Introduction

The numerous physical and psychological benefits of physical activity (PA) can be achieved by people of all ages and ethnic/racial backgrounds [1]. African Americans are disproportionally affected by many chronic conditions (e.g., diabetes, cardiovascular disease, some types of cancers, and disabilities) when compared with other racial groups [2,3]. Engaging in recommended amounts of PA has the potential to minimize the physiological effects of an otherwise sedentary and inactive lifestyle and increase life expectancy and healthy living by preventing or delaying the onset and progression of chronic diseases and disabling conditions [4,5]. Despite its well-known benefits, rates of PA participation at recommended levels are low in the African American population [6], and there is evidence that older African American women (AAW) are among the least active members of society [7].

The promotion of a physically active lifestyle as an affordable and effective means to prevent and treat chronic disease and to improve quality of life and well-being has become a priority for many researchers, government agencies, policy makers and health professionals. However, despite considerable efforts to alleviate racial/ethnic disparities in PA, disparities persist [8,9]. Efforts have been made to assess and understand perceptions and attitudes influencing PA participation among minorities and underserved groups [10–12]. For example, one study examined perceptions, barriers, and facilitators to PA and exercise among seven underserved and ethnically diverse older adults employing a focus group design. The authors observed that participants, in general, viewed PA and exercise as mean to promote health; and identified both health and social benefits related to being physically active. Furthermore, participants also expressed the notion that PA programs should provide culturally-appropriate activities, foster social relationships among participants, and partner with social service agencies to provide programming at convenient times and in convenient and accessible locations. Mathews et al. [11] observed that common barriers to PA among different ethnic groups aged 50 years and older include health problems, fear of falling, and inconvenience. Common facilitators included positive outcome expectations, social support, and program access.

Although studies can be found that explore factors influencing PA (i.e., positively and negatively) participation in African Americans [10, 12–14], most studies have focused on young adults, and those exploring PA in older AAW have not included women with different levels of PA [12,13,15]. Furthermore, previous studies have depended primarily on interview-based (i.e., focus group or individual interview) methods for data collection. In recent years, investigators have begun to advocate for the adoption of more evocative research methods, not as replacement, but to be used alongside interviews and focus groups. Photo-elicitation is a participatory research technique that invites participants to take photographs of salient features in their lives that are both personally meaningful and possess significant explanatory power. This research technique is based on the simple idea of inserting a photograph into a research interview [16]. It is believed that participants using cameras may better articulate the reality of their lives by focusing on a large array of individual, family, and community resources and needs [17]. Photo-elicitation has been successfully employed in studies addressing eating behavior [18], and in a few PA studies exploring attitudes, beliefs, and preferences around PA topics in older AAW [19], and in the Latino population [20]. For instance, Sebastião et al. [19] successfully employed photo-elicitation in a study exploring PA perceptions among insufficiently active (IA) older AAW. The authors observed that IA women had a vague and non-specific concept of PA. In addition, several personal and environmental facilitators and barriers were reported by the participants. However, to the best of our knowledge, such an approach has yet to be used to explore possible differences in perceptions, barriers and facilitators for PA in groups of regularly active (RA) and IA older AAW.

Ten years ago, a study [21] found that predictors for exercise adherence among younger individuals do not always apply for older adults. Similar concerns have been raised for factors affecting PA in different racial groups. Racially-specific barriers and facilitators that characterize older AAW’s PA beliefs and preferences have not been studied in depth. Exploring such issues is both important and timely given the low rates of PA participation in this population [7,22].

In the present study we employed a mixed-method approach to explore perceptions of PA among RA and IA older AAW and the factors that positively or negatively contribute to their decision to be physically active. This study adopted a participatory research technique known as photo elicitation [16] as a research tool to be used alongside in-depth semi-structured interviews and the objective assessment of PA. The objective assessment of PA was important because it provided valid and reliable data regarding PA, and enabled us to identify two groups that differed with respect to their PA status.

From a theoretical perspective, this study was grounded in the social ecological model of health behavior [23]. Ecological models (i.e., multi-level models) are frequently used to help explain complex behaviors such as PA, and these models are thought to have greater explanatory power than more simplistic single-level approaches. The social ecological model of health behavior suggests that individual behavior does not occur in isolation but emerges from a complex multi-level interaction between the individual, the environment, and the community. Due to the unique attributes of the African American population being studied, we decided to augment the social ecological model of health behavior with theoretical perspectives found in the health disparity literature that have been used to explain the higher burden of chronic diseases in African Americans [24–27]. Health disparities among African Americans are pervasive and numerous factors (i.e., financial issues, the legacy of slavery, segregation and discrimination, and distrust towards biomedical and public health agencies) have been used to try to explain the antecedents of these inequities.

