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Diffusion of Tai Chi in Older Populations

Permanent Link: http://ufdc.ufl.edu/UFE0044897/00001

Material Information

Title: Diffusion of Tai Chi in Older Populations Facilitators and Barriers to Adoption
Physical Description: 1 online resource (171 p.)
Language: english
Creator: Gryffin, Peter A
Publisher: University of Florida
Place of Publication: Gainesville, Fla.
Publication Date: 2013

Subjects

Subjects / Keywords: adults -- barriers -- facilitators -- older -- taichi
Health Education and Behavior -- Dissertations, Academic -- UF
Genre: Health and Human Performance thesis, Ph.D.
bibliography   ( marcgt )
theses   ( marcgt )
government publication (state, provincial, terriorial, dependent)   ( marcgt )
born-digital   ( sobekcm )
Electronic Thesis or Dissertation

Notes

Abstract: 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.
General Note: In the series University of Florida Digital Collections.
General Note: Includes vita.
Bibliography: Includes bibliographical references.
Source of Description: Description based on online resource; title from PDF title page.
Source of Description: This bibliographic record is available under the Creative Commons CC0 public domain dedication. The University of Florida Libraries, as creator of this bibliographic record, has waived all rights to it worldwide under copyright law, including all related and neighboring rights, to the extent allowed by law.
Statement of Responsibility: by Peter A Gryffin.
Thesis: Thesis (Ph.D.)--University of Florida, 2013.
Local: Adviser: Chen, Wei W.

Record Information

Source Institution: UFRGP
Rights Management: Applicable rights reserved.
Classification: lcc - LD1780 2013
System ID: UFE0044897:00001

Permanent Link: http://ufdc.ufl.edu/UFE0044897/00001

Material Information

Title: Diffusion of Tai Chi in Older Populations Facilitators and Barriers to Adoption
Physical Description: 1 online resource (171 p.)
Language: english
Creator: Gryffin, Peter A
Publisher: University of Florida
Place of Publication: Gainesville, Fla.
Publication Date: 2013

Subjects

Subjects / Keywords: adults -- barriers -- facilitators -- older -- taichi
Health Education and Behavior -- Dissertations, Academic -- UF
Genre: Health and Human Performance thesis, Ph.D.
bibliography   ( marcgt )
theses   ( marcgt )
government publication (state, provincial, terriorial, dependent)   ( marcgt )
born-digital   ( sobekcm )
Electronic Thesis or Dissertation

Notes

Abstract: 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.
General Note: In the series University of Florida Digital Collections.
General Note: Includes vita.
Bibliography: Includes bibliographical references.
Source of Description: Description based on online resource; title from PDF title page.
Source of Description: This bibliographic record is available under the Creative Commons CC0 public domain dedication. The University of Florida Libraries, as creator of this bibliographic record, has waived all rights to it worldwide under copyright law, including all related and neighboring rights, to the extent allowed by law.
Statement of Responsibility: by Peter A Gryffin.
Thesis: Thesis (Ph.D.)--University of Florida, 2013.
Local: Adviser: Chen, Wei W.

Record Information

Source Institution: UFRGP
Rights Management: Applicable rights reserved.
Classification: lcc - LD1780 2013
System ID: UFE0044897:00001


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1 DIFFUSION OF TAI CHI IN OLDER POPULATIONS : FACILITATORS AND BARRIERS TO ADOPTION By PETER A. GRYFFIN A DISSERTATION PRESENTED TO THE GRADUATE SCHOOL OF THE UNIVERSITY OF FLORIDA IN PARTIAL FULFILLMENT OF THE REQUIREMENTS F OR THE DEGREE OF DOCTOR OF PHILOSOPHY UNIVERSITY OF FLORIDA 2013

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2 2013 Peter A. Gryffin

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3 To my wife and children for their sacrifices, And to my committee, for their support and patience

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4 ACKNOWLEDGMENTS This 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 well being of society. I would like to also thank my committee members, Drs. W William Chen, Beth Ch aney, Morgan Pigg, Virginia D odd, 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 hea lth 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 wort h it in the end.

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5 TABLE OF CONTENTS page ACKNOWL EDGMENTS ................................ ................................ ................................ 4 LIST OF TABLES ................................ ................................ ................................ ........... 7 LIST OF FIGURES ................................ ................................ ................................ ........ 8 LIST OF ABBREVIATI ONS AND KEY TERMS ................................ .............................. 9 ABSTRACT ................................ ................................ ................................ .................. 10 CHAPTER 1 INTRODUCTION ................................ ................................ ................................ ... 12 Purpos e of this Study ................................ ................................ ............................ 12 Background and Overview of the Health Belief Model ................................ ........... 15 Research Problem ................................ ................................ ................................ 19 Research Questions ................................ ................................ .............................. 20 Delimitations ................................ ................................ ................................ .......... 20 Limitations ................................ ................................ ................................ ............. 21 Assumptions ................................ ................................ ................................ .......... 21 Significance of the Study ................................ ................................ ....................... 21 2 REVIEW OF THE LITERATURE ................................ ................................ ........... 24 Overview of Health Benefits from Tai Chi for Older Adults ................................ ..... 24 Diffusion of Innovations ................................ ................................ ......................... 33 Research f rom Knowledge, Attitudes, and Practice (KAP) and Related Studies .... 43 Studies using the Fishbone Diagram in a Focus Group Design ............................. 54 3 METHODS ................................ ................................ ................................ ............ 61 Study Design ................................ ................................ ................................ ......... 61 Institutional Review Board ................................ ................................ ..................... 63 Stu dy Sample ................................ ................................ ................................ ........ 64 Characteristics of Tai Chi class and Instructors at OTOW ................................ ..... 66 Focus Group Protocol ................................ ................................ ............................ 67 The Fishbone Diagram ................................ ................................ .......................... 73 Data Analysis ................................ ................................ ................................ ........ 73 4 FINDINGS ................................ ................................ ................................ ............. 81 Organization of Findings ................................ ................................ ........................ 81 Research Question One ................................ ................................ ........................ 81

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6 Research Question Two ................................ ................................ ........................ 85 Research Question Three ................................ ................................ ...................... 88 Research Question Four ................................ ................................ ........................ 91 5 DISCUSSION ................................ ................................ ................................ ...... 102 Organization of Discussion Section ................................ ................................ ..... 102 Facilitators related to Perceived Benefits and Threats ................................ ......... 102 Facilitators Related to Health Threats Identified by the CDC ............................... 107 Perceived Barriers to the Adoption of TC ................................ ............................. 109 Reco mmendations Related to Diffusion of Innovations Theory ............................ 111 Limitations and Bias ................................ ................................ ............................ 118 Conclusion & Recommendations ................................ ................................ ......... 123 Summary of Key Findings. ................................ ................................ ............ 126 Final Recommendations ................................ ................................ ................ 127 APPENDIX A REVIEW OF SELECTED TAI CHI PROGRAMS IN THE UNITED STATES ........ 139 B KEY TO CODES FOR FIGURE 5 1 ................................ ................................ ..... 157 C INSTITUTIONAL REVIEW BOARD SUMMER 2012 D OCUMENTS .................... 158 LIST OF REFERENCES ................................ ................................ ............................ 166 BIOGRAPHICAL SKETCH ................................ ................................ ......................... 171

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7 LIST OF TABLES Table page 2 1 Facilitators and barriers to TC in older adults. ................................ ................... 59 2 2 Comparison of facilitators and barriers. ................................ ............................. 60 3 1 Demographics of Tai Chi Group (TCG).. ................................ ........................... 77 3 2 Demographics of No Tai Chi Group (NTC). ................................ ...................... 78 4 1 Comparison of Benefits Identified by the Non TC and TC Group ....................... 93 4 2 Non Tai Chi (NTC) Group Perceived Benefits. ................................ .................. 93 4 3 Tai Chi Group (TCG) Perceived Benefits.. ................................ ......................... 94 4 4 Comparison of mean scores and standard deviation between groups for comparable benefits. ................................ ................................ ......................... 94 4 5 Comparison of Barriers Identified by the Non TC and TC Group ....................... 95 4 6 Non Tai Chi (NTC) Group Perceived Barriers ................................ ................... 95 4 7 Tai Chi Group (TCG) Perceived barriers. ................................ .......................... 96 4 8 Comparison of mean scores and standard deviation between groups for comparable barriers. ................................ ................................ ......................... 96 4 9 Comparison of Threats Identified by the Non TC and TC Group ....................... 97 4 10 Non Tai Chi (NTC) Group Perceived Threats ................................ .................... 97 4 11 Tai Ch i (TCG) Group Perceived Threats ................................ .......................... 98 4 12 Comparison of mean scores and standard deviation between groups for comparable threats. ................................ ................................ ........................... 98 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. ................................ ................................ ............. 135 5 3 Top seven causes of death in 2007 among persons 65 years of age and over 136 5 4 Perceived Barriers to th e adoption of TC identified by the focus groups. ......... 137

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8 LIST OF FIGURES Figure page 2 1 Overview and linkage of foundational concepts. ................................ ................ 57 2 2 Adopter categorization on the basis of innovativeness ................................ ...... 58 2 3 The innovation decision making process ................................ ........................... 58 2 4 Aggregate fishbone for IM residents. ................................ ................................ 59 3 1 Post It Note Phase of the Fishbone diagram. ................................ .................... 79 3 2 Perceived Threats, Benefits, and Barriers ................................ ......................... 80 4 1 Primary Knowledge of TC Benefits (from fishbone diagram) ............................. 99 4 2 Primary Perce ived Facilitators to TC Adoption ................................ ................ 100 4 3 Primary Perceived Barriers to TC (from fishbone diagram) .............................. 101 5 1 Overview of potential facilitators and barriers identified ................................ ... 1 38

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9 LIST OF ABBREVIATIONS AND KEY TERMS A DOPTION A term used in diffusion research related to the uptake of an intervention CTA Cues to action. The more relevant and pertinent the cues to action, the greater the likelihood a person may take action. Cues can be bodily events (chest or other body pains, weight gain), media reminders, and comments from others D IFFUSION Process in which an i nnovation is communicated through certain channels over time among members of a social system F ISHBONE D IAGRAM A trouble shooting tool originally used in business to visually diagram causes and effects for problem solving. HBM Health Belief Model. A psyc hological model for explaining and predicting health behaviors KAP Knowledge, Attitude and Practice. Identifying knowledge and attitudes which affect practice or adoption of a behavior O LDER ADULTS The current preferred term as identified by AARP to descr ibe adults aged 50 and older. QG Qi Gong. Any of a variety of Chinese breathing exercises, generally aimed at promoting health. Typically involving stationary or slow controlled movements combined with deep breathing, TC is oft en categorized as a form of Q G. T AILORED M ESSAGE Mes sages customized to an individual to promote adoption or uptake of a health behavior. Similar to CTA. T ARGETED M ESSAGE Mes sages customized to a group or societal level to promote adoption or uptake of a health behavior. Similar to CT A. TC Tai Chi. A slow moving health exercise which originated as a martial training method, and became popular as a form of Qi Gong (QG) SE engage in a specific behavior

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10 Abstract of Dis sertation Presented to the Graduate School of the University of Florida in Partial Fulfillment of the Requirements for the Degree of Doctor of Philosophy DIFFUSION OF TAI CHI IN OLDER POPULATIONS: FACILITATORS AND BARRIERS TO ADOPTION By Peter A. Gryffin Ma y 2013 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 identif ied 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 percei ved barriers P ercei ved threats, benefits, and barriers listed on the fishbone diagram were rated on a 0 9 scale and were evaluated a ccording to frequencies, mean group scores, as well as standard deviation.

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11 Additional qualitative data was gathe red during the discussion phas e. 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 barrier s T he largest opportunity for the promotion of TC identified related to perceived threats from f alls. 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 pot ential area to target Implications related to the dif fusion 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 recommendat ions for future research

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12 CHAPTER 1 INTRODUCTION Purpose of this Study 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 C hronic 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 red uced mobility, heart disease, cancer, stroke, and var ious 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 re ported for balance 5 7 cardiova scular disease 5,8 cardiopul monary disease 9 beneficial effects f or type 2 diabetes 10,11 various psychological and mental benefits 6,12 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 commun ity (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

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13 at OTOW, which tend to number around 18 20 per class (with 17 different class offerings, equaling a total of 37 classe s 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 ) D etermining facilitators and barriers to the ad option 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) s tudies 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 Nat ional 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 impor tance 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 challen ges 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 un usual 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).

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14 Other suggestions related to knowledge and attitudes include; the need to develop a clear and conc ise 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 su ccessful programs for media use ; develop information for distribution at community health fairs and other venues; and c ommunicate research findings to the media and health care professionals in Western terms. 18 These recommendations form the essence of the curr ent 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 wa s 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 T C 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 educat ion specialists in fulfilling their responsibilities as laid out by the National Commission for Health Educ ation Credentialing 19 The current study would address the following areas of responsibility: 1. Assess the needs, assets and capacity for health education: Th e primary purpose of the KAP assessment. 2. Plan health education: The results of the focus group study, using t he fishbone diagram results and follow up studies would assist with effective health education planning. 3. Conduct evaluation and research related t o health education: The function of this diss ertation

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15 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 K AP assessment will provide information and resources for health educa tors 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: T he di ssertation will provide baseline data for additional studies which can be used to advocate and communicate the benefits of participatory community research To accomplish these goals, a KAP assessment was conducted using a focu s group design using the HBM and fishbone diagram (see chapter 3: Methods, for detailed ove rview) as a framework. The focus of this study wa s to identify factors within two focus groups (one consisting of non adopters who have not considered adoption of T C, and a second focus group of current TC practitioners) to lay a foundation for future research towards the effective diffusion of TC in older adult populations Findings can be used to structure a case series towards refining facilitators and barriers t o the adoption of TC, and the eventual develop ment of a survey to validate findings relevant to a larger population, and to identify variables not uncovered through the current study design. Background and Overview of the Health Belief Model The Health Be lief Model (HBM) was developed by social psychologist s Godfrey Hochbaum, Irwin Rosenstock, and Stephen Kegels, for the U.S. Public Health Services 20 According to Cha mpion and Skinner 21 the HBM has been used on a wide basis to explain maintenance of and change in health behavior, and as a framework for developing health interventions.

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16 The model was developed to study and explain why people did not participate in health b ased programs. The model was later applied to the study of symptom response, response to diagnosis of illness, and most importantly, adherence to health routines and regimens. The model grew from two primary sources, Stimulus Response (S R) theory and Cogn itive T heory 21 According to Champion and Skinner, S R theory contributed an understanding of how reinforcements (or the consequences of an action) can affect the frequency of a behavior. From a TC perspective, inter nal enjoyment of the form, perceived health benefits and/or approval of friends and parents, would be positively reinforcing, resulting in an increased likelihood of performing TC (the Perceived Benefits construct of the HBM). However, if a consequence of practicing TC resulted in boredom, displeasure, and/or disapproval of friends or family members, then the experience would be negatively reinforcing, re sulting in a decrease in TC performance (the Perceived Barriers construct of the HBM). Social psychologi sts also incorporated elements of Cognitive Theory into the HBM, particularly the role of the subjective value of an outcome, and the subjective probability (the expectation) that a specific action will result in a specific outcome. Adding the cognitive el ement changed the nature of health behavior performance from primarily externally motivated (approval or disapproval of friends and family), to also consider the role of internal factors, subjective thoughts, and feelings regarding the experience. Champion and S kinner 21 sum this up as value expectancy, where health behavior can be predicted or influenced by the value of good health, and the

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17 expectation that health behaviors (i.e., TC ), will reduce or prevent the likeli hood of becoming ill. The HBM consists of five main constructs: Perceived Threats, Perceived Benefits, Perceived Barriers, Self Efficacy, and Cues to Action 21 Below is a description of each factor Perceived Suscepti bility is the belief that one has a chance of getting ill, or will be affected b y certain condition (i.e. injury from falling ). When Perceived Susceptibility is low health a ction s are less likely to be taken. When Perceived Susceptibility is high the perso n is more likely to take action 21 In older adults, several occurrences of loss of balance would act to increase the perceived susceptibility of falling. Perceived Severity is the b elief regarding how serious the cond ition is, and potential consequences. For example, in older adults, the perception that balance is compromised, leading to the threat of limited independence. Or, on the other hand, perception that balance is not compromised, and res ults of a fall will be minimal. T he higher the Perceived Susceptibility and Perceived Severity, the greater the likelihood one will take action. Collectively Perceived Severity and Perceived Susceptibility a re labeled as Perceiv ed Threat 21 For the purpose of the focus group setting, Perceived Susceptibility and Perceived Severity will be evaluated collectively as Perceived Threat Perceived Benefits is the belief that taking act ion will produce a benefit, and increases the likelihood of taking action. Taking action would be a factor of Perceive d Threat and the Perceived Benefit. The higher the Perceived Threat the greater would be the Perceived Benefit of taking action 21

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18 Perceived Barriers is the belief that certain variables (psychological and environmental) make action difficult if not impossible. Essentially Barriers are the costs of taking action. 21 For example, for fall preventi on efforts, the perceived barrier to TC for enha nced balance might be lack of time, lack of knowledge, and/or negative attitudes. The larger the ba rrier the lesser the lik elihood of taking action The reverse would also be true smaller the barrier the gr eater the likelihood of taking action. Perceived Threats, Benefits and Barriers will be the three main constructs used for structuring the fishbone diagram and focus group discussion. Other constructs of the HBM not being directly addressed by the focus gr oup design include Cues to Action Cues to Action to change 21 Examples might be e mail messages, advice, or visual reminders on the importance of developing balance. A spec ific example might be a targeted message specific to the older adult population, such as a poster showing a person lying on the ground with the infamous caption in a graceful TC pose with the captio relevant and pertinent the Cues to Action, the greater the likelihood a person may take action Champion and Skinner 21 however, state that little has been done empi rically to stu dy the actual effectiveness of cues to a ction. This would be an area worth pursuing. Focus group results regarding perceived threats, perceived benefits of TC, and perceived barriers to the adoption of TC, can provide initial data from which to develop larger scale and more detailed investigations from which effective cues to action. For the current study, total group and individual responses scores for each const ruct were examined, to identif y potential variables for testing in a larger popul ation

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19 or through a case series Individual responses to i tems can also be used to identify items of potential greatest concern, towards designing effective cues to action or targeted messages for testing in larger populations Research Problem Despite prov en benefits to the ol der adult population, Tai Chi may be under utilized. For example, according to the director of the community fitness center at On Top of the World (OTOW) Active Living Community a free TC class has been offered for over 6 years, yet despite active promotion efforts, attendance has remained level at 7 9 participants, out of a total population of 10,000 residents. Other fitness classes, including yoga, average 19 participants in each class. Another example indicating the paucity of TC i n society, compared to yoga, can be taken from the yellow pages phone directory. Yoga has its own heading (with 3139 listings in the state of Florida as an example), while TC is included under martial arts in the filter for a total of 2552 listings in Flor ida including other martial arts 22 Of critical importance is to develop an understanding of what will motivate individuals to become regular practition ers of TC, and what factors might account for lack of participat ion. The focus of this dissertation is to conduct a Knowledge, Attitude and Practice (KAP) study using a focus group design, to determine possible factors related to potential facilitators and barriers to effective diffusion of TC in older populations whi ch can be used to develop larger studies KAP studies have been used in various ways, particularly to identify knowledge deficits and negative attitudes which may act as barriers to adopt ion of an innovation 17 Since o ne focus group is being selected based on minimal exposure to TC, the current assessment focused on knowledge of TC (or lack of it) and factors which may help to facilitate favorable

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20 attitudes towards practice. Results will establish a baseline for larger studies to permit more effective diffusion of TC interventions, ultimately affecting long term impact on health care costs, discretionary spending, and quality of life. Research Questions 1. What knowledge do older adults have regarding TC (regarding perceive d benefits and relationship to perceived threats) ? 2. What are the primary barriers affecting adoption of TC in an older adult sample? 3. Wha t are the primary facilitators (perceived threats and b enefits) affecting adoption of TC in an older adult sample? 4. What d ifferences exist i n the above b etween the TC and Non TC groups ? Delimitations A focus group design was chosen due to the early stage of research into diffusion of TC. The strength of a focus group is the inclusion of multiple points of view, compar ed to a case study 23 although not as representative of a population as would be a survey. The focus group design was chosen to evaluate commonalities across individual cases in facilitators and barriers in TC adoption, particu larly relating to knowledge and attitudes between a TC group and a Non TC group Subjects consisted of volunteers from the older adult population age 65 and above from a specific site (OTOW), actively recruited from fitness center participants by the cente r director The focus grou p participants were limited to those active at the fitness center, as opposed to the general OTOW population, in an attempt to control for differences due to basic activity and fitness level. This fishbone diagram (see chapter 3: Methods) was used to help establish a common condition with an ability to more accurately compare group differences using reported items, frequency of responses, and rating of personal relevance of uncovered items on a 0 9 scale

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21 Limitations The limitati ons of a focus group study and the investigations include: Findings of st udy developed from focus groups at OTOW cannot be generalized to a larger sample or population Findings included self reported data, resulting in possible over or under reporting of data. Sample size does not lend itself readily to larger statistical analysis Findings may not be able to be applied to other health interventions. Data was collected during the s ummer of 2012, data collected at other time periods may differ. Group format may inhibit responses from individuals (Blinded aspect of fishbone diagram may help to control this limitation). Researcher bias may influence responses (also minimized through use of the fishbone diagram see Methods and Discussion Sections for explanat ion ). Assumptions The assumptions for this study include: The participants who volunteered for the study adequately represented the larger population of active older adults age 65 and above R ecruited participants will be able to complete the study. S ample size will be adequate for the research design and analysis. The focus group format will yield more data in a synergistic manner than would individual interviews. The researcher will be neutral and avoid biasing focus group discussion and the use of fishbo ne design will help to limit potential researcher bias, through blinded individual responses Significance of the Study Prevention has been identified as the best and possibly only viable strategy to reduce health care costs, Medicare spendin g, and disabi lity 2 which would have a direct effect on wealth and retirement income, as well as quality of life. With recent cuts in the

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22 prevention and public health fund by 5 billion dollars over the nex t five years 24 it is more important than ever to documen t the potential economic impact to society. Rula and colleagues assert that by 2023, preventive care and modest improvements in unhealthy behavior could reduce the number of chron ic disease cases by 40 million, with an associated reduction in co sts by $1.1 trillion annually. 2 Medicare savings based on projected scenarios could range from a $65.2 billion to $142.8 billion in annual savings Even small reductions in Medicare expenditures through modest interventions would have a large impact in the fiscal crises facing the Hospital Insurance Trust Fund. Rula and colleagues further note that studies on a current fitness program for Medicare A dvantage members, SilverSneakers, has resulted in significant reductions in hospitalizations and health care costs (saving $1663 the first year and $1230 the second year per participant, compared to nonparticipants). 2 Particularly relevant to the current study, aside from chronic diseases, is the threat of falls to older populations. According to the Center for Di sease Control falls among older adults resulted in estimated direct health care costs of over $28.2 b illion dollars in 2010. 4 Direct costs do not account for long term effects, including disability, dependence on others, and reduced quality of life. The CDC state d that approximately one third of older adults fall and falling is the leading cause of fatal and non fatal injuries in the United States for persons age 65 and older. 4 Of those who experience non fatal falls, 20 30% have reduced mobility and ability to live inde pendently. Reducing health care costs through effective low cost interventions will impact not only health care and disability costs, but will also enhance discretionary spending, quality of life, and retirement income. The CDC further

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23 documents that the c ost of fall injuries increase rapidly with age, which further indicates the importance of motivating TC uptake early in retirement based on the benefits for balanced as noted in the overview of TC benefits 4 The e conomic impact beyond costs related to fall reduction would be even greater, due to the many additional mental and physical health benefits of Tai Chi noted in the review of literature in Chapter 2. According to Guijing Wang an economist in the Applied Re search and Evaluation Branch of the CDC, direct costs of hypertension (high blood pressure) in the United States is over 108 billion dollars each year. 25 TC has been demonstrated in clinical studies to have a direct ben ef icial effect on blood pressure 8 Still to be determined is the development of an understanding of when and why people, particularly older adults, adopt or reject Tai Chi, and what factors will maximize uptake and diffusion in society, as an additional health activity to conventional forms of exercise with many unique benefits (C hapter 2). Understanding adoption factors of TC is an area identified by Chodzko Zajko and colleagues as an area in critical need of study towards r educing illness and health care costs in society 18 Addressing adoption factors through a focus group setting is the focus of the current study.

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24 CHAPTER 2 REVIEW OF THE LITERATURE In addition to a review of Everett Rogers semina l work Diffusion of Innovation 17 and diffusion research relevant to the current study a search was conducted using the EBSCOhost online reference system, which accesses multiple databases with on e search. A secondary search was also carried out in the EBSCO business searching interface. Search terms included focus group, Ishikawa diagram, fishbone diagram, KAP, knowledge, attitudes, knowledge attitude practice, exercise, health belief model, tai c hi, yoga and CAM. For the overview of health benefits of TC for older adults, another search was carried on the EBSCOhost online reference system, using the following search terms: Tai chi, older adults, elderly, health benefits, balance, cardiovascular disease, blood pressure, cardiopulmonary disease, diabetes, mental benefits, stress, and cancer. The review of literature is divided into four sections overview of health benefits of TC for older adults, constructs and elements of diffusion of innovatio n s as developed by Rogers 17 relevant to the current study KAP studies on TC and other forms of exercise, and review of studies relevant to using the fishbone diagram from a qualitative approach. Overview of Health Bene fits from Tai Chi for Older Adults Tai Chi 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 5,6 The weight of the body is shifted gradually between the right and left legs, with the knees slightly bent and the body held in an upright posture (the tailbone dropped and crown of the head lifted, as if pulled by a st ring in opposing

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25 directions. Tai Chi originated as a martial art, and has diversified into many styles of TC. The Yang, Wu, Hao, and Sun styles of TC are most representative of the slow circular movements of TC, while the Chen style retains many of the mo re explosive movements and jumps characteristic of its origins as a ma rtial art 6 From the review of literature below, the benefits of TC can be div ided into three main areas: physiological benefits, mental benefits, and benefits for b alance. Chiang and others 5 conducted an overview of literature to document a wide range of reported physical benefits for older adults. Five studies specific to TC and balance reported significan t effects (with a p value ranging from .01 to .05) compared to non TC participants Tai Chi can be an effective exercise for balance due to the shifting of weight from one leg to the other in a slow controlled manner, with the balance held over one leg (wi th an option for having the other leg balanced in the air during many Significant effects of TC for older adults were also reported for knee and ankle str ength, mental health and vitality, blood pressure, fitness levels, flexibility, body fat, psychosocial status, and se lf efficacy 5 Schleicher and colleagues 7 conducted a systematic review of 24 articles relating to the effectiveness of TC for reducing risk of falls in older adults. A limitation addressed by the authors is that not all studies reported the style of TC used. Those that did included Yang, Sun, Ng, and Chen styles and variations with Yang being the most prevalent Level of intensity was also not defined consistently (ranging from gentle to low impact). The authors further stated that frequency and duration of TC practice did not seem to impact outcomes, with significant improvements in balance being reported

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26 ranging from7.5 hours per week for 3 weeks, or 1 hour a week for 16 weeks. Significant improvements were shown in reduction of number of falls, fear of falling, and significant improvement in laboratory b ased balance measures. In studies reporting fall surveillance, five of the six studies reported fewer number of falls with the TC intervention compared to no intervention. Yeh and colleagues 10 documented the benefits of TC for cardiovascular disease (CVD) and risk factors. The authors reported beneficial effects related to effects on blood pressure effects and hypertension, particularly in patients with CVD risk factors. In the only randomized controlled trial reviewed us ing patients with CVD (comparing aerobic exercise to TC), both groups experienced significant reduction in systolic blood pressure ( p < 0.05), while diastolic pressure was improved only in the TC group ( p < 0.01). Greater compliance was reported with the T C class. The authors suggest that TC may be particularly appropriate for those unable or unwilling to engage in other forms of exercise, or as a bridge to more vigorous forms of exercise. The authors also report excellent compliance with TC interventions i n clinical trials, which may offer an attractive alternative to conventional cardiac rehabilitation programs which are cited as being underutilized. In a randomized controlled trial using patients with heart failure, a significant improvement was demonstra ted on the 6 minute walk test ( p < 0.01), improved B type natriuretic peptide ( p < 0.03) and improved QOL compared to usual care. Yeh and others 10 also support that TC may be safe for patients with cardiovascular disease noting that 3 studies with higher risk coronary patients reported no ill effects, with metabolic equivalents of 1.5 4.0, similar to low moderate intensity aerobic exercise.

