Background
The ageing population of the United Kingdom (UK)
continues to grow; whereas 40 years ago, life expectancy
for men was 68 years, it has now risen to 78 years; for
women, from 75 years to 82 years [1]. In England alone,
the number of people aged over 65 has doubled since
the early 1930’s. These figures have the potential to
impact on demand for places in long-term care (LTC).
Currently there are 19,000 LTC facilities in England,
with a capacity of 441,000 places. Projections of future
demand for residential care suggest that by 2020, this
figure will have risen to 500,000 [2].
The importance of physical activity (PA) in this older
population cannot be underestimated and there is good
evidence that prevention or minimisation of the impact
of sedentary lifestyles can have dramatic effects on physical
and psychological health [3,4]. This is important given the
global burden of multiple comorbidity, disability and frailty
which is linked to decreased functional ability, performance
of activities of daily living (ADLs), reduced health-related
quality of life, all-cause mortality and costs associated with
both health and social care services [3,5,6].
The American College of Sports Medicine (ACSM) [7]
guidelines recommend that older adults (defined as
those over 65 years old) should undertake 30 minutes of
moderate intensity, aerobic exercise or activity, five
times per week to incur any health benefits. Yet, globally
and more specifically across the UK, the number of
older people actually fulfilling this requirement is very
small and is likely to be even lower amongst those resident
in LTC [8] [9].
In 2010, a systematic review [8] of 49 randomised
controlled trials (RCTs) investigated the effectiveness
of physical rehabilitation in older adults resident in
LTC, specifically assessing factors such as activity restriction,
and strength and balance for older people. Thirtythree
of the included trials found significant benefits of
physical rehabilitation on outcomes of mobility, strength
and ADLs. Importantly, physical activity was acceptable to
those living in LTC.
Exercise was an intervention component in 46 of these
49 trials. In 27 studies, exercise was delivered in groups,
with the mean attendance rate at group exercise reported
in 17 studies as being 84% (range 71% – 97%).
However, only four of the 49 trials were conducted in a
UK setting. The overall mean sample size per clinical
trial was 74 patients, and only nine trials included a
sample ≥100. The authors concluded that larger scale
studies with longer-term follow up were required in this
understudied population.
Another systematic review [6] examined the motivators
and barriers to activity amongst the oldest old, defined as
aged over 80 years. From 44 qualitative and quantitative
papers, a total of 61 motivators and 59 barriers to activity
were identified. Although designed specifically to study
those aged over 80 years, none of the 44 included papers
exclusively described a sample of over 80 year olds;
highlighting the lack of studies conducted involving adults
in this age group. Additionally, only two of the studies
were based in LTC (USA and Canada). However, from
these two studies, the main barriers to physical activity
were health or physical impairments [10]. Motivators
often included physical/health benefits, having less
pain, previous physical activity experiences and the
social component and support of participating in physical
activity [10,11].
Similar themes of physical and social benefits, family
and staff support and previous lifestyle were identified as
motivators to exercise class participation in a qualitative
study of residents living in ‘low-level’ residential care;
with health limitations including past medical conditions,
pain, fear, lack of motivation and depression as barriers to
exercise [12].
Since many previous studies identifying the barriers
and motivators to exercise have been small and based in
community settings, it is clear that more research is
needed to identify predictors of attendance to exercise in
institutionalised older people.
Existing research has focused upon the influence of
patient or individual factors such as physical health,
depression etc. Yet institutional or home level factors may
also play a role in understanding barriers and motivators
to participation.
There are a number of sociological models
that provide a framework for analysing behavioural
change. Often considered the most comprehensive
model to account for exercise behaviour in older
adults, social cognitive theory incorporating a socialecological
model i.e. a model to understand the relationship
between personal and environmental factors,
is the theoretical basis for adopting a programme of
physical activity [13]. Behaviour is thought to be influenced
by interacting and potentially confounding
variables, such as those described above and can be
categorised into intrapersonal, interpersonal, institutional/
organisational, public policy and environmental factors
and are strongly linked to self-efficacy i.e. a person’s
sense of confidence or judgement in their ability to
perform or accomplish a particular task or level of
performance [14-16].
