Authors: Joanie Sims-Gould, Rei Ahn, Neville Li, Callista Anne Ottoni, Dawn C. Mackey, Heather Anne McKay
Categories: Original Articles, aging, health promotion, hegemonic masculinity, mobility, photovoice, physical activity
Source: American Journal of Men's Health
North American “hegemonic masculinity” values strength, autonomy, independence, and resilience among its ideals. As men age, their capacity is increasingly challenged and demands that they adapt to new physical and social realities. Although some reports on effective health-promoting programs for men are emerging, there is a need to better understand older men’s experiences with their mobility and physical activity. This is a photovoice study with men (N = 14) who were enrolled in a choice-based activity program for low active men. Based on in-depth interviews and analysis of over 800 photographs, three key themes the importance of social connectedness, supportive environments, and positive attitude toward the future. Findings are presented via a theoretical view of masculinities as socially constructed through relational behaviors and norms. Analyses provide insight into older men’s motivation to be physically active and highlight the need for programs and policies customized to promote physical activity of older men.
Keywords: hegemonic masculinity, aging, physical activity, mobility, health promotion, photovoice
North American “hegemonic masculinity” (Courtenay, 2000a) values strength (physical toughness), autonomy, independence, and resilience (Connell, 1987; Hearn, 2004;). Connell theorizes that masculinities are the performance of actions that depend on social context (Connell, 1995; Connell & Messerschmidt, 2005), which in turn posits that there is a “masculine ideal” of behavior. Value-based meanings of one’s self and behaviors are constructed through repeated actions and interactions in relation to this socioculturally based ideal. Men who are able to enact this ideal retain social positions of power (Connell, 1995).
Race, ethnic background, class, and sexual orientation are widely recognized as influencers of masculine identities; however, age is often overlooked. As men age, they are increasingly seen as “ungendered” and older men’s experiences are not considered in the masculinity script (Spector-Mersel, 2006). Factors associated with older age—loss of strength, mental capacity, independence, and autonomy—are in opposition to values of hegemonic masculinity. Loss of independence as people of either sex age affects health behaviors such as physical activity, recovery from injury, reliance, diet, and mental deterioration (Smith, Braunack-Mayer, Wittert, & Warin, 2007). Older men’s physical capacity is increasingly challenged as they age and encounter new physical demands and environmental realities. This study operationalizes gender as dynamic, where perceptions of gender may change over time, as physical and mental capabilities differ across age and geographical settings, thus invoking a life course perspective (Gibson et al., 2014).
In Canada, there are now more adults over the age of 65 years than there are children under the age of 15 years (Statistics Canada, 2017a). Within the next 30 to 40 years, this will escalate to two adults over age 65 years for every child under the age of 15 years (Statistics Canada, 2017b). There will be a greater increase in the proportion of adults over age 85 years than any other age group (Statistics Canada, 2017c). The proportion of Canadian men in the older adult population is increasing— an outcome of the shrinking gender gap in life expectancy (Statistics Canada, 2017c; United Nations, 2013), as older men are surviving longer than in previous generations.
The reported rates of physical inactivity, one of the leading risk factors for global mortality, continue to rise (WHO, 2010). Older adults’ active participation in physical activity and meaningful activities prevents disease and retains physical function (Kendig, Browning, & Young, 2000). Evidence that regular physical activity offers health benefits (Powell, Paluch, & Blair, 2011) and supports healthy aging ( Gabriel & Browling, 2004; Rowe & Kahn, 1997) is irrefutable. Despite these many benefits, less than one third of older adults in Canada meet recommended physical activity guidelines (Ashe, Miller, Eng, & Noreau, 2009).
A systematic review of older adult physical activity shows that most older adults do not meet recommended activity guidelines (Sun, Norman, & While, 2013); this holds true for studies using self-reported and objective measures (Sun et al., 2013). In addition, studies of physical activity in older adults have tended to emphasize the experiences of Paterson and Warburton’s (2010) systematic review on physical activity and function included six women-only studies; a systematic review of physical activity and social support (Smith, Banting, Eime, O’Sullivan, & van Uffelen, 2017) included four women-only studies; the vast majority of the individual studies included in these reviews had a higher percentage of women participants; and there were no men-only studies included in either review.