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27 Chiang and colleagues 5 also report ed be nefits for coronary heart disease, stroke, and hypertension. Six studies were reviewed, reporting significant improvements in systolic and diastolic blood pressure, noting that TC has similar benefits to low impact aerobic exercise, and increased peak oxyg en uptake during exercise. Effects on blood pressure may be a particular cardiovascular benefit of TC as indica ted by Yeh and colleagues 8 in a review of 22 studies on the effects of TC on blood pressure The authors found 22 studies reporting reductions in blood pressure using tai chi as the intervention (3 32 mm Hg systolic and 2 18 mm Hg diastolic BP reductions, p < 0.01 to 0.05). No adverse effects were reported. The authors suggest that TC may reduce blood pressure and serve as a practical method to manage hypertension, in conjunction with conventional hypertension management. Aside from cardiovascular disease, TC has also demonstrated effectiveness for cardiopulmonary disease (COPD). Chan and colleagues 9 conducted an investigation into the effectiveness of TC for enhancing respiratory functions and activity tolerance in 206 patients with COPD using a single blind randomized design. The exercise group was taught breathing techniques t o be used with walking. Participants in the control group maintained normal activities, while the TC group practiced 60 minutes twice a week for 3 months. A significant improvement was noted in improvement of respiratory functions and activity tolerance fo r the TC group ( p < 0.01). Only the TC group experienced improvements, with no change in the exercise groups, and a decline in lung function in the control group at the 3 month follow up. Several studies have been conducted investigating the potential effe ct of TC on diabetes. Diabetes is the sixth leading cause of d eath in older adults 1 Song and

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28 colleagues 11 examined the effects of adherence to 6 months of TC on glucose control, diabetic self care activities, and QOL among 99 adults diagnosed with type 2 diabetes. Sixty two participants completed pre test and post test measures. Thirty one participants who completed 80% of the TC sessions were compared to 31 who did not. The adher ent group had greater decline in fasting glucose (interaction effect F = 5.13, df = 2, p <0.05) and HbA1c (interaction effect F = 4.15 df = 2, p <0.05) and experienced better QOL in most mental components compared to the non adherent group. Other studies found similar benefits for type 2 diabetes, including a study by Shih Chueh and colleagues 11 who investigated the effects of TC on biochemical profiles and oxidative stress indicators in obese patients with type 2 diabete s using a randomized control trial format. Participants were randomized into either a TC group or a conventional exercise group, exercising 3 times a week for 12 weeks. Significant improvements were experienced by the TC group in serum lipids, HDL cholest erol, and body mass (BMI), while the hemoglobin A1C values did not decrease. Oxidative stress profiles also improved in the TC group, compared to the exercise group which experienced no improvement in BMI, lipids and oxidative stress profiles Tai Chi als o has many psychological benefits as a mindfulness based form of moving meditation 6,26 Jimenez and colleagues conducted a review of 43 studies investigating the psychological effects of TC. 6 According to the authors, the two primary areas of benefits can be categorized into quality of life (QOL) and cognitive function. TC has been documented in the literature as creating states of great calm and mental tranquility, and has been classified as a form of moving meditation. Yet it is noted that the majority of studies on TC focus on the physical benefits of TC for health.

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29 Jimenez and others conducted an extensive review of the literature for studies which i ncluded a psychological component. 6 The authors reported findings for significant effects on emotional well being, in regards to mood, stress reduction, anxiety, depression, general perception of mental health, as we ll as self perception related to self esteem. Nineteen of 22 studies found significant improvements in emotional well being, with 9 of 11 studies finding significant improvement in mood, 9 of 11 significant improvements in depression symptoms, 7 of 8 signi ficant improvements in anger and tension, 60 8 significant improvements in anxiety reduction, 6 of 8 significant improvements in the ability to manage stress more effectively, and 5 of 9 significant improvements in emotional disorders. Seven of 9 studies a lso found significant improvements in feelings of self efficacy, and 5 of 5 enhanced confidence related to fear of falling. Six of 7 studies found significant improvements for sleep disorders. The authors note concern regarding the wide range of styles, ne w forms that are being developed, and teaching styles as a large limitation in trying to generalize results. Several confounders which can affect study results were identified: Pace (i.e., slow versus fast), duration and frequency of practice, style and fo rm practiced, support patterns of footwork (i.e. single versus double weighted), height of stance, and intensity (the authors state that the slower TC is performed, and the deeper the stance, the greater the magnitude of muscle activation). The authors al so note that reported mental benefits of TC averaged 13 weeks of 2 3 sessions each week for 1 hour, although some cases reported effects after 5 weeks. Jim enez also notes that few studies have been carried out on the effects of TC on

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30 cognition, noting only two which confirmed significant improvements in attention, memory, concentration, and s peed of information processing. 6 The mindfulness component of TC may also have benefits for weight mana gement through raising aw areness to and habitual eating. TC has been demonstrated to be an effective mind/body exercise for establishing awareness and control of addictive behavior, based on effects in a smoking cessati on program 16 One recent study sought to determine potential effects of TC on brain size and cognition with possible effects on Alzheimer at the University of South Florida. 12 Participants in a TC group were compared to a literature discussion group. Both groups demonstrated a significant increase in brain volume comparable to previous studies documenting the benefit of aerobic exercise on brain volume. A control group demonstrated brain shrinkag e over the same period typical for the 60 to 70 year age group. The authors note that gradual cognitive deterioration which precedes dementia and is associated with increasing shrinkage of the brain as nerve cells and connections are gradually lost. It is unknown at this point if such activities could help prevent those who engage in regular physical exercise or are more socially active have a lower risk of Alzheimer. Ta i Chi has also been demonstrated to have a significant effect on immunity 27,28 Chiang and others documented a significant increase in myeloid dendritic cells in a TC group compared to a sede ntary control group. 27 According to the authors, dendritic cells are the most potent antigen presenting cells linking innate and adoptive immunity. White

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31 blood cell count was also higher in the TC gr oup. Irwin and c olleagues investigated the effects of TC on varicella zoster virus specific immunity in older adults, who are at risk for shingles 28 The TC group (n=18) demonstrated a significant increase in varicella zoster vir us specific immunity ( p < 0.05), with a 50% increase from baseline, compared to the control group (n=18). Although the second leading cause of death among older adult s as identified by the CDC 3 cancer is discusse d last due to a lack of convincing evidence on direct benefits of TC on cancer. In a systematic review of 27 potential studies co nducted by Lee and others 13 only four studies were included due to study design limitations. Overall the authors concluded that there was a lack of convincing evidence that TC is any more effective than other forms of exercise. Four common uses of tai chi in cancer care were identified, including relieving symptoms of vomiting, fatigue, nausea, an d depression. Lee and colleagues also conducted another review of 81 potentially relevant studies on the effects of tai chi on breast cancer. 14 Only 7 met inclusion criteria. Significant differences were found in improved mood and depression compared to spiritual growth and standard health care, as well as beneficial effect on mood and psychosocial adaptation compared with an education program. Significant differences on effects of tai chi on physical outcome measures inclu ded improved hand grip strength and flexibility and range of motion over an education program control group, and beneficial effects on pain and range of motion compared to no treatment. No adverse effects were reported in any of the included trials. Overal l the authors felt that

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32 there was a lack of convincing evidence in support of TC as an effective cancer intervention, possibly related to poor study designs and inconclusive findings. Yet a number of reported incidences by those with cancer indicate that i t may be important to keep an open mind on potential direct effects of TC on cancer treatment and possibly even preventi on 15,16 One possible underlying mechanism of why TC may have a potential benef icial effect on cancer (and possibly many other diseases as well) may be related to enhanced blood oxygen diffusion. An area of cancer research is the role of hypoxia in cancer Maleki and colleagues developed a mechanical device based on the idea of enhan cing tumor oxygenation through water electrolysis, utilizing an ultrasonically powered implantable micro oxygen generator (IMOG). 29 The IMOG device generates oxygen at the site of the tumor, boosting the cancer figh ting power of radiation and chemotherapy. The IMOG device has been used with significant effect in pancreatic tumors implanted in mice, generating oxygen and shrinking the tumors faster than without the device. It is common when performing TC to feel a pl easant tingling in the hands and arms, due to increased oxygen diffusion. Like the feeling one gets when blood flow returns to a limb that has fallen asleep, except pleasurable rather than painful. By enhancing blood oxygen saturation and diffusion, it may be possible for oxygen to have an increased range of movement across cell walls, enhancing the oxygen gradient. In a s tudy conducted by Gryffin blood oxygen saturation was measured in 31 TC practitioners using a pulse oximeter. 16 SpO 2 increased significantly ( p < 0.001 ) as did hear rate ( p < 0.001). The range of SpO 2 increase was from one to three points above resting level, with a mean increase of 1.29, compared to no significant difference

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33 between resting and acti ve SpO 2 levels for walking, and a significant decrease ( p < 0.05) in SpO 2 during cycling ( 2.9 %) and running ( 4.9%). These findings further support that TC may have a distinctly different effect on the body compared to conventional exercises, a difference which may enhance physiological functions in the body. Further research would need to be conducted to determine exact effects, and possible effects on other health conditions. Diffusion of Innovations The Diffusi on of Innovations is a comprehensive work o n the elements involved with the successful diffusion of an innovation. Rogers 17 define d Diffusion as the process in which an innovation is communicated or spread through certain channels over time among members of a s ocial system f or example, the diffusion of TC in the older adult population in general, or at an active living community in particular. In order to understand and facilitate diffusion, Rogers state d that it is important to understand the process of commun ication (communication channels) within which information is created and shared. Of particular relevance to the current study is the importance of u ncertainty which Rogers state d is the degree to which a number of alternatives are perceived with respect t o the occurrence of an event and the relative probability of these alternatives. In the case of TC, this would relate to possible lack of awareness combined with the many alternative choices for activity, ranging from gardening, walking, to watching TV. For TC, a s a relatively unfamiliar activity Rogers saw the innovation decision process as consisting of information seeking and information processing in order to reduce uncertainty regarding the advantages and disadvantages of an activity. Following is a n overview of key elements of diffusion of innovation t heor y

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34 supported with various studies relevant to the current study See F igure 2 1 f or an overview a nd l inkage of foundational c oncepts of the diffusion of i nnovation s. Knowledge, Attitudes, and Practi ce (KAP): Knowledge, Attitudes and Practice (KAP) surveys are an important part of diffusion studies 17 Unfortunately, according to Rogers, most KAP surveys will find a KAP Gap, a gap between development of knowledge a nd favorable attitudes, and the actual practice of the desired intervention. People may now be aware of the intervention, and its benefits, but may not be sufficiently motivated to wards practic e The Taichung Field Experiment wa s given as an example of on e of the largest and most successful KAP studies ever conducted. 17 The researchers used four communication strategies towards the adoption of family planning in Taichung, Taiwan Neighborhood meetings were held, by th emselves as well as in conjunction with the addition of mailed information, personal visits by change agent with the woman, and also personal visits by change agents with both the husband and wife. The area was also blanketed with family planning posters. In this study the key factor was home visits by change agents, which was the primary motivating independent variable (other independent variables included neighborhood informational meetings and neighborhood meetings plus mailed information). Visitations by change agents accounted for a 40% adoption rate. Another powerful factor identified was the continuation of interpersonal communication beyond formal programming, acting as informal change agents. Findings from the focus group study can be used to targ et potential change agents for a follow up case series, towards e ducating and train ing change agents to develop

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35 knowledge and favo rable attitudes in a target populatio n to encourage TC practice. An o verview o f KAP studies specific to TC and related exercis es is presented below following the overview of foundational concepts of the diffusion of innovations Time (the KAP Gap): As mentioned above, the KAP GAP is a critical element relating to the delay between favorable Knowledge and Attitudes, and Practice. 17 That is, the time lag between knowledge of an innovation, the attitudes formed regarding the innovation, and the actual practice of the innovation. An example would be aerobics. Ken Cooper published the book Aerobics in 1968. It would be another 20 years before it made significant in roads into society 30 An effective awareness campaign focused on creating a favorable attitude, as well as addressing lack of knowledge, may help to reduce or eliminate the KAP Gap, but to develop such an effort, it may be important to identify relevant knowledge and attitudes as well as barriers to adoption 31 Roberto documented the importance of awareness in clo sing the KAP Ga p, using a focus group approach. The author states provides greater understanding of the quality of awareness in the target population, which the author hypothesized to be the primary factor in the KAP Gap. In this study, f our focus groups w ere conducted, consisting of 8 to 10 married male and female participants, to determine the role s of awareness in condom usage. 31 Topics included attitudes towards condom use, factors which motivated use or rejection o f condom use, and the meanings associated with condom use related to time, manner, and reasons for accepting or rejecting condoms The author concluded that quality of awareness depends on experience with use and that most negative perceptions were imagina ry, but can be overcome with positive statements; buying condoms is embarrassing; and brand awareness is low. 31 The author recommended

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36 developing a consciousness campaign to overcome factors related to the KAP Gap and lack of awareness. The focus group design of this dissertation is targeted at identifying knowledge and attitudes related to TC, which might be used to develop larger studies towards closing the KAP Gap of TC. Perceived Attributes of Innovations Rogers st ate d that the five categories of the perceived attributes of an innovation listed below are the most important characteristics in explaining the rate of adoption of an innovation. 17 This is an important factor and driv ing force behind conducting a Knowledge, Attitudes, and Practices (KAP) assessment. Identifying KAP will help to identify the perceived attributes of TC (knowledge), and attitudes regarding the perceived benefits. Five general categories of perceived attri butes that can be used to increase adoption of an innovation include : 1. Relative Advantage What are the perceived benefits compared to other choices. Rogers considers relative advantage, and compatibility (below) as particularly important in explaining r ates of adoption. In certain respects, relative advantage may be comparable to decisional balance. 2. Compatibility is the innovation consistent with the values, experiences, and needs of the potential adopters. Roger notes that re invention may be critical in the process of adoption. For the successful adoption of TC in among older adults may necessitate adjustments in form, teaching style, and practice specific to desired target populations. 3. Complexity how difficult to adopt does the target population per ceive the innovation ? 4. Trialability an innovation Rogers states that innovations that can be tried before full commitment are adopted more quickly, and reduces the factor of uncertainty. 5. Observability is the degree to which an innovation is visible to o thers Rog ers states that although some ideas area easily observable and communicated, other innovations may be less so. According to Rogers, s pokespersons and role models may help overcome this limitation Pankratz and others suggest ed that a gap exists b etween researc h and practice, and that the perceived attributes of an innovation may be an effective way to close that

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37 gap. 17 The authors developed a scale to determine the perceived attributes of a health education pr ogram before it is developed, to allow program modification to enhance diffusion, as well as program follow up, to determine effective diffusion strategies. The author s findings confirmed the association between innovation perception and innovation adopti on, and the distinct constructs within the innovations perceptions ( although relative advantage and compatibility clustered into one factor). The authors also found that at the organizational level, complexity can be the greatest barrier to adoption of an innovation. This may be true at the individual level as well, and worth following up with in regards to TC. Also noted that observability may be most closely tied to programs that provide very tangible and immediate outcomes. Trialability was a weak predi ctor of adoption, which the authors note may be due to difficulty in measuring this construct, which may be less of a problem with more concrete interventions. The authors concluded that it may be important to adapt the perceptions to specific innovations. Communication Channels: Another key e lement in the diffusion process. Rogers states that communication cha nnels are critical to understand the nature of the information exchange relationship. Mass media channels are the most rapid and efficient method of creating awareness. To create effective mass media messages, it is important to know the KAP of the target market, which underscores the importance of this element of the current study. And although it may seem important to highlight scientifically proven benefits of an innovation in various media messages, according to Rogers, the majority of people do not evaluate an intervention based on scientific studies, but rather on the subjective evaluation of those who have already adopted the

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38 innovation. 17 This stresses the importance of recruiting stakeholders in the diffusion process from among the population who have adopted an innovation as spokespersons and salesmen, and the relevance of beginning s uch a project with a f ocus group to understand and train potential stakeholders. Rogers does state that support from scientific studies can be important in recruiting early adopters, but after that point, interpersonal communication is more important. Rogers also addresses the need of to the target population, the greater the response rate. Seth Noar evaluated a set of principles for effective communication campaigns, noting that reviews of campaigns revealed a disconnect between campaign design, evaluation, and practice. 32 Shortcomings identified included no formative research, non theory based, low audience exposure (36 42%), and weak outcome evalua tions. The author presents an integrated framework for communication campaigns which address these shortcomings, which he calls the audience channel message evaluation (ACME) framework for health communication campaign design. The first element is audienc e (who) and is relate d to audience segmentation, targeting who the campaign will be directed to, its homogenous or heterogeneous nature, demographic variables, attitudes, behaviors, as well as message and channel preferences. The second element, channel (ho w), relates to channel selection and strategic implementation. What is known about the audience segment channel preferences, which channels contain the desired properties, communication components, message placement, short versus long campaigns, and campa ign evaluation/mid course corrections. The third element, Message (what) relates to

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39 message design. What is a clear message, based on campaign goals, what are the behavioral determinants, what elements of behavioral and message design theory need to be in corporated (the look, feel, and attractiveness of the message), message sources and campaign slogans, audience message preference, and initial reactions to pretesting of messages? The last element is evaluation (did it work). Did the campaign and messages affect the intended attitudes or behaviors? Noar suggests that by following the above elements will increase the intended impact of a campaign. Social System : As a fairly homogenous system, retirement communities can be affected by social systems, which ac cording to Rogers are based on norms and accepted patterns of behavior 17 This may be a major barrier to the adoption of a new innovation (such as TC) if the innovation is seen as unusual and unfamiliar. Rogers state s that it is critical to focus on opinion leaders and change agents, also supporting the importance of stakeholder involvement. As more of the social structure becomes involved in an innovation the greater the level of uncertainty is reduced. Acceptabil ity: KAP studies are important for identifying factors involved in the acceptability of an innovation 17 Rogers states that such data can be valuable for t o or in conjunction with the individuals decision to adopt the interve ntion. A focus group study could help gather valuable data on deciding factors related to the acceptability of an innovation as indicated by Roberto in his study on factors involved in condom use described above under the KAP Gap above. 31 The author concluded that quality of awareness depends on experience with use and that most negative perceptions were imaginary, but can be overcome with positive s tatements

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40 Critical Mass: Accordi n g to Rogers critical mass is o ne of the more powerful factors of the diffusion of an innovation is the observation that once a certain percentage of a population adopts a new innovation, further diffusion tends to be sel f sustaining 17 Rogers states that peer influence is the major contributor to critical mass, and although the exact percentage of adopters can vary depending on the innovation, typically once 5 to 20 percent of the pop ulation has adopted an innovation, the diffusion process becomes self sustaining. This elaborates the importance of social marketing and diffusion efforts to reduce the KAP Gap, which can delay the diffusion of an innovation by decades (as in the case of aerobics mentioned above), until the requisite 5 to 20 percent of the population adopts. Rogers states that typically a small number of highly influential individuals can help facilitate diffusion faster than a similar number on non influential persons. Id entifying factors through the current focus group design which might persuade influential members of a population to adopt TC, may interest such individuals into playing such a role, and or to act as stakeholders in the diffusion of TC. Highly recognized r ole models can help promote the diffusion of an innovation Rogers provides four strategies for achieving critical mass: 1. Target highly respected individuals within the social system. 2. Stress the fact of others adoption, that the innovation is already mainst ream. 3. Identify sub groups to target, achieving critical mass initially in the sub group. 4. Provide incentives for adoption The focus group design is oriented around identifying what facilitators might motivate adoption in the sub group of users of the OTO W fitness center, towards becoming stakeholders in communicating the benefits of TC (incentives for adoption) to the larger community, to facilitate achieving critical mass in future studies and diffusion

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41 efforts. Arroyo Barriguete and colleagues state tha t the transition of society to an information based economy is important to consider in addressing an economy of networks and critical mass. 33 The economy of networks stresses the importance of network effe cts, in which adoption of an innovation snowballs to the exclusion of competing products. This may be an important considera tion in the diffusion of TC. The stretching or y oga (Appendix A ), may better targeting immediate consumer needs with a user friendly format, but at the cost of long term benefits. It is possible that this may result in the extinction of true TC, with a possible impact on TC benefits. Arr oyo Barriguete a nd others 33 as well as Rogers 17 give the QWERTY keyboard as a n example. Although the QWERTY keyboard is more efficient, the critical mass achieved with the slower DVOR AK keyboard eliminated the former from the market. This may be an important consideration in the diffusion of TC, related to a potential battle between user friendly and effective formats. An ideal situation would combine the two formats. Diffusion of Inno vation Bell Curve: The Diffusion of Innovation is characterized by societal changes, or adoption of innovations, by society at large. The Diffusion of Innovation model, popularized by Everett Rogers in 1962, 17 is base d on the observation that adoption of new innovations tends to follow the bell curve. It is a useful model for identifying needs to address in each category of adopters According to Rogers there are five adopter categories (Figure 2 2) that can influence the rate of adoption which exhibit a bell curve distribut ion Innovators are characterized by those who are among the first adopters of an innovation. They require the shortest adoption period, tend to like to try new things, and

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42 may be motivated by the idea of being in the forefront, or being different. They can also serve as peer educators for the next group of adopters. Early Adopters begin the process of introducing a new trend on a larger scale in society. They follow innovators as a trend setter, an d can be role models for a larger segment of society. Early adopters are ideal stakeholders for promoting a new innovation, as well as test subjects for innovation trials. Early majority see the benefits from the innovators and early adopters, and begin ad opting on a larger scale. They seek proven benefits and reliable service, and do not want to become experts to understand benefits, so they rely on testimonials from trusted sources. Cost/benefit ratio is more important to this group. The innovation, servi ce, or product needs to be user friendly. It is at this point critical mass is reached (see below), and the innovation will spread of its own accord, as society becomes aware of the benefits on a large scale. Late Majority are conservative and tend to resp onse slowly, resistant and skeptical of new innovations. Peer pressure from the early majority may bring them into adoption, as will economic necessity, while laggards may influence the late majority to further caution. It is at this point that the saturat ion point tends to be reached in a new market or innovation in the diffusion process. Laggards are the skeptics of society, and tend to stay with the status quo, with what they have always done. They see little need to change things in their lives, unless necessity forces them to. The Innovation Decision Process Model: According to Rogers the Innovation Decision process consists of five stages, which tend to follow an S shaped curve, due to

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43 the relatively rapid adoption by later stages in the diffusion pro cess following the initial adoption of a bout 5 25% of a systems members ( critical mass ) 17 Of the five stages (Knowledge, Persuasion, Decision, Implementation, and Confirmation), the first two stages are the most rele vant to the current KAP study, in order to identify what knowledge current and potential adopters may have about TC and what factors may create positive attitudes towards persuading adoption. Following is a description of Rogers Innovation Decision Process : 1. Knowledge Stage and benefits occurs. 2. Persuasion Stage the formation of a favorable or unfavorable attitude towards the innovation. 3. Decision Stage activities that lead to choosing or rejecti ng the innovation. 4. Implementation Stage putting the innovation into use. 5. Confirmation Stage seeking reinforcement of an innovation decision already made. Adopter may reverse decision if exposed to conflicting messages. Figure 2 2 presents an overview of the innovation decision making proces s. Research from Knowledge, Attitudes, and Practice (KAP) and Related Studies Knowledge, Attitudes, and Practice (KAP) studies were primarily developed in health issues in developing countries, in order to implement effective diffusion strategies for health interventions, particularly in the area of family planning 17 A KAP study relating directly to TC was a study con ducted by Sherry Beaudreau 34 Beaudreau conducted a focus group consisting of 12 individuals self selected from an invited population of 100 randomized individuals from an older adult volunteer research pool. F ourteen had volunteered for the TC focus group, but two were

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44 excluded due to significant self reported problems with balance and lack of physician approval, and that the focus group was full. This is notable, in that out of 100 indi viduals, O nly 14% expres sed interest in the free class, despite the promotion of the benefits of TC for increasing balance, flexibility, and strength in the recruitment flyer. Of these 12 participants, 4 dropped out, consisting of individuals who had little previous experience n or motivation for exercise, compared to the 8 who completed the study, 7 of whom had been regular exercisers in other forms of exercise. Another aspect of the study worth noting is that 10 of the original 12 partici pants were women The author did not stat e if the 4 who did not complete the study were male or female. The class consisted of 30 minutes of learning TC movements, twice a week for a 5 week period. As in other studies, this is a limitation that needs to be addressed, since what is being measured is learning TC as opposed to practicing TC, which may have significant impact on results, and explain the wide variation of significant and non significant findings for the same health concern. For the study conducted by Beaudreau (2006) this may be less o f a limitation, in that the researcher was evaluating variables related to motivation, class participation, and home practice. Thematic analysis was used to evaluate the results of transcribed notes. Key findings from the TC focus group included: Motivati on to take TC being tied to exposure from TV, a friend, or seeing it in a park (n = 5). Desire to improve balance, strength, coordination, or to decrease pain (n = 4). Difficulty practicing TC outside of class (n = 8), with desire for written or visual cue s to follow. Important to teach at a level appropriate to older adults. Recommendation for small class size (15 people or less).

