1. Introduction
Older adults aged 65 and over are the fast growing segment of the World’s population. According to the World Health Organization, the number of older adults are likely to double by 2050 [
1]. Within this time period the global population of over 80 year olds is forecasted to quadruple to nearly 400 million and in the UK alone, 85 year olds and over are the fastest growing population group [
2]. In addition, the age-related public expenditure in the UK is projected to increase to 26% of GDP by 2057.
A large part to this age related socio-economic burden is due to the societal and individual cost of managing multiple chronic disease and disablement in later life. Furthermore, there is strong evidence that physical activity is a modifiable health behavior that can prevent chronic conditions, help maintain independence and increase the quality of life and wellbeing in later life.
However, current epidemiological data shows that older adults are also the most sedentary segment of the population. In the UK and USA, older adults spend on average 70% of their waking hours being sedentary and at least half of everyone over 70 years old sits for 80% of the day [
3,
4]. In the UK, the healthcare cost of inactivity is estimated to be £8.5 billion per year, which equates to 10% of the national health care budget [
5].
Sedentary behavior is defined as time spent in non-exercising, seated or reclining pursuits, such as watching television, sitting in motorized transport or in front of a computer at work [
6]. Recent evidence from multiple lines of enquiry show that sedentary behavior has deleterious effects on health and is associated with an increased risk of chronic disease, disablement and premature death in older adults [
3,
7,
8,
9,
10]. Furthermore, a recent study also found that older adults who are sedentary are less likely to age successfully in the physical, psychological and sociological domain [
11]. The effect of sedentary behavior on health is two-fold [
12]. Firstly, the amount of time spent in sedentary pursuits tends to displace the time spent being active and therefore prevents individuals from reaping the health benefits that physical activity brings. More recently it has also been shown that sedentary behavior has a specifically deleterious effect on a person’s health, independent of the amount of physical activity that is carried out [
12]. Indeed, it is possible to carry out the recommended 30 min of daily physical activity and yet spend the rest of the day sitting down.
Consequently, several countries (USA, Canada and the UK) and the World Health Organization have issued guidelines for older adults to limit the amount of time spent sitting and recommended that research is carried out on interventions which reduce the amount of time that older adults spend sitting [
13,
14,
15].
To date only one study has attempted to modify the sedentary behavior in older adults [
16]. It showed that it is possible to change the amount of sitting time in young and healthy older adults using tailored behavioral interventions, but there is no evidence to show that this approach would transfer to older and frailer individuals. In addition the type of behavioral interventions that were addressed by this study only focus on personal factors and entirely neglects the interpersonal, environmental and societal factors that might affect the amount of time which older adults spend sitting down in any given day.
Current theoretical frameworks [
17,
18] hypothesize that a complex interplay between personal circumstances, environmental and social factors determine sedentary behavior. Research on the determinants of physical activity among older adults has shown that environmental social, behavioral and cognitive factors are key for the initiation, and long-term maintenance, of physical activity [
19,
20]. However, it is not known if these same factors also determine sedentary behavior.
In fact, the current dearth of information about the determinants of sedentary behavior is the single most important factor in limiting the development of interventions which modify sedentary behavior in older adults. While some very limited cross-sectional quantitative information exists in this area [
17], no studies have attempted to gather the views and opinions of older adults into the factors which determine their sedentary behavior. The aim of this study was to address this gap in knowledge by gathering this information from community-dwelling older adults with various levels of independence and frailty.
4. Discussion
Sedentary behavior, or time spent doing non-exercising, reclining and seated activities, is emerging as an important public health issue, particularly amongst older people who are the most sedentary group within the population. Several national guidelines recommend a reduction in sedentary behavior for the older adult population but currently there is little knowledge about what determines sedentary behavior within this population group and how to develop interventions which leads them to change their behavior [
13]. This is the first study to examine older people's views and perceptions about what determines their daily sedentary behavior. The findings of this study help identify opportunities for intervention and barriers to promoting sedentary behavior change.
Sedentary behavior appears to be viewed by older women as a necessity. Sitting time is built into their daily routines as a way of managing chronic disease symptoms, such as pain and stiffness, renewing or conserving energy levels and making life easier and more enjoyable. During these periods, older women do not see sitting as an unhealthy behavior but rather as a positive coping strategy which enables them to remain functional and independent. A number of participants actually challenged the view that sedentary behavior is intrinsically unhealthy and should be reduced as they felt “entitled” to sit whenever they wanted or needed to. In addition, sedentary time is often centered on activities that have either a social nature or provide mental stimulation such as: playing bingo, reading or doing the crossword. Older women deemed these activities, which are all performed sitting down, to be positive, pleasurable and beneficial to their wellbeing.
