THE DETERMINANTS OF LATE LIFE EXERCISEIN WOMEN OVER AGE 70bySANDRA O'BRIEN COUSINSB.P.E., The University of British Columbia, 1971M.P.E., The University of British Columbia, 1977A THESIS SUBMITTED IN PARTIAL FULFILLMENT OFTHE REQUIREMENTS FOR THE DEGREE OFDOCTOR OF EDUCATIONDepartment ofAdministrative Adult and Higher EducationWe accept this thesis asconforming to the required standardTHE UNIVERSITY OF BRITISH COLUMBIAApril 1993© Sandra O'Brien Cousins, 1993In presenting this thesis in partial fulfilment of the requirements for an advanceddegree at the University of British Columbia, I agree that the Library shall make itfreely available for reference and study. I further agree that permission for extensivecopying of this thesis for scholarly purposes may be granted by the head of mydepartment or by his or her representatives. It is understood that copying orpublication of this thesis for financial gain shall not be allowed without my writtenpermission.(signatDepartment of 4, A H, 1- , Administrative Adult and Higher EducationThe University of British ColumbiaVancouver, CanadaDate Aiiplif Pi/ 1990 DE-6 (2/88)i iABSTRACTToo many elderly women suffer rapid aging decline, frailty and hypokineticdisease simply because of inadequate levels of physical activity. While thebiopsychosocial benefits of regular exercise are now well-known, explanations arelacking for the reluctance of aging Canadian females to take up, or keep up,healthful forms of leisure-time physical activity. The purpose of this study wasto examine and explain the variability of participation in health-promoting formsof exercise in elderly women. Several health behavior theories and personalattributes have shown promise in explaining exercise behavior, and thus, a secondpurpose of the study was to test the utility of a composite theoretical model.The composite model included ten personal and situational attributes as well asfive cognitive beliefs about physical activity adapted from Social CognitiveTheory and a belief about personal control over one's health from Health Locusof Control Theory.A city-wide sample of 327 Vancouver women aged 70 and 98 years filled outsurvey questionnaires providing information on the 16 model variables in additionto kilocalorie estimates of exercise in the past week. Multiple regressionanalysis was used to explain late life exercise in three stages: 1) regressionon the ten personal and situational attributes; 2) regression on the sixcognitive beliefs; and 3) combined regression on all the significant predictors.From the life situational variables, health, childhood movement confidence,school location, and age were significant factors explaining 18% of thevariability seen in current exercise level. From the cognitive variables, currentself-efficacy to exercise and current social support to engage in physicalactivity were the only significant predictors (R 2 = 22%). A full regression modelwas tested by including the four statistically important situational variables111and the two cognitive variables from the previous analyses. The utility of theComposite Model was supported in that both situational variables and self-referent beliefs played significant and independent roles in explaining late lifeexercise (R 2 = 26%). The main reasons that older women were physically activewere: 1) they perceived high levels of social support to exercise (b = .239, p< .01); 2) they felt efficacious for fitness-types of activities (b = .185, p< .01), 3) they had satisfactory health (b = .174, p < .01), and 4) they wereeducated in foreign countries (b = -.125, p < .01). Health locus of controloffered some explanation but was not able to demonstrate significance alongsideother cognitive beliefs (b = -.106, p < .06). Education, socioeconomic status,work role, family size, and marital status were not able to explain late lifeexercise.This study found that health difficulties do indeed interfere with women'sactivity patterns. However, women are also influenced by perceptions ofdeclining social support, lower levels of movement confidence, and chronologicalage, to reduce their physical activity. Thus, regardless of their healthsituation, the explanation of exercise involvement in older women rests to alarge degree on the amount of social encouragement they perceive from family,friends and physicians, their self-efficacy for fitness activity, as well asperceptions of age-appropriate behavior.Older women who were educated as children outside of Canada, Britain andthe U.S. appear to be culturally advantaged for late life physical activityparticipation. Moreover, childhood movement confidence stands as a significantpredictor among the situational variables. These findings suggest thatparticipation in physical activity, and positive beliefs about exercise in lateoo , are rooted in competencies and experiences acquired in childhood.ivPerceptions of inadequate encouragement appear to be limiting females, fromchildhood on, to develop and sustain confidence in their physical abilities thatwould promote a more active lifestyle into their oldest life stage.TABLE OF CONTENTS^ABSTRACT iiTABLE OF CONTENTS ^ vLIST OF TABLES xviLIST OF FIGURES ^ xvACKNOWLEDGEMENTS xviiiDEDICATION ^ v^PROLOGUE xixCHAPTER I. INTRODUCTIONBackground to the Problem ^ 1Statement of the Problem 8Research Questions ^ 10Rationale and Significance of the Study ^ 10Definition of Key Terms ^ 14Delimitations ^ 18Limitations 18Organization of the Remaining Chapters ^ 20CHAPTER II. THE REVIEW OF THE LITERATUREIntroduction ^ 22The Poor Aging of Women ^ 24The Activity Socialization of Females Born Before 1921 . ^ 25A Demographic Profile of Women Born Before 1921 ^ 28Size of the Aging Population ^ 29vMarital Status, Family Size and SocioeconomicStatus ^ 31Education 33Ethnicity ^ 34Health Status 35^Institutionalization 36Elderly Women's Exercise Patterns ^ 37Known Exercise Patterns of Older Women ^ 37Known Benefits of Exercise Participation 40Introduction ^ 40The Benefits of Exercise ^ 41Immediate Benefits ^ 44Long-term Benefits 46Known Risks of Exercise Participation ^ 51Introduction ^ 51Known Risk of Sudden Death in the Elderly ^ 52Known Risk of Injury in the Elderly ^ 54Risk of Over-Exertion or Exhaustion 55Risk of Provoking Ill Health ^ 56Summary ^ 57The Determinants of Exercise Behavior: UsefulTheoretical Approaches ^ 57Introduction to Determinants ^ 57Social Epidemiological Perspectives 59Social Epidemiology ^ 59Age and Exercise miEducation and Exercise ^ 62viviiSubjective Health and Exercise ^ 63Health Symptoms and Exercise Behavior ^ 67Marital Status and Exercise ^ 68Motherhood, Children and Leisure-time Exercise . . ^ 69Work Role, Employment and Exercise ^ 72Socioeconomic Status and Exercise 74Socialization Theory ^ 75The Significance of Socialization for ChildhoodPhysical Activity ^ 78Childhood Situation: Opportunity, Mastery, MovementCompetence ^ 81Behavioral Health Psychology Perspectives ^ 85^The Health Belief Model 85Health Locus of Control Theory ^ 89Theory of Reasoned Action 91Social Cognitive Theory ^ 92Social Learning Theory 92The Constructs of Social Cognitive Theory ^ 93The Cognitive Determinants of Exercise: SCT 96Incentives or Motives to Exercise ^ 97Health as Incentive to Act 99Outcome Expectations ^ 100Self-Efficacy and Movement Confidence ^ 101Introduction: Self-Efficacy 101Barriers to Perceived Efficacy to Exercise . . .^103The Role of Habit and Previous Physical Activity . 105The Role of Efficacy on Exercise Behavior ^ 106viiiThe Role of Exercise on the Developmentof Efficacy ^ 109Environmental^Cues for Physical^Activity:^Social^Support .^. 113Ageist Practice in Communities 113Social^Support ^ 114Defining and Measuring Social^Support ^ 115Physical Activity as Social^Networking ^ 116Role of Group Cohesion 117Role of Companionship ^ 118The Role of Spousal^Support ^ 118The Role of the Physician 120Role of Friends and Family ^ 122CHAPTER III. THEORETICAL FRAMEWORKIntroduction ^ 124Selection of the Most Suitable TheoreticalPerspective ^ 124The Application of Social^Cognitive Theory^• •^.^. 126The Synthesis of Theory: The Composite Model ^ 128Life Situational^Variables ^ 131The Cognitive Variables 133Health Incentive ^ 133Outcome Expectations of Late Life Exercise ^ 135Perceived Benefits and Risks of ExerciseParticipation ^ 137Defining Perceived Risks of ExerciseParticipation ^ 139Age and Risk Perception ^ 143ix^Movement Confidence (Self-Efficacy) 143Social Support to Exercise ^ 147Health Locus of Control 148Summary of the Theoretical Framework ^ 149CHAPTER IV. DESIGN OF THE STUDYSurvey Questionnaire Construction ^ 150Description ^ 150The Older Adult's Exercise Status Inventory ^ 152Description ^ 152Reliability of the OA - ESI ^ 154Validity of the OA- ESI 155Use of the OA - ESI ^ 156Interpretive Variables 160Life Situational Measures ^ 162Introduction ^ 162Age 162Culture 162Socioeconomic Status ^ 163Marital Status 164Education 164Work Role 165Family Size: Number of Children 165Health Variables ^ 165Self-Rated Health 165Physical Symptoms 166xPerceived Well-Being ^ 166^Medications 166Composite Health Index ^ 167Body Mass 167Childhood Movement Confidence ^ 168Childhood Social Support to Exercise ^ 171The Cognitive Variables ^ 172Health Incentive 172Adult Movement Confidence ^ 173Adult Social Support 175Perceived Risks and Benefits of MCN Exercises . . ^ 175Health Locus of Control ^ 176The Pilot Study ^ 178Selection of the Sample ^ 182The Population 182Sampling Procedure ^ 183The Strategic Sample ^ 183Second Sampling Procedure: Convenience Sample ^ 188Data Collection Protocol ^ 193Data Preparation ^ 198Missing Data 198Cleaning the Data ^ 198Outliers ^ 199Statistical Analysis 199CHAPTER V. RESULTSDescription of the Sample ^ 202xiDescriptive Results of the Situational Variables . . . ^ 204^Age 204Marital Status ^ 204Family Size: Number of Children ^ 204Work Role ^ 204Cultural Origin: School Location 205Education ^ 205Socioeconomic Status ^ 205Medical Symptoms 206Self-Rated Health ^ 207Childhood Social Support ^ 207Childhood Movement Confidence 207Lifelong Status ^ 208The Typical Week 208Total Exercise Sessions in the Past Week ^ 208Hours of Activity in the Past Week ^ 209Change of Activity in the Past Five Years ^ 209Descriptive Results of the Cognitive Variables ^ 209Health Incentive ^ 210Adult Social Support to Exercise ^ 211Adult Movement Confidence to Exercise 211Outcome Expectations ^ 211Health Locus of Control 212Descriptive Results of Late Life Exercise ^ 212Energy Expended in the Past Week 212Statistical Findings ^ 214xiiCorrelations ^ 214Multiple Regression Analysis ^ 218Analysis 1: Life Situational Variables ^ 219Analysis 2: Cognitive Variables ^ 220Analysis 3: Best Situational and CognitiveVariables ^ 221Post-Hoc Analyses: Interactions ^ 226CHAPTER VI. SUMMARY AND DISCUSSIONSummary of the Findings ^ 228Descriptive Findings 228Theoretical Findings ^ 229Discussion of the Methodology 231Self-Report Interviews ^ 231^Statistical Analysis 231Movement Confidence and Social Support Scales . . ^ 232The Older Adult - Exercise Status Inventory . . . ^ 234Discussion of the Findings ^ 235Discussion of the Criterion Variable ^ 235Life Situational Variables ^ 237Cognitive Variables ^ 238Discussion of the Model: Theoretical Significance . . ^ 241Chief Limitations and Suggestions for Future Research^ 244Self-Selection Bias and Survivorship ^ 244Variables With Poor Response Rate 246Generalizability ^ 248Quality of the Data 249Unanswered Questions: Gaps in the Present Work ^ 252Missing Constructs ^ 252Identifying the Perceived Risks of Exercise . . . ^ 252The Significance of Domestic Activity ^ 253The Significance of Being a Turn-of-the-CenturyTomboy ^ 255Policy Implications of the Findings^257Creating Social Support for Physical Activity . . . 257Increasing Self-Efficacy and Incentive for PhysicalActivity^259Implications for Professional Practice in AdultEducation ^260CHAPTER VIII. REFERENCES 264APPENDIX A: The Questionnaire 311APPENDIX B: Ethics Approval Certificate ^ 336APPENDIX C: Agency Approval Forms 340APPENDIX D: Subjects' Letters and Comments ^ 343APPENDIX E: Post-Hoc Analyses: Missing Data ^ 355APPENDIX F: Residual Error ^ 359APPENDIX G: The Measurement of Physical Activity -The Outcome Variable ^ 361LIST OF TABLESTable 2.0^Demographic Structure of Elderly Women ^ 30Table 2.1^The Known Benefits of Exercise ^ 42, 43Table 4.0^Metabolic Units of 38 Activities ^ 159Table 4.1^Movement Skills Estimating Movement Confidenceand Past Experience 174Table 4.2^Correlation Coefficients and SignificanceLevels of Test-Retest Data ^ 181Table 4.3^Geographic Clusters and the RandomlySelected Sites ^ 187Table 4.4^Descriptive Characteristics of the TwoResearch Samples and the Pilot Sample^. . . . 190Table 4.5^Results of T-Tests on Key Variables Betweenthe Strategic Sample and Convenience Sample^. 192Table 4.6^Chronological Distribution and Return of theQuestionnaire by Research Site ^ 196Table 4.7^Distribution of Questionnairesby Program Type 197Table 5.0^Descriptive Characteristics of the Sample,Vancouver and Canadian Data 203Table 5.1^The Descriptive Statistics for the CognitiveVariables 210Table 5.2^Correlation Matrixof the Fxplanatnry Variables 216xivUnstandardized Regression Coefficients andStandardized Errors for the Regression ofLate Life Exercise on the SituationalVariablesUnstandardized Regression Coefficients andStandardized Errors for the Regression ofLate Life Exercise on the CognitiveVariablesUnstandardized Regression Coefficients andStandardized Errors for the Regression ofLate Life Exercise on the SignificantVariables of the Full ModelTable 5.3Table 5.4Table 5.5X V222223224Table E^Comparison of the Missing Data Groupwith the Completed Data Group 358xviLIST OF FIGURESFigure 2.0^Basic Elements of the Health Belief Model^. . . 86Figure 2.1^Basic Elements of Social Learning Theory ^ 93Figure 2.2^Bandura's Concept of ReciprocalDeterminism 95Figure 3.0^The Composite Model of Elderly FemalePhysical Activity 130Figure 4.0^City of Metropolitan Vancouver:The 18 Research Sites 185Figure 5.0^Activity Levels of Vancouver Women Aged 70+^. 213Figure 5.12^Proposed Model of Explanation of ElderlyWomen's Physical Activity 217Figure F^Probability Plot of Residual Error ^ 360xviiACKNOWLEDGEMENTSA project of this magnitude comes at a cost. I am grateful to my children,Catherine and Kristina O'Brien who waited and watched Mommy working on herdissertation for almost five years. They have provided patience and understandingbeyond their years.My mother, Gladys Hartley, was invaluable in filling out the original surveyquestionnaire. Her comments and suggestions significantly altered the form ofthe data collection and ultimately improved the quality of the research.David Cousins, my husband, is "the wind beneath my wings." He has been myhead coach on the computer and empowered me to become confident with many formsof software. Furthermore, David advocates a feminist perspective, and a criticalperspective, which I am sure has affected the way I went about this study.As I write this, those following the 1992 Summer Olympics in Barcelona arewitnessing the basketball "dream team" from the United States. It is also asuitable label for my doctoral committee: Dr. Patricia Vertinsky, Dr. Doug Willmsand Dr. Kjell Rubenson. Not only are all three stellar in their individualprofessionalism making them "the best", they are able to capitalize on eachothers strengths and work together as a graduate student's "dream team". I thankthem for their carefully thought out advice all along the way.To Patricia, in particular, I must acknowledge exceptional support. Theprovision of financial assistance and access to her files and journals werebeyond the call of duty. Until 1988, I had never met any academic who I wantedto emulate. She immediately earned my respect and I hope that we'll continue towork on collaborative projects into the future.Finally, I am indebted to the 17 women of the U of Agers gymnastics team andthe 327 women who gave of their valuable time to be part of the study.Unfortunately, most of these women may never fully appreciate the contributionthey have made to the limited field on knowledge about women's activity patternsover the life course and the determinants of them.DEDICATIONDad, this is for you. I remember your advice when I was 17 years old.You said, "Why don't you go to University just for one year so youwill know what it is like?" Well, here is the outcome of whathappened after that one year. Twenty-eight years later, I am in mytwelfth year of university studies. And the most important thing thatI have learned in all this time is that I will never stop learning.PROLOGUEIn 1985, I attended Dr. Ernst Jokl's keynote speech at the PhysicalActivity, Aging and Sport Conference at Westpoint Military Academy. I wasintrigued by something he said.Play bestows and conveys the attitudes of youth. An old person whoplays turns young. A young person who cannot play turns old.Ernst Jokl, 1985.The importance of physical recreation at all life stages is a concept that manyphysical educators endorse, but the lifelong significance of physical activity,exercise and sport has as yet to be scientifically determined. Dr. Jokl's speechstarted me thinking about the role of physical activity in healthy aging.Shortly after this conference, I began to teach fitness classes to adultsaged 50 to 75. Many of the participants were truly unfit, and among the womenin particular, were some who could not do even one modified pushup or situp.Others in the group demonstrated excellent physical abilities -- physical fitnessand skills which compared favourably to adults 30 to 50 years younger. Within afew months, the unfit were significantly fitter, and the already fit had startedtaking up new physical challenges, namely, gymnastics!This was an intriguing phenomenon: elderly women venturing beyond thechallenges of maintaining physical fitness, forging new skills in a young girls'sport, and then enjoying their efforts in public performances. There was avisible enthusiasm to test their physical limits and the commitment to trainingwas obvious. Why were these women so eager now to participate in more vigorousphysical activity?xixxxThe research literature is replete with evidence about the increasingbiological, psychological and social heterogeneity that accompanies aging; itseems that human variability is no better demonstrated than in the exercisepatterns and physical fitness measures of aging adults, some of whom have becomefunctionally frail while others appear to successfully counter aging declineswith high levels of physical activity and sustained physical fitness. Suchvisible evidence of these different outcomes for people led me to wonder whyolder people exercise as they do. Which of the many biological, social andpsychological forces are operating to create such diverse lifestyles and healthoutcomes by late life?The fitness class developed into a performing gymnastics team called the Uof Agers. Since May of 1986, the twenty-five women and men on "the team" havebeen seen live and on national television news broadcasts on a number ofoccasions. They are the documentary centrepiece of the National Film Board's(1990) "Age is No Barrier." They appear frequently on CBC's "The Best Years" andare solicited to perform at major events across Canada. These older adults havebecome a remarkable social phenomenon mainly because the Canadian public has sounderestimated the physical capabilities and interests of older adults. Thissocial perspective, which finds elderly athleticism incongruous, drives thesociological and psychological aspects of this research.Never before has society been better able to offer leadership, supportivetechnology and diverse opportunities for the physical education and recreationof aging adults. While a minority of elderly are ready for, and interested in,physical activity, the majority, do not appear to be interested enough to becomeparticipants. Curiosity about what leads to highly active versus highlysedentary living in older adulthood, has brought my research into focus.1I. INTRODUCTION"Much more information is needed on how the determinants of physicalactivity change with age, with particular reference to factorsinfluencing the participation of children and of middle-aged andelderly people." (Bouchard, Shephard, Stephens, Sutton & McPherson,1990, p.10)Background to the ProblemDifferences in the way individuals age have intrigued scientists as well aslay people for years. The contemporary search for perpetual health andimmortality has failed to find any "fountain of youth," but we knowthat people do age with remarkable variation (Nelson & Dannefer, 1992). Probably,the spectrum of aging possibilities are best seen in people's day-to-daylifestyle behaviors and the outcomes of these behaviors over the life-span.For at least three decades, gerontologists have proposed that there are twoways of growing old: "usual" aging and "successful" aging (Butler, 1988; Dermody,Saxon & Sheer, 1986; Havighurst, 1963; Meusel, 1991; Nowlin, 1985; Palmore, 1979;Rowe & Kahn, 1987). In recent decades, increased longevity has illuminated theproblems of "usual" aging, clarified what is normal and abnormal aging, andcompelled societies to "rethink how we age" (Prado, 1986). Evidence is rapidlyaccumulating that regular and moderate forms of physical activity are a resourceto adults which foster opportunities for improved survival, life quality and moresuccessful aging (O'Brien & Vertinsky, 1991; Stewart & King, 1991). Althoughknowledge about how to age better is improving, population disability levels areclimbing due to the relative aging and inactivity of the population (Ramlow,Kriska & Laporte, 1987; WHO Health Education Unit, 1986).2Enough scientific support exists to suggest that moderate and frequentexercise may be the "best preventive medicine" for old age. Exercise is beingprescribed, first to prevent premature aging (Spirduso, 1986), and second, toprevent premature disease by controlling hypertension, heart disease, bowel andbreast cancer, the immune response, osteoporosis, obesity, arthritis, diabetes,insomnia, and depression (see Chapter 3 for a complete review). Exercisescientists are beginning to understand the significant role which exercise canplay in controlling aging decline and delaying mortality (Blair, Kohl,III,Paffenbarger, Jr., Clark, Cooper, & Giddons, 1989; Donahue, Abbott, Reed & Yano,1988; Grand, Grosclaude, Bocquet, Pous, & Albarede, 1990; Kaplan, Seeman, Cohen,Knudsen & Guralnik, 1987; Linsted, Tonstad, & Kuzma, 1991; Rakowski & Mor, 1992).Physiologists estimate that up to half of what we currently know as usualaging is a phenomenon of disuse (Berger, 1989; Bortz, 1982; DeVries, 1970, 1974;DeVries & Adams, 1972; Shephard, 1989a; Smith, 1981) -- disuse which hurries morewomen than men toward experiences of hypokinetic disease (Abdellah, 1985; Butler,1968; Heckler, 1984; Ostrow, 1989; Verbrugge, 1990; Vertinsky, 1991). Governmenthealth promotion. programs (Don't Take It Easy, 1983; Choosing Wellness, 1988) areconspicuous public health campaigns addressing the issue of unfit aging in Canada- an issue particularly targeting women who appear to have much to gain fromincreased participation in physical activity.Dozens of scientifically-controlled exercise interventions, particularlysince the 1980's, have provided substantial evidence that elderly individuals canpositively affect their mobility, endurance, strength and balance by first,reversing the circulatory and neurological limitations they have acquired throughsedentary living (MacRae, 1989; Spirduso, 1986), and second, by elevating theirfunctional capacities to the level of adults decades younger than themselves3(Conger & O'Brien, 1989; Dummer, Clarke, Vaccaro, VanderVelden, Goldfarb &Sockler, 1985; Fiatarone, Marks, Ryan, Meredith, Lipsita, & Evans, 1990). Lee(1991) has reviewed the exercise intervention studies pertaining to middle-agedand older women and concludes that "older women have the potential to benefitfrom exercise to much the same degree as men" (p. 133).Furthermore physical activity is known to be more than just a preventive andcontrolling measure; at certain intensities, sustained human activity is health-promoting and can lead to a "high-level wellness" (Dunn, 1961; Teague, 1987).Exercise elevates function to levels which guarantee more years of independentliving (Health & Welfare Canada, 1989). Regular physical activity places controlson aging decline which, in "usual" aging, contributes to physiological losses ofabout one percent per year in most body systems (deVries, 1979). A consensus isforming that the health of most adults, including the able elderly, can best bepromoted with brisk walking at 40 to 75% of one's maximal heart rate (MHR = 220 -age)(Bouchard et al., 1990).Until recently, however, little attention has been placed on the mechanismsof women's aging and activity patterns. Frail elderly women, especially, havebeen virtually invisible in feminist, sociological, and gerontological literature(Evers, 1985, p. 86). By many accounts, most women can expect to live to theripe age of 80 years or better, but are not likely to age very "successfully"(Dulude, 1978; Lewin & Oleson, 1985; Posner, 1980; Quinlan, 1988; Verbrugge,1990a; 1990b; Verbrugge & Wingard, 1987). As women age, they are said to slowdown, and for many, up to 55% of their body mass becomes infiltrated with fat(Young, Blondin, Tensuan & Fryer, 1963). Significant declines in strength,endurance and aerobic fitness are apparent even by middle-age (Alexander, Ready,& Fougere -Mailey, 1985; Cinque, 1990). Rarely are older women found participating4in the more vigorous forms of sport and recreation (Cauley, LaPorte, BlackSandler, Schramm, & Kriska, 1987).Indeed, among older women, such activity is almost nonexistent except forthe 12% who over a four-week period undertake from time to time a walk oftwo miles or more. (Abrams, 1988, p.32)Health promoters are concerned, not only about older women, but about muchyounger females too. Only 24% of Canadian girls aged 15 to 19 could achieve therecommended levels of aerobic fitness on a recent Canada Fitness Survey (Stephens& Craig, 1990). Other research has found that 20% of Canadian children areconsidered to be obese and that 80 to 85% of those children remain obese asadults. Despite public awareness of the benefits of exercise at every life stage,as yet, females at all ages are less active than their male counterparts(Stephens, Craig & Ferris, 1986), and they are seen to become progressively lessactive as they get older (Alexander, Ready, & Fougere-Mailey, 1985). By latelife, only a small minority are adequately active to benefit their health andwell-being (Blair, Brill & Kohl, 1988; Lee, 1991; Stephens & Craig, 1990; Teague& Hunnicutt, 1989). Statistics Canada (1990) reports that only 10% of women overthe age of 45 are considered to be "active" compared with one in three males. Inthe U.S., only 1% of adult women regularly performed more than one vigorousactivity (Sallis, Haskell, Wood, Fortmann, Rogers, Blair & Paffenbarger, Jr.(1985).In the eight extra years that women, on average, outlive their malecounterparts, too many of them endure poor mental health (Grau, 1988), over one-third are frail and physically limited (Charette, 1988), and almost one quarterof women over age 65 use sleeping pills (Health & Welfare Canada, 1989). Theaging difficulties of women have prompted researchers to examine differences inle r lifestyle. both medical and social professions would probably agree; the5one factor that is most likely to exacerbate the emotional and physicaldifficulties of very aged women is their inadequate leisure-time exercise --often a lifelong deficiency of vigorous and strength-promoting physical activity(Biddle & Smith, 1992; Verbrugge, 1990a; Vertinsky, 1991, Work, 1989).While "doctor's orders" might activate up to 25% of women, almost 60% ofolder women have said that "nothing would persuade them to increase theirphysical activity" (Shephard, 1986, p.136). Of interest is the fact that whereother health behaviors are concerned, women generally exhibit better life habitsthan men; physical activity is the only positive health behavior that is pursuedby men more than women (Stephens, 1985; Stephens & Craig, 1990). While publichealth campaigns about the risk of heart disease has spurred many men intojoining health-promoting exercise programs (Davidson & Sedgewick, 1978), simplyraising the issue of heart disease may have frightened aging women away.If there is a persuasive force to mobilize aging women to more activity, itmight be "figure improvement" (Davidson & Sedgwick, 1978) and stress reduction(Duda & Tappe, 1989). "Feeling better" and "looking better" are important reasonswhy women have been physically active in the past (Canada Fitness Survey, 1983).But this reasoning is problematic. Almost half of Canadian females over age 45are at risk of health problems due to obesity - a group who could most benefitfrom increased physical activity but who are at risk by doing so. Those women whoare more inclined to be active are already leaner and healthier, and thus, thewomen who least need to increase activity levels are the most likely to do so(Dishman, 1990; Sallis, Haskell, Wood et al., 1985; Stephens & Craig, 1990).Possibly concerned about their health and safety, women prefer to exercise ingroups under expert leadership. About 50% of active women over age 65 say theyexercise in public places and are more likely than men to be in supervised6activity settings (Stephens & Craig, 1990). Female propensity for publicparticipation does pose a problem for bigger and older women. Recent research hasfound that overweight women perceive social disapproval for their body size;unfortunately they also perceive disapproval and experience embarrassment in theexercise setting where they most anticipate rewards for participating (Bain,Wilson, & Chaikland, 1989). Evidently, older women who are active are alreadysomewhat comfortable with their physique in public settings; the heavier women,who most want to look and feel better as they age, are unfortunately less likelyto participate in, or adhere to, the kinds of programs which might help themsucceed.But more important than female appearance must be female health. Just asmany women will die of heart disease as will men (Statistics Canada, 1986), andyet women's risks have not been a focus of heart health campaigns (Nachitall &Nachitall, 1990). While women's spines and abdomens "take a tremendous beatingin pregnancy and childbirth" (Davidson & Sedgewick, 1978, p.27), "older women whoperform aerobic exercise for the sake of improved health are generally viewedsomewhat suspiciously" (p. 27). Without sufficient exercise, older women exhibita level of muscle weakness that places them in a category of "functionallydisabled" (Branch & Jette, 1981; Work, 1989).Social scientists have argued convincingly that women have merely learnedtheir social roles well; passive behavior is thought to be the outcome of alifelong experience of female disempowerment and learned helplessness (Fedorak& Griffin, 1986; Myers & Huddy, 1985; Schulz, 1980; Zinberg & Kaufman, 1963).Others point to women's chronic stress from poverty (Labonte & Penfold, 1981),their commitment to caregiving for others (Robinson, 1988; Thomas, S.P., 1990),and fatigue from "daily hassles" (Mishler, Amarasingham, Hauser, Liem, & Others,71981; Spacapan & Oskamp, 1989). Aging individuals apparently live up to the"self-fulfilling prophecy" of social expectation that labels older people, andwomen in general, as less physically competent (Kuypers & Bengston, 1973). Evers(1985) proposes that elderly women, more than men, continue to live at home withdisabilities because "women are simply expected to be able to put up withlimiting disabilities to a greater extent than are men" (p.89).Indeed it is a paradox that one of the main reasons given in surveys ofelderly women for not being more physically active is their declining healthand the perception that they are "too old," while at the same timescientific research increasingly demonstrates that one of the certainbenefits of physical activity is health improvement. It is a furtherparadox that, while women have proven more durable than men from aphysiological standpoint, they have done so in a culture which has, untilrecently, encouraged them to take on the characteristics of aging tooreadily. (Vertinsky, 1991, p.8)Elderly women, suggest some critics, impose more on the health care system,collect social security benefits and receive government assistance longer thanmen, and are most at risk of living out their last decade of life with severelydiminished capacities (Statistics Canada, 1990 Women in Canada; Wilkins, Murb &Adams, 1983). These phenomena concern government and health care systems(Eriksson, Mellstrom & Svanborg, 1987), especially since older women are thefastest growing segment of the population. The women who reach the age of 90outnumber their male counterparts by almost 3:1 (Statistics Canada, 1990).There are, however, examples of remarkably athletic elderly women withlimited resources who have not shied away from vigorous involvements with theirown serious and sometimes multiple health conditions (Drinkwater, 1988; Dummer,Clarke, Vaccaro, Vandervelden, Goldfarb, & Sockler, 1985; Gandee, Campbell,Knierim et al., 1989; National Film Board, 1990; Ruder, 1989; Starischka &Bohner, 1986; Wilmore, Miller & Pollock, 1974). While some females at all ages1 es y e, insu icien par icipation, especially inV.• •^-^I'^.8vigorous play and sport, is more characteristic of the female life course fromadolescence on (Vertinsky, 1992) and serves to highlight the heterogeneity ofthis social group. This heterogeneity is aptly described by Eric Pfeiffer asfollows:In my considerable contacts with elderly persons, both clinically andsocially, I have run into not only the lonely and the despaired and disabledelderly. I have also met some very, very exciting older people. Olderpeople who were intellectually and socially stimulating and exciting, whowere physically active and who obviously seemed to have made a successfuladaptation to their growing years. Yet as I observed one after another agingperson with whom I came in contact, there did seem to emerge a set of commoncharacteristics for all or almost all of these persons. It struck me asthough the successfully aging person was someone who somewhere along the wayhad decided to stay in training. He or she had decided to stay in trainingphysically, intellectually and emotionally, and socially. (Pfeiffer, 1973,P. 3 )This holistic view of human aging accounts for physical, intellectual, emotionaland social developments and provokes the conception of biopsychosocial modelsthat could better guide research, have clinical utility, and provide morecomprehensive understanding (Engel, 1980; Levy, Derogatis, Gallagher & Gatz,1980). McPherson (1986a) advocates the interdisciplinary approach in aging andsport research:...there could very well be greater levels of explanation achievedconcerning aging phenomena and the elderly if sport scientists fromdifferent disciplines were to pool their expertise. Specifically, greaterattention needs to be directed to possible interactions among social,psychological, biological and physiological variables. (McPherson, 1986a,p. 8)Statement of the ProblemToo many older women are at heightened risk of suffering hypokineticdiseases and rapid aging decline simply because they are insufficientlyphysically active. Yet, the reasons for the deficient physical activity patternsof women in their seventh, eighth and ninth decade of life are virtually9unexplored. The paradox, that those aging women who could best improve theirwell-being through regular exercise, may often be the least likely to do so,suggests that certain barriers may be operating. These barriers to more activelifestyles need to be identified if women are to age with better life quality,less chronic disease, and full independence. Until the main barriers to olderwomen's physical activity involvement are more clearly identified, social andeducational programs cannot be designed with clear objectives for change.As evidence mounts regarding the significant health-promoting role ofexercise in mental, social and physical well-being, social scientists ask, "Whyare so few older women taking advantage of the 'best preventive medicine?'" Toaddress this question, some researchers have focussed on people's beliefs aboutphysical activity -- beliefs which are thought to be socially learned andinternalized. Other research suggests that people are victims of theircircumstances, and that gender, age, health, education and financial means aremore likely to be the limiting forces affecting individual lifestyle behavior.Little research has attempted to mesh these two theoretical perspectives into asingle study even though both perspectives appear to have merit in theexplanation of why some older women are highly active while many more fall farshort of adequate physical activity.This study brings together the most promising explanations of late lifeexercise for older women by merging the cognitive beliefs of Social CognitiveTheory and Health Locus of Control Theory with ten personal and situationalattributes. Guided by a composite theoretical approach, this study aims tocapture the most important influences on the physical activity behavior of acommunity-wide sample of women over age 70.10In particular, I am interested in the answers to these research questions:1. What are the participation patterns of older women in leisure-time physicalactivity?2. To what extent can life situation explain variability in leisure-timephysical activity behavior in women over age 70?3. To what extent can cognitive beliefs explain variability in leisure-timephysical activity behavior in women over age 70?4. Does a composite theoretical model have utility in explaining late lifeexercise?Rationale and Significance of the Study The research presented here explores needed and promising explanations forolder women's exercise behavior. This study integrates potentially usefulconstructs from several theoretical perspectives; altogether there are 16variables with biological, psychological, sociological, or environmental originswhich have been found to predict health behavior and physical activity behavior.McPherson has asserted that:...future work concerning socialization in a sport context needs to abandonthe almost exclusive use of the functionalist perspective and become moretheoretically integrated. This does not imply that eclecticism shouldprevail, but rather that conscious attempts to examine the process from amerged theoretical perspective are needed to advance knowledge... In short,not only is there a need for greater use of microlevel theories but also forthe integration and synthesis of theories within sociology and betweensociology, psychology, and related disciplines. (McPherson, 1986b, p.116)To assist in understanding the barriers to more active lifestyles, theHealth Promotion Survey (Charette, 1988) and the recent Campbell's Survey(Stephens & Craig, 1990) provide substantial information on the physical activityof Canadian adults of all ages. These government-funded studies have assessed activity behavior in representative populations and have begun to identify11various situational and psychological barriers to exercise by age and gendergroupings. But to date, little is known about the relative importance of thesebarriers in explaining exercise behavior. More importantly, much of the researchhas searched for explanation without the guidance of human behavior theory. Whenbehavioral theories have been used to predict exercise, they are often partiallyapplied using only one or two key constructs. Moreover, current behavioraltheories do not account for past situations and former attributes which may beimportant to the explanation of older adult behavior. Behavioral theories havetended to focus on the prospective perceptions, attitudes, and beliefs of adults,(all of which are considered to be alterable), with little regard for theirsocial settings and personal circumstances which may make behavior modificationdifficult. Thus there is inadequate information about the relative influence ofsocial and environmental factors versus individual beliefs in explaining latelife exercise. Yet identifying the main biopsychosocial determinants' of activelifestyles and their relative significance and interactions would assist a rangeof professionals and agencies on how best to help older women age moresuccessfully.This study will enrich Canadian data concerning the epidemiology of women'sexercise patterns in old age - information that may assist physical educators andhealth practitioners in promoting the physical abilities and interests of olderwomen. The specific nature and scope of the physical activity patterns ofCanadian women over age 70 is poorly understood and data are lacking on theparticular activities in which older women are engaged. As well, normative dataare lacking on the amount of energy expended on weekly exercise by older women.The term determinant is used according to the definition of Dishman (1990), that is to denote areproducible association or predictive relationship other than cause and effect.12The development of the Older Adult Exercise Status Inventory for the purposeof this study will provide a potential solution to the problem of assessing theweekly participation of the elderly in exercise pursuits. The inventory, basedupon a seven-day recall design in combination with the Canada Fitness Surveyform, was designed specifically for older adult activity assessment. This kindof inventory is considered to be "a pragmatic approach for large populations forwhich direct observation or objective monitoring cannot be implemented" (Dishman,1990, p.94). The inventory is easy to use, yet it generates a great deal ofinformation about the frequency, intensity, duration and specific type ofactivities engaged in by older adults. The instrument has demonstratedreliability, concurrent validity with two contemporary field instruments and isbuilt upon instruments that have demonstrated criterion validity.While much health promotion literature is aimed at finding ways to increasethe physical well-being of the elderly, the age cohort of women under study (age70 and older) has largely been neglected in previous research in terms ofunderstanding the factors related to lifelong vigor and exercise participation.This study examines women, rather than men, because of their unique and oftenlimited experiences with vigorous forms of physical activity, because of theirrelatively poor participation rate in late-life physical activity, and the factthat women are long-living, more chronically ill, and under-researched.Unique to this study is the self-assessment of the perceived risks andperceived benefits of six different fitness-related activities. In addition toLikert rating scales, subjects were asked open-ended questions about what theyperceived to be the benefits and risks of six specific exercises commonly foundin adult fitness classes. These data appear to be the first of their kind to13elicit responses from older women about their fears and hopes about the expectedoutcomes of participating in a contemporary exercise setting.This study initiates an important line of enquiry exploring the lifesituations and personal factors which lead to movement confidence and theperceived ability to be physically involved at different life stages. Recentwork in the epidemiology of exercise participation stresses the importance of alife course perspective in forming