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45 Important to have a patient, interested, and participant appropriate teacher (n= 7). Physical benefits after 5 weeks: improved posture, balance, body awareness (n = 3). Mental benefits after 5 weeks: improved mood, relaxation, feels good (n = 3). It is worth noting that 3 participants experienced pain or difficulty from holding movements. This supports that it is important to co nsider teaching style and ability, since TC is typified by flowing movements, rather than holding postures, indicating a hold various positions for extended length s of time while walking around to correct movements. Kue i Min Chen and colleagues conducted 7 focus groups in Taiwan to explore the knowledge and attitudes frail elders have related to TC. 35 F ocus group s consisting of 40 frail elders living in long term care facilities were recruited for the study, 22 who had never practiced TC (divided into 4 groups) and 18 from a previous quasi experimental study evaluating the effects of a six month Yang style TC intervention (d ivided into 3 groups) The authors used a cross sectional descriptive study utilizing a focus group. Questions related to perceptions of TC in the non TC group included: 1. How many times per week of TC practice do you suggest? 2. What is your suggestion for t he length of a TC session? 3. When would be the best time to practice TC when we design a program? 4. How many people per group do you suggest for learning TC? 5. Where is the best location to practice TC? 6. What type of TC instructor do you prefer for learning TC? As can be seen from the questions, the perceptions evaluated pertained to the organization of a TC class, and not perceptions of what TC is or how it might be of

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46 benefit. The above study highlights the nature of KAP studies as being useful for evaluating n ovel interventions in a new culture, since the questions did not pertain to knowledge and attitudes about TC, but rather the practice of TC. The study took place in Kaohsiung, Taiwan. Content analysis was utilized to evaluate the data, conducted independen tly by two co leaders with expertise in qualitative research, and then cross checked for consistency. The primary leader then validated the content analysis, and presented the data using descriptive statistics, by describing t he most frequently occurring t hemes as well as presenting frequencies and percentages The primary findings of interest were the comparisons between the two groups in regards to time of practice and practice location. The majority of the TC group ( n = 18) preferred early morning ( n = 1 0; 55.56%), while the majority of the non TC group ( n = 22) preferred afternoons after napping ( n = 12; 54.55%). As for location, the TC group preferred indoors ( n = 11; 61.11%) while the non TC group state they would prefer outdoors ( n = 19; 86.36%). The majority of participants reported preference for practice twice each week (TC n = 10, 55.56%; NTC n = 9, 40.91%), with a duration of 31 60 minutes per class (TC n = 13, 72.22%; NTC n = 10, 45.45%). As for group size, the majority preference was for 10 20 s tudents (TC n = 14, 77.78%; NTC n = 15, 68.18%). For characteristics of a TC teacher, 55.56% ( n = 10) of the TC group expressed preference for a gentle instructor, while 50% ( n = 11) expressed preferences for an experienced instructor. In a study on the fa hen, Snyder and Krichbaum identified a strong need to understand reasons for TC adoption and barriers to adoption. 35 The authors conducted a cross sectional descri ptive study in

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47 Taichung Taiwan. Face to face interviews were conducted in community settings such as parks, athletic grounds, or participants homes. Participants consisted of 80 community dwelling elders aged 65 and older, 40 who practiced TC and 40 who di d not, using a convenience snowball sampling strategy. It is worth noting that the TC group consisted of very serious practitioners the average practice was 74 minutes per practice seven times per week, which contrasts to most studies in which TC is prac ticed two to three times per week for 30 to 60 minutes. The following questions were asked of the TC group: 1. What led you to practice TC? 2. What are the reasons you continue TC? The non TC group were asked the following questions: 1. Have you ever considered p racticing TC? 2. If yes, what has kept you from practicing Tai Chi? 3. If no, why not? Data were analyzed using descriptive statistics Perceived benefits to health ( n = 21; 52%), encouragement from others ( n = 14; 35%), increased leisure time in retirement ( n = 9; 22%), and admire graceful movements of TC ( n = 8; 20%) where the primary motivating reasons for beginning TC in the TC group. Being close to home was listed by 4 participants. Primary reasons for continuing practice included positive health outcomes ( n = 28; 70%), habit ( n = 11; 27.5%), and social rewards ( n = 7; 17.5%). Among those who have never considered TC, 17 (48.6%) felt they were too weak to practice TC, 8 (22.9%) felt the movements were too complicated and would be difficult to remember, 5 (14. 3%)felt they were too old to practice TC, and 4 (11.4%) stated that they had no time.

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48 The above results indicate the importance of social support, health expectations, knowledge of what TC consists of, and perceived benefits in developing a TC program Bei ng a convenience sample of a small group none of the percentages in either group are necessarily representative of the general older adult population, either in Taiwan nor the United States, but they do highlight the importance of discovering the knowledge and attitudes towards TC that may act as barriers and facilitators. T he following studies relate to KAP and complementary and alternative medicine (CAM), yoga, and exercise Avino conducted a KAP assessment regarding complementary and alternative medici ne (CAM) of nursing faculty and students, to investigate knowledge due to growing demand among consumers. 36 The survey tool Complementary and Alternative Medicine Survey of Knowledge and Attitudes of Health Profession s Students used for the survey, for which the face validity was established by the developers. The survey measured 11 general attitudes and 8 barriers to the use of CAM on a 7 point semantic dif ferential scale, ranging from very strongly agree to very strongly disagree. Effectiveness of CAM was measured using a 6 point semantic differential scale (highly effective to harmful, and no opinion). Previous education on CAM and training needs were eval uated with a 4 point semantic differential scale (none, some but not enough to advise, sufficient to advise patients about use, and sufficient to personally provide). A descriptive study design was used to evaluate frequencies and differences in attitudes and perceived barriers, in addition to specific provider questions. Findings of particular interest to the current study include sources of information on CAM among faculty (peers 90%; professional journals 75%; and mass media 58%)

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49 and students (peers 73%; mass media 55%; and professional journals 52%). Mass media was also reported as a primary source of knowledge regarding the benefits of exercise during pregnancy cited above, while peers as a source of information is in keeping with the importance of inte rpersonal networks from diffusion theory. Lack of evidence regarding the effectiveness of CAM was also cited as a barrier (82% students; 96% faculty), as well as lack of access (81% students; 92% faculty) and cost (77% students; 90% faculty). Benefits, bar riers, and cues to action were evaluated in the promotion of yoga using a focus group approach by At kinson and Permuth Levine 37 The authors also identify a lack of research on factors that e ncourage and deter yoga practice. The HBM was used as the theoretical framework for the study, due to its focus on behavior perceptions and effects on actual behavior. The authors used a focus group approach to understand the nature of the perceptions of people who might attend o r have attended a yoga class. Fifty participants were split into two groups of three levels of yoga experience: (1) never practiced yoga, (2) practiced less than one year, and (3) practiced more than one year. Questions were developed and coded using selec t HBM constructs and attitudes. Internal cues to action among yoga practitioners consisted primarily of physical ailments, injury prevention or rehabilitation, and mental health problems or emotional concerns. External cues to action consisted of hearing a bout yoga from friends or colleagues, as well as print and television media. Perceived benefits, reported by all groups including non practitioners, were health promotion effects, disease prevention effects, and social/psychological benefits. Variation bet ween practitioners and non

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50 practitioners was observed in perceived barriers, primarily in time constraints. Although time constraints were mentioned by all groups, non practitioners had the additional burden of not already having time allocated for yoga, a nd having to make a decision of what to give up to have time for yoga. Both groups mentioned cost constraints, but again the burden was higher in non practitioners, who not knowing yoga did not have the choice of practicing on their own at home. Negative p reconceptions included a belief by all groups that yoga is dominated by women, and that women are better at yoga due to their inherent flexibility. As such many male practitioners stated they felt self conscious when starting yoga. Other negative perceptio ns noted by all groups included perceptions of yoga practitioners as having alternative lifestyles. Among non practitioners, additional barriers were identified as perceptions that yoga is not challenging aerobically, requires flexibility, and not wanting to start as a novice. Non practitioners did not want to waste time on an activity that would not benefit them aerobically, or be difficult to learn. Negative teacher traits (judgmental or unfriendly) were also identified as a barrier. Negative health effec ts were noted as a minor barrier across groups, mainly the possibility of joint and other injuries. Other negative perceptions included the thought that yoga might undo the benefits of running or strength training. The authors state that initial positive e xperiences with yoga may help non practitioners to overcome most of the identified barriers, as well as shorter classes, and increased accessibility. Non critical and adaptable instructors were also noted as advisable. An informal survey by the Yoga Allian ce identified misperceptions about Yoga as a barrier to practice. 38 The following attitudes towards yoga were reported as barriers:

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51 4. Yoga is religious 5. Only those who are flexible can practice yoga. 6. Yoga is not reall y exercise 7. 8. Uncertain benefits Zhang and others conducted a survey on fall prevention KAP of community stakeholders and older adults. 39 Of particular note is the i nvolvement of key stakeholders in t he form of senior serving organizations. The questionnaire consisted of 24 open and closed ended questions for service professionals, and 52 closed ended questions for older adults age 65 and older conducted via a telephone survey. Descriptive statistics were used to evaluate data E mployees identified falls to be an urgent (62% very urgent, 38% somewhat urgent) issue in the older population. Insufficient resources were identified as the main barrier to regular fall preventions services (80%), followed by lack of trained personnel (28%), lower organizational priority (24%), and low awareness of the importance of fall prevention (22%). Results from the older adult survey also yielded some notable results. Thirty four percen t reported falls to be their least important health concern. The primary barrier to fall prevention activities was the perception of not feeling at risk for falling The authors conclude d that a disparity exists between proven prevention strategies and older adult awareness and understandin g of these practices. Essentially a KAP Gap. Lack of knowledge and opportunity of services was also identified as a major barrier. When practices for fall prevention were perceived as important, ready availability of the preventive measure seemed to promot e adoption (59% of community dwelling older adults with access to strength and balance training perceived strength and balance training as important, and 54% actually participated in the activity). This

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52 study is relevant in stressing the importance of unde rstanding older adults health views, motivations, and adoption factors. Buttery and Martin conducted a knowledge, attitudes and intentions assessment regarding participation in physical activity of older post acute hospital inpatients. 40 The authors sought to determine knowledge of benefits of physical activity, attitudes and barriers to participation, and intentions towards future physical activity. The survey was developed from questions from surveys on older pe ople and physical activity, with the inclusion of questions regarding knowledge, attitudes, barriers and intentions. Pilot testing was utilize d to establish face validity. Forty six participants consented to participate, with two withdrawing due to fatigue Results of the knowledge portion of the assessment found that while the majority of respondents acknowledged benefits of exercise for preventing heart disease (n = 31; 70%), keeping supple (n = 40; 91%), improving health (n= 39; 89% ) and lengthening lif e (n = 29; 66%), a fair number were unsure or disagreed (ranging from 9 27% depending on the item) Reasons for not exercising were primarily linked to difficulties walking and breathing. Social factors and lack of interest were other identified factors in exercise adherence (no statistics were given for these variables). Identified barriers included injury and disability, poor health, prefer other uses for time (rest and relaxation), do not enjoy exercise, and lack of energy. A large well designed st udy by Crombie and others randomly selected 409 older persons aged 65 to 84 years of age to investigate why older people are reluctant to participate in physical activity, as well as strategies for promoting activity. 41 The questionnaire was developed from a variety of resources, including findings from focus

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53 groups and four in depth interviews. Questions on beliefs, attitudes and intentions to be physically active were on placed on a Likert scale. 97% of subjects (n = 395) believed physical activity helps to keep one supple, and 96% (n = 392) believe physical activity can improve health. However, despite high level of knowledge of benefits of physical activity, levels of actual activity were low (31% reported walking for health less than two hours per week). 53% did less than two hours of all forms of leisure activity (gardening, bingo, church, lunch/coffee with friends, etc.) per week, with 36% doing none at all. It is interesting to note that althoug h significant barriers identified to physical activity included lack of transport, shortness of breath, lack of energy, lack of interest, and embarrassment in joining a group (p < .0001), lack of time was not identified as a barrier. Being an assessment of a retired population this is not surprising, and may not be a major barrier among older adults. Ribeiro and Milanez investigated the KAP of women in Brazil with respect to physical exercise during pregnancy. 42 Th is descriptive study sought to determine the KAP of exercise in pregnant women and why some women do not exercise during pregnancy. 161 women between 18 to 45 years, in their third trimester of pregnancy were interviewed. Despite 65.6% ( n = 103) of the wom en being informed about the benefits of exercise during pregnancy, with 93.8% ( n = 151) being in favor of exercise, only 22.9% ( n = 37) got adequate exercise. Lack of time ( n = 63; 55.8%) and feeling tired and uncomfortable ( n = 37; 32.8%) were given as th e primary reasons for not exercising. It is also worth noting that the majority stated they learned of the benefits of

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54 exercise for pregnancy through television ( n = 89; 55.3%), followed by books and magazines ( n = 39; 24.2%). In summary, the primary barri ers to TC, yoga, and exercise identified by the above KAP studies include d: L ack of fitness/poor health, pa rticularly shortness of breath; 35,40,41 cost and lack of access; 34 37 La ck of adequate/patient teacher ; 34 difficulty remembering ; 35 Too old ; 35 L ack of knowledge/perception new age/perception no t an exercise ; 37,38 and Lack of time 35,37,42 The primary facilitators to TC, yoga, and exercise identified include d : Exposure to TC ; 34,37,42 P erceived health benefits includi ng enhanced suppleness ; 34,35,37,40,41 S ocia l aspe cts ; 34,35,40 Appropriate/Patient teacher ; 34 and E vide nce based programs 36 Studies using the Fishbone Diagram in a Focus Group Design The fishbone diagram, also known as the Ishikawa Diagram after the originator, is a method used in the manufacturing industry to identify cause and effect relationships, and to identify weak nesses in the manuf acturing process 43 Hermens document ed an adaption of t he Ishik awa diagram by Metrobank to uncover weakness and val ues in customer service in focus group s consisting of key administrators (no n was given). The method was used to find hidden customer value s and match services with needs. The author reported more open communication as a result of the fishbone diagram. According to Hermens the Ishikawa diagram, or fishbone diagram, presents a data ready tool from which to capt ure participant needs and wants by efficiently categorizing responses and permitting quantifiable responses Fluker et al. 44 utilized a focus group design with the fishbone diagram to gather more specific data following a survey to evaluate physicians knowledge, attitudes, and practice ( to identify barriers to counseling ) I nternal medicine

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55 residents ( n = 158) completed a KAP questionnaire, which was analyzed usi ng descriptive statistics. The KAP questionnaire exposed a clinical knowledge deficit, lack of familiarity with national guidelines, and low self efficacy. Lack of time was the largest barrier to counseling ( n = 25; 15.9%). A fishbone diagram was used to uncover additional barriers not identified by the KAP questionnaire. The f ishbone diagram was created by conducting a focus group session and asking residents to silently write down as many barriers as possible on adhesive notepads (one barrier per note) during a 5 10 minute period. 44 Notes are not shared until collated on the fishbone diagram. No identifying information is given on the adhesive notepads. The participants then worked together for 10 minutes orga nizing related barriers into categories of their choice. A fishbone diagram was then drawn on a otes were then grouped into categories onto the bones of the fish (including duplicates, to count how often each barrier was mentioned (Figure 2 2). The authors state that the fishbone technique allows a structured approach allowing everyone input, provide s a visual display, and stimulates a more thorough exploration of the problem. D uckett and Nijssen Jordan used a fishbone diagram to map and identify causes of long waits in emergency departments 45 The authors first created a fishbone diagram as a framework of current initiatives related to emergency department long stays. Brainstorming sessions were then held of operational leads to review the initiatives and propose new strategies. The data was then entered into spreadsheets, which were then updated pending new strategies identified at weekly meetings. Group

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5 6 sizes and number of meetings were not given. A final report was made incorporating the fishbone diagram with approved strategies. The authors stated that the fishbone diagram helped to promote greater involvement of participants in a coherent manner.

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57 Diffusion as the process in which an innovation is communicated or spread through certain channels over time among members of a social system (Rogers, 2003). Diffusion of an innovation involves the process diagramed below (from initial knowledge and relevance to the social system, to adoption and confirmation of the innovation). The chart is based on the innovation decision process model developed by Rogers (2003), and provides an overview of the factors addressed in the theory section in the review of literatu re. The current study focuses on the first two stages of the model (in bold), and where the research questions fit into to the proc ess affecting the diffusion of an innovation. Communication Channels (What factors ( perceived benefits, threats, and barriers) may make TC messages more effective towards achieving Critical Mass the percentage of the populat ion necessary for an innovation to become self sustaining) Adoption ( Influenced by adopter category: Innovators, Early Adopters, Early and Late Majority, and Laggards). Rejection Characteristics of the Perceived Characte ristics Decision Making Unit of the Innovation ( Factors which may affect attitudes towards adoption of an innovation (Rogers, 2003). SOCIAL SYSTEM 1. Relative Advantage What are benefits of TC compared to other choices? (Factors which can affect 2. Com patibility Acceptability, how consistent is TC with existing values & needs? Time the KAP Gap, the delay 3. Complexity How difficult do older adults perceive TC? between Knowledge, 4. Trialability What is the current ability to try TC? What facto rs of trialability might affect adoption? Attitudes and the Practice or 5. Observability How observable is TC? What options exist to increase observability? adoption of an innovation The above questions are addressed in Chapter 5, under Recommendat ions, related to how findings might be (TC in this case). applied to promoting diffusion of TC among older adults, and recommendations for future research. Figure 2 1. Overview and linkage of foundational concepts of diffusion of in novations base d on Rogers model of five stages in the innovation diffusion process. 17 I. KNOWLEDGE RQ1: What knowledge exists? RQ3: What are perceived threats & benefits? RQ4: What differences in TC & Non TC groups? III. Decision V. Confirmation IV.Implementation II. PERSUASION RQ2: What barrier s exist? RQ3: What facilitators exist?

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58 Figure 2 2. Adopter categorization on the basis of innovativeness. From Rogers 17 Figure 2 3. The innovation decisi on making process 17 The first two stages are pertinent to a KAP study: Identifying current knowledge among a specific group of potential or current adopters (with shared characteristics), and identifying which characteristics of an innovation may create favorable attitudes towards adoption.

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59 Figure 2 counseling in hypertensive pa tients 44 Table 2 1. Facilitators and barriers to TC in older adults 34 Facilitators Barriers Smal l class size ( n =8) Lack of visual/written cues ( n =8) Repetition, clear instruction ( n =8) Get confused when try on own ( n =5) Interested, patient instructor ( n =7) Holding positions hurt ( n =3) Saw on TV, park, or friend suggested ( n =5) Wanted to improve balance ( n =4) Age appropriate classes ( n =4) Needed exercise ( n =4) Convenient time/location ( n =2) Group size: n = 8

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60 Table 2 2. Comparison of facilitators and barriers from a survey of older adult TC ( n = 40) and Non TC practitioners ( n = 40) i n Taiwan Facilitators and barriers originally stated as 35 Facilitators (TC group reasons for practice) Perceived benefits to health/ relieve pain/trea t illness ( n =21; 52.5%) Encouragement from others ( n =14; 35%) More leisure time in retirement ( n =9; 22.5%) Admire graceful movements of TC ( n =8; 20%) Interested in TC ( n =7; 17.5%) Keep active in old age ( n =6; 15%) Close to home ( n =4; 10%) TC group reasons for continued practice Positive health outcomes ( n =28; 70%) Fell into the habit ( n =11; 27.5%) Social rewards ( n =7; 17.5%) Relaxed and less moody ( n =5; 12.5%) Clear headed and think better ( n =5; 12.5%) Barriers (Non TC group reasons for non pract ice) Too weak to practice ( n =18; 45%) Memory/movements too complicated ( n =8; 20%) No time ( n =7; 17.5%) Too old ( n =5; 12.5%) Not interested ( n =4; 10%) No patience to learn the movements ( n =2; 5%) Too fat ( n =2; 5%) Do not know where to go to learn ( n =1; 2.5% ) NOTE: These categories are not mutually exclusive. Participants may appear in more than one category.

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61 CHAPTER 3 METHODS Study Design Two focus groups were conducted consisting of TC practitioners and Non TC practitioners to determine barriers and facilitators to adoption of tai chi in older adults, at Focus groups have been defined in the literature as an interview with a small group of people on a specific topic. Flick addresses the benefit of the focus group design in permitting more efficient sharing of individual and group views. 23 Focus groups have been identified as being particularly valuable for revealing important areas of knowledge and deficits for understanding of human behavior (which can lead to an explanation of patterns of adoption or non adoption) which may be missed through a broad based survey or q uantitative design. Flick states that in many ways a small group of people brought together as a discussion or resource group is more revealing than a representative sample in a quantitative study. 23 Groups typically are composed of six to eight people who participate in the interview for one half to two hours 23 however, alth ough Fern indicated that optimal group size for creative tasks is less than 8, group design and purpose can greatly affect this. 46 Fern report ed group sizes ranging from 5 12 to 20 or more for greater synergistic effects. The main drawback reported for larger groups involving greater degrees of group discussion is frustration with participants opportunities for participation, and the amount of time available for discu ssion. An important consideration is the nature of the g roup participation. Fern report ed that nominal groups (groups in which individuals submit and then rank views before discussion ) out performed real groups (groups

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62 regarding the number of ideas produced, and in creativity of ideas (stating that group pressure can inhibit interaction and expression of ideas, particularly in brainstorming sessions). In the study conducted by Fluker and others using the fishbone diagr am for gathering and ranking participant ideas, focus group size included 10 12 participants. 44 The focus groups in this study included 10 participants in the Non TC group, and 11 in the TC group, due to the eff icacy of the fishbone diagram in organizing efficient use of time in a focus group setting as described above The fishbone diagram also permits blinded responses to minimize bias from focus group interaction and potential researcher bias. The discussion p hase is limited to clarifying responses on the post it notes, and noting additional unprompted observations made by the focus groups on the margins of the fishbone diagram ( with the exception of asking participants in the Non TC focus group about their pe rspective regarding a class specifically for beginners, and perspectives on any possible influence of views regarding TC related to previous military experiences at the end of the discussion phase, based on suggestions from dissertation committee members). The fishbone diagram was utilized to organize topics and permit anonymous response to topics. Group discussion followed the development of the completed fishbone chart. During the focus group process the fishbone charts efficiently categorized responses according to the constructs of t he Health Belief Model and permitted quantifiable responses. Responses between the Tai Chi group and Non Tai Chi group are also compared with threats to health in older adults according to death rates as recorded by the CDC (T able 5 2) to identify potential lack of knowledge related

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63 to perceived versus real health threats. The protocol of the focus groups followed the process as elaborated on in an I Cubed program workshop on qualitative inquiry on use of the fishbone diagr am in a focus group setting at the University of Florida, as well as the Ishikawa diagram pr ocess outlined by Hermens 43 and Fluker and colleagues 44 These processes incl ude a brainstorming session, linking health concerns (perceived threats), opportunities (arising from perceived benefits), and problems or causes (perceived barriers). The HBM was utilized to structure the fishbone diagram for theory driven thematic analy sis 47 described below to organize discussion and responses according to the constructs of the HBM. The primary measure s for the focus group design at OTOW is theory driven thematic analysis (from the fishbone diagram and discussion phase) as well as frequencies of responses (number of post it notes) related to knowledge and attitude s oriented around facilitators (perceived threats and ben efits) and perceived barriers to TC adoption P articipant s also rated per sonal relevance of each item identified on a 0 9 scale Following the focus group sessions, descriptive data w ere analyzed using theory driven thematic analysis (see data analysis below), as well as f requencies of responses and item scores (0 9), including means and standard deviation using statistical software package SPSS 17 The following sections detail participant recruitment focus group process and data analysis Institutional Review Board The study was submitted to the Institutional Review Board (I RB 02) at the University of Florida. The institutional review board reviews research studies involving human subjects. A description of the study as well as participants rights are included on the fir st page of the informed c onsent form. Identifying inform ation will be kept on the

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64 hard drive of the investigators office, locked and accessible only with a password. Hard Study Sample designed for those who are age 55 and older with approximately 10,000 residents located in Ocala Florida According to the OTOW website 48 i t is a retirem ent community known for an advanced approach to the ol der adult lifestyle. OTOW emphasizes a wide variety of lifelong learning program with its own education center and a faculty of over 100 educators. The sample frame for th e focus groups consisted of two groups 10 participants in the Non TC group (5 men and 5 women) and 11 in the TC group (all women), recruited from active users of the OTOW fitness center, in an attempt to control for lack of adoption of TC due to a seden tary lifestyle Selection criteria for the Non TC group also included being in the precontemplation stage, having never contemplated adoption of TC. Selection criteria for the TC group included being active TC practitioners. All TC group members were activ e in the TC classes at OTOW. Residents of OTOW were recruited by the community fitness director, from the current TC class es and those active in the other activity classes. The director made an announcement in each activity class, asking for volunteers for a focus group study on health concerns and class offerings at the fitness center, and their views on TC. It was also announced that each participant would receive a gift certificate or coupon donated by local area restaurants (ranging in value from $10 to $25). Interested residents signed up on one of two sign up

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65 sheets provided by the director (one for those practicing TC, and one for those who have not considered TC. The threat of self selection bias is minimized through the homogenous nature of the po pul ation and the purposeful nature of the sample. 49 Higgens and S t raub note that groups that are similar in nature can help minimize bias due to differences that may result from a randomized sample from a larger and mor e diverse population base. The more similar group members are to each other, the less self selection will affect the study. Since the sample was purposely taken from active members who regularly engage in exercise at the fitness center, with a shared locat ion as residents at OTOW, focus group members are more homogenous and representative of the OTOW population than if participants were randomly selected from a larger area (or even from OTOW, if exercise habits were not similar). Flick also recommends a cer tain level of homogeneity on characteristics which ma y affect group discussion. 23 Flick states that for some studies, a more homogenous group with shared characteristics have more points for common discussion. Ten resid ents signed up for the Non TC group, consisting of 5 men and 5 women currently active at the fitness center at OTOW. These participants had never taken the TC class at OTOW, nor had ever considered taking the class, according to self report. Eleven residen ts (all women) signed up for the TC group, consisting of active members in the TC class at OTOW which consisted at that time (Summer 2012) entirely of women, which may be a limitation of the study Participant two, although had never contemplated taking t he TC class at OTOW (nor anywhere else according to his statement ), had tried it on a cruise ship, not out of

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66 intention t o practice TC outside of the cruise ship class (and to gain his perspective as a non interested participant in a TC class), he was included in the Non TC focus group. To control for possible bias ing effect during the discussion phase remarks and input from participant two regarding his experiences were dis cussed last during the discussion phase The fishbone diagram eliminates possibility of bias and influence from his experiences during the development of the diagram, since individual responses are noted silently on post it notes. See Tables 3 1 and 3 2 f or an overview of participant characteristics. Characteristics of Tai Chi class and Instructors at OTOW OTOW was in the process of changing teachers for the TC class during the summer of 2012. The first teacher (teacher 1) had minimal experience (three ye ars, and 50 but later was certified to teach did not feel comfortable teaching the hour long class due to her lack of experience, and cool down exercises, and his TC for Arthritis form (typically taking approximately 20 minutes to follow this section), s ome instruction, and incorporated various additional qi given for leaving the TC program was that teacher 1 was a resident of OTOW, and class participants expressed frustratio n when the instructor was away travelling. The second teacher (teacher 2) was not a resident at OTOW, but was a professional dancer and exercise class group leader. She had learned TC as part of her dance training 25 years ago, and had incorporated a varie ty of stretching, warm ups,

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67 50 Instructor 2 emphasized a more dynamic class, repeating individual movements in a style similar to low impact aerobics. Th e instructor stated she based the faster movements on Chen style TC, an early and more martial form of TC. The class also stressed balance during a variety of faster pace dynamic movements. Instructor 2 stated that it was important to get participants hear ts moving, increase VO2, and work on range of movement and balance. Instructor 2 also stated that she has found that participants seem to enjoy faster paced TC similar to Chen style. Focus Group Protocol As discussed above b y using a group process facili tated by the fishbone diagram to streamline the group discussion and input, the focus groups for the purpose of this study included 10 participants in the Non TC group, and 11 participants in the TC group To allow discussion on factors of TC ado ption foll owing development of the fishbone diagram a two hour format was conducted. Flick 23 addresses the bene fit of the focus group design as permitting more efficient sharing of individual and group views. A limitation of foc us groups is difficulties in note t aking, which is addresse d through the fishbone diagram process described below. Focus group proceedings were not audio recorded, in part t o address potential bias identified in the literature which can result from focus grou p recording, due to self monitoring of remarks by focus group participants. 23 Flick recommends restricting the use of audio recording unless absolutely necessary for the collection of data relevant to the research q uestion. Audio recording t o capture all responses was less of a concern due to the strength of the fishbone diagram in capturing the majority of participant views and comments in a written forma t 44

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68 Focus group s were conducted in the morning, in a conference room at the fitness center at OTOW. Each session lasted approximately two hours in length the maximum time limit for a focus grou p, as recommended by Flick 23 A 15 minut e break was conducted half way through the session for each group, f ollowing collection of the post it notes, to permit bathroom breaks and snacks, which were provided by the researcher. Bottled water, chips, a vegetable platter and dip were provided. Duri ng the break, the post it notes were collated and results written on the fishbone diagram for group discussion following the break The diagram was then hung on the wall for group discussion. Before a general discussion of the completed fishbone diagram, a brief discussion was held to confirm that grouping of similar terms matched participant views o f their response. The collation of post it notes formed items for group discussion, as well as for item s to be rated on a 0 9 scale for personal relevance follo wing the group discussion. Rating the items uncovered by the fishbone diagram process followed group discussion to clarify understanding of items listed, and to address the added item of perceptions related to lack of a beginners class at OTOW. Additional comments made during the discussion phase not already noted on the fishbone diagram were noted on the margins of the chart. Following completion of rating individual perceptions of items on a 0 9 scale participants filled out a follow up questionnaire on current physical activities to gather additional demographic dat a (see Appendix C ). G ift certificates were then raffled off to participants. A detailed overview of the focus group process is given below. The procedures for running the focus group incorpora te d the method laid out by Flick 23 and Boyatzis 47 and were modified based on the use of the fishbone diagram as

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69 discussed abov e as well as training in the fishbone diagram process at an I Cubed program workshop on qualitative inquiry at the University of Florida. Each focus group was moderated by the researcher, utilizing methods and training gained during a qualitative research methods class at the University of Florida, i n addition to training at the I Cubed workshop on qualitative methods mentioned above. Following is a detailed overview of the focus groups conducted at OTOW: Focus Group Process Set up: Prior to arrival of focus group members, bottled water was placed on the three tables in front of each seat, along with pens, markers, and post it notes. Introduction and instructions for focus group: Introduction of moderator (the investigator) and explanation of focus group protocol. Participants were informed that they w ould be noting concerns or thoughts related health threats, knowledge of benefits of TC, and barriers to TC practice on post it notes (one thought or comment to each note) which would be stuck to a plain piece of p aper with the appropriate construct on it and gathered by the moderator, collated by commonalities, and posted on the chart in the appropriate areas. Participants were informed that no names were to be written on the notes, so that responses would be anonymous. Participants were then informed t hat the observations and comments would be transferred to the fishbone diagram during a brief break, during which snacks would be available. Focus group members were then informed that following the break, the group would discuss the finished diagram foll owing wh ich they would rate identified items created on the fishbone diagram on a 0 9 scale and would also complete a brief questionnaire related to their current physical activities. Participants were also informed

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70 that there would be a raffle of the gif t coupons provided by local area restaurants at the conclusion of th e meeting Expectations fo r level of participation were g iven, which in this case was primarily orient ed around the fishbone diagram Time frame: 15 minutes. Completion of Informed Consent : Following the introduction of the moderator and explanation of the focus group protocol, participants were given the option of withdrawing. All participants chose to stay, and then completed the informed consent, following an overview of the informed con sent form by the moderator. Time frame: 10 minutes Introduction of focus group members : A short introduction of the members to each other, emphasizing the common ground of the members to enhance community and personal health Time frame: 5 minutes Constr uction of Fishbone Diagram : Beginning the discussion with a the questions of threats to health, knowledge of benefits of TC, and barriers which may affect TC practice. Also presentation of HBM constructs in the form of t he fishbone chart, and reminder of instructions for us ing the chart as presented in the introduction Participants were reminded of aspect of their replies via the post it notes. Participants were asked to write their participant number down on the back of each post it note for later analysis, but that numbers would not be revealed to the group, nor identifying information used in later analysis. Participants were each given a blank sheet of paper titled with one of the three main constructs of the HBM (threats, benefits, barriers), upon which they were asked to stick the notes to.

