Abstract
Older people who are wanting to support their own ability to age well may benefit from attending community-based group programs. However, many of these programs are designed and implemented by health professionals without direct input from older people, which may limit the opportunity to ensure such programs are authentically meeting the needs of this population group. A qualitative approach, using an interpretative phenomenological analysis (IPA), was undertaken with seven (six female and one male) participants, aged between 62 and 80 years to explore the experiences of participating in a pilot Ageing Well Program. Interviews were transcribed and analysed according to IPA principles. Three themes emerged from the analysis of the interview data: (1) The value of focusing on different aspects of ageing; (2) Learning new knowledge; and (3) Transferring skills to everyday life. Participants in the pilot of the Ageing Well Program highlighted that those aspects of the Program, such as the focus on adding value through targeting multiple aspects of ageing, as well as developing strategies to successfully learn, apply, and translate new knowledge into their everyday lives, were beneficial and supported engagement. However, future programs would benefit from the inclusion of clear and coherent written material to provide an aide in remembering the strategies and new information learnt during the Program. Findings support the importance and value of engaging with older people to assist with the development of community-based programs that are authentically designed to align with the expectations of older people, through a process of quality improvement.
1. Introduction
For some older people, ageing can be associated with reduced independence, mobility, and social isolation, leading to reduction in quality of life and increased risk of becoming dependent on aged care services [1]. Ageing in place is seen as a key priority, but also a challenge for health services and governments, given the rapid increase in ageing globally [2]. As such, it is imperative that older people can continue to undertake activities that are meaningful to them and are supported to successfully ageing well [3]. Ageing well is a concept that involves multiple dimensions, which includes addressing the physical, cognitive, and social wellbeing of older people [4]. For older people, the ability to remain independent and adapt to age-related limitations is an important aspect to the ageing well concept [5, 6].
Within many community settings, various group-based programs are available, with evidence suggesting that these programs can assist older people to maintain or improve their functional activities of daily living as well as support social engagement [7–10]. But few community-based programs focus on simultaneously addressing the multidimensional aspects of ageing well. Additionally, the literature also identifies several barriers in attending such programs, which may reduce further engagement in these types of programs. Examples of barriers include individual physical limitations, social influences, access and availability of programs, whether the program will meet individual needs, and a lack of understanding of the personal benefits of the program [11–13]. These barriers may be further exacerbated for older people who are residing in rural and regional communities [14] where there are often unique challenges associated with reduced healthcare resources and services, resulting in poorer health outcomes, particularly for older people [15, 16].
Importantly, many of the community-based programs are designed and implemented by health professionals without the direct input from older people [17]. This may further limit the opportunity for these programs to meet individual needs and potentially impact on the engagement with such programs by older people [18]. To ensure that healthy ageing programs better reflect older people’s needs and perspectives, it is imperative that opportunities exist for older people to evaluate their experiences in these programs and facilitate a contribution to the design of such programs [18, 19]. To better support older people to maintain their quality of life as they age, while remaining socially connected within their communities, “fit for purpose” community-based programs need to be available for community members, that incorporate the individual needs of older people, while targeting the multidimensional concept of ageing well [5].
Engaging with older people as part of a quality improvement approach ensures community-based programs, designed for older people, are actually meeting the older population’s needs, resulting in greater benefits for older people in relation to their overall health and wellbeing as they age [20]. Additionally, evidence suggests that using participatory co-design approaches has shown to promote person-centred care and increase program uptake and program effectiveness, while incorporating broad stakeholder input into the development and review of health services [21, 22]. Therefore, the aim of this study was to explore the experiences of older people participating in the pilot of a healthy ageing program to determine what aspects of the program they valued and what improvements could be made for future participants’ experience and engagement within the program.
