrenand youth [15, 22]. Discussion focusing on whetherthese were relevant and appropriate for the older adultpopulation ensued (topic assessment). The CWG agreedthat the conceptualization of a potential model in rela-tion to older adult age range was warranted, and there-fore pre-planning proceeded with the discussion of topicrefinement. The CWG adopted the operational defin-ition of older adults to include men and women, aged65 years and older, living independently in the commu-nity. The CWG acknowledged the diversity of the olderadult population and indicated that future refinement ofa PL model would need to be inclusive of sex, gender,ethnicity and socioeconomic status. The CWG alsoproposed that the model would comprise a frameworkto better understand the competencies/modalities to as-sist this population to meet the current PA guidelinesfor older adults. To that end, the CWG agreed to usethe current Sport for Life PL model [23] as a guide.However, because of issues of entry points, baseline PLlevels, and potential re-entry points (varying across thelife course), the CWG decided to use the InternationalPhysical Literacy Association’s definition of PL; “the mo-tivation, confidence, physical competence, knowledge andunderstanding to value and take responsibility for en-gagement in physical activities for life” [8]. The CWGleads were tasked with developing a preliminary frame-work to act as a starting point for meeting one.Meeting oneMeeting one was conducted using a teleconference for-mat. The CWG leads presented a preliminary frameworkof PL in older adults that was distributed ahead of themeeting (Fig. 2a). The preliminary framework attemptedto encapsulate the characteristics central to PL, sup-ported by factors that influence these characterisiticswithin the context of older adults and the CWG’s expertopinion. The components essentially represented an in-dication matrix related to PL for older adults. Using anominal group technique, each of the components wasdiscussed as to their relevance, importance, andFig. 2 Evolution of the Physical Literacy Model for Older AdultsJones et al. BMC Geriatrics  (2018) 18:13 Page 4 of 16influence on PL by the expert CWG. Overall, the discus-sion of the components emerged to be heavily framedwithin a broader definition of PL, ultimately leading to aconsensus that, moving forward, the model would beanchored by componenets at the individual level (repre-senting a core set of physical skills and physiological andpsychological capacities) and would further evolve intoan ecological model, which considered various otherbroader aspects of the surrounding social and physicalenvironment, and constituent organizations (programsand services) that come to bear on older adults and howthey might optimize their PA participation.In order to populate this preliminary list of indica-tions, the CWG was tasked with providing extendedfeedback following meeting one. Specifically, each CWGmember was asked to provide, via email, individualjudgements on components (socio-cultural expectations,environment, physiological reserve capacity/fitness) andrelated influencing factors (tuning and/or retuning func-tional movement skills, knowledge and awareness,accessible opportunities, willingness to adapt, positiveself-esteem and self-confidence). In addition, feedbackwas requested with respect to the context of compo-nents, how each component might be assessed, and howeach might be maximized to induce changes in PAlevels. Feedback was summarized by the CWG leads andincorporated in the next draft of the model, discussed atMeeting two. Literature searches to confirm evidence-basis and best-practices for included components andinfluencing factors (as they relate to the older adultpopulation) were conducted [24].Meeting twoMeeting two was conducted via teleconference. The CWGleads presented a refined framework on PL in older adults,distributed in advance of the meeting (Fig. 2b).Refinement of the framework resulted in an expansionand restructuring of the model to reflect a socio-ecological framework. Thereafter, there were three stepsto further refine the model: 1) An assessment ofCanada’s Physical Literacy Consensus Statement; and 2)Consensus that the four elements outlined in Canada’sPhysical Literacy Consensus Statement translate to anolder population; and 3) Specifying the statement to theolder adult. As such, each component of our emergingmodel was harmonized with identified elements fromCanada’s Physical Literacy Consensus Statement. TheCWG acknowledged that the four elements outlinedwithin the statement would support older adults, at leastat the individual level, on how to succeed with lifelongPL and were described as:1) Knowledge and understanding about successfulaging, including what physical, psychological andsocial determinants influence well-being and whatpast experiences might help support or impede PL;2) Physical competence and capacity, acknowledgesthat older adult maintain physical capacity (fitness)in order to be able to engage in PA and sport. Olderadults can be educated on the consequences ofage-associated physiological decline and how thatimpacts PL;3) Motivation and confidence will foster resilience toage-related decline and the accumulation of comor-bidity throughout the aging process (allowing olderadults to adapt); and4) Responsibility and understanding of current PAbehaviours (i.e. steps per day, min/week, andreducing sedentary behaviours) so that anappropriate dose of PA may be achieved thatpromotes health, fitness and disease prevention.Individual panel members were provided an opportun-ity to make full and equal contribution through a post-meeting quasi-anonymous online consensus survey. Thesurvey