Older men do acquire more leisure-time physical activity than older women do, but these findings are less clear when looking at total physical activity (Sun et al., 2013). Notthoff, Reisch, and Gerstorf’s (2017) systematic review of physical activity in older adults specifically examined gender, with results that were “somewhat inconclusive” (p. 451). Men appear to acquire more physical activity, but only when assessing leisure-time activity, transportation, and sport (Notthoff et al., 2017; Sun et al., 2013). Women appear to acquire more activity that pertains to the performance of household tasks (Notthoff et al., 2017; Sun et al., 2013). Irrespective of gender, motivation and self-efficacy are significant drivers of physical activity in older adults (Notthoff et al., 2017).
A systematic review on the physical activity preferences of older adults suggests some gendered differences (Amireault, Baier, & Spencer, 2017): Older women prefer lower intensity activities, compared to men; older women may prefer exercise close to home or in the home, more so than older men; and older women may prefer exercises indoors, compared to men. But, as Amireault and colleagues conclude, their review is “mainly generalizable to white-Caucasian females from the US” (2017, p. 1). There is limited evidence regarding the physical activity preferences and experiences of older men.
Modifiable health risk behaviors such as physical inactivity have negative impacts on health outcomes. Courtenay (2000b) contends that men and boys are more apt to adopt unhealthy beliefs, and behaviors generally, as a means to signify manhood. Societal expectation is for men to portray traits such as independence, self-reliance, and imperviousness to pain and illness; Western culture celebrates men’s capacity to carry these traits into middle and late adulthood (Smith et al., 2007). While studies have examined aging male bodies (Calasanti & King, 2005; Marshall, 2006) and health behaviors (Smith et al., 2007; Tannenbaum & Frank, 2011), more research is required to better understand how masculinity plays out for older men.
The primary objective was to shed light on older men’s experiences with their mobility and physical activity, through the use of the photovoice method. In doing so, the study provides insight into whether and how self-efficacy and masculinity underpin older men’s experience with mobility and physical activity. The secondary objective was to better understand the impact of the Men on the Move randomized, controlled trial (RCT), as part of a formative evaluation of the RCT. The results presented here focus on the primary objective.
This study is guided by symbolic interactionism. Symbolic interactionism states that “the meaning that things have for human beings are central in their own right” (Blumer, 1969, p. 3); these meanings form the basis of social interaction (Sims-Gould, Hurd Clarke, Ashe, Naslund, & Liu-Ambrose, 2010). Hence, human behavior can be understood from the perspective of individuals as they create their own realities (Hewitt, 2006; Prus, 1996).
Photovoice is a qualitative research strategy “by which people create and discuss photographs as a means of catalyzing personal change” (Wang, Yi, Tao, & Carovano, 1998, p. 75). It is often used to bring forth perspectives of individuals who are not typically heard in research (Frohmann, 2005; López, Eng, Randall-David, & Robinson, 2005; Moffitt & Vollman, 2004; Wang, 2003; Wang, Burris, & Ping, 1996). Participants are given cameras and asked to photograph, reflect upon, depict, and communicate their life experiences. The end results are photographs that provide powerful visual representations of one’s experiences, knowledge, and perception; in this case, older men’s perception of physical activity and mobility. Our research team has conducted several large, in-depth qualitative studies with older adults discussing their physical activity and mobility (Franke, Tong, Ashe, McKay, & Sims-Gould, 2013; Ottoni, Sims-Gould, Winters, Heijnen, & McKay, 2016; Tong, Sims-Gould, & McKay, 2016). In these qualitative studies, we consistently found that it was difficult for individuals to express concepts such as “reasons for physical activity.” In this study, we sought a research design with different mechanisms for participants to express themselves and critically discuss their perspectives on physical activity. Photovoice is distinct from interviews, in that the initial round of data collection is largely driven by the participant rather than the researchers; in this sense, photovoice is both participatory and “democratic” (Wang, 2003). The use of participants’ photographs provides researchers and participants with thought-provoking discussion prompts. Previous studies have demonstrated the utility of photovoice with older adults (Novek, Morris-Oswald, & Menec, 2012) and with older adults discussing their local environments and physical activity (Mahmood et al., 2012). Photovoice was selected as a catalyst for discussion and to promote an understanding of how older men engage in and perceive physical activity.