1.1. The Ageing Well Program
The Ageing Well Program was a community-based dual-task program, delivered in rural Australia, focusing on simultaneously improving the physical, cognitive, and social wellbeing of rural older people. After evaluation of the strengths and limitations of existing community-based programs for older people, the Program was designed to target individualised strategies to build and maintain confidence in performing everyday tasks and activities, to enable older people to remain active, independent, and engaged within their communities. Community-dwelling older people, aged 60 years and older, who self-reported some changes to either their cognitive or physical abilities or both, were encouraged, through media advertisements, to self-refer to the program. Participants in the Program were screened to ensure they were independent community-dwelling (with or without supports), ambulant (with or without a walking aid), and had sufficient English language skills and cognitive ability to understand verbal instructions in a group setting, without a formal diagnosis of cognitive impairment as determined by the Mini Mental State Examination. The Ageing Well Program was a ten-week group-based program where participants attended for one hour per week and were involved in undertaking a range of individualised simulated functional activities in small groups with a focus on improving mobility and cognition skills, alongside targeted education sessions to support the development of knowledge and strategies to facilitate ageing well [23].
2. Methods
2.1. Study Design
A qualitative approach was chosen to understand the experiences of older people participating in the pilot of the Ageing Well Program to inform the future design of the program. The use of a qualitative approach enables the focus to be on the participants’ unique understanding related to the experience or topic through in-depth discussions with the participants [24]. Specifically, this study used an interpretative phenomenological analysis (IPA) approach due to its focus on the meaning of everyday life experiences and the individual’s interpretation of these experiences [25]. Central to the IPA approach is the data collection and analysis from a small number of purposively selected participants who have a mutual experience, which enables a detailed analysis of the phenomena by incorporating an individual’s unique experience through an idiographic process [26].
2.2. Participant Recruitment
A purposive sampling approach to recruitment was undertaken. Eleven older people completed the pilot of the Ageing Well Program, and all were invited to voluntarily attend a semistructured in-depth interview at the completion of the pilot program to share their experiences and provide feedback. All invited participants had been previously assessed for English language skills and cognitive ability to provide consent as part of their participation in the pilot of Ageing Well Program. Following the initial invitation to participate in the study, individuals who expressed interest in being involved were provided with an information sheet outlining the purpose of the study and what their involvement would entail, as well as any potential risks from participating. Potential participants were also given the opportunity to ask any questions before agreeing to be involved.
2.3. Data Collection
Shortly after completion of the pilot Ageing Well Program and after obtaining informed consent, in-person semistructured in-depth interviews were undertaken with the lead author. Semistructured interviews are commonly used in IPA as they enable the individual participant to share their interpretations of a particular experience [26]. A semistructured interview guide was used to inform the interviews, with open-ended questions focusing on the participant’s experience of the program, what aspects they found useful and what aspects they believed could be improved for future program offerings. The interview questions were phrased in a manner that encouraged discussion such as “Can you describe the aspects of the program that were most beneficial to you?” Where needed, additional probing questions were used such as What was it about the aspect that made it helpful or valuable? Each interview took approximately 60 minutes and was audio-recorded and transcribed verbatim.
2.4. Ethical Considerations
The lead author (KR) who conducted the interviews with participants was also involved in assisting with the delivery of the pilot Ageing Well Program. Therefore, it must be acknowledged that this may have influenced the responses participants provided on their experiences of being in the program. To minimise the impact of this perception, all interviews were deliberately framed in a way that facilitated genuine enquiry on exploring participants’ feedback, both positive and negative, so that their perspectives could be incorporated into future offerings of the program. This was also highlighted in the participant information sheet, provided to participants before they agreed to be involved, and reiterated at the beginning of each interview.
2.5. Data Analysis
Data analysis was undertaken in line with IPA principles, with each individual transcript being read and reread to become immersed in the content of the interview [26]. While the transcript was read, the audio-recording of the interview was also listened to, to facilitate a detail understanding of the entire participant interview [26]. During this process, initial descriptive and interpretative comments and notes (“exploratory notes”) were made, reflecting on what the participant said, to facilitate a deeper understanding of the participant’s sense making [26]. This led to the development of key ideas from the participant data and the development of themes [26]. Through the analysis of these exploratory notes, connections, patterns, and relationships were identified, across the participant transcripts, which enabled the creation of emergent themes [26]. The emergent themes were derived from capturing the essence of the participant’s sense-making of their experience and the researcher’s interpretation of this knowledge [26]. After the emergent themes were identified, further analysis was undertaken to identify connections across themes [27].
