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Understanding connections between older men's masculinities and physical activity Thandi, Manpreet Kaur Gill 2017

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   UNDERSTANDING CONNECTIONS BETWEEN OLDER MEN’S MASCULINITIES AND PHYSICAL ACTIVITY   by   Manpreet Kaur Gill Thandi   BScN, Vancouver Community College, 2012    A THESIS SUBMITTED IN PARTIAL FULFILLMENT OF THE REQUIREMENTS FOR THE DEGREE OF   MASTER OF SCIENCE IN NURSING  MASTER OF PUBLIC HEALTH   in    The Faculty of Graduate and Postdoctoral Studies     THE UNIVERSITY OF BRITISH COLUMBIA    (Vancouver)    December 2017     © Manpreet Kaur Gill Thandi, 2017 ii  Abstract One of the most significant factors influencing the health of older men is their engagement in physical activity. Although the benefits of physical activity are well-established, inactivity tends to increase with aging, with men being at a significant risk of sedentary behaviour. Aging men may face significant pressures to embody dominant masculine ideals, affecting their motivations and experiences with physical activity.   The purpose of this qualitative study was to enhance understanding of older men’s contextualized experiences with physical activity in their day-to-day lives, with an emphasis on the influence of masculinities on these experiences. These experiences were situated within socioecological and masculinities frameworks to assist healthcare providers develop health promotion interventions that are specific to older men, facilitating healthy aging and enhancing quality of life in this subpopulation.  Four older men, over the age of 65, participated in in-depth data collection methods including an initial sit-down interview, three walk-along sessions, and photovoice, resulting in 2.17 hours of video, 10.17 hours of audio, and 54 pictures across the four men. An interpretive descriptive approach to data analysis was used to identify key areas of the men’s personal experiences with physical activity. Data analysis resulted in three key themes: Aging Male Bodies, Out in the Community, and Social Connectedness and Physical Activity.  Findings from this study add to the growing knowledge around connections between older men, physical activity, and masculinities. Understanding the intersections between these factors will enhance understanding of older men’s experiences with physical activity in the context of their day-to-day lives, and assist healthcare providers develop health promotion programs targeted to the unique needs of older men.    iii  Lay Summary   Participation in physical activity is essential to the health of older men; however, it is known that men’s activity levels decline as they age. There may be various reasons for this, but one that remains understudied is the influence of what it means to be men, and how a need to demonstrate masculine characteristics may impact participation in physical activity. The purpose of our study was to understand older men’s experiences with physical activity within their day-to-day lives. We learned that there are many connections between gender, age, and social and physical environments that influence older men’s abilities and motivations to be active that need to be taken into consideration. Our new understandings of older men’s experiences with physical activity will help healthcare providers design physical activity programs that will specifically benefit the needs of older men.                          iv  Preface   This thesis project was a part of the “Shape the Path” study, a team-based study consisting of 7 research/project teams, coordinated by The Center for Hip Health and Mobility (CHHM), a research center affiliated with the Faculty of Medicine at The University of British Columbia and supported by the Vancouver Coastal Health Research Institute. “Seek to Understand” was “Project IV” within “Shape the Path,” for which I was the project coordinator; this study formed the basis of this thesis project.   Along with other research assistants, I was responsible for the data collection for “Seek to Understand.” I was present at three of the four original sit-down interviews, every walk-along session, as well as every photovoice session with the four participants. The identification and proposal for this thesis project was developed in collaboration with Dr. Alison Phinney, my thesis supervisor, and thesis committee members Dr. Sabrina Wong, and Dr. John Oliffe. Dr. Alison Phinney is also the primary investigator for the “Seek to Understand” study. I was responsible for the analysis of the data, and was the primary writer of the work presented in this thesis, with support from my supervisor and thesis committee.  This study was funded by the Canadian Institutes of Health Research (CIHR) as part of a larger team-based grant titled Shape the Path: Targeting the Health and Mobility of Older Men Through Key Community Partnerships. Ethical approval was obtained from Fraser Health Research Ethics Board (FHREB-2015-033), University of British Columbia Behavioural Research Ethics Board (H14-03317), and Vancouver Coastal Health Research Institute (V14-03317). Co-Investigators in this study included: Joanie Sims Gould, Steve Robinovitch, Dawn Mackey, Heather McKay, Meghan Winters, Christiane Hoppmann, Karim Miran-Khan, and Alison Phinney.   v  Table of Contents  Abstract …………………………………………………………………………… ii  Lay Summary …………………………………………………………………………… iii  Preface …………………………………………………………………………… iv  Table of Contents …………………………………………………………………… v  List of Tables …………………………………………………………………………… viii  List of Figures …………………………………………………………………………… ix  List of Photographs …………………………………………………………………… x  Acknowledgements …………………………………………………………………… xi  Dedications …………………………………………………………………………… xii  Chapter 1: Introduction………………………………………………………………… 1 1.1 Background ….……………………………………………………………… 1 1.2 Problem …………………………………………………………………. 4 1.3 Significance …………………………………………………………………. 6 1.4 Purpose …………………………………………………………………. 7 1.5 Theoretical Frameworks …………………………………………………. 7 1.5.1 Socioecological Model of Health Promotion …………………………. 7  1.5.2 Masculinities …………………………………………………………. 9 1.6 Research Questions …………………………………………………………. 11  Chapter 2: Literature Review …………………………………………………………. 12 2.1 Existing Knowledge …………………………………………………………. 12 2.1.1 Factors Influencing Older Men’s Physical Activity …………………. 13 2.1.1.1 Functional Mobility………………………………………………... 13 2.1.1.2 Socioecological Factors: Intrapersonal and Interpersonal Factors… 14 2.1.1.3 Socioecological Factors: Environmental Factors …………………. 16 2.1.1.4 Life Changes………………………………………………………. 18  2.1.2 Older Adults’ Motives for Physical Activity …………………………. 19 2.1.3 The Influence of Masculinity on Older Men’s Physical Activity……... 21 2.1.4 Current Physical Activity Programs for Men …………………………. 27 2.2 Gaps in Knowledge …………………………………………………………. 30 2.2.1 Lack of Emphasis on Personal Experiences …………………………. 30 2.2.2 Focus on Quantitative Methods and Traditional Interviews …………. 30 2.2.3 Greater Need to Focus on Men………………………………………… 31 2.2.4 Lack of Physical Activity Promotion Programs Specific to Older Men 32 vi  Chapter 3: Design & Methods………………………………………………………….. 33 3.1 Introduction ………………………………………………………………….. 33 3.2 Study Design ………………………………………………………………….. 33 3.3 Sampling Plan ………………………………………………………………….. 35 3.3.1 Sample Population ………………………………………………….. 35 3.3.2 Inclusion Criteria ………………………………………………….. 36 3.3.3 Recruitment ………………………………………………………….. 36 3.4 Procedures and Data Collection ………………………………………….. 38 3.4.1 One-on-one Interviews ………………………………………….. 38 3.4.2 Walk-Along Interviews ………………………………………….. 40 3.4.3 Photovoice ………………………………………………………….. 42 3.5 Data Analysis ………………………………………………………………….. 45 3.6 Ethical Considerations …………………………………………………………. 48 3.6.1 The Consent Process ………………………………………………….. 48 3.6.2 Power Relations and Potential Harm ………………………………….. 49 3.6.3 Privacy and Confidentiality ………………………………………….. 50 3.7 Ensuring Quality of Research ………………………………………………….. 50 3.7.1 Rigour ………………………………………………………………….. 51 3.7.2 Reflexivity ………………………………………………………….. 53  Chapter 4: Findings ………………………………………………………………….. 56                4.1 The Sample ………………………………………………………………….. 56        4.2 Theme #1: Aging Male Bodies………………………………………………… 57    4.2.1 Past, Present, and Future: The Importance of Routine ………………….. 58  4.2.2 Remaining Capable: Resisting Old Age?.................................................... 63  4.2.3 Engaging in Risky Behaviour ………………………………………….. 67        4.3 Theme #2: Out in the Community ………………………………………….. 70  4.3.1 Walking for Leisure vs. Walking for Transportation ………………….. 71  4.3.2 The Manly Act of Driving ……………………………………………….. 72  4.3.3 Importance of the Physical Environment …….………………………….. 73        4.4 Theme #3: Social Connectedness and Physical Activity ……………………… 77  4.4.1 Community Involvement: Doing as Connecting ………………………… 77  4.4.2 Relying on Others vs. Helping Others ………………………………….. 81         4.4.3 Lone Wolf vs. Desire for Socialization ………………………………….. 83  Chapter 5: Discussion …………………………………………………………………. 86        5.1 Gender and Physical Activity…………………………………………………. 86        5.2 Resiliency and Motivations: Maintaining Independence and Quality of Life… 90         5.3 Implications for Practice: Targeting Health Promotion Programs at Older Men 93 5.3.1 Use knowledge around motivational factors to attract           community-dwelling men to physical activity programs………………… 94 5.3.2 Consider the influence of the men’s social and physical environments           when implementing interventions………………………………………… 96 5.3.3 Include the men in the programs; using a strength-based approach in           focusing on what the older men are physically capable of doing; and,           using an activity-based approach in designing activities that the give           the men enjoyment and meaning…………………………………………. 98 vii  5.3.4 Implications for Nursing Practice…………………………………………. 103        5.4 Study Limitations and Overcoming Difficulties………………………………... 105  5.4.1 Study Limitations………………………………………………………….. 105  5.4.2 Overcoming Difficulties…………………………………………………… 107        5.5 Conclusions……………………………………………………………………... 107  References …………………………………………………………………. …………… 110  Appendices ………………………………………………………………… …………… 123 Appendix A:  Invitation to Participate in the Study …………………………… 123 Appendix B:  Recruitment Postcard …………………………………………… 124 Appendix C:  Recruitment Poster …………………………………………… 125 Appendix D:  Information Letter & Consent Form (Initial Interview) ………… 126 Appendix E:  Interview Guide and Field Note Template …………………… 132 Appendix F:  Demographic Questionnaire …………………………………… 138 Appendix G:  Honorarium Receipt …………………………………………… 141 Appendix H:  Consent Form (In-depth data collection methods) ……………    142 Appendix I:  Walk-Along Interview Guide …………………………………… 149 Appendix J:  Photovoice Data Collection Instructions …………………… 151 Appendix K:  Photovoice Form for Participants’ Notes …………………... 152 Appendix L:  Interpretation Framework for Analysis ……………………    153                           viii  List of Tables   Table 1: Themes and Subthemes Revealed in Data Analysis……………………………. 56                                             ix  List of Figures  Figure 1: Environmental Factors Influencing Older Adults’ Physical Activity…………. 17                                            x  List of Photographs  Photograph 1……………………………………………………………………………… 63  Photograph 2……………………………………………………………………………… 64 Photograph 3……………………………………………………………………………… 68 Photograph 4……………………………………………………………………………… 68 Photograph 5……………………………………………………………………………… 69 Photograph 6……………………………………………………………………………… 70 Photograph 7……………………………………………………………………………… 74 Photograph 8……………………………………………………………………………… 74 Photograph 9……………………………………………………………………………… 75 Photograph 10 ……………………………………………………………………………. 75 Photograph 11……………………………………………………………………………. 76 Photograph 12……………………………………………………………………………. 76 Photograph 13……………………………………………………………………………. 76 Photograph 14……………………………………………………………………………. 82            xi  Acknowledgements   I would like to first thank my thesis supervisor, Dr. Alison Phinney, of the School of Nursing at the University of British Columbia. Dr. Phinney was always available and willing to offer her assistance whenever I was struggling or had a question about my research, my writing, or my personal and career plans. She consistently allowed this paper to be my own work, but also steered me in the right direction when she thought I needed it.    I would also like to thank Dr. Sabrina Wong and Dr. John Oliffe, my thesis committee members. The completion of this thesis project would not have been possible without the ongoing support of Dr. Phinney, Dr. Wong, and Dr. Oliffe. I have the utmost appreciation for their guidance and expertise and I am genuinely thankful for their continuous feedback and ongoing patience with my work and my education.   I would also like to thank the “Seek to Understand” and “Shape the Path” team at the Center for Hip Health and Mobility. Without their passion and willingness to facilitate the learning of students like myself, this project would not have been possible. Additionally, I would like to thank the University of British Columbia and the School of Nursing for giving me the opportunity to further my education and my career.   Finally, I must express my deep appreciation to my family, my friends, and my husband for providing me with unconditional support and continuous encouragement throughout my years of study and through the process of researching and writing this thesis. This accomplishment could not have been possible without them. Thank you!      xii  Dedications Thank you to my family and friends for all your love, support, and encouragement.  To my mother,  The strongest and most resilient person I know, who taught me to trust in myself and push through difficult times and persevere. Thank you for all the sacrifices you have made to help me succeed in my career and in my life.   To my father, You faced continuous challenges and struggles with courage and hope; you did so having never given up, and I hope that you have finally found peace. I know that you have been right beside me in this journey.   To my husband,  Your support and pride in me and my work encouraged me to pursue a higher education. Thank you for your unconditional love, your ongoing patience, and for always believing in me, even when I underestimated myself.  To all my family and friends, Thank you for your genuine interest in my work and for your continuous support and love.    1   Chapter 1: INTRODUCTION  1.1 Background Older men, defined as males over the age of 65, are part of the fastest growing age group in the Canadian population (Daley & Spinks, 2000; Locket, Willis, & Edwards, 2005; Metz, 2000; Van Cauwenberg et al., 2012). In 2016, there were over 750,000 people aged 85 and older living in Canada, making up 2.2% of the Canadian population and about 13.0% of the population was 65 years and older (Statistics Canada, 2017). From 2011 to 2016, the number of people aged 85 and older grew by 19.4%, which is almost four times the growth rate of the overall Canadian population. Further, this population will continue to increase in upcoming decades and by 2051, approximately 2.7 million people in Canada will be 85 years and older (Statistics Canada, 2017). These figures reflect an increase in life expectancy for both men and women, an increase of 24.6 years since 1921, reaching an average life expectancy of 81.9 years in 2016 (Statistics Canada, 2016). A publicly funded healthcare system, reduced deaths from circulatory and respiratory diseases, and the advancement of medical interventions are a few of the reasons for this growing life expectancy (Statistics Canada, 2016). However, at every stage of the life cycle, males are more likely than females to die, creating a gender gap in life expectancy that has been evident for over a hundred years (Statistics Canada, 2016). Men usually suffer more severe chronic conditions, have higher death rates in 15 different leading causes of death, and die younger than women (Statistics Canada, 2015). Over the years, this gender gap has decreased from 7.7 years in the 1970s to about 4 years as of 2011 (Statistics Canada, 2015); however, this sex difference in life expectancy continues to exist and is worthy of consideration when aiming to promote the health of older men.   2   Aging is a complex process situated within various interrelated personal, societal, and environmental factors that influence behaviours and the aging process. Men in older age groups are less likely to monitor their health status even though they are at the greatest risk of negative health outcomes (Resnick, 2001), and although Canadians are living longer, the ability of many older men to perform key health functions declines as they age. It is the responsibility of healthcare providers to ensure that quality of life is optimized in remaining years of life through effective health promotion strategies. Generally, health promotion aims to enable people to increase control over, and to improve their health; it moves beyond a focus on individual behaviours and considers a wide range of social and environmental factors (WHO, 2016). The increasing proportion of Canadian men who are reaching older ages increases demands on healthcare (Statistics Canada, 2015) which can be enormous if older men are in poor health as they age. One of the most significant factors influencing the health of older men is their engagement in physical activity, the benefits of which have been established and are well-documented. Physical activity plays a significant role in the health, well-being, and quality of life of men, allowing them to live longer and healthier lives (PHAC, 2011).  Regular physical activity is essential for healthy aging; it can significantly influence the mobility and ability of older men, allowing for the maintenance of independence and enhanced quality of life (Rajeski and Mihalko, 2001). Quality of life is defined here and throughout this research as subjective and individual perception of physical and mental health and their correlates – including health conditions, functional ability, social support, and socioeconomic status, among others (CDC, 2016). Physical activity, even in high frequency and intensity, cannot stop the aging process; however, it can reduce the development and progression of disabling conditions (Mazzeo et al., 1998) and is conclusively linked to several improved health 3   outcomes (Health Canada, 2002). It is beyond the scope of this research to fully discuss the extensive physical, social, psychological, and cognitive benefits of physical activity for the aging population. However, it is noted that physical activity can reduce the risk of chronic diseases such as cardiovascular disease, arthritis, osteoporosis, stress-related conditions, diabetes, obesity, certain cancers, stroke, respiratory illnesses, and peripheral vascular disease, among others (Health Canada, 2002; Mazzeo et al., 1998). Physical activity can also improve cognitive functioning and mental health, as well as enhance emotional and social wellbeing, and reduce the risk of depression and anxiety. Alternatively, physical inactivity can increase the risk of falling, increase fatigue, decrease bone and muscle strength, enable the loss of functional ability and independence, facilitate the development of chronic health conditions, lead to social isolation and depression, and contribute to lower quality of life, among several other negative health outcomes (Allender et al., 2008; Chaudhury et al., 2012; Health Canada, 2002; Locket et al., 2005). Regular physical activity does not need to be of high intensity to have positive influences for older men. In fact, it has been shown that even activities related to leisure, transportation, and household chores can prevent, delay, or minimize negative experiences related to aging and chronic disease (Allender, Hutchinson, & Foster, 2008; Chaudhury et al., 2012). Although engagement in regular physical activity is strongly recommended and encouraged, a large portion of older men in Canada do not engage in sufficient levels of physical activity that are needed to maintain or promote their health (Health Canada, 2002). With the majority of older men failing to meet national recommendations of engaging in 30 minutes of moderate activity daily (Dacey, Baltzell, & Zaichkowsky, 2008), older men are the least physically active age group with a trend towards high rates of inactivity and declining leisure time energy expenditure (Hirsch et al., 2010; Lockett et al., 2005; Van Cauwenberg et al., 2012), In 2002, Health Canada 4   reported that 60% of older men were not active enough to achieve optimal health benefits, and according to the National Population Health Survey study in the same year, only 14% of older men were sufficiently active, 21% were moderately active, and 65% were inactive (Health Canada, 2002). It has been stated that inactivity among older men increases with age; in those over the age of 65, inactivity levels may even increase to 79% based on the Canadian Fitness and Lifestyle Research Institute (Health Canada, 2002). Given their changing body composition and greater risk factors for functional decline, it is understood that older men may face significant challenges when engaging in physical activity; however, they are still encouraged to be as physically active as their abilities and physical conditions allow them to be (Mazzeo et al., 1998). Focusing on the health promotion of older men is especially important given their increased risk of chronic conditions and loss of functional ability with age that can be alleviated with physical activity (Office of Disease Prevention and Health Promotion, 2016).  1.2 Problem  It is well understood that physical activity can facilitate healthy aging; however, factors that are associated with the engagement or lack thereof in physical activity are poorly understood (Booth, Owen, Bauman, Clavisi, & Leslie, 2000). In light of the various benefits of physical activity for older men, there is generally a poor understanding of this population’s personal experiences with activity in the context of their daily lives. There are various factors and challenges that may affect older men’s participation in physical activity and the types of activities they engage in. These include but are not limited to: social and cohort norms and beliefs about physical activity; personal attitudes and capacities; awareness around active aging; fear of injury or harm; illness or disability; physical and social communities and environments; and barriers around time and energy expenditure (Health Canada, 2002). Aging can be a very 5   complex process that involves many of these intersecting factors (Mazzeo et al., 1998), making it difficult to study the interconnected nature of aging and physical activity in a social culture which does not necessarily encourage or facilitate this behaviour in this population (Health Canada, 2002; Yeom, Fleury, and Keller, 2008). Various epidemiological studies have reported that there is a lower risk of mortality associated with those who are physically active in comparison to those who are sedentary (Hirsch et al., 2010); however, there are also social, physical, and environmental factors that mediate this relationship (Allender et al., 2008). Life events and life circumstances are factors that require attention when considering older men’s experiences with and engagement in physical activity. Experiences may vary for men and women; however, gender remains an understudied factor in relation to experiences with both aging and physical activity (Men’s Health Forum, 2014). Although the sex difference in life expectancy continues to exist, the proportion of older men in Canada is increasing, reflecting an overall increase in life expectancy (Statistics Canada, 2015). In order to optimally promote the health of growing numbers of aging men, their experiences with physical activity must first be comprehensively understood and considered in light of the intersecting nature of various contextual and personal factors.  Gender is “a set of socially constructed relationships which are produced and reproduced through people’s actions” (Courtenay, 2000, p.1387); it is a set of socially constructed behaviours and thoughts that one continuously engages in (Courtenay, 2000). Men may think and act in certain ways because of societal concepts and expectations about what it means to them to be masculine. Further, aging men may face unique pressures to reflect masculine ideals (Courtenay, 2000), which may be evident in the choices they make such as the types of physical activities they engage or do not engage in. Men are more likely than women to report being 6   physically active; however, the proportion of men who meet the recommendations for physical activity declines with age (Mens’s Health Forum, 2014), the reasons for which are poorly understood. Before healthcare providers can optimally address physical activity in the aging male population, a greater understanding of the broader sociocultural contexts of older men’s lives is necessary (Health Canada, 2002). Without considering the various interconnected factors of influence on older men’s experiences with physical activity, healthcare providers cannot truly understand or accurately promote this dimension of health.  1.3 Significance   The current high levels of physical inactivity in the majority of older men coupled with the growth in the number of older men requires a greater effort towards healthy aging and health promotion in this subpopulation (Health Canada, 2002). It is essential to understand existing motivations and barriers to physical activity for older men, but it is also essential to recognize that there are various interconnected factors that may influence older men’s personal and unique experiences with physical activity. Healthcare providers are unaware of these unique contexts of older men’s lives in which men may face great challenges to physical activity due to societal expectations of what it means to be aging men (Courtenay, 2000). If older men’s experiences with physical activity are more comprehensively understood, healthcare interventions can be more appropriately tailored to help older men enhance their quality of life and maintain their functional ability, ultimately reducing a significant anticipated burden on healthcare (Metz, 2000). Thus, the significance of this research is to address this existing gap in knowledge around older men’s contextualized experiences with physical activity so that health promotion interventions can be appropriately informed to benefit this population (Rasinaho, Hirvensalo, Leinonen, Lintunen, & Rautanen, 2007; Shumway-Cook et al., 2002).  7   1.4 Purpose  The purpose of this research is to enhance understanding of older men’s contextualized experiences with physical activity in their day-to-day lives, with an emphasis on the influence of masculinities on these experiences. Understanding older men’s experiences with physical activity will assist healthcare providers to develop interventions that are specific to older men, and thus facilitate healthy aging and enhance quality of life in this population.   1.5 Theoretical Frameworks Although healthcare providers continue to encourage physical activity, in order to do so effectively and optimally, it is imperative to consider the various factors of influence that may exist. Using frameworks in analyzing data may risk limiting interpretation and narrowing the focus of the analysis, resulting in biases of results and findings (Zaitseva and Stewart, 2014); thus, rather than directing the analysis of this study, the analysis was informed by a socioecological model of health promotion as well as a masculinities framework. The use of these frameworks permitted viewing individuals holistically and in larger contexts, as well as allowed for an enhanced understanding of older men’s experiences with physical activity and what it meant to them in their everyday lives (Disch, 2012).  1.5.1 Socioecological Model of Health Promotion The environment of individuals is multidimensional, encompassing social, relational, and physical components (Moran et al., 2014). There is growing evidence supporting the argument that there are interactions between people and their environments that influence their choices and behaviours in everyday contexts (Spence and Lee, 2002). Health behaviours such as engagement in physical activity are the result of these interactions, and require comprehensive approaches that consider multiple, intertwining factors (Perry, Saelens, and Thompson, 2013). The 8   socioecological model recognizes individual behaviours as a result of the interactions among intrapersonal, interpersonal, and environmental factors, while emphasizing the importance of an individual’s interactions with or within his surrounding environment (Van Cauwenberg et al., 2012; Yeom et al., 2008). This model was first discussed in 1997 by Dzewaltowski, Sallis and Owen in which they expressed the need for the approach when considering how to advance the study of physical activity research and health promotion (Spence and Lee, 2002).  Intrapersonal factors are subjective perceptions and characteristics (Perry et al., 2013) and include biological and psychological factors such as age, sex, socioeconomic status, educational level, marital status, disease status, motivational factors such as personality and self-efficacy, as well as lifestyle and physiological factors (Yeom et al., 2008). Interpersonal factors include social and cultural factors such as social relationships, and caregiver context (Yeom et al., 2008). Environmental factors include the physical environment, housing and living conditions, accessibility, housing satisfaction, safety features, and the availability of resources such as grocery stores, pharmacies, and medical offices (Yeom et al., 2008). Physical conditions such as the time of year, the availability of physical activity programs, neighborhood conditions such as sidewalks and scenery, air pollution, and traffic safety may also be influential.  Socioecological models incorporate the influence of both internal and external factors that may significantly impact men’s physical activity. Because these models of health behaviour consider individual, social, and environmental factors that may facilitate or inhibit individual behaviours (Giles-Corti and Donovan, 2002; Spence and Lee, 2002), the use of this model in the current research enhanced understandings of and situated older men’s lived experiences with physical activity within a broader context of their everyday lives.   9   1.5.2 Masculinities  Of the various factors that may influence older men’s experiences with physical activity, gender is key. As mentioned, gender is a “set of socially constructed relationships which are produced and reproduced through people’s actions” (Courtenay, 2000, p.1387). There is strong agreement in Western society about what is masculine, and these expectations can be powerful drivers for how men act and conduct themselves in their everyday lives (Spector-Mersel, 2006). Research indicates that men may experience significant pressures to endorse some masculine ideals (Courtenay, 2000) and conform to social practices that are widely accepted as manly behaviours (Spector-Mersel, 2006). Further, there are significant challenges in relation to masculinity faced with advancing age in which life events and circumstances can challenge older men to embody behaviours espoused as masculine by society (Ribeiro, Paul, and Nogueira, 2007).  Masculinity is a concept about holding power over social groups and promoting the dominant social position of men, not just over women, but also over other forms of masculinities (Donaldson, 1993; Oliffe et al., 2011; Verdonk, Seesing, and de Rijk, 2010). Masculinity is commonly associated with being white, heterosexual, educated, of European descent, and of middle to upper socioeconomic status (Bennet, 2007; Courtenay, 2000; Verdonk et al., 2010). It idealizes dominance and control along with characteristics of self-reliance, strength, and stoicism and refers to the traditional, patriarchal view of men and their behaviour as the most accepted performances of “manliness” (Smith, Braunack-Mayer, Wittert, and Warin, 2007). Male norms such as being emotionally restrained, independent, assertive, courageous, aggressive, autonomous, capable, and tough in mind and body are highly valued, requisite to breadwinner 10   and protector roles (Courtney, 2000). Societal expectations of men are created and normalized in society, in which some men align themselves with these societal and self expectations.    Men’s health behaviour is socially constructed and dependent on how men, as well as communities, define masculinity (Oliffe, Bottorff, Kelly, and Halpin, 2008). However, connections between masculinities and health behaviours are subject to change and are especially related to history, age, social class, and culture (Oliffe et al., 2008). Gender roles and associated stereotypes may change as men get older (Smith et al., 2007), as life circumstances transition to influence changes in personal meanings of masculinity. However, although individual beliefs around masculinity may change with advancing age, they may also remain reflective of engrained societal beliefs (Ribeiro, Paul, and Nogueira, 2007). For example, aging men may express control over illness and the ability to participate in daily functions as a way to maintain masculine ideals of independence and capability, whereas younger men may have different perceptions and values of what it means to be masculine such as competitiveness and power (Verdonk et al., 2010). Social constructions of gender can deeply influence and intersect with men’s decisions and experiences with healthcare in which men are encouraged to be independent, to deny the need for help, and to be strong. Independence is not only considered a masculine ideal, but it has been associated with men’s risky health behaviours; independence is also associated with the belief that men should be able to handle their own health, reflecting values of self-reliance, and emotional and physical control (Smith et al., 2007; Verdonk et al., 2010). Health promotion strategies cannot be considered without acknowledging the influence of these significant gendered societal expectations.   