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71 Each construct was addressed in turn, the paper with the post it notes affixed handed in to the moderator before going on to the next construct. Participants were then instructed to address the next construct ( participants were asked benefits of Tai Chi practice you can think of, and note each ben efit on a separate post it note; k of, and note each health threat on a separate post practice you can think of, and note each barrier on a separate post ). As participants worked on the next construct, the moderator removed th e post it notes from the papers, and collated them by commonalities (for example balance/falls memory loss, breathing/lung problems ), and then grouped them on the fishbone diagram. TC Time frame: 30 minutes (10 minutes for each construct). Snack Break and collation of post it notes onto fishbone diagram: A snack break followed with snacks (vegetables, chips, and dip) arranged on each table by the facility director. During the break, the moderator transcribed the collated post it notes onto the fishbone dia gram, using a large marker for easy visibility. Time frame: 15 minutes Clarification of items and discussion phase: Following the snack break, the moderator went over each transcribed item, and clarified any post it n otes for grouping into common themes an d items For example, clarifying the notations enhance anonymity, the group was asked to clarify potential meanings of the terms. This provides the author of th e note an opportunity to clarify their meaning, while getting

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72 group, is a post it note Following consensus on grouping of post it notes into common themes and categories, a final list of items for each construct was listed with a large marker on the fishbone diagram for group discussion and rating of personal relevancy on a 0 9 scale (see below). Group discussion: A g roup discussion followed, address ing factors unc overed by the fishbone di agram to explore possible other considerations. Members were asked to openly discuss the results of the fishbone diagram, and any other thoughts regarding what might promot e or inhibit TC adoption. The moderator guided discussio n through each area of the fishbone diagram noting which items were considered the most important with asterisks next to those items, and then asking participants to rate the starred items from most to least important. The moderator also made notes on the margins of the chart using a large marker, for areas brought up that were not already on the chart. When the last item was discussed, the moderator asked if there were any other thoughts or comments, before moving on to the next step. Time frame: 20 minutes Rating of personal relev ance of items: Members were then asked to rate on a piece of paper each item uncovered on the fishbone chart, using a 0 9 scale (zero being not applicable to the participant 9 being directly relevant) developed from the fishbone chart results A blank pa per was provided, upon which participants were asked to list each item created on the fishbone diagram divided by the three main constructs of the HBM (threats, benefits, and barriers) and their rating of perceived relevance. Following

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73 completion of pers onal ratings participants completed a follow up questionnaire regarding their current activities. Time frame: 20 minutes Conclusion and raffle: Conducted raffle for restaurant coupons, by handing out raffle tickets. As each number was called, participants came up to the table and chose one of the coupons. Thank ed members for participation and conclude d focus group session. Time frame: 5 minutes The Fishbone Diagram F igures 3 1 and 3 2 are an example of the fishbone chart developed by the TC group in the post it note stage and after collation of post it notes into specific items agreed upon by the group : Data Analysi s Data analysis consisted of theory driven thematic analysis as described by Boya tzis 47 using t he HBM for clustering based on constructs of the HBM Perceived benefits, threats and barriers identified by each member of the focus groups were noted on the diagram, including f requencies of responses (number of post it notes). According to Boyatzis 47 and Flick 23 the basic format of thematic analysis includes reviewing data and looking for common themes from which to create categories. Codes are created from words or phras es that create labels to be used as data (in this case lite rally, the participants labeling items with post it notes which were used as the basic unit of data ) Theory driven thematic analysis uses themes and codes which are based on an existing theory, e ither the research y, to drive and structure a focus group discussion 47 In the case of the current study, the Health Belief Model was used to categorize codes and determine themes (perceived benefits, threats and barriers) for group discussion apriori.

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74 Boyatzis stated that a theory driven code using framework not developed by the researcher (such as the HBM in this case) has a higher degree of validity than a theoretical framework developed by the researcher (due to potential conceptual rigidity). Inter rater reliability can also be affected by the source of the theory driven code. Boyatzis noted that researcher developed theories are more prone to differences in interpretation bet ween rate r s, as well as projection on the part of the researcher This is not a limitation in the current study, in that the data ready format of the fishbone diagram precluded the need for rating, other than participant agreement on collating post it note responses into relevant categories and items. In a sense, it could be said that the participants of the focus groups acted as raters, cross checking to verify accuracy of responses grouped on the chart. Boyatzis discussed this as synchronic reliability, t he consistency and judgment among multiple viewers. 47 Participant input during the discussion phase was also directly tied to identified items and theoretical constructs, and any additional data was listed on t he margins of the diagram following group consensus. Reliability issues are critical to consider when using thematic analysis, which relates to consistency of observation, labeling, or int erpretation 47 These r eliability issues can affect the potential for replication, extension and generalizability of the research, and are related to the validity of the judgments. Boyatzis further stated that reliability is a factor of consistency of judgments towards the inter pretive social scientists social construction of meaning. This reliability issue may be controlled for in the current study through the data ready format of the fishbone diagram and discussion input, which eliminates the need for judgment on the part of th e res earcher for

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75 translation and building of conceptual bridges discussed by Boyatzis Boyatzis also stated that reliability and validity of information obtained is directly affected by the way information is obtained. An example is given of video and aud io recordings to reduce variation in observations through repeated viewings by multiple observers to discuss coding of moments during the tape. Variation of observations was controlled for in the current study through use of the fishbone diagram to clearly identify items, as compared to regarding reliability relates to consistency and confidence of judgment, which is addressed through the fishbone diagram and clear labeling o f identified items and notations. The author also states that validity can be enhanced through confirmation, related to confidence of observations, which was addressed in the current study by having focus group participants confirm the grouping and final m eaning of responses and items on the fishbone diagram. Boyatzis further noted that thematic analysis can allow translation of qualitative codes into numeric expression for quantitative analysis although the author notes that quantitative analysis is consi dered by many to violate the methodologies and values embedded in qualitative research 47 However, the author states this primarily relates to the lack of a need to generalize to others, due to the uniqueness o f the people, organization, or event being studied However, if the group being studied is fairly representative of a larger population then quantitative translation can be useful. The author states that frequency of responses can be scored as an ordinal scale, and intensity of responses as an interval scale In the case of the dissertation study,

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76 frequency of responses (post it notes) for each item were recorded as an ordinal scale, with individual ratings of level of personal concern for each item (inten sity, on a 0 9 scale ), as an interval scale, for quantitative analyses Descriptive data were analyzed using f requencies of responses, as well as HBM scores (items rated on a 0 9 scale, with 0 being not rele vant and 9 being very relevant) calculating item means and standard deviation using statistical software package SPSS 17. Summary of Focus Group Process Related to Minimizing Bias The following research q uestions were addressed by the focus groups, using the fishbone diagram organized according to the constructs of the HBM. 1. What knowledge do older adults have regarding TC (re garding perceived benefits ) ? 2. What are the primary barriers affecting adoption of TC in an older adult sample? 3. What are the primary facilitator s (perceived threats ) affecting adoptio n of TC in an older adult sample? 4. What differences exist in t he above between the TC and No n TC groups?

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77 Table 3 1. Demographics of Tai Chi Group (TCG). *LSVT BIG is a Parkinson Exercise. For Race W = White PARTIC. NUMBER AGE GENDER RACE OTHER EXERCI SES HEALTH MOTIVATION LENGTH OF ACTIVITY(yrs) TCG1 70 F W Various exercises Increase Health had lung removed 3 TCG2 75 F W Aerobics/Weights/ Badmiton/Golf /Walk Increase Health/Slow Aging 9 TCG3 70 F W Stretching/Walking Increase Health need structure 4.5 TCG4 74 F W Just Tai Chi Feel Better balance,flex,focus 10 TCG5 70 F W Aerobics/Weights/ Stretching Better life habit 2 TCG6 71 F W Tennis/Kickbox/ Weights/Swim/Yoga Good Teacher/ Walking Distance life habit 9 TCG7 77 F W Balance Classes/ Web Qi Gong Prevent Falls/Care for Sedentary Husband availability of classes 10 TCG8 62 F W Walking/Biking Increase Health weight,stress, lif ehabit 30 TCG9 64 F W Gym/Walking/Zumba/ Water Walking Increase Health retiring,having time 2.5 TCG10 69 F W Aerobics/LineDancing/Golf Feel Better live long life 9 TCG11 70 F W LSVT BIG*/Walking Improved Mental State mental decline 9

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78 Table 3 2. Demographics of No Tai Chi Group (NTC). For Race A = Asian, W = White. PARTIC. NUMBER AGE GENDER RACE OTHER EXERCISES HEALTH MOTIVATION LENGTH OF ACTIVITY(yrs) NT C1 70 F A Balance/Strength/ Aerobics/Stretching Increase Health, strength accessability 1month NTC2 80 F W Walk/Gardening/ Balance/Birding Routine,partners knowledge, presence of cancer, seeing others condition Life time, Balance OTOW NTC3 70 F W Water Aerobic/Walking Weight loss/cardio flexibility, wellbeing 1 NTC4 78 F W Swim/Core/Balance/Gym DiabetesII/Fitness Weight 10 NTC5 80 M W Swimming/Posture/ Stretch/Gym (occasional) My Belly my wife 5 NTC6 75 M W Balance/Strength/Walk/ Jog/Gardening Increase Health weight 4 NTC7 76 M W Walking Lifetime NTC8 69 M W Walk/Bike/Aerobics/ Dance/Kickbox/Clog/Str. Fun, fast music, good teachers 8 NTC9 71 M W Treadmill/Elliptical/ Weights/Kickbox/Golf Feel good, live l onger for kids limited by bad hip, miss competition 55 (running) NTC10 67 F W WaterAerobics/Bike,step/D ance/Balance/Weights Lose weight, increase health, Feel better more strength and stamina 4

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79 Figure 3 1 Post It Note Phase of the Fis hbone diagram created by the TC group, identifying variables related to Perceived Threats, Benefits, and Barriers for TC adoption. Focus group participants brainstormed and listed results on individual post it notes, which were posted in appropriate areas of the diagram. Frequencies were noted for each item. Photo courtesy of Peter Gryffin.

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80 Figure 3 2 Perceived Threats, Benefits, and Barriers Identified by the TC focus group and listed on the Fishbone diagram. Numbers in parenthesis indicate multiple id entification of an item.

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81 CHAPTER 4 FINDINGS Organization of Findings Following is an overview of the fishbone chart results, categorized into tables according to the constructs of the Health Belief M odel (perceived threats, benefits, and barriers) as rate d on a 0 9 scale as well as discussion of a dditional focus group comments. An overview and chart of primary findings is presented at the end of this chapter The following section presents the findin gs from the focus group sessions as related to each of t he four research questions The following format is used for e ach relevant research question: Responses are groups according to theme or construct (for example threats to health ) Individual responses to each of the three main constructs of the HBM are rep orted as the nu mber or frequency of post it notes cre ated by each participant Following individual responses via the post it notes, personal evaluation of all noted threats, benefits and barriers (as record ed on a 0 9 scale) are presented, including indi vidual and group mean scores for each item as well as standard deviation Group observations and comments from the discussion phase are also presented. Research Question One: What knowledge and attitudes do es an o lder adult sample have regarding TC ? Knowl edge of TC was based on the results of the fishbone diagram for the perceived benefits of TC, as well results from the discussion phase. Attitudes towards TC were addressed during the discussion phase The Non TC group, consisted of 10 participants who had not previously considered uptake of TC, and had little in the way of exposure to TC outside of commercials (i.e. a Claritin commercial featuring a tai chi group in a grass field which all but one participant (participant number 8) recalled seeing at some time ). It should be noted that participant 2, although having never

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82 considered taking up TC as a regular practice, did participate in a TC class on a cruise ship, but he stated it was not out of any particular interest, and he did not particularly enjoy the class. He took the class as something to do, similar to other activities available on the ship. To ensure undue bias did not result from the experience of participant 2 his responses were considered carefully in relation to the other participants duri ng the discussion phase, which was a minor part of the focus group process (20 minutes). The majority of the focus group session was spent on developing the fishbone diagram, which is done silently by each individual without participant interaction or disc ussion. The responses on his post it notes were evaluated during placement on the fishbone diagram to ensure his experience would not bias the discussion phase. The only response participant 2 made related to his cruise ship experience was as a barrier re lated to efficacy of teaching which was eliminated from the responses Barriers were the last section of the discussion section, and the post it note related to teaching style from participant 2 was left as the last item for discussion. Since participant 2 still met the inclusion criteria of not having considered uptake of TC, and due to the format of the fishbone diagram and discussion phase which controlled for his input regarding this area, participant 2 was not exclude from the group. Another factor fo r the inclusion of participant 2 was to obtain the perspective of an individual who had never considered TC, yet had experienced a class. Other than his observations that he was off put by the teaching style, participant 2 stated that he could not remember anyth ing from the cruise ship class.

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83 Despite limited exposure to TC, the Non TC group identified six perceived benefits (although four of these benefits had only one respons e, or post it note (T able 4 1 ) ) The primary perceived benefit of TC was benefits for balance and reduction of falls ( n = 4), followed by general health benefits ( n = 3). As individual responses, via the post it notes, 4 participants did not identify any benefits, while three only reported one benefit (balance, agility, and general heal t h). Participant 5 identified 2 benefits (balance and fluidity, stating that it looks like slow motion kung fu). Participant 2 (who had taken the crui se ship TC class) also reported 2 benefits (balance and he alth ). Participant 3 reported 4 perceived benefi ts (balance/agility, flexibility, clears mind, and relaxation). T his contrasts with the greater number of perceived health threats and benefits identified by the TC group. Although the TC group only identified 3 more threats than the Non TC group, they al so identified 9 more benefits than the Non TC group. During the discussion p hase of the focus group meeting the Non TC group identified enhanced balance and fluidity as being the most important perceived benefit of TC, while the TC group identified enhanc ed balance, flexibility, memory, and breathing as the most important. The TC group observed that they liked how TC stopped the brain from going all the time, and felt that TC may enhance memory by improving brain connections. Overall the TC group had a pos itive attitude towards TC, noting the many health benefits they felt TC provided. Other benefits brought up by two participants in the Non TC group w as the perception of TC as a calm exercise that could be performed anywhere, and may be good for stress re duction (noting in reference to seeing Chinese people doing TC in a park on TV, and how calm and peaceful they looked). The Non TC group did not

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84 express any negative attitudes towards TC, the consensus was that they really did not know anything about it, a nd not seeing how it would benefit them, had never considered TC. Overall the attitude towards TC could be described as neutral. To address possible influence of experiences in the military, participants were asked if any experiences in the military might influence their views of TC. One participant had military experience, but he expressed surprise (based on facial expressions consisting of a pause and raised eyebrows) and negation that such experience might influence his views. The group consensus was tha t no previous experience related to the various Asian wars (or other experiences) affected their attitudes towards TC, which as stated above appeared to be neutral or ambivalent. See chapter 5 for a discussion on attitudes towards TC related to observation s of perceived benefits. Following the development of th e fishbone chart using the post it notes participants rated their perceptions for each benefit listed on the fishbone diagram on a scale of 0 (no perceived benefit) to 9 (high perceived benefit) to p ermit expression of the importance and personal relevance each participant felt each item had to their own situation In the Non TC group perceived benefits of TC for balance exhibited a mean score of 7 with all but one participant (number 8) noting possi ble benefits for balance on the 0 9 scale when they were asked to reflect on that item. O nly 4 participants initially noted benefits for balance using the post it notes S ee Tab le 4 2 for individual res ponses across identified benefits The TC group contra sted from the Non TC group, in that they identified 15 perceived b enefits of TC as opposed to 6 by th e Non TC group (T able s 4 1 and 4 3 ).

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85 The TC group exhibited a wider range of psychological and physiological benefits, including increased bone density an d benefits for arthritis. Balance was also the number one benefit in the TC group identified by 8 of the 11 participants with a mean score on the 0 9 scale of 6.58, and a standard deviation of 1.3 The standard deviation for flexibility was also 1.3, whi c h compared to other items (T able 4 4) indicates greater uniformity related to perception of benefit for balance and flexibility compared to other items for the TC group. Of the 15 perceived benefits identified by the TC group only 6 had a single post it note (benefits for arthritis, strength, dementia, life balance, focus, and increased movement). Calmness ( n = 5) was the second most identified benefit, followed by enhanced coordination ( n = 4), flexibility ( n = 4), meditation ( n = 3), and improved memory ( n = 3). Two participants identified benefits to health, breathing, and bone density. That improved health was only listed by two participants may be due to health benefits being listed individually. Research Question Two: W hat are the primary barriers which may affect adoption of TC in an older adult sample? The TC and Non TC group each identified a similar number of perceived barriers, 8 for the TC group and 11 for the non TC group (Tables 4 5 to 4 7) The perceived barriers unique to the Non TC group include ( n listed if more than one post it note): Balance problems ( n = 2), p erception that the form is too slow ( n = 2), lack of time ( n = 2), stamina/health problems ( n = 2), d arthritis, p oor flexibility and b elief that they could not reme mber the form. When asked about this, participant 2 stated that the cruise ship teacher told the group that only TC masters could accurately teach TC. P articipants 5 and 7 did not

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86 identify any barriers with the post it notes, stating they did not know enough about TC to know the barriers. Both groups shared perceptions rela ted to efficacy of the teacher. One member listed barriers related to teaching on a post it note (the participant who happened to tr y TC on a cruise ship A group mean score is not included for this barrier, since this experience was unique to participant 2 ) Three members of the TC group listed teacher efficacy as a poten tial barrier with a group mean score of 5.4 T ime constraints we re also listed as a barrier (Non TC, n = 2 ; TC, n = 3 ), as well as being too tired (TC, n = 1) and poor stamina /poor health (Non TC, n = 2 ). Other perceived barriers unique to the TC group included the class being too early, being indoors rather than outdo ors, poor motivation (or as put by the respondent too lazy), pain restrictions, and lack of space (all of th ese had one response ). It is also worth noting that except for teacher efficacy, ( TC M = 5.4; SD = 4.3) most barriers identified by the focus gro ups were rated below 4 on the 0 9 scale. The larger standard deviation also indicates less uniformity regarding participant perceptions regarding this barrier. As individual responses on the post it notes 5 participants in the TC group did not identify an y barriers, while 3 on ly reported one barrier; t ime (reported by 2 participants rted by the third, recorded on T able 4 5 ). One participant reported 4 barriers (bad teacher, pain, to o early, and feeling tired), another participant reported 3 barriers (Bad teacher, space, indoor classes), and a third participant 2 barriers (time and bad teachers). As individual responses by the Non TC grou p, two participants identified 2 barriers ( remem ber; the second identifying time and too slow). Three participants identified 2

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87 barriers ( one reporting balance problems, lack of flexibility; another listing know how; and the third noting balance, arthritis) Th ree identified one barrier each; poor health, too slow, and lack of stamina. During the discussion phase of the focus groups, several participants in the TC group mentioned that those instructors who use visualizations during class can be disturbing. Examples were given of a teacher sta ting to visualize anger leaving your body as orange streams of energy. The TC group also stated that they find it off putting the number of health claims made for TC, as a panacea to cure all ills, without evidence to back it up. Related to this, it was al so suggested that it would be important to educate society on why and how TC works. Several participants also stated that people do not see TC as exe rcise It was commented that people who view TC just see people waving their hands around in the air, and do not understand what it is that they are doing. Also that it is important to explain why breathing is so important in TC. The last consideration brought up by the TC group was the suggestion that for effective promotion, it should be stressed that TC can be performed in 5 minutes or so and does not need to be in the hour format typical of most classes. No participants in the Non TC group brought up negative connotations for TC rious Asian wars or other experiences might impact their interest, the individual and group consensus was that this did not relate to their views of TC. The primary barrier identified was related to lack of awareness of benefits. P articipants in the Non TC group also agreed on participant number 2 that having an effective teacher would be a primary factor in their adoption of TC. Participant 2 noted that the TC class members

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88 on the cruise ship had been told that inadequate instructors do not k now or get into the hidden reasons for TC, and that it was important to learn from a master (to avoid biasing earlier discussion, this observation was left for last during the discussion phase) The Non TC group was also asked to rate their perception of a beginners class compared to an ongoing integrated class. Group members agreed that having a class specifically for beginners who did not know TC would be preferred to an ongoing class of mixed levels. The group score for this barrier following the develop ment of the fishbone diagram was 5.4 (no post added to get participant views at the end of the group discussion as well as rating on the 0 9 scale). Research Question Three: What ar e the primary facilitators (perceived threats and b enefits) affecting adoption of TC in an older adult sample? Research question three takes a closer look at perceived threats, and potential influence of benefits of TC, which may facilitate adoption (from the HBM perspective, perceived threats are a primary facilitator towards action). The p erceived benefits of TC, as viewed by the TC group ( detailed i n research question number one) included: balance, relaxation, grace (fluidity), increased bone density, b enefits for arthritis, calmness, enhanced coordination, strength, flexibility, meditation, clear mind, improved memory, breathing, life balance, decreased dementia risk, and overall enhanced health. As facilitators to adoption of TC, perceived threats and benefits were considered together the various perceived health threats of the individuals in the TC group as possible motivating factors in their adoption of TC, due to benefits of TC addressing identified threats. Some p erceived benefits and threats ho ld relationships which may account for not being listed in both categories. For instance, under perceived threats,

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89 back pain, bad hips, and stiff neck might be cat egorized as the benefit of TC as enhanced ease of movement The focus of this section is on p erceived threats, and on the discussion phase for threats and benefits. Individual responses on the 0 9 scal e of health threats may be more revealing for the group s (see below) Looking specifically at percei ved threats identified, the TC group identified 18 perceived threats to health compared to 15 in the Non TC group. The health threats unique to the TC group included memory loss (n = 4), back pain (n = 3), flexibility issues (n = 3), stress (n=3), bad hips, high cholesterol, stiff neck, dizziness, poor reaction time, ), and poor nutrition Health threats unique to the Non TC group included shoulder problems (n = 3), diabetes (n=3), general age related decline, heart disease, feet problems, digestion problems, and safety issues (self defense). Threats shared in common included: balance concerns (TC, n = 8; NTC, n = 5), high blood pressure (TC, n = 1; NTC, n = 3), weight concerns (TC, n = 1; NTC, n = 3), cancer (TC, n = 1; NTC, n = 2), arthritis (TC, n = 1; NTC, n = 2), breathing problems (TC, n = 2; N TC, n = 1), and bone loss. See T ables 4 9 to 4 12 for more details on findings related to perceived threats. The mean balance perceived threat total is 7 versus 4 in the Non TC group. For the Non TC group, the highest m ean perceived threat total is 5 for weight concerns, which rated as a higher perceived threat than balance, which only 4 of the 10 participants listed a s a concern on their responses ). For perceived threats to health 35 threats were recorded on post it no tes, with a mean of 3.19 post it notes per participant Thre e participants recorded only 2 threats, with the most listed by one person being 6 post it notes. Participant 4 in this group recorded 1 concern (foot problems), while

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90 participant 5 recorded 2 pro blems (balance and breathing). All other participants in the Non TC group recorded 3 or more threats, with 5 health concerns being reported by partici pa nts 6, 9, and 10. See T ables 4 10 and 4 11 for indi vidual and group mean ratings for perceived threats t o health which may act as facilitators or motivators in the adoption of TC (or other health activities) During the post fishbone diagram phase, all participants in the TC group identified as important motivating factors in their adoption of TC as being re lated to health concerns. One participant began TC and other activity classes when they had a lung removed. Another began at the recommendation of a personal trainer, then continued upon seeing benefits. Another started TC after tryi ng yoga, due to a neck injury which prevented them from doing many of the yoga postures. Four participants mentioned looking to reduce stress as a primary motivator in trying TC, and 3 stated concerns for balance and falls were a motivating factor (although one of these stated t hey started TC out of general curiosity, and then continued when they saw improvement in balance). The Non TC group stated that health concerns were a lso a primary motivating factor in their uptake of their current forms of exercise. Other factors included interested partners, observing others who have not maintained health, weight loss (mentioned by 5 participants during the post fishbone diagram phase), and two stating that seeing the benefits of exercise motivated them. One participant stressed that fun and fast activities with music are more motivating, and another mentioned that they are trying to keep healthy, but that a bad hip was limiting their activities. This participant further stated that if they saw benefits of TC, and it would not cause furthe r injury, that they would be

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91 interested. Knowing proven benefits of an exercise was the primary theme for motivation for exercise. Research Question Four: What differenc es exist between the TC and Non TC Groups There were a number of notable differences b etween the TC and Non TC group, beginning with the number of categories identified for each construct of the HBM, particularly in perceived benefits of TC. The TC group identified 15 benefits of TC, compared to 6 benefits from the Non TC group. Four partic ipants in the Non TC group were not ab le to identify any benefits, with 3 identify ing 1 perceived benefit. The discussion phase of the TC group added one important factor, that of teaching methodology. The TC group expressed great dissatisfaction with vari ation of teacher knowledge, ability, and class structure (for example, if time is spent on new participants, regular students are ignored, and if time is spent on regular students, the new students get frustrated). One surprising difference which existed b etween the two groups was gender differences between the two groups. The TC group consisted of all women, whereas the Non TC group was evenly split, with half men and half women attending the focus group session. Both groups identified balance as a primar y concern (by 8 out of 11 in the TC group, but only 5 out of 10 in the Non TC group). Overall, despite being active in a variety of exercises (the Non TC group listed a total of 43 forms of exercise they regularly engage in, compared to just over 30 forms of exercise by the TC group (T able s 3 1 and 3 2 ), the Non TC group still identified a larger number of personal health threats, including high blood pressure (n = 3), diabetes (n=3), cancer (n = 2), and arthritis (n = 2). This contrasts with the TC group, in which diabetes was not even

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92 mentioned, and high blood pressure, cancer, and arthritis w ere only listed once Figures 4 1 to 4 3 present a summary of principle findings from the fishbone diagram and group discussion.