Throughout the data analysis phase, reflexive journaling was undertaken by the lead author (KR) with ongoing discussion with the second named author (MN) to support the interpretation process [28] by documenting ideas and thoughts that assisted the emerging initial connections and themes within the data [29]. The entire research team reviewed the finalised themes and subthemes as part of the development of the results section. This process enabled critical reflection on the analysis process and thus identification of preconceptions and biases [28] to ensure that participant data analysis was as accurate as possible and support trustworthiness of the analysis.
3. Results
Of the eleven older people who participated in the pilot of the Ageing Well Program, seven agreed to participate in the semistructured in-depth interviews. Interview participant details regarding gender and age as well as corresponding pseudonyms are provided in Table 1.
Three superordinate themes emerged through the analysis of the interviews with older people who had participated in the pilot Ageing Well Program. These were (1) The value of focusing on different aspects of ageing; (2) Learning new knowledge; and (3) Transferring skills to everyday life.
3.1. Theme 1: The Value of Focusing on Different Aspects of Ageing
Participants described the importance of having opportunities to develop skills and strategies in a range of “different aspects of ageing” (Cathy), rather than the focus being limited to one aspect, such as physical activity. By incorporating both cognitive and physical elements into each activity, it enabled participants to be challenge in different ways, which they perceived to add value to the program. Cathy highlights this point when talking about undertaking one of the Program activities.
And then we had the other group where you had to throw the ball and remember where they lived and their colour, favourite colour, number and their name. I thought that was really good too because you had to do it quick. (Cathy)
For Cathy, the ability to incorporate a cognitive challenge into the physical activity meant that she was able to exercise her mind while getting some physical exercise (this is the nature of dual-task interventions). It was also noted by the participants that this type of approach worked for people that maybe struggled in a particular area because it meant that all the focus was not on that area. This is illustrated in June’s excerpt:
Well, I think you’re covering the physical and cognitive, you know, you’re sort of dealing with two things without, some people who can’t remember very well or something like that, they get quite embarrassed. Well old people get embarrassed about forgetting things or not appearing to be on the same level that they used to be. (June)
The mix of activities was particularly important to the participants, especially if they were struggling in one area, as it enabled them to have a sense of achievement even if they were unable to perform all elements well.
The structure of the Program was also commonly discussed by participants as they perceived it facilitated greater engagement with each other. Being paired with other participants with similar goals to undertake each activity within the larger group meant that participants were able get to know people on a more personal level and have better interaction with other. Annie explained:
Well, because I’m hard of hearing you only had one person to deal with. Like even in the Hall when we were all in the Hall and different people were speaking I missed out on half of it. (Annie)
The larger group setting may not suit people with hearing impairment, and this can make the experience less appealing because they may miss vital information. The ability to break into pairs or triads regularly meant that participants like Annie were able to engage more in the Program because they were able to hear what their partner was saying.
While this approach worked well for some, others said they would have liked to be paired with different people across the Program so that they could build connections with multiple people within the group, as highlighted by Angela.
And challenged, you know, each person has their own challenges that they can give you and you can give them. And I just felt as though perhaps if we were mixed and matched in that group it might have been a bit better and then you all come together and, you know. (Angela)
The social connectedness was seen to be a significant feature of the Program and a strong motivator for continuing to attend. The participants talked about the encouragement to socially engage with each as being one of the most appealing aspects of the Ageing Well Program. This excerpt from Joe’s interview is an example of this:
I had a gain out of it. Just interacting with other people. That’s number one. I’ve always found it a little bit hard to interact with other people sometimes. I don’t know if I’m a bit self-conscious or what it might be. Reserved. But I always sort of sit back. And by coming here I sort of started to react, talk to these other people more than I probably would than I would have done two or three years ago. So it’s been good, I mean that way it’s been good. (Joe)
Joe’s experience demonstrates the importance of facilitating opportunities to create new social connections and friendships and highlights how this can positively impact on the psychosocial wellbeing of older people.