In Western society, being “old” or growing old are sometimes constructed as problems and the concept of masculinities in later life is not often considered (Slevin, 2008). Gender may 11   play a significant role in the way men experience physical activity as they age, and what it means for them to be men in the context of their daily lives; however, gender knowledge is rarely translated into interventions (Verdonk et al., 2010). In order to develop optimal and effective physical activity interventions for older men, the current research enhances understandings of older men’s contextualized experiences with physical activity in their day-to-day lives, while emphasizing the influence of masculinities on these experiences.   1.6 Research Questions This research explores two main questions: 1. What are the connections between masculinities and older men’s experiences with physical activity in the context of their day-to-day lives?  2. What can be learned from older men’s experiences to inform the development of interventions to support physical activity for older men?  In the context of this research, the concept of “physical activity” will reflect the World Health Organization’s definition of physical activity for older adults, in which physical activity is considered in the context of daily family and community activities and includes: leisure activities such as walking, dancing, gardening, hiking, and swimming; transportation such as walking or cycling; occupational if the individual is still engaged in work; household chores; games; and sports or planned exercise (WHO, 2016). Physical activity can be more broadly defined as “any bodily movement produced by skeletal muscles that requires energy expenditure” (WHO, 2016).    12   Chapter 2: LITERATURE REVIEW     The extensive health benefits of physical activity are well documented, including some recent evidence regarding factors associated with older men’s abilities and motivations to engage in physical activity. The purpose of this chapter is to provide a review of the literature relating to physical activity engagement within the older male population. Literature reviews are used to better understand phenomena and to evaluate where research on a particular topic has or has not been completed in order to inform practice and provide direction for future research (Colquohoun et al., 2014). This chapter does not claim to include all existing evidence around the topic of physical activity in older men; rather, it includes integrated and relevant evidence to offer a comprehensive understanding of current knowledge of the topic area (Rumrill, Fitzgerald, & Merchant, 2009). This chapter identifies and presents common trends in existing knowledge (Rumrill et al., 2009) around older men’s engagement with physical activity and discusses knowledge gaps in the existing literature. 2.1  Existing Knowledge   In order to comprehensively review the existing literature around physical activity and older adults, and specifically older men, inclusion criteria were set to determine which literature to include. The review included peer reviewed, quantitative and qualitative studies, and systematic reviews on topics related to: older adults (age 65 and older) and physical activity, the benefits and factors influencing participation of older people in physical activity (including gender), aging and masculinity, older men’s experiences with physical activity, and socioecological models of health promotion. Studies were limited to those in English and those that focused on men. Online resources such as Health Canada, Statistics Canada, the Public Health Agency of Canada, Centers for Disease Control and Prevention, and the World Health 13   Organization were also accessed in order to gain an understanding of the definitions, statistics, and recommendations around physical activity for older adults. This chapter is organized into four sections, each looking at literature around the following areas:  • Factors influencing older men’s physical activity, including functional mobility, intrapersonal and interpersonal factors, the environment, and life changes  • Older men’s motivations for engaging in physical activity  • The influence of masculinity on men’s engagement with physical activity • Current physical activity promotion programs for men  2.1.1 Factors Influencing Older Men’s Physical Activity    2.1.1.1. Functional Mobility   Mobility can be broadly defined as the ability to move oneself, either independently or by walking, using assistive devices, or by using transportation (Webber, Porter, and Menec, 2010). One of the most significant concerns for older men is their ability to carry out essential activities of daily living, including having the ability to walk safely and independently within their communities to complete daily tasks (Webber et al., 2010). Functional mobility has been found to be one of the most important factors influencing engagement in physical activity for older men (Shum-Cook et al., 2002; Webber et al., 2010). Metz (2000) described the following elements as essential to the concept of functional mobility: 1) being able to travel to achieve access to desired people and places, 2) being able to get out and about in the community, 3) being aware of the benefits of exercise in maintaining physical health as one ages, 4) involvement in local communities, and 5) being confident that tasks can be completed even if they are not actually undertaken (Metz, 2000).  14   Mobility limitation is defined as impaired mobility, in which individuals experience a limitation in independent physical movement (Yeom, Fleury, and Keller, 2008); it can also be defined as the inability to walk a specified distance without assistance (Shumway-Cook et al., 2002). This limitation is prevalent in 44% of older men and results in decreased participation in physical activity and thus loss of independence, decreased quality of life, institutionalization, and a greater risk of mortality (Hirvensalo et al. 2000; Rejeski and Mihalko, 2001; Yeom et al., 2008). Further, because the prevalence of chronic disease increases with age and can significantly influence mobility, preserving functional mobility through participation in physical activity is critical in preventing further disability (Shumway-Cook et al., 2002). Although the terms mobility and physical activity may be used interchangeably in existing literature, “mobility” is used here as a factor that influences engagement in physical activity, and not as a synonym for physical activity.  2.1.1.2 Socioecological Factors: Intrapersonal and Interpersonal Factors   Socioecological models emphasize the need to consider multilevel factors that influence engagement in physical activity (Moran et al., 2014; Yeom et al., 2008), allowing for a more well-rounded approach to health promotion for older men. These factors may be intrapersonal, interpersonal, or environmental.  Yeom et al.’s (2008) comprehensive literature review revealed several intrapersonal and interpersonal risk factors associated with engagement in physical activity. Individual factors such as biology and genetics, age, gender, marital status, motivation, lifestyle factors, educational level, and socioeconomic status were all stated as intrapersonal factors that may have an influence on older adults’ engagement in physical activity and have also been reported in multiple other studies (Booth et al., 2000; Spence and Lee, 2002; Yeom et al., 2008). Further 15   studies add to Yeom et al.’s (2008) list of individual-level factors influencing physical activity levels such as: cognitive status, self-efficacy, coping behaviours, and relationships with others (Giles-Cort and Donovan, 2002; Webber et al., 2010). These studies acknowledge the need for a comprehensive approach to older men’s ability or lack thereof to engage in physical activity.  It is also important to consider the influence of co-morbid conditions when examining physical activity in older men, as this population is more likely to experience pain, joint problems, diabetes, decreased cardiovascular and aerobic function, diminished senses, reduced range of motion and flexibility, muscular atrophy, among various other health conditions compared to younger men (Daley and Spinks, 2000; DiPietro, 2001; Giles-Cort and Donovan, 2002; Spence and Lee, 2002; Yeom et al., 2008). Older men who have more than six co-morbid conditions show increased mobility limitation, which may result in decreased physical activity; older men may also experience problems with stability, balance, and gait, as well as chronic fatigue, significantly influencing their ability to be physically active (Yeom et al., 2008). These physiological changes and factors associated with aging can directly influence functional mobility, and in turn result in decreased participation in physical activity (Hirvensalo, Rantanen, and Heikknen, 2000).  Interpersonal factors such as social relationships and participating in group activities have been shown to have a positive influence on older men’s participation in physical activity, whereas weak social networks and limited social activities have been shown to limit physical activity; these findings have been reported in several studies (Booth et al., 2000; Gilles-Corti et al., 2003; Giles-Cort and Donovan, 2002; Spence and Lee, 2002; Yeom et al., 2008). Although a lack of social networking may result in increased mobility limitation, it is also possible that mobility limitation may hinder social participation (Gilles-Corti et al., 2003; Giles-Corti and 16   Donovan, 2002; Spence and Lee, 2002). Social participation may contribute to physical activities such as being out in the community visiting other people, receiving visits at home, and participating in social activities with others; whereas, lower social participation may result in lower physical activity levels and thus functional decline (Gilles-Corti et al., 2003; Giles-Cort and Donovan, 2002; Spence and Lee, 2002). This literature reiterates the need to recognize that older men’s physical activity is relational and context dependent, in which participation in social activities can contribute significantly to daily physical activity levels. Social relations include both diversity in relationships and active social participation (Gilles-Corti et al., 2003). Diversity in relationships refers to how often one contacts significant others such as their children, grandchildren, siblings, relatives, and friends, while social participation refers to active engagement in social activities, both of which are extremely important in participation in physical activity for older men (Yeom et al., 2008). 2.1.1.3 Socioecological Factors - Environmental Factors    As the environment exerts a direct effect on physical activity, understanding the relationship of the environment to physical activity is critical in understanding and promoting the health of older men (Shumway-Cook et al., 2002; Spence and Lee, 2002). Physical conditions such as the season of the year, the weather, the availability of programs, neighborhood characteristics, and pollution may significantly influence participation in physical activity (Booth et al., 2000; Yeom et al., 2008). Much of the research in this area has relied on quantitative surveys which has provided a broad overview of the relationships between environmental factors and older adults’ physical activity levels; however, there a few key studies that have used qualitative methods to examine these relationships (DiPietro, 2001; Gilles-Corti et al., 2003; Lockett, Willis, and Edwards, 2005; Moran et al., 2014; Spence and Lee, 2002; Yeom et al., 17   2008). For example, Van Cauwenberg et al.’s (2012) study involved walk-along interviews with 57 older adults, allowing the breadth of these environmental factors to be shown by integrating them into the comprehensive model below:   Figure 1: Environmental Factors Influencing Older Adults’ Physical Activity            Van Cauwenberg, J., Van Holle, V., Simons, D., Deridder, R., Clarys, P., Goubert, L., & Deforche, B. (2012). Environmental factors influencing older adults’ walking for transportation: a study using walk-along interviews. International journal of behavioral nutrition and physical activity.   As shown in this model, the relationship between the environment and physical activity is especially important because many older men using walking as a means for transportation. As one of the few studies using in-depth qualitative data collection methods to examine these relationships, the use of walk-along interviews in addition to traditional one-on-one interviews in this study allowed for the consideration and direct observation of the influence of the environment on physical activity. These methods provided the authors with detailed and context sensitive information about the participants’ physical environments. Their findings showed several positive elements associated with engagement in physical activity such as: access and distance to facilities; access to public transit; familiarity and comfort with the neighbourhood; 18   safety features of the neighbourhood; social contacts with friends and neighbours; aesthetics; and, the weather and time of year.  As another example, a study conducted by Chaudhury et al. (2012) explored the influence of neighborhood density, physical, and social environments on physical activity of older adults in Metro Vancouver, British Columbia, using a photovoice method with 66 older adults. The use of photovoice allowed the participants to collect their own data and thus findings may have been more reflective of genuine experiences with physical activity. The authors aimed to explore differences in physical or social environmental aspects that were perceived as barriers or facilitators to physical activity in higher and lower density neighborhoods; their study resulted in four themes including: safety and security; accessibility; comfort; and, peer support. Chaudhury et al. (2012) reported barriers including traffic hazards and personal safety in higher density neighborhoods. These results align with findings previously discussed and add to the growing body of literature around the role of the environment on the physical activity of older adults; however, these studies were not limited specifically to older men. 2.1.1.4. Life Changes    As men age, they experience significant life changes or periods of transition and generally, life changes have been found to have negative effects on participation in physical activity (Allender, Hutchinson, and Foster, 2008). Allender et al.’s (2008) systematic review found several studies examining the relationship between physical activity and life events. This review identified several categories of life changes that may influence physical activity, including: developing chronic conditions; becoming disabled; experiencing a change in physical status; experiencing a new medical diagnosis; change in residence; the death of a spouse or partner; change in employment status; or, changes in relationships. This study was the first of its 19   kind to bring together a broad literature on life events and physical activity, and the findings emphasize the need to consider life changes as key transitions faced by older men that can have implications on their engagement in physical activity. 2.1.2 Older Adults’ Motives for Physical Activity   Motives to participate in physical activity are relatively understudied in the older male population; however, one study by Rasinaho, Hirvensalo, Leinonen, Lintunen, and Rantanen, (2007) addressed this important area of gerontological research. Although Rasinaho et al. (2007) reported on both older men and women, they provided important information that is worthy of consideration in the context of this research. In their study, the authors investigated the motives of 645 older adults aged 75-81, with severe, moderate, or no mobility limitation in engaging with physical activity. Self-reported questionnaires revealed factors that motivated or did not motivate the older adults to be physically active and resulted in the following findings. Older adults who were severely limited in their mobility more often reported fears and negative experiences with activity, a lack of social company, and an unsuitable environment as barriers to physical activity; a motive for physical activity for this group was disease management and the prevention of disease progression. Older adults with moderate or no mobility limitation stated health promotion and positive experiences with physical activity as motivators to be active (Rasinaho et al., 2007). This study highlighted the need to consider the physical capabilities of older adults with varying health conditions when assessing motivations to participate in physical activity, perhaps by using more in-depth qualitative methods.  Older frail adults have also reported a lack of energy, as well as unsafe and difficult weather conditions, poor perceived health, and self-reported mobility limitation as reasons why they felt unmotivated to be physically active (Rasinaho et al., 2007; Webber et al., 2010). 20   Sociocultural expectations have also been shown to inhibit older men’s motivations to be active, for example misconceptions exist in society as well as healthcare about older people just needing to rest at home (Rasinaho et al., 2007). Further, it has been suggested that older people may exercise less as they age because of societal expectations such as “acting one’s age” in which physical activity is seen as inappropriate after a certain “old age” (Daley and Spinks, 2000).  Despite these factors, maintaining health and functional ability is the most reported motivational factor for physical activity by older adults. Other motivators include: social contact and support; disease management; knowledge about the benefits of exercise; having expectations of positive outcomes; self-confidence; personal beliefs around physical activity; and, being told by a physician or a healthcare provider to be physically active (Daley and Spinks, 2000; Rasinaho et al., 2007). Self-efficacy has also been reported as a critical component in individuals’ motivation for engaging in health behaviours such as physical activity (Yeom et al., 2008). Self-efficacy was defined in Yeom et al.,’s (2008) literature review as one’s beliefs around ability to engage in a healthy behaviour, influenced by both social contexts and social beliefs. Not surprisingly, the authors reported that positive self-efficacy resulted in enhanced physical activity participation. The following factors were related to low self-efficacy: older age; poor self-reported health; uncertainty of the benefits of physical activity; the anticipation of not being able to engage in certain activities; and, the anticipation of tiredness. Dependence on family members or caregivers to perform daily activities was also noted to be a sign of lacking self-efficacy and disengagement in physical activity. This dependency may be a result of physical deteriorations associated with aging, but may also be the result of psychological beliefs and expectations around aging (Yeom et al., 2008). Thus, beliefs about capability and lack thereof may actually be rooted in beliefs about what is expected of older men as they age.   21   2.1.3 The Influence of Masculinity on Older Men’s Physical Activity   The intersectional nature of gender and aging is a growing area of interest in gerontological research (Smith, Braunack-Mayer, Wittert, and Warin, 2007). It is well known that there are definite gender differences when it comes to physical and physiological aspects of aging (Daley and Spinks, 2000). People of both genders experience changes in physical appearances and body composition, such as decreased bone and muscle mass and increased workload of the heart leading to greater energy expenditure. Age-related changes such as these may influence the ability to engage in physical activity; however, there may also be differences around personal and gendered experiences with physical activity in the context of day-to-day life (DiPietro, 2001). Gender is socially constructed; it is dependent on how individuals as well as members of society define masculinities and femininities (Courtenay, 2000; Oliffe, Bottorff, Kelly, and Halpin, 2008). Gender stereotypes are deeply engrained within shared societal beliefs about how men should and should not behave, and these expectations may or may not change and evolve as one ages (Courtenay, 2000).   The social practices that underlie men’s health are often signs of perceived masculinity in that what it means to be a man may influence patterns of everyday activity (O’Brien Hunt, and Hart, 2005; Ribeiro, Paul, and Nogueira, 2007). Health related behaviours that demonstrate masculinity were discussed in some depth in two older articles (Courtenay, 2000; Donaldson, 1997). The authors identified some of these behaviours as including denial of weakness and vulnerability, and having emotional and physical control. Men are also believed to deny the need for help, and make risky decisions to portray masculine characteristics of strength and courage. These health behaviours have also been documented in more recent literature, demonstrating 22   unchanging beliefs and expectations about what masculinity means in society (O’Brien, Hunt, and Hart, 2005; Oliffe et al., 2007; Ribeiro, Paul, and Nogueira, 2007). Men are more likely than women to report being physically active; however, the proportion of men who meet the recommendations for physical activity appears to decrease with older age (Men’s Health Forum, 2014; Yeom et al., 2008), demonstrating intersections between aging, gender, and physical activity. In a study by Verdonk et al. (2010), the authors aimed to explore men’s health beliefs and attitudes towards health promotion and found that ideal men were associated with being breadwinners and competitors, while taking care of health was a feminine attribute. Daley and Spinks (2000) reported that 16% of older males aged 70-78 are vigorously active, compared with only about 4% of females of the same age. However, physical activity rates have been shown to decline as men age (Statistics Canada, 2015), possibly providing conflicting evidence in relation to older men’s self-reports of high physical activity levels and what they are actually doing. Health related beliefs may cause men to overstate their activity due to masculine perceptions and expectations of being strong and active; however, this requires further exploration (Courtenay, 2000; Levy, 1988; Ribeiro et al., 2007).  In addition to the challenges older men face in remaining “masculine” as they age, they are often seen as an invisible, paradoxical, and unmasculine category by society (Slevin, 2008).  Western culture encourages older men to take on characteristics of a manly nature; thus, factors that influence engagement in physical activity for older men may be associated with beliefs and concerns about the appropriateness of physical exercise in old age, as well as which activities are socially accepted (Daley and Spinks, 2000). For example, Connell and James (2005) theorized that in order to be socially accepted, older men will continue to enact traditional male characteristics, which will be reflected in their daily behaviours, including their engagement in 23   physical activity. Further, Vertinskey (1991) discussed how even if older men are in poor health, they may continue to take on the “robust, active, and healthy” role. Disregarding their actual state of health may be a reflection of a need for men to agree with societal attitudes towards gender expectations and reinforce existing stereotypes, even into older adulthood (Smith et al., 2007; Morley et al., 2014; Vertinksy, 1991). Although there is relatively limited research focusing on masculinities in older men, a few key studies explored this concept and offered some important context. Four examples below helped to synthesize the findings around men’s perceptions around masculinities.   Verdonk et al.’s (2010) study consisted of interviews with 13 men, who demonstrated that the concept of invulnerability was positively related to being masculine. Men wanted to perceive themselves as invulnerable and independent; they talked about how they ignored health complaints during daily activities until they could truly no longer be tolerated or ignored. They believed that complaining about “minor problems” was something that women would do (Verdonk et al., 2010). Most men also considered themselves healthy even if they experienced health problems that were affecting their lives.  Further, Drummond (2008) conducted a study on men’s abilities to be physically active as they aged; they situated their analysis in the context of a culture in which the ability to be active represented masculine values of power, independence, and toughness, values that are unlikely to change as men age. However, with age, men may experience a decline in muscle use, motor control, senses, and skills which can influence their ability to be physically active, which in turn may affect their ability to portray those values of power, independence, and toughness (Drummond, 2008). Thus, although engrained societal values of what it means to be masculine may or may not change with age, the way these values are portrayed are more likely to change 24   with older age. For example, Drummond argued that “gym culture,” has been linked to younger men, where lifting weights and strength training may be values representing power and toughness. However, older adults may not see gym use as appropriate for someone who is elderly and aging, but they may view the ability to complete a hike or complete activities of daily living independently as ways of reflecting the same masculine values (Drummond, 2008; Spector-Mersel, 2006).  These two studies did not focus specifically on older men; however, a study by Smith et al. (2007) addressed this gap by interviewing 36 older men, making it one of the few studies that had a specific focus on aging men and masculinities. From their analysis around masculinity and aging, Smith et al. (2007) found that despite gender stereotypes, men were open to discussing aspects of their health such as depression, relationships with others, and physical changes associated with aging. However, masculine traits such as being tough, independent, strong, and in control were evident within the men’s comments, reflecting perceived societal expectations of masculinity. Functional independence in conducting daily activities was significant to the men, motivating them to be active, while preventing having to be cared for in the future; the men described successful aging as a long life-expectancy while minimizing physical and mental disability. The men were open to using walking and transportation aids, so long as it helped them maintain their independence; however, keeping their drivers’ licenses was very significant to the men, as they associated losing it with a loss of independence and a lower quality of life. Smith et al.’s (2007) findings demonstrate the need to consider independence and functional ability among older men as both a characteristic of their masculine identities as well as a component of successful aging for some men (Smith et al., 2007).  25   Another study focusing on aging men is one by Ribeiro et al. (2007), which involved in-depth personal interviews with 53 older men who had taken on the role of caregiver for their wives. While caregiving was still perceived as a feminine role, in their interviews these men highlighted issues around power within a caregiving relationship as well as their satisfaction with “being in charge.” These findings suggest that although gender roles may continue to be stereotyped as being a “masculine” or “feminine” role or activity, the person enacting this role may change in relation to their life circumstances and age. The complexity of these issues is also discussed by Spector-Mersel (2006), who stresses the importance of a temporal consideration of masculinity across the lifespan given the struggle faced by older men to adhere to Western beliefs around masculinity. It is very likely that this extends beyond the context of caregiving, and that the tension between shifting roles and entrenched masculinities requires greater exploration in the context of physical activity.   In addition to the complex interactions between aging, gender, and physical activity, sexual orientation may also influence experiences with manhood and aging. Within society, heterosexuality is normalized whereas homosexuality is stigmatized, and thus gay men may experience aging and physical activity differently than heterosexual men (Slevin, 2008). Gay men may often be “feminized” or “demasculinized” by society, possibly influencing their behavioural patterns and health choices; for example, they may be ridiculed as doing “female tasks” such as cooking and cleaning (Courtenay, 2000). Limited studies exist regarding older gay men, masculinities, and physical activity; however, one such study by Slevin (2008), interviewed 26 gay men with a common theme emerging to show that many of the men engaged in physical activity in order to remain healthy and to keep their bodies trim and fit in order to avoid the stigma of looking like old men. This topic requires further exploration.  26    Widowhood may also be a significant influence on masculinity and men’s daily experiences. A component of patriarchal masculine identity is having control over women; when men are widowed, there is no wife to dominate and thus a man’s masculinity may be impacted (Bennett, 2007). Bennett (2007) argues that widowed men face increased challenges in regards to their needs and their experiences. They may feel less masculine if they now must engage in typically “female activities” such as cooking and cleaning; the same argument can possibly be made for divorced men, as well as men who have never married. Bennett (2007) stated that these men may react by abandoning their masculine roles, or they may re-construct their perception of masculinity in which feelings of grief, loss, and pain may be overshadowed by actions of control and responsibility. Stereotypical beliefs about masculine values may be affected by life experiences such as bereavement and widowhood, which may challenge ideals of self-reliance, control, strength, and independence (Bennett, 2007). These experiences may also contribute to powerlessness and may subsequently influence older men’s daily behaviours and decisions, for example around physical activity. However, there is limited evidence around widowhood, older men, and physical activity.  Masculine values are reflected within men’s behaviour in everyday situations, as well as in decisions they make around physical activity (Connell and James, 2005; Schippers, 2007); however, men enact masculine values in different ways. For example, most men may agree that men should be tough and strong, but how they demonstrate toughness will differ according to age, culture, ethnicity, social class, and sexuality (Courtenay, 2000). Masculinity does not represent certain types of men, instead it represents how men socially position themselves in their everyday practices, choices, and relationships. Older men’s experiences with physical activity are deeply situated within their masculine values and need to be considered concurrently.  27   2.1.4 Current Physical Activity Promotion Programs for Men   While effective health promotion programs tailored to older men might significantly improve the health status of men as they age, there has been little research examining this question. However, a recent literature review conducted by Bottorff et al. (2015) provided a comprehensive evaluation of 35 articles published between January 2010 and August 2014 that described research conducted on 31 existing physical activity promotion programs for men. Most of the studies in their review (24) evaluated programs that were only available to men, with the primary outcome of interest being a change in physical activity. The programs varied in their mode of delivery including group sessions, individual face-to-face sessions with a personal trainer, or simply encouraging participants to exercise on their own. Some programs used various resources such as print materials, DVDs, personal reports, online food and exercise diaries, and email prompts with motivational messages. The internet was also used as a way for participants to engage in friendly competition with other participants regarding their progress. A similarity noted by Bottorff et al. (2015) was that all of the unsuccessful programs used an individual approach in which men were encouraged to engage in physical activity on their own. Effective programs included regularly scheduled physical activity in group sessions, and individualized exercise plans supervised by personal trainers; devices were also used to monitor activity such as pedometers or heart rate monitors. Bottorff et al. (2015) found that the majority of the programs were tailored to theory, rather than gender-specific strategies, in which self-efficacy and social support were important components of gender-neutral strategies such as goal-setting and providing advice. Programs that were highly successful examined the men’s interests and then built physical activity programs that were tailored to these interests or specific to commonalities within the group of men (Bottorff et al., 2015).   28   Bottorff et al. (2015) argued that older men can be a hard to reach population with unique challenges that exist in implementing health promotion interventions such as physical activity programs. They demonstrated that many men are unlikely to seek healthcare advice or to take an active role in disease prevention; further, there are only a limited number of physical activity programs that are targeted specifically towards men. In their literature review, the authors discussed how although existing programs aim to enhance male participation and retention, they do little to examine physical activity interventions that consider the influence of gender and masculinities. Men’s willingness to be involved in physical activity is a significant consideration when building successful health promotion programs; thus, motivation is a factor that must be addressed. Simultaneously, barriers to men’s engagement with physical activity must also be understood as carrying equal weight in knowledge (Bottorff et al., 2015). This review identified five themes that were evident in successful and sustainable health promotion work with men including: 1) settings that facilitate men’s engagement such as the workplace or sports clubs, 2) using a gender-sensitive approach, 3) incorporating feedback from men, 4) providing training and support, and 5) collaborating with community groups. While these themes might be relevant for older men as well, the review did not specifically address the question of age.  