«DIFFUSION OF TAI CHI IN OLDER POPULATIONS: FACILITATORS AND BARRIERS TO ADOPTION By PETER A. GRYFFIN A DISSERTATION PRESENTED TO THE GRADUATE SCHOOL ...»
DIFFUSION OF TAI CHI IN OLDER POPULATIONS:
FACILITATORS AND BARRIERS TO ADOPTION
PETER A. GRYFFIN
A DISSERTATION PRESENTED TO THE GRADUATE SCHOOL
OF THE UNIVERSITY OF FLORIDA IN PARTIAL FULFILLMENT
OF THE REQUIREMENTS FOR THE DEGREE OF
DOCTOR OF PHILOSOPHY
UNIVERSITY OF FLORIDA© 2013 Peter A. Gryffin To my wife and children for their sacrifices, And to my committee, for their support and patience
ACKNOWLEDGMENTSThis work would not have been possible first and foremost due to Dr. W. William Chen, without whose support I would not be here. Also deepest gratitude to everyone else involved with my selection for the Alumni Fellowship, in particular Dr. Barbara Rienzo and Dr. Kelli Brown. The support of everyone in HHP has been tremendous. I look forward to bringing many good things out of the program for the health and wellbeing of society.
I would like to also thank my committee members, Drs. W William Chen, Beth Chaney, Morgan Pigg, Virginia Dodd, and Beverly Roberts for their help and support with my dissertation and studies. I hope my efforts, current and future, will make you proud of the skills and knowledge you have shared with me for advancing the state of health education and behavior. Your knowledge, expertise, and wisdom were greatly appreciated, and I only wish I could have had more time with each of you.
My thanks would not be complete without acknowledging the support and help of Dr. Bernhardt, as well as JoAnne McLeary, Melanie DeProspero, Melissa Naidu, and Henry Lewis III. They facilitated my journey in more ways than I can say. Finally, I would like to acknowledge my family, for their patience in enduring a major life change. I hope it will all be worth it in the end.
TABLE OF CONTENTSpage ACKNOWLEDGMENTS
LIST OF TABLES
LIST OF FIGURES
LIST OF ABBREVIATIONS AND KEY TERMS
CHAPTER 1 INTRODUCTION
Purpose of this Study
Background and Overview of the Health Belief Model
Significance of the Study
2 REVIEW OF THE LITERATURE
Overview of Health Benefits from Tai Chi for Older Adults
Diffusion of Innovations
Research from Knowledge, Attitudes, and Practice (KAP) and Related Studies.... 43 Studies using the Fishbone Diagram in a Focus Group Design
Institutional Review Board
Characteristics of Tai Chi class and Instructors at OTOW
Focus Group Protocol
The Fishbone Diagram
Organization of Findings
Research Question One
Research Question Two
Research Question Three
Research Question Four
Organization of Discussion Section
Facilitators related to Perceived Benefits and Threats
Facilitators Related to Health Threats Identified by the CDC
Perceived Barriers to the Adoption of TC
Recommendations Related to Diffusion of Innovations Theory
Limitations and Bias
Conclusion & Recommendations
Summary of Key Findings.
APPENDIX A REVIEW OF SELECTED TAI CHI PROGRAMS IN THE UNITED STATES........ 139 B KEY TO CODES FOR FIGURE 5-1
C INSTITUTIONAL REVIEW BOARD SUMMER 2012 DOCUMENTS
LIST OF REFERENCES
2-1 Facilitators and barriers to TC in older adults.
2-2 Comparison of facilitators and barriers.
3-1 Demographics of Tai Chi Group (TCG)..
3-2 Demographics of No Tai Chi Group (NTC)..
4-1 Comparison of Benefits Identified by the Non TC and TC Group
4-2 Non Tai Chi (NTC) Group Perceived Benefits.
4-3 Tai Chi Group (TCG) Perceived Benefits..
4-4 Comparison of mean scores and standard deviation between groups for comparable benefits.