and maintaining health promoting behavioralpatterns - patterns which have the potential to be socially and environmentallyinfluenced positively or negatively at any point in life span. The presentresearch takes a retrospective and prospective look at female involvement invigorous physical activity at two life stages: memories from girlhood in theearly years of the 20th Century, and at late adulthood in recent years.If it can be confirmed that participation in school or organized sports asa youth leads to a more physically active adulthood, then appropriatechanges in policy should be vigorously pursued. At the moment, however, wehave little hard data with which to support such recommendations. (Powell& Dysinger, 1987, p.281)To date, little research has been done to begin to understand the past andpresent factors which would explain the reluctance of females, from girlhood on,to take up, or keep up, healthful levels of physical recreation, sport and play.This study will begin to explore, in retrospective fashion, possiblechildhood sources of physical competency for activity in later life. This studyis unique for its inclusion of several historical-situational variables:childhood social support, childhood movement confidence for six physicallychallenging skills, and country of main schooling as a child. The merging ofcurrent exercise behaviors and beliefs with perceptions of childhood opportunityand capability for skilled physical activity, promises to generate new14understandings about the attitudes and experiences of elderly women towardexercise and how these may be a lifelong consequence of previous experience.The study will provide information that can inform policies concerned withpublic health and physical education for the elderly. Policy makers and healthpromoters, however, need specific information on the enabling elements of societythat influence whether late life will be vigorously active or relativelysedentary. Physical educators can better design and instruct exercise programsif the attitudes and perceptions of the elderly toward fitness activities areknown.Vancouver, with its mild winter climate, provides a particularly appropriatearena for this kind of study. The city is one of the "retirement" headquartersof Canada, and Western Canadians are known to be more active than other Canadians(Stephens, 1988). Therefore the women in this study are thought to be found inthe "best of environments" for regular physical activity.Definition of Key Terms The following definitions will assist the reader in the interpretation ofthe theoretical framework and for the review of literature.Efficacy Expectation is the conviction that one can successfully execute thebehavior required to produce desired outcomes (Bandura, 1977a,b). Efficacy refersto personal judgements of how well one can organize and implement patterns ofbehavior in situations that may contain novel, unpredictable, and stressfulelements (Bandura & Schunk, 1981). Perceived efficacy can affect one's choice ofactivities and activity environments. Persons who continue to shun activities15out of self-doubts preclude opportunities for skill development and therebyremain inefficacious (Schunk & Carbonari, 1984).Exercise is a subset of physical activity that is planned, structured, repetitiveand has as an objective the improvement or maintenance of physical fitness(Caspersen, Powell & Christenson, 1985). Although "exercise" is usedinterchangeably with "physical activity," researchers recognize that "it hascharacteristics that separate it from many other physical activities" (Powell &Paffenbarger, 1985, p.118).Health is "a human condition with physical, social, and psychological dimensions,each characterized on a continuum with positive and negative poles. Positivehealth is associated with a capacity to enjoy life and to withstand challenges;health is not merely the absence of disease. Negative health is associated withmorbidity and, in the extreme, with mortality" (Bouchard, Shephard, Stephens,Sutton & McPherson, 1990, p.6).Health Incentive (Motive) is defined as the behavioral incentive, instrumentalvalue, or motivation to participate in health promoting behavior. In terms ofolder adult exercise participation, motivation to live a long and healthy lifewas the incentive considered in this study.Health Locus of Control is defined as one's perceived control over one's health.An external locus of control describes perceptions that a health event is due tochance or the actions of powerful others. Internal locus of control refers toperceptions that a health event is due to one's own personal actions (Kist-Kline16& Lipnickey, 1989; Wallston, Wallston, Kaplan & Maides, 1976; Wallston, Wallston& DeVellis, 1978).Health Benefits are defined as the degree of perceived advantage or positivehealth outcomes from participation in physical fitness activity.Health Risks are defined as the degree of perceived personal harm or negativehealth outcomes from participation in physical fitness activity.Movement Confidence is a combination of personal efficacy and personal experiencewhich represent a person's perception of assurance of success in physicalactivity and performance settings.Outcome Expectation (Perceived Risk or Benefit) is defined as a person's estimatethat a given behavior will lead to certain outcomes (Bandura, 1977a,b). Theexpected outcomes of exercise participation may be viewed as positive or negative(beneficial or harmful) to health and well-being.Physical Activity is defined as any bodily movement produced by skeletal muscleswhich results in energy expenditure. The energy expenditure can be measured inkilocalories (Caspersen, Powell & Christenson, 1985).Physical Competence describes the perceived mastery of complex motor skills ina particular movement situation as judged by an external authority. Such masterymay require a certain amount of physical fitness, but in addition, skilled17movement may require precision, strength, balance and coordination which requiressubstantial learning and practice.Physical Fitness is a set of functional attributes that are health- and/or skill-related which can be measured with specific performance tests (Caspersen et al.,1985). Tests of fitness aim to measure physiological attributes (such as muscularstrength, muscular power, cardiovascular endurance or flexibility).Physical Fitness Activity refers to self-regulated participation in fitness-enhancing exercise activities such as sport, dance, vigorous walking, home orcommunity exercise programs. Optimal benefits are thought to be achieved withregular sweat-inducing participation at least three times per week, and theactivity must have the potential to contribute in some way to development ormaintenance of aerobic fitness, joint mobility, muscle strength and endurance,posture or balance. For the purposes of this study, housework was not consideredin this definition.Physical Efficacy is the strength of an individual's perceived self-confidenceor belief that she or he can successfully complete a physical task through theexpression of movement ability (Brody, Hatfield & Spalding, 1988, p.32). Seealso "self-efficacy to exercise" and "physical competence".Self-efficacy to Exercise refers to the strength of an individual's perceivedself-confidence or belief that one can successfully complete a task through theexpression of physical ability (Bandura, 1977a). In some of the literature,physical^•al ly i s referred to as physical competence" although a distinction18should be made that competence in physical situations is often judged by othersand is not necessarily a personal judgement. For the purpose of this study self-efficacy to exercise is considered to be a reflection of self-perceivedperformance ability. Self-efficacy to exercise is potentially mediated by actualperformance knowledge and the known judgements of others.Social Support refers to the endorsement, approval, advocacy or encouragement bysignificant others of an individual's behavior (in physical activity).Delimitations The study is limited to women born in 1921 or earlier (presently age 70 orolder) who are currently attending community programs in Central Vancouver or whoreside within its proximity. The sample is all female, predominantly Caucasian,Canadian educated and middle class.Limitations Following the example of other prominent studies, the present research waslimited to a seven-day recall assessment of leisure-time physical activity,exercise, and sport. Thus the domestic physical activities of women have beenomitted from this study. The significant role which physical work in the homemay add to the overall physical activity patterns of women was considered at theoutset of the study. However, a conscious decision was made that the study wouldfocus on voluntary exercise normally found in leisure time. Thus gardening, butnot other domestic work was admitted to the activities assessed in this survey.The reader could argue that women's domestic work is often conducted in theirl eraure - time, and may be considered to be voluntary and enjoyable. In19retrospect, I may have erred in assuming that most women view domestic labour tobe a work experience, devoid of choice and pleasure.A further limitation exists with the weekly assessment of energy expendedon leisure-time or voluntary activity. Adults are known to overestimate theiractivity levels in self-report situations. Furthermore, the assessment is onlyan estimate of energy expended on exercise. While the assessment is detailed, theactual calculation of kilocalories is based on approximated MET units for eachparticular activity reported.A critic of this research would probably take issue with the retrospectivedata collected on childhood efficacy and childhood social support. These were"recall" measures and thus are vulnerable to memory loss and altered perceptionsover the years. However, these measures have demonstrated satisfactoryreliability in a pilot study, and although validity is not guaranteed, theperceptions of early efficacy and support are really what matter in providing thefoundation for the attitudes and beliefs of older women toward exercise. Validityfor the childhood recall measures was, however, found in this study as discussedin Chapter 6.Geographic community sampling improved the prospects of reaching older womenwho would be representative of all segments of society. However, non-randomsampling is susceptible to selection bias. Less represented in this study wereolder women who were house-bound as caregivers, or at home with their ownphysical limitations. Although senior's lodges and residences were representedin the sample, women in institutional settings or hospitals were not accessibleto this study.Volunteer subjects who fill out exacting surveys are, in many ways,except luludl indivi duals. They are more likely to be highly educated, at least20middle class, in good health and highly mobile. Furthermore, the oldest women inthis study represent the survivors of their generation - by longevity alone theyhave outlived most of their birth cohort, and thus may represent an array ofexceptional qualities attributable to genetics, biological resilience, positivecoping strategies and other skills for adaptation. Therefore the results of thestudy can only be generalized to mobile elderly women of metropolitan centerswith similar ages and social context.Organization of the Remaining Chapters The review of literature following next in Chapter 2 presents the keyconstructs of the main theories which guide the explanation of human behavior andsurveys the literature with regard to their application to the explanation ofphysical activity. From the review of literature, the theoretical model guidingthis study is drawn. The theoretical framework integrates key constructs ofprevious research into a Composite Model and thus a separate chapter is justifiedand follows immediately in Chapter 3. Chapter 4 explains the methodologicaldesign of the study from data collection to statistical analyses. Chapter 5reports on the descriptive results of the study and provides the outcomes of theregression analyses. Chapter 6 includes a summary and discussion of the findings,identifies policy implications and discusses unanswered questions. The referencesare displayed in alphabetical order in Chapter 7 followed by appendixed materialsas described below.Appendix A contains the survey questionnaire; Appendix B contains theapproval forms of the Ethics Committee of the University of British Columbia;Appendix C holds the form used to obtain agency approval, and also instructionsto the univerbi y students for oral administration of the questionnaire.21Voluntary letters from subjects who offered interesting comments and points ofview are found in Appendix D. Appendix E contains post-hoc analyses conducted onthe subjects who provided missing data. The residual error of the finalregression equation is plotted and discussed in Appendix F. Finally, AppendixG contains a critical review of literature pertaining to the reliability andvalidity of the outcome variable, "exercise in the past week".22II. REVIEW OF THE LITERATUREIntroduction The multidisciplinary nature of this study, as well as the number ofvariables involved, demands parsimonious selection and careful organization ofthe relevant research literature. Over 2000 articles were reviewed in the initialplanning of this study. Dozens of research papers were found on many of theindependent variables; despite this, few studies were found which specificallyrelated to the explanation of exercise behavior of aging adults, namely olderwomen. Therefore this chapter will focus on the literature most pertinent to thestudy at hand, namely that which is known about the theoretical variables drivingthe study and their known relationships to the dependent variable, weeklyexercise in late life.The chapter begins with a brief overview of the problems facing today'selderly women -- problems which are considered to be outcomes of their pastsocialization and experiences as younger females. Because of studies whichindicate that early activity habits may be maintained throughout the life course,the review explores historical perspectives and the activity socialization offemales born before 1921. Next, their contemporary characteristics are presentedin the form of a demographic profile of women born before 1921. In this sectionthe following topics are addressed: size of the aging population, marital status,family size and socioeconomic status, education, ethnicity, health status, andinstitutionalization rates. The profile sets the stage for understanding thewomen involved in this research by highlighting the significant contextualfeatures of their generation. 23Next comes a review of the literature about the known exercise and physicalactivity patterns of older women. Recent findings confirm that in the past tenyears, activity patterns of Canadians have actually decreased slightly, and themajority of older adults are still insufficiently active. At the same time, theenormous benefits of exercise have become known, and enough evidence hasaccumulated to know that the risks of participating in late life exercise arevery minimal. A thorough review of the known benefits and risks of exerciseparticipation are discussed in this chapter. Thus the logical conclusion is thatsignificant barriers must be operating which thwart the involvement of olderwomen in health-promoting physical activity.To examine these barriers, the second half of the chapter turns totheoretical explanations for understanding the determinants of late life exercisein women. Two theoretical perspectives which are used to generally guide healthbehavior research are introduced: 1) social epidemiology and socialization whichfocus upon the personal characteristics and environmental situation of theindividual; and 2) cognitive beliefs of an individual representing apsychobehavioral perspective. The chapter introduces the Health Belief Model,Health Locus of Control Theory, the Theory of Reasoned Action, and finally SocialCognitive Theory. The cognitive determinants of exercise are well-articulated inSocial Cognitive Theory, and the research literature related to the self-efficacyconstruct is strong. The chapter concludes with a focus on the relationship ofexercise and the main constructs of Bandura's Social Cognitive Theory: Incentive,Self-Efficacy, Environmental Cues (social support), and Outcome Expectations.24The Poor Aging of WomenAging for women is, in many ways, a "survival of the unfittest" (Isaacs,Livingstone & Neville, 1972) because a female's extra life span is usuallyaccompanied by significantly high levels of reported illness (Verbrugge, 1987).Simply too many women are encountering early onset of preventable chronicdiseases. Part of the explanation is that women may be more attentive to theirsymptoms of ill health, may perceive that society accepts, if not expects, themto report health problems, and may find it easier to visit doctors due toflexible work patterns (Waldron, 1982).Others blame the health difficulties of women on their more passivelifestyle - a lifestyle reinforced, in North America, at least, by public policywhich limits their participation in health promoting physical activities overmuch of the life span (Boutilier & SanGiovanni, 1983). The social sanctionsimposed on women in sport contexts, for example, have been likened to themarginal social status of the disabled whereby both have been viewed as helplessand are reinforced by society to compound this helplessness (Mastro, Hall &Canabal, 1988). The penalties of lifelong inactivity are ultimately seen infrailty, depression and inability to carry out the simple activities of dailyliving - factors which guarantee institutionalization for almost half of allwomen over the age of 85 (Fletcher & Stone, 1982; Gee & Kimball, 1987).In the following section, historical perspectives are presented about thesocialization of women born before 1921. The limited socialization of femalesinto vigorous forms of physical activity in the first half of the 20th Centuryhelps to explain why their aging is often accompanied by sedentary lifestyles andhealth difficulties. 25The Activity Socialization of Females Born Before 1921The social incentives and rewards for participating in vigorous exercise andsport have historically been lacking for girls and women (Csizma, Wittig, &Schurr, 1988; Greendorfer, 1983). The 1909 Board of Education's Syllabus ofPhysical Exercises for the Public Elementary Schools portrays femalesdemonstrating a number of static postures in the gym. In the same syllabus, boysare depicted climbing ropes, and in more dynamic situations showing movement andstrength (Board of Education, 1909). Adding to this lack of curricular supportfor girls to be as active as boys have been medical notions of female fragility(Vertinsky, 1988), social devaluation and invisibility (Gee & Kimball, 1987).Sport socialization research describes a clear picture of the genderconstraints on turn-of-the-century, middle-class females undertaking the morevigorous forms of exercise (Lucas & Smith, 1978; Morrow, Keyes, Simpson,Cosentino & Lappage, 1989; Verbrugge, 1990a). One conspicuous limitation was theheavy, multi-layered and cumbersome attire worn by females of all ages whichplaced women in greater danger than any physical exertion (Bolotin, 1987, 1980;Heisch, 1988; McCrone, 1988). The corset, for example, was not onlyuncomfortable, it deformed the ribs, and caused abdominal organs to bepermanently displaced. The wasp-waist corset bound the lower rib-cage so tightlyand restricted breathing so seriously that women easily fainted. Judged by theirclothing, women of this generation were indeed physically limited and helpless.As significant as fashion in dictating the physical abilities and activitiesof girls and women was their socialization into a particular feminine role --that of mother and caregiver for her family (McPherson, Curtis, & Loy, 1989).Childbearing was extremely important -- a fart which allowed medical authority26to have a crucial role to play in prescribing appropriate behaviors andactivities for females. Early adolescence was the focus of most medical concern,for this was the stage of maximum female growth for sexual maturation. Doctorsbelieved that all physical energies had to be conserved for the criticaldevelopment of reproductive maturity (Vertinsky, 1990). The complex physiologyof women seemed to overtax the understanding of an all-male medical profession;physicians many times prescribed even more passive behavior for females who werehaving physical or psychological difficulties with their lifestyles.Males, at all ages, were universally judged to be better physical specimensthan females - a phenomenon that seems to have been rooted in their morephysically aggressive play patterns in childhood. Tolerance for aggressivebehavior, even fighting, was the social context for boys and men, while thelabelling of active girls as "tomboys" and "bicycle faces" (Heisch, 1988) wasprobably only a small part of the larger socio-environmental forces limiting thephysical opportunities of females (Dishman & Dunn, 1988; Espenshade, 1969;Gilman, 1911). Tomboy style of play was considered by many to be rude and vulgar(Guttman, 1988). Once into the mothering role, a woman would have scant time andenergy to take on sportive or other recreative activity outside the context ofher family (Gee, 1987, 1986a, 1986b).Clearly deterrents to be as strong, as fast and as physically able as theaverage male were operating in the early twentieth century and undermined manyyoung female's motivations to be physically competent and able-bodied instrenuous undertakings. The negative reactions of the female body and mentalhealth to this narrow social role were explained at the time as further evidenceof the inferiority of women. For those women who did ignore society'sxpectations, L.umpe erIL les were acquired in skilled activities which no doubt27enhanced their physical well-being, but which may have taken a psychological tollon their status as they stepped outside of conventional female roles.There are some historical accounts and women still alive to tell us that,by necessity or choice, they did not adopt the passive role that society expectedof them. While middle and upper class women were socially constrained, there weremany working women who had to labor intensively in order to survive. Photographicevidence exists that show many immigrant women acting as "horse-teams" on theprairies, pulling ploughs when oxen were not available (Bolotin, 1987), whileothers combed the fields, literally on their hands and knees, at harvest time.Thousands of rural women, mostly immigrants, did intense and difficult workcarving out a pioneer existence and building homesteads in western North America.The physical challenge and skill of horse-back riding and ranching cattle werealso part of the lifestyle for many of these women.Just over one hundred years ago, young women were admonished for theirreckless attempts to learn how to ride bicycles (Lucas & Smith, 1978). By themid-1890's, a number of city women were riding bicycles for transportation andpleasure (Harmond, 1984). Some women found physical challenge in permissibleforms of dance such as ballet training and tap dancing. Social types of dancewere highly popular with both men and women and "marathon" dancing was in vogue.Others developed interest in tennis (Danzig, 1928; Heathcote, 1894), swimming,(Shea, 1986), golf (Nickerson, 1987), basketball (Smith, 1984), and figureskating (Cruikshank, 1921).In the early decades of the twentieth century, the more wealthy women werebeginning to experience the sport club scene in golf and tennis. While middle-class women were still being socialized into more passive roles than males, atti mes, necesbi y required that working class women contribute resilience,28endurance and sweat alongside the physical labour of men. This dialectic betweenthe roles of women according to their social class is perhaps part of culturalanswer in explaining the heterogeneity in physical activity which accompanieswomen's aging.In the next two sections, I present information which describes the presentlife quality and lifestyle status of today's elderly women. First, a demographicprofile touches on the size of the aging female population, followed by a briefexamination of their cohort features such as socioeconomic status, maritalstatus, family size, education, ethnicity, health status, and rates ofinstitutionalization. Second, the participation patterns of elderly women inphysical activity, exercise and sport are presented. These two sections summarizethe life situation of older women as it is known for the pre-1921 cohort.A Demographic Profile of Women Born Before 1921Each generation is accompanied by contextual features which help to makethat cohort unique. Reviewing these contextual features may help to set the stagefor understanding the physical activity and sport patterns of today's older womenin Western Canada. Although one's life circumstances do not remain stable overthe lifespan, one's short-term situation is often uncontrollable and irreversiblefrom an individual viewpoint. Thus, the prospects for rapidly improving women'squality of aging by knowing how past and present circumstances create barriersor opportunities for exercise involvement may be limited.29Size of the Aging Population Over 1.25 million Canadian women are over the age of 65, and of these, 13%reside in British Columbia. In the 1986 Census, 12.1% of the total population ofB.C. was over the age of 65 (Sources, 1991) and 5% were over the age of 75. TheVancouver Metropolitan Area Population Forecast, 1986 - 2011 (1988) predictedthat in 1991, 1.5 million people of all ages would reside in Central MetropolitanVancouver, and of these, 11.5% would be over the age of 70. Almost 6,000individuals were estimated to be over the age of 90!Canadian women over the age of 65 began to outnumber men in 1961 (Stone &Fletcher, 1980). In Vancouver, there are proportionally more older women in the65+ population than is found in B.C. or in Canada as an average. Women over theage of 65 in Vancouver now represent about 60% of the total seniors population(Table 2.0). By age 85, women outnumber their male peers by 2:1 and by age 90,by almost 3:1 (Statistics Canada, 1984).The City of Vancouver is home to approximately 28,000 women over the age of70, or about 1.5% of the general population (City of Vancouver, 1986 Census).The 327 women involved in this study represent over 1% of these 28,000 women.Table 2.0Demographic Structure of Elderly WomenVARIABLE CANADA' BRITISH COLUMBIA' VANCOUVER'65+ FEMALE POPULATION 1,269,440 166,340 9837065+ MALE POPULATION 1,010,850 131,830 68480% FEMALE OF 65+ POP. 55.7% 55.8% 59.0%MARITALSTATUSMarried 41.4% 34.5% 39.0%Widowed 50.5% 57.1% 48.4%Single 7.2% 6.4% 6.0%Divorced 1.1% 2.1% 4.3%EMPLOYMENT 6.0% (1981)4.6% (1985)5.4% 4.9%EDUCATION < Grade 9 41.7% 36.6% 31.0%Gd. 9 to 12 48.3% 38.6% 41.4%Post-Second. 22.0% 23.7%Univ. Deg. 2.9% 3.8%ETHNICSTATUSBritish 50% 63.7% 66%German 7.9% 8%Scandinay. 4.7%Chinese 2.9% 12%Other 20.8% 24%SELF-RATEDHEALTHExcellent' 20%Good 42%Fair 30%Poor 8%2 Profiles Part II. (1988). Census Tracts. Ottawa: Ministry of Supply & Services. Also data came from aspecial run on Census data from Statistics Canada.3 Seniors' Resources and Research Society of B.C. (1991).^Profile of seniors in British Columbia.Sources, #503 - 1185 West Georgia St., Vancouver, B.C., V6E 4E6. Also: Ministry of Health. (1988). DiseaseSurveillance, 9(8), 188-218.4 Profiles - Vancouver Part 2 (1988). Census Tracts. City of Vancouver (1986). Ottawa: Minister of Supply& Services.305 Statistics Canada. (1987). Health and Social Support, 1985. Ottawa: Minister of Supply& Services Canada.31Marital Status, Family Size and Socioeconomic Status Census data indicate that in Vancouver, about two-thirds of women over age65 are widowed, single or divorced (Table 2.0). After age 85, four out of fiveCanadian women are widowed (Statistics Canada, The Elderly in Canada, 1984).Statistics Canada reports in Women in Canada (1990) that the most significantgroup of persons living alone is that composed of females aged 65 and over. Thusby late life, the majority of Canadian women are without partners and many arewithout pensions: a predicament with serious economic implications for qualityof life and life choices.The statistics on the financial status of older women are shocking. Thetraditional social roles of women have meant that marriage has usually provideda woman a degree of financial security, at least while her spouse was alive. Butbeing widowed, living alone, and living with minimal finances are predictableoutcomes for the majority of aging women. In Canada, 60% of women over age 65are regarded as poor, and 80% of these women are widows. The National AdvisoryCouncil on Aging reports that some 43% of seniors received the Guaranteed IncomeSupplement in 1990, meaning that almost half of Canada's seniors have only amarginal monthly income. Housing represents 29% of the expenses of female seniorscompared to 16% of the expenses of the total population (NACA Precis No. 1,1991). In B.C., 56% of female seniors live in detached family homes whileanother 33% live in their own apartments. Even when mortgages have been paid off,property taxes and house repairs can be a major financial burden to an olderwoman living on her own.Even those women who had procured satisfactory employment in their youngeryears, had often earned the lower wages of women throughout the 20th Century,meaning that poverty often ac LAJImpanies thei rdying. More than 20% of Canada's32poor are senior citizens who are living on fixed incomes. Yet despite suchlimited finances, less than five percent of women over age 65 report any currentemployment income (Statistics Canada, 1986).In 1981, the average income of B.C. females aged 65 to 69 was $8,478 whilethat for same-age males was $16,802 (Sources, 1991). In 1988, the average annualincome of families headed by a person aged 65 and older was $37,462, but only$16,316 for singles aged 65 and over (National Advisory Council on Aging, 1991).In 1986, more than one-third of senior's incomes came from Old Age Security andthe Guaranteed Income Supplement.The high poverty rates among older females, no doubt, have some degree ofimpact on the health and activity behaviors of those affected. Limited financialresources place extra stress on the older woman, and ultimately limits hersolutions to health problems that accompany aging. Seniors in the upper-middleincome category are more than twice as likely (59%) to rate their health asexcellent as those in the very poor category (28%) (Sources, 1991).Family size may have contributed to the financial and health burden ofwomen. Older women tended to raise larger families than women do today. In 1920to 1924, the U.S. Bureau of the Census reported there were 2,701 children forevery 1,000 ever-married women. Although many North American women at the turnof the century remained single and up to 20% of all women were childless (U.S.Bureau of the Census (1975), between 1910 to 1920, 11 to 16% of all women aged15 to 44 years gave birth in any single year.33Education The Canada Fitness Survey states that "by most definitions of activeleisure, there is a direct relationship between amount of education and theprobability of being active" (Stephens & Craig, 1988, p.4).Recognition of a relationship between education and economic developmentand of the subsequent improvement of personal and social life, thusprovides a further economic argument for a radical change in theorganization of education, since education, economic development andimproved quality of life are intimately connected. (Cropley, 1977, p.25)Lack of education in Canada is significantly related to poorer health,physical limitations and less happiness. Canadian data reports that about 50% ofadults over the age of 70 had less than Grade 9 education while less than 5%received a University degree (Statistics Canada, The Elderly in Canada, 1984).In the 65 and over age group, 34% of those with only an elementary educationreport fair to poor health, compared to 7% of those with post-secondary education(Health & Welfare, Canada, 1989).According to the 1981 Census, 61.4% of B.C.'s seniors reported completingnine or more years of schooling. This figure is increasing over time (from 50%in 1971) and may have positive implications for the future educational programsseniors will attend. People in B.C. who have less than secondary education areless likely to have plans to improve their health than those with highereducation.In Vancouver, over 25% of the women in the age-group studied have post-secondary education and almost 4% have university degrees. But having highereducation doesn't guarantee women the same financial status as males. Forexample, Canadian women aged 65 to 74 with University degrees had an averageannual income of $14,500, half that of the same-age and qualified male income of34$27,900. Women with some university education had an annual income at the samelevel as males who had less than Grade 9 (about $9000).This data suggests that education may not be a good substitute variable forsocioeconomic status of women. Rather education may be important to examine aslending skills for information seeking about health knowledge, as well asextending opportunities to female students to participate in active recreationand sport further into their adult years.EthnicityIn Canada, the predominant ethnic groups among the elderly are of Britishdescent, who make up half of the elderly population, and those of French descent,who account for 25%. These ethnic features reflect Canada's demographic trendsover many decades in the past, when birth rates among the French were higher thanthose of the total population and when immigration of British persons wasparticularly high. Almost 17% of the Jewish population in Canada are over the ageof 65 while the Native peoples over the age of 65 account for less than 4% oftheir total population (Statistics Canada, 1984).In British Columbia, 64% of the elderly are of British descent with otherethnic groups represented in quite small proportions (<5% each). In Vancouver,English is the mother tongue for 66% of citizens, while French is represented by1.6%. Almost one third of Vancouver residents speak a non-official language.Chinese is the most prominent non-official language, and is spoken by 43% of thenon-official group (Burrard Health Unit, 1990).35Health Status General population health practices in Western Canada are considered to beslightly better than in the rest of the country. The B.C. Ministry of Health(1988) reports that B.C. is third behind the Yukon and Alberta for reportingregular exercise (66%, 63% and 61% respectively). Obesity (BMI = 28.6 in women)applied to 14% of B.C. women and 16% of B.C. men. Twenty-one percent of the womenwere underweight while only six percent of the men were underweight.As with other Canadian provinces, about 90% of British Columbians of allages perceived their health to be good, very good, or excellent. However, peopleof low socio-economic level and the elderly were two groups less likely to reportgood health. Not only was health poorer in these groups but plans to improvehealth were less common (B.C. Ministry of Health, 1988). While the averageperson visited a physician five times a year, persons between 65 and 74 make 7.4visits, and those over 75 make 8.2 visits (Schick, 1982). Functional problemsrise after the age of 80 and this is the point where need for support systemsgreatly increase (Stone & Frenken, 1988).The Health and Activity Limitation Survey (Statistics Canada, 1988) uses theWorld Health Organization's definition of disability, which is" ...any restriction or lack (resulting from an impairment) of ability toperform an activity in the manner or within the range considered normal fora human being." (Statistics Canada, 1988).In this survey, disabled persons were defined as those who indicated somedifficulty in performing any of the 17 activities, such as "Do you have anytrouble walking up and down stairs?" or "Are you limited in the kind or amountof activity you can do because of a long-term emotional, psychological or mentalhealth condition?" Older Canadians rate their health quite positivelyconsidering that about 30% of them have activity limitations, and 6% of these36limitations are considered to be severe (Health & Welfare, Canada, 1989). In1987, there were 494,340 disabled males over the age of 65 compared to 727,655disabled older women in Canada (Statistics Canada, 1988).Older women also rate their health less positively than men. Only 17% ofwomen over age 65 rate their health as excellent compared to 24% of men; 29% ofolder women rate their health as poor compared to 24% of men; 37% of women reportactivity limitations compared to 31% of men; 32% of older women say life isfairly or very stressful compared to 27% of men; 9% of older women say they arenot too happy compared to 6% of men (Health & Welfare, Canada, 1989).Institutionalization The proportion of Canadian seniors over age 85 who are residents ofinstitutions has risen since 1976 from 36.5% to 40.5% for women and 25.2 to 28.4%for men (Government of Canada, 1988). Below the age of 85, however, the numberof institutionalized adults is declining slightly, and at age 70 to 74, only 3.2%of women and 2.9% of men are living in institutions. About 55% of people confinedto nursing homes suffer from chronic mental conditions or senility (Schick,1986).In British Columbia, 56% of seniors live in houses, 33% live in apartmentsand 8% of the senior population live in nursing homes, old age homes or chroniccare institutions (Sources, 1991). In the age group 75 to 84, the proportion ofinstitutionalized elderly increases to 21% and then becomes as much as 55% of allthose over age 85. These numbers will likely continue for some years to come.In the U.S., women comprise 75% of all nursing home residents aged 65 andover (United Nations Office at Vienna, 1990) and yet families are still the• !I'^III^•^IIlar•est re37that the majority of informal caregivers are women, and many appear to be mid-life women who are caring for older women. Meta-analysis recently conducted ongender differences in caregiving contradicts this finding (Miller & Cafasso,1992), but in the majority of studies documented, most caregivers were women withfemale children claiming caregiver roles in 79% of the cases (Miller, 1990).The family unit as a caregiving resource for the elderly appears to be injeopardy. In Canada, Fletcher and Stone (1982) claim that the increasingincidence of childlessness or one-child families, the increasing rate of divorce,the high rate of mobility among young adults and recent increases in the labourforce participation of women, all point to the probability that an elderly personin the future will have less access for family support than present and previousgenerations of older persons. This means that more older adults need to bemaintaining their strength and mobility in order to live out their remainingyears with dignity and independence.Elderly Women's Exercise PatternsKnown exercise patterns of older women In reviewing the literature on the known activity patterns of older women,there are inconsistent findings. Part of the confusion arises because there aredifferent methods used to quantify physical activity and there have been dynamicshifts in participation trends over a period of a few years.While activity levels seem to be generally on the rise since 1981, Stephens(1988) warns that many adult Canadians are unaware of how much exercise isadequate. Most epidemiological literature supports an age-related decline inparticipation, with women exhibiting less activity and less physical fitness at38every age group (Alexander, Ready, & Fougere-Mailey, 1985). While post-adolescentgirls demonstrate a greater decline in fitness than at any other time, the nextmost critical period in terms of physical fitness decline is considered to be age40 to 49 (Alexander et al., 1985).Over 1200 women across six Canadian regions were interviewed in the 1985General Social Survey where active physical exercise was defined as "exercisewhich made one perspire or breathe more heavily than normal" (General SocialSurvey, 1987, p. 59). From this survey, it was estimated that only 27% of theadult Canadian population over the age of 15 were active enough to anticipatehealth benefits which may include additional years of life. The survey notes thatphysical activity declines sharply after age 24, and again after age 44. Inaddition, among adults over age 65, almost 40% are identified as sedentary. Only14% of the 65 and over women in this survey were in the "active" category, and36% were in the "sedentary" category.The report Changing times: Women and physical activity (Fitness and AmateurSport: Women's Program, 1984) stated that 53% of Canadian females over age 60were active in their leisure time (an average of at least three hours per weekover nine months of the year). Next, 21% of the women were moderately activewhile 24% were sedentary. Only 39% of the women studied achieved the recommendedlevel of cardiovascular fitness. Therefore, the agency concluded that "womenneed to increase the intensity of their participation" (p.2). But the reportWomen in Canada: A Statistical Report (1990) using data from the 1985 GeneralSocial Survey conducted a few years earlier, classified only 6.3% of Canadianwomen over age 65 as "active".The Campbell's Survey on the well-being of Canadians reports that 50% of menand 30% o ,,111'1^•^- ivi y39for at least 30 minutes every other day (Stephens and Craig, 1990). The reportsuggests that women are just as active as men in time spent, but do less intensephysical activities. The physical recreation activities which have the largestnumber of participants are walking (77% of all-age women), gardening (55% of all-age women) and swimming (48% of all-age women). With increasing age, the numberof adults walking and gardening increases, while the number who are cycling,swimming, and dancing decreases.While almost half of women over 65 claim to be exercising regularly (TheActive Health Report on Seniors, 1989), as few as 15 percent of older women areexercising at an intensity that would foster better health (Stephens, 1985).The Campbell's Survey (Stephens & Craig, 1990) notes that there is a generaldecline in participation with age, but since 1981, adults of all ages, andnotably older adults, have made significant efforts to become more physicallyactive. Still the most recent document on the physical activity of Canadians(Health Promotion, 1993) suggests that little change at all has occurred in thepast ten years.The deficient activity patterns of adults of all ages, and the particularreluctance of women to participate in the more vigorous activities, suggests thatthe benefits of involvement in moderately intense exercise are not well known orare of little consequence to the average citizen and the risks of exercise mayappear to be too great. On the contrary, the reality is that the benefits ofregular exercise are almost overwhelming to document as can be seen in the quitesizable section following. In addition, the negligible risks of adultparticipation are also presented.40Known Benefits of Exercise ParticipationIntroduction Health, in its broadest sense, is the topic of central interest and is theprimary reason for most research on physical activity. (Kohl, Blair,Paffenbarger, Jr., Macera & Kronenfeld, 1988, p. 1229)Evidence is rapidly accumulating that physical mobility