It was evident that participants really valued the opportunities to socially engage with each other. However, participants also indicated that not all healthy ageing programs facilitate this aspect, and the structure needs to be specifically designed to encourage social communication. Melodie explained this:
Yeah, it is because if it had have been just a group type session I probably would have just sat there and listened to people and not said much. I always found that when there’s a group of people I just spend most of my time just listening not participating in it. (Melodie)
For Melodie the ability to be placed in pairs or triads meant that she was able to build confidence in contributing to discussion with a few people to start with, which then in turn enabled her to be more comfortable within the larger group to form additional social relationships.
Overall, participants perceived that the way the Ageing Well Program was designed to incorporate both physical and cognitive aspects to each activity, through the inclusion of the dual tasking approach, as well as the specific integration of social engagement within the program, added value and was seen as being beneficial.
3.2. Theme 2: Learning New Knowledge
Participants discussed the importance of learning new knowledge throughout the Program to assist “with lots of little hints to really help at home” (Joe). For example, the program changed the way participants thought about ageing well and helped them to implement the learnt strategies at home. This was highlighted by June:
Just different things that come up, you know, like instead of washing up with two feet on the floor I stand on one. I practised. There’s a lot of things you can do at home that you didn’t realise that can help your balance. Strengthen parts and things like that. (June)
By practicing the different strategies every day, participants like June made it part of their regular routine to support ongoing health and wellbeing.
Participants commonly talked about the impacts of forgetfulness as they aged and reported finding it frustrating that they could not remember certain things, such as phone numbers. Participants valued the opportunity to practice strategies, such as chunking information, to enable them to more easily remember important information, as explained by Joe:
When I say learnt a great deal, I’ve learnt how to put numbers in chunks if you like and to remember that. I haven’t had a problem in the past. No doubt I will have a problem in the future about memory. But I did find that interesting. Lots of little hints that you’ve given us really helped at home. When I think about it now it has, I’d say it’s, well I couldn’t say it’s improved my memory but it’s given me strategies to undertake and like to use when I want to try and memorise something. (Joe)
For Joe, regularly undertaking activities in the Program that incorporated the strategy of chunking—to remember specific information, such as addresses and phone numbers—meant that he had confidence to use this technique to aid recall outside of the Program.
Sharing similar experience and challenges among participants was identified as a strength of the Program. Opportunities to be honest about the challenges they were facing, and to use the Program as a vehicle to explore alternative solutions to these challenges, were viewed as helpful. This is illustrated by Angela:
The best things that I got out of it was being with like-minded people. And knowing that what happens to me, happens to others and there’s a way around it where we were told like getting up off the floor or you know things like that. Just thinking of things in a different way. Stop, Think and Do. (Angela)
Supporting the participants to develop new strategies such as Stop, Think, and Do throughout the Program meant they were able to pause before doing a task automatically, giving them the opportunity to think about whether their approach to the task was the most appropriate or safest approach.
While the participants found regularly practicing strategies useful in applying the new knowledge they had learnt, they also indicated they would have liked to have additional specialised talks on key areas of interest so that they could learn more strategies to assist them in ageing well. Jocelyn explains:
Maybe adding a few more little chats at the end, you know. Little discussions like the pain one we had. Maybe throw in a falls chat one afternoon and just say this is the thing you could do if you think you’re going to fall down the stairs. Maybe something like that. (Jocelyn)
The participants indicated that the approach of presenting specific strategies with concrete examples relevant to their daily lives enabled them to understand why strategies could assist them to age well and this increased their overall understanding of the new knowledge learnt. There were suggestions that they would have liked to have learnt more additional strategies through targeted education sessions alongside the program.
3.3. Theme 3: Transferring Skills to Everyday Life
Participants discussed the need for program outcomes to be easily transferrable “so you can take the information away with you for the future” (Melodie). Participants also spoke about the importance of understanding how the activities they were undertaking in the Program related to their home life, as explained by June:
You know you think you’re learning but when you go home and you see something on the floor or something, you know, we think, “Oh, I should move that so I don’t fall over it,” you know. So it carries on from here to home in ways that I didn’t really anticipate. (June)
For June, the transferability of weekly strategies was not clear to her until she was at home and recognised a hazard that may have increased her risk of further fall. This revelation meant that she was able to use what she had learnt in the Program to keep herself safer at home which was a significant benefit for her.