was quasi-anonymous because, although theCWG were aware that all members were participating;the online responses had no identification tags, makingthe responses quasi- anonymous. In addition, the CWGcompleted a knowledge resource nomination worksheet,which assembled and categorized additional contentexperts and stakeholders in the broader field of PL (e.g.coaches, physical educators, etc.). The CWG leads sum-marized the results of the panel consensus survey andintegrated them into the model (Fig. 2c) that would beused within our Delphi survey.Delphi surveyIn order to increase the rigor and confidence of thedeveloped framework and to obtain broader consen-sus, a Delphi survey was conducted. As McKenna[25] has noted, the Delphi technique is most usefulwhen the research objective is to correlate informedjudgements on a topic spanning a wide range of dis-ciplines, as is the case in this initiative. The Delphitechnique involved an iterative, multistage process bywhich multiple rounds of questionnaire data collec-tion were conducted (Fig. 3). A web-based surveyserved as the mechanism for administering the ques-tionnaires. To reach consensus, agreement was re-quired by 75% of responders. This level of agreementdetermined the number of rounds used to administerthe questionnaire. Significant consensus was achievedin round one for each of the elements of our PLmodel (i.e. percentage responding either somewhatagree, agree or strongly agree); however, an additionalround with modifications was circulated to garnerJones et al. BMC Geriatrics  (2018) 18:13 Page 5 of 16consensus related to editorial modifications to themodel. These modifications were approved during apost-survey teleconference meeting with the CWG.Post-survey teleconference meetingThe CWG conducted a teleconference meeting to dis-cuss the first round of the Delphi survey. Group mem-bers provided feedback on the ratings, focusing on areasof disagreement or suggestions provided. A revisedmodel was distributed to the 29 respondents who com-pleted the first round. Again, Delphi survey expert par-ticipants reached significant consensus that theproposed model was representative of the concept of PLfor an older adult population. Feedback from round twowas distributed to the CWG, via email, ahead of Meetingthree.Meeting threeMeeting three was conducted in-person in Toronto, On-tario in September 2016, with seven out of the 9 CWGmembers participating and the remaining providingfeedback via email. Meeting three began with a review ofthe process to date. Then a review and discussion offeedback from participants of the Delphi survey secondround was conducted and consensus was reached onedits to the PL model by the Delphi process. Followingthis, an interactive discussion and editing of the modeltook place, with the goal of finalizing the model outline,components and content.ResultsDelphi surveyThe Delphi survey was sent out to 65 international ex-perts in PA and aging. This included researchers,Fig. 3 Delphi Survey ProcessJones et al. BMC Geriatrics  (2018) 18:13 Page 6 of 16practitioners, non-governmental organizations and olderadults engaged in physical activity promotion. Twenty-nine (45%) completed the survey, three were older adults(65+ years) (Table 1). The distribution of all the Delphiparticipants’ first round ratings are presented in Table 2.Twenty-three (79%) out of the original 29 respondentscompleted the second round of the Delphi survey. Ofthose, 17 provided their names to be included in thepresent manuscript. Results of the second round Delphisurvey are presented in Table 3.Proposed physical literacy model for older adultsThe final proposed PL model (Fig. 4) is structured with thedefining characteristics of core PL competencies (individ-ual/intrapersonal elements) at its core, with an additionalfour domains (interpersonal, organizational, community,and policy) that may influence both PA participation andthe quality of the PA experience. Each domain provides anexample of how PL may be utilized to promote lifelong PAin older adults. In particular, the core competencies of PLat the intrapersonal level may be realized to varyingdegrees, optimized or constrained, depending on condi-tions in the surrounding domains of this ecological model.Descriptions are provided for each domain to demonstratethe various facts and interactive components that need tobe considered in light of PL and the promotion of lifelongPA in older adults.DiscussionIntrapersonalThe individual older adult is at the centre of the PLmodel. Intrapersonal elements include personal factorsreflecting the four elements of the definition of PL, eachof which may increase or decrease the likelihood of anolder adult becoming or remaining physically active.Strategies that bring change at the individual level focuson an individual’s motivation and confidence, physicalcompetence, knowledge and understanding, and assist inengagement in PA participation as an integral part ofone’s lifestyle.Motivation to be physically active in the older adultpopulation can vary from younger populations; primarilyinfluenced by health concerns and anticipated benefits[26–28]. For example, as people age, motives that indi-cate pragmatic or instrumental concerns, seem to over-ride ones that might be more personally uplifting. Thishas previously been reported by Trujillo et al. [29] whodemonstrated that, as opposed to younger adults whoexhibit greater concern for interpersonal attraction out-comes, older adults exhibit greater concern for healthoutcomes. As such, health and maintaining physical andmental independence may be potent motivators for PAparticipation in older adults. Although there may begeneral age-related changes in participatory