One program appearing in the gray literature is “Fit Fellas” at the West Vancouver Seniors’ Activity Centre, for men aged 55 and older. Formed in the 1970s by the then director of recreation in West Vancouver, Fit Fellas is a group exercise program for older men with a strong socialization aspect (The Effervescent Bubble, 2016). This program has grown to include 195 members who meet up to eight times a week for a fitness class for men; it is led by four volunteer trainers and they do activities such as aerobics, strength training, coordination, balance, stretching, as well as optional social events. This program has been largely successful with over 29   45% of the members having been participants of the program for over 10 years (The Effervescent Bubble, 2016). “They keep in touch by email and a quarterly newsletter, volunteer in various community groups and events, and take part together in other sports, competitions, pub nights, and fund-raising activities. As much as the exercise, their goal is to have fun and build friendships.” (The Effervescent Bubble, 2016). Despite its success, the qualification criteria for this program is unclear, and the membership is currently full, meaning that there is a waiting list to join the program.  The Fit Fellas Program inspired a two-year study of the benefits of group exercise programs for older adults by UBC’s School of Kinesiology. Approximately 600 older adults, aged 65 and older, participated in the GOAL trial three times a week, led by volunteers at YMCA locations across Greater Vancouver (UBC, 2015). UBC researchers aimed to investigate the influence of both mixed and same gender classes for older adults; however, findings from this study do not appear to be available at this time.  In further review of the literature, there is very limited research around programs specifically targeted at older men. This is significant considering that there are even greater challenges associated with men as they continue to age which must be considered when designing effective interventions. Some of these may include physical changes and functional limitations (Drummond, 2008), changes in life circumstances, and the loss of social support networks (Allender et al., 2008), among others.  Thus, not only must efforts be made to increase attendance of physical activity programs by older men, healthcare providers also need to consider designing programs that will lead to retention of participants by adequately designing these programs in consideration of unique challenges faced by older men.  30   2.2 Gaps in Knowledge    2.2.1 Lack of Emphasis on Personal Experiences  Much of the existing literature around physical activity and aging is related to physiological aspects of aging bodies. While a large amount of research exists around the benefits of physical activity for older adults and the negative consequences of not being active enough, there is relatively less research around older men’s experiences with physical activity. The literature emphasizes individual behaviours and choices when it comes to engagement in physical activity; however, this may be harmful because the end result may be personal blame and victimization for “not being active enough” (Giles-Corti and Donovan, 2002). Individualistic approaches fail to consider the unique contexts within which health behaviours exist; personal experiences are deeply contextualized and need to be considered in light of many interconnected socioecological factors. There are significant interactions between individuals and their social and physical environments that influence older men’s experiences with physical activity in the context of their everyday lives including environmental settings, biological and physiological factors, life experiences, and societal expectations (Spence and Lee, 2002).  In light of the various benefits to physical activity, there is generally a poor understanding of older men’s personal experiences and motivations around physical activity (Booth, Owen, Bauman, Clavisi, & Leslie, 2000). While some research exists around factors influencing older men’s engagement in physical activity, these findings appeared to be surface level and of a descriptive nature, without more deeply exploring older men’s unique experiences. 2.2.2 Focus on Quantitative Methods and Traditional Interviews  The use of a comprehensive approach to health promotion is necessary and recognizes that gender and personal life experiences may shape individuals’ experiences, opportunities, and 31   behaviours around physical activity (Webber et al., 2010). Many previous studies on physical activity among older adults and older men have used quantitative data collection methods, and there are relatively few studies that have used advanced qualitative methods, beyond traditional interviews, to fully understand physical activity among older adults (Chaudhury et al., 2012; Lockett et al., 2005; Shumway-Cook et al., 2002; Van Cauwenberg et al., 2012). While quantitative methods have contributed to increased knowledge around influences on physical activity, more in-depth qualitative methods such as photovoice and walk-along interviews can further our understanding of contextual influences on active living. Qualitative methods can also assist in allowing us to examine more comprehensively and thoroughly, the factors that may impact older men’s experiences with physical activity.  2.2.3 Greater Need to Focus on Men   Older men become less physically active as they age and face significant societal pressures to adhere to masculine norms (Courtenay, 2000; Daley and Spinks, 2000; Webber et al., 2010). However, much of the available literature around aging has either focused on gender differences between men and women, or has involved studies with mostly female participants (Dacet, Baltzell, and Zaichkowsky, 2008; Rasinaho et al., 2007), making it difficult to translate this knowledge to benefit older men (Bottorff et al., 2015). Daily behaviours such as engagement in physical activity may be deeply gendered in the way they are enacted; masculinity in later life and especially, how life events impact masculinity as one ages, deserves more attention (Bennett, 2007; Daley and Spinks, 2000; Drummond, 2008). Older men’s lives are deeply tied to gender and masculine ideologies, but there is relatively little known about how older men understand and enact being male in their day-to-day lives (Smith et al., 2007). Much of the existing research that has attempted to look at the intersections between masculinity, aging, and physical activity, 32   has focused on the aging of male bodies and physical capacity (Smith et al., 2007). While these aspects are important, larger contexts need to be considered. Current gender knowledge has not been translated to interventions (Verdonk et al., 2010) and future health promotion interventions directed at older men need to consider these existing gaps in knowledge.  2.2.4 Lack of Existing Physical Activity Promotion Programs Specific to Older Men   There are relatively few existing health promotion programs that are tailored for older men, raising questions around sex and gender influences in developing targeted interventions for this population (Bottorff et al., 2015). Gender knowledge is currently mostly descriptive with relatively few studies informing health promotion interventions that are centered around older men. More recently, there have been increasing numbers of physical activity promotion programs that specifically integrate a gender-sensitive approach into the intervention, which have the potential for effective health promotion in older men (Bottorff et al., 2015). However, most of the existing physical activity programs for men do not adequately consider research around ways that older men access and engage in physical activity (Bottorff et al., 2015). Even programs that aim to reach men at places where they commonly gather, such as the workplace, create challenges for healthcare providers that are working with older men, an even harder to reach population. Older men are a unique subpopulation whose involvement in physical activity must be considered as deeply contextual and situated within aspects of their everyday lives. As innovations in physical activity programs that consider masculine ideals and gender influences specific to older men are lacking in current literature and in existing health promotion programs (Bottorff et al., 2015), further research on how to meaningfully and effectively engage this population in physical activity programs is necessary.   33   Chapter 3: DESIGN AND METHODS   3.1 Introduction  The purpose of this chapter is to explain the methods that were used to address the noted gaps in knowledge through the following research questions:  1. What are the connections between masculinities and older men’s experiences with physical activity in the context of their day-to-day lives?  2. What can be learned from older men’s experiences to inform the development of interventions to support physical activity for older men?  Research question two can be considered as part of a discussion that considers the findings from research question one. Through exploration of these two research questions, the intent was to enhance understandings of older men’s experiences with physical activity, and thus add to the existing knowledge around older men’s engagement with physical activity and what it means to them in relation to their day-to-day lives. Using a socioecological model of health promotion and a masculinities framework to inform analysis allowed for the consideration of the connections between masculinities and older men’s experiences with physical activity in a holistic and sociocultural context. Understanding these experiences can inform health promotion interventions around physical activity that can be more appropriately and specifically applied to facilitate healthy aging for older men.  3.2 Study Design  Qualitative research explores human behaviour and the concept of understanding through people’s actions, and thoughts (Maggs-Rapport, 2001); it is intended to take healthcare professionals to the heart of a patient’s experience (Biggerstaff & Thompson, 2008). This qualitative study used an interpretive descriptive approach with in-depth qualitative data 34   collection and analysis methods to identify key categories across older men’s experiences with physical activity in order to inform health promotion interventions specific to older men.  Interpretive description is a qualitative methodology that considers the applicability of qualitative research approaches in answering clinically relevant questions (Hunt, 2009; Thorne, Kirkham, & MacDonals-Emes, 1997). The discipline of nursing involves various sources of knowledge and unique principles, and interpretive description recognizes this by allowing us to develop knowledge about human health and experiences with phenomena that traditional qualitative approaches may not (Thorne, 1991; Thorne et al., 1997). Created and argued by nursing scholar Sally Thorne (2008), the aim of interpretive description is to generate knowledge that is relevant and applicable to the clinical context of applied health disciplines, without the need to adhere strictly to traditional qualitative methodologies and rules (Berterö, 2015; Thorne, 2016). Instead, interpretive description allows researchers to borrow from the vast amount of available design techniques that may be appropriate to the unique research question (Thorne, 2016). Thorne (2016) described interpretive description as an approach that derives purpose from three sources: “(1) an actual real-world question, (2) an understanding of what we do and don’t know on the basis of available empirical evidence, and (3) an appreciation for the conceptual and contextual realm within which a target audience is positioned to receive the answer we generate.”  Interpretive description does not consist of an exact way or set of rules to conduct a study; rather, it serves as an organizing framework within which a range of various data collection and analytic strategies can be used, as long as they are logical and consistent with the aim of the study (Thorne, 2016). Foundational to nursing knowledge is the recognition that experiences with health and illness are complex and are comprised of interactions between 35   physical, social, and biological elements (Thorne et al., 1997). Nurses depend on a diverse and large body of practical knowledge in order to translate ideas from research into the actual application of those findings in practice (Hunt, 2009; Thorne, 2016). Research questions open to interpretive description include those that involve a description of a phenomenon using an interpretive lens. Description is extremely important in bringing the awareness of a phenomenon to those in the health discipline, and interpretation allows us to construct meanings within subjective experiences (Thorne, 2016). It is the applicability of this description and interpretation that allows researchers to contribute meaningfully to the applied discipline of nursing (Hunt, 2009). Interpretive description is the most appropriate design for answering the research questions presented in this study, allowing for the generation of new knowledge in a form that is meaningful and relevant to the applied practice context of developing physical activity based health promotion interventions targeted at older men.  3.3 Sampling Plan  3.3.1 Sample Population  This research developed an in-depth understanding of older men’s experiences with physical activity. In order to engage in health promotion interventions with older men, understandings of the experiences and perceptions of older men were developed. It is argued that people who have lived with certain experiences are often the best source of knowledge about those experiences (Thorne et al., 1997). Thus, the target population involved older men, which in the context of the current study was defined as men over the age of 65 who are living in the community. This community setting was chosen because older men who are living in the community, either independently or with supports, may face specific challenges that influence their engagement in physical activity. A key principle of health promotion is enabling control 36   over ones’ health (WHO, 2016) and research shows that older adults would like to continue living in their homes in the community for as long as they are able (National Institute on Aging, 2010). An important factor in maintaining the independence necessary to be able to continue living at home is engaging in physical activity; thus, healthcare providers must understand the experiences of those community-dwelling older men in relation to physical activity before they can promote this aspect of health for these men.  3.3.2 Inclusion Criteria  A diverse sample was recruited, and inclusion criteria were intentionally kept broad. Participants:  • Self-identified as men  • Were able to communicate in English   • Were over the age of 65 • Lived in the community (including assisted living), either alone or with others  • Were able to move about and within their homes, either independently or with assistance  Participants were excluded from the study if they were acutely ill or if they were cognitively impaired and unable to provide informed consent.  3.3.3 Recruitment   Qualitative studies typically involve a small number of study participants, often 10 or fewer, to allow for in-depth exploration (Polit & Beck, 2012). We aimed to recruit 10-15 community dwelling older men using convenience sampling in the Greater Vancouver area. With this sampling approach, participants come forward and identify themselves as wanting to participate in the study (Polit & Beck, 2012). Convenience sampling is efficient, cost-effective, readily available, and results in useful and relevant data (Polit & Beck, 2012). Further, a sample created by “convenience” can be very appropriate in circumstances where the target population 37   is difficult to reach, as older men are known to be. Groups of people who are conveniently sampled may also be an excellent source of insight in describing aspects of a shared experience (Thorne, 2016).   Our use of convenience sampling was three-fold. Initially, letters were mailed out to a list of participants who had participated in previous research and had consented to being contacted for future studies (See Appendix A: Invitation to Participate in the Study). The inclusion criteria for the previous research involved being over the age of 65 and being English speaking and thus met eligibility criteria for our study; the list was scanned to ensure we only sent letters to men. In total, 21 packages with information about the study were sent out to these potential participants who had the option of calling the number provided in the letter, sending the research team a pre-stamped postcard found in their mailout package, or contacting the project coordinator of the study (See Appendix B: Recruitment Postcard). This technique resulted in the recruitment of 10 participants. Second, posters were displayed at two recreation centers in the Lower Mainland region of Greater Vancouver: Kennedy Seniors Recreation Center in North Delta, and Newton Seniors Center in Surrey (See Appendix C: Recruitment Poster). This recruitment technique resulted in one participant from Kennedy Seniors Recreation Center, but we were unable to recruit any participants from Newton Seniors Center. Finally, although not originally in the recruitment plan, three of the older men told other older men about the study, allowing us to recruit three more participants through snowball sampling (Polit & Beck, 2012). These three techniques resulted in a total of 14 participants; we also conducted a pilot interview with a community dwelling older man who was known to one of the researchers on the team and volunteered to be interviewed. Thus, we recruited a total of 15 community dwelling older men, each of whom participated in an in-depth one-on-one interview.  38    From these 15 men, we further selected a subsample of four men who were willing to be involved in further data collection beyond the single interview. We were limited by an agreement with the research team in which we were unable to pursue the men who were recruited from the mail out packages for further involvement in the study; the reason for this was to prevent a research burden on these men. Our subsample of four men consisted of the three men we recruited through snowball sampling, and the one man recruited from Kennedy Seniors Recreation Center.  3.4 Procedures and Data Collection   Data collection in interpretive description can take many forms (Thorne, 2016). An assumption underlying interpretive qualitative research is that people are always engaged in the world, and thus understanding of experiences is accomplished though examining activities, and relationships in everyday life (Phinney, Dahlke, & Purves, 2013; Thorne, 2016). Although in-depth one-on-one interviews have traditionally been the main data source in qualitative studies in nursing (Polit & Beck, 2012; Thorne, 2016), accessing experiences can be complicated and may require the use of multiple data collection methods (Phinney et al., 2013). In addition to interviews with the 15 men, photovoice methods and walk-along interviews were also used to gather in-depth data reflecting the experiences of each of the four participants who were recruited for further data collection. Focusing on these four men allowed for a better understanding of the phenomenon in terms of depth and context.  3.4.1 One-on-one Interviews    Each of the 15 participants were involved in an initial sit-down, one-on-one interview that lasted approximately 45 minutes. These 15 interviews resulted in a total of 678 minutes (11 hours and 18 minutes) of audio recorded data.  39   The purposes of the original sit-down interview were: to gain an overall understanding of the participants’ subjective experiences with mobility and physical activity in the context of their everyday lives; to understand what enables older men be more and less able to be physically active in their daily lives; and, to understand what it means to be physically active as men. Interviews were facilitated by research assistants, and were semi-structured with broad open-ended guiding questions, and appropriate probes and prompts to ensure that a specific set of topics was covered in the interview (Polit & Beck, 2012). Questions of an open nature encourage depth and vitality, and help concepts emerge through the collection of rich data (Doody & Noonan, 2013). A semi-structured interview guide was developed by the research team, however researchers encouraged participants to speak freely about the topics.   Two research assistants were present at each interview with one conducting the interview with the participant, and the other serving as a note-taker who documented non-verbal communication, the physical environment, and key comments made during the interview. At the start of each interview, the nature and purpose of the interview was described, as well as ground rules such as confidentiality agreements, and logistics such as interview length and format. Research assistants identified their roles in the research study and in the interview in order to build trust and establish rapport (Goldsmith, Wittenberg-Lyles, Rodriguez, & Sanchez-Reilly, 2010); verbal and written consent was obtained from each participant prior to the interview (See Appendix D: Information Letter and Consent Form (Initial Interview)).  Each interview was audio recorded and transcribed; transcriptions were completed by an outside source affiliated with the research team. The researchers who conducted each interview debriefed and reflected with one another following each interview. Interviewers also engaged in writing field notes following the interview, including a description of what happened in the 40   interview as well as some preliminary analytic notes (See Appendix E: Interview Guide and Field Note Template). The following two sections discuss further data collection methods conducted with the subsample of four men. Consent for both the walk-along interviews and the photovoice portion was obtained during a separate meeting with the participants prior to beginning this data collection (See Appendix H: Consent Form (In-depth data collection methods)). 3.4.2 Walk-along Interviews    Walk-along interviews were conducted with the sub-sample of four men. Each of these men participated in 3 walk along sessions, ranging from 30 minutes to 1 hour, resulting in 2.17 hours of video footage and 5.74 hours of audio recording.  Walk-along interviews are a way to generate in-depth qualitative data by accompanying participants on typical outings in their familiar environments, in which the researcher is “walking through” peoples’ lived experiences in their neighborhoods (Carpiano, 2009). Through asking questions and observing, we were able to examine the participants’ experiences, interpretations, and practices within this environment (Carpiano, 2009). It is argued that walk-along interviews generate richer data than traditional sit-down interviews because interviewees may be prompted by meanings and connections to the surrounding environment (Evans & Jones, 2011). The walk-along interview is based on the idea that walking with participants creates the ability to gain additional insights through participant observation (Butler & Derrett, 2014). It has been described by Carpiano (2009) as a hybrid data collection method involving both a form of interviewing and participant observation.  The walk-along interview was an ideal method for this study because it is extremely valuable in providing rich data about physical and social environments, functional ability, and 41   motivating factors that may influence engagement in physical activity. Similar to participant observation, walk-along interviews allow the researcher to spend time with participants, helping build rapport and trust, and gaining an enhanced understanding of participants’ day-to-day lives (Butler & Derrett, 2014; Carpiano, 2009). In addition, this data collection method has various other advantages: it is person-centered and designed to understand human experiences; it is more interactive and personal than traditional interviews; and, it captures individuals in the context of their everyday lives that may have been otherwise unnoticed. The participant is also able to show, rather than describe, their environments and their engagement in those environments, while allowing researchers to examine differences and similarities between what the participant says they do and what they actually do. Walk along interviews place participants in their everyday context, which may help participants articulate thoughts and remember stories, while allowing for convenience in which the researcher does not interrupt the participant’s everyday activities (Butler & Derrett; Carpiano, 2009; Clark & Emmel, 2010). Walk-along methods were used in this study to observe, experience, and make sense of older men’s everyday experiences with physical activity, with the aim of understanding how participants place themselves in socially constructed practices and position themselves as men in their everyday lives.    In this study, walk-along methods involved two research assistants walking with the participants as they moved about and engaged in their everyday environments. This method included observation in which hand-held video recorders were used to record certain portions of the walk-along interview, as well as a form of interviewing in which questions were prompted by what was going on during the interview. Participants selected where and when the interview would take place in collaboration with the researchers. The goal was to have participants choose activities that they normally engage in, both inside and outside their home, while describing their 42   experiences and thoughts in the context of this activity. Locations and activities for the walk-along interviews included: walks around the neighborhood; walking a participant’s dog; trips to grocery stores; running errands such as going to the bank or library; conducting house tours; participants conducting housework such as yard work and indoor household chores; and, accompanying a participant to a Senior’s Center in the community where he took part in carpet bowling. Within these walk-along sessions, the research team was looking for: how the physical environment influenced the older men’s physical activity; contexts of their everyday lives including the use of public transportation; physical function and abilities; safety aspects; and, social settings and social interaction.   With two research assistants present, one took the role of the primary interviewer who audio recorded the interview, and the other had the responsibility of taking observational notes as well as video-recording relevant components of the interview. The audio from each walk-along session was transcribed by a transcriptionist from an outside source affiliated with the research team (See Appendix I: Walk-Along Interview Guide). 3.4.3 Photovoice    The subsample of four men also participated in photovoice. The participants were not given a minimum or maximum number of pictures they should take; they kept the cameras for approximately 2-3 weeks, resulting in 54 photographs across the four participants. Interviews discussing these photographs resulted in a total of 1.57 hours of audio recording.  Photovoice is a participatory data collection technique in which participants record and reflect on their communities and experiences within those communities through photography (Novek, Morris-Oswald, & Menec, 2012); it puts the tool of research in the hands of the participants (Yankeelov, Faul, D’Ambrosio, Collins, & Gordon, 2013). Photovoice is used to 43   promote conversation and discussion through photographs taken by participants, allowing researchers to gain insight about participants’ perceptions of their physical environment (Wang & Burris, 1997). Photovoice also allows participants to think critically about their community, and to begin to describe the everyday factors that influence their lives, while at the same time allowing participants to feel empowered and in control of the data they provide (Wang & Burris, 1997). This data collection strategy enables men to assess the strengths and concerns of their community, share knowledge, as well as present their experiences. Taking photographs may also allow participants to express their stories in ways that may be difficult through conversation (Mahmood et al., 2012). With photovoice, different stories can be told, different experiences can be captured, and individuals can be heard and empowered, providing an effective and flexible qualitative approach that produces rich and meaningful data (Palibroda, Kreig, Murdock, & Havelock, 2009).  In the current study, photovoice was used to engage with the four older men in taking photographs of their everyday lives in order to understand how they experienced and interacted with their everyday social and physical environments. Each of the four participants were asked to take photos within his physical and social environment of aspects that influenced his mobility and physical activity. Instructions were left intentionally broad to allow participants the freedom to take photographs they felt were relevant. Generally, participants were invited to take photographs of their environments that most influence their everyday life and their participation in physical activity. It was explained that these photographs could be of things that made it easy or difficult for the participants to get around. They could also be pictures of things that motivated or prevented them from engaging in physical activity. It was also asked of the participants to write a small note for each picture while considering the following three questions:  44   •  How does the image in the picture influence your mobility?  • Does the image in the picture make it easy or difficult for you to get around or engage in physical activity? Why?  • In the picture, what is meaningful to you and your physical activity? Why? Participants were given a package containing instructions for the photovoice component of the study, a camera, and a booklet to write down their notes (See Appendix J: Photovoice Data Collection Instructions, and Appendix K: Photovoice Form for Participants’ Notes).  Once the cameras were collected from the participants, we examined the photos as well as the notes written with each photo. We arranged a final interview in which we discussed the photos with each of the participants; this interview was audio recorded and transcribed by an outside source transcriptionist who was affiliated with the research team. There were two research assistants present at each interview, one as the primary interviewer and one as the note-taker. During this interview, participants were asked to explain each photograph and why they took it, allowing participants to reflect on, share, discuss, and contextualize the pictures they took (Mahmood et al., 2012). We also used this final meeting as an opportunity to ask any questions that may have come up through our multiple meetings with the participants that may not have been answered. Thus, we met with each of the four participants on 6 occasions:  • A consent session proceeded by an initial sit down one-on-one interview with each participant  • A second consent session to explain further portions of the study (walk-along sessions and photovoice) • Three walk-along sessions with each participant  • Photovoice interview with each participant  45   Participants received a 10-dollar gift card to Safeway or Tim Hortons as an honorarium for each session they participated in; thus, each participant received $50 for participating in the study, as a thank you for their time and involvement in the research process. The research team believed this amount was appropriate, yet not coercive due to the time commitment to the research process. For one of the photovoice sessions, we included the participant’s wife in the interview as she provided a great deal of support for her husband and we felt she could provide valuable information. The participant’s wife also signed a consent form prior to this session and received a $10 gift card for her time.  3.5 Data Analysis    In order to explore in-depth, the subjective experiences of the older men, analysis was limited to the data collected from the four men who participated in the initial interview, the walk-along sessions, as well as photovoice. This sample of four men provided diversity in their range of experiences, as well as depth in the data that was generated, while simultaneously allowing for the maintenance of a reasonable scope for this thesis research.  Data analysis in interpretive description can take many forms, provided that the analysis plan is consistent with the research question(s) and researchers’ aims (Thorne, 2016). In order for meaningful themes and interpretations to emerge, data analysis requires total immersion in the data (Kleiman, 2004). The analysis for this study consisted of conducting a thematic analysis of the data collected for the subsample of four men; a thematic analysis is a common data analysis technique used in qualitative studies to discover themes or categories of experiences as viewed from the participant’s perspective (DeSantis & Ugarriza, 2000). A thematic analysis is useful in summarizing key features of large bodies of data, while offering thick detailed descriptions with in-depth interpretations, which can highlight similarities and differences across the data set. It 46   also allows for social and psychological interpretations in analyzing patterns of meaning in the data, which can then be applied to practice (Joffe, 2012; Parsons, 2013; Thorne, 2016).  A theme is defined here as a specific pattern of meaning that is found within the data (Joffe, 2012). Thematic analysis was developed as an advancement of content analysis in which categories are established and then the frequency of these categories are explored; thematic analysis goes beyond observable material and includes interpretations and meanings of the data (Joffe, 2012). The steps outlined below are stated by Kleiman (2004), and Joffe (2012), and were used in this study to conduct a thematic analysis of community dwelling older men’s experiences with physical activity.  