Eur J Appl Physiol

DOI 10.1007/s00421-007-0392-0

ORIGINAL ARTICLE

Physical activity and mental well-being in older people participating in the Better Ageing Project

Kenneth R. Fox · Afroditi Stathi · Jim McKenna · Mark G. Davis

Accepted: 3 November 2006© Springer-Verlag 2007

Abstract Increasing evidence suggests that physicalactivity can prevent some aspects of mental illness inolder people such as depression, dementia and Alzhei-mer’s disease. Additionally, limited research has shownthat engagement in structured exercise can improveaspects of psychological well-being such as mood andself-perceptions in older adults. However, the relation-ship between incidental daily activity such as walkingor time spent sedentary, with psychological well-beinghas not been investigated. The Better Ageing Projectprovided an opportunity to assess well-being and qual-ity of life using standardised questionnaires with 176adults aged 70 and over. Accelerometry was used toobjectively assess daily energy expended in physicalactivity at diVerent levels of intensity. In addition, anassessment of the impact of the 12-month Better Age-ing structured group exercise programme was assessedthrough questionnaires and interviews. Total daily

physical activity energy expenditure (joules/day) andamount of time spent in activity of at least moderateintensity were weakly related (r = 0.20–0.28) to qualityof life, subjective well-being and physical self-percep-tions. Time spent sedentary (min/day) was weakly andnegatively related to several mental health indicators.The quantitative data showed only minor psychologicalbeneWts of the exercise intervention. In contrast, inter-views with 27 research participants and 4 exercise lead-ers suggested that important improvements in perceivedfunction and social beneWts had been experienced.

Introduction and background

The recent Chief Medical OYcer’s report in England(Department of Health 2004) and the World HealthOrganisation (World Health Organisation 2002) havepresented convincing evidence for the importance ofregular, moderate intensity physical activity for publichealth gain. Reductions in risk arising from regularphysical activity in older age are at least as strong asthose found in middle age for all-cause mortality, car-diovascular disease, and type-2 diabetes. In older peo-ple, regular physical activity is also important for theincrease or preservation of muscle strength and power,maintenance of mobility and independent living, andprevention and reduction of falls and fractures(Department of Health 2001; Fiatarone-Singh 2002;Keysor 2003; Miller et al. 2000; Taylor et al. 2004;Young and Dinan 2005).

Although the case for physical activity in olderadults has largely been built on its impact on physicalhealth and function, evidence is emerging for positiveeVects on aspects of mental health. Recent large-scale

K. R. Fox (&) · M. G. DavisExercise, Nutrition, and Health Sciences, School of Applied and Community Health Studies, Centre for Sport, Exercise and Health, University of Bristol, Tyndall Ave, Bristol, BS8 1TP, UKe-mail: K.R.Fox@bristol.ac.uk

M. G. Davise-mail: Mark.Davis@bristol.ac.uk

A. StathiLondon Sport Institute, Middlesex University, London, UKe-mail: A.Stathi@mdx.ac.uk

J. McKennaCarnegie Faculty of Sport and Education, Leeds Metropolitan University, Leeds, UKe-mail: J.McKenna@leedsmet.ac.uk

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prospective studies have begun to document importantpreventive eVects for mental disorders such as depres-sion (Strawbridge et al. 2002), cognitive impairment,dementia and Alzheimer’s disease (Abbott 2004; Col-combe and Kramer 2003; Laurin et al. 2001; Rovioet al. 2005; YaVe et al. 2001) in older adults. Addition-ally, reviews have demonstrated the emergence of a lit-erature indicating positive eVects of engagement inactivity on various aspects of psychological well-beingin older people (Biddle and Faulkner 2002; Fox andStathi 2002; McAuley and Rudolph 1995; Rejeski andMihalko 2001) including the treatment of depression(Barbour and Blumenthal 2005; Blumenthal et al.1999). Furthermore, it is also likely, although not yetfully established, that functional Wtness is particularlycritical to mental well-being in older people as commu-nity mobility is inexorably tied to maintenance of inde-pendent living (Frank and Patla 2003).

Given the potential of regular physical activity toimprove physical and mental functioning, well-being,and quality of life, several questions remain about thenature of the association between activity and mentalwell-being. As with all age groups, activity can be cate-gorised as (1) daily routine activity or ‘lifestyle activity’such as regular walking or cycling to shops, services andfor leisure, and (2) structured or formal exercise sessionstaking place in sports, community, or residential centres.Information on the mental beneWts of activity in thesediVerent life contexts is essential for activity promotionpolicy development. The literature remains sparse, withmost studies conducted in the USA to investigate theimpact of structured programmes of exercise on mentalwell-being (McAuley et al. 2005; Rejeski and Mihalko2001). In contrast, very little is known about the rela-tionship between daily physical activity totals, diurnaland geographical patterns of movement, or time spentimmobile and their association with or impact on mentalhealth of older people. This is particularly the case foradults aged 70 and older in Europe.