Materials and Methods

Results

Accelerometer data analysis showed that 9 out of 20 women were RA (i.e., achieved the current PA recommendations of 150 minutes per week of MVPA). The average minutes per week spend in MVPA of the RA women was 270.6 ± 79.9 minutes per week, and 111.9 ± 30.7 minutes for the IA group. The difference was found to be statistically significant (t (18) = - 6.0863; p<0.001). The number of valid days wearing the accelerometer (5.8 vs 5.5; p = 0.58) and accelerometer wear-time (722.4 vs 680.3; p = 0.15) did not differ between groups.

RA and IA groups had similar socio-demographic and health characteristics. Detailed characteristics of the participants are given in Table 1 for both groups.

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Table 1. General characteristics of the participants.

https://doi.org/10.1371/journal.pone.0142703.t001

Factors influencing physical activity participation

Physical health and psychological and emotional health.

Participants reported that health issues often hinder them from being physically active. Although health concerns were reported by both RA and IA women, IA participants were more likely to report physical health problems and the RA women were more likely to identify psychological and emotional health concerns.

• “… right now I have an issue with lower back pain… even though I try to do things, it’s still hindering me, and I’m not as active as I could be … since the injury, it’s really decreased.” (62—Inactive)
• “… We have a lot of challenges that a lot of other communities don’t have. There’s a lot of trauma in the African American community… it’s like an injury that never heals kinda trauma… mentally you’re drained from the challenges that you have to deal with, just by virtue of being African American, you’re tired. You have limited mental ability to deal with everything else…” (60—Active)

Financial problems.

Participants in both groups mentioned that African Americans often live on a fixed income that often limits exercise and PA choices;

• “… when it comes down to fitness, African Americans I just think are traditionally hard working people … when you look at some of the gyms and some of the fitness centers their memberships were just astronomic.” (60—Active)

Family demands.

Some participants, regardless of PA status, expressed that their role as caregivers in their families prevented them from being more physically active.

• “… [She] has cancer, and every time she has an appointment I go down to talk with her and the doctors…. That’s the big thing why I am not in physical activity classes…” (74—Inactive)

Friends and family.

For some RA and IA women, friends and family enabled them to be more active.

• “… She’s my walking buddy, so we walk inside because she doesn’t like to walk outside… I used to have another walking buddy, and we used to walk outside, but then my other walking buddy couldn’t walk outside anymore, so I started walking with her…” (62—Active)
• “My daughter lives in Rantoul… I go up to help motivate her, as well as myself, to walk this track. We don’t run it, we walk it. And we just have mother and daughter time… at least once a week…” (62—Inactive)

Unsafe neighborhood.

RA and IA women alike often perceived their neighborhoods as unsafe for PA, mentioning problems related to bad sidewalks and poor lighting at night, and also by discussing their fear of crime.

• “You see this here [talking about a cracked sidewalk]. I almost tripped and fell on my face. My friend … actually did that and she had to go to the doctor … That is like about 2 inches up and if you are walking and you are not looking, anybody … could fall and hurt themselves” (72- Active)
• “… I don't like to go [walk in the evening, night]; I don’t like to go to places that I can’t see… It’s not too much light over in our area because we’re not paying to the city lights up there”. (73—Inactive)
• “… the least I like about it, is at night. And that doesn't necessarily mean this in my neighborhood but you hear some shooting.” (66—Inactive)

Green areas and parks.

Despite the problems reported by the participants in their neighborhoods, both RA and IA women identified green areas and parks as facilitators for PA:

• “I had a park around the corner … is the park where a lot of walkers walk around the park. I don’t know if it’s estimated to be a couple miles, I don’t know, but it’s there … it is conducive to a lot of physical activity….” (60—Active).

Churches and senior centers.

Regardless of PA status, participants discussed the importance of local churches and senior centers as a resource for PA. Participants mentioned health promotion initiatives developed by their churches that encouraged participation in PA. Others identified senior centers as a place for socialization and also as a facilitator for PA.

• “… My pastor is very much into health and wellness… They have a get up and move… He gets up out and we maybe walk around the park and he’s always challenging us… we’ll take those long walks … our church is very health conscious.” (72—Active)
• “… It’s our dance at Douglas Center… she is the dance instructor, and it’s about six of us that participate in the program, and it’s a good form of exercise…” (72—Inactive)

Fitness and recreation centers.

RA and IA participants mentioned that having access to fitness and recreation centers served as a facilitator for PA. Some RA and IA participants discussed the activities and equipment that are available in those locations.

• “…I have a picture here of the Planet Fitness center … I enjoy, it’s a lot of people, lot of various activities going on in there, and different treadmills, and all kinds of exercising equipment. So it’s a great place to go to get exercise.” (80—Active)

Table 2 summarizes the barriers and facilitators reported by the participants.