1. Examination of the full dataset. All data was read and viewed closely in its entirety in order to gain a good sense of the whole picture for each of the four participants. This data included: transcripts from the original sit-down interviews, walk-along interviews, amd photovoice interviews; the walk-along videos; the photovoice pictures, as well as their captions; and, the research assistants’ field notes.  2. Creating an interpretation framework. An interpretation framework for data analysis was developed to allow for the organization of data into headings and subheadings in order to answer the research questions (See Appendix L: Interpretation Framework for Analysis). All the data was read and viewed a second time, but this time, data was organized into this interpretation framework. This framework provided a tool with which to understand, examine, and classify the data into meaningful sections to address similar ideas; it also guided the thematic analysis. Although this framework was used at this point in the thematic analysis, analysis is an iterative approach in which data was interpreted and re-organized throughout the analysis.  47   3. Meaningful description. In reviewing the data for the third time, detailed descriptions were provided around both what was said by the men and what was observed by the researchers. Data was explored in depth using the identified socioecological and masculine perspectives as a way to inform data analysis. These theoretical frameworks were not specifically used to structure the analysis, but they were used as a lens in which to approach and think about the data. 4. The development of themes. The data was reviewed for commonalities within and across the data; categories were then developed to portray patterns and meanings within the data. This component is the most significant in thematic analysis, facilitating examination of themes, their interconnections, and their linkages with previous data.  5. One step further with interpretation. In addition to the development of themes and descriptions, these themes were elaborated on to include insights and interpretations of the data, using the raw data as support (Brocki & Wearden, 2006; Smith et al., 1997). Interpretation of the data involved exploring in detail the processes through which participants made sense of their own experiences, and how we as researchers made sense of their experiences (Brocki & Wearden, 2006) using socioecological and masculinities frameworks.  6. Transforming patterns into findings and application to practice. The main premise behind interpretive description is to generate knowledge that can be applied to practice. Data analysis took into consideration both what the participants had stated about physical activity programs, as well as interpretations around how the men’s experiences with physical activity can help inform the development of related health promotion interventions.  48   Data analysis is an iterative and ongoing process in which analysis and interpretation constantly occur together. Analysis looked at what the data said, whereas interpretation looked at what the data meant (Kleiman, 2004). The end goals of the thematic analysis were to: provide descriptions of the four participants’ experiences with physical activity; discover essential meanings within the data; and, use the data to inform the development of health promotion interventions for older men (Kleiman, 2004). The socioecological model for health promotion and a masculinities framework were used to inform, but not structure, this analysis.   3.6 Ethical Considerations   This study was funded by the Canadian Institutes of Health Research (CIHR) as part of a larger team-based grant. Ethical approval was obtained from Fraser Health Research Ethics Board, University of British Columbia Research Ethics Board, and Vancouver Coastal Health Research Institute. There were no conflicts of interest declared by the research team.  3.6.1 The Consent Process    Participants who met the inclusion criteria and voluntarily identified themselves as wanting to participate in this study were contacted with further information about the study dynamics and their role in data collection. Initial interviews were arranged in collaboration with the participants and took place in participants’ homes, community centers, local coffee shops, and the Center for Hip Health and Mobility (affiliated with Vancouver Coastal Health Research Institute). Upon first meeting with the participants, written and informed consent were obtained prior to the initial interviews. The two research assistants conducting the interview were present during this consent process.  If participants agreed to participate in further data collection methods (walk-along interviews and photovoice) after their initial interviews, we arranged for a second consent 49   session in which we explained what would be expected from them in this next portion of the study; participants again provided both verbal and written consent. They were told that the data they provided to us was to be used strictly for research purposes, that the information they provided will remain anonymous, and that they could withdraw at any point in the study without any consequences; the researchers would respect this decision. The study’s primary investigator was present at each of the consent sessions with the four men who agreed to partake in further data collection, as well as one of the research assistants.  3.6.2 Power Relations and Potential Harm  Research assistants were graduate students, which may have minimized perceived power gradients between researcher and participant. However, participants may have viewed the interviewers as researchers with higher authority. Efforts were made to provide comfortable and supportive environments for participants in which they did not feel any obligations in having to participate in the study or answer any interview questions they did not feel comfortable in answering. Trust and rapport were important in ensuring participants’ comfort, a position of equality and mutual respect was considered throughout the research study, and efforts were made to ensure that the participants were active members of the research process (Doody & Noonan, 2013). For example, working around the participants’ schedules and daily life commitments was something the researchers aimed to do from the outset of the study. Collaboration and communication between the research team and the participants was key throughout this study.  All sit-down interviews, walk-along interviews, and photovoice sessions were conducted by a team of two research assistants, both of whom received the same training in conducting interviews, walk-along methods, and video camera use, allowing for consistency in data collection methods.  50   There were no identified harms associated with this study; however, interviews of any sort have the potential to evoke strong feelings in the participant (Doody & Noonan, 2013). Participants were aware that they could take as much time as they needed, that they did not need to answer any questions they were uncomfortable in answering, and that they could end the interview at any time. We experienced no such situations and no participants withdrew from the study.  3.6.3 Privacy and Confidentiality    All researchers signed confidentiality agreements in maintaining information and ensuring the data provided by participants was kept private. Steps were taken to ensure that patient information was anonymous and unidentifiable: numbers were assigned to each participant, so data could not be connected to participants by outside sources. All participant consent forms, honorarium receipt forms, demographics, and hard copies of other documents were kept in a locked drawer and were accessible only by the research team. Electronic documents, transcripts, walk-along videos, and photos taken by participants were stored on password-protected computers, and all files containing personal participant identification were also password protected in which passwords were only shared with the research team. All data will be kept for at least five years following study completion and there will be no identifying patient information in publications of future research. If patients would like to see the findings of the study or have access to published research related to the study, they have been given the research team’s contact information to request these findings.  3.7 Ensuring Quality of Research   A fundamental characteristic of qualitative research is whether it provides an accurate representation of participants’ experiences (Barker, 2013). In order to address this, attention 51   needs to be given to how information was collected, and the accuracy of the information collected (Barker, 2013). In order to address the quality of this research, issues around rigour and reflexivity were considered.   3.7.1 Rigour  While the question of how to ensure rigour, or trustworthiness, of qualitative research continues to be a topic of debate in the literature, the four criteria proposed by Lincoln and Guba (1985) remain the most common: credibility, dependability, confirmability, and transferability (Houghton et al., 2013; Polit & Beck, 2012). These criteria, plus that of authenticity were used to address rigour in this study.  Credibility is the value and believability of the findings which are enhanced by prolonged engagement and persistent observation (Houghton et al., 2013; Shenton, 2004). This study addressed credibility with its in-depth data collection methods: interviews, walk along interviews and participant observation, and photovoice, providing data triangulation (Barker, 2013). Peer-debriefing also enhances credibility (Houghton et al., 2013); the researchers engaged in debriefing after each session with the participants, as well as during research team meetings. Further, two researchers were involved with the data collection, both of whom engaged in fieldnotes; fieldnotes by both researchers were used in the analysis, providing investigator triangulation (Polit & Beck, 2012). Completeness of data reflects gathering multiple perspectives from a variety of sources to develop as complete a picture as possible of the phenomenon, and also reflects honesty during sessions with participants. An environment of trust, rapport, and respect was conveyed in meetings with participants in which participants were aware that they could refuse to participate or answer questions they were uncomfortable with early on in the study. Overall, participants appeared to be comfortable and genuine in their responses to the 52   interview questions. Prolonged engagement and participant observation, triangulation, honesty during data collection sessions, and peer debriefing enhanced the credibility of this study.  Dependability refers to the stability or consistency of data over time (Houghton et al., 2013). Dependability reflects the notion that if the work was repeated in the same context, with similar methods and with the same participants, we would obtain similar results (Shenton, 2004). In addressing this aspect of rigour, the processes within the study are reported in detail with thick description, allowing future researchers to be able to replicate the study (Shenton, 2004). Detail was provided about the research design as well as the methods employed in the research, and reasons for decisions were also included in the field notes after each session with the participants, thus enhancing dependability in this study.  Confirmability addresses the neutrality, objectivity, and accuracy of the data (Houghton et al., 2013; Polit & Beck, 2012). Within qualitative research, complete objectivity is not necessarily the goal. It is important to remember that the way people understand and make sense of their world is subjective, and researchers’ values, attitudes, and personal experiences may in turn influence how they think about, analyze, and draw conclusions about the data (Ryan, 2006). In order to limit investigator bias in this study, the researchers engaged in reflexivity, as described in the subsequent section. The researchers also made an effort to identify any preconceived beliefs and opinions they had about the phenomenon, as well as identify any personal challenges that may be influencing the research study. Debriefing with other researchers and reflecting in field notes assisted with this process (Polit & Beck, 2012).    Transferability addresses whether findings can be transferred to similar contexts and situations (Houghton et al., 2013). With adequate descriptions, readers can make informed decisions and assess whether the study’s findings are transferable or applicable to other contexts 53   and situations (Houghton et al., 2013). In this study, thick descriptions were provided in regards to the sample characteristics, geographical locations where data were collected, and research methods that were used. Further, examples of raw data were also used to enhance the transferability of the study, allowing alternative interpretations to be considered (Houghton et al., 2013). It is acknowledged that the findings of qualitative research are specific to small numbers of particular contexts and individuals and thus claims cannot be made stating that findings and conclusions are generalizable to other populations and contexts (Shenton, 2004).   Authenticity is also considered to be a component of study rigour; a study shows authenticity if it invites readers into vicarious experiences of the lives being described (Polit & Beck, 2012). This study included narratives from interviews with participants as well as photos taken by the participants themselves to address authenticity; it was hoped that by doing so, readers would be able to get a better sense of the mood, feelings, and context of participants’ experiences (Polit & Beck, 2012).   3.7.2 Reflexivity  Within qualitative research, a known risk is subjectivity, as it can be very difficult to detach personal feelings and experiences from research to maintain an objective status (Berger, 2015). Characteristics of the researcher such as gender, race, age, and personal experiences and beliefs can greatly influence aspects of research process (Berger, 2015). These positions can shape the nature of the researcher-participant relationship, and the worldview and background of the researcher can affect the way language is used, how questions are posed, and how data is filtered in shaping the study findings (Berger, 2015). As an effort to maintain awareness of the aforementioned issues and how they may shape the research process and findings, research assistants engaged in reflexivity. Reflexivity is described here as the process of continued 54   internal dialogue and critical self-evaluation of the researcher’s position, acknowledgement, and recognition that this position may affect the research process and outcome (Berger, 2015). In order to address reflexivity, the research assistants present at each interview debriefed with one another immediately following the interview about the interview process in discussing what went well, what could be improved, and how they felt after each interview. Although these discussions were informal, they were valuable in critically reflecting on the interview and allowing the researchers to assess their own abilities as an interviewer. Further, the researchers wrote field notes after each interview, which can be effective in revealing potential biases within preliminary interpretations; the field notes also provided some documentation for rationale of decisions made during the data collection process (Houghton et al., 2013). The research team also discussed concerns, thoughts, and research processes within team meetings throughout the study. Numerous aspects of one’s personal social location can impact the research process (Silverman, 2015); for example, characteristics of the researcher such as background and position, can also influence interpretation and analysis of the data. As a young female, I may have received different data from the participants than I would have received if I had been a male, or an older male. I also possessed various traits of privilege in being young, healthy, of middle class, and educated. Although the men in this study were too of middle to upper class and educated, they struggled with their aging bodies and ongoing health challenges, which may have created some distance between myself and the participants (Silverman, 2015). At the same time, my efforts to understand the participants’ contexts and life experiences in a friendly and curious nature appeared to a provide a sense of comfort and willingness for the participants in sharing their stories with me.  55   Additionally, I come from a nursing background. Not only may this have led to interpretations or analyses of a health care nature, but it could have also influenced the motives of the participants to take part in the research. For example, two of the participants in this research study expressed interest in advocating for the health of seniors. They may have thought that because I was involved in healthcare, that I may be able to help them implement the changes they were hoping to see in their communities and in healthcare. However, being a nurse may have also brought comfort and trust to the participant-researcher relationship. Because I have worked extensively with older adults with chronic illnesses facing multiple health challenges, the participants may have felt ease in discussing their experiences with a healthcare professional.   In being the primary data collector for this research study, I got to know the data very well, while also being able to build relationships with the participants. Because the participants consistently saw me during the research process, they became more open and comfortable with me as the research proceeded. This allowed me to truly get to know the participants and consider the data within multiple contexts. However, being a fairly new researcher who is still learning and gaining experience in the field, I may not have been able to bring in as much depth and complexity that someone of more experience would have brought to the interpretation and the analysis. That being said, being a new researcher also allowed me to bring a fresh outlook to the analysis with the goal of learning and critically thinking about the data. I consistently engaged in an informal critical reflection of personal challenges experienced during the research process, and communicated concerns and ideas with other research team members.      56   Chapter 4: FINDINGS   This chapter discusses findings related to the four men who took part in the original sit-down interviews, walk-along interviews, and photovoice. This sample provided depth and diversity in life experiences as well as a range of experiences with physical activity in the context of their day-to-day lives. Analysis of the data revealed three significant themes that are discussed here, including:  • Aging Male Bodies  • Out in the Community • Social Connectedness and Physical Activity  Within each theme are three sub-themes that are discussed. See Table 1 below: Themes and Associated Subthemes Revealed in Data Analysis. Table 1: Themes and Subthemes Revealed in Data Analysis Theme Subthemes  Aging Male Bodies  a. Past, Present, and Future: The Importance of Routine b. Remaining Capable: Resisting Old Age?  c. Engaging in Risky Behaviours  Out in the Community   a. Walking for Leisure vs. Walking for Transportation  b. The Manly Act of Driving  c. Importance of the Physical Environment  Social Connectedness and Physical Activity a. Community Involvement: Doing as Connecting b. Relying on Others vs. Helping Others  c. Lone Wolf vs. Desire for Socialization  4.1 The Sample   The four men were white, of European background, in good general health, educated, and financially comfortable; details around sample characteristics will be discussed in subsequent sections. Three of the men lived in residential neighborhoods of a large urban centre, and the fourth lived in a large suburban city. Residences ranged from small apartments, independent 57   living complexes, to larger single-family homes, all of which were located in neighborhoods that were well-maintained and aesthetically pleasing. Ages ranged from 70-86 years old and education levels ranged from high school to a graduate degree. One man was single and never married, one was divorced and self-identified as gay, one was widowed, and one was currently married. All but one of these men had a valid driver’s license as well as access to a car; the one man who did not, had support from his family in getting around his community. Three of the men lived independently and one lived with his wife; all of the men were retired.  The participants were generally healthy at the time of the interviews and for the most part were functionally capable of completing their daily activities. These activities included cleaning, vacuuming, laundry, dishes, meal preparation, grocery shopping, and running errands such as going to the bank, going to the pharmacy, and taking care of doctor’s appointments. Two participants were independent in all of these tasks, whereas the other two participants required assistance with meals and house cleaning, in one case from his wife, and in one case from an outside hired source.  Apart from one participant who used walking aids during his recovery from a fall that occurred during the time he participated in the study, these men did not generally depend on walking aids to mobilize or to get around their communities. They all stated that they were “very comfortable” or “somewhat comfortable” in going outside and “very confident” or “somewhat confident” in walking around their neighborhoods.  4.2 Theme #1: Aging Male Bodies   As men age, it is almost certain they will face physical challenges that will influence their physical activity and day-to-day life. However, the findings from this study indicated that what it means to be physically active may or may not change with age. In addition to listing the types of 58   activities they were involved in, the participants thought physical activity meant, “not sitting down,” “walking or climbing a hill, anything [involving] walking up,” “exercising in the morning…doing things like push-ups”, and “walking, or activity around the outside of the house such as gardening, things like gutters, painting.” Given the definition of physical activity for older adults, reflecting the World Health Organization’s work, physical activity is considered in the context of daily family and community activities and includes: leisure activities such as walking, dancing, gardening, hiking, and swimming; transportation such as walking or cycling; occupational if the individual is still engaged in work; household chores; games; and sports or planned exercise (WHO, 2016). The men did not appear to link physical activity to household chores or activities that may appear to be too leisurely such as going for a walk outside. Rather, their ideas of physical activity related to doing push-ups or doing outdoor activities such as cleaning the gutters or painting, may reflect masculine values of strength and capability. When using the WHO’s definition of physical activity, the four men could be considered physically active individuals for participating in leisurely activities such as walking, community activities, and household chores; however, the men instead connected physical activity with activities that seemed to be more strenuous and requiring great effort. This was likely a belief that stemmed from their younger years, and continued into older adulthood in that the men continued to be as physically active as possible given their aging bodies.  4.2.1 Past, Present, and Future: The Importance of Routine  Conversations with participants revealed a tendency of the men to talk about a time when they were younger and how their life circumstances, as well as their physical health, had changed and continues to change with age. It was evident that the past was a significant influence on the men’s current activities and something that the men may have been holding on to as they aged. 59   For example, Participant #1 was an 86-year-old man who spent a significant amount of his life playing tennis. This participant had multiple chronic health conditions over the past decade including having had bilateral knee replacements, a history of transient ischemic attacks (TIAs), prostate cancer, a previous surgery for colon cancer, glaucoma, hypertension, back pain, unbalanced gait, as well as a fall that cracked his pelvic bone. He worked hard to recover from these health challenges and regain enough strength to be able to get out in his community independently and complete daily tasks and activities. This participant had been managing most of his diagnoses, but perhaps the biggest challenge for him was the loss of balance and stability that resulted from having two TIAs and bilateral knee replacements, ultimately leading to him having to give up tennis, a sport he had participated in for 70 years; he explained,  “I was getting bit wobbly on my legs especially with the titanium knees…I hated having to give up tennis, but I didn’t want to fall and break something if I got dizzy or unbalanced on the court.”  This participant believed he used to be a physically active person “because [he] used to play tennis two or three times a week.” However, he shared that he still continued to play up until 84 years of age, after being a member of the tennis club for more than 44 years. Through all of the health transitions the participant had recently faced, he continued to go back to the tennis club to visit and socialize with his friends. He shared that he went “down there about half a dozen times a week,” demonstrating the importance of the tennis club to his weekly activities and a routine he had been following for decades. It is evident that giving up tennis was significant to this participant, even changing his self-perception of his own physical activity levels. He also became more fearful of falling, resulting in more sedentary behaviours such as reading and watching TV for longer periods of time, and walking shorter distances. The participant also often experienced lower back pain and hip pain, requiring him to take rest breaks and/or analgesics. He managed 60   most of his activities such as grocery shopping, getting to doctor’s appointments, and doing some housework, but had hired someone to help him clean his home and help him with his laundry, specifically after his most recent fall. He had to resort to a wheelchair and a walker at times during his recovery, and needed to make adjustments to his home to include safety rails in the bathroom and in his bedroom. This participant was aware that his body was not as physically capable as it had been in the part, and accordingly, had made adjustments to his home to prevent future health challenges. However, he also continued to participate in activities that he had become accustomed to such as visiting the tennis club, demonstrating the significance of activities that continue to be meaningful to him in both the past and the present.   Participant #3 provided another example of how perceptions of the past can significantly contribute to current levels of physical activity. This participant was 78 years old and was generally healthy until he experienced a turning point in his life in the form of a stroke about a year prior to his interview. Since then he had some short-term memory loss, loss of peripheral vision, and some cognitive impairment. Aside from the cognitive impairment, the participant was able to almost fully recover from his stroke in terms of regaining strength and balance. His motivation for recovery was inspiring in that he was able to resume almost all his pre-stroke activities; other than a walking stick used occasionally on walks, this participant did not appear to have any significant functional limitations in terms of physical capability. In fact, the biggest change resulting from this participant’s stroke was the amount of activities he could partake in due to his wife now needing to drive him to activities, rather than him driving himself. He spent a great deal of time at his local seniors’ recreation center, in which he participated in multiple activities several times a week; his main activity was carpet bowling, a sport in which he won 61   many medals and had even competed for in the BC Senior’s Games. The participant took great pride in his carpet bowling accomplishments;  “Hmm, I love all sports, but I guess carpet bowling has been my goal or whatever you want to call it. I’ve got bronze and gold and silver. I have all three now.”   This participant appeared to be motivated by being able to do the activities he had always done in the past. He was in the military for eight years and proudly talked about being able to do push-ups and military marches in his home, possibly reflecting the importance of strength and resilience to this participant. When asked what motivated him to recover from his stroke, the participant said,  “I don’t know where that comes from, but I guess just the things I’ve always done, you know.”  This statement made by the participant possibly reflects a desire to hold onto the past and to adhere to routines that he had become accustomed to, allowing him to continue being as physically active as possible given his circumstances and reflecting masculine ideals of ability and strength.   As another example, Participant #2 has a congenital syndrome that caused increased shortness of breath as he became older, which the participant adjusted to by changing the intensity and/or frequency of his physical activity as needed. This participant used to run quite a bit in the past, but stated that he did it less now due to his shortness of breath, as well as due to his arthritis and lower back pain. Managed by analgesics, his arthritis and back pain were not as restrictive as his shortness of breath, which kept him from doing the hikes and runs he used to do. The following is an excerpt from when the participant was asked about how his physical activity levels had changed:  “I get short of breath very, very easily. And so for me to get decent cardio it’s difficult…I suppose one always wishes one could do more. Yeah, I would-- yeah, I think I do miss 62   running ‘cause I used to run a lot. I used to do a lot of cross-country running and I miss that. And part of it’s I’m getting more and more short of breath as I get older, but also I have a little bit of arthritis in my knees.”   Although the difficulty breathing was something the participant had been adjusting to his entire life, it had become more of a barrier lately as he aged. He shared that,  “It’s always been a slowing factor. It’s only really since I’ve turned 60 that…I couldn’t keep up anymore. My 50’s I could keep up with everybody, pretty much. Not everybody, most people. Now I’m usually at the back.”   Despite this barrier, the participant continued to be involved in walking and hiking groups, as much as he was physically capable, demonstrating the importance of this activity to him. The importance of routine and meaningful activities from the past were also evident in discussions around the types of activities the men stated they would like to see incorporated into possible physical activity programs. For example, participant #1 had enjoyed doing weights, walking, and swimming and would like to see these activities in a program, and participant #2 shared that he used to do a lot of boating and wished he could do more of it; “I would like to [do some] boating again, I’d like to add something on the water.”  Participant #3 shared he would like to see activities such as dancing, lawn bowling, and table tennis incorporated into a program, activities he used to participate in before his stroke. Finally, participant #4 expressed interest in a hiking or a swimming component to physical activity programs, activities that he once used to engage in and were of importance to him but could not do anymore due to a leg injury and “age related spinal changes.” It was evident that the men’s past experiences were important enough for them to continue holding onto these routines in their current patterns of physical activity, as well as influencing their future hopes for physical activity. The ability to participate in familiar activities may provide a sense of satisfaction in still being physically capable of the activities they had done for years, but these activities may also 63   provide purpose and comfort for the men in reverting back to what they already know and enjoy, providing connections between past, present, and future patterns of physical activity.  4.2.2 Remaining Capable: Resisting Old Age?   Maintaining health and functional ability was reported in the literature as the greatest motivational factor for physical activity for older adults (Daley and Spinks, 2000; Rasinaho et al., 2007). Remaining functionally able with advancing age is a key contributor to quality of life, and specifically for men, this quality may reflect masculine values of independence, self-reliance, and control. Men may make various adjustments to specific circumstances in their lives to help them maintain this capability and functional ability in being able to do things for themselves as they continue to age. For example, Participant #1’s experiences with multiple chronic health conditions forced him to make adjustments to his home as well as his mobilization. Below is Photograph 1 and was taken by this participant.          This participant also discussed his reliance on walking aids, specifically a wheelchair and a walker, when recovering from his recent fall; however, he explained that he was determined to regain enough strength to prevent using assistance in mobilizing. Aside from a walking stick, this participant did not use any other walking aids at the time of his final interview; however, he was Photograph 1 was taken by Participant #1, showing the grab bar on the side of his bed. After a recent fall, this participant had visits from home care nurses who suggested adding this as well as rails in the bathroom for the participant’s safety in preventing future falls  64   observed on multiple occasions using furniture around his home to help stabilize himself and move about within his home. These actions may reflect masculine ideals of independence, maintaining functional ability, and not wanting to appear old and incapable, values that may be of significance to this participant.   Participant #2 expressed concern about the possibility of being functionally dependent:  “the fear I have or the sort of negative future that I see is when I’m not able to walk or hike or climb up stairs.”   