The sample for this photovoice study was drawn from a group of 58 men who participated in Men on the Move, a randomized, controlled, single-blinded (outcome assessors), feasibility trial (RCT) (Clinical Trials Registry NCT02527655). The intervention was a 12-week choice-based physical activity and active transportation program based on the Community Healthy Model Program for Seniors (CHAMPS; Stewart et al., 1997). The inclusion criteria were as 65 years of age and older; identify as a man; English speaking; and demonstrate readiness for physical activity (by the PAR-Q+ questionnaire or a letter of recommendation from the physician). The exclusion criteria were as performed ⩾75 minutes of moderate-to-vigorous intensity physical activity during the past week; participated in any strength training in the past 3 months; participated in any aerobic exercise class in the past 3 months; live in a nursing home or assisted living facility; or have plans to be out of town for more than 7 days during the 12-week intervention period.
Men on the Move was conducted in Vancouver, British Columbia, from September 2015 to May 2016 and had three primary data collection points (baseline, intervention end, and follow-up). All participants lived in the Greater Vancouver area. The primary aim of Men on the Move was to investigate the rates of participant recruitment, retention, and adherence to the physical activity intervention. The secondary aim was to determine the influence of the intervention on physical activity and mobility. Participants were given a 12-week local transit pass (Compass Card) that provided them free access to local transportation networks across Metro Vancouver including all buses, SkyTrain, and the Canada Line. Men on the Move RCT and photovoice studies received ethics approval from the Research Ethics Board at the University of British Columbia.
All volunteers in the Men on the Move RCT were invited to participate in the photovoice study; 14 men were recruited and consented to participate. Men in the Photovoice study ranged in age from 64 to 88 years; mean age was 75 years (see Table 1 for participant demographics). Recruitment for the photovoice study began in February 2016, pictures were taken in April 2016 and interviews were conducted in April–May 2016.
To provide participants with some background in photovoice methodology, a photography instructor provided a 1-hour session on the use of the iPhone camera and on photo composition. The iPhone camera was selected, as participants were already familiar with iPads used in the Men on the Move RCT. Following the workshop, participants were asked to take as many photographs as they chose over 1 week, to best represent their responses to the following (a) What makes you want to be physically active? (b) What keeps you from being physically active? (c) How has the Men on the Move program changed your relationship with physical activity? Participants were instructed not to take pictures of any minors/children (under 18 years) and to obtain permission (using a Photo Release Form) for anyone over 18 years included in their photos. The participants were told that the photographs did not need to capture human subjects.
Collectively, the 14 participants generated a total of 870 photographs depicting their perceptions of mobility and physical activity. Each participant took 62 photos, on average.
In addition to the visual representations (photos), participants were also provided a log book to describe the relevance and meaning of each photograph. After 1 week, participants were invited back to participate in one taped interview and were asked to choose their three most preferred photographs. Participants were asked to reflect on what the pictures represented and why certain photographs were considered their favorites and/or provided the best answer to the research questions. Participants were asked to caption each photograph during the interview. On average, the interviews were 26 minutes in length. Each participant was provided an honorarium of $10 for participating in the interview; interviews were digitally recorded and professionally transcribed verbatim.
To organize and analyze the photographs, logs, and transcripts, the analysis consisted of a five-step process, based on similar processes used elsewhere (e.g., Castleden, Garvin, & Huu-ay-aht First Nation, 2008; Wang, 1999). Steps included the (a) View the photos and assign participant pseudonyms, (b) match the photos with corresponding descriptions, (c) examine themes and trends across the photo descriptions using NVivo 10 software, (d) analyze content of interview transcripts, and (e) confirm themes (member checking) with participants during a participation appreciation event where photos were presented and themes discussed.