Measurement poses a major challenge to increasingour understanding of the activity and mental healthrelationship. Attendance at structured and formalexercise classes can be assessed with reasonable accu-racy but incidental activity such as short but more fre-quent walking events is diYcult to remember andregister accurately on self-report tools. AccelerometryoVers an objective alternative as it can record minute-by-minute movement including level of intensity. Con-sequently, energy expended through physical activitythroughout the day, volumes of activity at light, moder-ate and vigorous intensity levels, and amount of timespent sedentary can be estimated with improved preci-sion (Craig et al. 2003; Washburn and Ficker 1999).

The European Commission Better Ageing Projectprovided our team with a unique opportunity toaddress several issues related to physical activity andmental health in older adults from three diVerentEuropean countries—Italy, France, and England. Theoverall aim of this multi-centre project was to investi-gate the determinants of frailty in older people with aparticular focus on muscle function, from the cellularto the functional level. However, the purpose of ourwork package was quite diVerent. With very little exist-ing research with the over 1970s, our aim was toadvance the Weld through the development and exten-sion of measurement methods for both activity andmental well-being. In the process we wished to providepreliminary insight into the links between (1) daily life-style activity and mental well-being and life qualityindicators, and (2) assess the impact of a structuredexercise programme on mental well-being in the ‘older’elderly. A mixed-methods quantitative/qualitativeapproach was devised that utilised standardised andnew questionnaires, objective measurement of physicalactivity, and interviews. This paper provides an over-view of this research, its objectives, methods, mainWndings, and implications for subsequent research pro-jects. SpeciWc objectives were as follows:

1. To assess the reliability and validity of a range ofpsychological instruments for the assessment ofaspects of well-being and life quality.

2. To investigate the relationship between daily phys-ical activity and sedentary living and a range ofindicators of mental well-being and quality of life.

3. To investigate the eVects of a standardised 12-month programme of structured exercise on indi-cators of mental well-being and quality of life.

Methods

The Better Ageing project as a whole has beendescribed more completely elsewhere in this volume andthe detail of the work related to the accelerometry mea-surement of physical activity is also reported in a sepa-rate paper (see Davis and Fox, this volume). Ethicalapproval for the study was established through MRECand local ethics committees in the UK, and standardprocedures in Italy and France. All participants pro-vided signed informed consent to take part in the study.

Participants

Participants were drawn from volunteers at researchsites delivering the Better Ageing exercise programme.

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Of the 204 participants recruited, 176 (64/79 controlsand 112/125 intervention) satisfactorily completedbaseline questionnaires. The sites were the Universityof Burgundy in France (UB), the University of Pavia inItaly (UP), and in England the Manchester Metropoli-tan University (MMU), and King’s College, London(KC). Participants were invited to take part in the pro-ject through local advertising. Patients with controlleddisease symptoms were included but those withadvanced neurological, endocrine dysfunction oruncontrolled disease or pathology were excluded.

Measures and instruments

We aimed to provide a comprehensive proWle of well-being and quality of life. The challenge was Wndinginstruments that were appropriate and valid for thisage group and that were also available in French, Ital-ian and English languages. In addition, we wished toextend the use of two instruments developed by ourteam with middle-aged and elderly British populationsthat had speciWc relevance to physical activity andmental well-being.

An extensive literature search identiWed instrumentsthat were already available in the three languages.However, these had not been widely administered toadults aged 70 and above and so were piloted withEnglish speaking participants. From these, the WHO-QOL-BREF (De Girolamo et al. 2000; Leplege et al.2000; WHOQOLGroup 1998), the Satisfaction withLife Scale (Diener et al. 1985) and the General Well-Being Schedule (Dupuy 1984) were chosen for thestudy. The Ageing Well ProWle (Stathi and Fox 2004;Stathi et al. 2002) and the short clinical version of thePhysical Self-Perception ProWle (Fox and Corbin 1989)were translated using the established back translationmethod. For example, for the Italian version, theinstrument was Wrst translated by an Italian-speakingresearcher into Italian, tested for face validity with agroup of Italian participants, modiWed and then back-translated into English using an independent languageexpert. Any anomalies with the original version werethen resolved to produce the translated version.

WHOQOL-BREF (WHOQOL)

The World Health Organisation sought a comprehen-sive instrument capable of assessing quality of lifeworldwide. It has therefore been developed throughapplication in several countries and populations and isavailable in 19 languages. This multidimensionalinstrument, with items in a Wve point Likert format,assesses self-rated physical health and function, psy-

chological health, satisfaction with social relationships,and satisfaction with material/environmental aspects oflife.

Satisfaction with Life Scale (SWLS)

the Satisfaction with Life Scale is a self-administeredquestionnaire with Wve non-speciWc items on a seven-point scale aimed at assessing global life satisfaction(Diener et al. 1985). It therefore carries no speciWc ref-erences to diVerent aspects of life and assesses overallfeelings. The SWLS has widely established validity andreliability including use with older adult populations(Pavot and Diener 1993; Pavot et al. 1991).

