TAI CHI FOR OLDER ADULTS: IMPROVING PHYSICAL AND PSYCHOLOGICAL HEALTH THROUGH A COMMUNITY-BASED TAI CHI PROGRAM AND IDENTIFYING BARRIERS TO PARTICIPATION JAMES D MANSON A DISSERTATION SUBMITTED TO THE FACULTY OF GRADUATE STUDIES IN PARTIAL FULFILMENT OF THE REQUIREMENTS FOR THE DEGREE OF DOCTOR OF PHILOSOPHY GRADUATE PROGRAM IN KINESIOLOGY AND HEALTH SCIENCE YORK UNIVERSITY, TORONTO, ONTARIO September 2014 © James Manson, 2014 ABSTRACT Older adults face aging challenges that occur naturally or are precipitated early in the aging cycle by physical inactivity. Using three prospective cohorts of ethnically diverse low- income older adults, this dissertation aimed to: i) assess the promoters and barriers of low- income older adults in terms of their enrollment in a locally-offered TC program, ii) examine the TC intervention effects in terms of physiological outcomes, iii), examine the TC intervention effects in terms of psychological outcomes, and, iv) assess the promoters and barriers of low-income older adults in terms of their adherence in a locally-offered TC program, with special sensitivity to ethno-cultural based issues. Results of the first objective uncovered six categories relating to enrollment with no clear barriers or promoters that related to gender and specific cultural limitations. Categories included physical and mental health, time of day, socialization, program pairing, accessibility and appropriate leadership/teacher. Results of the second objective showed significant improvements in both upper and lower body strength, low back flexibility, and the Short- Form Health Survey (SF 36) physical health scores (p < 0.05). Based on multiple linear regression analyses, no common health determinants explained a significant portion of the variation in percent changes of the musculoskeletal fitness and SF 36 measures. Results of the third objective did not find significant improvements when looking at SF 36 summary mental health scale, subjective happiness scale and the expectations regarding aging summary measure; however, there were significant improvements in two sub scales of the SF 36 of vitality (VT) and mental health (MH) in the combined cohorts and expectations regarding aging in the third of three cohorts (p < 0.05). Finally in the last objective there were ten categories found relating to adherence with no clear barriers or promoters that ii related to specific cultural limitations. Categories included common barriers/promoters that embraced biological, psychological, social and environmental influences. Overall, the results demonstrated that TC has the ability to be used as a good health-related PA program in a multi-ethnic, low-income, older adult population with possible potential for psychological health improvement and with key categories to help enrollment and maintain attendance. iii ACKNOWLEDGEMENTS I would like to strongly thank my supervisor, Dr. Hala Tamim, for her tireless work and amazing patience throughout my PhD studies. Dr. Tamim opened up an entire new world for me through the five years that we worked together and going forward into the future I would be lucky and honoured to able to call her a colleague and friend. I greatly appreciate the efforts of my committee members, Dr. Chris Ardern and Dr. Veronica Jamnik for their support, positive feedback, continued education and perspectives. I would especially like to add a special thank you to Dr. Veronica Jamnik for almost weekly support around navigating a PhD as a mature student. iv Table of Contents Abstract……. …............................................................................................................................. ii Acknowlegments .......................................................................................................................... iv Table of Contents ...........................................................................................................................v List of Tables ............................................................................................................................... vii List of Figures ............................................................................................................................. viii List of Acronyms .......................................................................................................................... ix Introduction ....................................................................................................................................1 Objectives......................................................................................................................................12 Overall Study Methodology ........................................................................................................14 Manuscript 1: Barriers and Promoters for Enrollment to a Community based Tai Chi Program for Older, Low-Income, and Ethnically Diverse Adults ................................................................37 Abstract ................................................................................................................................................... 38 Introduction ............................................................................................................................................. 39 Methods ................................................................................................................................................... 41 Results and Disccusion ........................................................................................................................... 45 Conclusion .............................................................................................................................................. 51 References ............................................................................................................................................... 53 Tables ...................................................................................................................................................... 56 Manuscript 2: Effect of Tai Chi on Musculoskeletal Health-Related Fitness and Self-Reported Physical Health Changes in Low-Income, Multiple Ethnicity, Mid-to-Older Adults ..................58 Abstract ................................................................................................................................................... 59 Introduction ............................................................................................................................................. 60 Methods ................................................................................................................................................... 62 Results ..................................................................................................................................................... 66 Disccusion ............................................................................................................................................... 68 Conclusion .............................................................................................................................................. 72 References ............................................................................................................................................... 