Many participants’ visual and textual images reflected their inspiration for movement and encouragement to be more active. This inspiration was portrayed in two different ways—as daily connections men have with the people around them and movement observed in their communities (e.g., children running).
Participants used images of outings to describe where they would go and what they would do. In these outings, they were not alone but with other people such as their spouse, children, or friends. In these relationships, children, grandchildren, and spouse acted as motivators to be more active. One participant discussed walks with his son and stated, “[My son’s] main thing is we don’t drive anywhere. We walk … we go to a restaurant or coffee shop, we walk. And he insists on that” (Lawrence, 85 years). Men’s family including grandchildren, children, and friends were their companions for walks. In the case of friends, motivation to be active was reciprocal.
Some regular outings were designated for specific people. Having taken a photograph of his three golfing friends he meets every Monday, a 70-year-old man
These social connections offered encouragement to engage in regular physical activity and made physical activity more enjoyable.
For some men, inspiration came from general movement, as represented by images of other people moving. Participants described others’ movement as encouraging, as it initiated the feeling of wanting to move more themselves. For example, a participant described how he felt when he saw a young child running on the street.
Participants frequently discussed being part of a moving crowd (e.g., Roland; Figure 1). Ultimately, being part of their surroundings allowed participants to feel connected to the world, although they were not directly involved in the movement. This sense of connection made some men feel as if they were not alone. For some participants, being part of a crowd and in proximity to others was sufficient for feeling as though they were connected to others. While many participants valued social connection, several participants also emphasized solitude in their daily activity and physical activity. Four participants viewed solitude as relaxing and enjoyable. Robert attends the gym alone, but this doesn’t mean his experience is devoid of social connection. He
Figure 1. Movement in stillness (Roland). A young lady crossed her legs, and seeing movements or motions encourages him to be active. Although the lady was standing still, she needed to move to get into this position.
In the context of photographs and text, built and natural environments compelled participants to go out into the community. To begin, many men used images of nature including flowers, bushes, and trees in parks and also sunsets at beaches taken in, or sometimes away from, their neighborhood. Participants took over 350 photos of nature. The natural environment was described as beautiful and tranquil. Men often visited these places to seek peace. When a participant was asked why he chose a photo of a sunset as his favorite, he said, “I always go to the beach for the sunset. It’s kind of therapeutic for me. It’s beautiful, and the colors— it’s a beautiful moment” (Figure 2; Timothy, 70 years). Another man expressed similar thoughts and displayed the desire to live closer to “I would like to live in one of these homes over here. Very lucky people to wake up every morning and look out over such beauty” (Edward, 73 years). This contrasted to where he currently lived, surrounded by tall buildings.
Figure 2. Active life (Timothy). The beautiful colors of the sunset have a therapeutic influence on his well-being and allow a reflection on life.
The built environment included pictures of interesting monuments or aesthetic structures in participants’ neighborhoods. Participants who took these photos discussed how accessible services and amenities in their neighborhood encouraged them to be out in their community (e.g., Wilbert, Figure 3). When describing his travel patterns, one participant said, “I don’t think I fill a tank in my car more than three times a year ’cause I walk all the time. I walk to the bank. I walk to my doctor’s. I walk to the groceries” (Ralph, 88 years). Similarly, participants expressed how the neighborhood they live in enabled them to walk more due to their proximity to available amenities. In contrast, a participant who recently moved away from a walkable neighborhood said this about his new neighborhood, “If I am going for a walk. And there really isn’t even a park close by and very busy roads, a lot of traffic … it’s not a place one would choose to walk in” (Ernest, 84 years). Due to the changes in his environment, Ernest had to adjust to driving more than usual, to travel to where he needed to be.
Figure 3. Neighborhood (Wilbert). The neighborhood that he lives in enables him to go out often.