General Well-Being Schedule (GWB)

This instrument was developed by Dupuy (1984) andtranslated into several languages by the Mapi ResearchInstitute, France. The scale reXects positive and nega-tive feelings in six dimensions that include anxiety,depression, general health, positive well-being, self-control, and vitality over the past month. Items are setin a six choice checklist format.

Ageing Well ProWle (AWP)

This is a multidimensional scale, assessing multipleaspects of subjective well-being relevant to the physicalactivity experiences of older people. Subscales usingitems in a Wve-point Likert format measure social(friendship, support and inclusion), physical (healthand function), developmental (independence, achieve-ment and challenge) and mental (mood and cognitivefunction) are included. The instrument has been sub-jected to rigorous psychometric development with sev-eral samples (Stathi 2001; Stathi and Fox 2004)including conWrmatory factor modelling and has indi-cated that the subscales are reliable and valid for anolder population in the UK.

Clinical Physical Self-Perception ProWle (CPSPP)

This is a multidimensional proWle designed to provide asummary of self-evaluations in the physical domain.The proWle includes three-item subscales in a four-pointstructured alternative format to measure perceivedsport competence, physical function, physical strength,physical health, and body attractiveness. In addition, athree-item subscale assesses overall physical self-worth.Developmental work with participants aged 60 andabove has indicated a moderately strong factor struc-ture and acceptable to good internal consistency.

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This battery of questionnaires produced a compre-hensive range of quality of life and mental well-beingoutcomes. Global elements such as life satisfactionwere assessed alongside more speciWc elements such asself-perceptions of physical health or subjective socialwell-being.

Physical activity and sedentary living

Physical activity was assessed minute by minute duringwaking time over a 7-day period by accelerometry. Themethod and procedures are described in detail inanother paper (see Davis and Fox, this volume). Sev-eral parameters were of interest to this study includingoverall physical activity as an indicator of indepen-dence and daily mobility, amount of activity at higherlevels of intensity that might provide speciWc mentalhealth beneWts, and amount of time spent sedentary.For the purpose of these analyses, four summary vari-ables were therefore extracted. These were: (1) dailyphysical activity energy expenditure (PAEE) assessedin total joules per day, (2) minutes of activity of nomore than light intensity per day (LPA), (3) minutes ofactivity of at least moderate intensity per day (MVPA),and (4) sedentary minutes per day (SED).

Intervention, design, and procedures

The intervention was a standardised exercise pro-gramme developed by King’s College, London Univer-sity and involved engagement in two group-trainingsessions and one home-based exercise session per weekfor a period of 12 months. Each group session lasted60–90 mins and included warm up, aerobic exercise,machine-based strength training and Tai Chi and Xexi-bility exercise.

Intervention and control groups matched on agewere formed at the MMU and KC sites. Randomisa-tion into intervention and control groups took placeonly at the Pavia site. Questionnaires and accelerome-ters were administered to all intervention and controlparticipants (1) before the Wrst exercise session, (2)after 6 months of the intervention (with the exceptionof KC participants) and (3) on completion of the inter-vention at 12 months. One-on-one assistance was avail-able on each occasion.

Interviews

In order to provide additional information on the per-ceived beneWts and costs of taking part in the interven-tion, and provide some indication of factors determiningadherence and dropout, we also conducted 24 individual

semi-structured interviews with participants in the Bet-ter Ageing project. Participants were volunteers at theUK research sites delivering the Better Ageing exer-cise programme (Manchester Metropolitan University[MMU], and King’s College, London [KC]). The exer-cise classes at the MMU site were delivered in the uni-versity campus facilities. The exercise classes at the KCsite were oVered in partnership with various health andWtness clubs in London.

Participants were purposively selected to provide adiverse range of experiences from those who com-pleted the intervention (n = 17), dropped-out (n = 4),or were in the control group (n = 3). Six interviewswere also conducted with exercise leaders (n = 4) andBetter Ageing researchers (n = 2) from the two cen-tres. The interviews were undertaken either (1) imme-diately at the end of the intervention (MMU), (2) 8 or12 months after the intervention (KC). The interviewsat the MMU took place at the centre where exercisethe programme was delivered. The interviews with theKC participants took place at their own homes afterthe completion of the Better Ageing project in order toexplore further motives and barriers for maintaining aphysically active lifestyle some months after the formalprogramme was completed.

A semi-structured phenomenologically driven inter-view format was chosen to explore in detail the per-sonal exercise experiences of participants. Interviewschedules were delivered Xexibly, although all topicswere covered in each interview, which lasted 30–50 min. With respondents’ expressed permission, inter-views were audio-taped, transcribed in full andimported into QSR NVivo software (QSR Interna-tional, 2002).