motives,Table 1 Round 1 Delphi Survey Participant CharacteristicsCharacteristic FrequencySex (26/29)Female 17Male 9Country (27/29)Australia 3Canada 16Italy 1Japan 1United Kingdom 3United States of America 3Occupation (26/29)Researcher 17Educator 2Medicine 1Non-profit Volunteer with National Organization 3Professor 1Professor and Masters Athlete Coach 1Kinesiologist 1Occupation involves working specifically with older adults (27/29)Yes 20Older adults are one sub-population 5Indirectly, research 2Number of years in this occupation (25/29)0–10 years 711–20 years 221+ years 18Area of Expertise (26/29)Exercise physiology (neuromuscular, musculoskeletal,metabolic)5Falls prevention / Injury prevention and aging 4Physical activity and aging 3Chronic conditions and aging 2Policy / advocacy 2Social theory and sport/physical activity participation 1Gerokinesiology 1Geriatrics 1Coaching 1Exercise and cognition 1Mobility and aging 1Successful Aging 1Physical culture of the aging body 1Housing, health promotion, elder abuse, disasters,gerontechnology1Responses to the specific question/responses to the questionnaireJones et al. BMC Geriatrics  (2018) 18:13 Page 7 of 16evidence suggests that motivation to engage in varioustypes of physical activities is multifaceted and draws ona wide range of reasons beyond health and fitness bene-fits, in both exercise and sport domains. For example,characterises of adaptive motivation may relate to deter-mination (fulfilling needs for autonomy, competency,and relatedness) and whether the motives are personallymeaningful and integrated to important values and be-liefs held by middle-aged and older adults [30–33].Adherence to structured exercise programs is consist-ently associated with higher exercise-related self-efficacy,that is, confidence in both performing specific exercisesand in planning to exercise [11, 34]. Further, confidenceto make and sustain feasible changes and confidence toovercome barriers, are key factors in the likelihood ofmaking lifestyle change among older adults [10]. Inaddition, as in younger populations, confidence relatedto current PA participation is shaped by past experiences[35, 36]. Therefore, it is important to gain insight intoan older adult’s past PA history; including understandingwhich PA skills they learned and the context in whichthey were learned, which skills they may be re-learning,or skills confronted for the first time. Finally, previousadverse events and perceived risks associated with PAparticipation may also impact confidence. As such, fearof falling or fear of exacerbating health conditions dur-ing physical activities are barriers that can be mitigated,for example, through improving balance confidence [37].The physical competence element of PL refers to anindividual’s ability to develop and/or re-learn importantfunctional movement skills and patterns, and the cap-acity to experience these skills through a variety ofmovement intensities and durations. Current PA modelsdescribe a pathway from birth to adulthood and there-fore may not apply to older adults who may not havedeveloped any or certain skills (base functional move-ment skills) or who have not engaged in activities usingthese skills for many years. Further, the current modelsreflect a time of growth and development during skillsacquisition and again, may not be applicable to the olderadult living with age-related physiological changes, whomay be more focused on retention rather than regainingpast skills or learning new ones. Therefore, an importantquestion toward increasing the physical competenceTable 2 Round 1 DelphiQuestion Posed StronglyAgreeSomewhatAgreeAgree Neutral Disagree SomewhatDisagreeStronglyDisagreeCannotAdequatelyRespondQ1. An appropriate way to frame the intrapersonal or‘individual’ level factors associated with physical activityliteracy in older adults is via the ‘elements’ of physicalliteracy: motivation and confidence; physicalcompetence; knowledge and understandings; andengagement in physical activities for life. (28/29)11 (39%) 5 (18%) 7 (25%) 2 (7%) 1 (4%) 1 (4%) 1 (4%) 0Q2. The “Interpersonal” level factors of the model areappropriately described by family, friend, caregiver,and health care provider influences. (27/29)12 (44%) 7 (26%) 5 (19%) 0 2 (7%) 1 (4%) 0 0Q3. ‘Organizational’ level factors are appropriately describedby program-based factors that offer personallymeaningful, culturally relevant, and accessible physicalactivity opportunities. (26/29)10 (39%) 6 (23%) 8 (31%) 0 2 (8%) 0 0 0Q4. It is appropriate to frame ‘Community’ levels factors inthe context in which the physical activity takes place.This includes the social, built, and natural environments.(27/29)17 (63%) 3 (11%) 6 (22%) 0 1 (4%) 0 0 0Q5. At the ‘Policy’ level, it is appropriate to include physicalactivity literacy, physical activity or healthy agingpromotion initiatives across various levels ofgovernment. (27/29)14 (52%) 4 (15%) 7 (26%) 1 (4%) 1 (4%) 0 0 0Q6. The International Physical Literacy Association’sdefinition of physical literacy (below) is appropriatefor the older adult age range. “Physical literacy is themotivation, confidence, physical competence,knowledge and understanding to value and takeresponsibility for engagement in physical activitiesfor life.” – International Physical Literacy Association,May, 2014. (27/29)9 (33%) 6 (22%) 6 (22%) 2 (7%) 3 (11%) 0 1 (4%) 0Q7. Overall, the proposed model is an appropriate way tovisualize physical activity literacy in older adults. (27/29)10 (37%) 7 (26%) 8 (30%) 0 2 (7%) 0 0 0Responses to the specific question/responses to the questionnaireJones et al. BMC Geriatrics  (2018) 18:13 Page 8 of 16element of PL in older adults includes what changes tothe