Similarly, many men relied solely on their automobiles as the primary mode of transport. For some this changed during Men on the Move when they were provided and trained on how to use the complimentary Compass Card. Participants who are new to the transit system discovered the convenience and joy of taking the transit to get around the city. Many participants took public transit to take photos for photovoice study. One participant said,
Another participant who rarely used public transit described his
The transit pass allowed participants to go to places on transit routes that they had never visited and use active travel to and from transit stops to increase their physical activity level. Active travel eliminated the hassles that come with driving and diminished the likelihood of sitting in a car in traffic.
Brighter future emerged as a central theme in photos and the interviews; several layers were represented. First, participants portrayed acceptance of their previous versus current self. One participant spoke about his “lost youth” (Philip, 76 years) early on in the interview when providing comments on a photo of flowers. He discussed how the flowers “sort of disappear after … so they have all their gorgeous stuff in the spring … everything sort of tapers off.” For this man, he was the flower and what he saw was the impermanence of his youth. Later on, when looking at a different photo of California poppies growing between cracks in concrete, he was amazed at the flowers’ survival. He described how the photo represented his “late blossoming youthfulness” and captioned the photo “Survival Anywhere.”
Some men displayed a similar positive outlook by showing examples of resilience through their photos. They also had a sense of curiosity when looking forward to their future and embraced the unknown.
This sense of positivity and forward momentum could reflect participation in Men on the Move, as many participants appreciated how the program provided them with motivation to go back out into their community. For example, in Robert’s (80 years; Figure 4) photograph of the crane and construction site, he concluded, *“*The crane maybe represents, to a certain degree … a program like Men on the Move … helping me to make it easier and moving me ahead a bit faster to reach my goals.” Many participants felt they benefited from participating in Men on the Move and that their health improved. One participant took a photo of his 93-year-old role model and stated, “She’s incredible … she lives on her own in her house and keeps her garden. Grows potatoes, figures there’s a lot of life yet … I admire her. I think she’s a good example for me (Rudy, 71 years).” Many participants shared their positivity for their current progress to better health and life in general and saw an opportunity for growth.
Figure 4. The beginning and progress of determination to finale (Robert). This construction site shows a work in progress. People hardly realize the changes that happen on a day-to-day basis, but eventually the frame will turn into a finished building. Robert thinks his life is also a work in progress and moves toward his destination each day.
Although some men discussed their loss of physical capacity and abilities, many also discussed physical activity opportunities in future. Ralph can no longer play hockey or tennis due to a loss of some mobility in his legs. He principally misses the social aspect of these sports. Reflecting on options for the future, he hopes to take up lawn “I tried [lawn bowling] maybe 30 years ago when I was playing tennis and it was too tame then. But I think I’ve kind of grown into it now” (Ralph, 88 years). Other participants rejected the notion that they were “old” and less physically capable. Edward, for example, emphasized how he still feels physically strong and people normally won’t see “a 73 year old man climbing around cliffs and riding on motorcycles” (Edward, 73 years). Edward does not frequent seniors’ centers, as they are for those who are “old.” Through his physical activity choices, Edward rejects stereotypes associated with aging.
In each theme, findings reflect the heterogeneity of men’s experiences of and perspectives on physical activity and mobility; participants shared imagery that was both stereotypically masculine and feminine; participants valued social connection, but also placed a high value on solitude and independence; and participants appreciated public transit, but many continued to solely rely on their personal automobiles for transportation.
There was variability among the photos and men’s perspectives as to conformity to masculine stereotypes. Some men took photos of “masculine” things such as a construction site to represent their physical activity progression. Others photographed a carpenter, tool boxes, and hockey skates to exemplify their physical activity in previous years. However, many photos were of flowers, which are generally seen as “feminine” (Thompson, 2006).While floral images are considered “feminine,” flowers evoke a positive emotional response and better self-reported moods of both older men and older women (Haviland-Jones, Rosario, Wilson, & McGuire, 2005). Gardens and flowers were just one example of a positive outdoor environment that supported participants’ physical activity. Supportive natural and physical environments also included sunsets, beaches, visually interesting monuments, and proximity to amenities. Participants described their local environments as “beautiful” and “tranquil.” Timothy invoked the notion and language of therapeutic landscapes (Milligan, Gatrell, & Bingley, 2004). Many photos with captions that participants shared invoked the notion that particular landscapes and gardens “harness the healing power of nature” for older adults who reside in these spaces (Milligan et al., 2004, p. 1781).