Using a social-ecological model, the aim of this study
is to determine individual and ‘home level’ predictors of
attendance at physiotherapy led exercise groups delivered
in LTC across the UK. To achieve this, individual,
clinical, and socio-demographic resident variables, and
socio-economic characteristics of residential and nursing
homes were identified and examined separately in order
to predict exercise behaviours (specifically attendance at
พื้นหลังประชากรสูงอายุของสหราชอาณาจักร (UK)ยังคงเติบโต ในขณะที่ 40 ปีที่ผ่านมา อายุขัยชาย 68 ปี ตอนนี้ได้เพิ่มขึ้นถึง 78 ปี สำหรับผู้หญิง 75 ปี 82 ปี [1] ในอังกฤษเพียงอย่างเดียวจำนวนของผู้ที่มีอายุกว่า 65 มีสองเท่าตั้งแต่ในช่วงต้น 1930 ของ ตัวเลขเหล่านี้มีศักยภาพในการส่งผลกระทบต่อความต้องการสำหรับสถานที่ในการดูแลระยะยาว (LTC)ขณะนี้มีสิ่งอำนวยความสะดวก LTC 19000 ในอังกฤษมีความจุของสถาน 441,000 คาดการณ์ของอนาคตแนะนำความต้องการการดูแลที่อยู่อาศัยที่ 2563 นี้จะได้แบกรูป 500000 [2]ความสำคัญของกิจกรรมทางกายภาพ (PA) ในรุ่นเก่าไม่สามารถ underestimated ประชากร และไม่ดีหลักฐานที่ป้องกันหรือ minimisation ผลกระทบของวิถีชีวิตประจำจะมีผลอย่างมากในทางกายภาพและสุขภาพจิต [3, 4] ซึ่งเป็นสิ่งสำคัญที่ให้การภาระส่วนกลางหลาย comorbidity พิการ และ frailtyซึ่งเชื่อมโยงกับความสามารถในการทำงาน ประสิทธิภาพการทำงานลดลงกิจกรรมของชีวิตประจำวัน (ADLs), ลดสุขภาพคุณภาพชีวิต การตายทุกสาเหตุ และต้นทุนที่เกี่ยวข้องกับสุขภาพและบริการสังคม [3,5,6]วิทยาลัยอเมริกันของเวชศาสตร์การกีฬา (ACSM) [7]แนวทางแนะนำว่า ผู้ใหญ่อายุ (กำหนดเป็นผู้ที่อายุมากกว่า 65 ปี) ควรทำ 30 นาทีบรรเทาความรุนแรง ออกกำลังกายแอโรบิก หรือกิจกรรม 5ครั้งต่อสัปดาห์จะเกิดประโยชน์ใด ๆ ต่อสุขภาพ ยัง ทั่วโลกand more specifically across the UK, the number ofolder people actually fulfilling this requirement is verysmall and is likely to be even lower amongst those residentin LTC [8] [9].In 2010, a systematic review [8] of 49 randomisedcontrolled trials (RCTs) investigated the effectivenessof physical rehabilitation in older adults resident inLTC, specifically assessing factors such as activity restriction,and strength and balance for older people. Thirtythreeof the included trials found significant benefits ofphysical rehabilitation on outcomes of mobility, strengthand ADLs. Importantly, physical activity was acceptable tothose living in LTC.Exercise was an intervention component in 46 of these49 trials. In 27 studies, exercise was delivered in groups,with the mean attendance rate at group exercise reportedin 17 studies as being 84% (range 71% – 97%).However, only four of the 49 trials were conducted in aUK setting. The overall mean sample size per clinicaltrial was 74 patients, and only nine trials included asample ≥100. The authors concluded that larger scalestudies with longer-term follow up were required in thisunderstudied population.Another systematic review [6] examined the motivatorsand barriers to activity amongst the oldest old, defined asaged over 80 years. From 44 qualitative and quantitativepapers, a total of 61 motivators and 59 barriers to activitywere identified. Although designed specifically to studythose aged over 80 years, none of the 44 included papersexclusively described a sample of over 80 year olds;highlighting the lack of studies conducted involving adultsin this age group. Additionally, only two of the studieswere based in LTC (USA and Canada). However, fromthese two studies, the main barriers to physical activitywere health or physical impairments [10]. Motivatorsoften included physical/health benefits, having lesspain, previous physical activity experiences and thesocial component and support of participating in physicalactivity [10,11].Similar themes of physical and social benefits, familyand staff support and previous lifestyle were identified asmotivators to exercise class participation in a qualitativestudy of residents living in ‘low-level’ residential care;with health limitations including past medical conditions,pain, fear, lack of motivation and depression as barriers toexercise [12].Since many previous studies identifying the barriersand motivators to exercise have been small and based incommunity settings, it is clear that more research isneeded to identify predictors of attendance to exercise ininstitutionalised older people.Existing research has focused upon the influence ofpatient or individual factors such as physical health,depression etc. Yet institutional or home level factors mayalso play a role in understanding barriers and motivatorsto participation.There are a number of sociological modelsthat provide a framework for analysing behaviouralchange. Often considered the most comprehensivemodel to account for exercise behaviour in olderadults, social cognitive theory incorporating a socialecologicalmodel i.e. a model to understand the relationshipbetween personal and environmental factors,is the theoretical basis for adopting a programme ofphysical activity [13]. Behaviour is thought to be influencedby interacting and potentially confoundingvariables, such as those described above and can becategorised into intrapersonal, interpersonal, institutional/organisational, public policy and environmental factorsand are strongly linked to self-efficacy i.e. a person’ssense of confidence or judgement in their ability toperform or accomplish a particular task or level ofperformance [14-16].Using a social-ecological model, the aim of this studyis to determine individual and ‘home level’ predictors ofattendance at physiotherapy led exercise groups deliveredin LTC across the UK. To achieve this, individual,clinical, and socio-demographic resident variables, andsocio-economic characteristics of residential and nursinghomes were identified and examined separately in orderto predict exercise behaviours (specifically attendance at
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