Analyses

Psychometric analyses including item and principalcomponents factor analysis and internal consistency(alpha coeYcients) were Wrst conducted to assess theperformance of the instruments. Descriptive statisticsincluding means, standard deviations and distributionsfor all scales and subscales were calculated by genderand also as sample totals to provide greater power.Separate psychometric analyses for English and newlytranslated French and Italian versions of the instru-ments were not possible because sample sizes were toosmall to produce robust results.

The associations between mental well-being mea-sures, physical activity participation and sedentary timewere assessed by Pearson zero-order correlation analy-sis on data at baseline. This provided an estimate of therelationship before any eVect of the intervention was

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possible. The impact of the exercise intervention onmental well-being was assessed by repeated measuresANOVA and MANOVA, separately for each gender.

Treatment of the qualitative data was based on theprinciples of interpretive phenomenological analysis(Smith and Osborn 2003). After the free textual analy-sis in which comments and preliminary interpretationswere prepared independently by the second and thirdauthors, thematic coding frames were developed forintervention participants and for intervention profes-sionals. Connections between emergent themes wereexamined and super-ordinate themes interpolated. Thethemes from Wrst cases oriented the subsequent analy-sis of the other cases taking into account convergencesand divergences in the data. The Wrst author thenchecked the list of super-ordinate themes for consis-tency and interpretation and contributed to the transla-tion of themes into a narrative account.

Results

The Wnal sample with full accelerometry and question-naire data at baseline were 78 males (m) aged75.8 § 3.8 years and 98 females (f) aged 75.4 §4.0 years. At baseline, there were 64 control (m = 26,f = 38) and 112 intervention (m = 52, f = 60) partici-pants distributed at four sites in three diVerent coun-tries (see Table 1). This reduced to 40 control (m = 17,f = 23) and 92 intervention (m = 41, f = 51) participantsat completion of the intervention period. Six-monthdata was not collected at the KC site and there was adisproportionate loss of control group females so base-line and 12-month data only were considered for fur-ther analysis. The majority of participants weremarried, educated to at least secondary level and hadno serious conditions of ill-health. Chi-square analysisrevealed no diVerences in these demographics and agebetween control and intervention participants for eachperiod.

Psychometric properties of instruments

These instruments have rarely or never been usedwith this population and item, factor and reliabilityanalyses were Wrst run on data at each time point.Results from baseline data (n = 176) indicated thatinternal consistency of scales and subscales rangedbetween alpha = 0.65 and 0.86 making them accept-able to good. Exploratory factor analysis revealedthat the well-established Satisfaction with Life Scaleproduced a single reliable factor. Using the number ofsubscales for each instrument to determine factornumbers extracted, factor solutions produced a highdegree of explained variance in the items (seeTable 2). However, the General Well Being Scheduleand WHOQOL-BREF did not produce clearly deW-ned factor structures and interpretation of resultsusing subscales should be tempered with some cau-tion. The newly developed CPSPP and AWP pro-vided good internal consistency and, with some minorexceptions, clear factor structures. As with otherunpublished results, the physical health subscale ofthe CPSPP did not form a clear factor and appears tomerge with other subscales, particularly the physicalfunction subscale. In general, the means and standarddeviations for the 21 psychological subscales acrossall instruments were invariant from baseline to12 months suggesting some degree of stability whenused with groups.

Results were replicated with minor exceptions whenthese analyses were conducted separately by gender.Although small sample sizes did not allow robust sub-analyses for each language, a preliminary view suggestedsimilar patterns for each suggesting that translations hadnot been detrimental. However, further work with eachlanguage version is required to fully establish reliabilityand validity. This early indication of reliability and facto-rial validity of these established and two new instruments(CPSPP and AWP), which assess mental well-being prop-erties particularly pertinent to exercise settings, provide

Table 1 Final sample by gen-der, site, and time point

Baseline 6 months 12 months

Control Exercise Control Exercise Control Exercise

SiteMMU, UK 26 29 16 29 16 27KC, UK 15 25 - - 10 20UB, France 9 31 9 31 7 23UP, Italy 14 27 14 22 7 22

GenderMales 26 52 21 43 17 41Females 38 60 18 49 23 51

Total 64 112 39 82 40 92

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an important base for further cross-national andnational research with elderly populations.

Relationship between well-being and physical activity

The association of well-being variables at baseline withvarious indicators of physical activity and sedentary liv-ing provided by the objective measure of accelerome-try was assessed using Pearson correlation analyses.Baseline data were chosen as it provided the largestsample and also reXected habitual physical activity ofcontrol and intervention participants before the inter-vention had commenced. Results for both genderscombined are summarised in Table 3. This produced alarge number of coeYcients for the sample size and

interpretation of the strengths of individual coeYcientsthat should be tempered. However, the matrix indi-cates several consistencies.