has become asurvival need for the elderly, and that society must change its attitudes towardolder women and their physical capabilities and requirements (Milde, 1988). Anarray of studies from a number of disciplines provide support for a long list ofbiopsychosocial benefits from involvement in physical activity throughout theentire life span: increased longevity, improved physical and mental health, aswell as independence and improved quality of life in very old age (O'Brien &Vertinsky, 1991).Some seniors appear to be aware of these benefits; 30% of older men andwomen with heart disease identified lack of exercise as a personal lifestyleproblem (Clark, Janz, Becker, et al., 1992). Not only do seniors want to avoidinstitutionalization, but they also seek opportunities for social involvement andpersonal growth (Toward A Better Age, 1989). However, recent research indicatesthat health promotion programs for older employees may have an insignificantimpact on increasing their exercise behavior, even when the employees have goodintentions to become more active. Sharpe & O'Connell (1992) failed to find anyincrease in exercise behavior of university faculty and staff after one year ofhealth promotion activities such as participation in walking groups, one-to-onecounselling, and work-site exercise programs. Predictors of intention to exercisewere level of education, gender, self-efficacy, outcome expectancies, perceivedbarriers, and baseline exercise frequency. However, at the end of the study, only41exercise at baseline was predictive of current exercise level. Thus work-basedinitiatives in promoting activity may not succeed if older adults are notconvinced of the personal benefits of exercise, or if other life circumstancesinterfere in their intentions to exercise.The Benefits of Exercise By the 1980's, the benefits of exercise for older women were becomingevident in the scientific literature; presently, physical activity isconsistently addressed as one of the most significant health interventions in thelives of the elderly. The preventive and restorative benefits of physicalactivity are recognized by medical and sport science research in most serioushealth threats. Table 2.1 outlines some of the exercise outcomes that have beenfound with aging women in relation to exercise intervention research. Althoughat least half a dozen studies have found no significant change in their dependentmeasure of exercise, it is because the intensity of exercise, the duration of thetraining program, or the type of exercise chosen are often inadequate to producebenefits. Overall the evidence seems to favor aerobic activity for bothpsychological and physiological impact. However, frail elderly women appear tobe able to make gains in functional status even with mild mobility programs.42Table 2.1The Known Benefits of ExerciseHEALTH BENEFIT SCIENTIFIC SOURCESAerobic fitness, increased maximum oxygenuptakeBadenhop, Cleary, Schell, Fox, & Bartels,1988; Barry et al., 1966; Blumenthal, Emery,Madden, Schniebolk, Walsh-Riddle, George etal., 1991; Blumenthal, Schocken, Needels, &Hindle, 1982; Cobb & Coleman, 1991; Foster,Hume, Byrnes, Dickinson & Chatfield, 1989;Hopkins, Murrah, Hooger, & Rhodes, 1990;Johannessen, Holly, Lui & Amsterdam, 1986;Kilbom^1971; Suominen, Heikkinen, & Parkatti,1977; Tonino & Driscoll, 1988.Management and control ofchronic obstructive pulmonarydiseaseAtkins, Kaplan, Timons, Reinsch, & Lofback,1984; Swerts, Kretzers, Terpstra-Lindeman,Verstappen, & Wouters, 1990, Webster, 1988.Prevention and control of heart disease McCunnev, 1987; Morev et al., 1989; Posner etal., in press; Sedo wick, Taplin, Davidson, &Thomas,^1988; Sidney & Shephard, 1978;Terpstra-Lindeman, Verstappen, & Wouters,1990; Upton, Hagan, Rosentswieg, & Gettman,1983.Control of obesity, lowercholesterolBlumenthal, et al., 1989; Shepherd, 1986b;Sidney, Shephard, & Harrison, 1977;Therapeutic value for arthritis Ellert, 1985; Harcom, Lampman, Banwell, &Castor, 1985; Lewis, 1984; Minor, Hewett,Webel, Anderson, & Kay, 1989.Incidence of cancer, heightened immuneresponseFiatarone, Morley, Bloom, et al., 1989;Prevention and control of osteoporosis Block^Smith, Freidlander, & Genant, 1989;Evans & Smith, 1987; Rikli & McManis, 1990;Smith, Reddan, & Smith, 1981; Snow-Harter,1987; Snow-Harter & Marcus, 1991.Social support and encouragement for exercise Andrew et al., 1981; Dishman, 1986; Gray,1987; Hauoe, 1973; Perusse, LeBlanc, &Bouchard, 1988; McPherson, 1982; Powell,Spain, Christenson, & Mollencamp, 1986;Snyder & Spreitzer, 1973; Spreitzer & Snyder,1973; Stephens & Craig, 1990; Tait & Dobash,1986; Wankel, & Berger, 1991; Wechsler,Levine, Idelson, Rohman & Taylor, 1983.continued^43Table 2.1 continued...The Known Benefits of Exercise HEALTH BENEFIT SCIENTIFIC SOURCEControl of hypertension Barry, Daly, Pruett, et al., 1966; Emes, 1979;Richardson, & Rosenberg, 1989;^Shephard,Corey, & Cox, 1982; Vaccaro, Ostrove,Vandervelden, Goldfarb, & Clarke, 1984;Weber, Barnard & Roy, 1983;Control and management of diabetes Cantu, 1982; Shepherd, 1984.Improved functional status Sulmar & Wilkinson, 1989.Cognitive processing speed Baylor & Spirduso, 1988; Dustman, Ruhling,Russell et al., 1984; Emery, 1991;^Powell,1974; Stacey, Kozma, & Stones, 1985.Balance Burger, 1989; Hopkins, Murrah, Hoeger, &Rhodes, 1990; Lichenstein, Shields, Shiavi, &Burger, 1989; Rikli, & Edwards, 1991.Positive self-concept, improved body image, andcontrol of depressionBolla-Wilson & Bleeker, 1989; Mittleman ,Crawford, Holliday, Gutman, & Bhakthan, 1989;Perri, II, & Templar, 1984-85;^Sidney &Shephard, 1976.Joint mobility Karl, 1982; Morey, Cowper, Feusner, et al.,1898.Muscular strength and endurance Brown, & Holloszy, 1991; Gueldner & Spredley,1988; Meredith, Frontera, Fisher, et al., 1989;Naso, Carner, Blankfort-Doyle, et al., 1990;Petersen, Petersen, Raymond, et al., 1991;Sinaki & Grubbs, 1989.Gait velocity Judge, Underwood, Gennosa, 1991.Posture and increased height Ball, VanderVeen, Johnson, & Lukert, 1991.No benefit or change found In balance (Emes, 1979; Clarke, Wade, Massey,& VanDyke, 1975);In cognitive speed and aerobic fitness (Molloy,Richardson, & Crilly, 1988);In physical and psychological measrues(Blankfort-Doyle, Waxman, Coughey et al.,1989; In bone mineral content (Nelson, Fisher„Dilmarian, et al., 1991); In hematological,anthropometric and metabolic comparisons(Nieman, Pover, Segebartt et al., 1990.44Research studies have begun to develop a profile of those elderly women whoare physically active. Whether she has been active all her life, or is a recentconvert to exercise, the physically active woman is likely to be one or twodecades younger physiologically than her sedentary contemporary (Drinkwater,1988). Master's athletes in their seventies can match performances of sedentary20 year old individuals (Vaccaro, Dummer & Clarke, 1981).In brief, knowledge is available about two types of benefits to be expected:first, within weeks, short term enhancement of physical, social and emotionalwell-being; and second, over years, long term contributions to prolonged goodhealth, resistance to illness, optimization of self-care and functionalindependence, reduced mortality risk and overall increased quality of life.Immediate Benefits Many health and fitness benefits of regular exercise participation are feltimmediately by the older adult. For example, those who are new to physicalactivity often report "feeling better" right away (Fitness and Aging, 1982; FeelBetter, 1980). Such feelings include the perception of doing something good foroneself (Dowall, Bolter, Flett & Kammann, 1988) as well as a sense of achievement(Lutter, Merrick, Steffen, Jones, & Slavin, 1985). Participants enteringsupervised programs generally find themselves in a social group with others oftheir age and the potential then exists to widen their social network. Socialsupport and interaction are thought to be among the most important factors inadherence and enjoyment in activity programs, although research is lacking inthis regard (Lee & Markides, 1990; Wakat & Odom, 1982). A quite strenuousseniors' 100 day cycling tour under the scientific scrutiny of Mittleman,Crawford, Holliday, Gutman and Bhaktan (1989) pruved instead to be a test of the45social relations of older adults with 6 of the 33 cyclists dropping out only oneweek from the conclusion of the tour. Feelings toward others and socialintolerance were cited as reasons. More study is obviously needed to determinethe social benefits and social risks of exercise in a variety of contexts.A number of inter-related psychosocial and physiological parameters havebeen positively linked with short-term exercise participation. Possibly amongthe most important outcome of physical activity is stress reduction (DeVries,1975) since coping with stress is probably linked to other benefits such asbetter sleep (Griffin & Trinder, 1978; Osis, 1986), muscle relaxation (Berger,1989), positive mood states (Bolla-Wilson & Bleeker, 1989; Monahan, 1986),improved self-image (Paige, 1987) and self-concept (Perri & Templar, 1984-85).Overall, exercise appears to act as a buffer in many stress-illness relationships(Eichner, 1987; Eisdorfer & Wilkie, 1977) possibly through biochemicalinteractions linking mind and body (Haug, Ford & Sheafor, 1985). For example,increased levels of beta-endorphins accompanying high-intensity exercise mayexplain some individual's enhanced perceptions of increased coping and relaxation(DeVries, 1981). However, it is doubtful that many older women exercise at thislevel of intensity.Exercising individuals demonstrate higher levels of self-efficacy (Atkins,Kaplan, Reinsch, & Lofback, 1984; Hogan & Santomier, 1984), internal locus ofcontrol (Perri & Templar, 1984-85) or sense of life control (Rodin, 1986). Noless important to psychological health is the opportunity created by exercise tosocialize, to play and have fun with peers, form new friendships and develop acommunity spirit with other elderly (Eckert, 1986; Langlie, 1977; Wakat & Odom,1982).46Possibly the most significant short-term benefit for females of all ages isthe potential to gain same day improvement in joint mobility (Burgess, 1992;Hartley-O'Brien, 1980). Mobilizing and lubricating major joints of the bodythrough a variety of stretching and relaxation regimes seems to have greattherapeutic merit by contributing to better motor control and dynamic balance(Manchester, Woollacott, Zederbauer-Hylton & Marin, 1989). However, jointmobilization, on its own, has not been researched for its potential in easing thestrain of everyday living.Long-Term Benefits The broader health benefits of regular physical activity can be realizedmonths or years later (Suominen, Heikkinen & Parkatti, 1977). Rikli and Edwards(1991) found significant improvements in motor function and cognitive processingspeed continuing throughout a three year period of exercise in older women, whiledeclines were evident in a non-exercising control group. Bortz (1980) claims thatthere is no medicine that can compete with the range of pathology for whichexercise has been prescribed: obesity, depression, diabetes, arthritis,hypertension, coronary heart disease, menstrual cramps, migraine, smokingcessation and many other states.The most tantalizing prospect is the ultimate extension of life and severalnew studies support the prospect of reduced mortality, at least for males,stemming from regular participation in physical activity (Blair, Kohl, III,Paffenbarger, Clark, Cooper & Gibbons, 1989; Grand, Grosclaude, Bocquet, Pous,& Albarede, 1990; Kaplan, Seeman, Cohen, Knudsen, & Guralnick, 1987; Karvonen,Klemola, Virkajarvi & Kellonen, 1974; Linsted, Tonstad, & Kusma, 1991;rger, Hyde, W iry, & Hsled, 1986; vattenbarger & Hale, 1975; Paffenbarger,47Wing, & Hyde, 1978). Reuben, Siu, and Kimpau (1992) have found that measures ofphysical performance can predict mortality over a two-year period. Rakowski andMor (1992) recently reported that less activity/ exercise was associated with ahigher risk of mortality for each of four questions relating to activity comparedto their peers, having a regular exercise routine, getting enough exercise, anddays walking a mile per week. For individuals with one or more impairments in theactivities of daily living, walking was associated with lower mortality.This investigation supports literature on the importance of maintainingphysical activity into older adulthood, and suggests that clinicians shouldattend to reports of activity level by their patients as one of the broaderpsychosocial domains of patient care. (Rakowski & Mor, 1992, p. M122)Added to the rapidly accumulating mortality data is an extensive list ofclaimed long-term benefits of exercise such as postponement of cardiac diagnoses(Marti, Pekkanen, Nissenen, Ketola, Kivela, Punsar, & Karvonen, 1989; Posner,Gorman, Prouty Sands, Gitlin, Kleban, Windsor & Shaw, in press); reducedmortality risk through mediating factors such as effective weight control (Evans& Meredith, 1989; Upton, Hagan, Rosenswieg & Gettman, 1983) and not smoking(Heydon & Fodor, 1988); lower blood pressure (Adams & deVries, 1973; Vaccaro,Ostrove, Vandervelden, Goldfarb & Clarke, 1984; Weber, Barnard & Roy, 1983);lowered cholesterol levels (Evans & Meredith, 1989; Blumenthal, Emery, Madden,George, Coleman, Riddle, McKee, Reasoner & Williams, 1989); reduced risk of coloncancer (Gerhardsson, Norell, Kiviranta, Pederson, & Ahlbom, 1986); and increasedaerobic fitness (DeVries, 1979; Buskirk & Hodgson, 1987; Seals, Hagberg, Hurley,Ehsani & Hollowszy, 1984).Some have argued that the prospects for life extension are effectively verysmall (Heyden & Fodor, 1988; Waterbor, Cole, Delzell, & Andjelkovich, 1988) andothers claim that life span changes are affected more by genetics (Johnson, 1988), or environment (Bourliere, 1973), or cultural factors (Waldron, 1976). At48least one animal study has revealed a possible age-threshold for mortalitybenefits; exercise initiated in older rats was found to actually reduce theirsurvival rates (Edington, Cosmas, & McCafferty. 1972). Palmore (1989) reviewedthe evidence and suggested that healthier people do have reduced mortality, andare naturally bound to be more active; hence reduced mortality may just be anassociation with healthier individuals who self-select for physical activity.A nine- to twelve-month exercise program of walking and/or jogging at 80%of maximal heart rate improved fat distribution patterns in 60 to 70-year-old menand women (Kohrt, Obert, & Holloszy, 1992). Older adults lost 3 to 4% of theirbody weight over the course of the intervention, all of the weight lost was fatweight, and furthermore, the fat lost occurred in the truncal area indicating "apreferential loss of fat from the central regions of the body (Kohrt, et al.,1992, p. M99). This study provides evidence that one mechanism by which exerciseoperates to reduce risk of disease may be the control of abdominal obesity.Evidence is accumulating that physically fit elderly adults experience lessprofound declines in cognitive performance than their less-fit contemporaries(Chodzko-Zajko, 1991). Other significant findings accompanying exerciseparticipation include quicker reaction time (Baylor & Spirduso, 1988; Rikli &Edwards, 1991; Spirduso, 1975, 1980), improved joint flexibility (Frekany &Leslie, 1978; Munns, 1978; Rikli & Edwards, 1991), muscular strength andendurance (Rikli & Edwards, 1991; Shephard, 1978; Work, 1989), increased musclemass (Meredith, Frontera, Fisher, Hughes, Herland, Edwards & Evans, 1989), andthe retardation of osteoporosis (Oyster, Morton & Linnell, 1984; Sidney, Shephard& Harrison, 1977) or even increased bone mineralization (Blumenthal et al., 1989;Rikli & McManis, 1990; Smith, Reddan & Smith, 1981) after only weeks of exercise(Beverly, Rider. Evans & cmitb, 1987).49A balanced program of nutrition, exercise, and stress reduction appear tobenefit all postmenopausal women (Davidson, 1986). A recent study of 3,110retired Florida residents, average age of 73, concluded that walking one mile atleast three times per week offered protection from bone fractures (Sorock, Bush,Golden, Fried, Breuer & Hale, 1986). Peterson and associates recently found that59 healthy women, ages 36 to 67, increased muscular strength over 12 months, butnot bone mass (Peterson, Peterson, Raymond, Gilligan, Chechovich & Smith, 1991).Aerobic exercise intervention, more than a basic calisthenics program,appears to be important in enhancing the cognitive skills of older adults. Whileresearch supports short-term neurophysiological improvements in measures ofmemory, intelligence and cognitive speed (Stacey, Kozma & Stones, 1985), a non-aerobic three month exercise program was ineffective in elevatingneuropsychological attributes in elderly institutionalized women (Molloy,Delaquerriere Richardson, & Crilly, 1988). Thus the level of intensity of anexercise program does appear to matter, but not whether the program is conductedat home or in a supervised setting (Miller, Haskell, Berra, & DeBusk, 1984).Aerobic efforts may not have the expected aerobic effect in very old age.In women averaging over 80 years of age, active women were walking briskly over100 minutes per week, while an inactive group was averaging about 5 minutes ofwalking per week. Exercise histories showed that the active group had followedtheir present exercise program of walking for an average of 28 years. Thesedifferences in activity level did not translate into significant differences inaerobic fitness in old-old age, a finding that is partially explained byinadequate sample sizes (Nieman, Pover, Segebartt, Arabatzis, Johnson & Dietrich,1990). The active women had higher aerobic capacities, less body fat, and loweris ica signs icance was-4^-50not reached. However in other studies on cardiovascular responses with smallsample sizes, the exercise effects have been powerful enough to obtain 30%increases in aerobic capacity (Seals, Hagberg, Hurley, Ehsani, & Holloszy, 1984).Most studies find that physical conditioning has significant positiveeffects on the older adult. Adults suffering from osteoarthritis and rheumatoidarthritis can also obtain important improvement in aerobic capacity, walkingtime, depression, anxiety, and increased habitual activity after a 12 weekwalking or aquatic exercise program (Minor, Hewett, Webel, Anderson, & Kay,1989).Researchers are exploring the possibility that exercise might prevent fallsby improving balance, but so far, the results are not promising (Emes, 1979).Twelve weeks of light physical activity is not apparently long enough, or intenseenough to reverse losses in proprioceptive function. A prospective studyattempted to reduce falls and injury in the elderly using stand-up exercises fromsitting in a chair, and step-ups onto a 6 inch high stool (Reinsch, MacRae,Lachenbruch, & Tobis, 1992). The researchers concluded that the exercise programhad merit, but was too light in intensity to reduce falls significantly.Many of the activities which seem to appeal to the interests of women arealso lacking adequate intensity and vigor. While old-timer hockey, golf and slow-pitch are attracting large numbers of middle-aged and older men, the pursuit ofskilled exercise and team sport activities do not seem to be favoured by manyelderly women; rather individual, expressive, socially cooperative and self-pacedactivities are more popular offerings of community programs for older women (e.g.Tai Chi, Yoga, Line dance, Keep fit, Aquacise). Older women seem to prefersupervised and low skill programs close to home. An important activity that isfitnecc enhancing, age appropriate, suitable tu both meh and women and selt-paced51is walking, and of course, gardening. Not surprisingly, walking is the mostpopular form of exercise with older adults (Fitness and Aging, 1982).Despite the remarkable benefits just outlined, the declining physicalactivity involvement as women get older suggests that there must be significantbarriers operating which undermine their participation. The fact that elderlywomen are rarely, if ever, seen in vigorous activities such as running and teamsports, suggests that older women avoid high exertion settings. In this nextsection, the known risks of exercise involvement are explored as possiblebarriers for older women.Known Risks of Exercise ParticipationIntroduction Although the real risks of engaging in physical activity are becoming known,risk assessment is often strictly based on personal beliefs, and not always isattached to personal experience. While susceptibility to risk of illness anddisease in general is under-rated by most people (Weinstein, 1984), andfurthermore is likely very much under-rated as an outcome of insufficientexercise, perceptions about susceptibility for harm from exercise participationis common (Heitmann, 1982; Monahan, 1986; Waller, B., 1985).Conrad (1976) observed that the elderly tend to exaggerate the risks ofexercise, overestimate the benefits of irregular physical activity, underestimatetheir exercise capabilities and believe that the need for regular exercisedecreases with age. Women, especially, appear to have greater fears aboutexercise risk even though incidents of sudden death are almost universally a malephenomenon (Ragosta, Crabtree, Sturner & Thomason • : , .^111 41 11..52influenced by the memory of past events and the imagination of future events.There is even the possibility that simply reminding people that exercise preventsCV disease may alert them to their personal vulnerability to heart attack andmake them even more cautious (Slovic, 1986)!Further discussion about the perceived risks of exercise is presented inChapter 3. In the following section, the known risks of sudden death, injury andill-health are presented.Known Risk of Sudden Death in the Elderly Serious complications in supervised exercise programs for even heartdisease patients are rare. Van Camp and Peterson (1986) observed one fatality per750,000 patient hours of supervised exercise and nine cardiac arrests per millionpatient hours of exercise - a mortality figure no different than would beexpected in non-exercising patients in this age group. Cardiac risk assessmentin the elderly is considered to be essential protocol in identifying "silentischemia" (Smith, 1988) and regular exercise is recommended in order to provideolder adults with early warning of symptoms related to disease and deficiency inthe cardiovascular system (Gottlieb & Gerstenblith, 1988).There is no medical evidence that physical activity - even strenuousexercise - is harmful to the healthy cardiovascular system. However a personwith structural cardiovascular disease, even if asymptomatic, is at an increasedrisk for sudden death during vigorous forms of physical activity and thereforesupervised and graded exercise for these individuals becomes mandatory (Van Camp,1988). Submaximal and maximal exercise stress assessment permits adifferentiation of changes in heart rhythm, heart rate, systolic blood pressure53and ECG manifestations if myocardial ischemia is present (Bruce & McDonough,1969).Van Camp and Petersen (1986) obtained data from 167 randomly selectedcardiac rehabilitation programs via mailed questionnaires reporting on over50,000 cardiac patients and over 2 million hours of exercise between 1980 and1984. Twenty-one cardiac arrests (18 in which the patient was successfullyresuscitated and three fatal) and eight nonfatal myocardial infarctions werereported. The 1.3 fatalities per 784,0000 patient-hours of exercise wasconsidered to be a normal mortality rate. The findings suggested that supervisedprogramming along with heart-rate monitoring provided low risk health promotingexercise opportunities for cardiac patients.Ewart and Taylor (1985) claim that the biggest barrier to recovery inindividuals experiencing a cardiac event is an unrealistic fear arising frominaccurate self-perceptions about one's physical abilities. Nearly half of themen under 70 years of age who survive three weeks after a myocardial infarctionare physically capable of resuming their normal activities within 12 weeks of theacute event. Many of these individuals become physically over-cautious while afew become overzealous and are apt to exercise too strenuously. These researchersmake a case for the role of self-efficacy assessment in identifying individualswho are deficient in perceived competence as well as those who are over-confidentin their self-perceived ability to resume normal activity levels.McKelvie (1986) claims there is no medical evidence that super-marathon typerunning protects one from coronary heart disease; rather, there is evidence thatextreme endurance events, especially in middle age, place people with unknownproblems at increased risk. People add to their own risk by ignoring symptoms ofvague or definite chest pain during activity - warning signs that should be54immediately addressed in order to reap the benefits of early detection. Aspopulation age increases, progressively larger numbers of aged adults will beaffected by serious pathologies where vigorous exercise is contraindicated. Insuch cases a reconditioning program at a steady heart rate of 100 to 120 beatsper minute provides an effective stimulus for senior citizens, meaning that forolder individuals new to exercise, "walking, recreational swimming, dancing, lawnbowling and even chair exercises have training value" (Shephard, 1986a, p.227).Shephard summarizes the available evidence by stating:Given the strong probability that moderate, progressive activity improvesthe quality of life, such findings are no reason to prohibit physicalactivity in an asymptomatic senior citizen. (Shephard, 1986a, p.227)Known Risk of Injury in the ElderlyTo consider "exercise" a health-promoting practice already implies that wehave prejudged its benefits as outweighing its risks. Indeed, tens ofmillions of people have already made this judgement, as they regularlyengage in a variety of aerobic exercise activities. However, if healthprofessionals are to promote exercise objectively, they need to provideconsumers with a balanced view". (Koplan, Siscovick & Goldbaum, 1985,p.190)While risk of musculoskeletal injury may be high, especially in sportactivities requiring training for competition, such risk may not exist at otheractivity levels. Kavanagh and Shephard (1978) found that in the early months ofgeriatric exercise programs, about 50% of the participants had encounteredmuscular injury. Yet, a ten week, five day-a-week aerobic program of briskwalking and jogging elicited not a single injury in sedentary middle-aged womenaccording to Johannessen, Holly, Lui, and Amsterdam (1986).Koplan, Siscovick & Goldbaum (1985) suggest that the risks of exerciseinjury are linked to the specific characteristics of the type of activityintensity, duration acid 8eyuenLy) dS well as the attributes of the participant55and the exercise environment. In this respect, incidence information isunavailable on the actual specific risks of exercise to specific individuals inspecific situations.In summary, there is little data on adults of any age group with which toobjectify and quantify specific exercise risk. Moreover the long-term effects ofexercise, such as relationships to osteoarthritis, do not exist. Adding to theproblem of insufficient short and long-term data are inadequate definitions.Comparisons across the exercise research on risk require standard definitions ofinjury, of the characteristics of various groups of participants, of the non-participants (or drop-outs), of the time interval or the main purpose of theparticipation etc. (Koplan et al., 1985). Without longitudinal and randomizedcohort studies, such challenges may be difficult to overcome. In summary, theliterature advises the pursuit of moderate exercise in a variety of physicalactivities allowing for adequate recovery, and this makes good sense until moreis known about incidence relationships (Bruce, 1984; Munnings, 1988).Risk of Over-Exertion or Exhaustion "In those callings that require great physical qualifications, old age isdecisive." (de Beauvoir, The Coming of Age, 1972:385)Clearly one has to be realistic about the aging process and admit thatphysical declines are part of the natural aging process no matter how heroic oneis in terms of disciplined participation in fitness activity. With even the mostambitious older adult, declining activity levels are likely to accompany old ageas one "often sinks into physical weariness, general fatigue and indifference"(de Beauvoir, 1972, p.404). Moreover, fitness for the future is no longerimportant as "our eager spring towards the future is broken" (de Beauvoir, 1972, p.404). Cooperating with one's finitude may in the long run be the more healthy56route, and acceptance to adapt where necessary is better than acceptance ofhelplessness. The only general statement that can be made about older adults isthat one cannot generalize!Risk of Provoking Ill Health Each year, one in five aged women suffer an injury requiring medicalattention and their injury rate surpasses that of elderly men. Moreover, olderwomen are more often ill and experience more days of bed-disability than men.The bones of elderly women are more vulnerable to fracture because they aresmaller and more porous, and while exercise is certain to help maintain bonestrength, activity itself is an inherent risk. Older women are twice as likelyas men to have arthritis and 13 percent of elderly women are limited by arthritisalone in their daily activities (Haug, Ford & Sheafor, 1985). But exercise isnot considered to be the threat to this disease as much as is the lack of it.In fact, Burckhardt (1988) reports that passive recreation pursuits aresignificantly more important to women with arthritis; she notes that particularlyfor the over 70 year old women, quality of life and dissatisfaction with activerecreation and personal fulfilment in general were significantly affected.Musculoskeletal fatigue, soreness, joint stiffness and delayed recovery isparticularly a risk for those who are unaccustomed to exercise and who do notinitiate exercise in very gradual and low intensity stages (Kasper, 1990). Thefirst experience with an exercise program for an elderly women may turn out tobe a painful experience, and one that is soon learned to be avoided.57Summary To this point in the chapter, the health difficulties and poor aging ofwomen have been addressed as likely outcomes of the past socialization andpresent lifestyle of women born before 1921. The benefits of exercise have beenwell-documented, while the known risks of participation appear to be almostinsignificant. The reluctance of so many older women to reap the many benefitsfrom physical activity demands explanation, and this explanation is explored inthe coming section presenting prominent theoretical approaches.The Determinants of Exercise Behavior:Useful Theoretical ApproachesIntroduction to Determinants The known determinants of physical activity can be categorized as past andpresent personal attributes, past and present environments, and physical activityitself (Dishman, 1990). Dishman (1990) uses the term determinant to "denote areproducible association or predictive relationship other than cause and effect"(p. 78).^Personal attributes are defined as demographic variables,biomedical^status, past and present behaviors, activity history, andpsychological states and traits associated with physical activity. Dishman claimsthat determinants residing or originating in the individual are important becausethey can identify personal variables or population segments that may be targetsfor interventions to increase physical activity, or conversely, can describeimpediments or people resistive to physical activity interventions. However,summarizing the associations of personal variables and exercise behavior posesa challenge.58The absence of uniform standards for defining and assessing physicalactivity and its determinants and the diversity of the variables,population segments, time periods, and settings sampled in publishedstudies make it difficult to interpret and compare results. (Dishman, 1990,p.78)The complexity of predicting a health behavior such as physical activity hasbeen aptly described as "a web of causation" (Sallis, & Hovell, 1990; Thomas,1984). Addressing this complexity are two major theoretical perspectives,representing two different research approaches: 1) social epidemiology, and 2)behavioral health psychology. An understanding of these two approaches isessential to the study of exercise behavior and theory development because:...the degree to which the true origin of the determinants resides in theperson or the environment remains to be determined. (Dishman, 1990, p.84)In the present study, personal attributes have been divided into twocategories:1) "situational" determinants, or the personal and socio-environmentalcircumstances of each older woman representing a social epidemiologicalperspective, and ...2) "cognitive" determinants, or the self-referent beliefs of the older woman,representing a psychobehavioral perspective.The material immediately following introduces social epidemiology andsocialization theory as perspectives which attend to the personal characteristicsand environmental situation of the individual. The situational characteristicsreviewed are age, education, health status, marital status, family size, workrole in mid-life, socioeconomic status, ethnicity, childhood socialization andchildhood movement confidence.59SOCIAL EPIDEMIOLOGICAL PERSPECTIVESSocial EpidemiologyThe social epidemiological perspective focuses upon personal characteristicsand the environmental situation of the individual (Berkman, 1980). The personalqualities and social circumstances of individuals have important associationswith health and activity behavior and thus are considered to useful predictors(Belloc & Breslow, 1972; Berkman & Breslow, 1983; Dishman, 1989).Such predictors infer that people are not the creators of their behaviors,but rather are victims of circumstance. Bandura (1989) calls this "environmentaldeterminism" or the study of human behavior in terms of "mechanical agency"(Bandura, 1989, p. 1175). In this view, internal events are mainly products ofexternal ones devoid of any causal efficacy on the part of individuals. Forexample, Sidney, Niinimaa and Shephard (1983) found that both active and inactivesenior citizens had equally positive attitudes toward physical activity. Theywondered why there were discrepancies between attitudes and behavior, andconcluded that "there must be other factors, perhaps more important thanattitudes, which influence behaviour" (p. 207). As another example, one's lifeoccupation can alter possibilities for active behavior later on. Svanborg (1988)reports on a longitudinal study that found previously sedentary workers were moredisabled in activities of daily living than those whose work had been strenuous.At the level of the individual, personal attributes and life situations arenot easily altered, and therefore are not entirely suitable to socialintervention and health promotion. Even so, epidemiological approaches are usefulbecause they identify specific social groups that can be targeted for particularassistance. Theoretically, however, demographic variahlps nn their own, are 60deficient because they only provide association, not explanation. Oncedescriptive associations are found, however, hypotheses can be developed toexplain the findings which then can be tested in further research. For example,if never-married women are found to be significantly more active in late life,hypotheses would then be generated and tested as explanations for this finding.McPherson (1986a) emphasized that demographic characteristics can interactor confound one another. For example, intracohort (age) differences, which couldexplain activity involvement, can vary dramatically by education, marital status,health status, economic status, degree of mobility, employment status, and socialnetwork. Nixon II, (1990) recently claimed that sport socialization research"needs to address these issues of 'contextualization'" (p. 35). In Sweden,understanding contextualization was essential to the development of acomprehensive health promotion intervention of 1200 adults over age 70 (Eriksson,Mellstrom, & Svanborg, 1987). For the Swedish study, a "life-style" hypothesiswas proposed: that the kind of everyday life led by the individual hadconsequences not only for social performance but also for functional well-being.We are only beginning to understand why some people are physically activeand others are not. The behavior is determined, at least in part, bycharacteristics of the person, the environment, and the activity itself.(Powell & Paffenbarger, 1985, p. 120)Ten life situational variables appear to have significance as potentialdeterminants for late life exercise. These ten variables are reviewed in thecoming section for their relevance in explaining late life exercise.Age and ExerciseAge is not just a chronological variable but also a social construct thatdefines social behaviour at specific points in the life cycle. Age is animportant form of social differentiation that can result in socialinequality because of ageism. (McPherson, 1984, p.223)61There is a well-documented and universal pattern of declining physicalactivity and sport participation by age, especially in the early twenties andagain after age 65. These sharp decreases in participation have been tied to twomajor life events - leaving highschool or entering the work force, and leavingthe work force (McPherson, 1984).The pattern of declining involvement with age appears to be more pronouncedamong the less educated, those with lower incomes, those in rural and smallercommunities, among females and blue collar workers and among those who live incountries where sport participation is not highly valued or promoted (Stephens& Craig, 1990). McPherson (1978) makes the point that, after peak performance agein many sports, incentives are lacking for adult participation. Facilities andcoaching time tend to be allocated to high performance children. With only youngrole models present in a sport, adults readily assume that these sports eventsare for the young.The most recent Canadian data states that 42% of men over 65+ and 23% ofwomen over age 65 are active (spending 3+ kilocalories per kg. per day onexercise) which exceeds that of middle-aged groups (Stephens & Craig, 1990). Inthe age group of 45-64, only 30% of men and 20% of women are classified asactive. Adults are at their most sedentary in the years just approachingretirement (Stephens & Craig, 1990).Little is known how physical abilities and skilled motor patterns actuallydeteriorate over the years, although disuse, muscle wasting, muscle deactivationand neural decline are thought to be inter-related (Shephard, 1989a; Smith &Serfass, 1981). There is evidence that simple daily motor patterns of adults overthe life course are developmentally altered in adaptation to age-related change62(Van Sant, 1989). More likely, however, individual behavior changes, such asreducing the more vigorous activities with age, are just as responsible fordevelopmental changes as are actual maturational processes.Education and ExerciseThe phenomenon that Canadians are less physically active as they age may bedetermined, in part, by lower levels of education (Rudman, 1986b). Education hasstrong associations with physical activity level in both free-living andsupervised exercise settings (Dishman, 1990). Many older individuals had only afew years of schooling and thus may lack knowledge or habits related to physicalactivity in public settings. For example, in 1911, only 80% of those aged ten tofourteen were attending Canadian schools (Harrigan, 1990). Boys and girlsattended about equally, although young people often withdrew in the their teensto work (Harrigan, 1990).Today, about 60% of Canadians over the age of 65 claim to have Grade 9 orbetter education. The Canada Fitness Survey (Stephens & Craig, 1990) reports that52% of adults with incomplete highschool education are inactive compared to 33%of those with a university degree. Furthermore, 89% of university educatedadults, 65 years and older, spend over 3 hours per week on physical activity intheir leisure-time compared to 71% of those who did not complete highschool.The interest in advanced education and participation in sports activitiesalso increase with economic status and level of education. This makes thefollowing very clear: The course for successful ageing is set predominantlyin childhood and youth. (Meusel, 1991, p.16)If this is true, then the challenges of activating individuals in adulthood willcontinue for some time. Recent studies reveal that contemporary lifestyles ofchildren are predominantly sedentary (Simons-Morton, O'Hara, Parcel, Huang,63Baranowski, & Wilson, 1990) and yet hyperactive behavior in school settings isbelieved to be the most common problem referred to child-guidance clinics in theUnited States (Alexander, 1990).Baecke, Burema and Frijters (1982) reported highly significant relationshipsbetween level of education and leisure-time physical activity in younger males(r = .38; p < .001). Godin & Shephard (1986) examined psychosocial factorsinfluencing intentions to exercise in a group of individuals ranging from 45 to74 years of age. Education influenced intention to exercise by interacting with"subjective norm," a construct representing a subject's perceptions about socialexpectations. Less educated subjects were influenced by social norms, and moreeducated people tended to exercise independently of external influences.Subjective Health and ExerciseSelf-assessed health is considered perhaps the most important variablelikely to explain late life exercise behavior. Individuals may simply not feelwell enough to exercise. Yet the process by which a person comes to understandand evaluate personal health is, in itself, poorly understood.Self-rating of health is thought to be a multidimensional construct whichencompasses a global sense of well-being (Zautra & Hempel, 1984). There issurprising statistical support for such a simple and subjective scale. Maddox andDouglas (1973) found "self- and physician-ratings of health are predominantlycongruous" (p.59). In fact several studies have found subjective ratings ofhealth to be superior to objective measures of health in terms of predictingwell-being, happiness, morale, and life satisfaction (Cockerham, Sharp, & Wilcox,1983; Zautra & Hempel, 1984). 