Being taught practical approaches that were transferrable to individual circumstances throughout the Program was highly valued by participants. This aspect was highlighted by Angela when talking about being taught how to get up from the floor.
I really feel as though it has benefitted me. Making me think about how I do things at home. If I’ve got to get down on the floor and getting back up again. I haven't fallen or anything like that but I was able to, if this is relevant, to pass on to my husband who is a photographer and he does, the other night he was out in the bush and they were down on the ground and he had trouble getting up so I was able to tell him the strategies to do. For him to help him to get up. (Angela)
For Angela, learning the steps of getting up and down from the floor during the Program meant that she had greater confidence in herself to be able to do this if she did have a fall at home. In addition, the ability to regularly practice the steps in safely getting up meant that she was able to teach her husband how to do this, thus further increasing the transferability of the skill.
Participants noted that the approach to reinforce key messages across the Program by concentrating and slowing down, rather than undertaking tasks in “autopilot,” was also transferrable to their everyday lives, as Cathy reflects:
It made you think about a lot of things like that you sort of regimented. You think about that more. You think about things before you do them. Whereas I’m a hell for leather person. But you think about it more. And especially with walking. Cause I tend to trip over a bit. So I walked yesterday and I was like, “Heel, toe.” Watch this. Watch that? (Cathy)
Cathy mentioned that she tended to rush all the time, and this may have contributed to her previous tripping events. The strategy to slow down and think about what she was doing meant that she was more confident when out walking in the community. The approach to regularly reinforce “slowing down and concentrating on tasks at hand” also assisted participants’ thinking. This can be seen from Jocelyn’s comment.
Remembering. I had things on post-it notes all over the house. So yeah, I’m a bit more thoughtful shall I say. Just making me slow down, be a bit more thoughtful. Watch, concentrate on what I’m doing. Yeah, but think before I jump in and do something. (Jocelyn)
Jocelyn explained that this strategy improved her memory at home, and this has been a great benefit for her. However, for some participants, just learning effective strategies to translate into their everyday lives was not enough and they would have preferred to have additional written resources that they could refer to regularly to assist them in actioning the strategies. Melodie highlights this point.
Probably to reflect back on or whatever, if you had just a flyer or something with that brief information about it and then when you read it you just think oh yeah, good. You sort of remember what was involved. Information explaining how to do it and how often to do it and sort of when to do it and at the bottom just put a notation do it so many times a day or every second day or whatever to reinforce it. (Melodie)
Participants noted that the ability to translate knowledge and skills they gained from the Program into their everyday life was a useful approach for supporting ongoing practice with what they learnt. They suggested that translation could have been further enhanced if written resources were also provided for ongoing reference.
4. Discussion
The aim of this study was to explore the experiences of the older people who participated in the pilot trial of the Ageing Well Program [23] to inform the future design of the program. Evaluating the program from the perspective of the older person enabled greater insights into the aspects that older people found valuable to support their ability to age well.
When referring to the types of aspects that were useful, participants reported that the ability for the program to incorporate a range of different elements, such as cognitive and mobility strategies alongside a focus on social engagement, was perceived to add value to the older person, as it enabled the development of different skills and capabilities that met individual needs. Evidence suggests that developing skills that focus on independence and autonomy, as well as being able to maintain social connection, matters to older people [30]. Ensuring that programs have a focus on identifying and supporting individual health needs of participants is likely to support better engagement [5] and may reduce issues associated with barriers to attending such programs [31]. Programs that support multiple elements of ageing can also facilitate improved quality of life for older people. This is supported by the findings of a large study of 296 older people undertaken by Merchant et al. [32] who incorporated both physical and cognitive exercises into a twice-weekly community-based program and found significant improvements in both areas, as well as a reduction in social isolation among participants.