nervous system, motor systems, and motor skilllearning will influence ability to engage in acquiredmovement skills and/or to learn new movements, in lightof primary age-related changes of physiological systems?Age-related declines in physical fitness and perform-ance are such that physical limitations may impinge onfunctional activities of daily living [2], resulting in higherrates of disability [38], and are associated with all-causemortality and premature death [39]. It is not surprisingthat mobility troubles, fear of falling, and health condi-tions are reported barriers to PA participation amongCanadian older adults [40]. Given the episodic nature ofmany chronic conditions, there may be more treatablemoments or thresholds at which time perceived barriersare more, or less, debilitating than at other times. Ap-propriate exercise training can minimize declines andmaximize physical competence, thus mitigating the ratesat which older adults cross thresholds of functionalinability. In addition, increased participation and compe-tence in PA can reduce negative attitudes towards theaging process [12–14]. This is analogous to applicationsof the concept of resilience to coping with illness amongolder adults, broadly defined as a dynamic adaptiveprocess through which individual traits, characteristicsof their environment, and their internal and external re-sources, and physical capacity, are utilized in the face ofadversity [41]. Older adults are capable of resilience toadverse health events despite socioeconomic backgrounds,personal experiences, and declining health. Research sug-gests that strong mental, social, and physical characteristicsare associated with better resilience among older adults[42]. Physical activity and social engagement often associ-ated with functional resilience are considered fundamentalin coping with chronic disease and multimorbidity, whichare common in older age groups [43].An older adult’s awareness and comprehension of thePA guidelines, understanding of the role of PA in healthyaging, knowing about movement skill parameters,methods of improvement, and safe participation modifi-cations are all knowledge and understanding elementsof PL. Similar to younger populations, older adults tendto have limited knowledge of current PA recommenda-tions for their age-group [44] and on accruing appropri-ate intensities for meaningful health benefits [45].Physical activity interventions that include an educa-tional component addressing these elements can in-crease outcome expectations, skills knowledge, andknowledge on effective doses and types of PA [46]. Inaddition, older adults should have knowledge and under-standing of what barriers to PA and sport participationexist. Not enough time, lack of motivation, ageism andfeelings of being too old, perceiving few sport facilitiesand/or physical activity opportunities nearby, and lack ofsupport from others, are all recognized as consistentbarriers for older adults. The literature on perceivedTable 3 Round 2 Questions and Level of AgreementQuestion Posed StronglyAgreeSomewhatAgreeAgree Neutral Disagree SomewhatDisagreeStronglyDisagreeCannotAdequatelyRespondQ1. An appropriate way to frame the intrapersonal or‘individual’ level factors associated with physical activityliteracy in older adults is via the ‘elements’ of physicalliteracy: motivation and confidence; physicalcompetence; knowledge and understandings; andengagement in physical activities for life. (23/23)14 (61%) 3 (13%) 4 (17%) 2 (9%) 0 0 0 0Q2. “Interpersonal” factors of the model are appropriatelydescribed by a spectrum of formal and informalpersonal relationships. (23/23)14 (61%) 6 (26%) 2 (9%) 1 (4%) 0 0 0 0Q3. ‘Organizational’ factors are appropriately described byevidence-based physical activity programs and servicesand physical activity opportunities that offer personallymeaningful, culturally relevant, and accessible physicalactivity opportunities. (23/23)16 (70%) 1 (4%) 2 (9%) 3 (13%) 1 (4%) 0 0 0Q4. ‘Community’ encompasses the context in which thephysical activity takes place: includes socialconnectedness and social-capital building; socio-culturalnorms and expectations; and affordances for physicalactivity within the built and natural environments.(23/23)12 (52%) 4 (17%) 5 (22%) 0 1 (4%) 0 0 1 (4%)Q5. ‘Policy’ factors include physical activity literacy, physicalactivity or healthy aging promotion initiatives acrosspan-governmental and multi-sectorial levels andincluding non-governmental organizations. (23/23)13 (57%) 3 (13%) 5 (22%) 1 (4%) 0 0 0 1 (4%)Responses to the specific question/responses to the questionnaireJones et al. BMC Geriatrics  (2018) 18:13 Page 9 of 16barriers to participate in PA and sport suggests thatthese challenges are consistently reported among olderadults [34, 47]. These barriers are all influenced by howolder adults view themselves and how they are cognizantof, and understand the ecology and opportunities sur-rounding them.There is vast room for improvement in encouragingolder adults to make the choice to be physically ac-tive. Along with previously identified motivators andbarriers, prioritizing and sustaining engagement inphysical activities as an integral part of one’s lifestylecan be influenced by outcomes expectations, percep-tions of older age and attitudes towards aging andexercise. The belief that a PA behaviour, in this casePA, will bring about a certain consequence (outcomesexpectations) and identifying which sub-category(physical, social and/or self-evaluative) is personallymeaningful may further increase engagement [48].Negative stereotyping of old age (including cultural,societal stereotypes) and low expectations for old age,may interfere with the possibility for