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Metrics details. Eight databases were searched to identify eligible studies using quantitative, qualitative, and mixed research methods. Using elements of narrative synthesis, engagement strategies, and reported facilitators and barriers were identified, tabulated and analysed thematically for each of the three groups of older people. Twenty-three studies 3 with oldest-old, 16 with BME older people, 2 within deprived areas, 1 with both oldest-old and BME, 1 with both BME and deprived areas were included.
Methods included 10 quantitative studies of which 1 was an RCT , 12 qualitative studies and one mixed-methods study. Facilitators for engaging the oldest old included gaining family support and having flexible sessions. Among older people in deprived areas, facilitators for engagement included encouragement by peers and providing refreshments.
Feeling too tired and lacking support from family members were additional barriers for the oldest old. Similarly, feeling too tired and too old to participate in research on health promotion were reported by BME groups. Barriers for BME groups included lack of motivation and self-confidence, and cultural and language differences. Barriers identified in deprived areas included use of written recruitment materials. Strategies to successfully engage with the oldest old included home visits and professionals securing consent if needed.
Strategies to engage older people from BME groups included developing community connections and organising social group sessions. Strategies to engage with older people in deprived areas included flexibility in timing and location of interventions. Peer Review reports. Globally, the ageing population is growing, contributing to pressures on health and social care systems [ 1 ].
Health promotion interventions to assist older people in building and maintaining their physical and cognitive function can reduce the risks of disease and loss of independence [ 1 ]. Preventative strategies for chronic diseases associated with older age have therefore become a public health priority [ 2 ]. The oldest old people aged 80 years and over , older people living in deprived areas and older people from black and minority ethnic groups BME have more health problems and health care disparities compared to the general older population [ 3 , 4 ].
The oldest old is the fastest growing age group in the population [ 5 , 6 ], making them an important target for health interventions. Furthermore, this group is a diverse section of the population, ranging from relatively healthy, independently living individuals to very frail individuals with multiple diseases, poor physical functioning and cognitive problems, presenting unique challenges for undertaking research on health promotion [ 7 ], and thus they are often excluded from studies [ 8 , 9 ].
However there is a growing body of evidence suggesting that the oldest old can gain substantially from various health interventions [ 10 ]. A systematic review has shown greater improvements from health promotion activities such as exercise in frail individuals aged 80—90 years compared to individuals aged 71—79 years suggesting that health interventions such as exercise classes can be beneficial to the oldest old [ 11 ]. Similarly, a meta-analysis has shown that balance training is effective in preventing falls in those aged 75 years and over [ 12 ].
However, no systematic reviews on the oldest old have to our knowledge considered a broad range of health promotion interventions within the review.
BME older people form a significantly increasing proportion of the ageing population in both Europe and North America [ 10 , 13 ]. However, older BME groups have been underrepresented in clinical research [ 14 , 15 ], and have reported greater difficulty accessing health and social care services [ 16 , 17 ]. A recent meta-ethnographic analysis on barriers to physical activity among BME groups aged 18—65 years in the UK showed that physical activity was often seen as a formal separate activity and a part of Western culture external to their own lifestyle and difficult to incorporate into their lives.
The authors suggested culturally sensitive health promotion interventions are crucial to increase physical activity levels in BME communities [ 18 ]. However we do not know if these findings apply in older people from BME groups. Furthermore, to our knowledge, no systematic reviews on older BME groups and engagement in broad health promotion interventions that is, not limited to one intervention e.
Multi-morbidity is more common and occurs 10—15 years earlier in older people who live in deprived areas compared to older people in affluent areas [ 19 ]. Nevertheless, health promotion interventions have not been employed extensively among older populations in deprived areas [ 8 , 20 ], and to our knowledge no systematic reviews have reviewed engagement in research on health promotion in older people living in deprived areas. Health inequity often underpins the diversity observed in older age and it has been suggested that disproportionate efforts should be made to reach sub-groups of older people that are particularly disadvantaged [ 1 , 20 ].
The most effective engagement strategies and intervention features in reaching disadvantaged older people need to be systematically determined in order to target those who could benefit the most [ 21 ].