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93 Table 4 1. Comparison of Benefits Identified by the Non TC and TC Group Non TC Group TC Group Balance ( n =4) Balance ( n =8) Memory ( n =3) Life Balance ( n =1) Health ( n =3) Health ( n =2) Breathing ( n =2) Focus ( n =1) Fluidity ( n =1) Coordination ( n =4) Bone Density ( n =2) + Movem ent ( n =1) Relaxation ( n =1) Calmness ( n =5) Arthritis ( n =1) Flexibility ( n =1) Flexibility ( n =4) Strength ( n =1) Clear Mind ( n =1) Meditation ( n =3) Dementia ( n =1) Table 4 2. Non Tai Chi (NTC) Group Perceived Benefits. Benefits in bold are unique to the NTC group. (Numbers in parenthesis are the number of people who responded with each area, if more than one post it note. Starred numbers where considered the most beneficial, during the discussion phase). PARTIC. NUMBER BENEFIT AVERAGE BALANCE(4)* HEAL TH(3) FLEXIBILITY FLUIDITY* RELAXATION CLEAR MIND NTC1 8.17 9 8 7 8 8 9 NTC2 8.33 9 9 8 8 8 8 NTC3 9.0 9 9 9 9 9 9 NTC4 8.5 7 8 9 9 9 9 NTC5 8.83 9 8 9 9 9 9 NTC6 6.5 5 7 7 6 7 7 NTC7 7.0 8 5 8 8 8 5 NTC8 0.0 0 0 0 0 0 0 NTC9 5.17 8 4 5 3 4 7 NT C10 7.67 9 9 6 9 6 7 Mean 6.92 7.3 6.7 6.8 6.9 6.8 7 SD 2.7 2.9 2.9 2.7 3.0 2.9 2.8

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94 Table 4 3. Tai Chi Group (TCG) Perceived Benefits. Benefits in bold are unique to the TCG. (Numbers in parenthesis are the number of people who responded with each area, if more than one post it note. Starred numbers where considered the most beneficial, during the discussion phase). Table 4 4. Comparison of mean scores and standard deviation between groups for comparable benefits. BALANCE HEALTH FLEXIBILITY RELAX/CALM CLEAR MIND/MEDT. NTC Mean 7.3 6.7 6.8 6.8 7.0 TC Mean 8.4 6.6 8.2 7.5 6.7 NTC SD 2.9 2.9 2.7 2.9 2.8 TC SD 1.3 2.8 1.3 2.4 3.1 PART. NUMBER BENEFIT AVERAGE BALANCE(8)* CALMNESS(5) COORDINATION(4) FLEXBILITY(4)* MEDITATION(3) MEMORY(3)* BREATHING(2)* BONEDENSI TY(2) HEALTH(2) ARTHRITIS STRENGTH DEMENTIA LIFEBALNCE FOCUS +MOVEMMENT TCG1 3.6 9 9 9 9 9 0 9 0 0 0 0 0 0 0 0 TCG2 7.07 9 7 6 7 6 8 9 8 9 4 4 3 9 9 8 TCG3 7.2 9 9 9 9 9 9 9 9 9 5 4 0 4 9 5 TCG4 8.6 9 9 9 9 9 9 9 9 9 9 3 9 9 9 9 TCG5 8.0 9 9 9 9 9 9 9 5 7 9 8 2 8 9 9 TCG6 4.73 5 3 5 5 3 5 3 8 3 8 8 0 5 5 5 TCG7 7.73 9 9 9 9 8 7 7 7 6 8 8 8 8 7 6 TCG8 7.53 7 9 8 8 9 7 8 7 8 8 7 5 7 8 7 TCG9 5.93 9 3 9 9 0 5 9 6 6 6 3 3 6 6 9 TCG10 5.33 8 6 7 7 4 2 8 7 8 7 3 5 0 4 4 TCG11 6.6 9 9 9 9 8 7 8 0 8 7 3 2 3 8 9 Mean 6.58 8.4 7.5 8 8.2 6.7 6.2 8 6 6.6 6.5 4.6 3.4 5.4 6.7 6.5 SD 1.52 1.3 2.4 1.5 1.3 3.1 3 1.8 3.2 2.8 2.7 2.7 3.1 3.3 2.8 2.8

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95 Table 4 5. Comparison of Barriers Identified by the Non TC and TC Group Non TC Group TC Group Balance ( n =2) n =1) Teacher ( n =3) Pain ( n =1) Health ( n =2) Arthritis ( n =1) Time ( n =3) No Space ( n =1) Too Slow ( n =2) Flexibility ( n =1) Too Tired ( n =1) Time ( n =2) n =1) Too Early ( n =1) Teacher ( n =1) Indoor ( n =1) Partner ( n =1) Motivation ( n =1) Table 4 6. Non Tai Chi (NTC) Group Perceived Barriers. Barriers in bold are unique to the NTC group. (Numbers in parenthesis are the number of people who responded with each a rea, if more than response. Starred numbers where considered the greatest barrier during the discussion phase). PARTIC. NUMBER BARRIER AVERAGE BALANCE(2)* STAMINA/HEALTH(2) TOO SLOW(2) TIME(2) PARTNER DONT KNOW TC ARTHRITIS FLEXIBILITY NO B EGIN. CLASS** NTC1 6. 30 5 7 1 8 1 9 8 8 8 8 NTC2 4. 00 6 3 1 2 8 6 3 2 7 2 NTC3 2.90 4 8 0 0 0 0 0 8 0 9 NTC4 5.0 0 5 6 5 0 5 9 0 4 7 9 NTC5 6. 20 9 9 0 3 9 9 5 9 0 9 NTC6 3. 00 1 0 0 3 1 8 1 7 0 9 NTC7 1. 80 0 0 0 0 0 5 5 0 0 8 NTC8 0.0 0 0 0 0 0 0 0 0 0 0 NTC9 2.1 0 0 6 8 7 0 0 0 0 0 NTC10 1. 10 0 4 3 0 4 0 0 0 0 0 AVG. 3.24 1.6 2.4 3.7 3.0 5.4 3.5 4.6 2.2 3.8 2.2 SD 2.17 3.2 3.6 2.3 3.2 3.6 4.7 2.9 3.9 3.6 4.3 ** No Beginner Class was added by moderator to have participants rate lack of a beginner s class at the facility, and was discussed last during the discussion phase.

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96 Table 4 7. Tai Chi Group (TCG) Perceived barriers. Barriers in bold are unique to the TCG. (Numbers in parenthesis are the number of people who responded with each area, if more than one response. Starred numbers where considered the greatest barrier during the discussion phase). PARTIC. NUMBER BARRIER AVERAGE TEACHER(3)* TIME(3) TOO TIRED TOO EARLY INDDOOR MOTIIVATION PAIN NO SPACE TCG1 1.13 9 0 0 0 0 0 0 0 TCG2 2.38 9 5 0 0 0 0 0 5 TCG3 2.38 7 8 4 0 0 0 0 0 TCG4 7.62 7 9 5 5 9 8 9 9 TCG5 2.25 9 9 0 0 0 0 0 0 TCG6 1.13 0 1 0 0 0 8 0 0 TCG7 5.0 0 9 9 0 5 9 8 0 TCG8 0.0 0 0 0 0 0 0 0 0 TCG9 0.0 0 0 0 0 0 0 0 0 TCG10 3.25 9 1 0 0 8 0 0 8 TCG11 3.38 9 8 5 5 0 0 0 0 Mean 2.59 5.4 4.6 2.1 .91 2 2.3 1.6 2 SD 2.2 4.3 4.1 3.2 2.0 3.6 3.9 3.5 3.6 Table 4 8. Comparison of mean scores and standard deviation between groups for comparable barriers. STAMINA/TIRED TIME NTC AVG 3.7 2.4 TC AVG 2.1 4.6 NTC SD 3.6 2.4 TC SD 3.2 4.1

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97 Table 4 9. Comparison of Threats Identified by the Non TC and TC Group Non TC Group TC Group Balance ( n =5) Heart Prob. (n=1) Balance ( n =8) Arthritis ( n =1) High B.P. ( n =3) Mental Prob. (n=1_ Memory ( n =4) Bad Hips ( n =1) Shoulder Prob ( n =3) Breathing Prob. ( n =1) Back Pain ( n =3) Cholesterol ( n =1) Diabetes ( n =3) Feet Prob. ( n =1) Flexibility( n =3) Bone Loss ( n =1) Weight ( n =3) Digestion Prob.(n=1) Stress( n =3) Stiff Neck ( n =1) Cancer ( n =2) Safety Issues (n=1) Breath Pro b. ( n =2) Dizziness ( n =1) Arthritis ( n =2) High B.P. ( n =1) ReactionTime(n=1) Age Decline ( n =1) Cancer ( n =1) Intolerance ( n =1) Bone Loss (n=1) Weight ( n =1) Nutrition ( n =1) Table 4 10. Non Tai Chi (NTC) Group Perceived Threats. Threats in bold ar e unique to the NTC group. (Numbers in parenthesis are the number of people who responded with each area, if more than one post it note. Stared numbers where considered the most threatening, during the discussion phase). PARTICPANT NUMBER THREAT AVERAGE BA LANCE (5)* HIGH B.P. (3) SHOULDER PROB.(3) DIABETES(3) WEIGHT(3)* CANCER (2) ARTHRITIS (2)* AGE DECLNE BREATHIG PROB.* FEET PROBLEMS DIGESTIN PROB. BONELOSS HEART MENTAL PROB. SAFETY ISSUES NTC1 5.0 9 3 6 7 4 1 8 1 9 7 2 9 7 1 1 NTC2 5.0 8 3 2 0 4 8 6 9 4 4 6 6 6 7 2 NTC3 1.67 2 0 9 0 5 0 0 4 0 0 0 0 0 5 0 NTC4 4.4 5 0 3 9 9 9 2 9 2 7 3 4 0 0 4 NTC5 4.67 9 0 9 0 5 0 9 0 9 4 4 4 9 4 4 NTC6 3.57 3 3 5 1 6 5 2 7 2 3 5 1 2 5 0 NTC7 1.33 0 5 0 5 5 0 5 0 0 0 0 0 0 0 0 NTC8 1.33 3 0 0 0 5 5 2 5 0 0 0 0 0 0 0 NTC9 3.67 3 8 0 0 4 7 6 9 2 0 0 0 8 2 6 NTC10 0.8 0 0 5 0 4 0 3 0 0 0 0 0 0 0 0 Mean 3.14 4.2 2.2 3.9 2.2 5.1 3.5 4.3 4.4 2.8 2.5 2 2.4 3.2 2.4 1.7 SD 1.68 3.4 2.7 3.5 3.5 1.5 3.7 3.0 4.0 3.5 2.9 2.4 3.2 3.8 2.6 2.2

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98 Table 4 11 Tai Chi (TCG) G roup Perceived Threats. Threats in bold are unique to the TCG. (Numbers in parenthesis are the number of people who responded with each area, if more than one post it note. Starred numbers where considered the most threatening, during the discussion phase) Table 4 12 Comparison of mean scores and standard deviation between groups for comparable threats. BALANCE HIGH BP WEIGHT CANCER ARTHRITIS BREATHING PROB BONELOSS NTC M 4.2 2.2 5.1 3.5 4.3 2.8 2.4 TC M 6.6 2.3 2.6 4.7 4.5 4.0 5.6 NTC SD 3.4 2.7 1.5 3.7 3.0 3.5 3.2 TC SD 3.0 3.6 3.2 3.7 3.2 3.9 3.9 PART. NUMBER THREAT AVERAGE BALANCE(8)* MEMORY(4)* BACK PAIN(3) FLEXBILITY(3)* STRESS(3) BREATHIG(2)* HIGH B.P. WEIGHT CANCER ARTHRITIS BAD HIPS CHOLEST BONELOSS STIFFNECK DIZZINESS REACION TIME INTOLERANCE NUTRITION TCG1 1.0 0 0 0 0 0 9 0 0 9 0 0 0 0 0 0 0 0 0 TCG2 3.61 8 2 2 7 8 8 0 5 8 0 0 0 6 4 3 4 0 0 TCG3 4.67 8 5 6 8 8 8 8 0 4 8 0 0 7 7 0 4 3 0 TCG4 4.89 9 5 9 5 5 0 2 5 0 9 1 8 9 9 9 0 3 0 TCG5 5.94 9 9 5 9 9 9 0 5 5 5 5 9 9 0 0 8 0 5 TCG6 2.22 5 5 5 5 0 0 0 0 0 3 3 0 0 3 0 3 8 0 TCG7 3. 22 9 8 9 4 0 0 0 0 0 3 9 0 8 0 6 1 1 0 TCG8 5.44 5 9 9 9 7 4 0 9 9 6 5 4 5 9 7 0 1 0 TCG9 2.17 3 3 0 3 0 0 0 0 3 3 0 9 9 6 0 0 0 0 TCG10 4.72 7 8 6 5 5 2 6 5 5 9 9 8 9 0 0 0 1 0 TCG11 5.61 9 9 2 9 9 5 9 0 9 3 2 8 0 9 6 6 6 0 Mean 3.95 6.6 5.7 4.8 5.8 4.6 4.0 2.3 2.6 4.7 4.5 3.1 4.2 5.6 4.3 2.8 2.4 2.1 .5 SD 1.62 3.0 3.1 3.4 2.9 3.9 3.9 3.6 3.2 3.7 3.2 3.5 4.2 3.9 3.9 3.5 2.8 2.7 1.5

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99 Figure 4 1 Primary Knowledge of TC Benefits (from fishbone diagram) NTC Group reported TC Group reported 6 benefits. Benefits 15 benefits. Benefits listed by more than 1 listed by more than 2 person listed below: persons listed below: Balance (n = 4; M = 7.3; SD =2.9) Balance (n=8; M = 8.4; SD =1.3) General Health (n = 3; M = 6.7; SD =2.9) Calmness (n = 5; M =7.5; SD =2.4) (4 reported no benefits) Coordination (n=4; M = 8.0; SD =1.5) Flexibility (n=4; M = 8.2; SD =1.3) Meditation (n=3 ; M = 6.7; SD =3.1) Memory (n=3; M = 6.2; SD =3) n = number of parti cipants listing each benefit; M = mean group score when rated on 0 9 scale (for comparison, low n and focus group design precludes statis tical significance ). It is worth noting th at TC SD for balance and flexibility is 1.3, and 1.5 for coordination, indicating greater uniformity relating to the perception of these benefits. Knowledge of TC (from discussion phase): Non TC Group: Perceived as potential benefit for balance and flu idity. Two members identified possible benefits for calmness and stress reduction, after commenting on how calm and peaceful a Chinese TC group looked (viewed on TV). TC Group: Perceived balance, flexibility, enhanced memory, and breathing as most impor tant. Attitudes to TC (from discussion phase): Non TC Group : TC Group: Indifferent Need to know benefits compared to current activities. If proven benefits, would consider TC (depends on how compares to b en efits of current activities).

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100 Figure 4 2 Primary Perceived Facilitators to TC Adoption (as threats to health from fishbone diagram). NTC Group reported TC Group reported 15 threats to health. Threats 18 threats to health. Threats listed by more than 1 listed by more than 2 person listed below: persons listed below: Balance Concerns (n = 5; M = 4.2 ; SD = 3.4) Balance Concerns (n = 8; M = 6.6; SD = 3.0) High Blood Pressure (n = 3; M = 2.2; SD =2.7) Memory Concerns (n = 4; M = 5.7; SD =3.1) Shoulder Problems (n = 3; M = 3.9; SD =3.5) Back Pain (n = 3; M = 4.8; SD =3.4) Diabetes (n = 3; M = 2.2; SD =3. 5) Flexibility (n = 3; M = 5.8; SD =2.9) Weight (n = 3; M =5.1; SD =1.5) Stress (n = 3; M = 4.5; SD =3.9) Cancer (n = 2; M =3.5; SD =3.7) Breathing Problems (n = 2; M = 4.0; SD =3.9) Arthritis (n = 2; M =4.3; SD =3.0) n = number of p articipants lis ting each threat ; M = mean group score when rated on 0 9 scale. (for comparison, low n and focus group design precludes statistical significance). It is worth noting that N TC SD for weight is 1.5 indicating greater uniformity relating to the perception o f weight as a threat Facilitators to TC (as threats to health, from discussion phase): Non TC Group: Concerns for weight, balance, arthritis, and breathing problems considered greatest threats to health. During the discussion phase, participants also noted sleep problems, and elaborated concerns for breathing problems in regards to lung problems. TC Group: Concerns for balance, memory, flexibility, and breathing problems considered greatest threats to health. Also noted that for shoulder problems, m ain concern was functionality.

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101 F igure 4 3 Primary Perceived Barriers to TC (from fishbone diagram) NTC Group reported TC Group reported 9 barriers. Barriers 8 barriers. Barriers listed by more than 1 listed by more than 1 person listed below: person listed below: Poor Stamina/Health (n = 2; M = 3.7 ; SD =3. 6 ) Poor Teacher (n = 3; M = 5.4 ; SD = 4.3 ) Poor Balance (n = 2; M = 3.0 ; SD =3.2 ) Lack of Time (n = 3; M = 4.6 ; SD =4.1 ) Lack of Time (n = 2; M = 2.4 ; SD =3.2 ) (5 reported no barriers) Too Slow (n = 2; M = 1.6 ; SD =2.3 ) (1 reported no barrier) n = n umber of p articipants listing each barrier ; M = mean group score when rated on 0 9 scale. (for comparison, low n and focus group design precludes statistical significance). Barriers to TC (from discussion phase) : Non TC Group: Lack of awareness of be nefits Bad teachers No beginners class TC Group: Bad teachers and mix of beginners and advanced students in one class were identified as the largest barrier. Participants also noted that visualizations can be disturbing. Embarrassment to do TC in public Claims that TC is a panacea are off putting. Misperceptions in the public that TC is not an exercise that people think they describe why breathing is important. Suggested that 5 minute formats may address barrier of time.

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102 CHAPTER 5 DISCUSSION Organization of Discussion Section Chapter 5 presents primary findings from the focus groups The f irst section highlights findings from the fo cus groups, followed by a comparison to health threats among older adults as identified by the CDC 3 which were either not identified or minimally identified by focus group participants Elements of diffusion of i nnovation presented in the review of literature are revisited in relation to findings from the focus group study. The last section discusses limitations of the findings, recommen dations for future research, as well as a summary of key points from the focus group study Facilitators related to Perceived Benefits and Threats See table 5 1 for e ight primary areas related to perceived benefits and threats identified by focus group participants, which may be potential areas to consider in larger studies. Finding s specific to the focus group results related to benefits of TC w ere closely linked to perceived health threats. This is particularly notable in that results of number of perceived threats for the NTC group we re similar to the TC group. The NTC group idend itifed15 threats, and a total of 29 post it notes, compared to 18 identified threats by the TC group, with a total of 33 post it notes (T able 5 2 ) possibly indicating that as older adults, both groups face similar burdens related to health threats (althou gh despite some similarities (i.e. balance), many listed perceived threats varied Also, worth noting is that the TC group identified 15 perceived benefits of TC with a total of 39 post it notes, compared to 6 perceived benefits and 12 post it notes in the Non TC group. It should be noted that for the most part, according to self report, the TC group members did not begin TC due to concerns for health threa ts and perceived benefits of

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103 TC. B ut it may be valuable to determine if knowledge of evidence based b enefits of discovered through trying TC is a factor, and if perception of personal health benefits is a factor in the maintenance of TC practice. Tracking this type of information may motivate adoption and maintenance of TC among non adopters. Other factor s such as convenience of location and access or affordability may also affect adoption. One particular health threat, problems with balance, may be a particular opportunity for motivating TC adoption. It was identified by 8 of the 11 participants in the TC group as a concern. That only 4 participants in the Non TC group identified balance as a health threat, and 3 participants in the TC group did not identify benefi ts for balance, indicates that may be important not only to educate older adults into the ben efits of TC for balance, but also that they are at high risk for falls. Indeed, 2 participants in the Non TC group identified poor balance as a barrier to adoption of TC, and 6 rated balance as a concern preventing TC adoption on the 0 9 scale This again supports that targeti n g evidence based benefits of TC and actual health threats may overcome many of the barriers to the adoption of TC related to lack of knowledge It is also worth noting that the S D for benefit for balance for the TC group was 1.3, comp ared to 2.9 in the Non TC group, possibly indicating great er uniformity of belief related to their experience with TC. It is also interesting to note that the perceived benefit mean score for balance and perceived threat for falls in the TC group were bot h high (8.4 and 6.6 respectively), compared to the Non TC group, in which as a group, perceptions of TC as benefiting balance was also high (M = 7.3) but mean perception of threats from falls was 4.2. This may be due to the TC group having a more accurate perception of the limitations of their

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104 balance, due to the nature of TC in working with balance. It is also worth noting th at 2 participants in the Non TC group noted poor balance as a barrier to TC with 5 participants rating it as a potential barrier (T a ble 4 6). Targeted messages aimed at the older adult population to increase perceived susceptibi lity for falls and severity of resulting injuries (including death) may be a prime opportunity for reducing incidences of falls in this population, as well as p romoting adoption of TC (while being sensitive to avoid creating a state of paranoia) Another suggestion might be to target older adults who have recently experienced a fall with individually tailored messages, by working with local area doctors. Having e xperienced a fall may result in stronger motivations for trying TC as a very physical cue to action The TC group also identified p sychologic al benefits as a primary benefit of TC. Calmness ( n = 5 SD = 2.4 ) was the second most identified benefit in the TC group, with 3 participants also identifying meditation and improved memory. Individual perceived benefit scores were also high for the se items, with a mean score of 7.5 6. 7, and 6 .2 respectively. Evidence based mental benefits may address concerns rel ated to memory, pending sufficient research. For the Non TC group only two participants listed tion of benefits for clear mind was 7, and the group mean score for relaxation was 6.8. A potential facilitator which may tie into the mindfulness or meditative aspect of TC may be potential effects of TC on weight management related to the development of mindfulness and awareness of eating habits Weight concerns were rated as the largest health threat by the Non TC group (n=3; group mean score = 5 .1 ; SD = 1.5 ) despite

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105 being of similar weight range as the TC group (neither group contained members who wou ld be categorized as obese). For comparison, only one member of the TC group identified weight as a concern on the post it notes, and the group score for weight was 2.6 Since TC may not be perceived as barrier to the general older adult population. It should be noted that Yeh and others (2009) report that TC has metabolic equival ents of 1.5 4.0, similar to low to moderate intensity aerobic exercise. D uring the discussion phase the TC group talked about the ef fects of meditative practices on the brain. The TC group observed that they liked how TC stopped the brain from going all the time, and felt that TC may enhance memory by impr oving brain connections. The risk comes in that this extends the benefits of TC t o include not only a wide variety of physical ills, but also mental health a nd functioning as well. Strong support from of evidence based promotional material may need to be accumulated and ified by the TC group. Related to this is the need to educate the public on the mechanisms of benefits for various threats to health There are several organizations which certify TC instructors, but potential limitations related to style, methodo logy and teaching methods (see Appendix A for more details ) may indicated a need to educate the public for personal evaluation of appropriateness of various programs to participant needs. As addressed in chapter 2 of this dissertation, b eing single weighted is a c ritical element of TC practice for developing bal ance, yet many teachers do not follow this principle ( A ppendix A ) Targeting the public as well as TC teachers on the benefits of single weighted practice may be important to maximize TC benefits for balance and minimize

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106 the barrier of not getting expected results. Related to the focus group findings, k nowledge of benefits may help participants to maximize the benefits of TC as well as find personally relevant classes, which may address some of the barriers related to teaching Essentially, creating an educated consumer, to put pressure on those who teach TC for health to create consumer appropriate classes. Other potential facilitators or opportunities for promoting adoption of TC identified by the focus gr oups include perceived benefits for flexibility. Four members of the TC group identified benefits for flexibility with the post it notes (group mean score = 8.2), and although only one person in the Non TC group identified potential benefits for flexibilit y, it received a group score of 6.8. But t hat lack of flexibility was also identified by one person in the Non TC group as a potential barrier to TC (barrier group mean score = 3.8 ) may indicate an opportunity for facilitating TC adoption by educating the public on the benefits of TC for flexibility. Two final areas which may facilitate interest in TC and potential adoption, is perceived threats related to shoulder and back pain, as well as for breathing problems. Three members of the Non TC group listed s houlder problems as a health threat (group mean score = 3.9 ), and 3 members of the TC group listed back pain (group mean score = 4. 8 ). Breathing problems were listed by 2 participants in the TC group as a health threat (group score = 4 .0 ), and by 2 partici pants as a benefit of TC (group score = 8 .0 ). These results may indicate an opportunity to facilitate TC adoption by focusing on evidence based benefits for back problems, movement, and pain, as well as breathing problems such as COPD, as listed in chapter 1.

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107 Facilitators Related to Health Threats Identified by the CDC To address actual health threats (as identified by the CDC ) to perceived threats identified by focus group participants, a comp arison table was made for the top 7 causes of death among older adults (age 65 and above) compiled by the CDC. 3 The Non TC group identified as barriers to TC practice many of the very benefits provided by TC according to the literature (see chapter 1). The Non TC group identi fied poor balance, poor flexibility, poor stamina and health, as well as limitations due to arthritis as barriers to TC T he absence of knowledge relating to TC and its benefits, may be a primary barrier to the adoption of TC Conversely, knowledge of TC and its benefits may be a primary facilitator in the adoption of TC. These findings indi cate the importance of targeting older adults rega rding potential health threats, and also indicate opportunity for promoting TC. Heart disease, the number one cause o f early death in older adults, was not identified as a threat at all by the TC group, and by only one person in the Non TC group Table 5 2 presents findings from the focus groups compared to the seven leading causes of early death in adults age 65 and old er 3 Deaths due to falls is also included due to the concern and incidence of falls among older adults. CDC causes of death are labeled CDC 1 7 and CDC f for falls. D eaths from falls is not among the top 10 causes of early death in older adults except as a subcategory of death by accidents, which is the 9 th leading cause of death following nephritis. It is worth noting that as a subcategory of accidental deaths, falls account ed for 19,700 deaths of the 38,292 deat hs due to unintent ion al injury reported 4 The statistics from the CDC are provided as potential areas to address as related to facilitators for motivating adoption of TC, a nd use in the overview related to elemen ts

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108 of the diffusion of innovations ( F igure 5 1) presented at the end of this chapter Heart disease, the leading cause of death, was not identified as a concern in the TC group, and received a mean group score of 3 .2 by the Non TC group. C ancer had slightl y higher mean group score s 4 .7 and 3.5 respectively (all scores are on a 0 9 scale), while the mean ri sk of stroke was only rated as 2 .3 and 2.2 by both groups (indirectly, through their concern for high blood pressure, a major risk factor for stroke ) A ll leading c auses of death received low group sco res, except for risk for falls in the TC group with a mean group score of 6.6 The low rating of mean group scores for the various threats indic ates a strong need for targeting older adults on threats to th eir health, along with opportunities for minimizing threats, such as TC, along with evidence based suppo rt and programming An opportunity for increasing awareness and motivation may be by raising perceived threat levels during doctor visits, during which personal relevance and susceptibility of threats can be addressed, along with opportunities such as TC for addressing these threats and the severity of potential consequences. Such an effort would necessitate cooperation and support of the medical communit y, which may be a limitation Overall, the key areas as identified by the CDC 3 which may be relevant to facilitating the adoption of TC, include addressing evidence base benefits of TC for heart disease, cancer, st roke, chronic lower respiratory disease, and falls, as well as possible benefits for Alzheimer and diabetes Benefits of TC on the immune system, relevant to deaths by influenza, may also be a factor among older adults lacking access or not av ailing themse lves of flu shots.