However, all the participants interviewed recognized that sitting too much could not be a healthy thing to do. However, this did not stem from an awareness of the detrimental effects of sedentary behavior on health. Instead, it was a result of personally experiencing the short-term consequences of sitting for prolonged periods, which most commonly included increased pain, stiffness and a depressive mood. Outside of the sedentary periods which they deemed necessary, periods of sedentary time were generally viewed as a bore and unpleasant experience.
Sitting too much also appears to be socially undesirable for older women and is strongly linked to ageism [
31]. Concerns about being judged as “lazy” or “not useful” seemed to create difficulties in acknowledging to themselves and others how long they genuinely sat down for. All participants felt that there was a social stigma attached with sedentary behavior for older people and that society expects them to sit all day. It is interesting to note that some recent epidemiological studies found that both older men and women self-report lower sitting time than younger age groups [
32]. This is in complete contrast to objective reports [
4] and hints that self report measures are strongly biased by social desirability. The feeling that there is a social stigma attached with sedentary behavior might be very pervasive amongst older adults, leading them to under-reporting of sitting time.
There is a sense amongst older women, that they are encouraged or even forced, to sit more than they wished to by the activities available to them and the social, community and urban environments they experience. This extends to the attitude of their family, friends and carers who commonly encourage older women to sit and actively discourage physical activity. While the participants acknowledged that these might be benevolent gestures, they felt strongly that it typecasts older adults as inherently dependent and removes their sense of purpose. There was a strong and unanimous desire to challenge this perception.
From the data, it was possible to identify some perceived determinants of sedentary behavior which fit within the personal, inter-personal and environmental categories of the current ecological models of sedentary behavior [
17,
18].
In the personal category the most common perceived determinant of sitting appear to be symptoms of chronic diseases such as pain, stiffness and fatigue. In particular, pain and stiffness seem to act both as reason to sit and a reason for breaking periods of sedentary behavior. While the sample of this study might not be representative of the general older adult population, their symptoms are very representative of this group [
33,
34]. It is therefore conceivable that pain and stiffness play an important role in determining sedentary behavior amongst older women. In addition, the data suggests that these, and in particular fatigue, might directly affect the behavior patterns of sitting.
In this study, most participants reported arthritis-related stiffness and pain. Therefore they should be more likely to experience difficulties in the morning [
35] and as result spend more time sitting. [
36]. However, surprisingly, the temporal pattern of behavior amongst all participants in this study appears to be the complete opposite of this. Everyone interviewed reported that they organize their day so that they can do what they have to in the morning and rest in the afternoon. This pattern is similar to what has been recently observed using objective measures of physical activity and sedentary behavior [
37] and is consistent with reports of patterns of daytime rest and napping in older adults [
38].
This pattern could be interpreted as an autonomic habitus [
39] that has been developed to manage fatigue and energy expenditure. However, it is not clear whether this is a result of a perceived physiological fatigue or an innate way of regulating energy expenditure. Consequently fatigue might be a direct determinant of sitting especially in the afternoon or it might be fatigue avoidance. Or it could simply be that older women feel more capable in the morning, as reported by some participants in this study. Regardless of the underlying reason for this pattern, the pattern itself should be acknowledged by any interventions which aim to decrease the amount of time spent sitting.
Mobility issues were also reported as being primary reason for sitting. Some of these reasons were physical limitations and impairments directly affecting an individual’s ability to stand and remain in upright postures. While other reasons seem more likely to be related to low self-efficacy [
40]. Some participants said that they sit a lot because they are scared of being active and suddenly finding they are tired and unable to cope. These well known determinants of physical activity in older adults [
41] seem to also affect sedentary behavior.
Depression is another known personal correlate of sedentary behavior [
7] that some of the participants gave as a reason for remaining sedentary. They explained that depression affected their motivation to stand up and be active.
Within the interpersonal category, the same ageist stereotypes and processes [
42] that affect the promotion of physical activity in older adults [
43] also seem to encourage sedentary behavior in this group. Although they may have good intentions, friends, family and carers may be overbearing in their desire to look after older adults, with participants reporting that they felt “molly-coddled” or “treated with kid gloves”. The most commonly reported activities that participants did while standing were in accordance with the social norms and tasks of daily living: house chores and taking care of others. Removing these social norms and providing greater support to older women than is needed reduces the opportunity for them to stand up and feel independent on a daily basis, in turn affecting their self-efficacy. Some of the participants actually said that they limited their standing activities out of a fear of being a burden to relatives or carers, in case they fell, got fatigued and did not cope while upright.