improvement viahealthy lifestyle behaviors [28]. For example, a sampleof inactive older persons perceived themselves to bephysically active, because their perception of PA wasgrounded in a social context [27]. Both of these per-ceptions may interfere with the recognition and valueof regular PA as a personally meaningful and integralpart of life. Conversely, highly active older adultsutilize their resourcefulness to support their PA andin turn, PA contributes to their definition of self [48].Similarly, literature on adult sport [49] [30, 50], indicatesthat negative attitudes and feeling too old to engage insport are common barriers constraining activity. This be-havioural PL element suggests a role in assisting olderadults to link the value of, or belief in PA and behaviourchange to regular PA participation.Finally, at the intrapersonal level, there are individualfactors identified to be unique to the PA levels of olderadults. For example, differences between males andfemales or variations across the older adult age-range.Other groups at risk for low PA levels include, women,older adults with low incomes and/or low educationlevels, older adults living with disabilities and/or chronichealth conditions, those who live in institutions or inisolation, and seniors who are members of ethno-cultural and ethnolinguistic minority population groupsFig. 4 Physical Literacy Model for Older Adults: An Ecological ApproachJones et al. BMC Geriatrics  (2018) 18:13 Page 10 of 16[51]. Each individual has a cultural identity and under-standing cultural context can act as starting point to as-sist older adults. In addition, there must also beconsideration for examination of PL from a life courseperspective. Such a broad perspective is important for allof these identified factors, which requires a flexible andtailored approach to PL. Although children and youthare likely to have some continuity to participation insport and PA, older adults are more likely to cycle inand out of the model as they advance across the lifespan.This ebb and flow pattern of PA is likely to be partiallydriven by intrapersonal engagement, and how many ofthe identified individual factors interact with social op-portunities, seen at the interpersonal, organizational andcommunity levels of the model.InterpersonalInterpersonal elements that influence PL in older adultsare described by a spectrum of formal and informal per-sonal relationships, often broadly termed social support.Personal relationships such as family, friends, andbroader personal social networks such as work/volunteerpeers, caregivers, health providers may influence PA par-ticipation among older adults [52]. While extensive re-search on each of these is limited, they representpotential sources (positive and negative) of interpersonalmessages and varying types of support influencing olderadult’s understanding of PL. A shrinking social circle(especially if they lose an exercise buddy) may nega-tively influence PA participation with age [53], as maylow social support from a ‘significant other’ [54], orfrom friends [55]. In older adult clinical populations,family support for PA may be lacking out of fear ofharm [56]. Conversely, positive personal social supportfrom family, friends, and neighbours can be enablersfor PA [57–59] as can be co-participants and PAleaders [60]. Social support through faith-based net-work positively supports PA participation [61, 62]. Pri-mary care physicians are often identified as having aneffective role in counselling older adults on PA. Ultim-ately, such actions would engender PL in the patient,particularly if it is addressed within the context of ahealth problem [58, 63, 64]. Understanding the influ-ence personal relationships can have on fostering PL inolder adults is of importance, specifically to facilitateindividual behavior change. By affecting social and cul-tural norms and overcoming individual-level barriers toorganized programs and services, that support partici-pation in lifelong PA we will be able to facilitate a dee-per understanding of PL by the older adult.OrganizationalOrganizational elements that influence PL in olderadults are described by programs, resources, andservices that offer personally meaningful, culturally rele-vant, and accessible opportunities for PA participation.With respect to program factors, in September 2007,the National Coalition on Aging, the National BlueprintOffice, and Active for Life in the U.S. convened a meet-ing entitled “Building on Best Practices: Physical ActivityProgramming in the Aging Network”. This meetingaddressed issues related to widely disseminating infor-mation on best practices and evidence-based programsto community organizations that serve older adults. Themeeting highlighted the importance of selectingevidence-based PA programs to optimize health out-comes, promoting current guidelines, the importance ofdeveloping user-friendly resources to increase programaccess and support, and the importance of quality pro-gram evaluation of these initiatives. In addition, Stewartet al., [65] highlighted the need for community physical-activity-promotion programs to be integrated into set-tings that have the infrastructure, culturally competentstaff, access to exercise specialists, and experience inproviding outreach and delivering the program to di-verse populations. Culturally appropriate interventionshave shown mixed results as to their advantage com-pared to standard interventions; however, most studiesare limited due to small target populations, short follow-up, and methodological problems [66].Yet, they signalthe importance of expanding frameworks for practice tobe consistent with the reality of diverse community con-texts and