64Mossey and Shapiro (1982) followed over 3500 randomly selected Manitobanresidents aged 65 and over and found a risk of early mortality almost three timesgreater for individuals who had rated their health as "poor" only two yearsearlier.Idler and Kasl (1991) studied mortality in over 2800 older adults with themean age for females being 74.9 years. About 12% of the women rated their healthas "excellent", 46.5% as "good", 33.7% fair, and 8.4% as "bad" or "poor". At thefour year follow-up, Idler and Kasl found that "the odds of death increased atevery lower level of self-evaluation of health" (Idler & Kasl, 1991, p. S60).Women who ranked their health as "bad" or "poor" were over three times morelikely to die within the four year period as were women who had rated theirhealth as "excellent". Idler and Kasl (1991, p. S64) concluded,The knowledge that expressions of subjective health status are sensitiveindicators of survival length should engender new respect among healthprofessionals for what people, especially the elderly people they treat,are saying about their health.Larson (1978) suggested that while physician ratings should provide the mostobjective evidence of the severity of illness in absolute terms, they may notaccurately reflect the extent to which an individual's physical condition isactually debilitating. Furthermore, there is evidence to suggest that whilephysician's ratings may be age-biased in favour of younger adults, the "old-old"category (75+) of adults have been found to rate their health more positivelythan "young-old" groups (Ferraro, 1980). Gender bias and age bias may beoperating since older groups are predominantly women, and older adults may havereduced expectations for optimal health. Thus deteriorating health may notnecessarily be reflected in the subjective self-rating.A majority of inactive elderly adults perceive themselves to have good toexcellent health and do not believe that they need more exercise (Gunter &65Kolanowski, 1986). These beliefs persist in spite of the fact that the prevalenceof illness and disability increases with age and is significantly greater forwomen than for men (Vallbona & Baker, 1984).Charette (1988) states that only 25% of inactive Canadians actually have anactivity limitation, and of these, more than half think that exercise willimprove their health either moderately or a great deal, regardless of theiractivity limitation status. What can explain why older adults, who arephysically inactive, and who state that exercise could improve their health, arestill inactive anyway?In most of the literature relating late life exercise behaviors to healthoutcomes, positive relationships are found. Exercise participation is relatedto better health, and better health is associated with increased levels ofphysical activity. The difficulty in the interpretation is which comes first?Do people exercise more because they have better health to start with, or dopeople who exercise actually create and/or perceive, better health? The problemof causality is partially answered in large population demographic studies suchas that of Belloc and Breslow (1972) and the longitudinal study on college malesby Paffenbarger, Hyde, Wing and Hsied (1986) which have linked habitual exercisein the lifestyles of large populations to favourable mortality outcomes. Moreanswers and confirming evidence need to be sought, especially for women who, witha life-span advantage over males of 7 to 8 years, are possibly more concernedabout health outcomes and quality of life than extending their life span.Perceptions about one's health may be the germinating force leading tospecific kinds of self-protecting behaviors. Possibly the prospects of chronicillness provoke certain women to action, while convincing others that it is timeto slow down. Both strategies can be considered health protective even though 66the behaviors are oppositional lifestyle choices. Such a dichotomy needs furtherexploration since women, in general, exceed males in all other personal healthcare behaviors except exercise (Verbrugge & Wingard, 1987) .A plausible explanation for the reluctance of females to be diligent aboutpromoting their health through exercise is that the way girls and women have beensocialized over the life course has lessened their advocacy and belief inexercise and sport as valued behaviors (Csizma, Wittig, & Schurr, 1988). By latelife, vigorous physical pursuits are not only seen as socially inappropriate, butalso viewed as high-exertion (Winborn, Meyers & Mulling, 1988), and thereforepotentially life and health-threatening.Evidence is accumulating that adults who perceive their health as poor aremore reluctant to adopt exercise than those who perceive good personal health.Morgan and colleagues (1984) studied an unspecified age group of General Foodsemployees and found that while male participants who enrolled in the fitnessprogram perceived good health and positive beliefs about exercise, womenassociated exercise with poorer health. Furthermore, female exercise adopters didnot improve their perceptions of health at retest, while male adopters did. Inshort, Morgan's team found that the exercise and health relationship differ formen and women.In a randomized walking exercise intervention on older women, those whoadhered to the two year exercise program were, at base-line, of lighter weight,already more active, and non-smokers (Kriska, Bayles, Cauley, LaPorte, BlackSandler, & Pambianco, 1986). However, the variable that best differentiatedbetween compliers and noncompliers was the frequency of reported illness over thetwo year period. Women who adhered to the exercise program reported significantly1 '^' II II I - a II^ i67in this population may be quite different from factors limiting physical activityin the young" (Kriska et al., 1986, p.562).Health Symptoms and Exercise BehaviorAlthough women are outliving their male counterparts by seven or eightyears, aged women are vulnerable to one or multiple chronic conditions throughmuch of the period of this extended life. A survey of Canadians in the mid-1980'sfound 55% of adults over 65 reporting arthritis/rheumatism, 39% reportinghypertension, 26% reporting heart trouble and 24% with respiratory problems(General Social Survey, 1985). "Normal aging" for elderly women typicallyfollows this profile: almost half are physically limited in daily activity; 60%of women over 65 were screened out of random public physical fitness testing forreasons of health risk (Canada Fitness Survey, 1983); and 46% areinstitutionalized by age 85. Many are truly unfit and cannot complete evenmodified fitness tests of basic strength (O'Brien & Conger, 1988). This lack ofbasic strength is blamed for the majority of the falls experienced by one thirdof all adults over age 65 (Blake, Morgan, Bendell, Dallasso, Ebrahim, Arie,Fentem & Bassey, 1988; Frontera & Meredith, 1989). One-third of women aged 65years and up will have one or more vertebral fractures. As women survive intotheir eighties, one third are expected to experience a hip fracture (Nelson,Fisher, Dilmanian, Dallal, & Evans, 1991).With widowhood, poverty and declining health as the norm for about half ofall older women (Arendell & Estes, 1987), women over the age of 65 are morelikely to report stress than men. Contributing to this stress are psychosocial68and physiological effects of motor-sensory deprivation due to physical inactivity(Winget & Derosha, 1986).Marital Status and ExerciseAn active life partner has been hypothesized to have a strong influence onthe activity patterns of their mate. In 1976, Spreitzer and Snyder advocated asocial learning perspective and suggested that the acquisition of the sport roleresulted from exposure to role models and reinforcement from significant others.Using self-administered questionnaires with a systematic probability sample on264 adults under the age of 61, these researchers found that female involvementappeared to be determined more by their spouses's degree of involvement than theextent to which women participated in their youth.Having a spouse who is indirectly involved in sports tends to reinforceearlier encouragement from one's parents and to interact with perceivedability partly to explain the degree to which one is involved in sport asan adult. (Spreitzer & Snyder, 1976, p. 244)Tait and Dobash (1986) claim that women consciously or unconsciously marrya male whose orientations in lifestyle are similar to their own. They suggestthat "women who take part in sport perceive a very high degree of support fromtheir nominated or significant male" (Tait & Dobash, 1986, p.268).The relationship between marital status and cardiovascular risk behaviorswas the focus of a study on 7,849 midwestern men and women (Venters, Jacobs, Jr.,Pirie, Luepker, Folsom & Gillam, 1986). Separated or divorced persons reportedhigher levels of relaxation-enhancing behaviors such as smoking, drinking andhigher levels of physical activity. Married men showed lower mortality rates oversingle men, but married women were not advantaged in this way over single women.69For women, "never having been married" was the most favourable status withrespect to educational attainment and reported history of heart attack andstroke. Being married, or over the age of 40, were situations that wereaccompanied by less physical activity (Rudman, 1986).Ishii-Kuntz (1990) studied the formal activities of elderly women and thedeterminants of their participation in senior's centers. Using a nation-wideprobability sample of 1,051 women over the age of 65 (data collected in 1981),this research categorized variables as: "predisposing" (age, race, education, andmarital status), "enabling" (income, employment status, health status, andtransportation) and "need" (loneliness and living arrangement). The average ageof the women were 73.2 and 62% were widowed. The major findings were that age,race and health status were influencing participation in voluntary organizationsand senior centers. Elderly widows were more likely to participate in voluntaryorganizations than married women and loneliness had a positive impact on seniorcentre participation.Motherhood, Children and Leisure-time ExerciseMotherhood and grandmotherhood are the most enduring social roles with whichwomen identify (Moen & Huntington, 1991). Yet little research has examined therole of motherhood on women's exercise patterns in middle age and beyond. Thenumber of children born, number of children raised in the household, the spacingof children, and the health of children cared for are plausible factors affectingwomen's leisure and physical activity patterns over much of the adult life course(Henderson, Bialeschki, Shaw, & Freysinger, 1990). The impact of family size onwomen's exercise patterns is likely to be a reflection of available leisure-time, 70availability of financial resources and a mother's interest in being physicallyactive in the play patterns of her family.Leisure for women has been, and largely still is, home-based.Since home is also a place, if not the place, of work for women, it is notsurprising that work and leisure activities are often intertwined andindistinguishable (Henderson, et al., 1990, p. 10).A Canadian time budget study by Shaw (1985) examined the distribution of leisureof 60 married women for a 48 hour period. While over 70% of gardening and animal-care chores were considered by the women to be leisure, only 4% or less of homechores and laundry were defined as leisure. Henderson and colleagues (1990) arguethat women have typically been oppressed in most aspects of their lives,including leisure. Allen and Chin-Sang (1990) studied the meaning of leisure andwork for 30 aging black women. When asked how their definition and experience ofleisure had changed over the years, most women said they "had no leisure in thepast" (p.737). Housework was clearly the predominant feature of their lives, butgardening was classified by many women to be a leisure activity. Even thoughhousework may be the predominant physical activity for many women, Verbrugge(1986) has reported that homemakers are not particularly enthusiastic about theirwork compared to employed men and women. Furthermore, employed women usuallyliked housework less than their jobs.An important example of family leisure is the holiday, at least for thosewho can afford it. Yet the family holiday is "often a breeding ground forarguments and family conflicts and where the domestic labour for women mayactually increase..." (Deem, 1982, p.112). Leisure outside the home has oftenbeen viewed as something that mothers should willingly sacrifice.As with today's contemporary women, even if pioneer women had beenrul es of Lhild rearing, housekeeping andysicatty71domestic skills such as cooking and sewing, would have consumed much of theirtime and energy during their maternal years. Housewives with young children arelikely to perceive little freedom in their lives because of constantly being "oncall" (Meissner, 1977).Children constrain women's leisure not just because of the considerablephysical care required by babies and young children, but also because oftheir social and emotional needs. The responsibility of child care, whichfalls disproportionately to women in society, reduces women's leisureoptions and inhibits a considerable number of leisure activities...(Henderson et al., 1990, p.123)Many pioneer women worked farmland or ranches or provided support systemsfor their husband's occupational pursuits. Home industry and responsibilitieswere often were initiated in the adolescent years, no doubt heightened during thedepression and war years, so that leisure-time physical activity may have beenlimited. Certainly the time required for skilled athletic development would nothave been highly valued by society as the preferred way for average women tospend their time.Women's time (each day and across their life span) was (and still is)perceived as time that could be interrupted for whatever needs or crisesarose, particularly those needs related to the family, while the time ofmen was respected as private. (Henderson et al., 1990, p.25).Deem (1982) has contended that leisure spaces are particularly difficult forwomen to find in their own home. When older, most females have establishedlifestyles without sport skills or habitual fitness activities, and the normalcourse of action is to taper activity in the later years, not increase it.An interaction effect between income and number of children demonstrates thecomplexity of developing a simple understanding of exercise behavior and one'sfamily situation (Fishwick & Hayes, 1989). This interaction effect indicates thatas number of children increases for lower income persons, participation inphysical^ edbeb. Fur hiyh income persons, participation72increases with more children. Women who have adequate financial resources maybe better able to afford the time and cost of engaging in activities alongsidetheir children. Children of middle class families may experience more instructionin lifelong activities such as tennis, swimming, skiing, skating, and golf.They, therefore, are in a better situation to participate in sports in whichwhole families can enjoy. Recent studies show, however, that parents typicallypay less for their daughters' sports equipment, instruction, and training thanfor their sons'.Work Role, Employment and ExerciseChanging patterns of activity involvement are thought to be the result ofaltered role transitions and altered opportunities across the life cycle(McPherson, 1984). Particularly relevant to leisure-time activity are the demandsof an individual's employment and non-paid work. McPherson suggests that "thedecisions concerning how to minimize costs and maximize rewards with respect tophysical activity involvement are related to commitment, adherence, and therelationship between work and leisure and between work and familyresponsibilities" (1984, p.223).Neither women's employment, nor domestic work role, have been studiedextensively for their role in determining physical activity patterns. Life workis thought to be closely tied to level of education, marital status, number ofchildren raised, health status, social class and so either types of work, asactivity-promoting forces for women, are difficult to study in isolation. Morgan(1986) points out that it is physical activity of any kind, not athleticism, thatis associated with quality and quantity of life. To date, no rpcearch- on the73fitness and health outcomes of women's domestic and/or employment activities havebeen reported. However, employed women are apparently more physically active.Almost 60% of Canadian women in manager/professional occupations report they areactive compared to only 44% of women in blue collar work (Government of Canada,1984).Recently, there has been information to suggest that employed women carrymost of the domestic work load at home in addition to full-time engagement inemployed labour. This means that leisure-time opportunities for employed womenmay be even more severely limited, and that opportunities for exercise may belacking unless women undertake activity during their normal work day.Fishwick and Hayes (1989) surveyed 401 adults aged 18 to 83 years of age todetermine their involvement in recreational activities by age, race, gender andsocial class. In contrast to much of the literature, they found that women werenot under-represented as leisure-time sports participants, but were vastlyunderrepresented as team sport participants possibly because time constraintsmade it difficult to schedule practices and games with other adults. In summary,Fishwick and Hayes emphasize that normative expectations channel women into"gender-appropriate" activities such as aerobics.Steinhardt and Carrier (1989) have examined early and continuedparticipation in a corporate work-site health and fitness program (Conoco Inc.).Using a broad array of variables representing socio-environmental factors,physical-behavioral factors and psychological factors, they obtainedphysiological and questionnaire data on 143 women aged 19 to 60 years old. Theyfound younger employees were more likely to be "starters" in the program whilethose who adhered claimed more "attitudinal commitment" and perceived the healthand fitness program was to be more convenient.74McPherson and Kozlik (1987) reviewed studies on Canadian leisure activitiesby age, and noted that participation rates drop severely after age 19 and againat age 64 - two points regarded as endpoints of labour force activity. At thesetransition points, men participated in sport activity to a greater degree thanwomen, and rates of participation increased in a linear pattern with income andlevel of education. More study is needed to understand how paid work facilitatesor undermines women's active leisure patterns, and how retirement from employmentencourages or discourages future participation.Socioeconomic Status and ExerciseFindings from Canada's Health Promotion Survey (1987) suggest that:Canadians who rate their health as excellent are three times more likely tobe in the highest income bracket than those who consider their health to bepoor.Canadians in the lowest income bracket are four times as likely to ratetheir health as only fair or poor as those in the highest income bracket.However, direct information on the role of financial situation and older adultexercise is lacking. McDaniel (1989) points out that economic inequities tend toaccumulate in old age and are exacerbated by a pension system that is notworkable for many women. More research will be needed to tease out the interwovenelements of socioeconomic status, gender, educational level, occupational leveland race which, in various ways, are likely to limit lifestyle choices, activitypatterns and outcomes of good health.75SOCIALIZATION THEORYIn this section, discussion continues on the situational determinants ofexercise. Socialization Theory is presented with particular attention paid to thesituation of childhood and how experiences and opportunity may lead to earlymastery and movement confidence. Because child socialization and child efficacyfor physical skill are historical variables, for the purpose of this study, theyare considered to be unalterable characteristics or "situational variables"."Social system theories" reflect the dynamic interaction between societyand individuals (McPherson, 1990). General sociological theory advocates theimportance of social structure, social processes, social roles and the effect ofthe environment on human behavior (George, 1985).Socialization is a lifelong process that enables an individual toparticipate in a society...Socialization is both a process and a product.As a process, socialization involves learning skills, traits, knowledges,attitudes, language, beliefs, norms, values and shared behavioralexpectations associated with present or future roles. The process may varybecause of such factors such as gender, socioeconomic status, community orethnic differences, cultural differences, and individual differences in thelifestyle and values of socializing agents. (McPherson, 1990, p. 130)One of the most significant social roles affecting human behavior is thatcreated by gender. A wealth of evidence exists to suggest that males and femalesare socialized very differently from an early age, particularly with respect toaggressive play and choice of toys. Traditionally, females have had littleencouragement to engage in vigorous and challenging forms of physical activityand sport (Lirgg & Feltz, 1989; Mangan & Park, 1987; Vertinsky, 1991). Females,from birth to death, have been socialized to be more passive physically, and inparticular, are lured away from aggressive forms of sport (Zoble, 1973). Wakatand Odom (1982) note that "although infant males and females start out withruuyi y file same physical capabilities, they soon begin to experience different76courses of development, as set down by society according to what is appropriatefor little boys and what is appropriate for little girls" (p.34).Media interest and the public popularity of contemporary male professionalsport heron attest to important differences in gender support for physicalactivity which still persist today (Cole, 1991; Kane, 1989). Hall (1976) reportsthat women's attitudes toward activity are generally favourable, and concludesthat socialization and opportunity are therefore most responsible for theinadequate participation of females.Apparently, contemporary females still experience considerable role conflictin certain athletic settings and that the female in sport is still considered tobe in man's territory (Csizma, Wittig, & Schurr, 1988). Since the 1970's, sportsociologists recognize that physical activity and sport are Used as an importantmedium in which males are "masculinized" (DiIorio, 1989; Hall, 1985; Theberge &Donnelly, 1984).Hauge (1973) wrote an early review paper of the influence of the nuclearfamily on female sport participation. She raised the possibility that apropensity toward tomboyish behavior might be affected by sibling order, familysize, parental modelling, and childhood opportunity. As important as the familyin socializing young people, is probably their school experience. Vertinsky(1992) presents a thorough summary and discussion of the challenges andopportunities physical educators face in providing gender equity in contemporaryschool settings. Thus with strong social forces operating at school and in thehome, the socializing determinants for physical activity participation are highlylikely to be different for men and women.In addition to gender, age is another socializing force affecting humanbehavior, ^ y N^aLLivi ty behavior. For example, being old in the771990's is the present identity of a particular social group who have experienceda certain social orientation to life and look upon retirement as "a well-earnedrest". Furthermore, social stereotyping or "ageism" dictates late lifeexpectations and behavior (Achenbaum, 1986; Palmore, 1990). Fraser (1989) hasfound that many disease processes such as hearing loss, vision loss, shortnessof breath and joint immobility are simply accepted by many elderly as "normalaging".Socialization theory, therefore, recognizes ageist practice as a socialconstruction whereby adults are reinforced for more passive roles and age-expected behaviors (McPherson, 1990; Ostrow, 1982; Ostrow & Dzewaltowski, 1986;Teague, 1987), for learning helplessness (Brown & Inouye, 1978) and carrying outa self-fulfilling prophecy of age decline, frAilty and illness (Edgerton, 1986;Waxier, 1980). Chronological age can therefore be hypothesized to play a role inexplaining physical activity, exercise and sport behavior.One's personal circumstances and socializing experiences are likely to playan important role in determining how active one would want to be over the lifecourse (Labonte, 1983; Rudman, 1986). Sport socialization theory morespecifically recognizes that individuals are socialized differently in physicalactivity settings often starting at a very early age. A number of studies supportthe hypothesis that early experiences in childhood physical activity createadvantages for adult participation later on (Butcher, 1983; Dishman & Dunn, 1988;Howell & McKenzie, 1987; Spreitzer & Snyder, 1976; Powell & Dysinger, 1987;Sofranko & Nolan, 1972). Adams II and Brynteson (1992) reported that middle-agedadults exercised more frequently, and held higher health value for exercise, ifthey had simply more hourly exposure to physical activity training as collegeor78participation in highschool increased adult sports involvement for both men andwomen.At least two studies do not support the early socialization hypothesis(Adams & Brynteson, 1992; Steinhardt & Carrier, 1989). Dishman and Dunn (1988)warn that the "available evidence on the relationship between childhood andadulthood exercise patterns is not compelling" (p. 186) because the associationscome exclusively from cross-sectional and retrospective surveys with adults andis limited to sport and physical education experiences.The Significance of Socialization for Childhood Physical ActivityA collection of studies have identified relationships among childhoodactivity opportunities, perceived physical ability and social support by one'sparents, peers, male siblings, teachers (Greendorfer, 1983; Griffin, 1982; Weiss& Knoppers, 1982; Wood & Abernathy, 1989). Research indicates that physical playand recreation during childhood contributes to an awareness of one's physicalworld and enhances the ability to manipulate and control one's surroundings(Lewin & Olsen, 1985, p. 216).Moore and colleagues (1991) researched the relationship between activitylevels of parents and those of their young children aged four to seven. Caltracaccelerometers monitored children, mothers and fathers for more than ten hoursper day for about eight days. Children of active mothers were 2.0 times as likelyto be active as children of inactive mothers. The relative odds of being activefor the children of active fathers was 3.5. When both parents were active, thechildren were 5.8 times as likely to be active.Possible mechanisms for the relationship between parents' and child'sactivity levels include the parents' serving as role models, sharing ofactivitieb by family members, enhancement and support by active parents oftheir child's participation in physical activity, and genetically79transmitted factors that predispose the child to increased levels ofphysical activity. (Moore, Lombardi, White, Campbell, Oliveria, & Ellison,1991, p.215)Boutilier and San Giovanni (1985) summarize a number of studies whichsupport the important role of early childhood physical activity in thedevelopment of role play, sense of group membership, fitness and motor skill,bodily awareness and improved self-concept. Although sex differences in motivesfor participation have been identified, with boys placing more emphasis onachievement, rewards and status, generally the motivational differences for boysand girls may no longer be so great (Gill, Gross, & Huddleston, 1983).Powell and Dysinger (1987) reviewed the available literature on theassociation between childhood and adult physical activity patterns. Insummarizing the available studies, they felt that the Harvard alumni study, whichconnected college sport to current activity patterns and absence of coronarydisease (Paffenbarger, Hyde, Wing & Hsied, 1986), provided the strongest evidencesupporting an association between youth and adult activity in males.Butcher (1983) examined three categories of variables which influenced 661adolescent girls: personal attributes, socializing agents, and socializationsituations. For competitive interschool teams and intramural activities, certainpersonal attributes (movement satisfaction and self-confidence, independence, andassertive self-description) were most important. For community-organizedactivities, socializing agents (parental influence) and socialization situations(socioeconomic status) were most influential, while for the total activitiesparticipated in, the amount of sports equipment was crucial. Butcher noted thatby Grade 10 there was a noticeable drop in girls' school physical activityparticipation, but not so in physical activity in the community setting. Three80types of social influence were family (parents and siblings), peers, and teachersor coaches.The physical education teacher is better qualified than most to open thepath towards successful ageing to individuals and society with their work.Should not the physical education teacher also learn and teach how sportactivity is to be adapted not only to the immediate but also to the long-term interests of the individual! (Meusel, 1991, p.16)Spreitzer and Snyder (1976) developed a path analysis model of early sportsocialization from self-administered questionnaires on a middle aged populationof 110 women and 154 men (mean age = 42 years), and an average education levelof 13 years. From seven predictor variables, 46% of the variance in sportinvolvement in men and 40% of the variance among women was explained. From theresults they formed a causal framework stated as follows:Parents (especially the father) who are interested in sports tend toencourage their offspring to participate in sports, which markedlyincreases the likelihood of a youth's participation in sports. One'sparticipation as a youth markedly affects how one perceives his/herathletic ability. This perception, in turn, has a strong impact on thedegree of adult participation in sport. (Spreitzer & Snyder, 1976:244)Howell and McKenzie (1987) found that participation in high school athleticprograms was related to team sport activity later in adulthood with some genderdifferences. The effects of high school varsity sport experience on late lifesport involvement was greater for men than for women, a finding similar to thatof Spreitzer and Snyder (1976) who obtained a correlation of .25 between youthand adult sport involvement for males, but no relationship at all for females.An interesting finding comes from Steinhardt and Carrier's (1989) study ofmen and women attending a health and fitness program in a large corporation.Their findings contradict research that indicates youth participation haspositive effects on initial participation in a work-site program. Instead theyfound that the individuals who were among the first to participate in the81corporate fitness program appeared to have been sedentary as youth. They suggest"that those individuals who were active as youth may be less attracted to anorganized program or perhaps less dependent on an organized program to exercise"(Steinhardt & Carrier, 1989, p. 123).Childhood Situation: Opportunity, Mastery, Movement Competence Growing evidence suggests that physical mastery, or an individual's self-concept of physical ability, may be the most important determinant of both affectand expectancy, and therefore, an important mediator of human motivation andmovement behavior (Roberts, Kleiber & Duda, 1981). Evidence is lacking, however,at what stage in human development the self-concept of movement ability must berealized to be incorporated into one's identity.Positive and early experiences with physical activity and sport seem to beimportant in some cultures. Raivio (1986) reports that interviews with Finnishfemale sport administrators, aged 29 to 60, indicate a similar childhoodbackground; all ten women had mainly participated in outdoor activities with bothboys and girls, and all but one had had a parent or close relative encouragingtheir participation in physical activities. Morgan (1986) found that former malehighschool athletes reported significantly more positive attitudes towardsactivity and their estimation of personal physical ability in young adulthood,yet were not necessarily more active than former non-athletes. He concluded thatformer athletes appeared to base their subjective judgements of physical abilityon an earlier reference point. Furthermore Morgan notes that former athletesstill regarded themselves as athletes.Dishman (1990) claims that organized sport experience in one's youth mightI I I^•^I y in a er82years and is amenable to large-scale public intervention" (p. 81). Thus, a causalrelationship between skilled participation in childhood and adult activity wouldhave strong implications for public health (Dishman, 1990). Yet no prospectivestudy has been conducted to specifically show this relationship; prospectivestudies of childhood sport or physical education as a determinant of contemporaryadult activity have not been reported. Rather, the numerous cross-sectional andretrospective studies that link youth sport history with contemporary physicalactivity must be viewed with caution. Thus, the question of whether physicalactivity determinants for the individual who begins habitual activity at middleage are the same as those of a person who was active since childhood remainsunclear.Research is consistently finding that perceived competence in physicalskills is an important influence on the participation and motivation of childrenin sport contexts. Young participants in organized sports are found to havehigher perceived competence, more persistence and higher expectations for futuresuccess than non-participant children (Roberts, Kleiber & Duda, 1981). Self-efficacy ratings and experience level in gymnastics were significant predictorsof the actual success of boys aged 7 to 18 in competitive gymnastics settings.There is preliminary evidence that mastery of high-risk sport skill may evengenerate increased self-efficacy for other physical and social tasks (Brody,Hatfield & Spalding, 1988).Yet what children say and do in the physical education setting may be highlysex-differentiated and a subtle socialization is part of a "hidden curriculum"(Griffin, 1982, p.84). Boys limit girls' opportunities to learn physical skill,and hence undermine their future confidence by hassling them, and interfere withtheir own 1 arning by clowning around.83Similarly, family members are thought to be powerful determinants of theactivity behaviors of children. Parents, in particular, are key role models andmay at first support the athletic achievements of a daughter. But "when parentsdecide that sport achievement is a threat to her social life and eventualmarriage, they push the feminine role" (Hauge, 1973, p.19) to be more competitivein the social setting. There is a tendency for like-sexed parent to have moreinfluence on a child's involvement than does the opposite-sexed parent (Snyder& Spreitzer, 1973). Years ago, Koch (1956) reported that girls with brothers morethan two years older had a tendency to be tomboyish. Petruzzello & Corbin (1988)also advocate that experience and gender are important determinants of performerconfidence. They conducted two studies on college-age males and females whichindicated that even on gender-neutral motor tasks, females rate thOselves withsignificantly lower levels of confidence. They concluded that the greaterexperiences and social rewards for males in physical activity raises theirexpectancies for success on new tasks.It becomes increasingly clear that experience affects self-confidence.Successful experiences/mastery attempts can serve to enhance self-confidence. As such, the more experience one has at a variety of tasks ina variety of physical situations, the greater the possibilities are thatself-confidence can be generalized to more situations. (Petruzzello &Corbin, 1988, p.182)The construct movement confidence was employed for predicting children'sphysical performance and play decisions. Griffin and Keogh (1982) developed aworking model which describes "movement confidence as both a consequence and amediator in an involvement cycle" (p.213). Movement confidence was defined asan individual feeling of adequacy in a movement situation.The confidence or assurance with which an individual approaches a movementsituation should be an important determinant of what an individual willchoose to do and how adequate the movement performance will be. (Griffin &Keogh, 1982, p.213) 84The Griffin and Keogh Model of Movement Confidence assumes that a cognitiveevaluation of self in relation to the perceived demands of a task is anantecedent to confidence. Utilizing a Movement Confidence Inventory (MCI),Griffin, Keogh and Maybee (1984) studied perceptions of movement confidence of450 college-age students for performing 12 different movement and sport relatedtasks. In that study it became clear that movement competence was not a lonepredictor of performance confidence; rather, it was accompanied by perceptionsof potential pleasant and unpleasant movement experiences.A playground movement confidence inventory (PMCI) and a stunt movementconfidence inventory (SMCI) were developed to identify children who may be inneed of special assistance in learning sport and physical activity (Crawford &Griffin, 1986; Griffin & Crawford, 1989). Griffin'and Crawford (1989) noted thatlevel of confidence varied according to the nature of the specific task andcontext. The Stunt Movement Confidence Inventory was able to reliablydiscriminate between high- and low-confidence children aged 9 to 11 on six"stunting" tasks.The next major section to be addressed in this literature review introducesfour prominent theories which have demonstrated utility in predicting healthbehaviors. The four theories are: The Health Belief Model, Health Locus ofControl Theory, the Theory of Reasoned Action, and Social Cognitive Theory. Thechapter concludes with the literature pertaining to the specific constructs ofSocial Cognitive Theory and their relationship to exercise behaviors.85BEHAVIORAL HEALTH PSYCHOLOGY PERSPECTIVESBehavioral research in health psychology is concerned with attitudes andbehaviors of adults regarding their health and independence. Some healthprofessionals suggest that individual knowledge and beliefs about one's world arethe main controlling determinants of one's behavior.Research is needed on how health attitudes and behaviours are acquired, areaffected by daily living, change as people grow older, and can be modifiedas scientific knowledge advances. (Health & Welfare Canada, 1990, p. 4)Rosenstock's Health Belief Model is prominent in representing this second stancein many contemporary health behavior change studies 6 .THE HEALTH BELIEF MODELThe Health Belief Model (HBM) of Rosenstock, Strecher and Becker (1988)defines health behavior as "any activity undertaken by a person who believeshim/herself to be healthy for the purpose of preventing disease". The modelhighlights cognitive mediating processes through an emphasis of the role ofsubjective beliefs or expectations held by the individual.According to Rosenstock (1974) and Becker (1974), health-related actiondepends on individual perceptions about perceived susceptibility to a specificdisease and perceived severity of the disease, environmental modifying factorssuch as cues to act, and likelihood of action based on perceived barriers andperceived benefits of taking preventive action (Figure 2.0).v or c ange is provided by Strecher,6A review of the rolee is, Becker, & Rosenstock, 1986).eINDIVIDUAL^MODIFYING^LIKELIHOOD OFPERCEPTIONS FACTORS ACTIONPerceived benefits ofpreventive actionminusPerceived bathos topreventive actionDemographic variables(age, sex, race, ethnicity, etc.)Sociopsychological variables--Jo86Figure 2.0 Basic Elements of the Health Belief ModelV •Perceived susceptability to Likelihood of TakingDisease "X" erceived Threat of1.■•••■■■11•11411111i1RecommendedPerceived Seriousness••■•••■••►Disease "X" Preventive HealthAction(Severity) of Disease "X"cum to &lionMass Media CampaignsAdvice from othersReminder postcard from physician or dentistIllness of family member or friendNewspaper or magazine article87The Health Belief Model has served as a conceptual core for many compliancestudies and has predicted health, illness, and sick-role behavior. Health beliefshave been positively associated with exercise adherence in older adults whenthere is more knowledge about the exercise regimen (Tirrell & Hart, 1980) andwhen individuals are knowledgeable about their actual health situation (Rakowski,1984).Janz and Becker (1984) report on a comprehensive review of 29 health-relatedinvestigations utilizing the Health Belief Model. Summary results providesubstantial support for the HBM, with "perceived barriers" and "perceivedbenefits" proving to be the most powerful HBM dimensions in demonstratingassociations with behavior.There are a number of conceptual difficulties and inconsistencies associatedwith the Health Belief Model. First, health beliefs are understood to be areflection on how knowledgeable people are about the consequences of their healthbehaviors. Blumenthal (1983) has acknowledged that the sole basis of evaluatingpeople's beliefs is to assess their biomedical knowledge. Thus health beliefsbased on personal experience, or beliefs based on social, psychological, andcultural foundations may be good predictors of behavior but are rarely examined.Kirscht (1974) was troubled by the fact that "supporting evidence for the utilityof the Health Belief Model has come primarily, but not exclusively, fromretrospective studies, and with reference to preventive behaviors (Kirscht, 1974,p.455). Yet, the Health Belief Model rests on the notion of beliefs causing behavior -- a time order sequence that is not often addressed in the research.The Health Belief Model hinges on an individual's perceived susceptibilityto a disease occurrence (Rosenstock, 1974). Yet some research suggests thathealth beliefs arc more predictive of health protective behaviur in the well88elderly who perceive lower susceptibility to risk or health threats (Lindsay-Reid& Osborn, 1980; Segall & Chappell, 1989). These views do not support the HealthBelief Model's readiness to act because of recognition of an illness threat(perceived susceptibility).Perceived severity of a health problem is another belief assessed by theHealth Belief Model; the original HBM has a disease-avoidance orientation.Individuals who are emotionally aroused by the provision of knowledge about theseverity of their condition are predicted to initiate or adhere to preventivehealth practice. There are, however, potential shortcomings in using threat orknowledge of threat to promote health practice. Gintner, Rectanus, Achord, andParker (1987) found that attendance at a blood pressure screening was cut in halfwhen an illness.