A systematic review therefore, focusing on facilitators, barriers and effective methods to engage the oldest old, older people from BME groups, and older people in deprived areas in health promotion provides a resource for current work and future research. The search strategy is outlined in Appendix A. The team consisted of researchers with expertise in ageing and health and social care, a research assistant, a PhD student and two patient and public representatives who were involved at all stages of the wider study including seeking funding.
Quantitative, qualitative and mixed-method studies of engagement of older people to research on health promotion published between 1 January and 31 December were included. In this paper, engagement refers to processes such as introducing, recruiting and retaining individuals into health promotion interventions. Systematic reviews and studies not exploring the topic of engagement in health promotion among at least one of the three sub-groups defined oldest old aged 80 years and over, BME older people, older people in deprived areas were excluded.
Searches were restricted to studies in English published between January and December References retrieved through the systematic searches were managed using Endnote X7 reference manager software. Following de-duplication of studies obtained from the database searches, abstracts were independently screened for eligibility by two researchers AJ and AL. Any disagreements were resolved by a third researcher KK. Abstracts not meeting the inclusion criteria were excluded, resulting in studies which were read in full text.
Studies not meeting the criteria were excluded, leaving 34 studies for quality assessment using the Critical Appraisal Skills Programme CASP guidelines [ 22 ], which enabled the studies to be classified into high, medium or low quality. Eleven studies were classified as low quality and removed because, for example, the authors referred to facilitators and barriers in previous studies but did not report or discuss potential facilitators and barriers derived from data from their own study or it was unclear whether the potential facilitators and barriers mentioned were reported by the participants or hypothesised by the researchers.
This resulted in a total of 23 studies for analysis 16 studies rated as medium and 7 studies rated as high. Narrative methods using thematic analysis can be used to synthesise quantitative and qualitative studies to identify and bring together the main, recurrent or most important issues or themes arising from the literature [ 23 ].
For this study, data extraction and analysis were guided by principles of narrative synthesis, including tabulation and thematic analysis [ 24 ]. The data were extracted inductively using a standardised data extraction form. The themes were identified by the same two researchers and then discussed, further developed and agreed with the team. A narrative approach was used to allow handling of a wide range of evidence from quantitative and qualitative research divided into facilitators and barriers.
This review reports potential facilitators, barriers and strategies to engagement in research on health promotion in groups of older people known to participate less, including the oldest old, older people from black and minority ethnic groups BME , and older people living in deprived areas.
From this data we have extracted key potential strategies, reported as having been successfully employed by authors to increase engagement with health promotion across the three groups. However findings should be interpreted with caution as only one study included in this review has formally tested the effectiveness of these approaches in an experimental study. Twenty-three articles were included in the systematic review Tables 1 and 2. Three studies were of the oldest old, 16 studies were of BME older people and 2 studies were of older people in deprived areas.
Two studies overlapped; one including both the oldest old and BME older people, and one including both BME older people and older people in deprived areas. Ten studies were of quantitative methods e. Family involvement in the form of the research team engaging with family carers was demonstrated to be important when undertaking research with the oldest old [ 4 ].
Further, allowing for flexibility in timing and length of the intervention was found to facilitate health assessments in participants reporting fatigue [ 4 , 26 ]. One study reported that min sessions were initially offered but some participants benefited from having several shorter sessions [ 4 ]. The risk of fatigue further resulted in researchers conducting the most relevant part of the assessment first [ 4 ]. On an individual level, poor health was a barrier reported in all studies [ 4 , 5 , 25 , 26 ].
Similarly, feeling too tired stopped people from taking part [ 4 , 5 ] or resulted in participants only undertaking a shorter version of the assessment [ 4 ]. In addition, family members may also ignore the request or be slow in providing participation assent for a relative who lacks decision making capacity, which may require more time and resources [ 4 ].
In-home sessions included barriers such as lack of facilities for example, a firm surface to lie down on for certain health and research measurements [ 26 ]. Recruitment via primary care health professionals who are known and trusted by participants was successful [ 25 , 26 ].
Invitation letters sent from the university undertaking the research study to potential participants asking for a structured interview, physical examination and access to medical records generated a good response rate for some recruitment sites [ 25 ]. Recruitment materials from the research team with photographs of the researchers accompanied with a letter from the local primary care clinic conveyed trustworthiness and encouraged prospective participants to contact the research team directly, rather than the primary care clinic, which also reduced workload [ 4 ].