individuals engaging in pluralistic options andhybrid approaches of PA [67].An important aspect of user-friendly and accessibleprogramming that can influence PL relates to the qualityof leaders and coaches associated with PA programs[68]. Curriculum guidelines outlining educational stan-dards for exercise leadership of older adults are available[69]. Nevertheless, in the exercise domain, the qualityand relatability of a group leader can be recognized as afactor to motivate and increase older adults’ adherenceto PA [60]. Peer-led activities, where older adults arematched with peers also demonstrate increased reten-tion to PA programs [70, 71]. Older adults who partici-pated in a fitness program with peer mentors hadimproved well-being, improved social functioning, en-hanced ability to carry out physical and emotional roles,and increased vitality [72]. In seniors sport, emergingwork underscores the importance of coaches who canrelate to, and understand, the nuances of interactingwith mature older adults [32, 73]. For example, effectiveleaders often take instructional steps or collaborativeconversations to satisfy older adults’ need to know therationale for why they are practicing something beforethey undertake it and afford opportunities to self-directwhen it is reasonable or safe to do so. Effective adult sportcoaches engage in more collaborative conversations andJones et al. BMC Geriatrics  (2018) 18:13 Page 11 of 16learner-centered questioning during learning activitiesthan they do with younger participants. Not all coachesuse such measures, nor do all older adults prefer such ap-proaches (based on given situations and the goals forlearning) [74]. However, this work suggests that qualityPA experiences depend to an extent on tailoring in-structional leadership and programs to older adults’preferences. Such considerations would plausibly cometo bear on intrapersonal factors related to motivation,competency, knowledge, understanding and responsi-bilities toward PA.While public health promotion focuses largely ongroup fitness programming for older adults, there isevidence to support the observation that many olderadults prefer to exercise independently (or with someinstruction either directly or through media-basedprograms) rather than in a group setting or class-based setting [11, 75, 76]. Therefore, there is a needto promote a wide range of options [77]. Evidencefrom trials comparing multiple long-term interven-tions suggests that mode of delivery is not necessarilyimportant for effectiveness but that tailoring theintervention to participants may be important [78]. Ithas also been identified that interventions and pro-motion needs to occur at multiple levels in a varietyof settings, and utilizing different technologies andmodalities, that fully take into account determinantsof PA [75]. Perceived lack of accessibility to nearbyfacilities due to transportation barriers or functionallyappropriate opportunities is also a valid consideration[30, 45, 47, 50]. In addition, there is need for quali-fied exercise specialists who will be able to administereffective programming to an older adult populationwith varied needs and abilities [69].Overall, these strategies are intended to facilitate individ-ual behavior change by influencing organizational systems,leveraging resources and participation of community insti-tutions, and advocacy groups, which represent potentialsources of support and communication. Strategies for opti-mizing programs and building capacity in various organiza-tions facilitate interactive support more broadly at thecommunity level.CommunityCommunity elements that influence PL in older adultsinclude the context in which PA takes place. This in-cludes considerations of how the individual is; sociallyconnected, influenced by socio-cultural norms and ex-pectations, and their interaction with the built and nat-ural environments where they live.Socio-cultural norms and expectationsThere is a growing body of literature on the importanceof culturally appropriate PA among ethnic minorities[79]. Cultural predisposition may positively or negativelyinfluence PA participation. For example, some culturesview structured PA as having social meanings tied to op-pression embedded in history that may not be in theconsciousness of “mainstream” society [80]. Alterna-tively, faith-based PA and education interventions havehad a positive influence upon participation by minoritygroups [62]. Effective facilitative factors in the context ofPA among older adults of cultural diversity include; folkdancing [81, 82] and qi gong [83] or tai chi [84, 85] aswell-known examples among the South Asian commu-nity. Although, these forms of PA are not usually viewedas such from a Western perspective, they are forms ofPA that may be considered extensions of cultural prac-tice and expression. Such forms of PA also promotesocial support and social inclusion through, group con-nection and shared understanding of the cultural mean-ing of the dance and collective movement [86]. Indeed,such forms of PA have become increasingly viewed ascomplementary and alternative to Western forms of PAand they provide insight into the social connectednesswithin the community environment that can facilitategreater knowledge surrounding PL.Built environmentThe nature of a neighborhood built environment can bean important consideration for older adults’ health andfunctioning [87] and can determine an older adults’ PAlevel [88]. Carlson et al., [89] demonstrated that a sup-portive environment for PA, that has; good walkability,good access to parks and recreation facilities, and goodneighborhood aesthetics, was associated with increasedmoderate-to-vigorous levels of PA in older