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109 Perceived Barriers to the Adoption of TC Table 5 4 presents an overview of potential barriers to the diffusion and adoption of TC. R eport ed perceived barriers are noted as potential areas t o address related to adoption of TC relevant to focus group findings. Seven primary barriers (B1 B 7 ) were identified by the focus groups. As mentioned above, t he Non TC group identified as barriers to TC practice many of the very benefits provided by TC according to the literature (see chapter 2 ). The N on TC group identified poor balance, poor flexibility, poor stamina and health, as well as limitations due to arthritis. In the survey of 40 Non TC practitioners con ducted by Chen and others 35 as mentioned in the review of literature, 45% (n = 18) indicated that they felt they were too weak to practice TC, and was the primary reason stated for not trying TC. The absence of knowledge relating to TC, and its benefits, may be a primary barrier to the adoption of TC T he TC group addressed that they find it off putting the number of health claims made for TC, as a panacea to cure all ills, without evidence to back it up. One of the greatest opportunities for the promotion of TC may be evidence based programs based on ri gorous research and proven physiological mechanisms balanced with benefits compared to aerobic and other exercises, to create an informed consumer. Teacher efficacy was identified by both groups as a major barrier during the discussion phase and on group scores (t o minimize bias and influence related to the experience of TC on a cruise ship of participant 2, barriers related to teaching were addressed last in the Non TC group, at the end of the discussion phase ). Poor teacher was the largest barrier repor ted by the TC group (n = 3, mean group score = 5 .4 ), and although only reported as a barrier by participant 2, it was rated as the largest potential barrier as well by the Non TC group ( mean group score = 5.7 ). It should be noted that

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110 the new teacher at OT OW has adapted the TC class to follow a format similar to an aerobics class, using repetition of faster paced movements, which the members of the focus group found displeasing, while the former teacher stopped teaching in part due to being uncomfortable te Also related to teaching as a barrier among older adults, is that TC, having originated as a martial art, is still often taught from a mar tial perspective (Appendix A ). A martial perspective may be more attr active to some individuals, but a bar rier for others. An important consideration for TC programs may be to match teaching style and style of TC to participant needs and objectives. Social aspects, following a fun exercise, learning TC for home practice, a nd learning TC as a martial art, may be areas for future development and research. During the discussion phase of the TC focus group, the social and health aspect seemed most important to participants, particularly the perceived health benefits participant s observed following adoption of TC. The difficulties of learning TC were minimally addressed, but a format allowing participants to follow along may be worth investigating. As noted in the review of literature, Beaudreau 34 also noted that clear instruction was identified as important by all 8 focus group participants and that an in interested and patient instructor was considered important by 7 of the 8 participants. During the discussion phase the TC group exp ressed frustration when classes contain a large number of beginners, stating that the teacher then spends too much time going over the basics rather than practicing TC A solution to this may be a separate beginner s class, or the Taoist Tai Chi group in A ppendix A

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111 Related to the barrier of lack of written or visual cues identified by participant 2 from his cruise ship experience, Beaudreau 34 a lso noted that lack of written or visual cues were identified as a barrier to learning TC by all 8 focus group members in that study group and that 5 noted that they get confused when they try TC on their own. Chen and colleagues 35 also identified the barrier to trying TC related to the perception that TC is too complicated by 8 of the 40 Non TC practitioners surveyed. Other barriers relate to observations by the TC group regarding an instructor who had them visua lize anger leaving their body as orange streams of energy, and found this disturbing. Unless instructors make a link to visualization as a useful mental tool ified by participants) aspect may be a distinct barr ier to the diffusion of TC. A proposed solution to this barrier would be to stress to teachers and the TC community to focus on evidence based benefits at least with beginning students and the general population. Recommendations Related to Diffusion of In novations Theory Figure 5 1 presents an overview of potential facilitators and barriers identified from the focus gr oup results, applied to elements of Diffusion of Innovation theory presented in chapter 2. The most important element related to the diffusi on of innovations may be targeting evidence based TC (barrier B1) to address lack of awareness related to uncertainty of benefits Rogers 17 stated that u ncertainty is possibly the greatest barrier to the diffusion of a n innovation, which also relates to the number of alternative choices available. Why try TC, when there are so many pr oven health exercises available? Related to this are the communication channels used to obtain information about new innovations, which w ould be a good follow up to the current study to determine

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112 which communications channels are most effective for TC in persuading potential adopters As mentioned in chapter 2, the review of literature, Rogers 17 identi fie d home visits by change agents a s a critical communication channel, which can account for up to a 40% adoption rate. For OTOW, it may be possible to set up a program in which TC advocates can volunteer for home visits or small group discussions. Alterna tively (rather than visiting potential adopters with home visits), as older adults visit doctors, physicians may be used as important change agents, making recommendations for TC practice as appropriate, as mentioned above. Stakeholders, via interpersonal channels, have been demonstrated to be more effective in overcoming barriers (B1, B7) for the later a dopter categories 17 This may be an important area to target for future research for motivating evidence based TC ad option. Another potential communication chan nels that OTOW or other active living communi ty might utilize could include local mass media (either in newsletters or working with local media) to deliver targeted messages (using facilitators CDC1 8 and F1 8) According to Rogers 17 as highlighted in the literature review, s tage one of t he innovation decision process ( knowledge ) is particularly dependent on the characteristics of the decision making unit (the social system) Future recommendations include in depth investigation of the characteristics of a targeted community (for example OTOW), to determine micro variable which might affect the quality and nature of knowledge (CDC1 8, F1 8, and B1) possibly through a case se ries (see final recommendations below) Rogers 17 identified 7 generalizations relating to knowledge of an innovation, which can be affected by educational level, social status, mass media use, interpersonal networks, a ccessibility to change agents (for example the staff at OTOW fitness center),

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113 social networks, and linkage to outside the social system (for example local news and media channels) Future research may wish to address each of these variables in designing an d testing effective targeted messages to enhance knowledge in the targeted community. Relative to the persuasion stage of the innovation decision process model are the five ch aracteristics that Rogers 17 considers the m ost important in explaining the rate of adoption of an innovation a s mentioned in the rev iew of literature Applying these characteristics to the observations from the TC and Non TC group, several areas to target for future research emerge. Relative advan tage and compatibility are considered by Rogers to be the two most important of the five characteristics of an innovation. The first, relative advantage, again stresses the importance of education and evidence based TC (CDC1 8, F1 8, B1) I n order for pote ntial consumers to be ab le to make accurate judgments a comparison study might be advised, to evaluate TC in relation to current activities in regard to benefits, economic costs, convenience, and satisfaction. Further study related to evidenced and dosag e based user friendly formats was also identif ied by Jimenez and others 6 as well as Schleicher and others 7 Schleicher and colleagues found significant effects reported f or balance with a wide range of time formats, ranging from 1 hour a week to 7.5 hours per week during a review of 24 studies. It would be worth comparing benefits from a 60 minute class twice a week (120 total minutes) to a 30 minute class 4 times a week ( 120 total minutes), as well as 5 minutes of daily practice 7 days a week. Providing a baseline for dosage may also help in creating consistent and evidence based messages

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114 Although the literature on the benefits of TC do include some comparison to other act ivities, little is presented in the way of detailed description of the format of TC used in various interventions, including time spent in each class learning versus practicing TC, and amount (if any) of time spent practicing at home 13,14 This situation can be confusing to researchers and those seeking to develop a TC intervention or program, and ability to create an educated consumer, as well as abil ity to make comparisons to other health activities for det ermining relative advantage. As mentio ned by Fry and colleagues 51 in a study on the effects of TC on the physical functioning and psychological well being the majority of each class was spent in lecture, so that it was difficult to determine if it was the expectation of benefits or the few minutes spent doing TC which delivered significant effects. A 12 week study using a format that takes 1.5 years to learn, would be measuring the effects of learning TC, verses the effects of practicing TC. It may be difficult to determine relative advantage from studies of this nature. To reduce the barrier of mixed or uncertain results, it is recommended that detailed instructions on method of instruction and style of TC be presen ted in studies, and if possible, detail a format that does not include a learning phase (or at least differentiate that any significant or non significant effects where derived while learning TC, as opposed to ongoing practice). In regards to compatibility Roger note d that re invention may be critical in the process of adoption (B4 7) For the successful adoption of TC in older adults, it may necessitate adjustments in form, teaching style, and practice specific to desired targ et populations Dr. Paul Lam has made efforts in this direction by applying a step wise progressive teaching method from the field of education to teaching TC 52

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115 The TC group suggested offering or teaching 5 minute formats of TC to address barriers o f time. It would be important however to first document the effectiveness of shorter formats of TC to address evidence based benefits, as well as various consumer friendly classes, in comparison to traditional format s of TC instruction to address compatibi lity issues ( A ppendix A ) This also relates to the third characteristic, complexity. TC, as taught traditionally, can be a very complex exercise. Lack of a teacher capable of teaching TC effectively (B2) and lack of a beginners class (B3) are two barriers r elated to complexity identified by both focus groups. Participant 2 noted that the movements taught in the cruise ship class were difficult to remember. Simplifying TC to its es sential elements for health may be critical. Even the basic way of moving, the coordina tion of upper and lower body, may be more c omplex and challenging than many Western forms of exercise, requiring careful adaptation of teachi ng methods. In a method developed at Fullerton College 53 this is add ressed by using the first 5 10 minutes with a new group in learning how the lower body moves, then the upper body, a nd finally coordinating the two and as mentioned earlier, by Dr. Lam using a step wise progres sive teaching method 52 Trialability, the opportunities to try TC without a large commitment or investment of time, is the fourth important characteristic. Rogers state d that innovations that can be tried before full commitment are adopted more quickly, and reduces the factor of uncertainty. This relates to the identification by both focus groups of the desirability of a class just for beginners (B2) where new people can try TC without the threat of trying to match or keep up with more experienced students, as well as the possibility of being neglected when the teacher focuses on more experienced students. Written or visual

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116 cues (in the form of a DVD or notes) enhancing ability f or home practice may address the barrier related to difficulty remembering the form (B8) as well as allowing potential adopters to try TC at home, or practice what was done in class. Recommendations in this area include developing and evaluating effective methods for home practice. Observability (the final characteristic), related to the vis ibility to non adopters regarding the benefits of TC among the adopting population, may be a limitation in TC promotion, in that most of the benefits of TC are not visible. It may be important to educate potential adopters regarding how long it might be be fore benefits are observed and evaluate targeted messages based on expected benefit time frames. For example, if a significant effect on balance (or at least in regards to TC challenging balance) was observed in one class, this may be applicable to creati ng effective messages. For some benefits, re sults may occur fairly quickly participant 9 noted that they started TC out of curiosity, and observing benefits for balance, continued practice. This is also an area addressed by Schleicher and others 7 as noted in Chapter 2, Review of Literature. Spokespersons and ro le models may help overcome the limitation of observability, as well as education into the benefits to longer term practitioners. As noted by the TC reas which would inhibit observability through public performance. Observability might be achieved through posters and targeted messages through vario us communication channels which is another area recommended for further research This may also help reduce the embarrassment factor by creating familiarity and acceptance in society. It is likely that people jogging in the park are less susceptible to embarrassment while

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117 exercising (although the first joggers who began this trend may have been self conscious) Recommendations in this area include evaluating impact of various messages in mass media channels. As noted abov e, what few perceptions the Non TC group had regarding benefits of TC were primarily related to a TV commercial featuring a group of TC practitioners in a green field. Five of the 8 participants in the study gro up conducted by Beaudreau 34 mentioned in the review of literature, exposure to TC may have been linked to seeing TC on the TV (or park, or friend suggested the author did not differentiate). Weinr eich Communications 54 a company which works with the media industry coordinating social media strategy may be worth following up with to p ut positive images and evidence based messages related to TC into the public media. ed by (and starring) Tom Hanks 55 related the misadventures of an older adult returning to college, and featured a scene in which the tai chi cured my diab movie, when the camera panned across the campus, and in the background could be seen the guidance counselor leading a group of students in tai chi. Such scenes would enhance familiarity and observability of TC, as well as informally educate the public on relevant benefits. One caution regarding this scene is that if benefits are not evidence based and conclusive, such messages may be counterproductive, creating more doubt than interest in TC. Diabetes is one health concern for which there is minimal evidence regarding the benefits of TC beyond type 2 diabetes particularly in relationship to acting as a cure. I nclusion of groups performing TC in the background of random scenes of

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118 various movies, just as you would have joggers running in the background, or kids playing, would also act to increase observability of TC. Limitations and Bias Various strategies related to the fishbone diagram were utilized to minimize bias during the course of the study. Researcher bias was minimized through the use of the fishbone diagram, which permits identification of threats, benefits and barriers with minimal researcher interaction. Researcher interaction is limited to handing out sheets of paper post it notes, and pens. Verbal interaction was limited to giving instructions to note as many threats, benefits and barriers as possible during each section of the fishbone diagram. This format of moderation is identified by Flick as formal direction, i n which researcher interaction is limited to control of the agenda, in the form of fixing the beginning, course, and end of the discussion, which reduces the potential for bias which may result from topical steering or steering the dynamics. 23 Following this process, the researcher asked focus group participants to verify grouping of identified items. In this sense, the focus group members acted as a second rater, confirming their own perceptions, as opposed to evaluatio n by an outside rater who may misinterpret meaning. Following recommendations by Boyatzis, 47 no opini ons were given by the researcher who restricted interaction to asking questions directly related to response judgment on the part of the researcher, since the participants themselves acted as a second rater to v erify meanings of items. 23 mouth s 56 was controlled for by using direct questions related to HBM constructs

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119 regarding focus group participants perceived threats, benefits of TC, and potential described in the focus group process. During discussion phase, researcher input was lim ited to asking the group to identify the largest perceived threats, benefits and barriers, and noting on the margins of the fishbone diagram any additional observations made by focus group members. For example, during the discussion phase, participants wer focus group also acted as a second rater during the discussion phase, by being asked to verify the accuracy of the comments made by focus group participants, which were written down by the researcher on the margins of the chart. Since the research design was based on a theory driven code based on the HBM, as opposed to a researcher develo ped theory, projection on the part of the researcher is minimized. 56 Question order bias may be a factor to address in future studies, in that respondents may be influenced on later constructs by their answers on earlier constructs. 56 It may be worth noting if respondents identified more or less (or different) threats and benefits if perceived benefits of TC were addressed before perceived threats to health That the questions were ver y general in relation to perceived threats, benefits and barriers may help address question order bias. 56 Writing down responses and creating the fishbone diagram before the group discussion also helped control for refer 56 Dominant respondent bias, which can result from a dominant respondent monopolizing time, was controlled for through the fishbone diagram, as was shyness

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120 bias. 56 Each respondent had an equal amount of time to note threats, benefits, and barriers in an anonymous manner. During the discussion phase, each participant was acknowledged in turn, to permit an opportunit y to provide additional input, changing table order to reduce respondent order effects. No person dominated discussion during this phase, and the anonymous format of the fishbone diagram helped to minimize bias from shyness and sensitivity, since participa nts did not need to personally identify with each item. Error bias related t o errors in memory and judgment was a minimal concern, in that the goal was to identify general perceptions most important to the focus group in regards to threats, benefits and b arriers, as opposed to all actual threats, benefits, and barriers. 56 What was not reported can be as significant as what was reported. The completed fishbone chart was referred to in the discussion phase to identify any areas not considered in the fishbone phase (such as benefits for sleep, which was identified during the discussion phase, but not the fishbone phase). The discussion phase helped to control for error bias, by cross checkin g findings, and permitting additio nal input that may have been overlooked. 56 Another advantage of the fishbone diagram is that it addresses sensitivity bias which may result from discussion of sensitive subjects, which can be compounded if proceedings a re audio recorded. 23,56 The blinded aspect of the fishbone diagram permits anonymous identification of responses, and discussion as an objective exercise independent of respondent identification. 44 Biased reporting of data was controlled for by reporting direct findings, independent of researcher observations and comments. Findings were reported in tables listing participant identified threats, benefits, and

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121 barriers, ratings on a 0 9 scale, and direct comments noted on margins of fishbone diagram. The threat of self selection bias is minimized through the homogenous nature of the po pulation and the purposeful nature of the sample which can minim ize bias du e to differences which may result from a randomized sample from a larger and more diverse population base. 49 Since the sample was purposely taken from active members who regularly engage in exercise at the fitness ce nter, with a shared location as residents at OTOW, focus group members are more homogenous and representative of the OTOW population than if participants were randomly selected from a larger area (or even from OTOW, if exercise habits were not similar). Th e fishbone diagram also helped maintain common conditions between groups, which uncontrolled for can be another source of bias 44 Despite efforts to control bias, several limitations must be kept in mind. A l imi tation which applies to the focus group study conducted at OTOW, is that the large majority of behavior change research and interventions is oriented around those most prepared for action. 57 This is also the cas e with the OTOW groups the Non TC group were all very active in various activities at the health center, which in many ways may already prime them for TC adoption. Targeting already active older adults may be a key prospect for achieving critical mass, w hich may then carry over to more sedentary individuals, but ultimat ely it may be important to address studies related to TC specific t o non users of the OTOW fitness center It may be worth considering if TC may be perceived as a more attractive form of ex ercise to sedentary individuals than more active forms of exercise

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122 Although a possible limitation of this study, it is worth noting that as a whole, the participants in the focus groups had not been particularly active until moving to OTOW. So access and time may be a particular key in the motivation towards adoption of health activities and stresses the importance of considering the environment and accessibility in promoting health activities. This may be a limitation in the current study, in that findi ngs may not apply to populations without access or free time. Ethically, it may be important to consider if mark eting and motivating adoption if TC is appropriate if not supported in the community or society at large (Appendix A ). On the other hand, educat ing the public (whether at OTOW or society at large), may be what is needed to create a demand and base for user friendly programs. As a focus group study, the findings cannot be generalized to the entire population of OTOW, nor to the general older adult population, particularly since the groups consisted of cu rrently very active individuals T he TC group also consisted of all women compared to the equal mix of male and female participants in the Non TC group which is a further limitation Economic statu s and diversity is sues may also be a limitation (a ll members of the focus groups wer e Caucasian with the exception of one person of Asian descent in the Non TC group) towards generalizability to other groups. B ut the findings may prove useful in developin g larger scale studies by pointing potentia l direct ions to go. Another limitation is developing interest in TC without a true understanding of how to maximize the benefits. Is five minutes of practice enough? Is the evidence strong enough? How long and h ow many times a week does one need to practice TC to get desired benefits, and how does this affect promotion of TC if these factors are not

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123 known? It should be considered if it is ethical to promote TC on a larger scale for conditions (such as diabetes an d cancer) which may have limited evidence of benefits, pending further conclusive evidence. Also to be considered is a limitation of promoting diffusion research with the current potential lack of accessibility to health and consumer friendly formats (Appe ndix A ) As discussed in Chapter 3: Methods, a final limitation is potential bias on the part of the researcher. From suggestions in th e literature 44 this bias may be minimized through the application of the fis hbone diagram, which limits researcher input to asking one general question related to the three main constructs of the HBM (threats, benefits, and barriers, i.e. note each health thr eat on a separate post from the researcher is limited to clarifying responses via the post it notes, and noting any additional comments on the margins of the chart, with the exception of asking participants in the Non TC focus group about their perspective regarding a class specifically for beginners, and perspectives on any possible influence of views regarding TC related to previous military experiences (as noted in Chapter 3: Methods Conclusion & Recommenda tions The key elements derived from the focus grou ps at OTOW, as indicated by the fishbone diagram results and group discussion include observations that the major barrier to adoption of TC in the general older adult population (at lea st among active olde r adults) may be related to lack of knowledge of what TC is, and its benefits. As mentioned in the review of literature, perceived benefits for health were also the primary reason for adoption of TC in a study on TC practice in Taiwan 35

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124 The attitude towards TC in the Non TC group could be described as neutral t he general c onsensus was that before adopting a new activity (particularly if it meant replacing a current form of exercise), they wanted to know exactly h ow it would benefit them, and what the advantages were over current forms of exercise. The benefits and mechanisms of aerobics and strength training are well established, but to most people, nd think we are An important area to target may be education into actual versus pe rceived risks, as evidenced by T able 5 2. Many of the specific benefits of TC, for example balance, were identified as a barrier to a doption of TC by the Non TC group. That weight was of more concern in the Non TC group (who were non obese active users of the OTOW fitness center), than specific health threats further indicates a strong need to educate older adults in actual versus perc eived threats to health. Primary perceptions of benefits in the Non TC group were linked to images in commercials, identified during the discussion phase. Only participant 8 stated that they could not recall seeing an advertisement featuring TC, and rated 0 perceived benefits (on the post it notes as well as ratings on the 0 9 scale ) This is worth noting in that the majority of literature on TC (which is located in the martial art section of libraries and book stores), as well as a large number of classes in t he United States ( Appendix A ) focus on fighting aspects of TC, metaphysical aspects, as well as physical health benefits. Those who see images of TC in the media as a peaceful and relaxing exercise may be dissuaded from actual adoption of TC if a class or other resources do not meet expectations.

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125 Lack of a separate as a major barrier, which may be addressed through regular monthly classes specifically to orient beginners, and/or by splitting classes into learning and prac tice phases, which can be attended separately depending on interest level and need. The Taoist TC Society ( Appendix A ) uses such a format, with a every three months. A large barrier related to this may be convincing curren t TC teachers to adapt current teaching methodology to accommodate a wider range of skill levels Gender differences are also an area in need of future research. All participants in the TC focus group were women. Aside from investigating gender differences in TC adoption, future studies targeting sedentary individuals would be important. Motivation for TC among sedentary individuals may be a critical area for future research, as i nd icated by Prochaska above 57 an d in Beaudreau 34 by the drop out of the 4 sedentary participants from the focus group, and the continuance of the 8 previously active participants. To address this issue, a future study could follow up with pa rticipants who try and then drop out of TC, to identify variables related to motivation as well as to address important issues related to effects of self efficacy Sel f Efficacy has been addressed in the literature as possibly the gr eatest deciding factor in the adoption of he alth interventions 21,58 Overall, the findings from the focus groups point to a possible need to provide evidence based classes and messages to reduce uncertainty, with tar geted messages specific to actual versus perceived health threats. Related to knowledge and attitudes towards TC, it may also be important to address that many of the benefits of TC were ac tually identified as a barrier That one teache r at OTOW quit their position due to not

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126 being comfortable with teaching large groups, and another adapted TC towards being more like an aerobics class, suggests a need for further research into how teachers might better meet the needs of the older adult population Summary o f Key Findings Related to Facilitators and Barriers Identified by OTOW Focus Groups future study). 1. Only 5 participants in Non TC group identified balance as a health threat (compared to 8 in TC group). Two participants in the Non TC group identified poor balance as a barrier to TC, with 6 ra ting it as a barrier 2. Barriers for Non TC group, aside from uncertain benefits, were related to the benefits of TC: Health concerns of poor stamina/healt h, flexibility, balance, and accessibility. 3. Mental benefits of TC for calmness, meditation (clear mind), and memory are among the highest rated benefits after balance for the TC group. Mental aspects and benefits may be a valuable opportunity for the promotion of TC and may help overcome the boredom element perception identified by the Non TC group as well as facilitate using only a f ew repeated movements for practice of TC f or health. 4. Non TC groups perceptions of benefits are linked to images in the media, and general concept it is supposed to be for health, but are uncertain of real benefits. 5. TC group also identified ignorance of what TC is, and its benefits, as major barrie r, indicating a need for evidenced based programming and marketing. 6. TC group noted that focusing on metaphysical or esoteric aspects of TC may alienate the general population. 7. Major health threats identified by the CDC, but not considered a priority by the focus groups included: Non TC group blood pressure, diabetes, osteoporosis, and mental concer ns (mean group scores ranging from 2.2 2.4 usi ng a 0 9 scale). Cancer scored 3.5 Arthritis 4 .3, while brea thing and heart problems were rated as a 2.8 and 3 .2 TC group no mention made of diabetes or heart disease. 8. Weight was rated as the number one perceived threat in th e Non TC group (M = 5 .1, SD = 1.5 ). 9. Aside from balance, the TC group identified memory concerns, cancer, arthritis, an d osteoporosis as a major health threat (mean group score 4.5 5 .7 using a 0 9 scale).