4-5 Comparison of Barriers Identified by the Non TC and TC Group
4-6 Non Tai Chi (NTC) Group Perceived Barriers.
4-7 Tai Chi Group (TCG) Perceived barriers.
4-8 Comparison of mean scores and standard deviation between groups for comparable barriers.
4-9 Comparison of Threats Identified by the Non TC and TC Group
4-10 Non Tai Chi (NTC) Group Perceived Threats
4-11 Tai Chi (TCG) Group Perceived Threats.
4-12 Comparison of mean scores and standard deviation between groups for comparable threats.
5-1 Possible facilitators to adoption of TC related to OTOW focus groups............. 135 5-2 Comparison of Perceived Benefits, Threats and Barriers as frequency of responses via post-it notes.
5-3 Top seven causes of death in 2007 among persons 65 years of age and over 136 5-4 Perceived Barriers to the adoption of TC identified by the focus groups.......... 137
2-1 Overview and linkage of foundational concepts.
2-2 Adopter categorization on the basis of innovativeness
2-3 The innovation-decision making process
2-4 Aggregate fishbone for IM residents.
3-1 Post-It Note Phase of the Fishbone diagram.
3-2 Perceived Threats, Benefits, and Barriers
4-1 Primary Knowledge of TC Benefits (from fishbone diagram)
4-2 Primary Perceived Facilitators to TC Adoption
4-3 Primary Perceived Barriers to TC (from fishbone diagram)
5-1 Overview of potential facilitators and barriers identified
TAILORED MESSAGE Messages customized to an individual to promote adoption or uptake of a health behavior. Similar to CTA.
TARGETED MESSAGE Messages customized to a group or societal level to promote adoption or uptake of a health behavior. Similar to CTA.
Chair: W. William Chen Major: Health and Human Performance According to the Center for Disease Control (CDC), seven out of ten deaths are due to chronic diseases, most of which are preventable. Prevention has been identified as possibly the only viable strategy for reducing health care costs, death, and disability, with potential Medicare savings of $65.2 billion to $142.8 billion annually. Falls, a specific health threat to older adults (as the leading cause of fatal and non-fatal injuries in older adults), resulted in $28.2 billion of direct care costs. A large body of evidence has demonstrated significant benefits of Tai Chi (TC) for balance and chronic diseases, yet TC is vastly under-utilized. Of critical importance is to develop an understanding of what will facilitate action for TC, as well as barriers to TC adoption. To accomplish this goal two focus groups were conducted, one group consisting of participants who had never considered adoption of TC (n=10), the second group consisting of participants who were TC practitioners (n=11). A fishbone diagram was utilized to structure responses according to the Health Belief Model (HBM) according to facilitators (perceived threats and benefits), and perceived barriers. Perceived threats, benefits, and barriers listed on the fishbone diagram were rated on a 0-9 scale, and were evaluated according to frequencies, mean group scores, as well as standard deviation.
Additional qualitative data was gathered during the discussion phase. Lack of awareness of benefits of TC, a need for evidence based benefits, as well as issues related to teaching style were identified as the greatest barriers. The largest opportunity for the promotion of TC identified related to perceived threats from falls. Threats identified by the focus groups were compared to statistics from the Center for Disease Control (CDC). A large dissonance existed between health threats identified by the CDC and threats identified by focus group participants, indicating a potential area to target.
Implications related to the diffusion of innovations are also presented, related to the five stage innovation-decision making process and the perceived characteristics of an innovation relevant to the adoption of TC, with recommendations for future research.