73 v Tables ...................................................................................................................................................... 76 Manuscript 3: Effect of Tai Chi on Psychological Health, Subjective Happiness and Expectations Regarding Aging in Low-Income, Multiple Ethnicity, Mid-to-Older Adults .........80 Abstract ................................................................................................................................................... 81 Background ............................................................................................................................................. 82 Methods ................................................................................................................................................... 83 Results ..................................................................................................................................................... 86 Disccusion ............................................................................................................................................... 88 Conclusion .............................................................................................................................................. 91 References ............................................................................................................................................... 93 Tables ...................................................................................................................................................... 97 Manuscript 4: Barriers and Promoters for Adherence to a Community based Tai Chi Program for Older, Low-Income and Ethnically Diverse Adults ................................................................99 Abstract ................................................................................................................................................. 100 Introduction ........................................................................................................................................... 101 Methods ................................................................................................................................................. 103 Results and Disccusion ......................................................................................................................... 107 Conclusion ............................................................................................................................................ 117 References ............................................................................................................................................. 119 Tables .................................................................................................................................................... 123 Conclusion: Main Findings, Strength & Limitations, Implications and Future Directions .......125 References ...................................................................................................................................130 Appendices ..................................................................................................................................137 Appendix A-Focus Group Informed Consent ...................................................................................... 138 Appendix A-Enrollment Focus Group Questions and Probes ............................................................. 140 Appendix A-Informed Consent to Enrollment to Tai Chi Program ..................................................... 141 Appendix B- Physical Activity Readiness Questionnaire for Everyone ............................................. 144 Appendix C- Tai Chi Participation Study-Physical and Psychological Measures ............................... 148 vi Appendix D- Adherence Focus Group Questions and Probes ............................................................. 164 Appendix E- Orientation to Life Questionnaire ................................................................................... 165 Appendix F- SF-12 Questionnaire ....................................................................................................... 167 vii List of Tables Cohort 1 Table: Baseline Socio-Demographic & Physical Characteristics of Program Participants: Completed and Non-Completed ..............................................................................17 Cohort 2 Table: Baseline Socio-Demographic & Physical Characteristics of Program Participants: Completed and Non-Completed ..............................................................................24 Cohort 3 Table: Baseline Socio-Demographic & Physical Characteristics of Program Participants: Completed and Non-Completed ..............................................................................31 Manuscript 1 Table 1: Baseline Socio-Demographic Characteristics of Pre Study Focus Group Participants ....................................................................................................................................56 Manuscript 1 Table 2: Themes, categories, and subcategories to enrollment resulting from the qualitative analysis ........................................................................................................................57 Manuscript 2 Table 1: Baseline Socio-Demographic and Physical Characteristics of Program Participants ....................................................................................................................................76 Manuscript 2 Table 2: Baseline Health-Related Musculoskeletal Fitness Characteristics and SF 36 Physical Scales and Physical Summary Measure of Study Participants ..................................77 Manuscript 2 Table 3: Mean Difference of Health-Related Musculoskeletal Fitness Measures, SF 36 Physical Scales and Summary Measure .............................................................................78 Manuscript 2 Table 4: Multivariate Linear Regression for Relationship between Musculoskeletal Health, SF 36 Physical Summary Measure and Determinates of Health ..........79 Manuscript 3 Table 1: Baseline Socio-Demographic, Psychological Health Related Characteristics and SF 36 Scales and Summary Measure of Study Participants ..........................97 Manuscript 3 Table 2: Pre and Post Mean Difference of Expectations Regarding Aging Survey, Subjective Happiness Scale and SF 36 Mental Health Scales and Summary Measure ................98 Manuscript 4 Table 1: Baseline Socio-Demographic characteristics of Post Study Focus Group Participants ..................................................................................................................................123 Manuscript 4 Table 2: Themes, categories, and subcategories to adherence resulting from the qualitative analysis ......................................................................................................................124 viii List of Figures Figure 1-Flowchart of Study ......................................................................................................34 ix List of Acronyms SES – Socioeconomic Status MET – Metabolic Equivalent PA – Physical Activity TC – Tai Chi TCH – Toronto Community Housing WHO – World Health Organization CPAFLA – Canadian Physical Activity and Fitness Lifestyle Approach x