Estimations of total daily energy expended by physi-cal activity PAEE were weakly (r = 0.17–0.24) but con-sistently related to the composite measures of lifesatisfaction, general well-being, quality of life, subjec-tive well-being, and physical self-perceptions. Closerscrutiny of the subscale correlations indicates that con-structs such as ‘psychological health’ (WHOQOL),‘subjective physical health’ (AWP), ‘perceived physicalfunction’ and ‘sport competence’ (CPSPP) produce thestronger coeYcients. Life satisfaction and general well-being scales produced the weakest correlations. Thiswould suggest that total movement was therefore

Table 2 Results of instrument factor and reliability analyses with both gender combined (baseline data n = 176)

Instrument Factor rotation

Factor (n)

% variance

Range of subscale alphas

Satisfaction with Llife Scale Direct 1 62.6 0.84General Well-Being Schedule Oblimen 6 69.4 0.58–0.86WHOQOL-BREF Oblimen 4 52.7 0.65–0.82Ageing Well ProWle Oblimen 4 54.1 0.75–0.84Clinical Physical Self-Perception ProWle Oblimen 5 70.9 0.62–0.81

Table 3 Pearson correlation coeYcients for relationships between psychological well-being and total daily activity, time spent seden-tary and light and moderate intensity activity: males and females combined

PAEE physical activity energy expenditure

*SigniWcant at 0.05, **signiWcant at 0.01

PAEE (Joules/day)

Sedentary time (minutes/day)

Light intensity activity (minutes/day)

Moderate intensity activity (minutes/day)

Satisfaction with life scale 0.17* 0.07 0.06 0.15WHOQOL-BREF 0.24** ¡0.20* 0.09 0.19*Physical health 0.20* ¡0.15 0.11 0.22**Psychological health 0.26** ¡0.16* 0.04 0.21**Social 0.06 ¡0.19* 0.04 0.08Environmental 0.21** ¡0.16* 0.05 0.25**

General well-being schedule 0.23** ¡0.09 0.15 0.19*Anxiety 0.16* ¡0.06 0.11 0.12Depression 0.18* ¡0.17 0.13 0.20Well-being 0.10 ¡0.17* 0.01 0.06Self-control 0.00 ¡0.03 0.02 0.08Vitality 0.07 ¡0.03 0.02 0.04Health 0.19* ¡0.05 0.02 0.05

Ageing well proWle 0.22** ¡0.14 0.21** 0.19*Developmental 0.19* ¡0.17* 0.23** 0.16*Physical health 0.28** ¡0.12 0.19* 0.23**Mental 0.13 ¡0.06 0.17* 0.12Social 0.12 ¡0.09 0.09 0.11

Physical self-perception proWle 0.21** ¡0.17* 0.09 0.17*Phys self-worth 0.17* ¡0.12 0.13 0.14Phys function 0.22** ¡0.16* 0.09 0.19*Phys health 0.13 ¡0.26** 0.15 0.11Phys strength 0.13 ¡0.14 0.03 0.07Body attractiveness 0.06 ¡0.01 ¡0.05 0.08Sport competence 0.21** ¡0.10 0.05 0.16*

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related to factors concerned with perceived conWdencein physical function and capability of being sporty andis reXected in positive feeling of physical health andpsychological well-being. The amount of time spent indaily moderate to vigorous physical activity (MVPA)was small (see Davis and Fox, this volume) but wasalso related to quality of life subscales ‘physical health’,‘psychological health’ and ‘satisfaction with environ-ment’ (WHOQOL), and ‘subjective physical health’(AWP). Once again, the SWLS and GWB instrumentsproduced only very weak relationships. Those whoexperience higher levels of moderate intensity physicalactivity seem to experience a better quality of life andperceived health.

Amount of time spent in light intensity activity perday was not related to any of the life satisfaction, qual-ity of life, general well-being or physical self-perceptionmeasures. The Ageing Well ProWle ‘developmentalwell-being’ and ‘physical health’ subscales producedweak correlations but there is no obvious explanationfor this.

As predicted, the amount of time per day spent sed-entary produced negative correlations with several psy-chological health indicators. Quality of life for thosemost sedentary was lower and their perceived physicalhealth and function was lower.

Although these correlations are not strong, theyprovide some indication that older people who movemore often and more intensively and/or spend less timesitting during the day perceive higher levels of mentalwell-being and life quality. Daily mobility, either as aconsequence, or determinant, of psychological well-being seems important for older people and deservesgreater research attention.

Intervention eVects: evidence from questionnaires

The Better Ageing exercise programme achieved a93% attendance rate, as assessed by records kept bythe exercise leader at each site. Self-reported compli-ance to the recommended home-based sessions perweek was 85%. This is an unusually high commitment,and perhaps particularly surprising for a population ofthis age. Gender distribution at baseline and 12 monthswas not signiWcantly diVerent. However, there weresigniWcant diVerences in well-being variables scoresbetween intervention and control group males at base-line on 12 out of 21 subscales. Intervention group par-ticipants scored higher on general and physical healthand well-being variables than controls. No baselinediVerences existed for females. There was a diVerential1980s to loss of the over 80 year old males throughoutthe programme. Because of lack of power, we used a