adults. Theexisting literature suggests that mobility among olderadults in urban areas is associated with higher streetconnectivity leading to shorter pedestrian distances,street and traffic conditions such as safety measures, andproximity to walkable destinations such as retail estab-lishments, parks, and green spaces [90]. Beyond encour-aging walkability, design features can be critical forpromoting and maintaining social engagement as well[87]. As such, there is a growing body of literature thatsupports the study of design features in communities tosupport mobility for their aging populations. However, alack of consensus regarding the definitive association be-tween the specific components of the built environmentand PA among older adults exists due to various meth-odologies employed, various settings studied, and thediscrepancies between perceived and actual environmen-tal conditions [64]. Specific to the role of the environ-ment in increasing walking in older adults, features suchas sidewalk functionality, safety from traffic (includingcurb cuts), and having proximal destinations are asso-ciated with increased walking in older adults [91].Jones et al. BMC Geriatrics  (2018) 18:13 Page 12 of 16Age-friendly communities address active aging as a keycomponent of their development and such approachescould be better-informed through research elucidating PLprocesses and interventions [92]. For instance, while pro-moting walking trails and green spaces for older adults,our model suggests a more coherent multi-level approachthat addresses the complex interrelationships at the micro,meso and macro levels affecting PA involvement and ul-timately PL engagement.Natural environmentNeighbourhood design that facilitates outdoor walkingmay be one avenue whereby PA levels of older people canbe enhanced, with benefit across socioeconomic strata[93]. In addition, interactions with landscapes embeddedwith therapeutic qualities including parks, gardens, streetgreenery, lakes, and ocean views can influence olderadult’s perceived physical, mental, and social health. Issuesof safety, accessibility, and personal perception have beenshown to complicate this relationship [94]. Finally, severefluctuations in weather (hot summer, cold winter) may in-fluence PA modality variations in older adults [95, 96]. Insuch cases, being physically literate may help to mitigatethe effects of climate on PA participation, through com-prehension of alternative PA options.PolicyThe multidimensional PL model presented in this paperis the product of the expertise and knowledge of a largemultidisciplinary team of researchers and stakeholdersengaged in PA knowledge translation aimed at increas-ing PA levels. At the outer-edge of our ecological modelresides the policy component which is integral to allother components within the model. Policy is what willshape and support elements within the model that facili-tate lifelong PA adoption. This model developed specif-ically for older adults is a recommended policy elementfor active and healthy aging initiatives across pan-governmental and multi-sectoral levels, and non-governmental organizations. The testing, refinement,and application of a PL model targeting older adults hasthe potential to be instrumental in improving quality oflife, and ultimately the health status, of a rapidly growingolder population. To ensure benefits are derived fromthese approaches, more tools and more effective toolsare needed to evaluate, translate, and disseminate re-search and its findings [97].Indeed, prevention and maintenance of chronic illness,and enriched quality of life, through the enhancement ofPA among older adults has an enormous potential to re-duce the burden on the health care system as we moveinto a period of rapid population aging [97].The PL model for older adults can be integratedwith other major policy developments, such as theage-friendly community movement, national strategiesto reduce social isolation [98] and foster communityengagement among seniors, ParticipACTION, andprevention components from the National Alzheimer’sStrategy [99], as well as those connected to a Na-tional Seniors Strategy [100]. Overall, policy makersmust consider all occasions that expose older adultsto different movement opportunities and experiences.However, policy makers must also recognise the het-erogeneity for both physical and cognitive functionobserved across the older adult population and assuch guide PL programing to be effective at both themarco and micro levels [101].ConclusionsPhysical literacy is an emerging strategy to remodel howwe promote PA participation across the lifespan. Olderadults are a unique group who have yet to be exposed toPL as a means to promote long-term PA participation.Our PL model for older adults uses an ecologicalapproach to integrate PL into older adult’s lifestyles. Thismodel integrates all components (intrapersonal, inter-personal, organizational, community, and policy) as be-ing involved and intertwined in the promotion andadoption of PL. Elements within each component sup-port how each might influence PL adoption by the olderadult. Understanding the interactions between compo-nents and elements which facilitate PL education andpractice may ultimately provide a new and effectiveblueprint to specifically target PA promotion and adher-ence for all older Canadians.Future Directions (Action Items): Evaluation, refinement, and application of the olderadult PL model. Improve upon methods to reliably and validly assesskey components of the operationalization of PL forolder adults, especially at the interpersonal level ofthe model. Application and adaptation of PL models andresearch studies to vulnerable groups who