He also shared a story about a rolling grocery bag he had bought for shopping but did not use for months because he was afraid it would make him look old; he eventually conceded and used this rolling grocery bag confidently. He also took a photo of an electric scooter (Photograph 2 below) and discussed how scooters such as these may be hazardous. After considering that this attitude against scooters may have been reflective of another concern around looking old and disabled, researchers asked the participant if he would consider using it if needed, he replied;  “Absolutely, if it came to that, yes…So the very first step along that was to get one of those [rolling] shopping bags… And, you know, I would usually buy a fair amount of groceries at one time. And carrying them in shoulder bags was pretty impractical, so I got one of those. And it sat in the closet for maybe even months, certainly weeks before I actually used it. I thought this is a sort of a, you know, I’m going to look old. Which is not really the case because everybody uses them. I felt that, I felt this is-- but I got over that and so using one of those [electric scooters], I think I could if it was helpful.”   Photograph 2 depicts an electric scooter, a photo taken by Participant #2. He captioned it “The operation of these devices on sidewalks by some users represents a hazard to my safety. If these heavy motorized vehicles are to be allowed on pedestrian sidewalks, they should be fitted with governors to present exceeding walking speed.” 65   It appeared as though the men were open to using walking and transportation aids so long as they helped them remain independent and functionally capable as they aged; however, it was also evident that the men would like to continue to build strength and enhance balance as they aged to prevent dependence on transportation aids. For example, in discussions around possible physical activity programs, participants shared that they would like to see some strengthening exercises built into the programs such as using stationary bicycles and weights, and activities that would help them with their balance. They were also open to having coaches and trainers in helping them achieve their goals. The following was a conversation between the researcher (Q) and Participant #3 (A):  Q: So if you had a coach or someone help you plan out what activities would work for you in your community, with a plan on how to get there, that would be helpful? A: That would definitely be helpful, yeah. Q: That’d be a motivator?  A: Yes, that would be a motivator to keep going and doing it with help. I always find that you need somebody to take a hold of the reigns. And when you get to our age, to try to start something up like that is a little bit difficult.   The men’s motivation to regain strength and balance may stem from wanting to avoid further functional decline and continuing to be physically capable and independent as they age. For example, immobility can be stigmatized as a deficit and a weakness that would signal dependence and subordinate masculinity; two participants provided some input around being entirely dependent on others in very old age. Whereas participant #2 had not thought much into the future, and participant #4 had just begun thinking about the possibility of home care, participants #1 and #3 expressed strong opinions about long-term care facilities. Both of these participants felt strongly about medical assistance in dying in that they both discussed “pulling the plug” if they were ever to get to a point where they could not take care of themselves, reflecting a craving for independence. Participant #1 stated,  66   “If I get that way I’ve got a bottle of pills that I would take. I don’t want to go into a care home and be like that. I fully agree with this issue of choice when you die and under what circumstances and with dignity and respect. When I see the people out there, all they’re doing, to put it candidly, is they’re eating and sitting in a chair and pee and poo and that --- that’s their day. And they got nothing. ….. I think this business of just lying around and vegetating, you're a vegetable, nothing else. It’s terrible.”   Dignity and respect also reflect masculine ideals of independence, in which the participant appeared to express concern about losing control, vulnerability, and shame. Similarly, Participant #3 stated,  “If I can’t feed myself and I can’t wipe my butt, pull the plug. And that’s what my daughter has in my will, my living will. And I was in that stage, very close to it with my stroke.”   For both of these participants, their main motivation in being physically active appeared to stem from this belief that being in a care home in a vegetative state is the worst outcome. Thus, wanting to avoid being bedridden in a care home, remaining independent and at home for as long as possible, and avoiding hospitals are common motivators for these participants in being active. This attitude towards care homes may also represent a sense of concern or worry about uncertainty, in which the men do not want to lose power and control of themselves, and be unable to make their own decisions or care for themselves. Independence and having emotional and physical control appeared to be of importance to these men, aligning with societal masculine ideals. Men also tend to deny vulnerability and the need for help (Courtenay, 2000); Participant #1 said, “As long as I got the brains, I’ll do it myself,” implying that remaining cognitively intact would allow him to take care of himself at home. Although he was open to getting assistance at home, the participant shared that he would make every effort to stay at home as long as possible. He appeared to associate being physically active with life and being inactive with end of life and death; it seemed that engaging in physical activity, especially independently, was highly valued by these participants, demonstrating masculine ideals of independence, resilience, and vitality.   67   4.2.3 Engaging in Risky Behaviour   As Courtenay (2000) and Donaldson (1997) stated, men may deny the need for help and make risky decisions to portray masculine characteristics of strength and independence. As men age, it is likely that they will become more dependent on others for certain tasks and activities; however, a desire to be self-reliant in these activities may be meaningful to the men in positioning themselves as strong, independent, and capable men. For example, Participant #4 was an 80-year-old man living independently in a home that he had lived in and owned for about 30 years. This participant spent more time at home in comparison to the other three participants, but engaged in various chores around the house including gardening, landscaping, painting, cleaning gutters, and other minor repairs. In doing these tasks, as evident by a walk-along interview with this participant, he carried all of his supplies from his backyard to his front yard; the supplies were quite large and heavy, and his stairs were quite steep with no railings (Photograph 3 below). This participant appeared to align with societal expectations of men in that he denied the fact that he may need assistance with these household activities, insisting that he was able to do them on his own, and creating a possible risk to his safety and well-being. Further, he also trimmed the branches of a tree in his backyard using a 16-foot ladder; in discussing Photograph 4 below taken by this participant, he stated,  “Okay, I’m on the 16-foot ladder at the top. The ladder’s propped against the tree. I’m right up at the top of a ladder using a hedge clipper to trim the tree. As long as I’m careful, you know, no problem.”   This task seemed to give the participant a sense of accomplishment and independence:  “Things can happen, but so far I’ve been able to do it and I feel it’s positive for my overall mental health… It means that I’m not completely out of it yet, given [my] age.” 68     This participant’s continued participation in these tasks may be about living on his own terms and doing the things he has always done; it may also be about mastering achievement and a sense of pride felt by remaining physically capable of these tasks.  As another example, Participant #3 routinely took his dog down a creek located nearby his home, shown in Photograph 5 below. This steep, downhill, creek was noted to consist of various trees and rocks, with muddy and slippery wet leaves. The participant’s willingness to take his dog down this creek during his daily walks constituted a significantly risky task. However, there was something about the participant being able to complete this task that was meaningful to him, perhaps representing masculine ideals of courage, toughness, and taking action. Additionally, this participant took part in this risky activity for his dog, and stated on multiple occasions that the dog needs to get out and be active as well. This idea of “doing for another” is another masculine value and ideal that may have been of significance in the participant’s willingness to ignore his own safety for the benefit of another.  Photograph 3 (left) depicts the stairs the participant uses to carry his yard tools to the front yard. Photograph 4 (right) depicts the tree that the participant climbs on a 16-foot ladder to trim.  69          As a third example, Participant #1 continued to drive regularly to complete his daily tasks and chores. He was an 86-year-old man with significant health challenges that definitely impaired his ability to drive safely, specifically a history of TIAs and vision problems. The researchers also observed the participant getting into his car with some difficulty, providing evidence of this participant driving at risk. However, this man relied heavily on his car, Photograph 6 below, for transportation. It may be possible that he did not want to give up his license out of concern around losing his independence, control, autonomy, and self-reliance in all of his activities, reflective of traditional masculine ideals (Courtney, 2000; Donaldson, 1997); he explained, “I’d be lost without my car. Because I’m, you know, I don’t think I’d be very good getting  on a bus, on and off a bus, especially if I’ve got any shopping or something like that. Yeah, I’d be terribly lost without a car. I’d have to be taking taxis.”  Photograph 5 (left) depicts Participant #3 going for a walk with his dog in his neighborhood. He captioned this photo “I took this picture because… It’s what we try to do daily and it was a beautiful day; the dog needs exercise too.”   70        These examples portray societal expectations of men engaging in risky behaviours to demonstrate independence and self-reliance. Further, they also seek to maintain familiar routines and activities at a time when they are experiencing multiple losses. As evident by these examples, values such as independence and autonomy continue into older adulthood, but may be portrayed in different ways relative to younger men. Although the particular risky behaviours that younger men and older men engage in may differ, their reflections on masculine values and ideals are likely to remain the same.  4.3 Theme #2: Out in the Community    Getting out and about in their communities was a key component of physical activity for the older men. The four men in this study engaged in a fair amount of walking and moving around in the context of their day-to-day lives.  Because many older people may use walking for transportation to accomplish daily tasks and activities, it is important to consider the influence of the community on older men’s ability to engage in physical activity, specifically when Photograph 6 was a picture taken by Participant #1 of his car. Losing his license would be a very significant transition for this participant due to his heavy reliance on his car for almost every activity that he engages in. However, this participant’s driving creates a significant risk to his safety and possibly the safety of other drivers.   71   considering why and how the men get around in their communities and the importance of features of the physical environment.  4.3.1 Walking for Leisure vs. Walking for Transportation    Although walking is one of the most common ways for older men to be physically active,  reasons and motivations around walking may differ, for example leisurely walking and walking as a form of transportation to complete daily tasks.   For Participants #2 and #4, walking was the most common method of getting around their communities, both for leisure as well as for transportation. They also took public transportation at times and reported no trouble or issues with being able to do so. If they were travelling long distances or bringing back heavy items such as groceries, they then drove their cars. A key factor in these two participants’ high frequency of walking was the convenience of the neighborhood in which they lived. Both of these participants had nearby access to amenities and facilities; grocery shops, banks, the library, public transportation, as well as restaurants, coffee shops, parks, and multiple other facilities that were within walking distance. The researchers accompanied both of these participants on walk-along sessions to the grocery store, the bank, as well as the library. Both participants felt that the city of Vancouver was very easy to get around in, “especially with the convenient locations of shops and easily accessible transit” as stated by participant #2. Interestingly, this participant stated that because he lived in Vancouver, he did not face any significant barriers to getting around his community, but felt that if he had lived in a more suburban community, he might have seen more inhibiting factors to his mobility. The following is a quote from an interview with participant #2: “Well, you know, if we were in a different community, different town, I might have a lot more to say. But I don’t want to sound sort of overly praising of Vancouver, but I really think Vancouver, at least at my level of mobility which is not really impaired, not majorly-- I don’t have a major impairment. So at this level I find getting around town, 72   particularly living here, is so easy…say we were in, well, I don’t know almost anywhere other than downtown Vancouver, say we were in Surrey or in, I don’t know, well, a small community in the Interior. There might be things that I would find difficult.”  This participant’s input around the convenience of his residence in Vancouver demonstrates the importance of the physical environment, and the proximity of amenities, to mobility and physical activity. His choice to live in a location central to amenities and public transportation may reflect the importance of independence, functional capability, and being able to walk to accomplish daily tasks and chores.  On the other hand, Participants #1 and #3 both relied on driving as their main form of transportation, either by driving themselves, or being driven by a significant other, and thus walked more so for the purposes of leisure. Although both of these men lived in urban and sub-urban areas, amenities such as grocery stores and public transportation were not as readily accessible for them without needing to walk fairly long distances. These men also faced greater health issues relative to the other two men, thus making walking long distances more challenging. These examples demonstrate the need to consider intersections between the environment, physical activity, and health situations for men as they continue to age. Options suggested by the four men if they were unable to get around with their current form of transportation included taking the taxi, HandyDart, or relying more on public transportation.  4.3.2 The Manly Act of Driving   As Participants #1 and #3 were heavily reliant on a vehicle for transportation, the ability to drive into older adulthood was an important concept that was evident in discussions with these two men. Participant #3 lost his drivers’ license after he had experienced a stroke and was not able to pass his drivers’ licensing exam to regain the ability to drive. His experience with the loss of his license was a significant one, to the point where he had suicidal thoughts. He felt a loss of 73   independence and manliness in that he had to rely greatly on his wife to drive him to places. He stated that if he still had his license, he would be out a lot more in his community, participating in even more activities. In regards to losing his license, the participant shared:  “An awful kick in the stomach, I’ll tell you. I mean I even had suicidal thoughts as well. I mean I’m not any good if I don’t have my driver’s license, stuff like that…it definitely is a manly thing, I guess, but-- in all walks of life as far as going to do some shopping or something like that. You need something-- I can go and get in the car and go get it. Now that doesn’t happen.”    This participant also felt that losing his license greatly impacted the number of activities he could participate in, as he did not want to over-burden his wife in driving him to additional activities. When asked if he believed losing his license had possibly made him more active due to having to walk more, he replied,  “Less active, less active. If I could drive, then — [I could be] out more and doing more things.”  Participant #1’s actions also demonstrated the importance of driving to him. Although this participant’s various health conditions put him at a safety risk when driving, he stated that he felt quite comfortable in doing so. His lack of recognition of the safety risk associated with his driving may signify an avoidance of wanting to give up something he has become accustomed to and something he relies on in order to independently complete his daily tasks, reflecting masculine values of self-reliance and control.  4.3.3 Importance of the Physical Environment    Aspects of the environment exert a direct effect on physical activity, which is especially important to consider for older adults who use walking as a means for transportation (Shumway-Cook et al., 2002; Spence and Lee, 2002). In addition to the aforementioned proximity of amenities and facilities, two features of the physical environment discussed by the participants in influencing their comfort and ability to walk outside included aesthetics and safety. All three of 74   the participants residing in the large suburban city discussed how much they enjoyed the beautiful views during their walks, specifically the mountains, the water, and the greenery. Participant #1 stated,   “You can see why I go down there because it’s-- you’re right on the sea and there’s a beach there.”   The following two photographs, Photograph 7 and Photograph 8, were taken by participants to reflect the aesthetics of their neighborhoods.   Both of these participants resided adjacent to beautiful parks and beaches, further motivating them to walk to where they needed to go. For example, participant #2 stated,  “Vancouver has made my mobility more, you know, inviting, more easy.” The weather has also been stated to be a significant factor influencing whether older adults use walking as a means of transportation (Van Cauwenberg et al., 2012). All four participants felt motivated and encouraged to be outside in sunny weather as evidenced by Photograph #9 and Photograph #10 below.  Photograph 7 (upper left) was a photo taken by Participant #2 depicting the aesthetics of the neighborhood while enjoying a meal; he captioned “Beautiful weather and miles of water and safe bicycle paths are a strong encouragement to get out and enjoy some exercise.” Photograph 8 (upper right) was a photo taken by Participant #4, showing the view from his house; he explained how this view encourages him to go for a walk.  75    The participants did not feel too discouraged by the rain or cold, and all four said they would still go outside with a jacket for a walk if it were raining or windy:  “…coming from England it wasn’t as much of [an issue]. And actually, when the weather  turns out like it is at the moment -- you forget all that because Vancouver’s so lovely.” – Participant #1  “…never stayed in the house all day. Even on the rainy days, you go, the dog has to go out” – Participant #3  “I don’t mind walking in the drizzle and this sort of stuff. And again, I have this idea that I should keep walking.” – Participant #4.  Although comments around aesthetics were generally positive and participants expressed satisfaction with their neighborhoods, all of the participants lived in areas that could be quite busy with heavy traffic from vehicles, pedestrians, or bicycles, making safety a possible concern worthy of consideration. For example, Participant #3 discussed on multiple occasions how the bike lanes were unsafe because they are often used as right turn lanes; he photographed the image below, Photograph 11.  Photograph 9 (above left) was taken by Participant #1 and Photograph 10 (above right) was taken by Participant #2. They both discussed how the sunny weather and bright light encouraged them to go for a walk or just be outside. This was a feeling re-iterated by all four participants.  76     As another example, participant #4 had an incident in which he was struck by a cyclist as a pedestrian, causing him ongoing leg pain, avoidance of certain areas of his neighborhood, as well as a change in the frequency and intensity of the activities he was able to engage in. Although these two men had unfortunate experiences with cycling and bike paths, Participant #2 discussed the positive aspects of his neighborhood around the safety of bicycle paths. This participant used bicycling leisurely and discussed how his city was a positive and safe motivating factor in him being physically active. Photograph 12 and Photograph 13 below were taken by this participant reflecting bicycle safety. Photograph 11 (left) was a picture taken by Participant #3; he believed the bike lanes were hazardous because people used them as right turn lanes, causing cyclists to use the sidewalk, creating safety risks for pedestrians. He stated, “Well, briefly, you should be able to ride a bicycle on the bicycle path, and I would actually ride a bicycle if I thought it was safe for anybody. Not just for me, but for anybody to go around on the bicycle. But they use the car-- cars use that bicycle path for a right turn lane. And with the kids going to school there, it’s just awful. And you say-- I mean, it’s very dangerous, but nobody’s had an accident there, so they won’t do anything.” Photograph 12 (above left) and 13 (above right) were taken by Participant #2 during walks and cycling.  77   In considering the overarching theme of “Out in the Community,” the four participants generally enjoyed the neighborhoods they lived in and felt comfortable walking outside. The proximity of amenities, the aesthetics, and the familiarity of the communities provided facilitating factors for the participants’ physical activity, especially in walking for leisure, whereas high-density neighborhoods and high-traffic areas may have posed challenges and barriers to physical activity (Chaudhury et al., 2012).  4.4 Theme #3: Social Connectedness and Physical Activity     Social environments may be crucial to one’s ability to get out and about in their communities and to be physically active. In terms of personal relationships, the four men in this study have had very different life experiences: one man was married and lived with his wife; one man was never married and lived independently; one man had been widowed for more than 25 years and lived independently; and one man was divorced and identified as a gay man who also lived independently. Personal experiences and relationships such as these can significantly influence older men’s current patterns of physical activity. For example, level of involvement in the community, the extent to which help is needed, and socialization with others are all factors that were evident in the data as being influenced by social situations and subsequently influenced physical activity levels. 4.4.1 Community Involvement: Doing as Connecting   Being involved in the community can significantly influence older men’s level of engagement with others. It can help motivate physical activity by promoting socialization, and it can give people a feeling of connection and belonging to a group of people with similar interests. For example, Participant #1 retained strong connections with a tennis club and its members, a club he was part of for 44 years. Although he was not physically capable of playing tennis 78   anymore, he still visited the tennis club several times a week to watch others play tennis, to have a meal, or have a beer with friends. The tennis club was a significant part of this participant’s physical and social life and he continued to identify himself with this club. It is probable that this tennis club provided a sense of comfort and routine for the participant, as well as a source of motivation to get out in his community to continue to be involved; he stated:  “Yeah, if a man can keep in a club of some sort it’s good, because, you know, he sees people of his own age who have also semi-retired from tennis. And you can watch tennis and there’s people swimming in the pool so-- going into the sea. And you can watch the yachts on the water and what’s going on and admire the view. And so I think my club has helped me a tremendous lot because there is somewhere to go. If men can stay active or, you know, go to their-- kind of social club of some sort, whether it’s a golf club or whatever, it’s-- they do last longer. I think they kind of give up.”   Participant #2 was also quite involved with his community; however, the specific activities he was involved in were due to the various challenges he described since “coming out” to his friends and family, leading to him getting divorced, losing communication with his son, and having to change his social circle and activities. He shared that he used to do quite a bit of boating and sailing but stopped since having to find a new group of friends; since then, he became involved in walking and hiking groups and built new social connections. Significant components of this participant’s life were the walking and hiking groups with whom he met a few times a week. He was involved with both the “Health Initiative for Men Program” which involved warm up exercises and light activity with other men, as well as “Out and About”, which was a gay men’s hiking group. This participant also had a history of depression, which was a significant factor in his motivation to be physically active. He believed that getting out in the community and socially interacting with others would prevent him from slipping back into depression. He stated,  “Oh, I am subject to periods of depression all my life and I’ve learned that activity’s a good antidote. So I try to get out every day as-- partly as therapeutic.” 79   It was clear that this participant’s community involvement was especially important in promoting social interaction and for him, maintaining mental and emotional health while preventing further episodes of depression.   Additionally, Participant #3 also maintained strong connections with his community, specifically in the form of a Seniors Recreation Center. The main activity this participant was involved in at the Seniors Center was carpet bowling, an activity to which researchers accompanied the participant during a walk along session, primarily for the purpose of observing his interactions with others. The intent of carpet bowling is to aim one’s bowling ball as close as possible to a designated ball on the other end of the carpet. The balls weigh about one pound each and are rolled on top of carpet; the game requires aim, balance, and some strength to get the ball to the other end. Watching the participant during this session truly showed how much he genuinely enjoyed doing this activity; the social interaction aspect of the game appeared to be a significant component of his motivation to continue to attend the sessions. The other members of the recreation center appeared to get along very well, forming a close-knit group. During the game, members were very supportive of one another, making comments such as “good job,” “great shot,” and “nice try,” while at the same time engaging in some friendly competition. The Seniors Recreation Center was overall a socially supportive place where the members welcomed new faces and encouraged one another to succeed; the participant appeared very comfortable in this environment. Participant #3 was an advocate for community involvement; similar to Participant #1’s feelings around his tennis club, he stated the following about seniors’ centers:   “you definitely need to join a senior centre. And once you get to a certain age, I think it’s very accommodating and it keeps you going.”   This participant was also a seniors’ advocate, in that he participated in community events and seminar talks such as prostate cancer meetings and presentations, and well as transportation 80   seminars to improve the transit system for seniors. This participant had clear connections with his community in various forms, significantly contributing to his patterns of physical activity and social interactions in his day-to-day life.   Participant #4 was not quite as involved with the community and activity groups as the other men; however, he did at times make an effort. When asked what motivates him to get out into his community, he shared:  “My physical health and certainly emotional health to a degree as well. The fact that you have done something or completed a job gives you a degree of satisfaction.”   This participant’s motivation was rooted in a combination of knowing that physical activity would improve his mental and emotional health, as well as it being good for him physically to keep going. Guilt was also something the participant had discussed in providing him with motivation to get out in the community, in that he knew he should be outside walking and would feel guilty for not doing so. During one of his walks, this participant was struck, as a pedestrian, by a cyclist in a park; not only did he since then avoid this area due to the high density of cyclists, but he also had ongoing issues with his right leg and knee due to this incident. Because of this incident, the participant had to stop hiking with a group he was involved with, causing a decline in his physical activity level, as well as a loss of social contact with other members of the group. He wished he could have continued hiking but shared that he became too slow and could not keep up with the others in the group; he also shared that he first signed up for this hiking group for the social interaction. The following is an excerpt from a conversation with this participant (A) and the researcher (Q):  Q: 10 years ago, what was it that motivated you to join the hiking club? A: Social isolation. Q: So you were looking for social interaction? A: Yes.   81   A commonality present in each of the men’s community-based activities is the social interaction component that appeared to be important, demonstrating connections between social interaction, community involvement, and participation in physical activity.   4.4.2 Relying on Others vs. Helping Others      In this study, we saw how the men sometimes relied on others for daily activities and tasks; however, they also took pride in being able to help others. This was the most evident in Participant #3’s situation. Initially, this participant had a large amount of support from his wife; not only did she drive him to all of his activities, but she provided a great deal of emotional support for him. This participant talked about how he would have been lost without his wife after his stroke and how she was a significant support for him in his recovery; he stated,  “I would have ended up in a nursing home if it weren’t for her.” The participant’s wife also managed all of his appointments and activities and ensured that he got to where he was supposed to be on time. Secondly, in addition to evidence of risky behaviour, the participant’s dog was a significant influencing factor for the participant’s physical activity in relation to reliance on others. The participant walked his dog two times a day for about half an hour each time, and when asked whether the dog was a source of motivation for him, the participant replied, Definitely a motivator, he has to go. He goes to the door and waits, like this morning…I  think that’s a good idea for any elderly people.”   Taking the dog out for a walk can be seen as both a form of the participants’ reliance on the dog, as well as helping both the dog and his wife. By being in charge of the dog’s walks, the participant was taking some of the burden off of his wife’s household tasks, as well as meeting the dog’s needs to get outside. However, it was also evident that the participant somewhat relied on this dog for his own patterns of physical activity, in that his leisurely walks were solely for 82   the purpose of taking the dog out. Aside from walking the dog, he did not engage in any other leisurely walking, and it is not known whether the participant’s walking would decrease without the dog. Additionally, the dog almost guided the participant; when the researchers accompanied him on a walk, the participant continued to walk further and further from his home until his dog took the appropriate turn to return back home, demonstrating a reliance on the dog to accommodate for the participant’s cognitive status and short-term memory loss. This participant provided a great example of the need to rely on others with advancing age: he relied on his dog to encourage him to go for walks, and he depended heavily on his wife for household tasks, for meals, and taking care of him, being reflective of traditional gender relations and norms.  Alternatively, a significant part of Participant #1’s daily tasks involved helping others. This participant was the main caregiver for a female friend at an extended care home. He ran errands for her such as shopping and banking, was her power of attorney, and took her to her appointments. He also called her daily and visited her twice a week, reflecting the importance of this activity to the participant.  Photograph #14 below was taken by Participant #1, as something that he believed influenced his physical activity. In addition to the social interaction involved in being a caregiver, it also encouraged his activity in getting out of his home into the community.  