repeated-measures ANOVA with the composite scalescore for those instruments whose factor structure hadnot been well deWned in earlier analyses (WHOQOL-BREF, GWB) and also the uni-dimensional SWLS.Repeated measures MANOVA was used for proWleswith clear subscale deWnition (AWP and CPSPP). Bon-ferroni adjustment was applied. Results indicated onlyone signiWcant change with all instrument means show-ing remarkable stability over a 12-month period. Therewas a signiWcant group £ time interaction for male inphysical self-perception proWles (CPSPP) (F[1,52] =8.938; P = 0.004). This was explained by the controlgroup deteriorating in proWle scores and the interven-tion group remaining the same over the time period ofthe intervention. The WHOQOL-BREF and AWP formales and females showed small diVerences in favourof the intervention group but did not reach signiW-cance. Overall, these results suggest that the exerciseintervention did not create large improvements inmental well-being and quality of life, although thereare suggestions that it may have prevented a decline inphysical self-perceptions in men.

Intervention eVects: evidence from interviews

Interviews were conducted to provide further informa-tion on (1) the eVect of the intervention on the well-being of participants, and (2) factors determiningadherence to, and dropout from, the programme andexercise in general. A summary of typical and illustra-tive comments on the eVects of the intervention onaVect, self-perceptions and social well-being are pre-sented here.1

Outcome expectations

There was clear evidence that participants entered theprogramme with a set of positive expectations aboutthe potential beneWts of the programme. These beneWtswere seen as mainly physical rather than mental. Post-poning physical deterioration was seen as a primaryreason for taking part in the programme. Those withprevious exercise experience in particular, expectedWtness improvements, better mobility and ability toperform everyday activities and weight loss.

I was interested in getting Wtter. (Karen, 74)

I thought, I’ll take step in advance and go on thefalls programme before I begin to fall. That waswhy I volunteered to take part. (Karl, 87)

1 Real names have been replaced with pseudonyms which arefollowed by the real age of the participants.

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Physical self-perceptions

Participants reported that early in the programme theybegan to notice Wtness improvement in areas such asstrength, Xexibility and general mobility which they felthad led to better functionality and performance in theireveryday activities.

I never used to walk anywhere and now I walk atleast an hour everyday. (Susan, 74)

I get out of bed easier. Hoovering is so easy youjust walk up and down much better. Becausethose were the movements that came into theexercise—the walking and the pushing. (Helen, p.73)

Some participants appreciated the strong focus of theintervention on strength and coordination and theycommented on the appropriateness and eVectivenessof exercises tailored to their functional needs.

I’ve got arthritis in my left foot. It always gave metrouble. Since I’ve been going to the gym, it’s deW-nitely helped me by strengthening my leg up.(Alex, p. 75)

Participants felt that strength training provided directfeedback and within a short period of time allowedthem to see their improvement. This provided chal-lenge and a sense of achievement and was a strongmotive for them to work hard.

The machines are better. Well they seem to needmore eVort and I think they increase yourstrength. The bands just keep your strength at thesame level I think (Helen, p. 73)

For some, this sense of achievement seemed to gener-alise beyond the exercise setting to more global levelsof self-worth.

I’m more contented with my own self. It’s everytime I’ve been and I walk back across that yard Ifeel that I’ve achieved something that I’ve got alittle bit stronger I’m more Xexible. I’m not a fail-ure. That’s the way I feel about it. (Colin, p. 73)

Connectedness and social support

There is evidence from the interviews that social well-being was experienced through support and interac-tion. Part of the enjoyment experienced in class wasclearly the quality of relationships and environmentcreated through a high standard of leadership exper-tise and support. Participants commented on theknowledge, the patience and the enthusiasm of both

the researchers and the class leaders. They praisedthe support they received especially during the Wrstsessions, which they felt was the most diYcult time forthem.

We have had good people teaching this. They hada super team and there isn’t one of them who hasnot been nice to us you know and they’re great,all of them have been super. It all helps doesn’tit? If you get someone—an instructor—someonewho you didn’t like, he was bit nasty, youwouldn’t want to come would you. When they areall so nice and welcoming they bring out the bestin you, hopefully. (Mary, p. 71)

The use of intensive tuition and one-on-one supportduring the Wrst weeks of the programme enabled staVto provide reassurance and help participants build bothconWdence and physical competence to cope with theexercise loading.

I watch each individual as we are doing the aero-bics—see how they’re coping with it... you see theexertion in the face... I’ll announce to everybody,‘If you’re Wnding this one hard, this is what youcan do. (A, exercise leader)

Some participants also mentioned that they appreci-ated the attitude of the leaders who they felt hadtreated them with respect, especially regarding theirage, and had made them feel valued. Exercise profes-sionals were sensitive to the importance of mutualinter-generational empathy.

We have never been talked down at. We havebeen encouraged and we have been entertainedand I think they’ve been entertained and I wouldregard them as friends.