-threat format was used to motivate participants. Participantswere more likely to attend the screening when a wellness appeal was presented.The structure and reliability of eight health beliefs were examined byJette, Cummings, Brock, Phelps, and Naessens (1981). They identified six generalhealth threats, perceived severity of five conditions, four perceived barriersto taking medications, four questions measuring general health concern, threeitems assessing trust in physicians, three items of perceived susceptibility,three items on perceived health status, and two questions about health locus ofcontrol. Factor analysis revealed that condition-specific measures of perceptionof susceptibility and severity and situation-specific measures of perceivedbarriers were empirically distinct from general measures of these beliefs. Theirfindings supported the theoretical assumption that HBM dimensions weresufficiently distinct to be considered deferent beliefs, but warned againstmixing specific and general questionnaire items within the same index.89Norman (1985) reviewed over 600 research articles in an effort to determinewhat is known about people's health habits and practices. He states,No one factor has been found to provide a sufficient basis for predictinghealth behaviour. People's health habits and practices are often dailyactions which have been influenced by a host of cultural, social,psychological and biological factors. (Norman, 1985, p.3)Norman claims that while knowledge and beliefs about the health consequences ofbehavior may have some impact on the way in which people behave, they do not, ontheir own, provide a strong basis for preventive health activities. This isbecause "it is an enormously complex task to present people with information ina way that will lead them to change their health beliefs" (p.3). Norman suggeststhat health education initiatives may well be futile considering the discrepancybetween people's health beliefs and their actual behavior. His scepticism aboutaltering people's beliefs in the hopes of altering their behavior mirrors thefindings of Haefner and Kirscht (1970) who found that merely changing theparticipants' beliefs about health was not enough to alter behavior.To date, little theoretical guidance has been given to the prediction ofolder adult exercise behavior, but two prominent theories have been explored(Dzewaltowski, 1989a, 1989b; Dzewaltowski, Noble & Shaw, 1990).HEALTH LOCUS OF CONTROL THEORYThe third theory in behavioral health psychology which is potentially ableto predict late life exercise behavior is the Health Locus of Control Theory.Rotter (1954, 1966) contends that a person learns or is conditioned operantly onthe basis of his or her history of positive or negative reinforcement. The personalso develops a sense of internal or external locus of control. Those with aninternal locus of control are more likely Lu belt - inilidte change, whereas those90who are externally controlled are more likely to be influenced by others.Therefore, locus of control refers to an individual's perceived influence inregulating outcomes.Waliston and Waliston (1978) proposed that an individual's sense of controlvaries by domains of experience and actions, such as health experiences. HealthLocus of Control (HLC) is defined as perceived control over one's health."Internal" locus of control refers to perceptions that a health outcome is dueone's personal actions, while "external" locus of control refers to perceptionsthat a health outcome is due to chance, external factors or the actions of others(Kist-Kline, 1989; Wallston & Wallston, 1978).According to Health Locus of Control Theory, individuals exhibiting morecontrol over their health (internals) would be more likely to be participatingin health-promoting behaviors such as physical activity. Many studies have foundthat participants who claim to be more physically active tend to be moreinternally controlled (Bonds, 1980; Carlson & Petti, 1989; Kleiber & Hemmer,1981; Lumpkin, 1985; Moore, 1980; O'Connell & Price, 1982; Perri & Templar, 1984-1985; Sonstroem & Walker, 1973). Internality may be found especially if they arein team sports (Lynn, Phelan, & Kiker, 1969; Kleiber & Hemmer, 1981). HealthLocus of Control has only modest associations with exercise (Calnan, 1988;McCready & Long, 1985), specifically free-living physical activity (Dishman &Steinhardt, 1990). Sometimes health locus of control is not predictive at all ofhealth behaviors (Calnan, 1988) or exercise behavior (Blair, Kohl, Pate, Blair,Howe, Rosenberg, & Parker, 1980; Dishman & Gettman, 1983; Kaplan, Atkins &Reinsch, 1984; Laffrey & Isenberg, 1983).People who believe in chance tend to be older (Calnan, 1988; female (Calnan,1988^less educated Bo 1911988). Recent research suggests that as soon as people learn that their healthhas deteriorated, they also exhibit more external perceptions of control (Waller& Bates, 1992). This loss of a sense of personal control for both success andfailure is associated with depression (Mirowski & Ross, 1990).THEORY OF REASONED ACTIONOne prominent theory is Ajzen and Fishbein's Theory of Reasoned Action(1977, 1980), recently revised as the Theory of Planned Behavior (Ajzen, 1985;Ajzen & Madden, 1986). The formation of "intention" to act is central to thistheory. According to this model, an individual's intention to perform a givenbehavior is a function of attitude toward the behavior, and normative beliefsabout what relevant others think one should do, weighted by personal motivationto comply with those relevant others. Behavioral intention is viewed as a typeof expectancy and is indicated by the person's subjective probability that shewill perform the behavior in question.In regard to predicting exercise intentions, the theory has been more usefulin explaining exercise intentions in males (Godin & Shephard, 1987), inexplaining exercise behavior compared to Kenyon's Attitudes Towards PhysicalActivity inventory (Godin & Shephard, 1986), but "has not identified apredominant cognitive profile of those who intend to exercise" (Godin, Shephard,& Colantonio, 1986). Riddle (1980) obtained success with Fishbein's modelobtaining a high correlation (r = .82) between jogging behavior and furtherintention to exercise. However, Riddle noted that her most important finding wasthat "joggers had stronger positive evaluations of the beneficial consequencesof regular jogging" while nonexercisers "were not as convinced" (p. 673). The92importance of these perceptions about the "consequences of exercise" is that"consequences" is not a theoretical element in the theory of reasoned action, butrather matches a component called outcome expectations in Social CognitiveTheory. Furthermore, recent attempts have been made, with some success, toimprove the Fishbein-Ajzen model by adding the self-efficacy component ofBandura's Social Cognitive Theory (de Vries, Dijkstra & Kuhlman, 1988; Wurtele& Maddux, 1987). This new work has found that "self-efficacy has also a directeffect on behavior after controlling for intention" (de Vries, et al., 1988,p.273).SOCIAL COGNITIVE THEORYSocial Learning Theory Although Social Cognitive Theory arose from a behavioral psychologyperspective, the theory incorporates important features related to socialization.Perry, Baranowski and Parcel (1990) trace the 50 year history of social learningtheory noting that Miller and Dollard (1941) originally introduced SocialLearning Theory to explain imitation of behavior among animals and humans. Rotterfirst applied early social learning principles to clinical psychology (1954),which in turn led to his development of the idea of "generalized expectancies ofreinforcement" (1966).Building on Rotter's social learning theory, Bandura is credited for thecontemporary development of Social Cognitive Theory (1977a, 1981, 1982, 1986,1989; Bandura & Cervone, 1986; Bandura & Schunk, 1981). Social Cognitive Theorycontinues to evolve as a broad conceptual domain that incorporates manytheoretical ideas and is employed by many areas of practice. Thus, with such93diversity, abuse is possible. Perry and colleagues (1990) point out a theoreticalpitfall of research using SCT; that pitfall is "one concept was often exploredwhile the others were excluded completely" (Perry et al., 1990, p. 180). Forexample, the concept of internal and external locus of control dominated sociallearning research at one time. Bandura stated that self-efficacy may be thesingle most important factor in promoting behavioral change. The emphasis on asingle variable oversimplifies reality but is "a reflection of the structure ofexperimental research, which usually permits analysis of only a few variables ata time" (Perry et al., 1990, p. 180). Clearly, research which examines all of themain constructs of Social Cognitive Theory should be encouraged.The Constructs of Social Cognitive TheoryOriginally, social learning theory emphasized the role of self-referentbeliefs or subjective expectancies held by the subject. Beliefs or subjectiveexpectancies about the possibilities and consequences of personal action wereconsidered to be the key mediating forces between a person and a specificbehavior (Figure 2.1).Figure 2.1 Basic Elements of Social Learning TheoryPERSON ^> SELF-REFERENT THOUGHTS ^ > BEHAVIOR94Recent years have witnessed a resurgence of interest in the study of self-referent phenomena. Bandura (1989) points to several reasons why self-processeshave come to pervade many domains of psychology.Self-generated activities lie at the very heart of causal processes. Theynot only contribute to the meaning and valence of most external influences,but they also function as important determinants of motivation and action.(Bandura, 1989, p.1175)According to SCT, individuals' beliefs of self-efficacy are central to theirdecision to participate in physical activity. Efficacy expectations are definedas a person's judgements of their capability to organize and execute their skillsand resources and that of the environment to perform an action that will lead toa designated outcome (Bandura, 1977, 1986). Specifically Bandura's theory claimsthg•human action is guided by a core set of four beliefs: motivation to obtaina goal (Incentive to Act), beliefs that a certain behavior will be beneficial inreaching a goal (Outcome Expectations), a belief in one's ability to perform theaction (Self-Efficacy), and finally, a perception that the action will beendorsed or "positively reinforced" (Social-Environmental Cues). Thus the fourexpectancies encompass internal and external factors that may affect individualbehavior. In contrast, perceived behavioral control (in the Fishbein-Ajzenmodel) and perceived barriers (in the Health Belief Model) are assumed to reflectexternal factors (availability of time, facilities etc).Exercise behavior, using a social cognitive perspective, is predicted tooccur when an individual:1) Highly values the outcomes of physical activity,2) Perceives that specific forms of physical activity will lead to healthbenefits and that harmful outcomes are not likely,y, an954) Perceives that they will be socially reinforced for participating.To the extent that individuals "learn" what to value, what is risky forthem, how competent they really are, and how much endorsement society will offerfor their activity, SCT beliefs indirectly reflect the socio-environmentalmilieu, cultural learning, and past experiences of the individual. Butindividuals are not considered to be passive recipients of environmentalinfluence. Inherent in SCT is the idea that people self-regulate theirenvironment as well as their actions.Bandura has described the nature and function of human agency as a"conceptual model of triadic reciprocal causation" (1986, p. 1175), also knownas "reciprocal determinism" (Perry et al., 1990, p. 165). Self-functioning isviewed as a continuous interaction between environmental factors, beliefs andbehaviors (Bandura, 1986) (Figure 2.2). The interaction is such that a change inone has implications for the others. According to SCT, the environment providesthe social and physical situation within which the person must function and thusalso provides the incentives and disincentives (expectancies) for the performanceof behavior.Figure 2.2 Bandura's Concept of Reciprocal DeterminismEnvironmentIncentivesSelf—EfficacyEnvironmental CuesOutcome ExpectationsPerson -4------m-----...— Behavior96The Cognitive Determinants of Exercise: SCTSelf-referent perspectives are important to understand because attitudes,opinions and beliefs are formative and modifiable (Dishman, 1990). Healthpromotion initiatives and program experiences can profoundly and quicklytransform individual perspectives and behavior and are claimed to have asignificant impact on mortality outcomes even after age 70 (Kaplan, Seeman,Cohen, Knudsen & Guralnik, 1987).Conceptual models to understand and explain the diverse determinants forparticipation in physical activity and exercise in the elderly are relativelyundeveloped. Motivational theories which have had some success are now beingcombined for further strength in prediction (Sharpe & O'Connell, 1992).Incentives, attitudes, beliefs, expectancies, perceived barriers, cues to act,and self-perceptions are among the most common constructs used in contemporarytheoretical models. Even in younger adult groups where there has been "aremarkable growth in applied interest about exercise adherence, the developmentof conceptual models leading toward a motivational theory of habitual physicalactivity has lagged far behind" (Dishman, 1988). In the forthcoming section, keystudies pertaining to the cognitive elements of Social Cognitive Theory asapplied to exercise behavior are reviewed. Earlier in this chapter, theoreticalmodels which utilize these cognitive elements are addressed in detail. InChapter 3, justification is made for the utility of Social Cognitive Theory inthe explanation of older adult exercise behavior.97Incentives or Motives to ExerciseDeveloping an understanding about the mechanisms underlying exerciseparticipation at every life stage poses a challenge. Many studies on motivationand exercise have concentrated on adherence, or the problem of keepingparticipants exercising once they have started. Less has been studied on thereasons why people start exercising, and little information is available on themotives behind the initiation or resumption of exercise regimens of older adults.Despite a remarkable growth in applied interest about exercise adherence,the development of conceptual models leading toward a motivational theoryof habitual physical activity has lagged far behind. (Sonstroem, 1988,p.123)Sonstroem (1978) advanced one of the first models for prediction of exerciseinvolvement. Key to his theoretical model, was the notion of "self-esteem". Inpredicting exercise participation, his model posits that self-perceptions ofphysical ability (Estimation) influence an individual's interest in physicalactivity (Attraction) and that Attraction provides the greater influence onexercise participation. Although Sonstroem's model has enjoyed only limitedsuccess in explaining the activity patterns of high school boys, it provides someimportant information: that is, people who are motivated to be more active willlikely turn to those activities to which they are attracted, in which they feelcompetent and confident and through which their self-esteem is likely to bemaintained.But there are many participatory motives that could apply with older adults.An individual may seek exercise as a way to relieve boredom or stress and get outof the house, to socialize, to have fun, to maintain or learn physical skills,to follow doctor's orders, to demonstrate self-discipline, to experioncP 98competition or self-measurement, to promote beauty and/or to obtain health andfitness benefits. Some research suggests that motives may differ by gender.Finkenberg (1991) used Kenyon's Attitudes Toward Physical Activity Scale andfound, in college students, that males were significantly more motivated toexercise for competition, while females were more motivated to exercise forhealth and fitness. Similarly, O'Brien and Conger (1991) have found that oldermen and women participating in the Alberta Seniors Games seemed to be motivatedby different expected outcomes. Male participants admitted they enjoyedmaintaining a degree of public acclaim for sustaining their physical prowess intoold age. In contrast, older women said that sport participation promoted theirhealth and personal independence so that they could sustain more active caregiverroles within their families.Godin, Shephard and Colantonio (1986) focused their study on middle-agedemployees who expressed a willingness to exercise but actually did not exercise.The overall findings identified surprisingly little difference between cognitiveprofiles of inactive and active adults. Individuals who had intended to exercise,but didn't exercise during the two month period of the study, differed fromfellow exercisers in perceiving a problem with "lack of time", and believing thatexercise required more effort and provided less health value. The researcherssuggested that motivation might not be the limiting factor for many inactivepeople; sedentary intenders might simply be confronted with more social andenvironmental constraints than those who are active. However, lack of leisuretime as a barrier to exercise, does not seem to rank high among many agingadults, most of whom are retired.99Health as Incentive to Act Of interest to this research is the expectancy of gaining health fromparticipation in physical activity. The value of an expectancy is an importantconstruct in Social Cognitive Theory and is seen as a key motive or incentive inexplaining human behavior. Thus, health as an expected outcome of participationin physical activity must be valued in order to be considered to be an incentive.That is, those individuals who place a high value on maintaining their health,and who understand the role of regular moderate exercise in maintaining health,would be hypothesized to be more likely to be exercising. There is scant evidenceto support this hypothesis. The Campbell's Survey (Stephens & Craig, 1990)reports that, by age 65, less than half of Canadian adults judged physicalactivity as very important to their health. In regard to their personal healthpromotion,females attach more importance than males to all factors, especially bodyweight, a good diet, and rest and sleep, with only one exception: regularphysical activity. (Craig & Stephens, 1990, p.43)Karen Altergott, editor of Daily life in later life (1988), includes achapter titled "Life course and the daily lives of older adults in Canada"written by Zuzanek and Box. They claim that, as a result of retirement, olderCanadians gain approximately 38 extra hours of disposable time per week.Paradoxically, although older adults possess greater amounts of free time,their rates of participation in leisure activities, and the number ofleisure activities they engage in, decline after retirement. (Zuzanek &Box, 1988, p.153)Substantial participation declines are noted to occur in the post-retirementperiod in sports, sport spectatorship, and outdoor recreation (especially forwomen), while activities affected little, or even slightly expanded, arevisiting, reading, radio listening, watching television, playing cards, hobbies,pleasure driving, and physically less demanding forms of outdoor activities such100as walking. These, then, are the activities which appear to most interest olderadults. Upon scanning the main activities chosen by seniors, few appear to havebeen chosen for their "health value".Rather, the recreational activities of the older Canadians often seem tohave been selected instead for their social and entertainment value. Thus onemight question the assumption that health value acts as an "incentive" inexplaining older adult involvement in physical activity. First, many older adultsmay not be aware of the health-promoting effects of exercise participation.Second, older adults may see less relevance to sustaining or taking up health-promoting activities as age advances, particularly if they believe that suchefforts are only likely to contribute to short-term gains. They may indeed feelthat their "life time" is running out and they are too late to realize anysignificant gains from serious participation in physical activities (O'Brien &Conger, 1991). They may feel that the finite life-span may cut short the fruitsof long-term gains from an exercise program, and thus undermine perceptions of"health value" to be gained from regular exercise participation. Perhaps therecomes a point in the life course when people stop doing "the right thing",because they perceive that life will soon end anyway. In those circumstances,older adults may be motivated to undertake activities primarily for pleasure andentertainment.Outcome ExpectationsExpectations about positive or negative consequences (benefits or risks) areimportant to the actions taken by individuals according to both Social CognitiveTheory and the Health Belief Model. The ability to envision the likely outcomes 101of prospective actions is one way in which anticipatory mechanisms regulate humanmotivation and action. "People strive to gain anticipated beneficial outcomes andto forestall aversive ones" (Bandura, 1989, p.1180). However, the effects ofoutcome expectancies on performance motivation are partly governed by self-beliefs of efficacy. In activities in which the level of competence dictates theoutcomes, the types of outcomes people anticipate depend largely on their beliefsof how well they will be able to perform in given situations. The association ofoutcome expectations and efficacy are such that "when variations in perceivedself-efficacy are partialed out, the outcomes expected for given performances donot have much of an independent effect on behavior" (Bandura, 1989, p.1180).Positive outcome expectations, in physical activity settings, would requirethat the individual would have to believe that the outcomes of participationwould be personally beneficial and the risks of participation would be reasonablylow. According to Bandura's interpretation, perceptions of risk would then bepredicted to be higher for individuals who have low self-efficacy for physicalactivity, and perceptions of benefits would be predicted to be higher for thosewho exhibit high self-efficacy for physical efficacy.More information and discussion about the perceived benefits and risks ofexercise are provided in Chapter 3.Self-Efficacy and Movement ConfidenceIntroduction: Self-Efficacy Self-efficacy is the most studied component of social cognitive theory andit has received a good deal of interest from researchers attempting to understandthe social-psychology of exercise behavior. Perceived self-efficacy appears to 102play an influential role in ways that affect motivation and "intention" forinvolvement in physical activity and sport. Since physical activity is oftenconducted in public settings, and performance is visible to any observer,confidence to perform may be particularly important in the exercise setting.Bandura (1977a) has defined self-efficacy as the strength of an individual'sperceived self-confidence or belief that he or she can successfully complete atask through the expression of ability. Although those who view themselves ashaving high ability for a task are also apt to feel efficacious for performingit, simply possessing the ability to perform a task does not guarantee a highdegree of self-efficacy. In addition to efficacy perceptions, Schunk andCarbonari (1984) claim that "ability" involves effort, luck and task difficulty -three additional elements that can explain the success or failure of personalactions. Furthermore, competent behavior is unlikely to occur if social,psychological or structural barriers exist, or if there are inadequate incentives(Bandura, Adams & Beyer, 1977).Without aspirations and active involvement in activities, people areunmotivated, bored, and uncertain about their capabilities. Life withoutelements of challenge can be rather dull. (Bandura & Cervone, 1986, p. 111)Self-referent perceptions of efficacy are at least partly responsible for thekinds of challenges which people choose to undertake, how much effort they willspend on an activity, and how long they will persevere in the face ofdifficulties (Bandura, 1986).Social cognitive theory claims that discrepancies between performancefeedback and personal standards lead to self-dissatisfaction which then servesas a powerful motivational inducement for enhanced effort. Those who distrusttheir capabilities are easily discouraged by failure, whereas those who feel• I^II103their performances fall short, and persevere until they succeed (Bandura &Cervone, 1986). Dzewaltowski (1989b) therefore suggests that a measure ofefficacy in the exercise setting should "examine individuals' efficacy towardcoping with difficult situations and still adhere to an exercise program" (p.254). Recent research suggests that task-specific efficacy measures are superiorpredictors of behavior over general efficacy measures (Bandura & Cervone, 1986).Thus self-efficacy in exercise research has been defined in many ways such asself-rated confidence to adhere to an exercise program, or confidence to sustainexercise for 60 minutes.The need to be specific in the assessment of efficacy expectations hasrequired researchers to develop their own measures to deal with their particularresearch question. Consequently, the available research on efficacy and exerciseat times appears to be haphazard. Some studies merely verify what Bandura'stheory has already demonstrated. Others add some interesting information butdirection is lacking.Barriers to Perceived Efficacy to Exercise The Campbell's Survey (Craig & Stephens, 1990) indicates that barriers andlack of perceived control interferes with the desire of 70% of 65+ Canadian womento regularly exercise. In general, males at all ages felt they had more controlover their life situations than did females. The major gender differences inperceived barriers were a greater emphasis by females on family time pressures,lack of energy, and lack of ability. Lack of a partner and lack of ability wereimportant explanations among those who resisted or lapsed in their activityprograms.104Davis-Berman (1989) has provided evidence that physical self-efficacy inaging women may be undermined by the effects of depression. Thirty percent ofthe variance in depression scores were explained by a physical self-efficacyscore.Research by Kelly (1987) serves to remind us that efficacy for specializedtasks may be undermined by numerous barriers largely outside of individualcontrol. Kelly studied leisure in aging adults and identified two kinds ofactivity which distinguished adults with the highest levels of life satisfaction:"those providing a context for interaction with valued others and 'highinvestment' activities" (Kelly, 1987, p.111).High investment activities are those that have been developed over a periodof time, require some acquisition of skill, and are most likely to yieldoutcomes of an enhanced sense of competence, worth, and Orsonalexpression" (Kelly, 1987, p. 112)Kelly suggests that the low rates of participation in exercise, sport and outdoorrecreation for those age 55 and above reflect the likelihood that real health andphysical ability limitations are operative. Exercise and sport settings are high-investment activities that call for special facilities, supervision and guidance,companions, specialized equipment and high levels of effort and skill -requirements and resources which may be harder to fulfil as people reach advancedage. Therefore, social contexts become more limited to family and neighbours andlocales of activity become limited to the private residence.Along the same lines, Godin, Shephard & Colantino (1986) found thatsedentary adults (average age 39) who had positive intentions to exerciseperceived regular exercise to be "tiring", "time-consuming" and placed less valueon "being healthy". The major perceived obstacles of intenders to exerciseparticipation was "lack of time" and "perceived exertion". Both of these factorscan be linked to one's efficacy to carry out a program of exercise.105Waller and Bates (1992) studied self-efficacy beliefs, multidimensionalhealth locus of control and lifestyle behaviors in 57 healthy elderly subjects(mean age 74.7) with a view to determine who could benefit most from healthpromotion programs. Most of the subjects were characterized by an internal locusof control belief (91.2%), high generalized self-efficacy (57.9%) and good healthbehaviors. Waller and Bates (1992) suggested that individuals with an internallocus of control and high generalized self-efficacy are more likely to benefitfrom a health education program than those with an external locus of control andlow self-efficacy, but this suggestion was not examined directly in their study.Woodward and Wellston (1987) examined age, desire for control, informationand general self-efficacy in 116 adults aged 20 to 99. They found thatindividuals over 60 years of age desired less health.,related control than didyounger adults, and preferred that health professionals make decisions for them.Perceived self-efficacy was lower for individuals over 60 years of age. Thefindings suggest that "those individuals most at risk for chronic illnesses andhospitalization are also those who are most likely to fail to take an active rolein their health care" (p.3).The Role of Habit and Previous Physical ActivityIn a random sample of 136 University of Toronto employees, Godin, Valois,Shephard & Desharnais (1987) examined, among other factors, the influence of pastbehavior on subsequent behavior. Three measures of "habit" were used: ImmediatePast Behavior (weekly score using MET units to quantify activity level), Past 4Months Behavior, and Adulthood Behavior (frequency of getting sweaty duringleisure time as an adult). They found that "distal" exercise behavior (threeweekc and two months later) was predicted by both intention to exer.i dud106Immediate Past Behavior. The important role of "habit" was highlighted in thisstudy. Godin and colleagues concluded that if a person has never engaged in aparticular behavior, it remains uniquely under the control of behavioralintentions. However as the behavior is repeated, the importance of the habitincreases, with a corresponding diminution in the importance of behavioralintention...the decision to adopt an active life-style, over the previous habit ofbeing sedentary, requires more "girding up of loins" than the decision tocontinue to exercise for an individual who has a well-established habit ofexercising. Consequently, a process of change has to take place, thisrequiring "will" in order to compete and resist the forces of the old habitin establishing a new habit. (Godin et al., 1987)While the role of "habit" has received only preliminary attention inpredicting current exercise behavior, habitual activity may have some bearing onadvancing intention into actual action. In this study, the notion of "habit" wasaccommodated in the variable "movement confidence" which combined self-efficacy("I am sure I can do this") with habitual experience ("I have done this a lot").The Role of Efficacy on Exercise BehaviorA number of contemporary studies are linking physical self-efficacy,perceived movement competence, or self-rated physical ability to predictions ofexercise behavior, physical fitness and adherence to fitness programs. Forexample, self-efficacy has been found to be the most powerful and statisticallysignificant correlate of both walking and vigorous exercise among ill and healthygroups alike (Hofstetter, Hovell, Macera, Sallis, Spry, Barrington, Callender,Hackley & Rauh, 1991).Ryckman, Robbins, Thornton, and Cantrell (1982) developed a general PhysicalSelf-Efficacy Scale (PSE) in order to identify an individual's perceived physicalself-confidence. While this instrument demonstrated adequate reliability and107validity in predicting general self-efficacy in sport, McAuley and Gill (1983)did not find this to be a useful instrument in evaluating female collegeperformer's efficacy for gymnastics performances. Rather, the Perceived PhysicalAbility (PPA), a sub-scale of the PSE was more situation-specific and offeredbetter prediction of performance outcomes.Duda and Tappe (1989) studied 145 adults aged 25 to 81 years of age with thepurpose of examining motivational differences in exercise by gender and age.Sense of physical competence was assessed with the Perceived Physical Abilitysubscale of the Physical Self-Efficacy Scale (Ryckman et al., 1982). They foundthat older and younger physically active adults did not differ in perceivedphysical self-efficacy and health status. However, middle-aged and elderly adultstended to engage in.exercise more for the positive consequences on health statusthan young adults. Males engaged in exercise more for competition than femaleswhile females exercised more for fitness reasons. There was also a trend forfemales to exercise more for affiliative reasons than males. Women tended to viewthemselves to be less physically able, perceive greater significant other supportfor their involvement in exercise, and believe that one's fitness status isprimarily of fate or chance occurrences (externality). Duda and Tappe concludedthat exercise has different meanings to young, middle-aged and elderly men andwomen noting that perceptions of efficacy and social support for exercise werethe major differences between men and women.Ryckman's Perceived Physical Ability (PPA) scale was used to examine therelationship between perceived physical ability and indices of physical fitness(Thornton, Ryckman, Robbins, Donelli & Biser, 1987). The males in the study(aged 17 to 64) generally were more physically fit relative to the females (aged18 to 64), yet there was no difference between their PPA ab predicted. They108concluded that their findings did not support the predictive utility of perceivedphysical ability where actual indices of physical ability were involved.Efficacy expectations were originally thought to be specific to particularbehaviors and not necessarily generalized to other behaviors. However, evidenceexists in one study that efficacy for exercise may be generalizable. Kaplan,Atkins and Reinsch (1984) examined specific versus generalized efficacyexpectations for exercise in older patients with chronic obstructive pulmonarydisease (COPD). All subjects (mean age was 65 years) were given a prescriptionto undertake two daily walks. The experimental group of the randomized designreceived three months of supervised training and advice while the control groupreceived only advice. After three months, the experimental group hadsignificantly increased their activity level, their perceived efficacy forwalking and also efficacy expectations for other similar physical behaviors incomparison to the control group. Their results suggest a "bidirectional" typeof causation, or a "reciprocal-causal" model meaning that "efficacy andperformance attainments may affect each other in reciprocal fashion" (Kaplan etal., 1984, p.239).Dzewaltowski (1989b) conducted a study comparing Bandura's Social CognitiveTheory to Fishbein and Ajzen's Theory of Reasoned Action. The theories'constructs were assessed on 328 physical education students prior to collectingdata on the total days exercised over an 8 week period. With all the variablesin a regression equation, the Theory of Reasoned Action could only account for6% of the variance in exercise behavior. When Social Cognitive Theory variableswere entered into the equation, they accounted for 14% of the variation.Dzewaltowski (1989a) concluded "it may be that those who exercise are confidentthat they sari exerLise despit e unLontrol1 able factors" (p. bb).109Self-efficacy has been used to predict over-exertion during programmedexercise in 40 men; The men were recovering CAD patients with an average age of55 years (Ewart, Stewart, Gillilan, Keleman, Valenti, Manley & Keleman (1986b).Patients' confidence in their ability to jog various distances was measured witha jog self-efficacy (SE) scale before an eight-week group exercise program wasbegun. Ambulatory heart rate monitoring disclosed significant noncompliance withexercise prescriptions: 33% of patients exceeded their prescribed range of 70 to85% of maximum treadmill heart rate for at least 10 minutes of the 20 minuteexercise bout. Another 25% spent 10 minutes or longer exercising below theprescribed range. "Overachievers" were patients who overestimated their abilityto jog, while "underachievers" were those who overestimated their exercise heartrate. Jogging SE proved superior to treadmill performance, depression measuresand Type A personality measures in predicting patient adherence to exerciseprescription.The Role of Exercise on the Development of EfficacyThe literature generally supports Bandura's theory that efficacy andperformance strengthen each other in reciprocal causation (Kaplan et al., 1984).Previous successful performance leads to stronger efficacy expectations, andstronger efficacy perceptions increase the likelihood of successful performance.Marcus and colleagues (1992) found that higher levels of self-efficacy forexercise accompanied higher levels of exercise activity in blue collar employees.Results indicated that employees who had not yet begun to exercise, in contrastto those who exercised regularly, had little confidence in their ability toexercise. Stewart and King (1991) suggest that exercise may enhance a sense ofg h^ P r dl IU11 of twu IlleL 1c1E1 I S1115 .y110Regular exercise may provide people with an enhanced sense of their abilityto handle problems. Regular exercise may also provide a model of control(e.g. "I obtain improved health by exercising") that may generalize toother life domains. (Stewart & King, 1991, p.113)However, no differences in a sense of control were found in at least onerandomized study of a twelve-week aerobic exercise and strengthening program for15 men and women aged 61 to 86 compared to a social activity control group (N =15) or a waiting list control group (N = 18) (Emery & Gatz, 1990).One of the best studies done on self-efficacy and exercise behavior wasrecently reported by McAuley, Courneya & Letturich (1991). Fifty females and 50males (average age of 54) were examined for the effect of acute and long-termexercise on self-efficacy responses in sedentary adults. Three measures of self-efficacy were employed to determine subject's beliefs in their physicalcapacities as related to exercise and fitness. Specifically, the efficacy scalesrepresented subject confidence to be able to succeed with 1) increasing numbersof sit-up repetitions in one minute, 2) cycling longer at increasing work loads.and 3) walk-jog successive quarter-mile distances within 4 minute intervals.Subjects participated in a 5 month aerobic exercise program, three times per weekin one hour sessions. Both males and females demonstrated significant increasesin efficacy following acute exercise. Females, who had demonstrated initiallylower self-perceptions than males, made dramatic increases in efficacy during theexercise program, equalling or surpassing those of males. Increased self-efficacy closely accompanied the actual measured physiological gains inperformance as expected. McAuley and associates concluded that their results areencouraging since sedentary individuals in their middle years were able to makesignificant health-related gains through a relatively low-impact activity suchas walking.111The effects of running the treadmill only three weeks following myocardialinfarction (MI) on subsequent physical activity were evaluated in 40 consecutivemen with a mean age of 52 years (Ewart, Taylor, Reese & DeBusk, 1983). The menwere examined for self-perceived ability to walk/run distances from one block tofive miles, climb stairs from several steps to four flights, engage in sexualintercourse from one to 20 or more minutes and handle objects from 10 to 75pounds. Patients' confidence in their ability to perform these activities wereassessed before and after a symptom-limited treadmill test of aerobic fitness.Significant increases in self-efficacy occurred after the treadmill test foractivities most similar to the test: walking, stair climbing and running.Another finding supports Bandura's specificity of SE and suggests that physicalefficacy perceptions can be quickly improved by successful performance on:arelated activity.In another study by Ewart and colleagues (1986b) examined 43 men withcoronary artery disease proposing that highly specific estimates of personalcapabilities mediate adoption of new or difficult exercise settings.Correlational analyses of self-efficacy in relation to strength and endurancetests strongly supported the contention that the adoption of novel activities isgoverned by highly specific self-perceptions. The pattern of findings suggestthat favourable appraisal of one's athletic ability increases motivation topursue sport, leading to greater participation, increased skill, more positiveself-appraisal, and consequently, higher motivation.Hogan and Santomier (1984) examined the effects of participation in a learn-to-swim program on the self-efficacy of older adults. The subjects were 38volunteers 60 years of age or older. This study was quasiexperimental in thatit utilt7ed a non-randomized control group. As such, the study k vulnerable to112the confounding effects of self-selection. As expected, significant changes inpost-test efficacy were found, but more importantly, this efficacy generalizedto other performance-related situations. Open-ended questioning indicated thatother aspects of their lives had been affected such as "now able to handle a tripto China", "my walking has improved" and "chores are more easy". Suchgeneralized efficacy outcomes are not in agreement with Bandura's theory thatefficacy expectations are specific.A ten week exercise program containing 69% women aged 55 to 80 was conductedby Howze, DiGilio, Bennett, and Smith (1983). "High-attenders" were those whoattended 15 or more sessions out of the 20 two-hour sessions. "Low-attenders"were less confident of their physical abilities and were more worried aboutinjury. Ninety-two percent of the participants said that they "felt better ingeneral" and felt more physically fit after the program. Howze and colleaguessuggested building self-confidence by progressive exercise which providedsuccessful participation all along the way.Feltz (1988) has examined gender differences in the causal elements of self-efficacy on a "high-avoidance" motor task (the back dive) in college agestudents. Feltz proposed a respecified model of Social Cognitive Theory thatincluded both self-efficacy and previous performance (experience) as directpredictors of approach/avoidance behavior on the dive. The diving efficacy scaleasked the subject to rate the degree of confidence he or she felt aboutaccomplishing the back dive successfully for each of four board heights. Eachrating was made on a 10-point scale from 0 (great uncertainty) to 10 (greatcertainty). Actual performance was measured by two trained observers using anobjectively designed performance evaluation. Females attempting the back divereported higher levels of state anxiety and autonomic arousal (high heart rates) 113than males on their first attempts. In perceiving heart rate changes, malestended to underestimate while females tended to overestimate their increases inheart rate. No sex differences were found in self-efficacy scores, and both malesand females significantly increased self-efficacy perceptions from Trial 1 toTrial 2. Thus previous performance and self-efficacy measures were both strongpredictors of subsequent performance for males and females.The reciprocal nature of efficacy and performance is confirmed in one otherstudy. Barling and Abel (1983) studied self-efficacy beliefs and tennisperformance in 40 active males (26.6 years). Three 10-item scales assessed self-efficacy strength ("I can play most of my strokes correctly"). Two judgesevaluated actual tennis performance (inter-rater r = .91; p < .001 in all 12rated skills). Tennis players who had higher•self-efficacy for tennis were ratedas the most skilful performers, meaning the relationship between efficacy andperformance holds even when performance is evaluated by others.Environmental Cues for Physical Activity: Social SupportThe objective of this section to review the known inter-relationships ofphysical activity, aging and social support systems. Understanding the impact ofvarious social reinforcements on individual and group behavior holds promise forcost-effective, community-level intervention.Alleist Practice in Communities Ageism, or the explanation of behavior by age considerations alone, isthought to be a powerful social element governing the present active livingchoices for adults as they age. One major theory of aging rests on this114discriminating