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Table 2. Factors influencing physical activity participation in regularly active and insufficiently active older African American women.

https://doi.org/10.1371/journal.pone.0142703.t002

Discussion

To our knowledge this study is one of the first studies to conduct an in-depth investigation of PA and factors influencing PA in older AAW employing a participatory approach (i.e., photo-elicitation). The findings of this study may help in the development of more culturally sensitive interventions and strategies to promote PA in this particularly vulnerable population. The study adds to the literature by exploring factors impacting PA in an under-represented, at risk group using an innovative research design including the objective measurement of PA and the use of photo-elicitation. Findings from our study suggest that: (a) some factors positively and negatively impacting PA are similar among RA and IA older AAW; (b) older AAW lack knowledge about the PA intensity necessary to achieve health benefits.

We observed that, regardless PA status, individuals think about PA in several different ways. Some women believe that PA encompasses a wide range of activities, including both traditional exercise, as well as, “lifestyle activities” such as gardening, housekeeping, and walking the dog. This broad interpretation of PA is consistent with the definition most frequently used in contemporary public health initiatives [5,30]. However, other individuals appear to be using a more traditional interpretation of PA that is synonymous with “exercise”, i.e., an activity that occurs at a specific place, usually for a specific duration and intensity, and often with the specific purpose of increasing physical fitness [5,33]. This finding of different interpretations for the “meaning” of PA is consistent with the findings of several studies examining perceptions, attitudes and factors influencing PA and exercise in both Whites and African Americans [12,34,35].

We observed that while some RA and IA women have a good understanding of the amount of PA needed in terms of frequency and duration, others in both groups had no idea of how much PA individuals in their age should perform. Although many participants mentioned frequency and duration of PA, none had an appreciation of the intensity of PA needed to obtain health benefits. This is unfortunate because intensity is a critically important component of PA for achieving health benefits. It is important to note that our findings about intensity may reflect the way we inquired about participant’s knowledge. Participants were asked how much PA should women in their age do and if they ever had heard about any government recommendations regarding PA. Follow up questions explored such topics as how many days, for how long, and at what intensity? However, we never explicitly probed participants using the words “moderate” or “vigorous intensity”. Many public health initiatives have targeted completely sedentary individuals in an effort to motivate them to build some level of activity into their everyday lives and settings (e.g., family, workplace, communities and clinical settings) [36]. For the most part, such initiatives fail to adequately stress the importance of PA intensity. There is solid evidence in the PA and exercise literature that not only frequency and duration but also intensity of exercise are necessary elements in order to achieve health benefits [1,5]. Some participants in this study expressed the belief that women in their age group should be as active as their bodies allowed them to be. This is an interesting finding and it is consistent with parts of the 2008 PA guidelines for Americans [4]. Older adults aged 65 and over unable to achieve the 150 minutes per week because of a chronic condition, should be as active as they can be, matching their activities to their fitness level. This government recommendation is consistent with the clinical characteristics of our sample, where 55% of the women in this study reported 1 or 2 chronic diseases; and 25% reported having 3 or more chronic diseases. Our findings suggest that many older AAW may have difficulty in setting realistic PA goals that are consistent with evidence-based guidelines. Wilcox et al., [12] observed that participants in their study held the opinion that frequency, duration and intensity should be chosen by the individual and not guided by an external criterion. Together, these findings suggest that there is a need to more effectively disseminate information about evidence-based guidelines and recommendations for PA. Individuals should be aware of the amount of PA needed per week in terms of frequency, duration and intensity in order to achieve substantial health and quality of life improvements.

Factors influencing PA participation in this study were generally consistent with the various levels of the social ecological model of health behavior [23]. Our findings corroborate the results of prior studies with similar purposes [10,11,14,37]. For instance, studies using focus groups to explore barriers and facilitators for PA have observed similar barriers and facilitators for PA participation as the present study [10,11]. Although in many studies health issues were reported as both a barrier and facilitator for PA [13,14,38], in the present study, health concerns emerged mainly as a barrier despite the fact some participants acknowledged an association between health and PA. Women in this study understood that health benefits accrue from PA, however, they seldom identified poor health as a factor that motivated them to be more active. On the other hand, others mentioned that they refrain from being more active because of their health conditions. This suggests that barriers and facilitators for PA may vary from person to person and that not all health messages are equally effective in all circumstances. This highlights the importance of conducting additional research in different AA communities in order to develop an in-depth knowledge about the community beliefs and preferences prior to implementing behavioral change programs. Leavy and Aberg [38] qualitatively explored perceptions of PA in older Swedish and Irish adults. They found that physically active and inactive participants reporting chronic diseases (e.g., arthritis, heart disease) have a distinct perception about health problems. Active participants viewed health problems as motivators for PA whereas inactive participants viewed health problems mainly as barriers to be more active. It is important to note that barriers and facilitators to PA are extremely challenging to compare between studies. While some studies have used a quantitative approach based on questionnaires or a list of statements [39–41], others have adopted qualitative approaches employing different methods for data collection, i.e. focus groups, interviews [10,11,14]. For instance, Siddiqi et al., [14] in their review identified at least four different types of experimental design, with focus groups being the most prevalent among older adults. Therefore, differences found between our study and others could be partially explained by the study design adopted, methods of data collection employed and sample characteristics.