Figure 14: This photo depicts the care home Participant #1 visits in caring for his female friend he has known for 20 years. He stated, “I also look after a lady that’s in the Louis Brier Care Home [and] have Power of Attorney. So I go up and visit her at least once or twice a week and she calls me every day. She gets very lonely up there, but she can’t walk now. She’s in a wheelchair so when she has to go to the dentist I drive her down there with a care worker. So that keeps me reasonably busy too.”   83   This participant was widowed and had been living independently since his wife died. His desire to continue taking care of a female friend possibly demonstrates the importance of the masculine values of capability and power in a caregiving relationship for this participant. This participant also occasionally helped take neighbours shopping and to appointments. Helping others may allow the participant to demonstrate his capability in engaging with activities that others his age are no longer able to do for themselves. Masculine ideals of functional independence and ability may be of importance to this participant and his identity; however, these activities may also represent protector and provider ideals, strong masculine roles that give men purpose and poise.   4.4.3 Lone Wolf vs. Desire for Socialization    Maintaining social networks and increased social interaction has commonly been reported as a feminine attribute; whereas independence, self-reliance, and solitary activities have been associated with masculine qualities and ideals. Although in some cases this may be true, findings from this study also illustrate that there may be a disconnect between what is expected of men by society as they age, and what is actually happening. Interestingly, three of the men associated women with being more social than men as they age:  “Quite a lot of men are kind of loners, you know. Women do like to get together and have a chitchat and gossip, whatever you want. And that’s why I think women last longer.” – Participant #1  “I think women seem to, from what I’ve seen anyway, keep a social network going, and enlarge it even as they get older. And I think for many men, they see their social network diminishing as people die or-- become ill, that sort of thing.” – Participant #2  “I generally--I think women have stronger social groups as they age…Much more socially active and a wider network of groups.” – Participant #4  However, these four men, perhaps with the exception of Participant #4 who lost most of his social connections with his hiking group after his bike accident, have all maintained social connections and built new significant social networks within their communities as they have 84   aged. For example, Participant #1 with the tennis club, Participant #3 with the Senior’s Center, and especially Participant #2 who maintained and even built new social networks after experiencing the transition of his divorce and “coming out.”   Two of the men referred to themselves as loners, but these two men also expressed a desire for a need for socialization. For example, Participant #2 shared that he likes to spend time alone but also relied on social interaction to prevent a relapse into depression and to enhance his mental health; Participant #4 enjoyed solitary activities such as going for walks on his own and reading, but also stated that he is only “vaguely happy” with his social interaction level and would like to do more of it. It seemed as though these two men were more introverted and wanted to spend time alone, but also wanted social interaction in their lives. Alternatively, Participants #1 and #3 were very social, a trait that was evident in interactions with these two men. Participant #1’s strong social ties to his tennis club and Participant #3’s strong social ties to his seniors’ recreation center demonstrated a possible need to question current existing beliefs and stereotypes around men as they age. For example, men are expected by society to be independent and relatively less social than women as they age. Men may be viewed as being private, strong, and silent types; however, there is some evidence in this research around men being quite social and even building social networks and connections as they continue to age. Men who are more introverted may have less of a tendency, or less skill in building and recreating social networks; however, they still desire social interaction and may need more support in doing so.   Additionally, discussions around physical activity programs revealed that one of the key facilitators in joining a physical activity program was around increased social interaction. Participants would prefer to join a group with social interaction, but within smaller groups rather 85   than larger groups. Participant #2 also shared that he did not have much motivation for solo exercise with his statement “self-motivation for solo exercise other than walking is-- it’s not there.” That said, an important consideration around physical activity programs is what is realistic and accessible for the participants, possibly implying that activity alone at home may be the easiest in certain circumstances. For example, participant #3 expressed some concern about transportation, as he believed getting to the program would be his biggest challenge. He discussed how although he supported the group atmosphere, he would choose to do physical activities at home due to his transportation challenge and not wanting to overburden his wife in driving him to another activity program:  “Well, you do need the group atmosphere at times, that’s for sure. But I like doing my exercise at home, rather than going to a gym. For I mean two or three reasons: the cost and also the time to get there and get back” … “Without a car, you just don’t dare to open your mouth and say oh, I’m going to do this or do that very often. So I don’t participate in that type of-- it puts too much pressure on my wife.”  Participant #3’s concerns demonstrate the need to consider factors such as accessibility, convenience, and social support networks when promoting participation in programs for older men. The men provided valuable information about their experiences with physical activity that would be useful for healthcare providers in developing health promotion interventions aimed at this population. The themes of aging male bodies, being out in their communities, and social connectedness are very relevant and applicable pieces of knowledge that can be incorporated into the development of physical activity programs targeted at older men.      86   Chapter 5: DISCUSSION      There are two main questions that this research explored:  1. What are the connections between masculinities and older men’s experiences with physical activity in the context of their day-to-day lives?  2. What can be learned from older men’s experiences to inform the development of interventions to support physical activity for older men?  In light of these research questions, this chapter provides a discussion around the findings presented in the previous chapter, focusing on three main areas:  • how masculine values may have been portrayed in the men’s daily physical activities, • how continuing to be independent as they aged was a significant motivational factor for the older men’s physical activity, • and, how health promotion programs can be targeted at older men in light of their thoughts around physical activity programs and their daily activities.  5.1 Gender and Physical Activity   There has been relatively little research around older men’s personal experiences with physical activity and how these experiences may connect with how they perceive themselves as men in a society that has high agreements about what is considered masculine (Spector-Morsel, 2006). In this study, masculine values appeared to be evident in the men’s day-to-day activities, how they thought about aging, the types of physical activities they engaged in, as well as their underlying motivations in being active.  The men connected the definition of what it meant to them to be physically active with activities requiring strength and effort such as push-ups, climbing a hill, or doing heavy chores such as taking care of the gutters, the yard, and trimming trees; the men continued to take on 87   more risks, regardless of their age or health. Courtenay (2000) discussed how when a variety of psychosocial factors were controlled for, beliefs about masculinity emerged as one of the strongest predictors of risk-taking behaviour. For example, Participant #4’s willingness to climb up a large tree with a ladder to trim the branches might on one hand represent a large safety risk, but it also reflects male norms of independence, courage, and capability (Courtenay, 2000). Participants #1 and #3 also engaged in activities that may be considered risky, but these activities were also important to the men in terms of being functionally able and independent. Participant #3 was more than willing to take his dog down a steep creek during his morning walk and Participant #1, an 86-year-old man, continued to drive on a regular basis to complete all of his daily tasks and activities. He had significant health challenges that may have impaired his ability to drive safely, but being able to drive also represented power, independence, and a higher quality of life. These findings align with Smith et al.’s (2007) findings about the importance of driving for men as they age. Smith et al. (2007) found that keeping their drivers’ licenses was very significant to the men in their study, as they associated losing it with a loss of independence and a lower quality of life. Driving cessation has also been reported by Webber et al. (2010) as being associated with various other negative consequences such as social isolation, depression, and increased mortality risk. The importance of driving was also reflected in the experience of Participant #3’s loss of his driver’s license, who described having had suicidal thoughts when he was no longer able to drive a car. It was perhaps in the context of this loss that he felt so proud of all of the activities he was still able to do after experiencing a stroke, for example, taking his dog down the creek behind his house. Negotiated the steep embankments and moving through the trees and rocks and slippery mud represents a significant risk, but there was something about being able to do this every day that was meaningful to the participant, perhaps representing the 88   masculine traits of courage and toughness that were important in his life. Traditional masculine values existed in all of the men’s daily activities in some way, whether it was the feeling of control Participant #1 felt in being a care provider for his friend, Participant #2’s physical and emotional control over his feelings of depression, as well as having confidence in himself as a gay man, and Participant #3 and #4’s continuous risky activities. Each of the men, in their own unique ways, appeared to value specific masculine traits, demonstrating the intersectional nature of gender and aging (Smith et al., 2007).  Slevin (2008) reported that older men may be seen as an unmasculine category by society and thus may face challenges in remaining masculine as they age. As older men, it is possible that the four men in this study resisted aging and being seen as un-masculine by society, and may have continued to enact risky behaviours and traditional male characteristics in order to feel and be seen as masculine. Often it is power that is used to demonstrate masculinity in older age, in the absence of other physical embodiments of masculinity (Buchbinder, 2002). For example, participant #2 expressed fears about not being able to walk or climb stairs in the future, but he also refrained from using a rolling grocery cart for months because he thought it made him look old. The behaviours and actions of all four participants demonstrated that they valued their functional ability and their independence as they aged, reflecting the notion that although men may continue to value traditional masculine ideals, the way they enact these traits are more likely to change as they age (Drummond, 2008). For instance, Participant #3 talked about being competitive in sports in his 20s in a masculine and powerful way, but he also talked about the ability to recover from his stroke and how men half his age may not have been able to recover as well as he did. Thus, strength in competition may have made him feel masculine when he was 20, but strength in stroke recovery may be how he enacts masculinity in his 80s. This is similar 89   to the “gym culture” discussed by Drummond (2008) in which lifting weights and strength training often represent values of toughness and power for younger men, but functional ability and living independently may represent these same values for older men.  Additionally, the societal expectation of women being more social than men as they age, was an ideology that was reflected by the men in this study. Although the men appeared to believe that women create larger social networks as they age, it was evident that the men in this study were also quite social and were able to maintain close social connections as they aged. This finding may reflect a possible disconnect between what the men say and what they do: they may express traditional societal beliefs around gender, but their actual behaviour represents a more complex reality.  Aging is a complex process. As Allender et al. (2008) discuss, men may face various transitions as they age including the development of chronic conditions, experiencing changes in physical status, losing a life partner, losing friends, and experiencing changes in relationship status. The importance of a temporal consideration of masculinity was stressed by Spector-Mersel (2006) in that circumstances of the life course such as physical and social losses are more common in older age, resulting in possible role changes and shifting ideals about what is considered masculine. For example, three of the men in this study lived alone, making it impossible for traditional male and female roles to be enacted in the contexts of their situations. Participants #1, #2, and #4’s “roles” are different than traditional “husband and wife roles”, and thus they may enact masculine values in ways that would be considered unique and based on life circumstances. For example, Participant #1’s caregiving role is one that is traditionally seen as a “feminine” activity. This context is explored in Ribeiro et al’s (2007) study in which the men in the study were the caregivers for their wives; although Participant #1 is widowed, he gave 90   himself the responsibility of being the primary caregiver for his female friend living in a long-term care home. This participant did not specifically discuss motivations or intentions for taking on this task, but it is possible that he may have felt similar to the men in Ribeiro et al’s (2007) study who discussed power and control in being in charge of someone else’s care within a caregiving relationship. Thus, findings from this study may align with Ribeiro et al.’s (2007) study in that conceptions of gender roles and masculine identities may be structured and sustained differently for older men; caregiving may represent self-worth and may even re-affirm men’s sense of masculinity (Ribeiro et al., 2007). This area of research would benefit from further investigation.  This study simultaneously considered older men’s experiences with physical activity and how what it means to be a man may influence patterns of everyday activity. Findings were interpreted using a masculinity approach; however, it is noted that gender alone is not the only factor of influence on older men’s experiences with physical activity. Our study’s findings aligned with Courtenay’s (2000) argument that although most men appear to agree that masculine values such as toughness, strength, resilience, and capability are important, how these values are enacted through physical activity will differ according to men’s age, culture, socioeconomic status, and sexuality. There was considerable diversity even in this small sample size and as such these men provided valuable perspectives on aging in the context of their situations. Of course, future studies of larger sample sizes are needed in order to truly understand the complexity of these factors.  5.2 Resiliency & Motivations: Maintaining Independence and Quality of Life  Allender et al. (2008) discuss the negative influence of life changes and periods of transition on participation in physical activity, specifically factors around developing chronic 91   conditions, changes in physical status, and changes in relationships. It is almost certain that with age, individuals will experience these changes that will negatively influence their physical activity; however, these four participants showed great resiliency in adjusting to these changes and continuing to be as physically active as possible.  The four participants each demonstrated some degree of resiliency in their life transitions and continuing to be physically active despite their challenges; however, it is almost certain that these men will continue to face further challenges and life transitions as they grow older. Maintaining health and functional ability has been reported to be the greatest motivational factors for physical activity by older adults (Daley and Spinks, 2000; Rasinaho et al., 2007); the findings from this study align with this existing literature. In some way, each of the four men expressed the desire to be able to do things for themselves as they age, with Participants #1 and #3 even discussing “doing anything” to prevent having to go to a nursing home where they could not take care of themselves. Other motivating factors for physical activity reported in the literature included social contact, social support, and knowing the positive benefits of exercise; these factors were reflected more so by Participants #2 and #4, but were evident in conversations with all four participants.  Quality of life is defined by the Centers for Disease Control and Prevention (CDC) (2016) as individual perception of physical and mental health – including health conditions, functional ability, social support, and socioeconomic status, among others. In this view, quality of life is subjective and depends on the perceptions of individuals (Gabriel & Bowling, 2004). In a study by Gabriel and Bowling, (2004), 80 older people participated in surveys, with most of them saying that having good health gave them good quality of life. Over two-thirds of the survey respondents also emphasized the importance of maintaining their independence for their 92   quality of life, including being able to walk, having good mobility, and avoiding dependency on other people. These are components of positive quality of life that were also reflected by the participants in this study. At the time of the interviews, the four participants were in overall good physical condition, and quite functionally capable of taking care of themselves with minimal assistance from others. Although the four men in this study were not specifically asked about their quality of life, they all said they were happy with their current lives and overall appeared to be positive and satisfied with their current situations. Concerns about the future however seemed to be mostly related to the possible loss of their independence, and how this would significantly impact their quality of life. Thus, preventing this dependency on other people and being able to remain as independent as possible appeared to be a significant motivating factor for the four participants and was evident in their incredible resiliency to life challenges and transitions.   Participants #1 and #3 spoke on multiple occasions about never wanting to go to a nursing home or being at a point in their lives where they could not take care of themselves; they even talked about being in support of medical assistance in dying. These beliefs may be reflective of their concerns and uncertainties about the future, while simultaneously being a motivating factor for the participants to continue to be as active as possible. Participants #2 and #4 did not speak about the future quite as much as the others; however, as discussed, participant #1 expressed concern about losing mobility as he aged, and participant #4 clearly valued having the ability to continue doing outdoor tasks, as risky as they may be. Each of the four participants appeared to be motivated by remaining independent, a trait considered to be highly masculine.   In Western society, growing old can be seen quite negatively, in which older men may be seen as “useless” and “unmasculine” (Slevin, 2008). The four men in this study did not see themselves as useless by any means; each of them in some way took pride in their various 93   activities, allowing them to feel that they were still contributing, whether it was by helping friends, connecting with their communities, or doing heavy chores around their yard. Connell and James (2005) discuss how older men may continue to enact traditional male characteristics in order to feel socially accepted, which are reflected in their daily behaviours and physical activities. The participants’ day-to-day activities reflected traditional male characteristics of strength, resilience, independence, control, and courage, among others. It is very possible that their behaviours and involvement in certain activities may be a way for them to feel masculine and independent in a society that does not necessarily see them in such a way. The pictures taken by the participants for the photovoice interview tended to reflect factors that supported their independence, again reiterating the importance of this trait to the men. For example, they took numerous photos of objects and environments that supported their mobility and their independence including bed rails, their cars, a rolling grocery bag, an electric scooter, stair railings, as well as photos of the outdoors demonstrating their ability to walk to amenities and complete daily tasks. Maintaining independence was clearly a trait that motivated these men to continue to be physically active, as well as one that represented the men’s masculine values. It is important to examine the implications of the interconnections between older men’s independence as they age and the influence of this on their masculinity, and quality of life. Promoting independence is crucial in engaging older men in physical activities and in encouraging them to have greater control over, and take greater responsibility for their own health and well-being (Smith et al., 2007). 5.3 Implications for Practice: Targeting Health Promotion Programs at Older Men    The literature review presented in Chapter 2 discussed gaps in current knowledge around older men and physical activity, especially a lack of emphasis on existing physical activity 94   promotion programs specific to older men. Findings from this study about older men’s experiences with physical activity in the context of their day-to-day lives can assist healthcare providers to develop health and physical activity promotion interventions that are specific to older men. In light of the findings presented in this study, three suggestions will be discussed to assist healthcare workers in informing the development of these interventions, including:  1. Using knowledge around motivational factors to attract men to physical activity programs.  2. Considering the influence of the men’s physical and social environments when implementing interventions.  3. Including men in the programs: using a strength-based approach in focusing on what the older men are physically capable of doing; and, using an activity-based approach in designing activities that the give the men purpose, enjoyment, and meaning  5.3.1 Use knowledge around motivational factors to attract community-dwelling older men to physical activity programs    Older men are particularly at risk for inactivity and functional decline as they age (Chaudhury et al., 2012), making their participation in physical activity programs an essential component of success aging. Societal expectations around gender may result in the belief that men are self-reliant and able to handle their own health without the assistance of healthcare or health promotion programs (Courtenay, 2000; Smith et al., 2007; Verdonk et al., 2010). However, the men involved in this study appeared to be welcoming of and willing to participate in programs that they believed would be beneficial to their social-emotional and physical health, whether it was through connecting with new programs, or maintaining their long-standing connections with existing groups. While the specific findings varied from one man to another, overall it appeared as though increased social interaction and strength-building were the main 95   facilitators for the participants joining in a physical activity program. Most importantly, they believed that these factors would help them maintain their independence as they grew older, which was their primary motivation for staying active.   Currently, recruitment for physical activity programs is done through advertisements at seniors’ centers, doctors’ offices, local media, patient education centers, and other public areas where older people may gather. Programs targeted at men may also be advertised in local bars or public places where men are known to gather. However, these strategies are known to recruit self-selected, healthy, and highly motivated individuals who express enough interest in physical activity to find these advertisements (Mills et al., 1996). Inclusion criteria for this study specified that the older men must be able to move about and within their homes, either independently or with assistance; thus, this discussion around physical activity programs is not meant to target those older men who face great challenges in their health status, or in moving around within their homes and communities. It is important to note that the four men in this study are relatively healthy, community-dwelling, and functionally able to access programs that would be offered to them, characteristics that make older men more likely to join programs (Mills et al., 1996). Thus, community level programs may be of the greatest benefit to those men similar to the ones in this study, men who are mobile enough to access the programs, and have an internal source of motivation to push them to join health promotion programs. However, even with men who are motivated to be active, it is difficult to attract them to a program that may not necessarily meet their needs, and even more challenging to retain those program participants (Hughes et al., 2009; Bottorff et al., 2015). As evident in the findings from this study as well in previous literature, older men value their independence, thus using this motivational factor as a means to recruit and retain participants may be beneficial. For example, healthcare providers and community program 96   facilitators and organizers can make an effort to emphasize the benefit of maintaining independence that results from physical activity, both in their advertisements to recruit participants, as well as in program sessions. It would also be beneficial for physicians to emphasize that independence and quality of life can be enhanced by increasing physical activity, allowing greater longevity and the ability to remain at home longer. The participants’ desires to be functionally independent, physically strong, and socially connected as they age may attract them to community programs targeted at older men 5.3.2 Consider the influence of the men’s social and physical environments when implementing interventions   Recognizing the influence of older men’s physical and social environments on their physical activity and access to physical activity programs can inform the development of successful interventions to promote the health of older men (Booth et al., 2000). Comprehensive strategies are required when working with older men in order to fully understand how to best optimize programs for the benefit of the participants.  Aspects of the physical environment are especially important in designing physical activity programs, specifically if there is an outdoor component to the program (Giles-Corti & Donovan, 2003). The physical environment was a significant factor for the four men in this study, in facilitating and encouraging them to be outdoors. These findings suggest that if a program is being designed to include outdoor activities, then it is important to consider factors such as the weather, the quality and safety of walking facilities such as sidewalks and crossings, and the density of the neighborhood such as other pedestrians or cyclists. Additionally, factors such as familiarity with the environment and aesthetics have been shown to have a positive influence on physical activity (Cauwenberg et al., 2012). All of these features of the physical environment were shown to be of importance to the men in this study as well.  97   The physical environment is also an important consideration for indoor programs, for example, how far the program is from the participants’ homes and how they can get themselves there. Because many older men do not drive and use walking as their main means of transportation (Lockett et al., 2005; Van Cauwenberg et al., 2012), it would be ideal for the activity program facilities to be accessible by walking or by public transportation. It is also important for program facilities to be well-maintained, aesthetically appealing, and in safe and familiar neighborhoods with little traffic (Van Cauwenberg et al., 2012). Almost all of these factors were raised spontaneously by the participants in this study, thus lending support to the previous literature in that these factors seem to enhance physical activity and motivation to get out in the community. It is also important to address deficiencies in accessibility when working with older men, such as inability to reach facilities and lack of suitable program activities (Rasinaho et al., 2007). Education about transportation for seniors in the community such as reduced transit fares and shared ride services are important from the outset in communicating with potential participants, so that these factors do not prevent the men from joining the program. While it was not a particular issue for this sample of well-to-do men, financial limitations may also be an obstacle in accessing programs (Rasinaho et al., 2007), thus subsidized programs or programs led by volunteers may be beneficial.   Although two of the men discussed being happy as “loners,” and there were differing opinions in regards to group size in exercise groups and solo-exercise, all four participants expressed an interest in social interaction as being a part of physical activity. It is important to remember that some older men will enjoy group activities and others may not, and some older men will enjoy solitary activities, while others may not. Perhaps, having a combination of solitary activities as well as group activities would result in greater retainment of older men in 98   physical activity programs, and more importantly making it clear that this option exists within advertising for the programs. For example, the “Fit Fellas” program (The Effervescent Bubble, 2016) had great success and a large part of its success was the social connection the men felt to one another. The program included optional social events for the men to get to know one another, allowing them to more enjoy their physical activities together. It is not known however whether “Fit Fellas” included both individual and group components.  Older men’s social environments in their day-to-day lives is also an important consideration when designing physical activity programs based in the community. If older men do not have support and encouragement from loved ones, they may be less likely to become involved in such programs. Although only one of the men in our study had a wife, this man relied heavily on her, not just for support but also for transportation; she was a key factor in him accessing physical activity programs. Our findings demonstrate the importance of connections between social interaction, community involvement, and participation in physical activity that need to be considered when working with this subpopulation. Consideration of older men’s social networks further adds to a comprehensive health approach, essential in designing effective programs for older men to optimally promote their health.  5.3.3 Include men in the programs; using a strength-based approach in focusing on what the older men are physically capable of doing; and, using an activity-based approach in designing activities that the give the men purpose, enjoyment, and meaning   Research has shown that when programs are tailored to specific populations or interests within a group of men, they are highly successful in accomplishing what they are designed to do (Bottoroff et al., 2015). In healthcare, patient-centered care reflects the notion that “patients are known as persons in context of their own social worlds, listened to, informed, respected, and involved in their care – and their wishes are honoured during their health care journey” (Epstein 99   & Street, 2011). The fundamental characteristics of patient centered care are patient involvement in care, and the individualization of patient care (Robinson, Callister, Berry, and Dearing, 2008). Because research has shown that patient centered interactions promote adherence and lead to improved health outcomes (Robinson et al., 2008), health promotion programs should also be participant-centered. It is not enough to tell older men that they should be active, rather they need to feel included as influential members of the programs they are involved with.   One way to involve participants in physical activity programs is to have a discussion around the types of activities they would like to do, and what their goals in joining the program are. For example, the four men in this study would like to see activities such as walking, weights, swimming, tennis, stationary bicycling, running, boating or sailing, carpet bowling, dancing, as well as strengthening exercises. The participants were also open to coaching or training within physical activity programs. It is important to be realistic in that every participant of the program will not have the same interests as other men, thus perhaps giving men options from available activities would be beneficial.  