The lack of provision of community-based activities, facilities and services which encourage older women to stand, appears to be another strong determinant of sedentary time. Most participants complained of a lack of facilities and opportunities that encourage or enable older women to be active and regretted that they were mostly offered activities that required them to be seated. This might be the result of a widespread risk adverse culture within organizations and policies which cater for older women [
31].
Weather conditions and urban design were also emerging themes which fall within the environmental category of determinants. In Scotland, were the study took place, poor weather was described by the participants as a reason to sit more than they would wish to and lead to them feeling less motivated to be active. Counter intuitively, the participants blamed a lack of sitting facilities spaced around the urban environment or within community facilities as a reason to stay sedentary. They explained that more seats would enable them to rest when needed and pace themselves, giving them increased confidence which in turn would allow them to venture further outside and do more standing up. This is not an issue that has been considered by research on neighborhood walkability [
44] or built environment design to promote self-efficacy and physical activity [
45].
There was not a strong interest in reducing the amount of sitting time amongst this sample of older women. Fear of disrupting daily routines built around managing already difficult circumstances, a lack of energy and a sense that they already did the best they could were the most strongly expressed reservations. However there was a lot of interest in changing their pattern of sitting and a genuine hunger for engaging in more standing activities, provided they can rest and pace themselves when needed.
The results of this qualitative investigation suggest that there are some opportunities and factors to be considered in the development of interventions.
The pattern of sedentary time throughout the day could determine the effectiveness of interventions. Morning interventions could be more successful but would target the least sedentary part of the day therefore yielding a limited change. Most participants reported thinking that morning intervention would be easier for them. However some of them recognized that they would welcome the chance to change their pattern of behavior. It is therefore possible that interventions which target sedentary times during the afternoon and evening might be more successful and effective in reducing total sitting time. This might however require spreading the interruption of sitting periods throughout the day, using strategies such as pacing. Frequent short interruptions while sitting was thought by some of the participants as the easiest and most manageable way for them to change their sedentary behavior. This implies that intervention monitoring should focus not only on the achieved reduction of sedentary behavior but also in measuring a change in pattern.
Interventions should pay attention to the individual pattern of sedentary behavior and not disrupt periods of sitting that are used as coping strategies or deemed beneficial by older women. Therefore it would be sensible to work with older women on an individual basis to both monitor the pattern of sitting and identify those beneficial periods. This will require a system of classification of sedentary periods to be used [
46].
Short term benefits, such as relieving and managing stiffness, pain or depression, seem to be strong motivating factors in breaking long periods of sitting that are already adopted spontaneously by older women. Interventions should consider harnessing these salutogenic behavior adaptations and the person’s own coping strategies to foster sustainable change.
Together these last two points suggest that interventions should be individualized and tailored [
47] and might explain the success in the short term reduction of sedentary behavior obtained by Gardiner
et al. [
16].
The desire for social interaction and for assuming a purposeful role within society, such as caring for others, appears to be other opportunities for encouraging behavioral change. This seems to advocate the delivery of interventions through peer-mentoring schemes which have demonstrated success in the areas of fall prevention and physical activity promotion [
48,
49].
Finally, the activities which community services offer older women appear to lack the stimulation which encourages them to stand up. Interventions should also consider targeting organizations which provide services to older people. This might require changing organizational culture and staff training as well as looking at the design of the interior and urban environment to ensure there are enough resting spaces in the right location and density.
It is not possible to tell from this study if similar factors determine sedentary behavior in older men. However, there was no indication in the data that the factors reported by the women in this study are gender specific. The participants tended to talk about older people and the effect of ageing rather than making statements about older women, yet they answered from women perspectives. It is reasonable to assume that a number of these factors, in particular physical factors, might determine older men sedentary behavior, but it is likely their effect is of a different magnitude and nature. It is also conceivable that older men might express different view and qualitative investigations should be undertaken to fill this research gap.
There are some limitations to this study. Firstly, the sample was small, even for a qualitative study, although it fulfilled the criteria for saturation according to Morse [
50]. The sample was fairly homogeneous so this limits the ability to generalize the results. Finally, the themes extracted could not be triangulated with the screening questionnaire (
Table 1).