assumption: disengagement theory endorses the withdrawal fromsocial participation as a natural and healthy course of aging (Cumming & Henry,1961). Others would argue that disengagement is not at all a choice, but ratheris aggressively driven by the political economy of age stratification, withcertain privileges being denied, and access to social participation limited,based simply on the age of individuals. Examples of age discrimination inphysical activity are: limited access by the elderly to high-demand public sportfacilities, few opportunities to receive expert coaching and instruction,disinterest by the media and general public, and a lack of publicly organizedevents and activity programs representing the broad interests of older adults(Curtis & White, 1984).Ageist practice socializes older adults into a narrow range of "appropriate"activities, even though those activities may not represent those in which olderadults have developed lifelong skill or interest (McPherson, 1984). Views thatolder adults should exert themselves less as they age, and should become lesscompetitive at the activities they do, are consistent with the social forces thatare present in much of contemporary society. When these social forces areevident, it becomes clear to older adults that social acceptance is lacking forthem to demonstrate many of the varieties of athletic excellence. Ageism isprobably the most obstructive form of adult socialization preventing older adultparticipation in some of the most valued forms of physical activity.Social Support Of interest to the present research are studies which 1) identify the typesof people who lack interest and desire to exercise, and 2) the kinds of physicalAnd cultural environments which promote more physical daivity. Among the115prominent relationships between socio-environmental context and optimal healthis a powerful construct called "social support."Many studies have already demonstrated with clarity that social support isimportant to the maintenance of good health (Pilisuk & Minkler, 1985), includingreduced psychological distress (Holahan & Moos, 1981), and reduced mortality inelderly populations (Blazer, 1982). Exercise scientists are similarly beginningto appreciate the significance of social support in physical activity settings.Indeed, while physical activity settings may be among the most important sourcesof social contact and support in the lives of older adults, other forms of socialsupport must apparently already exist. For older adults to live actively, somedegree of social support may be an essential prerequisite.Defining and Measuring Social Support The scientific measurement of social support is a recent phenomenonrequiring clear operational definitions. Social support has seen a rapidevolution of conceptual meaning ranging from individualized emotional andaffective dimensions to large, contextual features of a particular society(Esdaile & Wilkins, 1987). Most measurement to date has addressed social supportat the "micro" level. For example, an early definition of social support wasgiven by Cassel (1976) as the gratification of a person's basic social needs(approval, esteem, succorance). Cobb (1976) conceived social support to beinformation leading a person to believe that they were cared for, esteemed andbelonging to a network.The measurement of a multidimensional construct such as social support isdifficult, if only because there are now a legion of available instruments whichtap intn emotional support, tangible support, informational support and support116provided to others at both perceptual and enacted levels. Social support, as aquantity, can be measured objectively as the number of social contacts one has,or the number of phone contacts or visits from friends in the past week. Thequality of social support can be subjectively assessed with perceptual ratingscales about the adequacy of one's support network.Physical Activity as Social Networking Recreation centres, senior's groups, sport clubs and even shopping mallsprovide positive settings in which to engage in socializing and physical activity(Graham, Graham & MacLean, 1991). Within these social settings, both formal andinformal structures can provide instrumental aid, information and advice. Inaddition, such settings supply one of the biggest benefits of leisure activity -companionship (Ishii-Kuntz, 1990; Tinsley, Teaff, Colbs & Kaufman, 1985).Institutionalized elderly are known to place high priority on the social contextof physical activity, although they also hope that exercise will also enhancetheir health and fitness (Mobily, Lemke, Drube, Wallace, Leslie, & Weissinger,1987).Women have, in the past, been less likely to take advantage of theseexisting community networks for participation in physical activity and sport.Even though finding companionship for activity has occurred with more frequencyfor males (Curtis & White, 1984), women do not necessarily choose to exercise athome alone. From young adulthood on, females are found more often in caregivingand domestic situations which may limit their ability to formalize socialnetworks outside the home environment.117According to a national survey on women with disabilities, physicallimitations and medical concerns were not considered to be their primarylimitations to activity participation.The primary changes that would encourage greater participation in physicalactivities were accessible facilities that are closer to home,knowledgeable instructors, people with whom to participate, and moreavailable information on programs. (Fitness Canada Women's Program, 1990).Social encouragement from other adults may be lacking for older women withlimitations. Almost half of the women surveyed said they alone were responsiblefor getting involved in activity while family and friends were influential inactivating only 13% of respondents.For older adults, ease of transportation to physical activity settings andcosts of participation may be practical barriers to obtaining the support theyneed to be more active. Many elderly women never learned to drive the family caror can no longer afford to maintain a car and therefore limit their activitiesto whatever is available in their neighbourhood.Role of Group Cohesion Social support and group cohesiveness have been studied with a view tounderstanding why people begin physical activity, why some maintain theirinvolvement and why others stop participating altogether. Dishman (1984) hasnoted that after six months, over half of those who begin an exercise programhave already dropped out. As might be expected, people who do not adhere to aspecific fitness or sport setting are less personally attracted to the group'stask and to the group as a social unit (Carron, Widmeyer & Brawley, 1988). Theliterature underscores the need for an awareness of how the social and physicalenvironment can affect the elderly individual's sustained involvement in groupactivity, as well as the need for understanding how activity engagement may118relate to the individual's evaluation of the environment and of the self (Barris,1987). In other research, a series of six studies examined the behavioral andcognitive procedures which would enhance adherence to a 3-day-per-weekwalking/jogging program in sedentary adults (Martin, Dubbert, Katell, et al.,1984). Overall, the results of the studies confirm the importance of socialsupport, including instructor feedback and praise during exercise.Role of Companionship Lack of social support for older women in the form of sport opportunitiesand companionship is one of the key findings of a study by Curtis and White(1984). Using a sample of 33,762 native-born Canadians who filled out a nine-pagesurvey questionnaire, they found that older females participated in - fewer sportactivities than younger women, but participated more frequently in the past year.Only 10 percent of women over age 60 had at least one physical recreation whichthey had pursued one or more times on an annual basis.Problems in finding others with whom to participate was a problem for over20% of the elderly women, and they were the one age group who had the mostproblems with finding companionship. Older women had twice as much difficultyas same-age men with finding companionship, yet at the same time, reported thattime conflicts in activities were only half the problem that men had experienced.Ishii-Kuntz (1990) reports that widowed women, in particular, are likely to beseeking companionship and social opportunities in senior's centers.The Role of Spousal Support One hypothesis is that women who have active life companions, activepartners or active spouses are more likely to be physically active themselves119(Snyder & Spreitzer, 1973). Having a spouse who is indirectly involved in sportsis thought to reinforce earlier encouragement from one's parents and to increaseone's perceived ability to be involved as an adult (Spreitzer & Snyder, 1976).In analyzing family influence on sports involvement, researchers haveclaimed that there is considerable similarity of activity patterns between acouple.Evidently, they mutually reinforce one another's interest in this sphere ofleisure behavior. Explanations of this finding might lie in the mateselection process where a common interest in sports might serve as anadditional inducement for the match; also, the findings might suggest thata strong interest in sports on the part of one spouse is graduallytransmitted to the partner. (Snyder & Spreitzer, 1973, p.252)Other research suggests that "women who take part in sport perceive a very highdegree of support from their nominated or significant male" (Tait & Dobash,1986). This evidence notwithstanding, compared with men, women aged 45 and olderreported less support from their spouse and experience less encouragement to beactive with advancing years (Stephens & Craig, 1990). Furthermore, Hauge (1973)has suggested that "middle class men look outside the home for sport companionsalmost twice as frequently as the women do" (p.25).One of the few available studies on the role of spousal support to exerciseadherence is unfortunately available only in relation to men. Myocardial patientswere studied for drop-out rate from an exercise program over a seven year period(Andrew, Oldridge, Parker, Cunningham, Rechnitzer, Jones, Buck, Kavanagh,Shephard, Sutton & McDonald, 1981). Of all the determinants being considered,spouse approval was the most significant finding. The drop-out rate of thosewith little or no support from their wives was three times greater than in thosemen with positive spousal encouragement.Ishii-Kuntz (1990) examined how predisposing, enabling and need factorsinfluenced elderly women's participation in voluntary organizations and senior120centers. A nationwide probability sample provided data which indicated that age,race and health status influenced participation. Elderly widows were more likelyto be involved in voluntary organizations than married women, with lonelinessbeing a major factor leading to seniors center participation.The Role of the Physician The cautionary warnings that one must always consult a physician beforetaking up any interest in physical activity may be doing more harm than good.Certainly anyone who is doubtful about one's personal state of healthshould consult a physician. In principle, however, there is less risk inactivity than in continuous inactivity. In a nutshell, our opinion is thatit is more advisable to pass a careful medical examination if one intendsto be sedentary in order to establish whether one's state of health is goodenough to withstand the inactivity. (Astrand, 1986, p.4)Evidence suggests that ordinary people will not get extraordinary advice from aphysician about how to start an exercise program. Moreover the "see yourphysician" prescription may prevent many adults from ever getting started sincea chain of dependency is then formed (O'Brien Cousins & Burgess, 1992). Becomingmore physically active depends on seeing the doctor, and it also depends on whatthe doctor has to say. Because of time constraints, physicians often do notdiscuss their attitudes and knowledge about exercise with their patients. Thedependency continues as one then seeks out an activity program in which exerciseneeds are met. If the program is good, one may become dependent on a highlyprescriptive program and the motivational skills of its leader in order to becertain to adequately exercise.Regular pulse rate checking serves to remind people that they may be at riskof something going wrong with the heart, and consequently individuals may becometoo anxious to exercise on their own. This scenario is an example of how some121forms of social support can backfire and become barriers to individualized andindependent involvement in physical activity.Health promoters have begun to examine the interest and competency ofphysicians to provide encouragement for their patients' activity patterns. It hasbeen noted that physicians who have graduated since the late 1960's are morelikely to believe in the importance of regular aerobic exercise, but overall,only about one-quarter of physicians have been found to think engagement inaerobic activity three times a week is very important to health (Wechsler,Levine, Idelson, Rohman, & Taylor, 1983). Internists are more likely to ask aboutexercise behaviors than general practitioners (53% to 31%) and all physicians aremore likely to ask about smoking, alcohol and other drugs, than they are likelyto ask about diet, exercise and stress (Wechsler, et al., 1983). Only 3 to 8percent of physicians thought they were "very successful" in helping patientsachieve changes in various health behaviors, but 21 percent were optimistic abouttheir ability to help patients increase exercise.Surveys of physicians in Massachusetts and Maryland indicated that just lessthan 50 percent of primary care physicians routinely inquire about theirpatients' exercise practices (Wechsler et al„ 1983). In an exercise interventionstudy on women aged 55 to 80, only 5% of the participants noted that regularexercise had been recommended to them by a physician (Howze et al., 1983). Inanother study, only 27% of the physicians felt that exercise was "very important"for the average person. Thus "a large proportion of physicians are not fullyconvinced of the value of exercise for health" (Powell, Spain, Christenson, &Mollenkamp, 1986). Whether physician inquiries include in-depth questions aboutintensity, during or frequency of exercise is not known, nor do we know howphysicians alter their questioning with younger and older individuals.122Current views on the athletic potential of older adults, and older women inparticular, are considered to be overly conservative even by health promotionexperts and exercise physiologists. Most professionals may be concerned moreabout the risks of participation for more frail elders and the potential for harmand litigation outcomes than they are for raising activity levels of the entirecommunity (DeLorey, 1989).Added to this professional conservatism, there has been a persistent mythamong older adults advocating the scientific concept of "conservation of energy."Retirement, for many, means that it is time to take a long-deserved rest fromlifelong physical work demands. The social norm for retired individuals has beenrather passive leisure pursuits, and it is difficult to change expectations aboutactivity choices if the participant is perceived to be already more ambitious than others of the same age. Particularly if an adult has been physicallyinactive in recent years, physicians and friends are unlikely to try to convincehim or her that now is the time to start exercising.The Role of Friends and Family The number of close friends which a person has appears to be significantlyassociated with the pursuit of general preventive health behaviors such as non-smoking behavior and exercise (Calnan, 1985). While companionship for physicalactivity is considered to be a reinforcing factor (Biddle & Smith, 1991), inrecent decades, time pressures are evident, at least in middle age families.Inflationary pressures and changing attitudes towards the social roles of men andwomen have seen the rapid rise of two-career families and what some call the"death of leisure" (Posner, 1991). Over half of the adult female population isin the labour force full-time; this means that there has been a significant123change in the workload patterns of women. About one quarter of Americans at workare spending 49 hours or more each week on the job (Kilborn, 1990). It has beenestimated that women average 66 to 75 hours per week at combined job and familyresponsibilities as compared with 42 to 49 hours per week 50 years ago (Edwards& Hill, 1982). The implications of this for women's physical activity patternsis that many women have too little leisure time in which to be physically active,and friendships and social networks may also become more difficult to sustainunder these kinds of time pressures.The next chapter identifies the theoretical framework for the study basedon the literature that has been outlined in this chapter. The theoreticalframework discusses the selection of Social Cognitive Theory as the most suitablestarting point and then justifies a system of synthesis of theories. The 16constructs of importance to a Composite Theory of late life exercise arepresented and the next chapter concludes with a visual working model for thisstudy.124III. THEORETICAL FRAMEWORKIntroduction The review of literature, in the previous chapter, has identified as manyas 16 constructs from different theoretical models which have demonstratedpredictive relationships with exercise behavior. One purpose of this study wasto develop a theoretical framework which would have utility in explaining latelife exercise for older women. This chapter begins with an explanation of why theHealth Belief Model and Theory of Reasoned Action have not been adopted in thisstudy. Next, the chapter presents a rationale for synthesizing 10 constructs fromsocial epidemiology and Socialization Theory with six cognitive constructs fromSocial Cognitive Theory and Health Locus of Control Theory. This is not a newmodel, but rather a more comprehensive application of Social Cognitive Theory,and provides an opportunity to clarify the interpretation of SCT theory. Bycombining situational variables with cognitive variables, the Composite Modelwill offer a test of the power of cognitive beliefs to reflect the individual andsociety from which they form. An illustrated model of the Composite Model isfound on page 3-6. Further discussion on each construct of the model is foundin the remaining sections of the chapter.Selection of the Most Suitable Theoretical Perspective Since older women may lack efficacy for physical skills and fitnessexercise, assessing their perceptions of physical ability was believed to beimportant to the prediction of late life exercise behavior. Neither the Theoryof Reasoned Action, nor the Health Belief Model assess these perceptions aboutefficacy. The self-efficacy element of SCT, as well as the theory's other self-125referent beliefs, appear to hold the most promise for the explanation of olderwomen's exercise behavior. In addition, health locus of control is a logicaladdition to a framework which is attempting to explain a health behavior such aslate life exercise.Dzewaltowski (1989b, 1990) has twice shown that Bandura's Social CognitiveTheory is a superior predictive model to the Fishbein-Ajzen model in theexplanation of exercise in older adults. Dzewaltowski (1989b, 1990) has comparedthe ability of SCT with the Theory of Reasoned Action to predict exercisebehavior over a seven-week period (1989b), and four-week period (1990), incollege-age physical education students. The Theory of Reasoned Action explainedonly 6% (Dzewaltowski, 1989b) and 10% (Dzewaltowski, Noble & Shaw, 1990) of thevariance in exercise behavior while two SCT variables predicted 16% of exercisebehavior variance (Dzewaltowski, 1989b), and could explain 7% more variance aftercontrolling for all the variance explained by the Theory of Reasoned Action(Dzewaltowski, et al., 1990). In a separate study attempting to explain femaleexercise behavior, intention scores emerged as the only significant predictor,accounting for only 9% of the variance (Wurtele & Maddux, 1987). Dzewaltowskiconcluded that "the theory of reasoned action did not account for any uniquevariance in exercise behavior over the social cognitive theory constructs"(1989b, p. 251), and that "the social cognitive theory constructs were betterpredictors of physical activity than those from the theory of reasoned action andplanned behavior" (Dzewaltowski et al., 1990, p.388).A further reason to reject the Theory of Reasoned Action was thatintentions to exercise, and planned behavior to exercise may not be particularlyrelevant to the elderly who may possess "constricted future expectations" and may•^Oa126(Rakowski & Hickey, 1980, p.287). Since the main goal of this study was toidentify important determinants of current exercise behavior, Social CognitiveTheory was selected as the more suitable theory.The Application of Social Cognitive TheorySocial Cognitive Theory conceptualizes that environmental events, personalfactors, and behavior all function as interacting determinants of each other.People can exert some influence over their life course by their selection ofenvironments and construction of situations (Bandura, 1989).Social cognitive theory subscribes to a model of emergent interactiveagency. Persons are neither autonomous agents nor simply mechanicalconveyors of animating environmental influences. (Bandura, 1989, p.1175)This perspective of individual activity and reactivity. supports the centralthesis that "self-referent thoughts mediate the relationship between knowledgeand action" (Schunk & Carbonari, 1984, p.230). However, some experiences andcontextual elements of one's life cannot be easily altered and are thought tomake significant contributions to one's control beliefs. Therefore one'scultural context and personal situation are thought to alter the subjective valueof an expected outcome and the subjective probability (or expectation) that aparticular action will achieve that outcome.To date, all of the cognitive mechanisms from Bandura's social cognitivetheory (1986) have not been applied in concert to explain exercise motivation(Dzewaltowski, 1989b, p.252). Furthermore, SCT has not been tested directly forits ability to explain exercise behavior alongside the cultural context andpersonal situation of the individual. A test of this interpretation is attemptedin this study, since both situational factors and cognitive variables are allI • • II • I I •^• •127regression analysis permits simultaneous analyses of multiple independentvariables. If cognitive determinants account for all of the variance in exercisebehavior, and situational variables do not compete for power of explanation, thenthe interpretation of Schunk and Carbonari (1984), that cognitive beliefs areadequate proxy for personal and environmental circumstances, will be confirmed.If socio-environmental factors offer unique explanation in addition to cognitivevariables, then support will exist that human behavior may be affected bysignificant mechanistic forces. A third possibility exists. Situationalvariables may over-ride all cognitive explanation, meaning that socioculturalenvironment and personal situation are the most important controllingdeterminants of leisure-time physical activity. The latter finding would forcea conclusion that there is little potential for behavioral intervention, sincethe situational environment would then be the only route to improving theactivity patterns of elderly women.A theoretical framework was sought which would attend to the cognitivebeliefs of the older woman about exercise. If a woman places little value on thehealth outcomes of exercise, feels unskilled in popular fitness pursuits, has fewfriends or little social reinforcement to be more active, perceives the risks tobe of more import than the benefits, and believes that she cannot improve herhealth or life outcomes by her involvement, then she would not very likely be aphysically active individual. On the other hand, a physically active woman maybe one who wants to live a long an healthy old age, who feels that physicalactivity is a low-risk and sure way to promote this goal, who feels physicallyconfident to participate in fitness pursuits, and who knows that she will beencouraged to do so by others. This is the multi-hypothetical stance governingthis t d 128The Synthesis of Theory: The Composite ModelThree main theoretical perspectives - Social Cognitive Theory, SocialEpidemiology, and Health Locus of Control Theory provide important elements forconstruction of a Composite Model of exercise behavior. The model is "acomposite" in the sense that the structure combines biological, social andpsychological constructs found across the research to be potentially explanatoryof a health behavior such as leisure-time physical activity. Moreover, thetriangular model of ENVIRONMENT (situational attributes) - PERSON (cognitivebeliefs) - BEHAVIOR (leisure-time physical activity in the past week) proposedby Bandura (see Chapter 2-78) is preserved.For ENVIRONMENT, the Composite Model provides a detailed socio-environmental context; features such as age, health, ethnicity, education,socioeconomic status, family size, marital status, and work role are potentialforces which can provide windows of opportunity or overwhelming barriers to humanbeliefs and behavior (see Chapter 2-39).Representing the PERSON, the Composite Model presents four key constructsof Social Cognitive Theory which have demonstrated predictive ability in healthbehavior research: 1) the incentive to take action, 2) positive and negativeexpectations about the outcomes or consequences of the action, 3) socio-environmental cues which encourage the action to take place, and 4) self-efficacyto successfully undertake the action. In the Composite Model as it is applied tolate life exercise behavior, the incentive to take action is the motive to livea long and healthy life. Self-efficacy is interpreted as adult movementconfidence to undertake six fitness types of exercise. Perceived social supportto exercise represents the "environmental cue" or reinforcement for late life129exercise. Outcome expectations are interpreted as perceived risks and perceivedbenefits of participation in fitness types of exercise. The model adds animportant cognitive construct, health locus of control, which has demonstratedsuccess in predicting preventive health behaviors.In addition to eight situational variables, childhood movement confidenceand childhood social support are included in the model to represent past masteryexperiences and early situations of opportunity. If retrospective childhoodmeasures predict late life exercise, tentative evidence will be provided thatolder adult exercise participation may be rooted in early development andsocialization of people. Adding the early origins of efficacy and environmentalcues were thought to theoretically strengthen the Social Cognitive Theoreticalmodel for its application in explaining adult physical activity (Figure 3.0).In the next section, the sixteen constructs of the Composite Model arepresented along with acknowledgement of the literature which supports theirinclusion as explanatory variables of exercise behavior. The ten life situationalvariables are presented first, followed by the six cognitive variables. Asummary of the theoretical framework concludes the chapter.130Figure 3.0 The Composite Model of Elderly Female Physical ActivitySituationalEnvironmentAgeHealthEducationWork RoleMarital StatusNumber of ChildrenCultural BackgroundSocioeconomic StatusChildhood Social SupportChildhood Movement ConfidenceCognitiveBeliefsHealth IncentiveRisk a Benefit Outcome ExpectationAdult Movement ConfidenceAdult Social SupportHealth Locus of ControlBehaviorLeisure-timephysical activity131Life Situational VariablesAn hypothesis advanced to explain women's lack of participation in regularand vigorous exercise is that "personal and societal barriers or obstacles in thelives of women make it difficult for them to exercise" (Yoshida, Allison &Osborn, 1988). Dishman (1990) documents as many as 44 variables that are possibledeterminants of exercise behavior (Dishman, 1990, p.93). Under "personalattributes," education, white-collar occupation, past exercise participation, andperceived good health are positively linked to current activity behavior. Under"environmental factors," past family influences and school programs arepredictive of physical activity. In another study, Yoshida and colleagues (1990)report that lack of time due to work, cost and access to programs, family sizeand family responsibilities are structural barriers to regular exercise for women(Yoshida, et al. 1988).Chapter 2-37 reviews the ten situational variables most likely to explainlate life exercise behavior. In brief, the research literature has found thatphysically active women tend to:1) be younger (Brooks, 1988; Ishii-Kuntz, 1990; Mobily, Lemke, Drube, Wallace,Leslie & Weissenger, 1987; Maddox & Eisdorfer, 1962; Ostrow & Dzewaltowski,1986), not middle - aged (Unkel, 1981),2) be single or widowed (Altergott, 1988; Brooks, 1988; Canada Fitness Survey,1983; Fasting & Sisjord, 1985; Ishii-Kuntz, 1990);3) be better educated (Brooks, 1988; Godin & Shephard, 1987; Health & WelfareCanada, 1988; Sallis, Haskell, Wood, Fortmann, Rogers, Blair & Paffenbarger,1985; Unkel, 1981; Yoshida et al., 1988);1324) be employed or 5) have good income and higher socioeconomic status (Boothby,Tungatt, & Townsend, 1981; Brooks, 1988; Calnan, 1986; Eggers, 1988 (negativeassociation with employment); Gale, Eckhoff, Mogel, & Rodnick, 1984; Health &Welfare Canada, 1988; Stephens, Jacobs & White, 1985);6) be generally healthier and fitter (Boothby et al., 1981; Burckhurdt, 1988;Ishii-Kuntz, 1990; Kolanowski & Gunter, 1988; Thomas, S.P., 1990), or believethey are in quite poor health (Morgan, Shephard, Finucane, Schimmelfing &Jazmaji, 1984; Rechnitzer, 1989);7)be geographically / culturally / racially differentiated (Ishii-Kuntz, 1990;Stephens, Jacobs, Jr., & White, 1985; The Perrier Study, 1979);8) have smaller family size (Fishwick & Hayes, 1989; Yoshida et al., 1988);and more freedom and time (Fasting & Sisjord, 1985; Yoshida et al., 1988);9)have lifelong habits and competencies for physical activity (Fishwick & Hayes,1989; Godin, Valois, & Shephard, 1987; Rikli & Busch, 1986); and,10) have been encouraged at a younger age in physical activity (Greendorfer,1983; Greendorfer, Blinde, & Pellegrini, 1986; Greendorfer & Lewko, 1978).Other important explanations for late life exercise are likely to come frompsychobehavioral constructs of Social Cognitive Theory and Health Locus ofControl Theory. Six cognitive beliefs were chosen for representation in theComposite Model and are discussed below. For more information on Social CognitiveTheory and Health Locus of Control, the reader should consult Chapter 2.133The Cognitive VariablesIn this study, the PERSON is linked to the behavioral variable (thecriterion) of LEISURE-TIME PHYSICAL ACTIVITY (exercise level in the past week)through five beliefs about health and exercise: four SCT beliefs and health locusof control (Figure 3.1):Figure 3.1 The Cognitive Variables related to Social Cognitive Theory andHealth Locus of Control Theory* HEALTH INCENTIVE (Incentive to Act)* RISKS / BENEFITS (Outcome Expectations)* MOVEMENT CONFIDENCE (Efficacy expectations)* SOCIAL SUPPORT (Environmental cues)* HEALTH LOCUS OF CONTROLThe following section interprets the cognitive constructs as they are applied tothis study.Health IncentiveBandura's "incentive to act," behavioral goal or motive is represented inthis study as the incentive to live a long and healthy life (Health Incentive).Setting goals for maintaining or improving health is considered to be a keydeterminant in explaining why adults might take up health-promoting exercise inlate life. For example, individuals who highly value their health, and also value134the future effects of physical activity, are hypothesized to make a significanteffort to maintain or initiate a more active lifestyle."By representing foreseeable outcomes symbolically, future consequencescan be converted into current motivators and regulators of behavior"(Bandura & Cervone, 1983).The capacity to exert self-influence by setting personal challenges and re-evaluating one's own goal attainments provides an important cognitive mechanismof motivation (Bandura & Cervone, 1986). "Motivation through pursuit ofchallenging standards has been the subject of extensive research on goal setting"(Bandura & Cervone, 1986, p. 92). Motivation based on standards involves acognitive comparison process.When people commit themselves to explicit standards or goals, theperceived negative discrepancies between performance and the standard theyseek to attain create self-dissatisfaction that serves as a motivationalinducement for enhanced effort. Activation of self-evaluative reactions byinternal comparison requires both personal standards and knowledge aboutone's performance level. (Bandura & Cervone, 1986, p.92, 93).If this study finds that older women with health problems are more active thanhealthy women, this could be interpreted as a self-dissatisfaction with one'shealth. Social Cognitive Theory would hypothesize that falling short of one'spersonal health goals would then act as additional motivation for engaging inhealth-promoting forms of physical activity.Few studies have examined the hypothesis that values for sustained healthmay predict exercise behavior. One study has particular relevance to the health-value hypothesis. Petersen-Martin and Cottrell (1987) used the Rokeach ValuesSurvey and the Martin Index of Health Behavior with 83 males and female studentsaged 17 to 49. Twenty-five percent of the sample ranked health as their mostimportant, or second most important value, and 43% of the sample ranked healthin their top four values. Petersen-Martin and Cottrell expected that people withhigher self-concept might exhibit better health behaviors, but this outcome was135not supported. Only one significant difference was found between persons withdiffering values for health. "Persons who placed a high value on health exercisedmore than persons who placed a low value on health" (p = .006) (Petersen-Martin& Cottrell, 1987, p.8).For older women, the motivation to live a long and healthy life seems tobe a logical prerequisite to pursuing health-maintaining behavior. Logically,women who feel that they have little reason to live much longer, or to expectbetter health, may have less incentive to achieve health-promoting levels ofphysical activity. Supporting the association between value for health and healthbehavior, Kristianson (1985) has found that respondents who reported goodpreventive health behavior in a mail survey, also valued health more than didthose who reported poor preventive health behavior. She,warns that health valueis more likely to be predictive of behavior involving a direct, rather than anindirect risk to health, such as drinking and driving, or wearing adequateclothing for the weather.Outcome Expectations of Late Life ExerciseWhile susceptibility to risk of illness and disease is under-rated by mostpeople (Weinstein, 1984), perceptions about susceptibility to harm from exerciseparticipation is common (Del Monte, 1985; Heitmann, 1982; Lindsay-Reid & Osborn,1980; Monahan, 1986; Waller, 1985a, 1985b). Women in particular seem to downplaythe benefits of physical activity and have heightened anxieties about vigorousexercise even though incidents of sudden death are almost universally a malephenomenon (Ragosta, Crabtree, Sturner & Thompson, 1984). The reader is referred136to Chapter 2 for extensive reviews about the known risks and benefits of physicalactivity for adults of all ages.Exercise is a complex, time-consuming and high effort behavior - one thatat times requires discipline and commitment. Active adults may already havedeveloped certain positive expectations about the value of exercise in theirlives which is adequate compensation for the effort involved. Similarly, inactiveadults may have developed negative outcome expectations that act as barriers totheir participation. Social Cognitive Theory hypothesizes that beliefs about theexpected positive and negative consequences of exercise would be importantdeterminants of exercise participation. Bandura (1989, p. 1178) states that,people avoid potentially threatening situations and activities, notbecause they are beset with anxiety, but because they will be unable tocope with situations that they .negard as risky. They take self-protectiveaction regardless of whether they happen to be anxious at the moment.(Bandura, 1989. p. 1178)Explored in the Composite Model guiding this research study are theimportance of the perceived health benefits and the perceived health risks ofparticipating in fitness-type of exercise situations. In this study, older womenare asked to evaluate their expected risks and benefits in six exercise settingswhich are reflective of community program offerings or at home fitnessactivities. SCT would hypothesize that the perceived risks and benefits,representing negative and positive expected outcomes of exercise, would beimportant determinants of exercise participation. More specifically, SCT wouldsupport the hypothesis that adults who perceive personal benefits fromparticipation in exercise, and who perceive little risk of harm, would be morelikely to be physically active.Part of this construct reveals the public and private knowledge thatindividuals have acquired about these activities and also reflects their137perceived ability to participate safely. Even though the health benefits ofregular exercise may be publicly known, several researchers claim that olderwomen may feel particularly vulnerable to injury or exaggerate the risks tohealth in physical activity settings (Calnan & Johnson, 1985; Heitmann, 1982;Siscovick, LaPorte & Newman, 1985).Perceived Benefits and Risks of Exercise Participation While there is little evidence to support the idea that older adults maybe aware of the benefits of physical activity, participation in Seniors Games andgeneral physical activity is on the rise. Interest in more intense activitiesseems to be growing as evidenced by various community and regional sportdevelopments in whiCh older women and men are seeking strenuous physicalchallenges that require months of conditioning, technical skill, first-rateequipment and expert instruction (O'Brien Cousins & Burgess, 1992; U. of Agers,1990).The perceived benefits of physical activity participation may be distortedfor women who have been warned throughout their lifespan about the reproductiveconsequences that accompany physical exertion on the body (Vertinsky, 1990). Thesocial justification for women to exercise has primarily been for weight control,perhaps not so much for health reasons as for beauty's sake. Traditionally,female beauty has been considered an important precursor to successful partneringwith men, and successful partnering with men has been, until recently, the onlyroute to elevated social status for women. Thus a female's greatest perceivedbenefit may be maintaining her "physical attraction" despite natural agingprocesses. Believing that her youth cannot be retrieved and with physical strain138ever more present, many older women may see little benefit in undertakingvigorous physical activity.Some activities may be perceived to be more beneficial for older adultsthan others, although it is doubtful that adults are necessarily attracted toprograms solely on the basis of these differences. For example, participation insafely implemented high-risk activity is thought by programmers to be superiorto low-risk activities in fostering cooperation, confidence, self-esteem and asense of empowerment, but older adults may not necessarily agree (Alessio, Grier& Leviton, 1989; O'Brien Cousins & Burgess, 1992). Still, recreationalprogramming for older adults has not been well researched in terms of the roleof adventure and risk-taking on positive/negative outcomes. As yet, there is noway. to tell if increasing the challenges and interest level of older adultsprovides comparable increases in perceived benefits that would make participationworthwhile.Data providing information on the perceived (and actual) benefits and risksare nonexistent, even for the six most frequently utilized activities in theUnited States - walking, jogging, swimming, cycling, calisthenics and racquetsports. Empirical data about the most common activity for all ages, walking, isabsent. Furthermore, dose-response, or how much exercise is associated with howmuch benefit/risk, needs to be explored in more detail.Such effects need to be explored at various points in the life span andthe benefits and risks cannot be considered in isolation. It may benecessary to study them separately, but the overall effect of physicalactivity on the health of the population requires that both be known, bothbe studied with equal care, and that both be considered dispassionately.The potential overall beneficial impact of physical activity on healthwill be poorly served if activity patterns are recommendedindiscriminately for all groups without regard for the subgroup-specificbenefits and risks. (Powell & Paffenbarger, 1985, p.121)139Defining Perceived Risks of Exercise Participation According to Giovacchini (1983), "safe behavior" is defined as 'freedomfrom unreasonable risk or significant injury under reasonable foreseeableconditions of use'. He further defines "risk" as 'the chance of getting hurt,losing, failing, or placing one's self in a dangerous or hazardous condition'.This kind of definition, if applied in the sport and physical activity setting,may be interpreted to mean that every activity has one or more risks associatedwith it, or at least a situation of zero risk is unlikely in most humanundertakings.Risk perceptions are thought to vary depending upon one's point of view,value system and personal priorities. As such, risk is meaningful only as it isself-defined, and therefore risk is as real as is the person's perceptions whois defining it. The problem with such self-defined risk is that highly motivatedindividuals are often unrealistically optimistic about their personalsusceptibility to hazards while sedentary adults are often negatively biasedabout their personal odds (Weinstein, 1984). These "why it won't happen to me"perceptions appear to be highly resistant to change, even when new scientificinformation is provided that should counter that view.Estimates about personal risk are likely carved out of past experience andone's perceived competence in a given situation. For example, a physicallycapable older woman may be wary of carrying out her daily walk in an unfamiliarcity while another woman may judge the traffic and pollution to be moredetrimental than the benefits of a walk. Still another may worry that gettingbreathless or provoking angina is her primary risk or may worry about falling onicy pavement if the weather is inclement. These are examples of risk perceptionsthat create self-defined barriers to a regular walking program.140The fact that everyone faces risks and hazards does not mean that we areall accurately evaluating risk and making good decisions about personal safety.On one hand, the hazards confronting people in daily life are often externallycontrolled, and on the other, various risks are difficult to