have lowlevels of PL (e.g., low income seniors, Aboriginal andother ethnocultural groups, and socially isolatedolder adults). Formative and effectiveness evaluation studies of bestpractices and innovative interventions to promote PLuptake. Including how the model will influence and beused by frontline people and older adults. Integration with other government initiatives aimedat enhancing healthy lifestyles and preventive healthbehaviours of older adults. Including investigatingpolicy channels that will be most effective inpromoting PL.Jones et al. BMC Geriatrics  (2018) 18:13 Page 13 of 16AbbreviationsCWG: Collaborative working group; PA: Physical activity; PL: Physical literacyAcknowledgementsDean Kriellaars, PhD.Associate Professor, Faculty of Health Sciences.College of Rehabilitation Sciences,University of Manitoba,Winnipeg, Manitoba, Canada.The authors wish to thank and acknowledge the contributions of the 23participants involved in both rounds of the Delphi questionnaire. These havebeen listed below in alphabetical order.Bettina Callary, PhD.Assistant professor, Department ofCommunities and Connections, Sportand Physical Activity Leadership(Coaching),Cape Breton University.Donald H Paterson, PhDCanadian Centre for Activity andAgingSchool of Kinesiology, WesternUniversity,London, CanadaWojtek J. Chodzko-Zajko, PhDDean, Graduate College Shahid andAnn Carlson Khan Professor inApplied Health SciencesUniversity of Illinois at Urbana-ChampaignCaterina Pesce, PhDAssociate ProfessorItalian University Sport andMovement “Foro Italico”, Rome, ItalyAssociate Professor Rochelle EimeFederation University,Australia Victoria University, AustraliaVicky Scott, RN, PhDSchool of Population and PublicHealthFaculty of Medicine, University ofBritish ColumbiaGloria M. Gutman, PhD,Simon Fraser University GerontologyResearch CentreBritish Columbia, CanadaJoanie Sims-Gould, PhD,RSW Assistant Professor CIHR NewInvestigator, MSFHR ScholarUniversity of British Columbia,Department of Family PracticeJoan HironsNorthwest Territories DirectorCanada Seniors’ Games AssociationKiyoji Tanaka, Ph.D., FACSMProfessor, Department of SportsMedicineUniversity of Tsukuba, JapanShanthi Johnson, PhD, RD, FACSM,FDC, & FGSAProfessor, Faculty of Kinesiology andHealth Studies, University of ReginaRegina, Saskatchewan, CanadaOlga Theou, PhD,Research scientist, Geriatric Medicine,Dalhousie University and Nova ScotiaHealth AuthorityHalifax, Nova Scotia, CanadaProfessor Stephen R. LordSenior Principal Research FellowNeuRA,University of NSW Sydney, AustraliaDr. Emmanuelle Tulle, MSc, PhDReader in SociologyGlasgow Caledonian UniversityDr Jamie S McPheeSchool of Healthcare Science.Manchester Metropolitan UniversityUKSusan Yungblut, BScPT, MBADirector, Exercise is Medicine CanadaOttawa, Ontario, CanadaIan Newhouse, Ph.D.School of Kinesiology, LakeheadUniversityThunder Bay, CanadaFundingCanadian Institutes of Health Research, Institute of Aging, Planning andDissemination Grant #345252. The funding agency reviewed the initial grantproposal, but had no role in the design of the study, or the collection,analysis and/or interpretation of the data. The funding agency was notinvolved in the writing of the manuscript; it only provided the financialresources for this independent research project.Availability of data and materialsData sharing is not applicable to this article as no data sets were generatedor analysed during the current study.Authors’ contributionsGR and LS planned, carried out, and analyzed the Delphi survey. BY, AW, SC,PC, MD, DM, and PN contributed to the planning stages and refinement ofquestions for the Delphi survey. GR, LS, BY, AW, SC contributed extensively tothe drafting of the manuscript. All authors read and approved the finalmanuscript.Ethics approval and consent to participateEthics approval was provided by the University of British Columbia’sBehavioral Behavioral Research Ethics Board [Ref# H17–00884] andconformed to the Declaration of Helsinki. All interview participants gaveconsent to participate in the survey.Participants were first contacted by email regarding their willingness tocomplete the survey. Participants consented to complete the survey byresponding to the email request. A link to the online survey was then sentto the participant.Consent for publicationParticipants were first contacted by email regarding their willingness tocomplete the survey. Participants consented to complete the survey byresponding to the email request. A link to the online survey was then sentto the participant.Competing interestsThe authors declare that they have no competing interests.Publisher’s NoteSpringer Nature remains neutral with regard to jurisdictional claims inpublished maps and institutional affiliations.Author details1School of Health and Exercise Sciences, Faculty of Health and SocialDevelopment, University of British Columbia Okanagan Campus, Kelowna, BCV1V 1V7, Canada. 2School of Kinesiology, Faculty of Health Sciences,University of Western Ontario, London, ON N6A 3K7, Canada. 3School ofHuman Kinetics, Faculty of Health Sciences, University of Ottawa, Ottawa, ONK1N 6N5, Canada. 4Gerontology Department, Simon Fraser University,Vancouver, BC V6B 5K3, Canada. 5School of Social Work, Faculty of Health &Social Development, University of British ColumbiaOkanagan Campus,Kelowna, BC V1V 1V7, Canada. 6Active Aging Canada, Shelburne, ON L9V 398,Canada. 7Canadian Society for Exercise Physiology, Ottawa, ON K1R 6Y6,Canada. 8Physical Literacy, Sport for Life, Port Moody, BC V3H 4W6, Canada.9Canadian Senior Games Association, Edmonton, AB T6H 4J8, Canada.Received: 9 May 2017 Accepted: 12 December 2017References1. 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