Respectful and empathic telephone calls by researchers approaching prospective subjects were reported as a successful recruitment strategy if a home visit had been undertaken before or after the phone call [ 4 , 26 ]. Carrying out the recruitment process over several stages over several months may also have facilitated participation by minimising subject burden and limiting resource intensity for the research team [ 26 ].
It was reported that ongoing face-to-face and written communication aided long-term engagement, and the research team also found it useful to ask the participant to nominate someone with whom the research team could liaise in case the participant would lose capacity during the course of the study [ 4 ]. In one study, location of data collection was discussed, and the oldest old stated a preference for home visits over external venues such as hospital or other clinical settings [ 4 ].
Most studies on the oldest old unsurprisingly reported problems with high mortality risks [ 4 , 25 , 26 ], including identifying potential participants who died before being contacted for recruitment [ 4 , 25 ], and mistakenly having tried to enrol participants who had recently died [ 26 ].
Strategies reported as useful in minimising these risks included checking their status with their GP and posting recruitment letters within 24 h after such checks [ 4 ]. It was further reported that the research team needs to know how to communicate with family members of potential study participants who died very soon after recruitment letters had been posted to minimise distress to the family [ 4 ]. Several studies reported that developing strong connections to the targeted community and its leaders was essential as it resulted in greater acceptance of the study and the study team, increasing engagement [ 25 , 27 — 32 ].
Matching participants and researchers by ethnicity facilitated communication and allowed for mutual understanding of cultural practices [ 25 , 28 , 30 ], and this resulted in a greater number of individuals being willing to take part compared to non-ethnically matched recruiters [ 28 ]. Trust included initial contact made by known and trusted primary care health professionals [ 25 ], and reassurance from clinicians that sickness or disability would not be a problem when engaging in, for example, physical activity interventions [ 33 ].
Health promotion interventions that participants thought would personally benefit their health [ 34 , 35 ] as well as their families [ 25 , 33 ] including sessions targeting mental and physical health e. Social support from family, friends and healthcare professionals was important in encouraging participants to enrol as well as remain in the study [ 34 , 37 ].
Social support also included group-based health interventions [ 30 , 31 , 36 , 38 , 39 ], which were preferred to individual sessions because of their social element [ 30 , 31 ]. Many studies reported that having other priorities such as family responsibilities including caring for grandchildren particularly women [ 34 , 36 , 39 ], schedule or timetabling conflicts [ 39 ] or lack of time [ 25 , 30 , 33 , 39 ] prevented participation. Some older people from BME groups were reluctant to receive home visits [ 38 ].
Barriers to engage in health promotion further included poor health being too burdensome for subjects to participate [ 25 , 31 , 33 , 35 — 38 , 40 ], and feeling too old to benefit from health promotion [ 35 — 37 ]. In one study participants thought the health assessment was too long and asked for a partial assessment [ 25 ]. Cultural and language barriers included the contact person of the research team speaking English only [ 29 ], having difficulty obtaining information due to lack of translated materials [ 41 ] or a lack of large print translated versions of publicity material [ 41 ].
In addition, religious practices including fasting [ 37 , 41 ] and mixed-sex sessions prevented participation in physical activity interventions [ 37 ].
Lack of confidence furthermore included fear of embarrassment of taking part in a specific screening test [ 42 ]. Participants were more likely to take part if the research on health promotion was held in a familiar place [ 43 ]. Recruitment in churches [ 43 ] and senior centres [ 32 , 38 ] resulted in the highest enrolment rates.
In contrast several studies reported problems recruiting potential participants when using leaflets [ 27 ] and local radio and newspapers publicity [ 28 , 32 , 38 ].
Face-to-face and gatekeeper referrals were the most successful recruitment methods in one study [ 28 ]. Recruitment was also more likely to be successful if participants had heard about the study by word-of-mouth first [ 27 , 43 ]. Introductory meetings about the study at community centres in combination with posters and newspaper advertising facilitated recruitment [ 29 , 32 ] and encouraged prospective participants to telephone the research team to enrol [ 29 ].
However, another study reported that telephoning potential participants was more effective than distributing leaflets, letters, organising presentations and TV adverts [ 27 ].