compare. As anexample, just "being old" could be considered to be a risk."Being old, for instance, is risky in that it introduces potential costsand dangers, but the attitude to 'being old' is likely to be of adifferent order from attitudes to climbing stairs" (Brearley, Hall,Jeffreys, Jennings & Pritchard, 1982, p.53).The present activities of older adults are thought to be a reflection oftheir beliefs about expected outcomes and self-perceptions of ability. Forexample, about 70% of older Canadians claim to be walking and gardening, but lessthan 20% claim to be swimming or cycling (Stephens & Craig, 1990). Of all agegroups, older adults are more likely to exercise alone (about 60%) and at home(40%). The reasons for these findings are not clear. Perhaps older adults aremore inclined to walk and garden because their energies would then be appliedconstructively to no-cost transportation or to accomplishing tasks around theirhome.A number of possible psychological, social and situational barriers maybe operating to prevent many older people from participating in cycling andswimming, or in activities outside of their homes. Many older adults do not ownswimsuits or bicycles; for many, lycra swimsuits and 21 speed dirt bikes are tooexpensive and beyond their needs. Swimming requires convenient pool facilitieswhile cycling requires paved terrain and good weather. In Canada, neither thefacilities, nor the weather, are often suited to participation.The elderly probably associate greater risks with these activities. Theymay fear traffic and the speed needed on roadways and possibly are concernedabout their ability to balance safely on bicycles; in swimming, adults must own141acceptable attire and be prepared to undress in public places. Older women arevulnerable to stares from young people in the locker room and on the pool deck.Further they must be confident about moving in water, even if the watertemperature is below their comfort level; they must feel able to swim well ifthat is the perceived expectation. With severe Canadian winters the norm in mostparts of the country, these two activities are not likely to be very inviting forolder adults as year-round activities.For older adults, understanding about the need for daily exercise isapparently improving, but overall, specific knowledge about the benefits andrisks of different exercise behaviors is lacking. When asked about why theyexercise, adults often can only reply that they "feel better" or "look better"(Canada Fitness Survey, 1982).Adults of all ages are warned to consult their physician before increasingactivity or taking up any new activity, and therefore the health-promotingmessage may be drowned out by this acknowledgement of what is likely a very smallrisk. The conscious effort by individuals to assess the nature and scale of thepossible hazards in order to make self-protective decisions is likely made "inan environment composed of all gradations of ignorance and fear" (Zuckerman,1983, p.v).Physical activity has been found to become less structured and more casualwith age (Stephens & Craig, 1990). Ironically people may become more and moreindependent from supervision in the exercise setting at the very life stageswhere they may also feel that they are at increased risk in exercise. However,casual participation does guarantee a sense of personal control over the "pace"of an activity and likely reduces perceptions of risk by removing socialpressures to "keep up" (O'Brien & Burgess, 1992).142Females participate at about half the rate of males in organized sport, andparticipate at about twice the rate of males in supervised activity (Stephens &Craig, 1990). This finding suggests that social support for safe participationin activity settings is required more by women while males seek support foractivity in higher risk settings. Yet, considering body fat patterns, males areat greater risk than women. Men are much more likely to weigh too much for theirheight and to have abdominal rather than low-trunk fat which place them atincreased risk of cardiovascular disease (Stephens & Craig, 1990). Still, menover the age of 45 are more likely than women to report obtaining encouragementfor activity participation and are more likely to report a sense of control overtheir ability to participate in regular activity. Females, on the other hand, aremore likely to report family pressures and a lack of energy as significantbarriers to being active (Stephens & Craig, 1990).Sofalvi and Airhihenbuwa (1992) have researched the impact of the media onpublic beliefs about health issues. The media has been keen to report incidencesof sudden death in the exercise setting, such as the death of exercise advocate,James Fixx. Educators concerns for contraindicated exercises combined with mediainterest on rare fatalities during exercise shows why certified fitness leaderstend to reinforce participation in supervised classes and give reason forreluctant exercisers to avoid physical activity altogether.Behaviors based on risk assessment and behaviors related to healthenhancement both seek to avoid personal harm. But while physical activityparticipation may have biological relevance to self-protection from disease, manyindividuals participate for entirely different social or psychological reasons(Thuen, Klepp, & Wold, 1992). Clearly specific, scientific information on theIs I •^•^ • !143in certain populations vulnerable to joint and cardiac stress, is badly needed.Without this information, misinformed outcome expectations will continue toundermine social support initiatives for increasing activity in aging adults.Age and Risk Perception A common perception exists that the elderly are afraid or incapable ofacting for themselves. They are considered helpless and hesitant with little tooffer the community. Sadly, many behave according to ageist expectations andsocial labels and perpetrate the self-fulfilling prophecy (Edgerton, 1986).Although older people are stereotyped as being more cautious, some research doesnot bear this out (Brearley, Hall, Jeffreys, Jennings, & Pritchard, 1982). InLittlewood's (1989) study on the elderly, 19% agreed with the statement that"regular exercise can do you more harm than good". While such data only scratchesthe surface of the risk perceptions of aging adults toward the risks and benefitsof exercise, these findings do lend support to the idea that lack of involvementin health-promoting exercise may indeed have much to do with people's overallassessment of benefit and harm.This study will be among the first to specifically assess the perceivedrisks and benefits of six forms of late life exercise in women as described inthe next chapter on methodology.Movement Confidence (Self-efficacy)Among the mechanisms of personal agency, "none is more central or pervasivethan people's beliefs about their capabilities to exercise control over eventsthat affect their lives" (Bandura, 1989, p.1175). Perceived self-efficacy is a144cognitive factor which appears to play an influential role in personal agency inways that affect motivation. As such, self-efficacy, or "people's judgements oftheir capabilities to organize and execute courses of action required to attaindesignated types of performances" is the most studied component of socialcognitive theory (Bandura, 1966, p.391).Self-efficacy beliefs affect thought patterns in self-aiding or self-hindering ways. A strong sense of efficacy is required to remain task-orientedin the face of judgemental failures. "Those who have a high sense of efficacyvisualize success scenarios that provide positive guides for performance"(Bandura, 1989, p.1176). Thus self-referent perceptions of efficacy are at leastpartly responsible for the kinds of challenges which people choose to undertake,how much effort they w.11 spend on that activity, and how long they willpersevere in the face of obstacles (Bandura, 1986, 1989)."When faced with difficulties, people who are beset by self-doubts abouttheir capabilities slacken their efforts or abort their attemptsprematurely and quickly settle for mediocre solutions, whereas those whohave a strong belief in their capabilities exert greater effort to masterthe challenge" (Bandura, 1989, p.1176).Maintaining motivation for life pursuits is thought to be fostered byadopting challenges in accordance with one's perceived capabilities and havinginformative feedback that supports these perceptions of capability. Thus,experiences of mastery strengthen perceptions of efficacy. Even cognitiveimagery (mental simulations) in which individuals visualize themselvescompetently executing an activity can enhance performance. Therefore, perceivedself-efficacy and cognitive simulations affect each other reciprocally. A highsense of efficacy fosters cognitive images of effective actions, while successfulexperiences with efficacious courses of action strengthens self-perceptions ofefficacy (Bandura & Adams, 1977).145Schunk and Carbonari (1984) acknowledge that competence is conceptuallysimilar to self-efficacy, but ability is only one of the possibilities along witheffort, luck and task difficulty that can explain success or failure of personalactions. Although those who view themselves as having high ability for a task arealso apt to feel efficacious for performing it, simply possessing the ability toperform a task does not guarantee a high degree of self-efficacy, nor iscompetent behavior likely to occur without adequate incentives (Bandura, 1977a,1977b).The "self-efficacy" element of Social Cognitive Theory has been highlysuccessful in the explanation of a host of health and behavioral outcomes eventhough the tools for assessing efficacy have varied from study to study(Strecher% DeVellis, Becker, & Rosenstock, 1986). People must have a robust senseof personal efficacy to sustain the persevering effort needed to succeed inphysical activity, exercise and sport settings. Self-efficacy, the belief thatone is able to perform a specific activity, is the most powerful andstatistically significant correlate of both walking and vigorous exercise amonga number of adult groups (Hofstetter, Hovell, Macera, Sallis, Spry, Barrington,Callender, Hachly & Rauh, 1991). Of interest to this study, perceived self-efficacy in the physical activity setting has predicted:1) positive mental health, self-esteem, and stress management (Davis-Berman,1989; Holahan & Holahan, 1987; Holahan, Holahan & Belk, 1984; Rogers, 1987;Ryckman, Robbins, Thornton, & Cantrell, 1982; Sonstroem, 1976; Wells-Parker,Miller, & Topping, 1990);2)pain management (Litt, 1988);1463) over -exertion (Ewart, Stewart, Gillilan, Kelemen, Valenti, Manley & Kelemen,1986; Ewart, Stewart, Gillilan, & Keleman, 1986) and strenuous performance(Bandura & Cervone, 1986);4) skilled motor performance (Brody, Hatfield & Spalding, 1988; Crawford &Griffin, 1986; Feltz, 1988; Griffin & Crawford, 1989; Griffin & Keogh, 1982);5) competitive sport performance (Barling & Abel, 1983; Feltz, 1988; McAuley &Gill, 1983; Roberts, Kieiber, & Duda, 1981; Weinberg, Gould, & Jackson, 1979;Weinberg, Yukelson, & Hackson, 1980; Weiss, Wiese, & Klint, 1989);6) explanations of competitive sport performance (Duncan & McAuley, 1987);7) eating and other preventive health behavior (Sallis, Pinski, Grossman,Patterson, & Nader, 1988; Waller & Bates, 1992);8) attendance at a fitness program (Howze, DiGilio, Bennett, & Smith, 1983);9) physical fitness and activity behavior (Atkins, Kaplan, Timms, Reinsch, &Lofback, 1984; Dzewaltowski, 1989; Ewart, Taylor, Reese & DeBusk, 1983;Hofstetter, Novell, Macera, Sallis, Spry, Barrington, Callender, Hackley, & Rauh,1991; Kaplan, Atkins, & Reinsch, 1984; Marcus, Selby, Niaura, & Rossi, 1992); and10) indices of physical fitness (Neale, Sonstroem, & Metz, 1970; Thornton,Ryckman, Robbins, Donelli & Biser, 1987).Furthermore, efficacy in physical activity settings may be directlyobservable by others (Keogh, Griffin, & Spector, 1981), enhanced by experienceand practice (Hogan & Santomier, 1984; Kaplan, Atkins & Reinsch, 1984; McAuley,Courneya & Lettunich, 1991) and even generalizable to other performance relatedsettings (Hogan & Santomier, 1984). Efficacy expectations for exercisesituations are stronger for males and younger adults (Duda & Tappe, 1989).147Social Support to ExerciseOf interest to this study are the socializing forces or cues that might beperceived by an older woman relative to her exercise behavior -- perceptions ofendorsement, approval, advocacy or encouragement for physical activity. In broadterms, these socializing forces could reflect the processes of the family and thecommunity, as well as the larger forces of society, in influencing differingroles, age norms, behaviors and lifestyles of men and women (Hobart, 1975;McPherson, Curtis, & Loy, 1989).Expectancies about how others may view a behavior brings into play asocially normative variable called social support affecting whether one mightparticipate in late life physical activity, exercise and sport. In this study,the local environment is considered to be a source of immediate social supports,such as friends and family. Social feedback from friends, family, andsignificant others provide cues for reinforcement and discrimination (Perry elal., 1990). In this respect, social support can be thought of as a "socialefficacy to be physically active." For women, affiliative benefits have beenemphasized as important personal incentives for physical activity involvement(Duda & Tappe, 1989).Social support to exercise in late life is thought to be an important"environmental cue" for older women since some of those who plan to meet theirfitness requirements with their choice of daily exercise may well experience:1) disapproval from their spouse (Andrew, et al., 1981; Dishman, 1986; Perusse,LeBlanc, & Bouchard, 1988; Snyder & Spreitzer, 1973; Stephens & Craig, 1990; Tait& Dobash, 1986);2) lack of peer interest and companionship (Hauge, 1973);1483) discouragement by the immediate family (McPherson, 1982; Spreitzer & Snyder,1973; Spreitzer & Snyder, 1983); and4) inadequate encouragement from physicians (Dishman, 1986; Gray, 1987; Powell,Spain, Christenson, & Mollenkamp, 1986; Wechsldr, Levine, Idelson, Rohman &Taylor, 1983).Health Locus of ControlCombining Health Locus of Control Theory with Social Cognitive Theory hasbeen advocated as an important theoretical step (McCready & Long, 1985). Despiteinconsistent findings in the literature, health locus of control is theoreticallyimportant to include in the model guiding this study for this reason: an olderwoman may be highly motivated to live a long and healthy life, but if sheperceives she has little control over her health (external HLC), she is unlikelyto take on a health-promoting behavior such as exercise.A fatalistic attitude was uncovered in a survey by Littlewood (1989) inwhich 69% of the elderly agreed with the statement "there is no point worryingabout a heart attack - you can't prevent it". Loss of appetite (43%) andconstipation (40%) were as much associated with ageing as was mental illness(42%). If elderly people see certain health events as inevitable functions ofaging, they are therefore less likely to act on them. With application to thestudy of late life exercise behaviour, health locus of control theory wouldhypothesize that older adults who keenly value their health and longevity, andwho believe that they have some degree of positive control over their health by149participating in exercise, would be more likely to be found engaging in late lifephysical activity.Summary of the Theoretical Framework A Composite Model of explanation has been proposed for this research whichexplores the situational and cognitive determinants of late life exercise inwomen over the age of 70. The Composite Model provides some advantages over othermodels in that:1) a comprehensive assembly of beliefs derived from Social Cognitive Theory andHealth Locus of Control Theory are examined.2) a comprehensive list of personal and situational variables are explored.3) several types of social support have been incorporated.A detailed explanation of the application of this model are provided in thenext chapter on study design.150IV. DESIGN OF THE STUDYThis chapter includes the detailed methodology used to test the CompositeModel and includes: survey questionnaire construction; measurement andvalidation of the outcome variable; discussion of the interpretive variables;measurement and coding of life circumstance variables and cognitive mediatingvariables; the pilot study; the sampling procedure; the data collection protocol;a second sampling procedure; and procedures used in the data analysis.Survey Questionnaire ConstructionDescriptionThe survey instrument was a booklet composed of questions which weredesigned to assess the many constructs of the Composite Model: 1) the tensituational variables (age, marital status, education, economic status, health,school location, work role, number of children, childhood movement confidence andchildhood social support for physical activity); 2) the five theoretical elements(health incentive, perceived risks and benefits, adult movement confidence, adultsocial support, and health locus of control); and 3) measurement of the leisure-time exercise in the past week.Questionnaire construction was guided by Statistics Canada's Development and Design of Survey Questionnaires (Platek, Pierre-Pierre, & Stevens, 1985) withconsideration given to the older adult reader wherever possible. For example, alarger than normal reading size font was used to assist readers, some of whomwere likely to have visual difficulties. The questionnaire, stapled inside abright pink cover, included a title page with an explanation of the study, a151carbon-backed consent form and 22 pages of questions, well-spaced, to facilitatereading (see Appendix A).The questionnaire conformed to the requirements of the Human Ethics ReviewCommittee of the University of British Columbia (see Appendix B). A number ofinstruments were included in the questionnaire which have been widely used. Theirvalidity and reliability are reported later in this chapter. Instruments designedfor this study have a reported test-retest reliability and concurrent validityvalue.The outcome variable, exercise status in the past week, was assessed usinga newly designed instrument. The Older Adult Exercise Status Inventory combinesa number of positive attributes from other seven-day recall instruments used. Areview and critique of the literature pertaining to these instruments can befound at the end of the Review of Literature. The inventory provides moredetailed assessment of physical activity than most instruments and accounts forthe unique activities of older adults as recommended by Washburn, Jette, andJanney (1990).To facilitate comparisons among studies, Gordis (1979) recommends uniformwording of questions. Standardized questions such as those used on the CanadaFitness Survey (1983) and the General Health Survey (1985) assessed lifesituational measures on items such as age, PARQ health symptoms, number ofmedications, self-rated health status, marital status, and education. In additionto these, I designed questions on cultural background: country of main schooling,socioeconomic status, employment activity, number of children and childhoodsocial support to be physically active. I assessed childhood movement confidenceusing the format of a validated stunt movement confidence inventory and creatingment cdllyd "MuvemenL C onfidence as a child.".152I designed four of the six instruments used for the cognitive measures ofthe study: health incentive, perceived risks with exercise, perceived benefitswith exercise, and social support to be physically active. Adapting the formatof a stunt movement confidence inventory, I created a new instrument called"Movement Confidence Now" to assess adult movement confidence. Health locus ofcontrol was measured using a validated instrument which has been widely used inhealth promotion research.The Older Adult's Exercise Status InventoryDescription Exercise status (ENERGY) in total kilocalories was the criterion measureused for this study. For this study, a seven-day recall instrument is designedto assess the type, duration, frequency and level of intensity of the physicalactivities of older adults (See Appendix A).The design brings together the strengths of a number of instruments whichhad been used in prominent epidemiological research projects (Blair, 1984;Paffenbarger, Hyde, Wing & Hsieh, 1986; Canada Fitness Survey, 1988; Taylor,Jacobs, Schucker, Knudsen, Leon & Debacker, 1978). In general, the Older Adult'sExercise Status Inventory (OA-ES') used in this study compromises some instrumentbrevity for increased detail and rigor than in other studies which have used theseven-day self-report. The OA-ES' is among the first physical activity assessmenttools to quantify the specific exercise patterns of adults over age 70.The Canada Fitness Survey (1988) used an inventory called "PhysicalActivity in Your Spare Time" for recording the activities of individuals over anentire year. This inventory excludes many activities where seniors are active 153such as curling, line dancing, horseshoes and darts. Another criticism of thisinventory is that recall over a full year may be too difficult for adults of anyage. Still, the column-row style combined with a seven-day recall format appearedto have merit. Compared to the CFS Inventory and the Physical Activity Index(PAO used by Paffenbarger, Wing and Hyde (1978), the OA-ES' is age-relevant andmore comprehensive in documenting types of exercise participation.As with the CFS Inventory, the OA-ESI examined exercise as a form ofleisure behavior, and therefore did not include domestic work, nor employed workactivity as part of the weekly energy estimate. The work energy of women ondomestic tasks has, unfortunately, received little interest by researchers. Atleast two studies claim that domestic activity accounts for much of women's dailyphysical activity and must be documented in the future (Cauley, LaPorte, Sandler,Schramm & Kriska, 1987; Mattiasson-Nilo, Sonn, Johannesson, Gosman-Hedstroem,Persson & Grimby, 1990).The OA-ESL is a two-page inventory which prompts subjects with categoriesorganized in columns by the seven days of the week and organized in rows by alist of 38 physical activities. The 38 activities were considered age-appropriatesince they were chosen for the list from personal observation and experience withthe activities available to older women in Edmonton and Vancouver.The 38 activities provided a comprehensive list of leisure-time physicalpursuits likely to closely reflect older adult's types of exercise involvement.Two open categories called "Other" accommodated any other activities that werenot already included on the main list. These exercise categories acted as memoryprompts and were listed alphabetically from "aerobic fitness class" to "walking(no sweating)". Aquacize activity was subdivided into "vigorous" and "gentle",cycl ing, gardening, 1v yymy and wdlkiny were subdivided into "sweat-154inducing" and "no sweating". The purpose of the sub-categories was to reduceerror in estimating the intensity of a particular activity and thereby improvethe estimate of the criterion variable, weekly energy spent on exercise. To aidprecision, subjects were asked to report the "time spent in minutes" for eachactivity on each day.Reliability of the OA-ESI As a test of reliability, the 0A-ESI was administered twice in a four-weekperiod to 16 older women from Edmonton (mean age of 67). Pearson Product Momentcorrelations (rp)were used for interval and ratio data; Spearman Rank ordercorrelations (r e) were used for ordinal variables such as school location,marital status, education, and work role. Out of several self-reported activitymeasures, only mild exercise demonstrated poor reproducibility (r p = .114; n.s.)and undermined the reproducibility of the total amount of exercise reported(rp = .340; p = .198). Moderate exercise was reported more consistently (r p =.756; p <.001) while vigorous exercise was only moderately reliable (r p = .505;p <.05).^(See The Pilot Study).Ironically these inconsistent findings for mild exercise patterns providesupport for construct validity. The initial survey and retest were conducted inthe four weeks of September during which the pilot sample entered various fallsport and fitness programs. Thus substantial changes in the nature of physicalactivity occurred over the four-week pilot study. Many of the women in the pilotstudy were re-initiating participation in structured, supervised and vigorousforms of exercise and forfeiting some of their less structured and milder summeractivities at that time of year. In this regard the piloted questionnaire wassensitive to these changes in activity patterns of the 16 women. In doing so,155self-reported activity as measured by the OA-ES' appeared to demonstrate weakreproducibility, but, at the same time, validated the known changes inparticipation. This phenomenon provided a degree of confidence that the seven-day recall had adequate sensitivity to be administered to a larger sample.Validity of the OA-ES' The Older Adult's Exercise Status Inventory (OA-ES') used in this studyintegrates the best assessment strategies of the other validated surveyinstruments for physical activity and thus is considered to retain adequatevalidity. Moreover, as a simple record of daily exercise involvement, the OA-ES'has demonstrated adequate construct validity in the pilot study by representingwhat was known to be seasonal changes in exercise patterns (see the above"Reliability of the OA-ESI").Concurrent validity is demonstrated by examining the correlations of ENERGYin kilocalories with other concurrent activity indicators on the same OA-ES'survey. For example, ENERGY (total of weekly kilocalories based on self-report)had a correlation of rp = .403 with LIFESTAT, a subjective question aboutlifelong activity status similar to that used by Godin, Valois, and Shephard(1987). This question was worded, "How would you describe your physical fitnessactivity over your entire life course?" (See page 4 of the questionnaire inAppendix A). The five response choices were reduced to two for dummy coding: 1= Currently active, 0 = Not currently active.To another subjective question used by Godin & Shephard (1982), "How oftendid you participate in vigorous physical activities long enough to get sweatywithin the past four months?", the present ENERGY score correlated r p = .411(p <.UUU1).156Exercise activity has been shown to decline with age and poorer healthstatus. In this study, ENERGY supported this relationship with an r p = -0.226(p <.0001) with age and rp = .222 (p <.0001) with a positive health self-rating.These relationships provide evidence for construct validity.Use of the OA-ESI The F.I.T.T. formula is used in Canada by fitness and lifestyle counsellorsto account for frequency, intensity, type of exercise and time spent on exercise.All four variables are considered useful measures of exercise involvement andtherefore were considered to be essential measures in this study. Thus the OlderAdult's Exercise Status Inventory specifically assessed: type of exercisereported, intensity of exercise reported (MET units), total duration of exercise(hours of activity), and total number of exercise sessions (frequency). The typeof exercise reported was used two ways: first to provide descriptive informationon the activity preferences of older women, and second, to estimate moreaccurately the energy expenditure of each type of activity."Amount of exercise in the past week" was calculated using reportedmetabolic charts giving MET units for physical activities (Cantu, 1980; Passmore& Durnin, 1955; Taylor, Jacobs Jr., Schucker et al., 1978; Wilson, Paffenbarger,Morris & Havlik, 1986). The MET is the ratio of working metabolic rate toresting metabolic rate and is a convenient method of expressing energyexpenditure (Sallis et al., 1985). It can be thought of as the ability of anindividual to tolerate multiples of their resting energy level (Astrand, 1992,personal communication).One MET = 1 kcal/kg/hour, an equivalent of one kcal of energy expended byd 60 kg. person sitting for one minute. MET units account for the intensity of157the activity, the duration of the activity as well as the body weight of theindividual (if they are not too different from 60 kg.). For sake of convenience,many studies assume an average body weight of 60 kg., meaning that the averageindividual, sitting at rest, spends about 60 kilocalories per hour or 1.0kilocalorie/kg./hour, or 1.0 MET.From the information provided on the OA-ESI, a number of dependent measureswere identified: total energy in kilocalories spent on reported exercise in thepast week (TOTKCAL); total kilocalories spent on reported exercise but adjustedfor individual body weight (ENERGY); total kilocalories spent in three intensitycategories of exercise, from mild (<4 METS), and moderate (4 to 5.9 METS) tovigorous forms of exercise (>6 METS). These three exercise intensity measureswere called MILDKCAL, MODKCAL and VIGKCAL. Also the total number of hours ofactivity (ACTHOURS) and total number of separate exercise sessions (TOTSESS) overthe seven days were counted.There is some debate whether the weight of an individual should be used inthe calculation of energy expenditure, since the MET unit is meant to be ametabolic ratio, independent of body weight. The work/rest ratio method assumesthat a task performed by a heavy person raises metabolic rate to the same extentas the same task performed by a person weighing less, even though the caloricexpenditure might be different (Reiff, Montoye, Remington, Napier, Metzner &Epstein, 1967). In the Five City Project, researchers suggested that themeasurement of exercise in "kilocalories per kilogram per day was not anacceptable measure for overweight populations" (Sallis et al., 1985, p. 95).Being overweight added to the energy estimate of exercise and was considered tonegatively affected the reliability of their self-report data.158In the present study, however, the MET units were calculated according toindividual body weight (according to personal advice from Dr. R. S. Paffenbarger,Jr., April 19, 1991). Thus the duration of each activity reported in minutes wasrecorded along with the individuals's body weight (kg) so that total kilocaloriesspent on exercise accounted for portions of an hour as well as individualdifferences in body size.Where the reported MET estimates differed in the literature, the moreconservative estimate was used. The MET unit was multiplied by the individual'sreported participation time in hours over the seven days for each activity andadjusted for body weight in kilograms.ACTIVITY STATUS (KCAL) = Duration x Intensity x Body Weight= X minutes/60 (hours) x MET unit (kcal/kg/hr) x weight (kg)= kilocaloriesTotals for mild, moderate and vigorous exercise categories were calculated.All three categories were then summed, thereby providing a seven-day ExerciseStatus (ENERGY) measure in the form of kilocalories spent on exercise in the pastweek.EXERCISE STATUS (ENERGY) = Reported Mild Activity + ModerateActivity + Vigorous ActivityThe MET units used for the 3R activities in this study arc in Table 4.0.Table 4.0Metabolic Units of 38 ActivitiesActivity Type MET Unit'Aerobic Fitness Class 6.0Aquafit/Aquacize Class (Vigorous) 7.0Aquafit/Aquacize Class^(Gentle) 4.0Badminton 5.5Bicycling outdoors 4.0Bicycling indoors^(sweat-inducing) 6.0Bicycling indoors^(no sweating) 4.0Bowling^(any kind) 3.5Calisthenics 4.5Canoeing or kayaking 3.5Curling 3.0Dancing^(Square,^tap,^folk) 6.0Dancing^(Ballroom,^ballet) 5.5Dancing^(Line,^Hawaiian) 5.0Darts,^Billiards,^Pool 2.5Gardening^(sweat-inducing) 6.0Gardening^(no sweating) 4.0Golf 5.0Gymnastics or rhythmics 6.0Hiking hilly terrain 7.0Horseshoes 3.5Jogging^(sweat-inducing) 8.0Jogging (no sweating) 6.0Rebounding (trampoline) 6.0Rope skipping 8.0Rowing (machine) 6.0Skating^(ice or roller) 7.0Stair climbing for fitness 8.0Stretching exercises 3.5Swimming^(gentle) 5.0Swimming^(non-stop lengths) 10.0Table Tennis 4.0Tai^Chi 3.5Tennis 6.0Walking^(sweat-inducing) 4.0Walking^(no sweating) 3.0Weight Training 6.0Yoga 3.5159The metabolic estimates were compiled using reported metabolic charts asdescribed on page 4-7.160Interpretive VariablesA number of questions were asked to provide support and understanding ofthe criterion variable. These were as follows:Normal Activity Level (TYPICAL)Subjects were asked "How typical was this past week in terms of your normalactivity level?"( ) more activity than typical( ) quite typical( ) less activity than typicalThese were dummy-coded into "typical week" (0) or "not a typical week" (1).Change in Activity Level (CHANGE)A second question assessed changes in level of physical activity in thepast five years. Response choices were:( ) Significantly decreased( ) Somewhat decreased( ) Not changed( ) Somewhat increased( ) Significantly increasedWith dummy-coding, responses which indicated no change or an increase in activitywere labelled "no decrease" (0) and "decreased" (1).Participation in the Past 4 Months (PAST4MON)A question from Gaston Godin's (1982) survey instrument (unnamed) from theSchool of Physical and Health Education at the University of Toronto wasincluded. Since a number of studies have reported stronger relationships betweenconcurrent criteria when subjects self-report more vigorous forms of exercise,161it was logical to include a question which captured such vigor. Subjects wereasked "How often did you participate in vigorous physical activities long enough to get sweaty with the past four months?" Response categories were:( ) not at all( ) less than once a month( ) about once a month( ) about 2 to 3 times a month( ) about once a week( ) two or more times a weekGodin, Jobin and Bouillon (1986) reported on a concurrent validation studyfor this question on 32 male and 29 female volunteers aged 19 to 66 years. A two-week test-retest reliability coefficient was .64. Values of maximum oxygenintake, body fat and muscular endurance, expressed in percentiles of appropriateage and sex categories, were used as concurrent criteria validity. Correlationcoefficients between reported physical activity in the past four months were r= .38; p <.001 for maximum oxygen intake, r = .43, p <.01 for body fat and r =.54, p<.001 for muscular endurance. This is in agreement with Siconolfi and co-workers who also demonstrated that a simple "sweat" question taken fromPaffenbarger's Physical Activity Index Questionnaire had concurrent validity ofr = .60 with self-reported physical activity over the past week (Siconolfi,Laseter, Snow, & Carleton, 1985).In the pilot study, no relationship was found between test and retest ofthis question on 16 older Edmonton women (r s = .048; p= .861). The reliabilityappeared to have been undermined by substantial changes in exercise patterns dueto the time of year.162Life Situational MeasuresIntroduction The role of an individual's life circumstances in creating opportunitiesand incentives, and in creating obstacles and barriers, are recognized aspossible determinants of exercise behavior. The literature reviewed in Chapter2 suggests that habitual physical activity patterns are likely if the individualis male, younger, economically secure, of a higher educational level, of lowerbody mass and in good health.Less is known about the role of ethnicity and cultural background, maritalstatus, family size and domestic/employment status although they are thought tobe circumstances that are likely to be important at certain life stages inexplaining activity patterns. In the following section, the contextual variablesused in this study and the instruments chosen to measure them are identifiedalong with their eight-character computer label in brackets. Test-retest Pearsoncorrelation coefficients are also included from the pilot study on 17 olderwomen.Age (AGE)Age was obtained by subtracting the year of birth from 1990 as reported inthe question "In what year were you born?" (Test-retest rp (AGE) = .998;p<.0001).Culture (SCHOOLOC)Cultural background was obtained from a checklist of countries whichrespondents used to reply to the question, "In which country did you completemnct of your schooling as a child?"163(1) Canada(2) United States(3) Britain(4) Japan(5) Germany(6) China(7) Italy(8) Scandinavia(9) OtherCulture was dummy-coded as "English-speaking country" (1) which includedthose schooled in Canada, Britain and the U.S. and "foreign language speakingcountry" (0) which included all other countries. Test-retest r s (SCHOOLOC) = .926(p<.0001).Socioeconomic Status (COMPSES)Three questicins were asked:1) Do you feel financially secure for the remainder of your life? (SECURE)2) Are you able to handle unexpected expenses with no worry? (NOWORRY)3) Which of the following financial assistance do you receive? (INCOME)( ) None( ) Guaranteed Income Supplement (GIS)( ) Spouse's Allowance/ Widowed Spouse's AllowanceTo the first two questions, respondents answered "yes", "not sure" or "no". Thesewere dummy coded as "Yes" = 1, and "Not sure" or "No" = O. The women reportingreceipt of the Guaranteed Income Supplement (GIS) and or Spouse's Allowance wereexpected to have more marginal financial resources since their economic statuswould have already been determined by the Government of Canada. Dummy coding forquestion 3 was: "No GIS" = 1; GIS/Allowance = O. Test-retest reliabilities were:rs (SECURE) = .778; p<.0001; r s (NOWORRY) = .763; p<.001; r s (INCOME) = .562;p<.03.164These three economic indicators were standardized and pooled usingprincipal components analysis to provide a composite indicator of socioeconomicstatus:COMPSES = .867 (No financial worry) + .866 (feeling secure) + .364 (noGIS) / 1.637 (eigenvalue).Marital Status (MARITAL)Five standard categories were provided for marital status: single (nevermarried), common-law partner, married, widowed, and separated/divorced. Test-retest rs (MARITAL) = 1.0. These were re-coded into dummy variables of"partnered" (1) and "unpartnered" (0).Education (EDUCATIO)Eight forced-choice categories covered various levels of years and type ofschooling from:1) No schooling2) Grade 1 to 43) Grade 5 to 84) Some high school5) Completed high school6) Business or trade school7) Some university or college8) University or college degree(s)Test-retest rs (EDUCATION) = .797; p<.0001. These eight levels were dummy-codedinto "less than highschool graduation" (0) and "at least highschool graduation"(1)165Work RoleThe survey asked: "What kind of work situation best describes you from age35 to 65? (Pick only one).(0) No paid employment(1) Part-time or intermittent full-time employment(2) Steady full-time employmentThe test-retest rs (WORKROLE) = .886; p < .0001. Dummy coding scored never-employed women a (0), while women reporting part- or full-time employmentscored (1).Family Size: Number of Children (CHILDREN)The question "Which domestic situation best describes your adulthood?"provided choices of "on my own", "homemaker, no children", and "Mother of children". A domestic role variable (not used in the regression analysis) wascoded "mother" (1) or "no children" (0). The number of children was the numberreported. Test-retest rp (CHILDREN) = 1.0.Health Variables Self-Rated Health (HEALTH)In this study respondents were asked to describe their current state ofhealth from (1) "poor", (2) "fair" (3) "good" to (4) "excellent". Ratings rangedfrom 1.0 to 4.0. Test-retest reliability for self-rated health of 16 olderEdmonton women in the pilot study obtained an rp (HEALTH) = .506; p<.046. Thescale, while considered reliable and valid in younger populations, may be lessuseful in the very old. For example, some of older adults might increaseactivity levels to combat a known disease, while others might significantlydeck-pace Activity to "reserve their strength".166Physical Symptoms (SYMPTOMS)The Physical Activity Readiness Questionnaire (PAR-Q) is a yes-no screeningdevice used by Fitness Canada to eliminate high-risk exercisers. Five questionsevaluate physical symptoms of "heart trouble", "frequent pains in your heart andchest", "often have spells of severe dizziness", "doctor has said your bloodpressure is too high" and "other good physical reasons why you should notexercise...". An individual who scores a "yes" (1) on any single item isconsidered to be at higher level of risk for fitness exercise participation thana "no" (0) response and is recommended for exclusion from physical fitnesstesting (Fitness Canada). Symptoms were additive so that total symptoms reportedranged between 0 to 5. The test-retest reliability in the pilot study of olderwomen was .667 (p < .005).Perceived Well -Being (TOTPWB)A 14 item, seven point Likert scale type of instrument (strongly agree tostrongly disagree) called the Perceived Well-Being Scale (Reker & Wong, 1984)assessed physical and psychological well-being. Scores could range from 14 to 98.The pilot study obtained a test-retest rp (TOTPWB) = .565; p < .02) over a fourweek period. The scale included two subscales: psychological well-being(PWBPSYCH) and physical well-being (PWBPHYS). Reliability of the subscales were.604 for PWBPSYCH (p <.05) and .590 for PWBPHYS (p <.05).Medications (MEDICINE)Subjects were asked how many prescription medicines they were taking thatrequired a written prescription by their doctor. Scores could range from 0 to 7167(seven medications or more). A test-retest reliability of .857 (p <.0001) wasobtained in the pilot study.The Composite Health IndexSince health was represented by four variables (self-rated health, PARQ,number of medications and the Perceived Well-Being Scale), a composite variablewas created using weights derived from Principal Components Analysis. Thecomposite health variable correlated r p = .324; p = .0001) with Exercise Levelas calculated from the equation:COMPOSITE HEALTH = .801 Well-Being - .782 PARQ + .749 Self-Rated Health - .740 Medicine/2.362Body Mass (Quetelet Index) (HEIGHT; WEIGHT; BODYMASS)Body height and weight were self reported and converted to metric for usein a formula to calculate a body mass index. This variable was used in thedescriptive data only.