The support provided by the Program for participants to attain new knowledge and increase understanding of the ageing process, along with specific strategies to enhance their ageing experience, was a key finding in this study. The ability for older adults to learn new information and strategies to support their overall quality of life is important to the ageing process [33]. However, evidence suggests that the ability to cognitively process information quickly can decline as we age, although rates of decline can be variable across the older population [33]. Therefore, regular practice strategies that involve chunking meaningfully associated pieces of information together, like those undertaken in the Ageing Well Program, have shown to have better outcomes in transference of information to long-term memory [33, 34], likely resulting in improved capacity for older people to retain learnt information or strategies. Additionally, evidence suggests that the opportunity to undertake new learning alongside peers within a social setting has also shown to play a role in promoting and understanding healthy ageing behaviours [35]. It was noted by participants in this study that the inclusion of written material on the strategies and new information they were learning during the Program would have been a positive addition to support ongoing practice at home and increase the transferability of knowledge learnt. A systematic review focusing on health-related patient information leaflets undertaken by Sustersic et al. [36] found that well written information provided to patients can improve general knowledge of topics and increase adherence to interventions to improve overall health and wellbeing. As such, additional written resources were developed for subsequent offerings of the Program to support this aspect.
Efforts to translate knowledge and strategies developed during the Ageing Well Program into participants’ everyday lives were important to enable the sustained benefits of the Program. Evidence suggests that if we want to encourage older people to change behaviour towards healthy ageing strategies, then older people need to understand how these strategies can be translated into action. [37] Gothe et al. [38] in their study focusing on home-based physical activity found that the ability to regularly reinforce written education materials was critical to optimising the outcomes of the program for older people. Evidence also suggests that incorporating behavioural change techniques, such as individual goal setting into ageing programs, can increase the success of programs, as it supported acquisition of sustained behavioural skills [39, 40]. As such, it is important that community-based programs that support older people move beyond the environment in which the program is delivered and consider the broad influences that impact on the ability to age well and ensure there is an emphasis on transferability to everyday contexts [5].
4.1. Strengths and Limitations
The strength of this study is that it provided older participants the opportunity to provide authentic feedback based on their personal experiences of being involved in the pilot of the Ageing Well Program, through a process of an in-depth semistructured interview contributing possible beneficial modifications to future offerings of the Program. Participants undertook the interviews shortly after they completed the Program to ensure their reflections aligned to their current reflections of being part of the Program. The limitations of this study include that only participants from the first cohort of the Program were recruited and while most Program participants chose to participate in the interview, there was a gender dominance with only one male agreeing to participate. Additionally, the Ageing Well Program was one specific program run in one rural geographic location. Further use of similar approaches is needed to understand the perspective of older people in general, rather than a specific response to an individual program. Additionally, educational background and ethnicity were not collected as part of this study. All these aspects can potentially limit the transferability of the study outcomes to other settings and contexts.
5. Conclusion
Understanding what is meaningful to older people who wish to participant in programs that support ageing well is important if we want to ensure that these types of programs are useful to their target population. This study found that participants in the pilot Ageing Well Program highly valued the specific design of the Program which they perceived added value through targeting multiple aspects of ageing, enabled them to successfully learn new information and strategies, and supported their ability to translate this new knowledge into everyday life. However, there were aspects of the Program that could be improved upon, such as written material to support ongoing practice of new strategies. Ensuring the needs of this growing population are met through effective design of healthy ageing programs is critical to enabling ageing programs that can demonstrate sustained acceptability and cost benefits through effective ongoing engagement.
Data Availability
Anonymised participant data may be available for research purposes on reasonable request from the corresponding author, subject to approval.
Ethical Approval
Ethics approval for this study was obtained from Charles Sturt University Human Research Ethics Committee, approval number: H18015.
Conflicts of Interest
The authors declare that they have no conflicts of interest.
Acknowledgments
We would like to acknowledge the contribution provided by the participants who provided valuable insights into their experiences of being involved in the pilot Ageing Well Program. External financial support has not been provided to this study. However, authors (KR and MN) involved in this work are supported by Three Rivers Department of Rural Health, who are funded by the Australian Government under the Rural Health Multidisciplinary Training (RHMT) Program. Open-access publishing was facilitated by Charles Sturt University, as part of the Wiley-Charles Sturt University agreement via the Council of Australian University Librarians.