As noted already, another important aspect of health promotion programs is around whether participants prefer solitary or group events. There have been successful physical activity programs using group, individual, or mixed modes (individual and group) (Bottoroff et al., 2015); using data from this study, it would appear that mixed modes of program delivery may result in the greatest adherence and participant satisfaction. Bottoroff et al.’s (2015) literature review of physical activity programs for men discussed how the most effective programs are those that include regularly scheduled physical activity in group sessions, and individualized exercise plans supervised by personal trainers. This idea is similar to one of group medical visits, which are a form of healthcare delivery in which medical appointments are offered to a group of 100   patients with the same disease (Housden, Wong, and Dawes, 2013). These group medical visits combine an individual medical appointment with education and a peer-supported group discussion to improve self management of health conditions (Watts, et al., 2015). The combination of individual sessions combined with group sessions can be greatly beneficial to participants of physical activity programs, meeting needs for both social connectedness as well as at times wanting to spend time alone. Further, because older men may face significant health challenges, embedding support groups within the physical activity programs may be helpful for the men. Significant value may come from facilitated peer interaction, specifically around aspects of self-management of health and empowerment regarding complex health conditions (Stevens et al., 2014). For example, the success of “Fit Fellas” was largely related to the men feeling connected to other men and supported by those who are similar to them (Effervescent Bubble, 2016).  Social connectedness has been shown to be an essential component of successful programs. It is interesting to note that three of the four men in this study discussed the importance of social interaction to them even though literature around masculinity expresses a societal belief around women being more social than men as they age (Courtenay, 2000). Thus, it is important for healthcare providers to be aware of their own beliefs and biases when promoting the health of older men. “Fit Fellas” emphasizes having fun and building friendships, and it is evident that men, like the ones in this study, would appreciate and benefit from building connections within their communities and with other older men. For this population of older men, physical activity is often accomplished as a part of daily life, such as walking for travel, completing daily tasks, or recreation within one’s neighborhood (Chaudhury et al., 2012). Thus, if health promotion programs designed to target this population can focus on building friendships 101   and social connections, older men may be more likely to maintain these friendships in their communities and engage in physical activity and daily tasks with other members of the program. Ways to incorporate social connection into programs may include offering social events for program members, taking part in fundraisers or volunteer events as a group, attending pub nights, as well as keeping in touch outside of the program with email or a regular newsletter (Effervescent Bubble, 2016). Using such strategies would create supportive social environments, a finding that has been documented in previous literature. Encouraging people to walk with others or engage in daily activities with others has also been associated with higher levels of physical activity (Giles-Corti & Donovan, 2003).  Finally, having the older men as active participants in the programs means purposefully including them in the development of the program. Older men can be a hard to reach population, one that is unique in the challenges they face and one that would benefit from health promotion interventions designed specifically for their needs as well from a diverse set of delivery platforms (Bottoroff et al., 2015). The older men in this study suggested various activities for physical activity programs, but they also discussed the activities they do on a daily basis or have done in the past that could be incorporated into a program for older men. For example, two of the participants discussed being a part of organized sports teams (when they were younger) and expressed interested in being able to do this again; thus, some sort of sporting competition adjusted for older men may be appealing for some men. One participant talked about wanting to do some boating and sailing within a program, something that could be arranged by building community partnerships. Hiking and walking was a common interest to all four men, and walks around the neighborhood could be fit in quite easily to a program.  102   The men’s discussions around their past experiences with physical activity demonstrate the activities that these men used to do in the past are something that they continue to hold onto in their patterns of physical activity as they continue to age. For example, continuing to engage in yard work and tree trimming using a 16-foot ladder may be risky, but it may also be reflective of routine and a sense of purpose. Incorporating activities that may have given men purpose throughout their lives such as building projects and using tools into programs for older men has proven to be a successful idea. The Canadian Men’s Sheds Association is a peer-run community group that allows groups of men to get together in safe and friendly environments to socialize and engage in common interests (Canadian Men’s Sheds Association (CMSA), 2017). “In a shed, men get together for activities like woodworking projects, cooking, bike repairs, music, and watching sports on television” (CMSA, 2017). These sheds have been especially useful for men after retirement to prevent isolation, loneliness, and depression; they can also contribute to enhanced community involvement, and improved mental and physical health. Men’s Sheds have proven to be greatly successful in bringing men together in the community; they connect the importance of routine, purpose, and social connectedness, while considering the influence of masculinities on aging men. Successful physical activity programs will not only include the men in program planning, but also use a strength-based approach in focusing on what the older men are physically capable of, as well as use an activity-based approach in designing activities that give the men purpose, enjoyment, and meaning.  Current physical activity programs may focus on gender in that there are different programs for men and women, and they may focus on age in that there are various programs for older adults. However, there are relatively few physical activity programs that consider both of these factors, age and gender. The effectiveness of interventions is dependent on the 103   consideration of intersections between gender, age, social and physical environments, and individual factors, among others (Bottoroff et al., 2015). Using knowledge around older men’s motivational factors to attract them to physical activity programs, considering the influence of physical and social environments, and including men in the development of programs to ensure they are enjoyable and meaningful are a few of the ways to tailor health promotion programs to the unique needs of this diverse population. Greater exploration is important and necessary in order to guide the development of optimal physical activity programs for older men. Further efforts are also required in investigating how to successfully engage this population in health promotion programs while simultaneously empowering them to take control of their physical activity and overall health.  5.3.4 Implications for Nursing Practice   Conventional health promotion strategies are centered around individual lifestyle interventions that reflect dominant societal discourses and do not necessarily benefit certain populations. In addition to community program developers, findings from this research can be used to inform aspects of nursing practice that can ultimately address the unique needs of older men and their participation in physical activity.  Due to the growing population of older adults, many patients who are admitted to hospitals are of older age, and face significant health challenges influencing their mobility and physical activity levels. In order to enhance participation in physical activity, nurses must promote this aspect of health both within and outside of the hospital environment. Nurses working in hospitals can contribute to community health promotion by incorporating it into their discharge planning efforts. Educating patients around the importance of physical activity to their health and well-being and connecting them to community resources that are available to them 104   will assist in increasing the number of older men who meet the requirements for physical activity, and reduce the risk of further health deterioration, thus possibly even decreasing associated demands on healthcare.   Further, nurses in the community can similarly promote physical activity for older men by advocating for and connecting them with available health promotion programs. They can help recruit program participants, and they can assist in designing optimal physical activity programs that are tailored to the specific needs of older men using the aforementioned suggestions. In regards to long-term care nurses, it may be beneficial for their nursing practice to enhance their understanding of connections between older men’s masculinities and patterns of physical activity. Nurses in long-term care can work with recreational, occupational, and physical therapists in their facilities to develop activity programs that would benefit older men. However, because the men in this study were community-dwelling and generally healthy, it is not known whether the findings can be extrapolated to those older men in long-term care.   A recommendation for all nurses is to be aware of how dominant societal ideals may exist in their own beliefs and practices. For example, a common societal belief is that older men are not as social as women as they age, thus healthcare providers may not recognize the need to promote socialization for older men. However, our findings suggest that this is a key component of older men’s participation in physical activity, demonstrating a need for healthcare providers to first examine their own biases and assumptions related to masculinities and older age. Being cognisant and considerate of the intersections between gender, age, and physical activity will help healthcare providers to develop interventions that are specific to older men, and thus facilitate healthy aging and enhance quality of life in this population.    105   5.4 Study Limitations and Overcoming Difficulties  5.4.1 Study Limitations   This study and its design pose a few important limitations that limit transferability of its findings. First, because our sample consisted of urban-dwelling, white, educated, functionally able, and financially comfortable men, these results cannot be extrapolated to those older men who live in rural areas, are less educated, face socio-economic challenges, or to men who have significant mobility impairments and health challenges. Also regarding sampling, participants who had agreed to participate in the study were volunteering themselves as participants. This study asked for participants who are generally able to move about and within their homes, either independently or with assistance, which may have inclined certain participants who are already physically active in their communities to participate. Speaking English was another requirement for participating in the study that may have excluded many individuals. Additionally, 10 of the 15 original participants from which the subsample was drawn were men who were more likely to participate in research, as they had agreed to be contacted for further research after a previous study they had participated in. Three of the men in our subsample were then recruited through snowball sampling from these original participants, a sampling technique which will generally recruit participants with similar characteristics as the original participants, for example, activity levels (Polit and Beck, 2002).  The use of our specific data collection methods may also be a limitation. The use of interviews as a method of data collection is susceptible to bias for various reasons: participants may have a desire to please the researcher and may say what they think the researcher wishes to hear (Doody and Noonan, 2013); they may have a desire to create a good impression and thus their answers may lack honesty; there is also a tendency of participants to say something rather 106   than nothing in interviews, even if a participant has nothing to say about a specific topic; finally, the researchers views can influence the participants responses by showing emotions such as surprise or disapproval (Doody & Noonan, 2013). Furthermore, when using walk-along methods and participant observation, participants may act differently than they would if the researchers were not observing them (Pope & Mays, 1995). It is not known whether our participants’ interactions with their physical and social environments during the walk-along interviews were the same as they would have been on any given day. Finally, with the use of photovoice, the number of pictures people take may be reflective of how comfortable they are with using a camera. Participants also make choices about what they select as important for their photographs, as well as what they do not select for their photos, choices which undoubtedly influence the research findings (Palibroda, 2009). However, the use of our specific data collection methods may also be viewed as a strength because we conducted multiple interviews in various contexts, as well as received 54 photographs from the four participants, providing depth to our research.  Both of the research assistants involved with the data collection from walk along interviews and photovoice sessions were young women; one young male research assistant was present at the original interview with participants #1, #3 and #4. It is not known whether having older interviewers, or having a male presence at subsequent sessions would have changed the data that we received, especially when considering questions around gender and aging. Additionally, the data that was provided may also have been dependent on the participants’ motives to participate in the research study. For example, participant #2 had ideas about accommodating older men in men’s only health programs, and participant #3 wanted to see a change in seniors’ healthcare; thus, these two participants may have thought the research assistants could help them achieve these goals as healthcare professionals. 107   Despite these limitations, this study resulted in valuable findings about community-dwelling older men’s experiences with physical activity in the context of their everyday lives.  These experiences can be useful in informing health promotion interventions that are targeted specifically at older men who are functionally capable and able to access these services.  5.4.2 Overcoming Difficulties   Potential difficulties that developed during the research study were planned to be addressed in collaboration with research team members as well as the participants. Potential difficulties may have been: participants withdrawing from the study, problems with technology regarding audio and video recordings, and health challenges. When working with the older adult population, it is a possibility that health events may occur that may interfere with the research study. One of our four participants experienced a fall prior to our first scheduled walk along session. In collaboration with the primary investigator and with the participant, the research team decided to have another sit-down interview with this participant. We then combined this interview with a house tour in which the participant showed us around his home; this participant experienced many health issues throughout the study in which he had to cancel interviews due to medical appointments. However, working around the participants’ schedules and daily life commitments was something the researchers aimed to do from the outset of the study. Collaboration and communication between the research team and the participants was key throughout this study.  5.5 Conclusions   The benefits of physical activity have been greatly documented in previous literature, and although it is well-known that physical activity can facilitate healthy aging, the factors associated with the engagement or lack thereof in physical activity have not been as well understood. This 108   study adds to the growing knowledge around older men, physical activity, masculinities, and the connections between them. In addressing the discussed gaps in existing literature:  • This study provides a greater understanding of older men’s personal experiences and motivations around physical activity in the context of their everyday lives. • This study drew on existing knowledge around masculinity and aging, and explored the connections between this existing knowledge and older men’s experiences with physical activity and aging. • This study used data collection methods beyond traditional qualitative interviews and quantitative methods that have been used in previous studies. In-depth qualitative methods including walk-along interviews and photovoice allowed for further exploration and understanding of contextual and socioecological influences on the older men’s physical activity. An individual’s use of community and health services is dependent on the effects of factors such as gender, age, and the influence of physical and social environments (Smith et al., 2007), all of which must be considered when designing health promotion interventions tailored to specific populations. Learnings from this study allow us to consider these factors and their influence on older men’s experiences with physical activity so that physical activity programs can be more appropriately designed to benefit this population.  The use of multiple data collection techniques in this study allowed us to comprehensively explore the men’s experiences with physical activity in the context of their everyday lives. This study involved the participation of four older men living in the community, a small sample that provided depth and diversity in life experiences as well as a range of experiences with physical activity. However, it is also recognized that the four participants were 109   similar as white men, of European background, in good general health, educated, and financially comfortable. Thus, the aforementioned findings and recommendations in designing physical activity programs may be beneficial for other older men in similar contextual positions, however they may not be extrapolated to older men of different social backgrounds and/or who face greater challenges in health and access to services.   Further exploration of areas around masculinity and aging, with the consideration of factors such as sexual orientation, widowhood, and marital status would greatly benefit this topic of research. However, new knowledge gained from this study can be used to help us understand some of the experiences that older men have with physical activity as they age. 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(2014). Triangulation in institutional qualitative data analysis: clarity     from viewing through multiple lenses. Higher Education Institutional Research Network (2), 1-8. Retrieved from http://www.heirnetwork.org.uk/wp-content/uploads/2014/01/OPS2-Elena-Zaitseva-and-Martyn-Stewart.pdf         123   APPENDICES  Appendix A: Invitation to Participate in the Study   T H E  U N I V E R S I T Y  O F  B R I T I S H  C O L U M B I A  Adult Development and Health Lab Department of Psychology Vancouver, BC, Canada 2136 West Mall Avenue V6T 1Z4 Tel: (604) 822-8428    May 28, 2015  Dear Previous Study Participant:    As the season changes to spring we are enjoying a busy time here at the Health and Adult  Development lab at UBC. We are collaborating with the Center for Hip Health and Mobility at UBC on a new Team Grant that will tackle key health challenges of men to generate new knowledge and innovative approaches for health promotion.    We are approaching you today because you had expressed an interest in participating in future research and we would like to garner your interest in an upcoming study that is spearheaded by Dr. Alison Phinney, Associate Professor in the School of Nursing at UBC. The primary purpose of this study is to understand supporting and limiting factors that influence older men’s ability to move about their neighborhood and participate in their community as well as the challengers and facilitators faced by care providers, family members, and community programmers and volunteers as they provide support and services to try and keep older men active and mobile.     You are eligible for this study if you identify as a man who is:   • Able to communicate and consent to an interview in English  • 65 years and older   • Able to move about, within, and outside of your home     Should you choose to participate in this study, you will be asked to participate in an informal “conversational style” interview that would last about one hour. The interviews will take place at a time and place convenient for you (which could include your home or a community centre). By participating, you will receive a $10 gift card from our research team to thank you for your time.     If you are interested in participating in this study, know someone who might be interested, or would like more information, please contact Project Manager, Suzanne Therrien at 604-8754111 ext. 21720; or, you may complete the included pre-addressed and stamped postcard and we will be in touch with you shortly to provide you with further information. Please include your name and contact number or email on the postcard.     If you have any concerns about this research or your rights as a research participant, you may contact the Research Subject Information Line in the UBC Office of Research Services at 604822-8598.     Thank you kindly for your consideration in being a part of this study.     Sincerely,       Christiane Hoppmann, PhD  Associate Professor, Michael Smith Foundation for Health Research Scholar, and Canada Research Chair in Health and Adult Development  124   Appendix B: Recruitment Postcard     125   Appendix C: Recruitment Poster    126   Appendix D: Information Letter and Consent Form (Initial Interview)  Information Letter and Consent Form for Community-Dwelling Older Men  SHAPE THE PATH: TARGETING THE HEALTH AND MOBILITY OF OLDER MEN THROUGH KEY COMMUNITY PARTNERSHIPS  “SEEK TO UNDERSTAND” STUDY ______________________________________________________________  Principal Investigator:  Dr. Heather McKay, PhD     Professor, Depts. of Orthopaedics & Family Practice Faculty of Medicine University of British Columbia (UBC)   Contacts: Alison Phinney, PhD, RN  Associate Professor University of British Columbia (UBC)  School of Nursing  Manpreet Gill Project Coordinator -Seek to Understand University of British Columbia (UBC)  School of Nursing   You are being invited to participate in this study.  The primary purpose of this study is to understand supporting and limiting factors that influence older men’s ability to move about their neighbourhood and participate in their community as well as the challenges and facilitators faced by care providers, family members and community programmers and volunteers as they provide support and services to try and keep older men active and mobile.  Should you choose to participate in the study you will be asked to participate in a sit-down interview. A detailed description of this is included on the next pages of this information letter.  If after reading the study description, you would like to learn more about the study, please call our project manager or lead academic investigator whose contact information is listed above.   Thank you for your interest in the study.   127   Consent Form  SHAPE THE PATH TARGETING THE HEALTH AND MOBILITY OF OLDER MEN THROUGH KEY COMMUNITY PARTNERSHIPS  “SEEK TO UNDERSTAND” STUDY  Introduction You are being invited to take part in this research study because you meet participation requirements.  Your participation in this study is entirely voluntary, so it is up to you to decide whether or not to take part in this study.  Before you decide, it is important for you to understand what the research involves.  This consent form will tell you about the study, why the research is being done, what will happen to you during the study, and the possible benefits, risk and discomforts.  If you wish to participate, you will be asked to sign this form.  If you do decide to take part in this study, you are still free to withdraw at any time and without giving any reasons for your decision. If you do not wish to participate, you do not have to provide any reasons for your decision not to participate nor will you lose the benefit of any medical care to which you are entitled or are presently receiving.  Please read the following information carefully before you decide.  Who is conducting this study? This study is being conducted by Dr. Heather McKay, Dr. Joanie Sims Gould, Dr. Dawn Mackey, and Dr. Alison Phinney at the University of British Columbia and the Centre for Hip Health and Mobility.   Background Mobility is “being able to move oneself within environments that expand from one’s home to one’s neighborhood and to regions beyond.”  There has been surprisingly little research examining men’s experience of mobility—a key factor influencing their quality of life. There is also a need for interdisciplinary research teams to better understand why men often adopt less healthy behaviours than their women counterparts.   128   What is the purpose of the study? The primary purpose of this study is to understand supporting and limiting factors that influence older men’s ability to move about their neighbourhood and participate in their community.    Who can participate in this study? You can participate in this study if you are: 1. able to communicate in English and  2. 65 years and older,  3. able to move about within and outside of your home (either independently or with assistance).  Who should not participate in this study? You should not participate in this study if you identify as a woman; are under 65 years of age; are unable to leave your residence; and/or cannot consent to be involved in research.  What does the study involve? This study is taking place in the City of Surrey and Vancouver in the places where you live and spend time on a usual basis. We plan to enroll about 10 participants. You will be asked to participate in a sit-down interview. A researcher will meet with you at a location and time that is convenient for you to ask you to describe your day to day experiences getting around and what things help you or make physical activity and getting around easy or difficult for you. These interviews will be recorded. You do not have to answer any questions for any of the study activities if you are not comfortable with them.  How much of my time is required? The total time required for the interview is about 1 hour.    What are the potential risks of taking part in this research? Taking part in any of these activities may result in a loss of privacy. However, you can decide how much you are willing to share your experiences. You may also get tired during the activity. If so, you can take a rest, or continue the activity on a different day.    129   There may not be any direct benefit to you to take part in this research, although you may find it satisfying to share your experiences as a way to contribute to new knowledge. You may also find some of the research activities enjoyable.  You will also receive a $10 gift card to thank-you for your participation. An additional $10 gift card will be provided to those who participate in the focus group.  What will happen with the results of this research? The results of this research will be shared widely with other researchers, health care professionals, and members of the general public. We plan to publish the results in an academic journal and present the results at a conference for researchers and health care professionals. We will also share the results of this research with study participants through a written report and a public presentation of the findings. You will be given a copy of the report, and “products” of your individual research activities (e.g. audio recordings) upon your request.  What happens if I decide to withdraw my consent to participate? Your participation in this research is entirely voluntary. You may withdraw from this study at any time and no reason for withdrawal needs to be provided. If you decide to enter the study and to withdraw at any time in the future, there will be no penalty or loss of benefits to which you are otherwise entitled, and your future medical care will not be affected. If you choose to enter the study and then decide to withdraw at a later time, all data collected about you during your enrolment in the study will be retained for analysis.    You do not waive any of your legal rights by signing this consent form. If you wish to withdraw please contact us.   What happens after the study is finished? Once your participation in the study is concluded, you will be provided with a one page summary of the general study findings. No personal feedback will be provided.   What will the study cost me? You will not incur any personal expenses as a result of participating in the study.     Will my taking part in this study be kept confidential? Your research activities will be transcribed into written form and members of the research team will see this transcript. The transcript will not have participants’ names included on them but rather a study identification number that can be linked to participant’s identity. This means that all identifying information will have been 130   removed or changed and you will not be identified by name in any reports or presentations of the completed study. Information that discloses your identity will not be released without your consent unless required by law. However, because some of the research activities take place in public, others may be aware that you are a participant in this research and may have opportunity to overhear what you are saying to the researcher.  All study materials will be saved on a password protected hard drive and stored in a locked filing cabinet in Dr. Phinney’s research office at UBC or at the Centre for Hip Health and Mobility.    Who can you contact if you have questions about this research? If you have any questions about this research, please contact one of the study team members. The names and telephone numbers are listed on the first page of this form.  Who can you contact if you have complaints or concerns about this research? If you have any concerns about your rights as a research subject and/or your experiences while participating in this study, you may contact the Research Subject Information Line in the UBC Office of Research Services at 604-822-8598 or if long distance e-mail RSIL@ors.ubc.ca or call toll free 1-877-822-8598.  Who do I contact if I have any questions or concerns about my rights as a subject during the study?  If you have any concerns about your rights as a research subject and/or your experiences while participating in this study, you may contact the Research Subject Information Line in the UBC Office of Research Services at 604-822-8598 or if long distance e-mail RSIL@ors.ubc.ca or call toll free 1-877-822-8598.     131   SUBJECT CONSENT TO PARTICIPATE IN THE “SHAPE THE PATH: SEEK TO UNDERSTAND” STUDY  • I have read and understood the subject information and consent form.   • I have had sufficient time to consider the information provided and to ask for advice if necessary. • I have had the opportunity to ask questions and have had satisfactory responses to my questions. • I understand that all of the information collected will be kept confidential and that the result will only be used for the scientific objectives. • I understand that my participation in this study is voluntary and that I am completely free to refuse to participate or to withdraw from this study at any time without changing in any way the quality of care that I receive. • I understand that I am not waiving any of my legal rights as a result of signing this consent form. • I understand that there is no guarantee that this study will provide any benefits to me. • I have read this form and I freely consent to participate in this study. • I have been told that I will receive a dated and signed copy of this form.  I am interested in future studies and consent to be contacted.            Yes        No  We may use the data collected in this study for further analysis in future studies interested in enhancing the health and mobility of older adults. For example, we may examine this data in conjunction with an individual follow-up interview.   I understand that my data may be used in this manner.    Yes    No      ---------------------------------------------------------------------------------------------------- Printed name of subject   Signature   Date   ---------------------------------------------------------------------------------------------------- Printed name of researcher/  Signature   Date Designated representative  132   Appendix E: Interview Guide and Field Note Template  INTERVIEW GUIDE FOR OLDER ADULT INFORMANTS  SHAPE THE PATH: TARGETING THE HEALTH AND MOBILITY OF OLDER MEN THROUGH KEY COMMUNITY PARTNERSHIPS  “SEEK TO UNDERSTAND” STUDY  _______________________________________________________________________       Purpose This first section of this document outlines the questions that we will ask each participant in the qualitative interview. Questions do not necessarily need to be asked in order but can be covered off with the natural flow of information the participant would like to share.  The subsequent ‘field notes section’ will be completed by the interviewer as soon as possible (ideally within 2 hours of the interview, or at least within 24 hours). This is a standard field notes template used for in-depth interviewing and ethnographic studies to track the interviewing process (e.g. it tracks the length of the interview, interruptions, technical problems, etc.). Tracking things such as the weather, cleanliness of the location, who was present at the interview, and body language are necessary for crafting the “complete picture” of the interview (e.g. family member in another room, may impact how the participant answered some questions).  