^Body mass is only an indicator of proportional orrelative weight, not fatness. In sedentary people however, body mass is usuallyconsidered an indicator or adiposity. Body mass index was calculated asfollows:BODYMASS- Weight v kilogramsHeight 2 meters 2168Childhood Movement Confidence (CHILDMOV)This variable was viewed as a measure of predisposing context, rather thana current mediating variable. The 'Movement Confidence As A Child' (MCC) scaleretrospectively evaluated childhood movement confidence as perceived confidenceand experience to engage in six childhood physical skills. Childhood MovementConfidence, in this study, is a measure of self-efficacy which is reinforced by"habit" or at least considerable experience with successful performance.The MCC scale was adapted from a contemporary instrument called the 'StuntMovement Confidence Inventory' (SMCI) which assessed a) perceptions of personalcompetence for performing a task, b) experience in performing a specific task,and c) perceived potential for physical harm during the performance (Griffin &Crawford, 1989). However, "perceived movement confidence as-a child" (CHILDMOV)is built on Griffin and Crawford's theoretical model with some alteration. TheMCC scale used in this study omitted Griffin and Crawford's measures for"perceived enjoyment" and "potential for harm" since they were alreadyrepresented in the Integrated Model with Bandura's construct "outcomeexpectations (perceived benefits and risks of exercise). As with Griffin andCrawford's study, the skills were portrayed in picture form (See Appendix A).In this study, for each of the six recalled physical skills,individuals were first asked about their movement confidence in childhood: "Howsure are you that you could have done this as a youth?" and this was scored "Verysure" (4), "Pretty sure" (3), "Not very sure" (2) and "I know that I couldn't"(1). Secondly, the survey asked "how many times would you have done this as ayouth?" and this was scored "I have done this a lot" (4), "I have done this a fewtimes" (3), "I tried it once" (2), and "I've never done this" (1). Scores forchildhood movement confidence and eAperienLe were summed and averaged (Range =1691 to 4 for each of six exercise skills). Thus MCC scores could range from 6 to24.Test-retest reliability over four weeks was examined in the pilot study onolder women and the MCC scale produced an extremely strong coefficient ofrp (CHILDMOV) = .951; p <.0001.The SMCI has components of Harter's Perceived Competence Scale forChildren, an instrument which had originated from her factor analysis of variouselements of competence (Harter, 1982). She hypothesized that perceived competence...should be positively related to one's^intrinsic motivationalorientation to prefer challenge, to be curious, and to engage inindependent mastery attempts. (Harter, 1982, p. 94)Higher order factoring revealed that perceived cognitive competence was stronglyrelated to preference for challenge (r = .57), to independent mastery ( r = .54),and moderately related to curiosity (r = .33). These four variables formed adistinct factor with high loadings of .76, .87, .80 and .79 respectively.Emphasis was placed on this factorial (construct) validity which remained stableacross this grade range.Harter found stable patterns in Grade 3 to 6 children who consistently(over 6 different samples) identified four theoretically meaningful components:cognitive competence, social competence, physical competence and general self-worth. The internal consistency of her physical competence scale across allsamples was .77 to .86 while test-retest correlation was .87. Teacher's ratingsof physical competence correlated .62 with pupils' own self ratings. Discriminantvalidity was supported in that participants of school athletic teams scoredsignificantly higher on perceived physical and social competence.That same year Griffin and Keogh (1982) published a significant theoretical emen s: se^O...^aloe_^ I^II^•170assessed competence, potential for enjoyment and potential for harm. Theelements of competence, enjoyment and harm were incorporated into the PlaygroundMovement Confidence Inventory (PMCI) published by Crawford and Griffin in 1986.The PMCI was tested with 250 fifth-grade students using a cluster samplingprocedure. A test-retest reliability coefficient was .78 with the Grade 5 schoolchildren.The PCMI was validated using significant discriminant functions (p <.05)which classified subjects above chance levels into experience/confidence cellson the basis of systematic response variation to the movement confidence model.Classification accuracy ranged from 77.87% to 92.62%. Cross-validation of thePMCI was achieved through splitting the original n into estimation (60%) andholdout (40%) samples. The function values obtained from the estimation samplewere applied to the holdout sample with the following classification results: avalidity coefficient (r = .9768) was obtained with 84.65% classificationaccuracy or a 49.51% improvement over basic chance.Using the same response format, but different physical skills, the SMCIscale was then designed. Meant for contemporary boys and girls, SMCI used "stick"drawings of people performing risky physical stunts such as skateboarding overa ridge and cycling over a hill (Griffin & Crawford, 1989). Test-retestcorrelations with the SMCI were .82 for self-report experience and .80 for self-reported confidence with the task. Test-retest correlations for competence,enjoyment and harm were .88, .79 and .85 respectively.For the empirical cross-validation procedures, discriminant analysis wasused to determine total scale classification power. Regression weights developedon one group (an estimation group) were applied to a second group (a holdoutsample). Application of the regress jun weiyhis derived from the estimation sample171to the holdout sample data set resulted in a validity coefficient of r = .98 withan 88.2% classification accuracy.In this study the MCC scale retained the SMCI rope climb and bike ridingwith slight modification (feet on the rope and no aerial phase on the bike) andreplaced the SMCI roller skating, skate boarding, stilts and pogo stick jumpingwith other challenging play elements that would have been available to some younggirls in the early twentieth century. The MCC represented six physical challengecategories of trunk strength, arm strength, aquatic activity, leg power, hipflexibility and balance.Childhood Social Support to Exercise (CHILDSOC)Four questions with five-point Likert scales were designed toretrospectively examine childhood social support for exercise. Four recallquestions were asked relative to: 1) family athleticism (FAMSPORT), 2) personalencouragement by a parent, teacher or friend (CHLDHELP), 3) childhood opportunityto participate in vigorous physical activity in one's free time (OPPORTUN) and4) enjoyment of physical education, exercise and sport at school (PEFUN). Thescales represented important theoretical elements in the literature. In thepilot study, the scale for childhood social support in physical activitydemonstrated good reliability (rp =.785; p <.0001).172The Cognitive VariablesThe Integrated Model of Exercise Behavior suggests that there are fivebeliefs or cognitive perceptions that one might consider in deciding whether toengage in exercise in their later years. These are: Health Incentive, MovementConfidence, Social Support, Outcome Expectations (Perceived Risks and Benefits)and Health Locus of Control. These five beliefs were measured as follows:Health Incentive (MOTIVE)A variable called Health Incentive represented Bandura's theoreticalelement called "incentive to act." This construct assumed that if older adultswere exercising, it was for reasons of maintaining or improving health andlongevity. Health Incentive was measured by four statements about prolonginghealth and longevity. These were:"I don't really care how much longer I live" (LIVECARE)"I am motivated to avoid illness any way I possibly can" (AVOIDILL)"I am trying to live as long as I possibly can" (LIVELONG)"I am trying to stay healthy as long as I possibly can" (HLTHLONG).Four-point Likert scales were used to score responses: Strongly agree (4), Agree(3), Disagree (2), and Strongly disagree (1), except the first statement whichwas reverse-scored. Scores could range from 4 (low motive to live a long andhealthy life) to 16 (high motive).^The scale showed adequate test-retestreliability in the pilot study (r s = .559; p <.03).173Adult Movement Confidence (ADULTMOV)The 'Movement Confidence Now' (MCN) scale evaluated adult movementconfidence as perceived confidence and experience in six adult physical fitnessactivities. The MCN scale was similar to the MCC scale but had wording to reflectthe present tense, and evaluated whether each of the six specified fitnessactivities were done in the past year. Scores for adult movement confidence andexperience were summed and averaged (Range = 1 to 4). Therefore the MCC and MCNscales would each provide scores between 6 (low confidence + low experienceaveraged) and 24 (high confidence and high experience averaged). The MCC and MCNscales were approximately matched for representative physical categories of trunkstrength, arm strength, aquatic activity, leg power, hip flexibility and balanceas described in Table 4.1.174Table 4.1Movement Skills Estimating Movement Confidence and Past Experience Movement Category^MC as a Child'^MC Nowb1. Trunk strength2. Arm strength3. Aquatic activity4. Leg power5. Hip flexibilitySwing by the knees(KNEECONF; KNEEEXP)Rope Climb(ROPECONF; ROPEEXP)Dive into deep water(DIVECONF; DIVEEXP)Jump from high object(JUMPCONF; JUMPEXP)Splits(SPLITCON; SPLITEXP)Curl-up 10 times(CURLCONF, CURLEXP)Knee push-ups 5 times(PUSHCONF; PUSHEXP)Aquafit class (50 min.)(AQUACONF; AQUAEXP)Brisk walking (20 min.)(WALKCONF; WALKEXP)Toe touch(FLEXCONF; FLEXEXP)Cycle for 20 min.(BYCCONF; BYCEXP)6. Endurance, balance^Ride a two-wheel bike(BIKECONF; BIKEEXP)' Movement Confidence as a Child is a recall measure.b Movement Confidence Now is a current measureThe MCN scale represented activities which contemporary seniors wouldlikely find in their communities in exercise programming for older adults. Wherepossible, MCN items attempted to closely represent the MCC child activity inadult form. For example, stationary exercise cycling (as an adult) matchedoutdoor bike riding (as a child), aquafit exercises (as an adult) matched divingand swimming in deep water (as a child), jumping from a high box (as a child) wasreplaced by the leg power required for brisk walking (as an adult), and a sittingforward stretch (as an adult) represented flexibility to do the splits (as ac ild175Validity was not directly tested, because the MCN scale was a modifiedversion of a previously validated instrument (the SMCI). Furthermore, the MCNscale used clear illustrations of the performance requirements of the activitieswhich should have maintained face validity. Test-retest reliability for the MCNscale was rp = 0.799; p <.001 in the pilot study.Adult Social Support to Exercise (ADULTSOC)Prospectively, four items, matching childhood social support were wordedalong the same lines to assess adult social support for exercise: 1) familysupport (FAMSUPP), 2) encouragement by at least one person to be active(ADULTHLP, 3) peer involvement in physical fitness activities (FRENDACT) and 4)physician endorsement for vigorous activities in late adulthqcd (DOCSUPP). Eachquestion used a forced-choice format ranging from 1 to 5 (strongly disagree tostrongly agree). Total scores could range from 4 (low support) to 20 (highsupport).In the pilot study, reproducibility was poor for the adult social supportscale. It appeared to be undermined by substantial seasonal changes in thephysical and social activity of the pilot group from August to September.Consequently the test-retest reliability for adult social support was low andnon-significant (r p = .372; p = .156).Perceived Risks and Benefits of MCN ExercisesThe fifth cognitive mediator in Social Cognitive Theory was the OutcomeExpectation. In this study, the risks and benefits as outcomes from currentexercise participation were rated as perceived outcomes. An example of one of176the six items was "Please rate the possible risk to your health of doing a 50minute aqua-fit class".Five-point continuous Likert scales "(1) low risk...(3) moderate risk...(5)high risk" and "(1)low benefit...(3) moderate benefit...(5)high benefit"accompanied each adult exercise in the MCN instrument. This provided six ratingsof perceived risk and six ratings of perceived benefits which were thenseparately summed to represent "Total Perceived risk" (TOTRISK) and "TotalPerceived Benefit" (TOTBENE).Open ended statements concluded each exercise section of the MCN scalewith: "The major risk for me would be " and "the major benefit for mewould be ..In the pilot study, the perceived benefits of the six adult movement skillswere reproduced within a four week period with rp (BENEFITS) = .837; p <.001.This was an encouraging indicator that the scale was highly reliable. However,perceived risks of the six movement skills gave an r p (RISKS) = .266 and did notreach significance. This finding is hard to explain, but may indicate asensitivity of the perceived risk scale to the seasonal change in activity thatthe women experienced between test and retest. The mean risk declined from 10.15to 8.39 at retest - a reduction in perceived risk that may have accompanied theirrenewed involvement in activity.Health Locus of Control (TOTHLC)Health locus of control was added to the theoretical model as a fifthcognitive variable because recent studies suggest that individuals would not belikely to undertake health promoting behavior if they felt they were unable topromotetheir177The Health Locus of Control Scale (HLOC) of Wallston, Wallston, Kaplan andMaides (1976) uses eleven Likert items (6 points from strongly agree to stronglydisagree) to assess internal versus external sense of control over one's health.Internal locus of control is an attributional style whereby an individualperceives that they are in control of an outcome. External locus of control isfound in individuals who believe that an outcome is due to fate, chance or luck.The original 1976 scale was used for this study because it was shorter than the1978 version and more statements were relevant to health and exercise.The HLC scores range from 11 to 66 with lower scores meaning "internality"and higher scores meaning "externality". According to locus of control theory,"internals" would be more likely to take steps to better their personal conditionthan would externals. Therefore, in a program designed to modify health-relatedbehaviors, one might expect internals to be more successful than externals whosebeliefs are leaning toward helplessness. Internality has been associated withhigher levels of leisure-time and sport behavior in women (Bonds, 1980; Calnan,1988; Carlson & Petti, 1989; Dishman & Steinhardt, 1990; Kleiber & Hemmer, 1981;Laffrey & Isenberg, 1983; Lee, 1980; McCready & Long, 1985; Perri & Templer,II,1984-85;), but externality seems to accompany aging and declining health (Calnan,1988; Kist-Kline & Lipnickey, 1989; Lumpkin, 1985).Wallston et al. (1976) reported a mean score of 35.57 (sd = 6.2) forcollege students with internal reliabilities of .72, .54, .50, and .40 on variouscollege and community populations. The scale was reported to have a concurrentvalidity of r =.33 with Rotter's I-E scale. Moreover the scale was claimed notto discriminate by gender nor reflect a social desirability bias.178The Pilot StudyIn mid-December, 1989, three anonymous women in their late nineties wereinterviewed using the prototype questionnaire as an interview guide. Next,Gladys Hartley, a retired professional figure skater and dance teacher,critically evaluated the initial questionnaire for readability and comprehension.Finally, the questionnaire was also reviewed by Dr. Gloria Gutman, Director ofthe Simon Fraser Gerontology Centre, as well as the members of the ResearchSupervisory Committee. I made numerous revisions according to their advice duringthe first half of 1990.At the end of August, 1990, the questionnaire was piloted with 18 olderwomen from the "U. of Agers" Women's Gymnastics Team (average age 68) at Hinton,Alberta during the Alberta Seniors Games. Subjects in the pilot study repeatedthe same questionnaire two to four weeks later in Edmonton and these were mailedback to me at the end of September. A serious car accident forced one woman intohospital so that only 17 women were retested. After the second administration ofthe questionnaire, statistics on the reliability of the subjects to reproduce thesame information were calculated. Test-retest correlation coefficients andprobability levels for all variables are reported in Table 4.2. Pearson ProductMoment correlations (r e) were used for interval and ratio variables; Spearmancoefficients (r e) were used for marital status, education, work role, and schoollocation.Women were 100% reliable in reporting marital status and number ofchildren. The majority of measures were highly reliable with many correlationsin the range of .70 to 1.0. The criterion variable, moderate exercise, was highlyreliable (rp = .756, p < .001). Weak and non-significant correlations were found179in five of 24 variables: total amount of exercise; amount of mild exercisereported; adult social support; perceived risks; and health locus of control.Lack of reliability in reported exercise was initially a concern. Howeverreproducing these women's activity patterns during the particular four weeks ofthe pilot study proved to be difficult under the circumstances. Since the U ofAgers fall classes resumed after the summer recess (in the interim period of theadministration of the two questionnaires), it is not surprising that these threevariables demonstrated an inconsistency. The questionnaires were, however,reflective of these altered activity patterns in the early fall.Indeed, closer examination of the test-retest data for total weeklyexercise level indicated that variance more than doubled from test to retest (S 2= 392.1 to 968.2). Although moderate exercise reported was highly reliable, itwas evident from the self-reports that some women engaged in less mild activitiesand more vigorous activity in late September than in late August. The alteredexercise status reported on the second questionnaire coincided with renewedinvolvement in the fall gymnastics program. The timing of the retest, then, isprobably responsible for the decreased and inconsistent reporting in the mildexercise category (r p = .114) and the increased and inconsistent reporting in thevigorous exercise category (rp = .505). Although the total of mild activityreported showed a decrease at the retest, this change was insignificant (t =0.541; p = .597). Therefore it appears that low test-retest coefficients may bemore an issue of real lifestyle changes than a reflection of the quality of thesurvey instrument.Changing activity patterns may also explain the inconsistent reporting inperceived social support, perceived risk and health locus of control.Examination of the means indicated no s ignifiLdul change in level of social180support from test to retest; however, the variability was reduced noticeably onthe second questionnaire (S 1 2 = 21.116 and S 22 = 6.729). In other words, at thetime of the second questionnaire, the women perceived more similar levels ofsocial support. It is possible that a few women perceived less social supportduring the summer months when the group was on recess, and that by lateSeptember, everyone was back together and perceiving similar social incentivesto exercise together.In terms of perceived risk, a similar phenomenon occurred. Perceptions ofrisk at the retest were significantly reduced (t = 2.570; p = 0.26) and variancereduced (S 1 2 = 5.074, S 22 = 3.912). The reduced risk perceptions accompanying theresumption of seasonal exercise programs reported on the second questionnairemight be related to the resumption of the supervised activity program. Thereforeit is possible that reliability in reporting risk perceptions was undermined byreal changes in perceived level of risk that occurred over the month ofSeptember.The lack of consistency in reporting mild exercise, social support,perceived risk and locus of control were in conspicuous contrast to the high andsignificant correlations of all the other variables examined and appeared to bedue to known seasonal changes in lifestyle.Table 4.2Correlation Coefficients and Significance Levels for Test-Retest DataTYPE OF MEASURE TEST-RETESTCORRELATIONPROBABILITYLEVELAge r= .998 p<.0001Marital Status rs=1.000 p<.0001Number of Children r=1.000 p<.0001Education rs= .792s^. p<.0001Work Role rs= .886 p<.0001School Location rs= .999 p<.0001Height r= .998 p<.0001Weight r= .679 p<.004Self-rated Health r= .506 p<.046PARQ Symptoms r= .667 p<.005Perceived Well-Being r= .565 p<.028Number of Medications r= .856 p<.0001Childhood Social Support r= .785 p<.0001Child Mov. Confidence r= .951 p<.0001Health Incentive rs= .660 p<.025Adult Mov. Confidence r= .779 p<.001Adult Social Support r= .372 n.s.Perceived Risks r= .226 n.s.Perceived Benefits r= .837 p<.001Health Locus of Control r= .472 p<.077Mild Exercise r=-.114 n.s.Moderate Exercise r= .756 p<.001Vigorous Exercise r= .505 p<.046Total Amount of Exercise r= .340 p<.198181182Selection of the SampleThe Population Women who were born in 1921 or earlier were the target population of thisresearch. One difficulty in surveying older adults is that a substantialminority are simply not well enough to participate. This study purposely excludedthe very ill and institutionalized older women - women who represent about 8 to10% of this age cohort. Also excluded were women who had adequate health, butwere not venturing into their community at the time of the study. Thus, the biasinherent in studying the well-elderly further exaggerates the statement:If gerontology has a central message, it is that those who have survivedto old age often represent a special case. (Branch & Jette, 1984,p.1128)Prohibitive costs required that the study be limited further to situationswhere surveys could be distributed and collected without mailing. Thus thepopulation under study was delimited to women, age 70 and over, who could befound in Metropolitan Vancouver regularly attending community programs.There were a number of difficulties associated with surveying this targetpopulation. First, Canadian women in this age group feel vulnerable toexploitation by business groups, and indeed, in the Vancouver area, to twouniversities who are interested in gerontological research. Many of the womenrefused to fill out the survey questionnaire because they had "already beenresearched to death".Second, there were a number of women who had never been involved in surveyresearch before and were immediately suspicious of the intent of the study.Several looked at the survey briefly and could not see any personal value totheir involvement in this type of research. Often a second explanation wouldLorivince some women to take part, especially it one of the "ring-leaders" of a183particular group appeared to endorse the project. Although the survey wasanonymous and did not ask them for specific income levels, several women feltthat it was "too personal" for them to participate.Almost 20% of the questionnaires were returned empty and eventually"recycled" to other volunteers. Follow-up phone calls to those women who changedtheir mind about participating revealed the following excuses: the survey was toomuch bother; they felt simply too busy to participate; the questions were "toopersonal;" exercise was of no importance at their age; the survey questionnairewas lost or thrown out; the questionnaire was left at the program site; they hadforgotten to fill out the survey; they couldn't remember anything about thestudy; the questionnaire was too long; they came down with an illness or seriousaccident; their spouse had become seriously ill; they were not exercising andtherefore did not feel worthy of participation; they had filled it out andthought it had been returned, and so on.Sampling ProcedureThe Strategic SampleThe purpose of the survey was to examine and explain the physicalactivities of elderly women who were mobile in their communities. With thispurposive sample, I intended to survey all eligible women who were willing toparticipate.The sampling procedure first required identification of all communityfacilities where seniors could be found in formal and informal programs andsocial groups. All available seniors programs publicized in the City of VancouverCommunity Resource Directory for Seniors, Fall Recreation Program Guide '90, TheVancouver Courier Fall Program Guide '90 and the B.C. Tel Yellow Pages were184documented. From these public resources, a comprehensive list of 120 older-adultfacilities (program sites) and seniors residences (but not extended care centres)was identified for Greater Vancouver. This list was then reduced to 69 sites bydelimiting to only those located in the Metropolitan Vancouver city boundaries.These metropolitan boundaries were Georgia Straight on the north, the PacificOcean on the west, the Fraser River on the South and Boundary Road on the east(See Figure 4.0).Rubin and Babbie (1989) note that in field research "controlled samplingtechniques are normally inappropriate" (p.343). Although a probability samplewould have been appropriate, it was not possible for this survey due to the cost.However, the principle of geographic representativeness was utilized.As with other cities, Vancouver has west to east bands of high, middle andlower socioeconomic status. To improve socioeconomic representativeness of thesample and to increase its heterogeneity, I employed a geographic clusteringstrategy. The 69 program sites were individually located on a City of Vancouverstreet map. Based on visual proximity to one another, I assigned sites to one of18 clusters with three or four sites per cluster. A random numbers table(Havilcek & Crain, 1988) was used to randomly select a representative site fromeach cluster. In this way 18 visitation sites were selected from the 18 clusters.To verify that the clusters and sites were distributed from all sectionsof the city, two roadways were identified which divided the city into quadrants.Oak Street is a major road dividing the city in half vertically from north tosouth (Figure 4.0). Nine (50%) of the selected sites were west of Oak Street andthe other half were to the east. King Edward Boulevard divides the cityapproximately in half horizontally. In the two northern quadrants, there were tensites, wh i l e e i ght sites were located in two southern quadrants.186Two site managers were not willing to participate and were replaced by twoother sites, each randomly drawn from the same geographic cluster. On average,the clusters incorporated facilities within a one to two mile radius. Thesmallest geographic cluster was in the dense downtown area of old Vancouver nearnorth Commercial Avenue. The Lions Den Seniors Centre represented this clusterwhich had four program sites in a 0.5 mile diameter area. The largest cluster wasin south-east Vancouver with four programs spread over the area approximately 3miles long and 1.5 miles wide. This cluster was represented by Champlain HeightsCommunity Centre (Table 4.3).Table 4.3Geographic Clusters and the Randomly Selected Sites CLUSTER GEOGRAPHIC AREA SITE NO. SITE^SELECTED1 Point Grey 9 UBC Aquatic Centre2 Dunbar 43 Dunbar Community Centre3 Kerrisdale 48 Kerrisdale Seniors Centre4 Kitsilano South 39 Canadian Memorial C.C.5 Kitsilano North 44 False Creek C.C.6 Vancouver General Hospital 52 Mount Pleasant C.C.7 Shaughnessey 4 Golden Age Club8 Langara 51 Marpole-Oakridge C.C.9 Killarney 50 Killarney C.C.10 Queen Elizabeth Park 35 Riley Park Rec. Centre11 Kensington/ Trout Lake 47 Kensington C.C.12 Boundary 56 Renfrew Park C.C.13 Commerical/PNE 17 North Health Unit14 Grandview 34 lions Den Rec. Centre15 S.E. Marine Drive 30 Champlain Heights C.C.16 City Harbour 60 YWCA17 Downtown 8 Vancouver Aquatic Centre18 West End 33 West End C.C./ Barclay187188Second Sampling Procedure: Convenience Sample A decision to employ a second sample was made after rigorous efforts toobtain a strategic sample size of over 400 women. The decision was made tosurvey more older women through a convenience sample with the help of universitystudents. Two graduate level education classes and one undergraduate psychologyclass were approached. These students were studying survey research techniques(education) and gerontology (psychology). The course coordinators approved myvisitation to their courses for research purposes and instructors announced theproject to their students as an optional educational experience.In each class, I explained the objectives and requirements of the study inabout 15 minutes. I specifically asked each student to consider takingresponsibility for seeing that one questionnaire was filled out by an olderfemale relative such as an aunt or grandmother, or by someone they knew in theirneighbourhood who was over age 70. The students were told that the survey couldbe given orally or left with the subject for a few days. A return date wasestablished and I left time for questions. Many students were enthusiastic aboutcontributing to a research project and accepted one or more questionnaires. Forthe education students, oral administration of the questionnaire was required bythe instructor so that students could experience guided interviews.Geographic area was not limited in the convenience sample and a fewstudents recruited subjects from locations as far as Nanaimo and the interior ofB.C. The majority, however, obtained subjects within the Greater Vancouver area.The quality and completeness of the questionnaires from the conveniencesample was generally superior to the strategic sample because the surveys wereindividually administered to a cooperative neighbour or relative. In most cases,ab well-known to the student, and the survey experience was enjoyed189by both individuals. Consequently, there were few items with missing data.Despite the good response for most students, a few students did not succeed infinding a single volunteer. Discussion with the students revealed that they hadmade an adequate effort in this regard, and this served to confirm that obtaininginformation from elderly populations is sometimes difficult.The students returned the questionnaires to me within four weeks time. Icompared the descriptive statistics of the two research samples and the pilotsample (Table 4.4). T-tests compared the convenience sample with the strategicsample for demographic differences in age, education, self-rated health, reportedmedical symptoms, number of medications, marital status, number of children,socioeconomic status, and activity status (Table 4.5). T-tests also assessed fordifferences in five cognitive mediators and the criterion variable (CurrentExercise Status).The convenience sample (N=47) did not differ significantly in demographiccharacteristics from the strategic sample, except for education and socioeconomicstatus. The convenience sample reported a significantly lower average educationallevel and a significantly higher socioeconomic status (Table 4.5). This was aninteresting finding because lower educational level is not usually accompaniedby with higher socioeconomic status.190Table 4.4Descriptive Characteristics of the Two Research Samples and the Pilot SampleELDERLY WOMEN CONVENIENCE SAMPLE STRATEGIC SAMPLE PILOT SAMPLESAMPLE SIZE 47 280 17AGE 77.7 76.4 66.5EDUCATION 31.9% > High School 56.7% > High School 94% > High SchoolHEALTH MEAN= 3.0 ("GOOD")81% GOOD OR BETTERMEAN= 3.1 ("GOOD")78% GOOD OR BETTERMEAN=3.3 ("GOOD")BODYMASS 24.1 24.0 23.1MARITAL STATUS 51.1% Widowed34.0% Married19.4% Other55.4% Widowed25.4% Married19.2% Other17.6% Widowed64.7% Married17.7% OtherCHILDREN 2.83 1.86 no dataSES (ASSISTANCE) 43.5% G.I.SUPPLEMENT 40.6% G.I.SUPPLEMENT 17.7% GISPARO SYMPTOMS 27.7% No Symptoms25.5% Heart Problems10.6% Angina10.6% Dizzy40.4% High B.P.42.1% No Symptoms29.8% Heart Problems14.6% Angina15.3% Dizzy41.0% High B.P.76.5% No SymptomsSCHOOL LOCATION 75.0% Canada13.0% Britain2.1% U.S.2.1% Germany2.1% Scandinavia6.1% All Others71.4% Canada14.3% Britain3.9% U.S.1.4% Germany2.5% Scandinavia6.4% All Others64.7% Canada5.9% Britain17.6% U.S.11.8% ScandinaviaLIFELONGACTIVITY STATUS6.5% = Never22.0% = Not Anymore2.2% = Just Recently19.6% = Intermittent22.0% = Always17.3% = Never14.0% = Not Anymore9.0% = Just Recently26.3% = Intermittent33.5% = Always0.0% = Never0.0% = Not Anymore11.8% = Just recently29.4% = Intermittent58.5% = AlwaysEXERCISE IN THEPAST 4 MONTHS12.8% Sweat 2 or moretimes per week64% never sweated21% Sweat 2 or moretimes per week50.4% never sweated87.5% Sweat 2 or Moretimes per week0% never sweated711 kcal 1578 kL.41^ 2150 kcalEXERCISE STATUS(KCAL)191The two samples differed on one cognitive mediator; the convenience samplewas significantly different in perceived social support (T = 2.861; p <.005) withthe strategic sample reporting higher levels of support. The convenience samplealso approached significance in perceived movement efficacy by reporting lessefficacy than the strategic sample.Comparing exercise status, or energy expended on exercise in the past week(Table 4.4), the original pilot sample was highly active, averaging 2150 kcal perweek. The strategic sample (1578 kcal/week) reported twice the activity of theconvenience sample (733 kcal/week). When the samples were merged, the averageweekly exercise level was 1496 kcal. Other studies have found that older womenaverage between 1050 to 1200 kcal per week in self-reported exercise (Cauley etal., 1987; LaPorte et al., 1983). Thus the combined sample was more active thanhas been found elsewhere. The convenience sample was more representative ofcensus data of Vancouver women in this age group for educational level andmarital status.Graphed frequency distributions of the original strategic sample were notvisibly altered by adding the convenience sample nor were regression analysesidentifying the key predictors of current exercise status substantiallydifferent. The samples were therefore pooled to make a total sample of 327subjects. The convenience sample made up 14.5% of the pooled sample.192Table 4.5Results of T-Tests on Key Variables Between the Strategic Sample and ConvenienceSample VARIABLES Strategic Sample (SAMPLE 1) Convenience (SAMPLE 2) TStatisticProbabilityN MEAN S.D. N MEAN S.D.Age 272 76.4 5.347 46 77.8 6.019 -1.456 p = 0.146Education 277 4.7 0.441 47 3.7 0.500 2.281 p = 0.023*Health 277 3.1 0.999 47 3.05 1.009 0.682 p = 0.496Symptoms 278 1.0 0.996 47 1.23 1.012 -1.413 p = 0.159Medications 278 1.4 0.968 47 1.9 1.151 -1.845 p = 0.066Bodymass 266 24.0 0.987 45 24.1 1.083 -0.147 p = 0.883Marital Status 280 -0.01 0.442 47 0.084 0.486 -1.379 p = 0.169Children 276 1.86 1.905 47 2.4 1.836 -1.729 p = 0.085Composite SES 271 -0.098 1.632 46 0.404 1.346 -1.976 p = 0.049*Work Role 276 0.670 0.471 47 0.787 0.414 -1.600 p = 0.111Well-Being 266 77.5 1.008 47 76.7 0.965 0.404 p = 0.687Adult Efficacy 246 14.6 1.002 47 13.4 0.965 1.759 p = 0.080Health Locus ofControl268 40.6 1.025 47 40.5 0.855 0.145 p = 0.884Health Motive 279 3.5 0.997 47 3.4 1.023 0.678 p = 0.498Current SocialSupport272 12.5 0.998 46 10.7 0.931 2.861 p = 0.005*PerceivedBenefits123 18.2 0.979 30 16.6 1.076 1.273 p = 0.205Perceived Risks 144 13.8 0.983 36 15.6 1.046 -1.617 p = 0.108CurrentExercise Status(kcal)266 1577.7 1459.93 47 733.4 762.920 3.405 p = 0.001*e* Denotes that the two samples were significantly di fferent from each other.193Data Collection ProtocolTo organize the data collection process, I created a research file listingeach program site, contact name, address and phone number. Information about eachsite included the weekly schedule of all the available seniors programs currentlyoffered at a single agency, a contact name for each program, helpful informationgathered from the site coordinator, a record of agency approval forms and arecord of the actual programs visited. Using the agency name, I organized thefile alphabetically to facilitate the retrieval of information for setting upformal visitations with agencies. A few days before the visit, I confirmed theprevious arrangements by phone with the agency coordinators and adjustments weremade if necessary.In early October, 1990, I contacted all the agencies both by letter andtelephone explaining the purpose of the study and requesting approval for theresearch to proceed. Accompanying the letter was the agency approval form and astamped self-addressed envelope for the prompt return of the approval forms. Iverified visitation schedules either in person, or on the telephone, with theagency coordinator. A few agency coordinators requested to see the questionnaireand meet with the investigator before approving the study. These meetings werecarried out with no rejections of the study.Once a site was approved by the agency as a data collection point, fullparticipation sampling occurred on a volunteer basis. Some of the selected siteswere very large facilities, such as Kerrisdale Seniors Activity Centre and theWest End Community Centre, with estimated registration of over a thousand seniorseach in their annual membership. Other centres located in the east end, such as194Renfrew and Kensington, offered relatively few programs for older adults andthese were sparsely attended.Each site demanded a slightly different visitation protocol, largelydepending on the number of programs offered, the number of seniors frequentingthe facilities, the cooperation and interest of the agency coordinator and aswell, the health and cooperation of the seniors. On many days, unusually heavyrains reduced attendance noticeably, and to compensate, extra visits to programswere made. For major community centres, a number of seniors programs would occurover the course of each day, and it was practical to stay on the site for theentire duration of each of week day. In other situations only one program forseniors was offered and I moved between sites to contact a number of theavailable seniors programs that day. In some cases I was able to give surveys towomen coming and going to their formal programs in casual settings such aslounges, hallways and lunchrooms on the site.Over a 10-week period, I personally introduced the study to over 2000 olderadults in the 18 research sites (Table 4.6). In many cases, the adults Iapproached were willing, but too young to participate, since many seniors wereunder the age of 70. Several men were disappointed the study was exclusive towomen. In other cases, very frail or very old individuals simply did not want tovolunteer.Fifty-eight individual seniors groups were contacted in total. These 58groups represented 30 different types of programs requiring 37 site trips (Table4.7).I was introduced, or introduced myself, to either a group or an individualand explained the nature of the study: over 480 questionnaires were given out totie wumeti w 10 were age-eligible and interested in participating. Participants195were asked to take the questionnaire home to fill it out and return it to theagency office or program staff the following week. Each agency was provided witha survey collection box which was kept secure inside the office headquarters.Most frequently a group of seniors were addressed during a research visit,but in any setting only a portion of the whole were females born in 1921 orearlier. Furthermore, not all eligible women were interested in participating forthe reasons expressed earlier in the chapter. Women who wanted to takequestionnaires home were anonymous participants but many recorded their name andphone number on a temporary list so that a reminder phone call could be made tothem if the questionnaire had not been returned by late December.At the end of eight weeks, only 90 out of the first 250 questionnaires hadbeen returned. Between mid-December and mid-January I telephoned subjects who hadnot yet turned in questionnaires. The phone contact strategy did bring in morequestionnaires to the collection boxes. In a few cases, women decided to mailthem in, and in other cases, I picked up questionnaires at private homes.From January to March, the distribution of questionnaires and follow-upphone calls continued. Dozens of questionnaires were returned blank without anyresponses. These were redistributed to other individuals. By early February, 230questionnaires had been collected from the various sites. Questionnairescontinued to be returned until mid-March, 1991. At this point, the returns endedand the survey concluded with 280 returns out of 486 questionnaires distributed.This was a 57.6% return rate, if we do not count the redistributedquestionnaires. This response fell far short of the projected sample size ofover 400 subjects.Table 4.6Chronological Distribution and Return of Questionnaires by Research SiteRESEARCH SITE DATEOF VISITCONTACTPERSONPHONE QUESTIONNAIREDISTRIBUTIONOUT INChamplain Heights Comm. Centre Oct. 12 M. Goodale 437-9115 15 15Renfrew Community Centre Oct. 16, 17, 18 J. Besdan 434-6688 21 11Downtown YWCA Oct. 18 P. Hunter 683-2531 1 1U.B.C. Aquatic Centre Oct. 21, Nov.6 L Grundy 228-4522 27 24Marpole/Oakridge Comm. Centre Oct. 23 M. Bates 327-8371 0 0Vancouver Aquatic Centre Oct. 30 S. Baskin 665-3424 12 7Riley Park Community Centre Nov.5, 7, 13, 14, 15, 16 K. Feay 879-6222 24 16Kerrisdale Seniors Centre Nov.6, 13, 19, 22, Dec.5 G. Pirie 266-1003 103 65Chalmer's Lodge Nov.6, 9 Mr. Estergard 731-3178 20 10False Creek Community Centre Nov. 7 J. Becker 665-3425 14 8Granville Park Lodge Nov. 8 T. Clarke 732-8633 8 8Golden Age Club Nov. 14 G. Levitt 266-9111 26 2Commodore Bowling Lane Nov. 16 V. Potter 873-6185 16 5West End Community Centreand Barclay ManorNov.20, 21, Dec. 3, 4 D. Chin 698-3876 89 67Canadian Memorial Society Nov. 28 A. Jarrell 732-1477 7 7Kensington Community Centre Nov. 16, 29 D. Stark 327-9401 8 6Lions Den Nov. 30 C. Innis 253-9716 16 8Dunbar Community Centre Dec. 4 A. Walkinshaw 224-1374 15 5Seniors 411 Centre Dec. 12 M. Melnyk 684-8171 7 0Unknown 57 16Facilities = 20 Visits = 37 TOTAL 486 280196Table 4.7Distribution of Questionnaires by Program Type PROGRAM TYPE SURVEYSOUTSURVEYSINBallroom Dance 4 2Bell-ringers 2 0Be Well Fun and Fitness 23 15Bingo 26 13Bowling, 5 Pin 15 9Bowling, Carpet 6 1Bridge 28 . 22Chocolate Making 5 1Choir 11 5Crafts 10 5Crossreach (Adult Daycare) 7 7Dance and Social 3 1Fitness Class, gymnasium 16 14Fitness Class, water 63 44Foamball Tennis 4 3French Lessons 2 2Line Dancing 38 20Lodges/Seniors Apartments 28 18Lunchrooms 11 6Oil and Water Painting 2 2Orchestra 1 1Osteoporosis Class 6 6Senior's Meetings 60 37Square Dance, Scottish Dance 11 11Swimming 1 1Tai Chi 6 3Tap Dance 6 1Walkers Club 8 5Weight Training 1 1Yoga 2 1Unknown 40 23PROGRAMS = 30 486 280197198Data PreparationMissing Data Missing data on one or more variables was a concern for almost everyquestionnaire - a problem that was not an issue in the pilot study. Missingdata was particularly injurious to the regression analysis because thesoftware program used listwise, rather than pairwise deletion of subjectsmissing data. This meant that an individual missing any data on the modelvariables was totally excluded from the analyses.Fortunately, most subjects had provided their phone numbers for thisvery kind of follow-up. Subjects with missing data were contacted bytelephone and verbal responses were obtained from those reached. The follow-up ended, if after three attempts, the respondent could not be reached. Thefollow-up calls proved to be an important way to correct for missing data.Cleaning the Data SYSTAT and SYGRAPH 5.0 (1991) were the software packages used toanalyze and graphically display the 162 variables on each of 327 subjects. Aspreadsheet style of data entry prevented most row and column entry errors,but not typing errors. I visually scanned the data for mistakes using rawdata, ranges of scores, frequency tables and scatterplots on each variable.Data entry errors were corrected by referring back to the original data fromindividual questionnaires.Discrete variables such as education, marital status, work role andschool location were "dummy coded" into dichotomous (0,1) categories. Age inyears and the number of children were "centered"; this procedure subtrarts 199the average score of the group from each individual score so that the mean of'X' is centered on zero of the 'X' axis. The outcome variable (exercisestatus in kilocalories) and all remaining independent variables werestandardized.Outliers Scatterplots were made for all model variables against the criterionvariable (Level of Exercise in the Past Week). SYGRAPH provides scatterplotswhich visually enlarge the influential outliers i
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UBC Theses and Dissertations
The determinants of late life exercise in women over age 70 Cousins, Sandra 1993
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