Participants in both RA and IA group expressed the perception that living in an unsafe neighborhood (i.e., bad sidewalks, poor lighting, and dangerous neighborhood) was a barrier to PA. In fact, information provided by the cities of Urbana-Champaign, suggests that the concerns raised about neighborhood safety are often grounded in reality. For instance, a number of neighborhoods have inadequate or non-existent lighting. Furthermore, the violent crime rate in Champaign is more than twice the average observed in the State of Illinois.

This study also found that economic issues and psychosocial stress due to life conditions may be hindering older AAW from being more active. It is important to note that economic issues have been constantly reported by African Americans and seldom mentioned by other racial groups as barriers to PA [11,14]. Psychosocial stress (e.g., racism, discrimination) has been used by sociologists primarily to understand disparities in diseases and conditions and access to and type of care received [28]. Psychosocial stress in the context of PA participation has been much less frequently studied. Edwards and Cunningham [42] examined how opportunities for PA and community racism are associated with decreased engagement in PA. The authors observed that when community racism was low, respondents found ways to be active; however, when community racism was high, perceived lack of opportunities significantly obstructed PA engagement. It is not clear whether factors such as discrimination and life history alter how the Social Ecological Model applies in different ethnic and/or racial groups. Future research should explore whether the interactions among levels of the social ecological model are impacted by the disproportional burdens faced by many African Americans that may deter them from engaging in PA.

The findings of the present study constitute important information for public health practice and for health professionals aiming to implement PA programs for older AAW living in the community. In view of the findings, action will be needed from different sectors if we are to increase PA levels among older African Americans with special attention being paid to providing access to no or low cost opportunities to be active in safe environments. Williams and Jackson [43] note that health disparities are embedded in a larger historical, geographic, sociocultural, economic, and political context. Therefore, changes in a broad range of public policies are needed to effectively address these systemic and ongoing disparities.

Our findings provide insight with respect to some of the ways RA and IA older AAW are similar. Socio-demographic variables, health characteristics, or factors influencing PA cannot be used to explain why some women are active and others are sedentary. However, objective PA data collected shows that some participants are achieving the PA recommendations and some are not. Although we do not have clear evidence with regard to why this is the case, a study conducted by Edwards and Cunningham [42] on perceived racism and level of PA offers a partial explanation. The IA group in our study may perceive higher levels of racism in the community compared to the RA group and may not be fully aware of the whole range of possibilities for being active. Additionally, RA women may have found ways to keep motivated and maintain enjoyment in being physically active [44]. Developing strategies to buffer the impact of racism/discrimination on healthy lifestyle choices may be one way to increase PA level in this group and should be further explored.

This study benefited from the use of both the objective measurement of PA and the use of photo-elicitation. Distinct from other methods of data collection (e.g., interview or focus groups), photo-elicitation helped in breaching the communication impasse, bridging geographical and cultural gaps between investigator and participants, and making participants feel more aware of and responsible for their role and importance in the study. The combination of both qualitative and quantitative approaches is a promising research design for in-depth understanding of behavior, attitudes, and perceptions. Although important, our findings must be interpreted with care due to the following limitations. Qualitative research has its limitations, including the inability to generalize findings to a reference population, (i.e., the general population of older AAW living in the United States). Our study was based on women living in a small town, relatively well educated, with a reasonable annual income. Accordingly, caution is warranted when generalizing/transferring the outcomes to the broader population of older AAW. An additional limitation of our study was that data were only collected during one season of the year (winter/spring/summer/fall), it is possible that participant’s perceptions and values regarding PA may fluctuate from season to season. It would be helpful for a study to explore how seasonal variation impacts these perceptions. Finally, we did not require that MVPA occur in bouts of at least 10 minutes when determining whether or not participants were meeting the PA recommendations. Rather, we employed a more nuanced approach by counting every minute in MVPA, which is consistent with current public health messages used to increase PA at the population level. However, it is important to note that differences in PA level have been reported when comparing MVPA data between “bout dependent” and “bout independent” approaches [7, 45].

Supporting Information

Acknowledgments

The authors thank Coordenação de Aperfeiçoamento de Pessoal de Nível Superior (CAPES) for the scholarship provided to ES to pursue his PhD (process number BEX 5718/10-4).