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127 10. Gender differences were noted between the Non TC and TC grou p. Half of the Non TC group consisted of men, but the TC group was composed of all women. According to the OTOW director, the majority of TC class participants are women. 11. Teacher capabilities were identified as the largest barrier by the TC group, and perceived as potentially the largest barrier by the Non TC group. This relates to instructional methodology and class format, whic h may be the greatest barrier to the diffusion of TC in society (Appendix A ). Final Recommendations and Application of Focus Group Study Future research would benefit from a multi pronged approach. Before targeting non adopters and pre contemplators, it i s recommended to establish or use an existing program that includes the user friendly characteristics identified by the focus group participants. An evidence based user friendly class is recommended in order to avoid frustration which may result from creat ing a demand for a class which cannot meet consumer expectations. Focus group participants identified the importance of TC for balance, and a need for understanding how and why TC benefits balance (which also indicates that a class needs to address TC for balance in a user friendly and non threatening format). Focus group participants also stressed the importance of developing separate beginners and ongoing classes to create a more user friendly format for all levels of experience. Studies following the dev elopment of a user friendly class can elaborate and extend focus group findings related to class preferences, as class offerings become more popular and feasible. A primary area to target for future research relates specifically to motivations of non adopt ers. Following the focus group study, a lecture on evidence based TC was presented, to thank OTOW for recruiting and hosting the focus groups. The message advertising the talk targeted elements identified by focus group

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128 participants as being particularly i mportant related to health threats and perceived benefits of TC. Following is the excerpt from the advertisement for the lecture: Tai Chi Evidence Based Practice for Health & Well being Recent research on the health benefits of Tai Chi will be presented including scientific findings of how Tai Chi affects the body, and why it benefits health in so many ways. Studies related to the use of Tai Chi for balance, cancer, back problems, mobility issues, breathing problems, high blood pressure, stress, and sm oking cessation (with implications for weight management) will also be presented Over 100 residents from OTOW attended the talk, one of the largest presentations according to the director. Following the lecture, over 20 new people signed up for the TC c lass at OTOW, which previously had averaged 7 9 participants. The class went from being one of the smallest to being one of the largest activity classes at OTOW. The question is, what are the differences between the 80 who did not decide to try TC and the 20 who did? It is recommended that a similar presentation be given at a targeted active living community, to track adoption and maintenance of participants who begin TC, as well as to conduct a study in order to identify differences between the adopters an d non adopters. A series of presentations can be formatted building on findings from each level of adopters and non adopters. Initial efforts would target contemplators, identified as those who have contemplated TC to the degree that they attend the prese ntation. Following these contemplators through the decision making and preparation/action/rejection process may identify factors which can be used as leverage for achieving critical mass in the target population. In addition to factors in the decision maki ng process related to TC, primary research questions may address what differences exist between adopters and non adopters in socio economic characteristics (including distance from classes

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129 and transportation availability), exercise patterns, motivation, se lf efficacy, personality traits, and fitness level. Findings can also be compared to the current focus group findings. Following the presentation on evidence based TC, it is recommended to recruit 10 20 participants from those in attendance who do not try the TC class, based on suggestions by R ichie 58 for a case series, to track the decision making process. It is also recommended to recruit a similar number from new adopters for comparison. Aside from having a group for comparison and statistical analysis, tracking adopters would permit documentation of efforts towards adoption and maintenance. This would allow identification of potential barriers and opportunities for new adopters not identified by the focus groups, as well as to permit potential validation of focus group findings in a larger population. To facilitate recruitment, key stakeholders and spokes persons would be utilized, as well as incentives identified by stakeholders as being particularly attractive. The case series approach permits identifi cation of micro variables for better understanding of motivations and factors related to adoption or non adoption of TC. Case series are a type of case study in which commonalities are evaluated a cross individuals 59 Case series have been identified as being particularly valuable for revealing important relationships and implications through evaluating a series of cases that can lead to an explanation of patterns tha t can arise across examples. Case series have an ad vantage over case studies, in that statistical analysis can be made between subjects, and of pre test and post test results 59 The National Health and Medical Research Council in Australia has recognized case series as an important addition to

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130 clinical research, to the point of including case series as an important scientific method for obtaining evidence, as level four in the Four Levels of Evidence in a handbook series on preparing clinical practice guidelines 58 Following the adoption or rejection process in a case series may identify important details, by monitoring participant perception and responses to targeted messages, identifying potential self efficacy issues, as well as documenting factors related to thei r adoption or rejection of TC (including any attempts at trying TC). Such micro variables may also help identify factors related to gender differences. All of the TC focus group were women, compared to half men and half women in the general exercise group. The majority of TC prac titioners surveyed in appendix A were women, which has also been identified as a trend in other studies. Following identification of primary variables related to the adoption or rejection of TC, it is recommended that findings be compared to the current focus group study, towards developing a survey for testing within a targeted population Consistent findings may identify important areas to target, to maximize messages and communication channels, as well as areas to address towards developing an organized social marketing effort within various communities. The following scales are suggested for identifying motivational and self efficacy issues: Amotivation Towards Exercise Scale (ATES) Develo ped by Viachopoulos and Gigoudi to be a short, reliable, valid scale for older adults. 60 The scale measures outcome beliefs (perceived benefit of the exercise), capacity beliefs (perceptions related to capacity to perform the exercise), effort beliefs (perception of ability to maintain the exercise behavior) and value beliefs (value placed on the exercise).

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131 Exercise Self Efficacy (ESE) Scale. Since Self Efficacy is considered possibly the largest factor in th e adoption of health behaviors, the exercise self efficacy scale will be included as a subscale. The Exercise Self Efficacy (ESE) Scale is designed to be self administered as part of a larger questionnaire, and was developed from the General Self Efficacy Scale (GSE) to assess SE for exercise by Eve rett and colleagues. 61 The above scales may also be administered as repeated measures for the case series groups, to assess effects of programming and various tailored and targeted messages. In addition, a personality inventory such as the Big Five traits subscale may also be administered to the case series groups. The Big Five traits subscale measures personality traits related to Extroversion, Agreeableness, Conscientiousness, Emotional Stability, and Openness to Expe rience, which have been associated with many health related behaviors, incorporating elements of Self Determination Theory. 62 Self Determination Theory (STD) is a theory of human motivation which has been used to im prove exercise adoption, adherence, and feelings of well being 62,63 Aside from quantifiable measures which can be subjected to statistical tests, the case series approach also permits documenta tion of subjective experiences and adoption efforts, including progress through the stages of change. In addition to the above scales, current exercise habits, access and centrality to the TC class location, and perceptions of TC which may act as barriers will also be assessed with a short open ended questionnaire The overall goal is motivation for health behavior. The Innovation Diffusion Framework and findings from the proposed study may be adopted as necessary to meet participant and community needs, sin ce TC is but one activity which may meet health

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132 needs of an older adult population. TC is the focus of the current study, to develop a framework which can also be applied for motivation for other health behaviors, as well as due to the identification of TC as being a particularly suitable exercise for older ad ults 5,7,18 Areas to focus on in the targeted community from a theory driven approach related to the perceived characteristics of an innovation are listed below. The following constructs might be evaluated with a community level survey, which can target precontemplators as well as contemplators. Education and targeted communications focusing on Relative Advantage To tip decisional balance and address uncertainty, using various communication channels target Pre contemplators, focusing on Threats to health and Benefits of TC. Since balance was identified as a major perceived benefit by the TC group, and a primary threat by both groups, it may be advantageous to target benefits for balance compared to other forms of exercise. Train teachers and develop formats focused on Compatibility with the older adult population Initial focus may be on singular benefits of critical need, identifying Sub Groups such as TC for balance, TC for Arthritis, and TC for blood pressure, to address Complexity and Self Efficacy issues, as well as to minimize Barriers to learning and maximize understanding of health Threats and Bene fits of TC for specific health concerns. Findings from the focus group study indicate that it may be important to target perceived mental benefits as well as benefits of TC for balance. Develop and promote beginners classes to allow Trial ability to reduce barrier of uncertainty. As separate beginners classes (as suggested by the focus

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133 groups) or other format (such as a 5 minute format suggested by the TC focus group), to support Preparation (but stressing regular practice (Action) to see desired benefits). It may also be important to determine evidence based effective dosage and expected time frame to see benefits (for example, for pain management, TC practice has been demonstrated to be effective within two weeks of daily practice 16 and within 5 15 weeks of one hour of practice two times each week. 64 Promotional efforts to create Observability and reduce uncertainty. (public performance). Work towards making TC mainstream and acceptable, which was identified as a major barrier by the TC focus group. It is recommended to target the Contemplation stage, combined with evidence based benefits to develop understanding of mechanisms behind healt h benefits (reducing barrier of uncertainty, and returning again to increasing awareness of Relative Advantage and support of Maintenance stage). Also highlight Current Adopters and recruit notable Spokespersons from those highly respected within the socia l system. Develop tailored messages which can be provided by local area medical providers. Also encourage and promote observability by encouraging a TC class or group meeting in a public place, such as a local area park. The multi faceted approach suggeste d may target diffusion of TC from a variety of areas sufficient to generate an understanding of how to promote, structure, and target TC in a community towards achieving critical mass. Other areas to target which may also affect TC adoption is the perceive d versus actual health threats discrepancy, identified from the focus group findings of perceived threats compared to threats identified by the CDC. The recommendations for future research is an initial suggested plan, which may be adjusted dependent on th e experience, expertise, needs, and

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134 suggestions of stakeholders involved with the project. The proposed research primarily targets contemplators, the 80% who contemplated TC sufficiently to attend the talk on TC but were not sufficiently motivated to try T C. It would also be worth targeting those who did not come to the talk, the precontemplators, to determine variables related to non attendance of the lecture. It may be a simple matter of time conflicts or accessibility, or it may be due to disinterest in TC. Targeting this segment of the community would be important to identify variables related to pre contemplators. Community level surveys, and possible a case series recruiting non attendees, may uncover new layers for understanding effective diffusion o f TC related to the various adopter categories, as well as the stages of change. Overall, the primary areas stressed by the focus group participants is a need for evidence based benefits they want to know what works, and why (with the primary identified need and in terest related to balance). Another area to target is accessibility user friendly classes with teachers able to address their needs with an actual TC format. Also stressed was a need for promoting greater exposure for TC, so that people are mo re familiar with the exercise and its benefits developed to confirm or modify findings from the focus group study, towards identifying an e ffective path for diffusion which may be more valid and reliable for motivating effective diffusion and adoption of TC in a larger population. As indicated in the introduction, targeting health benefits of TC, particularly for balance, may offer valuable c ontributions to reduce the health burden in society, medical cost savings, and may enhance quality of life among the older adult population.

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135 Table 5 1. Possible facilitators to adoption of TC related to OTOW focus groups. n = number of response via the p ost it notes, M = mean group score (for comparison, low n and focus group design precludes statistical significance). FACILITATOR NTC n NTC M TC n TC M F1: BALANCE Perceived benefit fall s 4 7.3 8 8.4 Perceived threat falls 5 4.2 8 6.6 F2: WEIGHT CONCERNS Perceived threat weight 3 5.1 1 2.6 F3: MENTAL BENEFITS Perceived benefit calm/relax 1 6.8 5 7.5 Perceived benefit memory 3 6.2 Perceived threat stress 3 4.6 Perceived threat memory loss 4 5.7 F4: FLEXIBILITY Perceived benefit flexibility 1 6.8 4 8.2 Perceived threat flexibility 3 5.8 F5:PAIN/ARTHRITIS/BACK/SHOULDER Perceived benefit arthriti s 1 6.6 Perceived threat arthritis 2 4.3 1 4.5 Perceived threat back pain. 3 4.8 Perceived threat shoulder problem 3 3.9 F6: COPD/BREATHING PROBLEMS Perceived benefit breathing 2 8 Perceived threat br eathing 1 2.8 2 4.7 F7: CANCER Perceived threat cancer 2 3.5 1 4.7 F8: DIABETES Perceived threat diabetes 3 2.2 Table 5 2: Comparison of Perceived Benefits, Threats and Barriers as frequency of responses via post it notes. PNotes = total number of post it notes (responses) for each construct for each group. Total # is the number of benefits, threats, or barriers identified for each construct for each group. Benefits Threats Barriers PNotes NTC 12 29 15 PNotes TC 39 33 12 Total # NTC 6 15 11 Total # TC 15 18 8

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136 Table 5 3. T op seven causes of death in 2007 among persons 65 years of age and over (CDC, 2010 ). Deaths from falls in 2008 included, due to status as primary perceived health threat among persons age 65 and older. In 2009, 2.2 million non fatal injuries among persons 65 and over due to falls were treated in emergency rooms. Columns to the right (No TC Group Perceived Threats, and TC Group Perceived Threats) are the number of participants in each group which expressed each category as a concern, followed by mean scores for each threat. 1 Concern expressed as high blood pressure. 2 Concern expressed as breathing problems. 3 Concern expressed as memory loss Causes of Death % Number Deaths Non TC Threat ( n ) N on TC Threat(M) Non TC SD TC Group Threat ( n ) TC Group Threat (M) TCGroup SD CDC1: Heart Disease 28% 491,559 1 3 .2 3.8 CDC2: Cancer 22% 386,225 2 3.5 3.7 1 4.7 3.7 CDC3: Stroke 7% 122,890 3 1 2.2 2.7 1 1 2.3 3.6 CDC4: CLRD 6% 105,334 1 2 2.8 3.5 2 2 4.0 3.9 CDC5: Alzheimer 4% 70,223 1 2.4 2.6 4 3 5.7 3.1 CDC6: Diabetes 3% 52,667 3 2.2 3.5 CDC7: Influe nza 3% 52,667 CDCF: Falls .01% 19,700 5 4.2 3.4 8 6.6 3.0

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137 Table 5 4. Perceived Barriers to the adoption of TC identified by the focus groups. n = number of responses via the post it notes, M = mean group score (for comparison, low n and focus group design precludes statistical significance). BARRIERS NTC n NTC M TC n TC M B1: Lack of Awareness of Benefits Poor health seen as a barrier 2 3.7 Perception TC not exercise (from discussion) Unsupport ed cure all needs evidence (from discussion) B2: Lack of Adequate Teacher 3 5.4 B3: Lack of Beginner Class** 5.4 B4: Lack of Time 2 2.4 3 4.6 B5: TC Too Slow 2 1.6 B6: Visualizations can be disturbing (from discussion) B7: E mbarrassment doing in public (from discussion) B8: Lack of Written/Visual Cues 1* 2.2

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138 Communication Channels (What factors may make TC messages mor e effective towards achieving Critical Mass, factors to address for Targeted Messages ) CDC1 CDC f ; F1 F8;B1; B8) Adoption (Influen ced by adopter category: Innovators, Early Adopters, Early and Late Majority, and Laggards). Rejection Characteristics of the Perceived Characteristics Decision Making Unit of the Innovation ( Factors which may affect attitudes towards adoptio n of an innovation (Rogers, 2003). SOCIAL SYSTEM 1. Relative Advantage What are benefits of TC compared to other choices? CDC1 CDC f F1 F8, B1 (Factors which can affect 2. Compatibility Acceptability, how consistent is TC with existing values & needs? B4 B7 Time the KAP Gap) 3. Complexity How difficult do older adults perceive TC? B2, B3, B8 4. Trialability What is the current ability to try TC? What factors of trialability might affect adoption? B3, B8 5. Observability How observable is TC? What options exist to increase observability ? B7 Figure 5 1. Overview of potential facilitators and barriers identified from the focus group results, applied to elements of diffusion of innovation, based on Rogers five stage innovation diffusion process model. 17 See Appendix B for key to codes. I. KNOWLEDGE CDC1 CDCf ; F1 F8;B1 II. PERSUASION CDC1 CDCf ; F1 F8;B1 B8 III. Decision IV.Implementation V. Confirmation

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139 APPENDIX A REVIEW OF SELECTED T AI CHI PROGRAMS IN T HE UNITED STATES Results from the Tai Chi (TC) group from the dissertation study indicated a large dissatisfaction related to teaching style and opportunities for TC. The classes at the On Top of the World Community (OTOW) in Ocala Florida had gone through a variety of teachers. The first took a traditional long term approach, in which participants would learn TC over the course of a year or more. The second taught a format she learned principles and formats developed by Health2 (see below) in which most of the class at OTOW was spent lear ning a shortened version of TC over a 3 to 4 month period. Participants in the TC group expressed dissatisfaction with these classes, in that more time was spent learning versus practicing TC. Since user friendly formats may be an important facilitator to the adoption of TC, and lack of access to such classes may be a major barrier, a visitation was made to 8 major TC programs in the United States (based on program size, publications, and public exposure), as well as a class at a large retirement community which used one of the major program formats, for a comparison. The following research questions were addressed: RQ1: What style of TC was taught? RQ2: Is the format single or double weighted? RQ3: How long does it take to learn the form? RQ4: What was th e class format? RQ:5 What were the perceived benefits identified by the students? RQ6: What were the primary facilitators identified by the students? RQ7: What are the primary barriers identified by the students? RQ8: What teacher attributes are percei ved by the students as most important?

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140 Methods Major programs were identified as based on influence on TC development in the United States, as well as accessibility to the public (based on number of schools, publications, or public exposure). R efer to tabl e A 1 and A 2 for an overview of programs. A visitation was made to representative schools for each program, du ring which a class was observed and class participants were asked to complete a sh ort 9 question open ended questionnaire developed from findings from t he focus group study (Appendix D ). Both groups completed an informed consent form as part of the IRB approved study. Thematic analysis was used to identify recurring themes, oriented around perceived benefits of TC, facilitators to TC adoption, barr iers to TC adoption, and teacher qualifications. A second rater, also with a background in holistic health, independently evaluated student s responses, and then met with the researcher to discuss conflicting ratings, to determine a common understanding for each factor to resolve any discrepancies, and combine like items (for example combining individual responses for back, knee, and shoulder pain into a single category). Responses were evaluated by the raters for themes which were compiled into 15 perce ived factors for benefits, 14 for facilitators, 8 for barriers and 6 teacher qualifications. Program Overview All programs acknowledged the benefits of TC for health to one de gree or another. S tudent responses at all programs indicate a perception of TC b eing beneficial for health, regardless of program orientation (Table A 3). The programs visited were divided up based on the focus of the instructional methodology. Health1 4 used an

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141 adapted form of TC, shortening, or in the case of Health1eliminating, the learning curve. Health1 used a format similar to a group aerobics class, including a warm up period, push ups, and various strength and relaxation exercises more similar to qi gong and yoga than TC. When asked about this, the instructor stated that they c alled several of their qi gong yoga classes TC, since there was a public demand for TC, but that they taught the same material in all classes (qi gong and TC classes), focusing on individual user friendly movements. Health2 4 used a shortened format of TC (developed by Health2), with a shorter learning curve (stated as being approximately 3 4 months). Health 4 also incorporated various other styles of TC, including the 24 short form, a style of TC based on a Hawaiian form of Karate, and had separate classes for the Health 2 format, a beginners class for the other forms, and an ongoing class for advanced practitioners in the mixed styles. Two programs (TC1 2) used a more traditional format of TC (the 108 yang long form), with a more traditional teaching style which took students 1 2 years to learn, but with minimal focus on the martial aspects of TC. MA1 and MA2 taught traditional forms and formats as well, but also taught other Chinese martial arts, and included TC weapon training in the TC class as well as two person martial exercises (push hands). MA1 taught Chen style TC, while MA2 taught the 108 Yang long form. Below is a brief overview of each school: Health1 Is an extensive chain of schools with over 10,000 branches throughout the United States accordin g to their website The focus of the program is on forms of qi gong, marketed as a form of yoga. Most locations also offer a TC class. The hour long TC class is run like a fitness class, with moves more consistent with strength based

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142 forms of qi gong and W estern exercise (push ups were included). The school visited was the programs flagship program. Health2 Is one of the largest TC for health and certification program in the world, with over 2 million students trained or certified and over 14 instructional focus is on teaching a short 2 3 minute form, targeting various health issues. The class format begins with a series of stretching exercises (10 15 minutes), followed by learning individual movements. At the end of the class the form is perform ed as a group. Health s Health3 is a low cost public program aimed at seniors, from a certified instructor using Health 2 for over eig ht years. The class follows a 3 4 month format, teaching the TC for arthritis form in recurring cycles. This next year the instructor plans to alternate with Health 2 TC for energy form. The class spends 10 15 minutes doing stretching exercises, followe d by 20 30 minutes of instruction on various movements. The remaining class time is spent practicing the form. Health4 is a retirement community program, consisting of two groups of TC. It was included for comparison to more general public programs, and du e to its use by both instructors of Health2 fitness center, is primarily based on Health2 form. The class follows the same format at Health3. The other i nstructor teaches in more of a club format, using a combination of Health2 and a Hawaiian style of TC based on a karate form. The second instructor has an

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143 ass that meets one day a week. TC1 is the largest non profit TC organization in the world. TC1 has locations in 28 states, and offers classes almost dail y at many locations. The s ite visited was one of their larger programs, with 43 classes offered through out the week. The program teaches a traditional format (i.e. the 108 long form), with a focus on health and Taoist religious practice. The class begins with a series of qi gong (breathing exercises) for 10 15 mintues A beginner s class cycles every 3 months with it typically taking a year or more to learn the form. TC2 was the first official school of a national organization aimed at promoting traditional TC and qi gong for health. The organization is the official source of TC information for HealthFinder.g ov. The organization has changed its webpage since the visitation, and no longer lists TC2 (nor any school) as an official school, and may be in the process of restructuring. The organization offers certification for instructors, but the current focus may be more on promoting TC than on certification. The one hour class at TC2, offered 2 times per week, focuses on qi gong warm ups, instruction, and time practicing the form. MA1 is the United States headquarters of the oldest and largest Chinese Zen Buddhis m and Chinese martial arts organization in the world. Although the focus is on kung fu, a TC class is offered (the more martial style of Chen TC), and due to the teacher and program prominence, attracts those looking for TC for health. According to Health 1 located in the same city, Health 1 regularly gets students who were looking

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144 for TC for health who tried MA1 first due to their prominence, but became discouraged by the difficulty of the martial oriented movements. MA2 is the headquarters school of fou nded by a TC teacher and writer, gong over the past 30 years published in over 13 languages. His publications are primarily martial oriented. The focus of the class is on the traditional 108 Yang long form, weapons, and two man training (although enhanced health is an acknowledge benefit). Facilitators and Barriers Identified by TC Students A total of 58 students consented to complete the questionnaire. See tab le A 1 for a n overview of students for each TC school or program. It is worth noting that the majority of students were women (n=43), as well as for each class observed, with the exception of MA1 and MA2, which had a more martial orientation to classes, as well as Hea lth2, which was focused on certifying teachers. Although the majority of students were women, all but one instructor for all classes observed were men (Health1 had a female instructor). Perceived Benefits As can be seen in table A 3 the primary perceived benefit identified related to balance (n = 26). This is consistent with the focus group findings, and further indicates that benefits for balance may be a primary area to target. Twenty two mentioned either benefits for general health, or specific chronic conditions (stated as Parkinson (n=1), stroke (n=1), scoliosis (n=1), and physical disability due to injury (n=1). The responses also support focus group findings related to perceived mental benefits of TC, with 20

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145 students reporting benefits for clear mi nd, calm state, or meditative aspect of TC. Relaxation was also a typical response. Specific benefits for back, knee and shoulder pain were also mentioned, as were improved focus, happier/less stress, improved breathing and flexibility, increased walk spee d and mobility, enhanced memory, improved strength, more energy, and improved sleep. Seven students specifically mentioned challenge as a benefit of TC. Individually, specific benefits noted by individual students include: "Feeling light and agile when I actually have a heavy stiff (arthritic) body." "I have scoliosis sideways curvature of the spine. I am in constant pain. Doing TC reduces the pain, and standing correctly allows me to st and and walk. I also have titanium legs, hip replacement, and arm. TC is what allows me to love life. It did change my life. "I had a lumpectomy 4 yrs ago. Surgery on Friday, went to class on Wed. Surgeon said my recove ry was advanced because of the tai c hi I had no swelling of my arm and my scars have almost disappeared Complete flexibility in my arm." Perceived Facilitators to Adoption of TC See Table A 4 for an overview of facilitators identified. The greatest facilitator mentioned by students were re commendations that TC be promoted more in the media (n=31). Thirteen felt that public exposure, such as practicing in the park, would generate more interest and awareness of TC. One student noted that while visiting China seeing people practicing in the mo rning in the parks got them interested in TC. Another was first introduced to TC through a hospital program (they did not say why), and one by their chiropractor. One student noted: (I) w atch ed tai chi'ers in C alifornia on the beach and was amazed."

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146 Twe nty two were attracted by the flowing graceful movements of TC. Seventeen were fairly frank that people need to realize that they need to practice at home to get the benefits of TC. This may be an important area to consider in educating potential consumers As stated by one student: "Frankly I do not do enough practicing at home. You get out of it what you put into it. The most impressive aspect of TC to me is that people in their eighties can practice it and still benefit from doing so." However, anothe r noted that there is also value in a user friendly format that does not require practice: "Decide whether to teach exercise or form. Form more difficult and require s steady attendance. Residents are often travelling so can't attend regularly." Personal r ecommendations brought 11 students to TC, indicating the importance of interpersonal communication channels. Greater availability of TC (as more classes) was mentioned by 10 participants as something that would facilitate more practice of TC, while 9 felt that it would be important to teach TC at a young age, which may increase familiarity with TC or encourage practice from a younger age. Nine began TC just to try something new, while 7 were attracted to the social aspect, and 7 were attracted to the spirit ual or mystical aspect. One student liked how TC allowed them to This indicates that at least for a few people, the metaphysical side is an attraction. See Perceived B arriers below for the comments of one student regarding their negative perceptions of a religious context to TC. One student stated that they felt men need to

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147 be targeted more, while another suggested targeting the martial aspect of TC to attract more men. Four students felt that more classes specifically oriented for beginners would help facilitate the adoption of TC. One of these students made a specific comment that (b eginners, intermediate, and advanced) can be frustrating to those who already know the TC form: "I feel too advanced for this class, I feel I have to wait while the s low learners catch up." Perceived Barriers See Table A 5 for an overview of facilitators identified. Difficulty memorizing movements were cited as the largest barrier, mentioned by almost half of the students surveyed (n=26). Difficulty coordinated movements were mentioned by 12 students, while 7 cited difficulties with balance as a barrier, a nd 8 noted difficulties concentrating or focusing on movements. The different styles of TC, lack of patience, difficulty relaxing and time were each listed twice. O ne individual (not listed on B 5 ) since this barrier was listed by only one student, indicat es another potential barrier related to those who incorporate religious or spiritual aspects to their classes: "The shrine is insulting to anyone who practices one of the three major religions. I'm considering leaving to avoid worshiping false idols." Fa cilitators and Barriers Related to Teacher Characteristics See Table A 6 for an overview of positive teacher characteristics identified. Perceptions related to what qualifications a teacher should have included teaching

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148 ability, even more so than experien ce with TC or knowledge of the form. One student stated : "If you truly love TC you can teach the little you know." This indicates that those programs that focus on teaching effectiveness over form knowledge (such as Health2 and Heath3) recognize this and a re trying to meet that need. Patience was mentioned by 23 students. That 4 students in each of Health2,3 and TC1 note the importance of patience, indicates that older adults in particular may value a patient instructor (The mean age of participants in thes e locations was over 50, compared to other programs). It should be noted that 4 of the 7 students who mentioned instructor certification as important were from Health 2, which stressed certification of instructors (the workshop, aside from learning the sho rt TC form, was also focused on certifying those interested in becoming instructors). Conclusion and Recommendations Most of the schools followed the tra ditional format of TC (Table A 2 ) Students spend 3 12 months or more learning the form, targeted for individual home practice. Health 2 and 3 (different locations, but same organization) focused on effective teaching methods of select movements, shorting the learning curve to about 3 months, while all the other schools stated they had a 12 to 18 month le arning period (except Health 1 see below). Little class time was spent in any of the schools for performance of TC, with the exception of Health1, which was oriented more like a yoga or fitness class, holding individual movements for extended periods of time, usually double weighted (weight distributed over both feet). The class began with 20 push ups which is atypical of TC

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149 schools, and may not be a user friendly format for older adults. As noted above, all the schools programs are run the same, with som e of the classes called TC to target those looking for TC. This is rather surprising, and indicates a large potential barrier and a strong need to educate potential consumers on what to look for in a TC class. One school observed, separate from the study on major TC programs in the United States, spent the class doing a fast set of calisthenics loosely based on TC. The class also included explosive deep knee bends (squatting and then springing up) which may be particularly unsuited for many adults, particu larly in the older adult population. Another had a more traditional format for TC instruction, but did the Yang 108 long form in approximately 13 minutes, which is a very fast pace for this form. MA1 used the Chen style of TC, which is a faster paced form of TC. They also used a more double weighted style of movement, as did MA2. When asked about this, the instructors replied that being single weighted makes it too easy to be pushed over in push hands competition (push hands was originally a method of pract icing with a become more of a form of competition). Although MA2 used the long 108 form, this martial emphasis reduces the benefits of TC for balance, further indicating the importance of creating an educated consumer. Another major program observed (it was a training workshop for association teachers) also focused on the martial aspect and double weighting for push hands competition. In this workshop, one exercise consist ed of smashing your shoulder as hard as you could against another person. The martial orientation of many programs may be a major limitation towards the diffusion of TC, if potential students attend a program thinking all TC is the same, and

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150 all TC is for health. TC originated as a martial art, but the majority of people, as indicated in the survey, may be more interested in TC for health. A person walking into a martial oriented class, not knowing the difference, may become discouraged from further [prac tice if they do not experience the benefits expected (for example for balance, due to the focus on being double weighted). Even more alarming is those schools who are not teaching TC (such as Health1), yet are calling their classes TC. Health1 was specific ally targeting health, and as a Yoga or strength based class may have many benefits, but not what would be expected from TC. Yet this program has over 10,000 branch schools according to their website. It is also worth noting that Health1 regularly got stu dents who had first tried MA1 (they are located in the same pace and harder training of Chen style TC. Another potentially large barrier is that all of the programs (exc ept Health1) were oriented on learning TC. Considering 26 students expressed difficulty memorizing the movements, this may be a limitation, particularly if students are not disciplined enough for home practice. It is recommended that a model similar to tha t followed by many teachers in the public parks of China and large Chinese communities in the United States (such as Monterey Park, CA) may be particularly effective in creating a user friendly format of TC. The format used includes the use of loud speaker s to broadcast verbal instructions that permit people to follow TC without having to learn it. A park in Monterey Park CA often had 300 people or more every weekend following TC Programs may also benefit from having a DVD students can use for home practic e,

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151 the need to determine if the same benefits for health can be derived from following TC as compared to independent practice of TC. Focusing on increasing public exp osure of TC, in the media and through promoting public practice in parks may be an important considera tion. For media exposure it may be important to consider promoting accurate evidence based benefits ing) Tom Hanks (Hanks, 2011) related the misadventures of an older adult returning to college, and featured a scene in tai chi cured reference to tai chi until the end of the movie, when the camera panned across the campus, and in the background could be seen the guidance counselor leading a group of students in tai chi. One caution regarding this scene is that if benefits are not evide nce based and conclusive, such messages may be counterproductive, creating more doubt than interest in TC. Diabetes is one health concern for which there is minimal evidence regarding the benefits of TC beyond type 2 diabetes, particularly in relationship to acting as a cure. I nclusion of groups performing TC in the background of random scenes of various movies, just as you would have joggers running in the background, or kids playing, may also act to increase observability of TC. Increased public exposure might also be achieved by tapping into World Tai Chi Day, an organization and event (worldtaichiday .org, 2013 ) created to promote TC, with an annual public practice of TC on a specified day each year in communities throughout the world. Such an organizatio n has the resources to promote and encourage regular weekly public practice by local instructors throughout the year. Such a format would

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152 increase exposure of local instructors enhancing recruitment of new students, as well as enhance familiarity with TC i n the general public. Another large opportunity to facilitate adoption of TC in the older adult community, as indicated by the majority of respondents, is to focus on the benefits of TC for balance. Overall, the above findings and tables indicate multiple opportunities to facilitate adoption of TC, and areas to address related to barriers to TC.

