Social-ecological influences on physical activity in care homes for older people

: a focused ethnographic study

Abstract

Background and aims: Robust evidence confirms that physical activity (PA) levels among older people who live in care homes are considerably lower than those who live in their own homes, with care home residents estimated to spend between 70 - 80% of their waking time inactive. Low PA in care homes may reduce independence, function, and quality of life. This PhD aimed to:

1. Explore influencing factors for PA from the perspective of staff and residents.
2. Explore how the nature of daily life in care homes influences PA.
3. Use evidence gathered to explore strategies for developing effective approaches for PA promotion in care homes.

Design and methods: (1) Two scoping reviews (qualitative and quantitative) of the existing evidence around care home PA were conducted. (2) Focused ethnography in n=5 care homes for older people. The focused ethnographic method involved nonparticipant observations and semi-structured interviews with n=15 staff purposefully selected according to their role (carers, managers, activity coordinators). The observation data informed the content of the interviews, which sought explanations for observed phenomena. All data were analysed using thematic analysis informed by a social-ecological perspective.

Findings: Scoping Reviews: The scoping reviews highlighted a need to address PA levels through strategies that operate at multiple levels simultaneously (residents, staff, social and physical environment), and that there was a lack of intervention studies that have taken such an approach. Additionally, although the reviews identified social and physical environment influences on PA in care homes, no single exploratory study examined these multiple aspects together. Focused Ethnography: Overall, the findings from the main ethnographic study reflected the notion that carers were best placed to facilitate PA because they had the most daily contact with residents. Four main themes explained PA in care homes. The theme, ‘Physical activity promotion: a continuum of formal and informal practice’ shows how care home organisational structures influenced the carer’s role, identity, and sense of purpose regarding PA facilitation. The second theme, Empowerment and disempowerment from physical activity’ explores processes that empower or disempower carers’ capacity to work in ways that allowed them to promote PA. The third theme, ‘Social spaces as destinations for physical activity’ captures the notion of different physical areas in care homes emerging as walking destinations. The fourth theme, ‘Environmental adaptation’, explores how staff responded to perceived inadequacies of the physical environment related to residents’ PA. The findings are placed in the context of a social-ecological model that can be used to support the development of interventions to increase PA in care homes.

Conclusions and implications: The findings from this study illustrate the utility of social-ecological models in understanding PA in care homes, providing a systematic approach to informing the development of future interventions to increase PA among care home residents. Care staff are the most appropriate people to sustain facilitation of PA on a regular basis, however, this is contingent on addressing detailed individual, interpersonal, organisational, and physical environmental influences on PA. A comprehensive approach to increasing PA levels in care homes that is informed by social-ecological models is required to ensure strategies to increase PA in care homes are sustainably embedded rather than ‘bolted on’ as an extra activity. Additional research is warranted to: (i) co-design multi-level interventions with residents, staff, and family members, and (ii) examine their implementation using a whole systems approach to evaluating barriers and facilitators to implementation using appropriate implementation outcomes.

Date of Award	2022
Original language	English
Awarding Institution	University of Dundee
Sponsors	Chief Scientist Office
Supervisor	Jacqui Morris (Supervisor), Miles Witham (Supervisor) & Thilo Kroll (Supervisor)