According to the Center for Disease Control,1 seven out of ten deaths are due to chronic diseases, most of which are preventable. In 2002, half of Medicare beneficiaries had been treated for at least five chronic conditions, which accounted for more than 75% of Medicare spending. 2 Chronic diseases are primarily lifestyle illnesses, and as such, are the most preventable, through the adoption of a healthy lifestyle. Older adults in particular are beset by a number of additional health problems atypical to most of society, in particular threats from loss of balance and falling, as well as threat of reduced mobility, heart disease, cancer, stroke, and various other conditions.3,4 Tai Chi (TC) is characterized by slow gentle movements focused on controlling the central balance of the body, and has been identified as an exercise suitable for all ages, including older adults.5-7 Benefits have been reported for balance,5-7 cardiovascular disease,5,8 cardiopulmonary disease,9 beneficial effects for type 2 diabetes,10,11 various psychological and mental benefits6,12, and potential benefits for cancer.13-16 Refer to overview of benefits of TC for older adults in chapter 2 for more information.
Yet TC tends to remain under-utilized by society, including in the older adult population. For example, On Top of the World community (OTOW), in Ocala Florida, an active living community of approximately 10,000 residents, has been offering a TC program for over 6 years, yet attendance is constant at around 7 to 9 participants. From discussions with other active living communities in Central Florida, such low attendance rates are typical. TC has the lowest attendance rate, compared to other fitness classes at OTOW, which tend to number around 18-20 per class (with 17 different class offerings, equaling a total of 37 classes each week, not including TC). As a comparison TC is under-utilized, particularly considering it is a low impact exercise that is particularly beneficial for older adults (refer to the review of literature in chapter 2).
Determining facilitators and barriers to the adoption of TC may provide insights which can be used to promote adoption of a variety of health exercises.
The question is, why do people not take advantage of health offerings, particularly when offered at no cost? Knowledge, attitudes and practice (KAP) studies have been established as an effective means to discover key adoption factors.17 Chodzko-Zajko and others,18 during an national expert meeting sponsored by the National Blueprint office at the University of Illinois and the National Council on Aging, identified a strong need for studies on the most effective ways to deliver evidence based TC and Qi Gong programs to the public, including elements related to the importance of understanding current knowledge and attitudes towards TC.
Primary issues identified by the authors, aside from the development of more effective ways to teach TC outside the traditional expert or master format, was the need to address the challenges of integrating TC into the aging network and to develop an effective program to meet the needs of a diverse population. These challenges include the need to identify barriers such as misinformation (knowledge), perceptions that the practices are too unusual or esoteric (attitudes), that TC does not mean learning a martial art (knowledge), as well as lack of understanding of the benefits of TC (knowledge).
Other suggestions related to knowledge and attitudes include; the need to develop a clear and concise marketing message regarding the benefits of TC for target populations, particularly older adults; marketing the value of program adoption to community based organizations; gather testimonials from successful programs for media use; develop information for distribution at community health fairs and other venues; and communicate research findings to the media and health care professionals in Western terms.18 These recommendations form the essence of the current study – to identify KAP, barriers, facilitators, and an effective social marketing platform for the effective diffusion of TC in the older adult community.
The purpose of this dissertation was to identify facilitators and barriers to the adoption of TC through a focus group design, comparing knowledge and attitudes between TC practitioners and those who have never considered TC adoption, relevant to perceptions of health threats and benefits of TC, as well as barriers which may affect the diffusion of TC. The Health Belief Model (HBM) was used as a framework, in conjunction with a fishbone diagram to structure responses. The study will be valuable for health education specialists in fulfilling their responsibilities as laid out by the National Commission for Health Education Credentialing.19 The current study would
address the following areas of responsibility:
1. Assess the needs, assets and capacity for health education: The primary purpose of the KAP assessment.
2. Plan health education: The results of the focus group study, using the fishbone diagram results and follow up studies, would assist with effective health education planning.
3. Conduct evaluation and research related to health education: The function of this dissertation.
4. Administer and Manage Health Education: Focus group results, and follow up studies, can be used by OTOW management for better meeting community needs.
5. Serve as a health education resource person: The KAP assessment will provide information and resources for health educators to better serve the public, by laying a foundation from which to conduct rigorous studies for validation, as well as initial findings from the focus groups.
6. Communicate and advocate for health education: The dissertation will provide baseline data for additional studies which can be used to advocate and communicate the benefits of participatory community research.