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153 Table A 1. Student characteristics. Total Health1 Health2 Health3 Health4 TC1 TC2 MA1 MA2 Total Students 12 34 ** 7 18 2 7 Compl. Survey 58 5 7 11 13 7 7 2 6 Mean age <50 yrs <50yrs* >50 yrs >50 yrs < 50yrs > 50yrs <50yrs <50yrs Women 43 4 3 10 13 7 4 1 2 Men 15 1 4 1 3 1 5 Experience < 1 year*** 20 3 1 3 4 4 2 3 1 3 years 19 1 1 7 6 3 1 4 9 years 12 3 1 5 2 1 10 + years 7 1 2 2 2 *Total students were not recorded for Health 2 due to workshop nature of class with founding instructor, and predominant number of instructors at workshop. **Total students were not recorded for Health 4 due to students meeting separately from two classes, one of which was not meeting at the time of the study. Based on participant report, class size typically ranged from 7 9 participants for each group. *** 17 of the 20 had been doing TC 3 4 months, one less than one month, and t wo for 7 9 months.

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154 Table A 2. Overview of Schools. Health 1 Health2 Health3 Health4 TC1 TC2 MA1 MA2 Style Qi gong, strength Sun Sun Sun,Po, Yang Yang Yang Chen Yang Weight DW SW SW SW SW SW DW DW Format follow learn learn learn learn learn learn learn Time N/A 3 mo 3 mo 3 12+mo 12+mo 12+mo 12+mo 12+mo DW = Double weighted, the weight of the body primarily balanced equally between both legs. SW = Single weighted, the weight of the body alternating balanced between the left and right leg. Time = Typica l time necessary to be able to do the complete TC form. Table A 3. Perceived Benefits Perceived Benefit Total n = 58 Health1 n = 5 Health2 n = 7 Health3 n = 11 Health4 n = 13 TC1 n = 7 TC2 n = 7 MA1 n = 2 MA2 n = 6 Balance 26 2 1 8 6 2 4 1 2 Health/ch ronic cond. 22 4 3 2 6 3 1 3 Clearmind/calm/Med 20 4 2 1 6 1 2 1 3 Relaxation 20 2 6 7 1 2 1 1 Back/knee/shldr pain 13 1 1 6 2 3 Focus 12 1 2 1 2 3 1 2 Happier/less stress 12 2 2 1 2 2 2 1 Improved breathing 10 1 1 3 2 1 2 Flexibil ity 8 1 1 2 2 1 1 Walk speed/mobility 8 1 1 2 3 1 Challenge 7 1 1 3 2 Enhanced memory 5 1 1 2 1 Improved strength 5 1 2 1 1 More energy 5 1 1 2 1 Improved sleep 3 1 1 1

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155 Table A 4 Facilitators Fac ilitators Total n = 58 Health1 n = 5 Health2 n = 7 Health3 n = 11 Health4 n = 13 TC1 n = 7 TC2 n = 7 MA1 n = 2 MA2 n = 6 Media Promotion 31 2 6 6 6 5 3 1 2 Flow/grace 22 1 5 6 3 2 2 1 2 Practice 17 2 1 8 3 1 1 1 Public Exp/outdoors 13 3 2 2 3 1 2 Personal recomm. 11 1 1 2 3 2 2 More classes 10 1 5 2 1 1 Teach young 9 1 1 1 2 1 1 2 Try something new 9 1 2 3 2 1 Social Aspect 7 2 2 1 1 1 Spiritual 7 3 1 1 1 1 Low impact/easy 6 1 1 2 1 1 DVD of form 4 1 2 1 Beginr class/simplify 4 1 1 2 Martial applications 4 1 1 2 Table A 5. Perceived Barriers Barriers Total n = 58 Health1 n = 5 Health2 n = 7 Health3 n = 11 Health4 n = 13 TC1 n = 7 TC2 n = 7 MA1 n = 2 MA2 n = 6 Memorizin g moves 26 2 4 3 8 4 2 3 Coordination 12 1 2 4 2 2 1 Balance 7 1 3 1 1 1 Focusing/concentratng 8 3 2 2 1 Different styles 2 1 1 Lack of patience 2 1 1 Relaxing 2 1 1 Time 2 1 1

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1 56 T able A 6 Teacher Q ualifications. Teacher Qualifications Total n = 58 Health1 n = 5 Health2 n = 7 Health3 n = 11 Health4 n = 13 TC1 n = 7 TC2 n = 7 MA1 n = 2 MA2 n = 6 Teaching ability 27 1 3 8 6 3 2 4 TC Knowledge 25 1 2 4 6 4 4 1 3 Patience 23 2 3 4 4 4 4 2 Passion 8 1 3 1 1 2 Certification 7 4 2 1 Humor 4 4

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157 APPENDIX B KEY TO CODES FOR FIGURE 5 1 F1: Evidence Based Benefits for Balance F2: Evidence Based Benefits for Weight Management (i.e. Mindfulness) F3: Ev idence Based Mental Benefits Calmness, Memory, Stress Reduction F4: Evidence Based Benefits for Flexibility F5: Evidence Based Benefits for Pain Arthritis/Back/Shoulder Pain F6: Evidence Based Benefits for COPD/Breathing Issues F7*: Evidence Based Benefi ts for Cancer F8*: Evidence Based Benefits for Diabetes CDC1: Heart Disease CDC2: Cancer CDC3: Stroke CDC4: CLRD CDC5: Alzheimer CDC6: Diabetes CDC7: Influenza CDC f Falls B1: Lack of Awareness of Evidence Based Benefits Claims of being a panacea off putting, misperceptions TC not an exercise, see benefits of TC as a barrier (poor stamina/health, poor balance). B2: Lack of Adequate Teachers/Classes Do not meet needs of participants (focus martial or learning vs practicing TC, also need for greater pa tience with older adults and ability to break down movements). B3: Need for Beginner Class most classes mix beginners to advanced, resulting in frustration. B4: Lack of Time knowledge of how to integrate into daily life (possible 5 minute formats). B5: TC Too Slow lack of patience for slow movements of TC. B6: Visualizations can be disturbing (i.e. visualizing anger leaving your body as orange streams of energy) B7: Embarrassment doing TC in public. B8: Lack of Written or Visual Cues Get confused wh en try on own. FACILITATOR/BARRIER CODES (F = Group identified facilitators; B = Group identified barriers; CDC = Health concerns according to the CDC)

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158 APPENDIX C INSTITUTIONAL REVIEW BOARD SUMMER 2012 DOCUMENTS UFIRB 02 Social & Behavioral Research Protocol Submission Form This form must be typed. Send this form and the supporting documents to IRB02, PO Box 112250, Gainesville, FL 32611. Should you have questions about completing this form, call 352 392 0433. Title of Protocol: DIFFUSION OF TAI CHI IN OLDER POPULATIONS: FACILITATORS AND BARRIERS TO ADOPTION Principal Investigator: Peter Gryffin UFID #: Degree / Title: Doctoral Student in Health Education and Behavior Mailing Address: ( If on campus include PO Box address ): Email: Dep artment: Health Education and Behavior Telephone #: Co Investigator(s): UFID#: Email: Supervisor (If PI is student) : Dr. William Chen UFID#: Degree / Title: PhD, Professor Mailing Address: ( If on campus include PO Box address ): Email : Depar tment: Health Education and Behavior Telephone #: Date of Proposed Research: 06/01/2012 06/01/2013 Source of Funding (A copy of the grant proposal must be submitted with this protocol if funding is involved): None.

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159 Scientific Purpose of the S tudy: To lay a foundation related to an understanding of reasons for practice, adoption, or rejection of Tai Chi, and what factors may enhance the maximum diffusion of Tai Chi in older populations. Describe the Research Methodology in Non Technical La nguage: ( Explain what will be done with or to the research participant. ) Two focus group sessions will be conducted, one group with interest in Tai Chi, and a second group who has never considered Tai Chi (or who have tried Tai Chi and rejected it). Focus groups will last up to two hours. The first hour will be used to build a fishbone chart (a chart dividing the discussion into the benefits and barriers of Tai Chi, which uses post it notes to allow anonymous thoughts and considerations to be posted for ea ch category). The following hour will be used for group discussion of the completed fishbone chart, as well as self assessment of risks, benefits, and barriers using a self created survey. Each participant will be assigned an identifying number. Data or fi ndings will not be linked to identifiers. Informed consent will be obtained prior to focus group sessions. Describe Potential Benefits: This study will add to the understanding of underlying factors behind non adoption of Tai Chi. The findings from thi s study can promote discussions about possible support systems and structures that might be needed to help promote Tai Chi in the older adult population. Describe Potential Risks: ( If risk of physical, psychological or economic harm may be involved, des cribe the steps taken to protect participant.) No more than minimum risks are anticipated. Describe How Participant(s) Will Be Recruited: Participants will be recruited by e mail, through an in house e mail system at Oak Hammock Independent Living Commu nity, as well as through flyers posted at the facility. Maximum Number of Participants (to be approached with consent) 30 Age Range of Participants: 55 100 Amount of Compensation/ course credit: None. Describe the Informed Consent Process. (Attach a Cop y of the Informed Consent Document. See http://irb.ufl.edu/irb02/samples.html for examples of consent.) An informed consent form will be provided to participants prior the interviews. Participation is completely voluntary.

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160 (SIGNATURE SECTION) Principal Investigator(s) Signature: Date: Co Investigator(s) Signature(s): Date: student): Date: Department Chair Signature: Date: Protocol Revision Form For Alrea dy Approved Studies Institutional Review Board Office 02 (Social and Behavioral Research) UFIRB Number: 2012 U 584 PROTOCOL TITLE: Diffusion of Tai Chi in Older Populations: Facilitators and Barriers to Adoption NAME : Peter Gryffin PHONE: EMA IL: Revision / Amendment to Protocol State the revision(s) you are making to the study : Addition of questions for a backgrounder related to the instruction and promotion efforts of Tai Chi. Change to recruitment and methodology to include instructors a nd directors of Tai Chi programs. Methodology addition: Interviews will be conducted with teachers and directors of Tai Chi programs, using 10 open ended questions, to identify factors affecting the diffusion of Tai Chi in older populations. Classes will be observed to document differences between programs on teaching methodology that might affect the diffusion of Tai Chi in older populations. There will be no interaction with students, other than asking permission to observe the class. Recruitment additio n: Instructors and directors of Tai Chi programs will be recruited by phone, asking if they would complete a brief interview, and permit observation of relevant classes. Justification for Revision

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161 Protocol Revision Form For Alrea dy Approved Studies Institutional Review Board Office 02 (Social and Behavioral Research) Provide reason / justification for this change : Initial f indings from focus groups indicate a major barrier is instructional methodology. Tai Chi has diversified considerably since its introduction into the United States for a variety of reasons. The backgrounder questions are to document modifications, and obta in perspective of instructors and directors of Tai Chi programs on the barriers and facilitators to the adoption of Tai Chi. Does this change affect the following? Please attach Revised Copy. Informed Consent Yes No Questionnaire Yes No Flyer Yes No Number of Participants Yes #_ 1000 _of participants No SIGNATURE SECTION Principal Investigator: (Date) If PI is student) : (Date) *******This section is for irb02 use only******* Reviewer Comments: Signature: IRB Chair Approval Date:

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162 Informed Consent Protocol Title: DIFFUSION OF TAI CHI IN OLDER POPULATIONS Please read this consent document carefully before you decide to participate in this study. Purpose of the research stu dy: To describe barriers and facilitators to practicing Tai Chi. What you will be asked to do in the study: To help develop a chart of facilitators and barriers to Tai Chi through anonymous post it notes, followed by discussion regarding the finished chart and participation in a self created survey. Time required: Up to 120 minutes Risks and Benefits: No more than minimal risk. There is no direct benefit to the participant in this research. However, this research can add to the understanding of reason s for practice or non practice of Tai Chi. Compensation: A free raffle will be held at the end of each focus group meeting for local area gift cards. Confidentiality: Your identity will be kept confidential to the extent provided by law. The names of the p articipants will not be used in any research reports or presentations. Your name will not be connected to your responses once the focus group meeting is over. The final results will be presented in a dissertation, and might be sent to education journals a nd magazines for possible publication. Voluntary participation: Your participation in this study is completely voluntary. There is no penalty for not participating. Right to withdraw from the study: You have the right to withdraw from the study at anytime without consequence. You do not have to answer any questions you do not want to answer. Whom to contact if you have questions about the study: Peter Gryffin, MS., Department of Health Education and Behavior, University of Florida Whom to contact about you r rights as a research participant in the study: UFIRB Office, Box 112250, University of Florida, Gainesville, FL 32611 2250; ph 392 0433. I have read the procedure outlined above. I voluntarily agree to participate in this study and have received a cop y of this description. _____________________________________ _____________________________________

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163 Participant #:___________________ Follow Up Questions: 1) What health acti vities do you currently engage in? 2) What do you find to be the largest motivating factor in your current health activities? 3) What were the largest factors in motivating you to begin your current health activities? 4) When did you begin your current health activities? 5) What do you find to be the biggest barrier to engaging in a health activity? 6) What would most motivate you to begin a new health activity?

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164 Participant Number:_____________________________ Tai Chi Student Backgrounder 1. How long have you been practicing Tai Chi? 2. What made you want to learn Tai Chi? 3. What do you find the most challenging in learning Tai Chi? 4. What parts of Tai Chi do you like the best, and why? 5. What do you think would make Tai Chi easier to learn?

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165 6. What do you think would make Tai Chi more popular ? 7. Do you have any particular observations you would be willing to share regarding benefits you feel you have received due to Tai Ch i? 8. What qualifications do you feel a Tai Chi teacher should have? 9. Do you have any other thoughts or observations you would like to add?

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166 LIST OF REFERENCES 1. Center for Disease Control (CDC). Chronic disease prev ention and health promotion http://www.cdc.gov/chronicdisease/overview/index.htm Updated 2010. Accessed February 16, 2012. 2. Rula EY, Pope JE, Hoffman JC. Potential medicar e savings through prevention and risk reduction. Pop Health Manag 2011;14:S 35; S 44 3. Center for Disease Control (CDC). Health, united states, 2010. with special feature on death and dying http://www.cdc.gov/nchs/data/hus/hus10.pdf Updated 2010. Accessed February 16, 2012. 4. Center for Disease Control (CDC). Costs of falls among older adults http://www.cdc.gov/HomeandRecreationalSafety/Falls/fallcost.html Updated 2011. Accessed February 16, 2012. 5. Chiang L, Cebula E, Lankford SV. Benefits of tai chi chuan for older adults: Literature review. World Leisure J 200 9;51(3):184 196. 6. Jimen ez PJ, Melendez A, Albers U. Psychological effects of tai chi chuan. Arch Gerontol Geriatr 2012;55(2):460 467. 7. Schleicher MM, Wedam L, Wu G. Review of tai chi as an effective exercise on falls prevention in elderly. Res Sports Med 2012;20(1):37 58 8. Yeh G, Wang C, Wayne P, Philips R. The effect of tai chi exercise on blood pressure: A systematic review. Prev Cardiology 2008;11(2):82 89. 9. Chan AW, Lee A, Suen LK, Tam WW. Tai chi qigong improves lung functions and activity tolerance in COPD clients: A single blind, randomized controlled trial. Complement Ther Med 2011;19(1):3 11. 10. Yeh GY, Wang C, Wayne PM, Phillips R. Tai chi exercise for patients with cardiovascular conditions and risk factors: A systematic review. J C ardiopulm R ehabil Prev 20 09;29(3):152 160 11. Song R, Ahn S, Roberts BL, Lee EO, Ahn YH. Adhering to a t'ai chi program to improve glucose control and quality of life for individuals with type 2 diabetes. J Altern Complement Med 2009;15(6):627 632. 12. Mortimer JA, Ding D, Boren stein AR, et al. Changes in brain volume and cognition in a randomized trial of exercise and social interaction in a community based sample of non demented chinese elders. J Alzheimer's Dis 2012;30(4):757 766.

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167 13. Lee ML, Pittler MH, Ernst E. Is tai chi a n effective adjunct in cancer care? A systematic review of controlled clinical trials. Support Care Cancer 2007;15:597 601. 14. Lee ML., Choi T., Ernst E. Tai chi for breast cancer patients: A systematic review. Breast Cancer Res 2010;120:309 316. 15. Ja hnke R. The healing promise of qi. New York: McGraw Hill Books; 2002. 16. Gryffin P. Qi: Implications for a new paradigm of exercise. Integr Med 2013;12(1):36 40. 17. Rogers E. Diffusion of innovations. NY: Free Press; 2003. 18. Chodzko Zajko W, Beattie L Chow R, et al. Qi gong and tai chi: Promoting practices that promote healthy aging. J Active Aging 2006;5(5):49 56. 19. National Commission for Health Education Credentialing (NCHEC). Responsibilities and competencies for health education specialists. http://www.nchec.org/credentialing/responsibilities/ Updated 2010. Accessed March 8, 2012. 20. ReCapp. How the health belief model was devloped. Resource Center for Adolescent Pregnancy Prevention Web site. http://www.etr.org/recapp/index.cfm?fuseaction=pages.TheoriesDetail&PageID=34 4 Updated 2007. Accessed March 15, 2012 21. Champion V, Skinner C. The health belief model. In: Glanz K, Rimer B, Viswanath K, eds. Health behavior and health education: Theories, research, and practice. San Francisco, CA: Jossey Bass; 2008. 22. Yellowpages. Yoga, tai chi. Yellow Pages Web si te. http://www.yellowpages.com/ Updated 2012. Accessed November 25, 2012. 23. Flick F. An introduction to qualitative research. CA: Sage; 2009. 24. Haberkorn J. Prevention and public health fund by 5 billion dollars over the next five years. Health Policy Brief Web site. http://healthaffairs.org/healthpolicybriefs/brief_pdfs/healthpolicybrief_63. pdf Updated 2012. Accessed March 20, 2012. 25. Wang G. Economic cost of hypertension http://www.orau.gov/hsc/hdspinstitute/2008/pres entations/AccessiblePDF/ac_Sessi on6AB Wang.pdf Updated 2008. Accessed March 8, 2012.

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168 26. Gryffin PA, Chen WC. Implications of T'ai chi for smoking cessation. J Alternat Complement Med 2013;19(2):141 145. 27. Chiang J, Yu Yawn Chen, Akiko T, et al. Tai c hi chuan increases circulating myeloid dendritic cells. Immunol Invest 2010; 39(8):863 873. 28. Irwin MR, Pike JL, Cole JC, Oxman MN. Effects of a behavioral intervention, tai chi chih, on varicella zoster virus specific immunity and health functioning in older adults. Psychosom Med 2003;65(5):824 830. implantable micro oxygen generator (IMOG). IEEE Transactions on Biomedical Engineering 2011;58(11):3104 3111. 30. Aerob ic.org. Aerobic history. http://www.aerobic.org/aerobic/aerobic history.asp Updated 2012. Accessed February5, 2012. 31. Roberto E. Closing the condom KAP gap. Options Policy Pr act 1977;3(4):3 10. 32. Noar SM. An Audience Channel Message Evaluation (ACME) framework for health communication campaigns. Health Promotion Practice 2012;13(4):481 488 33. Arroyo Barriguete J, Ernst R, Lopez Sanchez J, Orero Gimenez A. On the identifi cation of critical mass in internet based services subject to network effects. Service Indust J 2010;30(5):643 654. 34. Beaudreau SA. Qualitative variables associated with older adults' compliance in a tai chi group. Clin Gerontol 2006;30(1):99 107. 35. Chen K, Snyder M, Krichbaum K. Facilitators and barriers to elders' practice of T'ai chi. J Holistic Nurs 2001;19(3):238 255. 36. Avino K. Knowledge, attitudes, and practices of nursing faculty and students related to complementary and alternative medicin e: A statewide look. Holistic Nurs P ract 2011;25(6):280 288. 37. Atkinson NL, Permuth Levine R. Benefits, barriers, and cues to action of yoga practice: A focus group approach. Am J Health Behav 2009;33(1):3 14. 38. Archer S. Yoga survey reveals american attitudes. IDEA Fitness Journal 2010;7(5):64 64. 39. Yu S, Chen S, Lin K. The immediate effect of wheelchair tai chi on autonomic nervous modulation in subjects with chronic spinal cord injury: A pilot study. International Sport Med J 2012;13(3):96 108

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169 40. Buttery AK, Martin FC. Knowledge, attitudes and intentions about participation in physical activity of older post acute hospital inpatients. Physiotherapy 2009;95(3):192 198. 41. Crombie, I.K.: Irvine, L.: Williams, B., McGinnis AR. Why older people do not participate in leisure time physical activity: A survey of activity levels, beliefs and deterrents Age and Ageing 2004;33(3):287 292. 42. Ribeiro C, Milanez H. Knowledge, attitude and practice of women in campinas, sao paulo, brazil with respect t o physical exercise in pregnancy: A descriptive study. Reproduct Health 2011;8(1):31 37. 43. Hermens M. A new use for ishikawa diagrams. Qual Prog 1997;30(6):81. 44. Fluker S, Whalen U, Schneider J, et al. Incorporating performance improvement methods in to a needs assessment: Experience with a nutrition and exercise curriculum. JGIM: J Gen Intern Med 2010;25:627 633. 45. Duckett S, Nijssen Jordan C. Using quality improvement methods at the system level to improve hospital emergency department treatment t imes. Qual Manage Health C are 2012;21(1):29 33. 46. Fern EF. Focus groups: A review of some contradictory evidence, implications, and suggestions for future research. Advances in Consumer Research 1983;10(1):121 126.. 47. Boyatzis RE. Transforming qualit ative information: Thematic analysis and code development. Thousand Oaks, CA US : Sage Publications, Inc; 1998. 48. On Top of The World Communities. Welcome. http://ontopofthew orldcommunities.com/#&panel1 1 Updated 2012. Accessed August 5, 2012. 49. Higgins PA, Straub AJ. Understanding the error of our ways: Mapping the concepts of validity and reliability. Nurs Outlook 2006;54(1):23 29. 50. Lam P. Tai chi for health institut e. http://www.taichiforhealthinstitute.org/about_us/#purpose%22 Updated 2012. Accessed March 13, 2012. 51. Frye B, Scheinthal S, Kemarskaya T, Pruchno R. Tai chi and low impact exercise: Effects on the physical functioning and psychological well being of older people. J Applied Geront 2007;26(5):433 453. 52. Lam P. Teaching tai chi effectively. Australia: Shannon Books; 2006.

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170 53. Gryffin P. Essential tai chi. https://sites.google.com/site/essentialtaichi/ Updated 2012. Accessed March 20, 2012. 54. Weinreich Communications. Weinreich communications: Change for good Social Marketing Web sit e. http://www.social marketing.com/ Updated 2010. Accessed March 8, 2012. 55. Hanks T. Larry crowne. [DVD]. Universal Pictures; 2011. 56. Hoets H. What is bias in qualitative research? Focus Gro up Tips Web site. http://www.focusgrouptips.com/qualitative research.html Updated 2012. Accessed March 2, 2013, 2013. 57. Prochaska JO, Marcus BH. The transtheoretical mod el: Applications to exercise. In: Dishman RK, ed. Champaign, IL England: Human Kin etics Publishers; 1994:161 180. 58. Prochaska J, Velicer W. The transtheoretical model of health behavior change. Amer J Health Prom 1997;12(1):38 48. 59. Ritchie JE. Case s eries research: A case for qualitative method in assembling evidence. Physiotherapy Theory Practice 2001;17(3):127 135 60. Vlachopoulos SP, Gigoudi MA. Why don't you exercise? development of the amotivation toward exercise scale among older inactive indi viduals. J Aging Phys A ctivity 2008;16(3):316 341. 61. Everett B, Salamonson Y, Davidson PM. Bandura's exercise self efficacy scale: Validation in an australian cardiac rehabilitation setting. Int J Nurs Stud 2009;46(6):824 829. 62. Lewis M, Sutton A. Un derstanding exercise behaviour: Examining the interaction of exercise motivation and personality in predicting exercise frequency. J Sport Behav 2011;34(1):82 97. 63. Edmunds J, Ntoumanis N, Duda JL. Helping your clients and patients take ownership over t heir exercise: Fostering exercise adoption, adherence, and associated well being. ACSMS Health F itness J 2009;13(3):20 25 64. Abbott, Ryan B.Ka Kit HuiHays,Ron D.Ming Dong LiPan, Timothy. A randomized controlled trial of tai chi for tension headaches. Ev idence based Complementary & Alternative Medicine (eCAM) 2007;4(1):107 113

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171 BIOGRAPHICAL SKETCH Originally from Pasadena, Californi a, Peter A. Gryffin earned his Master of S cience in kinesiology and health p romotion in 1997 from California State Polyte chnic University, Pomona. Following this, he began teaching at Fullerton College, where developed eight new courses based on holistic health practices and experiential education, using the development of mindfulness as a core component for creating awaren ess of self destructive behavior, as well as motivating positive psychological and physiological health through alternative fitness. Peter returned for his PhD at the University of Florida to lay a foundation for researching, developing, and promoting inno vative and evidence based programs for health and wellness. A large part of his study included social marketing and effective diffusion of health behavior (currently tai chi), as well as the development of a Health Belief Model Tool (HBMT) for prediction a nd motivation of health behavior and effective development of tailored messaging. His research interests also include motivation and awareness as it relates to health and behavior change across the lifespan (including application to hypokinetic diseases, a s well as addiction). Peter has published over 10 articles in mainstream magazines, and is enjoying using his writing talents for journal publication and active dissemination o f health interventions. Peter was also the assistant editor for the Internationa l Electronic Journal of Health Education (IEJHE), a publication for the American Association for Health Education (AAHE) His previous works and interests include research into physiological mechanisms behind the benefits of tai chi for a variety of chroni c conditions, and the use of experiential fiction as a teaching aid for motivating greater behavioral control over life incidences.