One person said to me the other day that he usedto think that young people sort of looked downon them. I can remember the exact words heused. But after working with our group, he hadmore faith then in the younger generation. (J,Researcher)

The positive social interaction provided by thegroup-based exercise was a primary source of enjoy-ment and an important reason to attend. Comparingthe two components of the exercise programme, thegroup exercise and the individual home-based exercise,participants reported a clear preference for the groupactivity.

Several participants described the home-based pro-gramme as boring and providing little motivation. Incontrast, the exercise group setting oVered a friendly

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and supportive environment with opportunities forsocialisation.

DeWnitely the class was better because of theother people there as well. (Mary, 71)

It was lovely to meet up with everyone twice aweek, whenever we were all there. It was verynice. It broke down the barrier eventually tobeing nervous of going to the gym, because onehas this idea of everyone being in their slinky leo-tards, fantastic gear and everything. (Margaret,70)

Support and positive reactions from signiWcant oth-ers such as family and friends also seemed to be impor-tant for some participants.

My family think it’s absolutely brilliant.(Rebecca, 75)

My two sons were amazed that their retired fatherstill had the energy to have a go at something andmy wife was delighted as she felt that I wasn’t get-ting enough exercise anyway. (Martin, 75)

Enjoyment

Participants, including dropouts, reported that theexercise classes had been an enjoyable experience. Thecreation of a welcoming and social atmosphere wasparticularly important. The only unpleasant elementsmentioned by some participants were concerned withthe discomfort of some of the research tests.

I think we enjoyed everything about it you knowand various little things cropped up at diVerenttimes which could make you laugh. (Ray, 75)

it was really fun, everybody knew everybody else.(Charlotte, 74);

The second time I enjoyed it so much I wanted tocome again. (Mary, 73)

Empowerment and energising eVects

The exercise classes were used by some participants asa way to escape falling into lethargic routines.

I’m sure if I stayed here, and didn’t take any exer-cise, my mental state would be very poor. Butgoing about, doing that, and having the incentiveto go out every day, is good for the mental thing.(Susan, 74)

For some this was expressed in a sense of increasedenergy and motivation in other aspects of their lives.

Now I’ve got to the stage, where if I don’t go out,I don’t feel right—which for me is amazing.Before, weekends were just spent working andcatching up on sleep I hadn’t had in the week,from getting up at 4:45. Friday afternoon, wouldcome in and shut the door, and wouldn’t go outtill Monday morning. Now if I don’t go out in theweekend I feel weird. (Susan, 74)

Altruism

A factor that had not previously been consideredemerged from the interviews.

Engagement in the research project had provided anopportunity for altruism.

What we decided was that this was obviouslyputting something back into medical science andwe’ve had quite a bit out of it over our years so itwas a means of putting something back in. (Jack,73)

There were strong feelings that it had provided achance for “pay back” to the community. To someextent, acting as a research participant was seen as asocial duty and this allowed them to endure some ofthe less enjoyable research tests involving electricalstimulation and CT scanning.

I have enjoyed it all, even the twitches that areconfusing, the electric shocks which are not pleas-ant. But I would go through it again, it would notput me oV. (Mary, 71)

Few minor negative outcomes were reported andthis is reXected in high attendance and low dropoutfrom the programme. Furthermore, serious healthproblems or important family commitments ratherthan a problem with the programme were the mainreasons for the very few participants who dropped-out.

Last December my brother was diagnosed withcancer and he’s very ill—that was the reason Idropped out. (Sandra, 75)

In summary, there is clear evidence from the inter-views with participants and exercise leaders that physi-cal and mental beneWts were experienced in the BetterAgeing exercise programme. Most of these beneWtsarose from attendance in the group exercise sessions.For a variety of reasons, these were seen as enjoyable.The activities and interactions themselves were gener-ally seen as a lot of fun. They provided an opportunityto experience high quality social interactions with exer-cise specialists and also with people with similar inter-ests and needs. They produced a sense of improved

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physical competence through increases in strength,general Wtness, and ability to perform tasks of daily liv-ing. They also provided opportunities to feel that aworthwhile eVort had been made to counteract theageing process. For some, it also seemed importantthat this produced positive reactions from family andfriends. These Wndings have been seen elsewhere ingroup-activity programmes for older people (Cattanet al. 2005; McAuley et al. 2000a, 2000b; Stathi et al.2002, 2003). The degree to which these positive speciWcoutcomes translated into higher order aspects of well-being such as self-esteem or self-determination is diY-cult to conclude from these data.

Discussion

This research has provided an important opportunityto apply and develop methods to assess psychologicalwell-being and physical activity with this under-studiedbut growing population of European adults over theage of 70. Administration of a battery of instruments inthree languages demonstrated the feasibility of ques-tionnaire data collection with this population thatincluded adults up to the age of 86. Psychometric anal-yses of instruments indicated that they generally pro-duced meaningful results with adequate reliability.Sample size did not allow robust analyses of versions ineach language but overall results appeared similar.However, factor analyses suggested that the multidi-mensionality of two standard instruments—the WHO-QOL and general well-being schedule, was not clearlyestablished and individual subscales or sub-dimensionswere not all well deWned. On the other hand, the newshorter version of the physical self-perception proWleand the Ageing Well ProWle produced sounder factorstructures and good reliability. These instruments arepurpose-designed for use in the physical activity settingand oVer a valuable base for further cross nationalresearch. This is already underway with data collec-tions in Italy and the UK.