This comprehensive tracking is an essential component of ethnographic research, and enhances to overall rigour of the study. These field notes are a product of the chosen methodology, not necessarily the research question.   133   Daily Mobility 1. Starting with when you get up, can you please talk me through a typical day for you – explain it to me like a story.  • Probes: tell me - what do you do, where do you go, how do you get there, and who do you see?  2. What activities do you like to do in your daily life?  • Probes: Where do you like to go? Who do you like to go with? How often do you engage in these activities? Out of these, which do you Love? Thinking about all of these activities together, are you mostly sitting, or mostly moving about?  3. How often do you get out and about in your community?  • Probe: How often do you leave the house? Every day? Once a week?  4. Are you happy with how often you currently get out into your community?   5. When you get out and about in your community, do you typically go by yourself, or with other people?  • Probes: Does anyone help you get around? Does anyone drive you places? Walk with you? Do you help others get around or accomplish daily tasks?   6. If given the opportunity, what if anything would you do differently?  • Probe: What do you hope for in your day?  7. What are some of the things that encourage you get out and about in your community?   • Probe: What people or services or programs help you get out and about?  8.  What are some of the things that get in the way from you leaving your home more often?  • Probes: lack of transportation, no one to go with, weather, health-related challenges? [If yes to health challenges: How does your diagnosis affect your ability to get around? Could you tell me about how your mobility affects your ability to manage this diagnosis/health challenge?   134   Transportation Patterns 9. When you leave your home, how do you get around?  • Probes: Do you walk? Use public transportation (what kind)? Do you drive a car? Are you a passenger in a car?  10. What is your preferred/ideal way to get around (if you had it your way)?  • Probes:  If this is different than how you mentioned getting around, why is your preferred way not feasible? What could work better?  If you were no longer able to get around by your preferred mode, then what would you do? Do you own a car or have you ever? In the past or present have you ever drove?  Can you describe the time that you went from having your licence to not?  What was challenging about that?  What do you think are the advantages for you not driving—if any?  11. Do you ever take public transit?   • Probes:  Tell me more about that?  If yes, what kind of transit do you take and where do you go?  How often? How do you plan your route and get information about transit times, stops and routes? Do you have to walk to a stop? How far? What do you like about transit?  What makes it challenging?  Are there reasons that some days your take transit and others not?  If no, would you consider it an option for you? Why or why not? What challenges do you have? Would you be interested in receiving training to ride transit?  Physical Activity Present 12. When I say physical activity, what comes to mind?  • Probes: What does it mean to you to be physically active? What do you see as physical activity? What do you see as the benefits to being physically active?   13. Do you consider yourself a physically active person? Why or why not?  14. How are you physically active?  • Probes: What do you do? What do you like about being physically active? Do you prefer to be alone or with others when you are active? How do you get to your physical activity (walk, drive, bus)?  15. What are your favourite ways of being physically active?  What do you like about this?  • Probes: What motivates you to keep up your activities?  PHYSICAL ACTIVITY DEFINITION: Any bodily movement (produced by skeletal muscles) that increases heart rate and breathing and requires energy expenditure (Canadian Society for Exercise Physiology, 2011.) 135   16. What are your least favourite ways of being physically active?  • Probes: Does this contribute to your inactivity? Do you prefer to be inactive? IF so, doing what? Do you think there’s anything that might make [this activity] more enjoyable for you?)   17. How do you feel about your current level of activity?  • Probes: Are you happy with your current level of physical activity?  If ‘yes’: What is it that keeps you motivated to keep up your activities? If ‘no’: How would you like to be more active (or less active)?   18. What keeps you from being more physically active?  19. What types of support or assistance would help you to start regular physical activity?  • Probes: Would it help to have a coach to help you plan your activities and check in with you occasionally? Would it matter if this person was male or female, young or older?  Past/Changes over time 20. Think back to the time in your life that you felt most physically active. Can you describe it to me? • Probes: How old were you?  What activities were you involved in?  What made it possible at the time to do those things?  21. What has changed over time that has had the biggest impact on your physical activity?   • Probes: Since last year, are there any activities that you can no longer do or that have changed? If yes, please tell me a bit more about that. Because of health issues or caregiver responsibilities? • Are there any new activities that you do now, based on your current ability level and circumstance?  22. Do you participate in any regular physical activity programs?  How did find out about them? If you don’t participate, are you aware of any (or any more) that you may consider participating in? • Probe: what are the biggest attractions and/or turnoffs?  23. If we were to design a physical activity program that was ideal for you, what would this look like?   • Probe:  Where would it take place (In your home? In the community?) What sorts of activities would it involve? Where would you like to find out about such a program?   136   Influence of Aging & Masculine Identities 24. When it comes to getting older, do you think it is different for men and women?   • Probes: How is this different?  Can you tell me more about what you mean about that?  25. When it comes to changes in physical activity as people age, do you think it is different for men and women?   • Probes:  Can you give an example from your own life? Do you feel as strong as you once were? How do new or certain types of activities differ?  Closing 26. When we came to this interview today is there something that you thought we were going to ask that we didn’t?  Is there anything else that you would like to add to our discussion today?   Thank you so much for your time and insights.                           DEMOGRAPHICS AND DESCRIPTIVE INFORMATION:  Now, just to finish-up, I have a few quick “tick-box” questions to go over with you (Interviewer, proceed to completed “Demographic Questionnaire for Older Adult Informants” 137   Field Notes Guide                                        ** To be completed by the interviewer within 24 hours of the interview **   Participant ID:  Prepared by:  Interview Date:  Starting Time:                    Ending Time:   Participant chose to illustrate some answers by drawing on paper [yes/no]:   Location of interview (e.g. participant’s home, community center, etc.):   Description/your impressions of the neighbourhood:  Technical Problems (e.g., timing of interview, tape recorder):   People present:   Description of the home environment (include 5 senses):   Content of Interview (e.g., use key words, topics, focus, words or phrases that stand out): Interviewer’s impressions (e.g., discomfort of participant with certain topics, emotional responses to people, events or objects)  Nonverbal behaviour (e.g., tone of voice, posture, facial expression, eye movements, forcefulness of speech, body movements, and hand gestures):  Preliminary Analysis (e.g., interviewer’s questions, tentative hunches, trends in data and emerging patterns, insights, interpretations, beginning analysis, working hypotheses):  138   Appendix F: Demographic Questionnaire   DEMOGRAPHICS AND DESCRIPTIVE INFORMATION  1. Year of Birth   2. Sex  Male  Female            Refused/Other  3. Were you born in Canada?  No   Yes If No, how many years have you lived in Canada: ________years  4. Ethnicity  European descent                                         Filipino  African descent  Latin American  Chinese  Arab  Metis\Inuit\First Nations   Southeast Asian                         South Asian                                West Asian                                  Japanese  Korean  Other:_______________ 5. Marital Status  Single (never married)  Married (or common law)  Widowed  Separated  Divorced 6. Living Arrangement a. What is your current living arrangement?   Alone  With a spouse or partner  With another family member  With a friend or roommate  Other:__________________  b. If you live with someone, does this person ever:    Go with you for walks  Go with you on the bus  Go with you in the car or drive you places  Help you with directions or finding your way around  ID:  139   7. Highest Education Level  Grade School  Secondary school  Trade/technical school or college diploma  University degree  Graduate degree 8. How long have you lived in your current neighbourhood? _________________________(years)  9. How long have you lived in your current residence?  _________________________(years)  10. Do you rent or own your current place of residence?   Rent        Own      Other:__________________ 11. How much do you like to walk outside? Please circle one  Not at all Not much Neutral Somewhat Very much 1 2  3  4  5   12. How confident are you walking in your neighbourhood?   Please circle one  Not at all Not much Neutral Somewhat Very much 1 2 3 4 5  13. What is your current  employment status?  Please CHECK one.   Retired and not working  Employed full-time  Employed part-time  Other: _______________      140   14. Do you use a mobility aid when you walk?  No    Yes    If Yes, please specify type of mobility aid (choose all that apply)   Walker  Cane   Crutches  Orthopedic shoes  Brace (leg or back)  Prosthesis  Wheelchair/Scooter  Other __________________________________ 15. Do you currently have a valid driver’s license?  No    Yes  16. Do you have access to a car?  No    Yes  17. Do you own a dog?  No    Yes  19. Are you limited in getting out and about in your neighbourhood by any of the following factors?   Check all that apply     A fall / fear of falling  Heath reasons (e.g. acute or chronic injury, illness)  Your location of residence  Inability to access transportation services (e.g. Handydart,    Community bus programs)  Limited access to a car and/or loss of ability to drive  Emotional reasons (e.g. grief, depression, anxiety)  Caregiving and/or family responsibilities  Personal finances  20. Have you fallen in the past year?     No    Yes   If Yes, how many times  _______  21. Did you sustain an injury from your fall?  No    Yes                      NA      141   Appendix G: Honorarium Receipt    Honorarium Signature Sheet                                     Participant ID  Date  Amount  Participant Initials  142   Appendix H: Consent Form (In-depth data collection methods)  Information Letter and Consent Form  SHAPE THE PATH: TARGETING THE HEALTH AND MOBILITY OF OLDER MEN THROUGH KEY COMMUNITY PARTNERSHIPS  “SEEK TO UNDERSTAND” STUDY ______________________________________________________________  Principal Investigator:  Dr. Heather McKay, PhD     Professor, Depts. of Orthopaedics & Family Practice Faculty of Medicine University of British Columbia (UBC)   Contacts: Alison Phinney, PhD, RN  Associate Professor University of British Columbia (UBC)  School of Nursing  Manpreet Gill Project Coordinator -Seek to Understand University of British Columbia (UBC)  School of Nursing  You are being invited to participate in this study.  The primary purpose of this study is to understand supporting and limiting factors that influence older men’s ability to move about their neighbourhood and participate in their community as well as the challenges and facilitators faced by care providers, family members and community programmers and volunteers as they provide support and services to try and keep older men active and mobile.  Should you choose to participate in the study you will be asked to participate in several walk-along video interviews, a photo-taking activity, a sit-down interview and an optional focus group.  A detailed description of these activities is included on pages 4 to 5 of this information letter.  If after reading the study description, you would like to learn more about the study, please call our project manager or lead academic investigator whose contact information is listed above.   Thank you for your interest in the study.   143   Consent Form  SHAPE THE PATH TARGETING THE HEALTH AND MOBILITY OF OLDER MEN THROUGH KEY COMMUNITY PARTNERSHIPS  “SEEK TO UNDERSTAND” STUDY  Introduction You are being invited to take part in this research study because you meet participation requirements.  Your participation in this study is entirely voluntary, so it is up to you to decide whether or not to take part in this study.  Before you decide, it is important for you to understand what the research involves.  This consent form will tell you about the study, why the research is being done, what will happen to you during the study, and the possible benefits, risk and discomforts.  If you wish to participate, you will be asked to sign this form.  If you do decide to take part in this study, you are still free to withdraw at any time and without giving any reasons for your decision. If you do not wish to participate, you do not have to provide any reasons for your decision not to participate nor will you lose the benefit of any medical care to which you are entitled or are presently receiving.  Please read the following information carefully before you decide.  Who is conducting this study? This study is being conducted by Dr. Heather McKay, Dr. Joanie Sims Gould, Dr. Dawn Mackey, and Dr. Alison Phinney at the University of British Columbia and the Centre for Hip Health and Mobility.   Background Mobility is “being able to move oneself within environments that expand from one’s home to one’s neighborhood and to regions beyond.”  There has been surprisingly little research examining men’s experience of mobility—a key factor influencing their quality of life. There is also a need for interdisciplinary research teams to better understand why men often adopt less healthy behaviours than their women counterparts.   144   What is the purpose of the study? The primary purpose of this study is to understand supporting and limiting factors that influence older men’s ability to move about their neighbourhood and participate in their community.    Who can participate in this study? You can participate in this study if you are: 1. able to communicate in English and  2. 65 years and older,  3. able to move about within and outside of your home (either independently or with assistance).  Who should not participate in this study? You should not participate in this study if you identify as a woman; are under 65 years of age; are unable to leave your residence; and/or cannot consent to be involved in research.  What does the study involve? This study is taking place in the City of Surrey in the places where you live and spend time on a usual basis. We plan to enroll 30 participants. Participation sessions will take place at a time and location that is convenient for you.  You will be asked to participate in 3 activities and a fourth optional activity:  1. Walk-along video interview (30-45 min  x 3 times= total 1.5- 3 hours) This will involve walking with a researcher through your everyday environment. You will be asked to show the researcher around, both inside and outdoors, as you would engage in usual activities.  The researchers will hold a hand-held video camera to capture where you go as well as you talking and describing your experiences on this route and in these places where you live and go.     2. Photovoice activity (Approximately 1 hour):  After the first walk-along video, we will provide you with a camera to take photographs within your physical and social environments that most influence your everyday life and participation in physical activity: i.e. “What makes it easy, what makes it challenging for you to get around? What helps you take part in everyday physical activities? What makes it difficult?”    145   3. Sit-down interview (Approximately 1 hour) A researcher will meet with you to ask you to describe your photos taken in the photo-voice activity. The researcher will ask you to describe your day to day experiences getting around and what things help you or make mobility difficult for you. These interviews will be recorded.  4. Focus groups (OPTIONAL, Approximately 1 hour) We will also be hosting several focus groups in which we invite you to review your photographs, as well as the photographs of other participants to develop a photo-montage and an art exhibit to showcase in a public arts forum.   You do not have to answer any questions for any of the study activities if you are not comfortable with them.  How much of my time is required? The total time required for the walk-along video, photovoice activity and sit down interview will range from 3.5-5 hours over 1 year.  The optional focus group activity will take an additional 1 hour.  What are the potential risks of taking part in this research? Taking part in any of these activities may result in a loss of privacy. However, you can decide how much you are willing to share your experiences. You may also get tired during the activity. If so, you can take a rest, or continue the activity on a different day.  What are the benefits of participating in this study? There may not be any direct benefit to you to take part in this research, although you may find it satisfying to share your experiences as a way to contribute to new knowledge. You may also find some of the research activities enjoyable.  You will also receive a $10 gift card to thank-you for your participation. An additional $10 gift card will be provided to those who participate in the focus group.  What will happen with the results of this research? The results of this research will be shared widely with other researchers, health care professionals, and members of the general public. We plan to publish the results in an academic journal and present the results at a conference for researchers and health care professionals. We will also share the results of this research with study participants through a written report and a public presentation of the findings. You will be given a copy of the report, and “products” of your 146   individual research activities (e.g. photographs, journals, and audio or video recordings) upon your request.  What happens if I decide to withdraw my consent to participate? Your participation in this research is entirely voluntary. You may withdraw from this study at any time and no reason for withdrawal needs to be provided. If you decide to enter the study and to withdraw at any time in the future, there will be no penalty or loss of benefits to which you are otherwise entitled, and your future medical care will not be affected. If you choose to enter the study and then decide to withdraw at a later time, all data collected about you during your enrolment in the study will be retained for analysis.   You do not waive any of your legal rights by signing this consent form. If you wish to withdraw please contact us.   What happens after the study is finished? Once your participation in the study is concluded, you will be provided with a one page summary of the general study findings. No personal feedback will be provided.   What will the study cost me? You will not incur any personal expenses as a result of participating in the study.     Will my taking part in this study be kept confidential? Your research activities will be transcribed into written form and members of the research team will see this transcript. The transcript will not have participants’ names included on them but rather a study identification number that can be linked to participant’s identity. This means that all identifying information will have been removed or changed and you will not be identified by name in any reports or presentations of the completed study. Information that discloses your identity will not be released without your consent unless required by law. However, because some of the research activities take place in public, others may be aware that you are a participant in this research and may have opportunity to overhear what you are saying to the researcher.  If you take part in a focus group, confidentiality may be limited. We will encourage participants to not discuss the content of the focus group to people outside the group, but we can’t guarantee that they will keep the information confidential.   147   If you agree to have your activities video-recorded, you will receive a copy of the recording and you can decide if the research team can use examples from the video in presentations or publications.  Likewise, if you take photographs for the Photovoice activity, you will receive a copy of the photos and you can decide if the research team can use any of the photos in presentations or publications.  All study materials will be saved on a password protected hard drive and stored in a locked filing cabinet in Dr. Phinney’s research office.    Who can you contact if you have questions about this research? If you have any questions about this research, please contact one of the study team members. The names and telephone numbers are listed on the first page of this form.  Who can you contact if you have complaints or concerns about this research? If you have any concerns about your rights as a research subject and/or your experiences while participating in this study, you may contact the Research Subject Information Line in the UBC Office of Research Services at 604-822-8598 or if long distance e-mail RSIL@ors.ubc.ca or call toll free 1-877-822-8598.  Who do I contact if I have any questions or concerns about my rights as a subject during the study?  If you have any concerns about your rights as a research subject and/or your experiences while participating in this study, you may contact the Research Subject Information Line in the UBC Office of Research Services at 604-822-8598 or if long distance e-mail RSIL@ors.ubc.ca or call toll free 1-877-822-8598.  You can also contact the Fraser Health Research Ethics Board co-Chair by calling 604-587-4681.    148   SUBJECT CONSENT TO PARTICIPATE IN THE “SHAPE THE PATH: SEEK TO UNDERSTAND” STUDY  • I have read and understood the subject information and consent form.   • I have had sufficient time to consider the information provided and to ask for advice if necessary. • I have had the opportunity to ask questions and have had satisfactory responses to my questions. • I understand that all of the information collected will be kept confidential and that the result will only be used for the scientific objectives. • I understand that my participation in this study is voluntary and that I am completely free to refuse to participate or to withdraw from this study at any time without changing in any way the quality of care that I receive. • I understand that I am not waiving any of my legal rights as a result of signing this consent form. • I understand that there is no guarantee that this study will provide any benefits to me. • I have read this form and I freely consent to participate in this study. • I have been told that I will receive a dated and signed copy of this form.  I consent to be video-recorded               Yes        No  I would like to participate in the OPTIONAL  focus group activity (1 additional hour)     Yes        No  I would like to be contacted for future studies.              Yes        No  We may use the data collected in this study for further analysis in future studies interested in enhancing the health and mobility of older adults. For example, we may examine this data in conjunction with an individual follow-up interview.   I understand that my data may be used in this manner.   Yes    No    ---------------------------------------------------------------------------------------------------- Printed name of subject   Signature   Date   ---------------------------------------------------------------------------------------------------- Printed name of researcher/  Signature   Date Designated representative 149   Appendix I: Walk-Along Interview Guide   WALK-ALONG INTRODUCTION   This research is about older men and physical activity. We want to learn about how older men get around in their day-to-day lives and the nature of their physical activity. We started by doing some “sit-down” interviews, and now we want to do some “walk-along interviews”. What this means is that we would come along with you during an everyday activity and have a conversation with you as you are doing this activity.  The idea is to talk about it as you are doing it, sort of like “thinking out loud”. We would also bring along a video camera in case there are opportunities to record some of this activity so we can watch it later to get more of the details.   Which activities we come along for will be up to you – it depends on what kinds of activities you are usually involved in. It might be something recreational (e.g. going for a walk or gardening), or it could be household activities (e.g. grocery shopping, or doing laundry). We can talk about it to decide what would be most suitable.    INTERVIEW GUIDE  This will be a conversational style interview. You can let the participant and the activity take the lead, but should have a few key questions in mind to ensure you cover all the topics that are germane to the research questions. Remember that we are interested in:  Physical environment You will want to talk about the where of the activity and how that influences their ability to be physically active  - material objects, built structures, sounds, sights, weather, etc.  Social environment You will want to talk about the who of the activity and how that influences their ability to be physically active – family, friends, neighbours, other people in the community, and the nature of their relationships, interactions, support/ lack of support, etc.   Mobility You will want to talk about how they experience their body in the course of the activity – this has to do with the issue of mobility as a bodily capacity, and how they feel it influences their physical activity – strength, endurance, energy, comfort/pain, etc.  You will want to talk about changes over time, listening carefully for “turning points” – we want to hear about key transitions that made a notable difference in relation to their experiences of mobility and physical activity (e.g. loss of a spouse, illness or injury, retirement, moving to a new neighbourhood, etc.).  You will want to talk about meaning – why this activity matters to the participant, how is it important, and what would be the implications if they did not do it anymore?  150   The issue of gender may be difficult to confront with a direct question, but you will want to be alert for opportunities to hear more about their experiences as men in relation to physical activity - their masculine identity, their roles in the family and community, beliefs/attitudes about older men in relation to physical activity (including self and social perceptions). For example, if you are in a laundromat and he is the only man there, that is worth a question, e.g. “How is it for you being the only man here?”   OBSERVATION GUIDE  The role of the observer is to accompany the participant and interviewer in the activity, and to observe carefully for the duration, paying attention to the same issues as indicated in the interview guide: physical environment, social environment, and body. The observer will take notes as possible (jottings) and flesh these out into detailed field notes after the session is done.   The observer will also carry a small hand held video camera, and will record samples of the activity. The primary goal of these recordings is to gather details of how the participant moves in the environment. Normally this will involve stepping back to ensure suitable framing (full body and some context). This should be done so it does not interfere with the activity (normally from the side or behind).   Long video clips are hard to work with. The duration of each sample will depend on the situation, but would normally be no more than 5 minutes. That said, the observer should use his/her own best judgment about what will be possible and valuable to record.   The observer will seek permission to record the participant. If others interact with the participant and are visible in the frame, normally the camera should be turned off or turned away, unless the person has given explicit permission to be recorded.                151   Appendix J: Photovoice Data Collection Instructions  Shape the Path: Project IV Seek to Understand  Photovoice Instructions  Dear Participant,   The Shape the Path: Project IV Seek to Understand research team invites you to participate in the Photovoice component of our research study. This study seeks to understand facilitating and limiting factors that affect your ability to move about your neighbourhood and participate in your community.    We invite you to take pictures of your physical and social environments that most influence your everyday life and participation in physical activity. These pictures can be of things that make it easy or difficult for you to get around. These pictures can also be of things that motivate you to engage in physical activity or things that prevent you from engaging in physical activity.   After taking each picture, we ask that you briefly describe the picture and why you took it. The following questions may be helpful in writing your responses.  • How does the image in the picture influence your mobility?  • Does the image in the picture make it easy or difficult for you to get around or engage in physical activity? Why?  • In the picture, what is meaningful to you and your physical activity? Why?  Once you feel you have taken pictures of all the things in your physical and social environments that most influence your everyday life and participation in physical activity and have completed your descriptions for each picture, please contact Manpreet Gill, Seek to Understand Project Coordinator, to make arrangements to have your pictures and envelope containing your descriptions of the pictures collected.    Thank-you for your participation,   Alison Phinney, PhD, RN Associate Professor  University British Columbia  School of Nursing   152   Appendix K: Photovoice Form for Participants’ Notes  (participants were given multiple copies of this form for each of the photographs they took)  Shape the Path: Project IV Seek to Understand Photovoice: Participant ID ________   Photograph #_____  Brief description of this picture…       I took this picture because…         Photograph #_____  Brief Description of this picture…       I took this picture because…    153   Appendix L: Interpretation Framework for Analysis   STUDY PURPOSE: The purpose of this research is to enhance understanding of older men’s experiences with physical activity in the context of their everyday lives, with an emphasis on the influence of masculinities on these experiences. It is hoped that understanding older men’s experiences with physical activity will assist healthcare providers develop interventions that are specific to older men, and thus facilitate healthy aging and enhance quality of life in this population.    MAIN RESEARCH QUESTIONS: 1. What are the connections between masculinities and older men’s personal experiences with physical activity in the context of their everyday lives?  2. What can be learned from older men’s experiences to inform development of interventions to support physical activity for older men?   **In considering these questions, detailed descriptions will be provided around both what is said by the men and what is observed by the researchers, which will then be interpreted from a masculinity perspective that may not be explicit in the data**   What are the connections between masculinities and older men’s personal experiences with physical activity in the context of their everyday lives?  (Incorporate the men’s thoughts around gender where relevant and interpret from a masculinity perspective)   • What are the patterns of everyday physical activity for the men?  o What physical activities are the men involved with?  o What form of transportation do the men use?   • What facilitates or constrains the men’s physical activity (consider the socioecological model) in terms of:   o The physical environment  o The social environment  o Bodily capacity/functional ability/health status   • What key transitions have the older men experienced?   o Has his physical activity changed with respect to growing older?  o Have there been significant experiences the men have faced that have influenced their physical activity and how have they adjusted to these experiences?  • What is the underlying motivation for the older men’s engagement in physical activity?  o What motivates these men? What keeps them going?  o What are the men’s thoughts around anticipated changes in relation to physical activity and aging?  o What are the challenges these men may face as they grow older?   154   What can be learned from older men’s experiences to inform development of interventions to support physical activity for older men?  (Consider both what the participant has stated about physical activity programs, as well interpretations around how the men’s experiences can help development of further interventions)  • What are the men’s experiences with physical activity programs in their communities? o Do the men participate in any programs currently? What are their thoughts?  o How did the men find out about the programs?   • What type of programs would encourage the men to get involved?  o What are the biggest attractions and/or turnoffs around physical activity programs?  o Where would the programs take place? (Home, community, etc.)  o What types of activities would the program involve?  o How would the men like to find out about such programs?     

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