To our knowledge, mental well-being parametershave not been previously set alongside objective mea-surement of daily physical activity with this age group.Previous data have relied on self-report and almost allstudies have addressed the activity/mental health rela-tionship in the context of structured group exercise.Little is known about the impact of volume of energyexpended or higher intensity daily activity throughphysical activity. Findings indicated that there was aconsistent positive but weak relationship between sev-eral indicators of perceived health, physical function,and self-perceptions with total volume of activity, and

activity of at least moderate intensity. Conversely,weak negative relationship emerged with amount oftime spent in a sedentary mode. Older people in thisstudy, who move more often and spend less time sittingdown, experience higher levels of self-rated mentalhealth and well-being than those who are less active.

Both causal directions for this relationship are plau-sible and likely. High total amounts of activity andachievement of greater amounts of moderate intensityactivity may have contributed to higher levels of men-tal well-being. However, it is equally possible thatthose with higher levels of mental well-being and per-ceived health are more capable and motivated to beactive on a daily basis. Randomised controlled studieswill be needed to address dominant directions of thiscausality. Accelerometry provides a viable means ofdocumenting the eVectiveness of interventions toincrease daily activity and provides a sounder basis forinvestigating its consequences for psychological well-being.

This study also oVered a preliminary opportunityto investigate the eVects of a 12-month structuredgroup exercise programme on psychological well-being. Results from questionnaires produced at best,inconsistent evidence of a beneWcial eVect of exercisefor men. These small changes in only a few measuresof mental well-being across the intervention periodwere unconvincing and it is not possible to conWrmsubstantial positive changes in well-being as an out-come of the programme. However, the researchdesign did not allow a deWnitive trial. Recruitmentand statistical power were determined by thedemands of the key physiological research questionsin the Better Ageing project. Participants were notrandomised at three sites and matched-controlling failedto produce equivalence in the initial psychologicalproWles of the males.

Recruitment of a representative sample to studiesinvolving physical activity interventions poses a partic-ular challenge with this population. Consenting volun-teers tend to be Wtter, more physically able, bettereducated, socially aware and mentally healthier thanaverage. Although there were no diVerences betweencontrol and intervention participants in age, educa-tional, marital or health status, it is possible that theweak quantitative Wndings were at least in part a resultof participants already experiencing high levels of men-tal well-being. The qualitative approach in thisresearch has conWrmed a strong commitment in partici-pants to contributing to research among participants.This is reXected in very high attendance and low drop-out rates and it might have produced inXated baselinescores.

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In contrast, to the results from standardised ques-tionnaires, the data from interviews with participantssuggest that important mental beneWts were experi-enced by many participants as a result of the interven-tion. These included enjoyment of the sessions thatled to improved mood, improved physical self-percep-tions of strength, Wtness and ability to function betterin the tasks of daily living. Social beneWts were com-monly reported as a result of the quality of the exer-cise environment and the opportunity for interactionthat it provided. It is possible that the group of partic-ipants volunteering for interview may have been aselect group of particularly enthusiastic individualsbut their comments were also reXected in responsesfrom exercise leaders and researchers. The anomalybetween quantitative and qualitative results could beexplained by a lack of power for psychological out-come variables or a shortfall in sensitivity to detectdiVerences in people who may already be in thehigher percentiles of well-being on measures. At thispoint, it is not possible to fully determine which ofthese is the case.

This research has provided important groundworkfor future research concerning physical activity in theover 70s. It has provided some preliminary evidence ofreliability of instruments able to assess aspects of psy-chological well-being and life quality. This includes twonew instruments to assess exercise-related subjectivewell-being and self-perceptions. However, more workis required to fully establish the properties of the Age-ing Well ProWle and the Clinical Physical Self Percep-tion ProWle in diVerent languages. The WHOQOL-OLD is a new 24-item 6-facet measure designed toassess sensory abilities, autonomy, past, present andfuture activities, social participation, death and dying,and intimacy which can be used in conjunction with theWHOQOL-BREF for assessment of quality of life inolder adults (Power et al. 2005).

Accelerometry emerged as a feasible method forassessing daily physical activity levels which has previ-ously not been attempted with this age group. Thestronger and more consistent associations with physicalactivity were with physical self-perceptions and per-ceived health and well-being. Future studies shouldassess physical function, degree of disability and ill-health, and body-weight related variables to determinethe extent to which they mediate the activity/well-being relationship.

Acknowledgements This study was supported by the EuropeanCommission Framework V fund (‘Better-Ageing’ Project NoQLRT-2001-00323). The authors wish to thank Dr Lijung Chenfor her assistance with statistical analyses

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