An established body of literature supports a connection between social experiences, the social environment, and physical activity (Bauman et al., 2012; McNeill, Kreuter, & Subramanian, 2006); a supportive social environment and social connectedness increase older adults’ physical activity (Smith et al., 2017). As noted, the physical activity literature has tended to focus on the experiences of older women. In Smith et al.’s (2017) systematic review, they found a strong association between social support and physical activity among older adults, especially when this support comes from family members. This review included four women-only studies and four studies that stratified results by gender; there were no men-only studies. The review found a strong association between social support and physical activity for women, but there was not sufficient evidence to determine this association in men (Smith et al., 2017).
Men in this study demonstrated a connection between their activity and social connections, both familial and nonfamilial. Participants described how both stronger (e.g., walking with a son) and weaker social connections (e.g., seeing familiar faces at the gym) motivated them to be mobile and physically active. Notwithstanding, several men in the study emphasized solitude and their desire to be active and mobile on their own as important. Within a wider cultural context that asserts hegemonic masculinity, men are expected to be independent, autonomous, and self-reliant (Smith et al., 2007); “men” are lone wolves who do not require assistance. Within the context of health care and health maintenance, older men are also encouraged to be independent; independence is a marker of successful aging (Smith et al., 2007). In this study, and the Men on the Move RCT, participants balance these competing social connectedness as means to health and well-being versus independence as a marker of successful aging.
The personal automobile and driving is often seen in Western culture as an “enactment of gender,” an activity often associated with masculinity (Walker, Butland, & Connell, 2000, p. 3). Older Canadian men are more likely to rely on an automobile to get around, even in densely populated areas where public transit is available (56% of men, compared with 26% of women, reported the car as their main mode of travel in Canadian Metropolitan Areas [CMAs]; Turcotte, 2012).For many men in this study, driving was still their preferred mode of travel. However, in the Men on the Move RCT, men adopted more active, and communal, transportation modes when provided with a free public transit pass. [Note that results of the Men on the Move RCT will be available in forthcoming manuscripts and through the Clinical Trials Registry # NCT02527655.] Participants made a range of transportation choices depending on their individual circumstances.
Through their photos and captions, participants reflected on the past, present, and future. Specific to physical activity, they reflected upon what they were able to do in the past and what they looked forward to doing in future. While participants had lost physical capacity compared to their younger years, they were also keen to explore activity options currently available to them. Through their willingness and ability to adapt, participants demonstrate resilience—the ability to maintain or regain mental and physical health after changes or loss (Resnick & Inguito, 2011). While participants’ physical activity profiles and abilities may have changed over the years, there was a clear sense that these men are keen to continue moving, to improve their mobility, and to increase their activity levels. They were even willing to try something new, be it lawn bowling or taking a city bus. There is a strong link between self-efficacy, the belief that one can be active, and participation in physical activity (Bauman et al., 2012; Notthoff et al., 2017).
Many participants emphasized that casual and more meaningful social interactions enhance and encourage their physical activity; however, many participants also emphasized the value that they place on “solitude.” It seems the diversity and heterogeneity of these findings can inform development of future programs that promote men’s health and physical activity. For example, to maximize adherence to and participation of men in physical activity, a program might offer group activities for social connectedness that some crave, coupled with solitary/individual activities for those who value “solitude.” Lefkowich and colleagues (Lefkowich, Richardson, & Robertson, 2017) posit that those working in health promotion must more readily and meaningfully involve men in the development of men’s health promotion programs, as this has been lacking.
Generally speaking, older men do not actively engage in the design and implementation of programs related to men’s health (Lefkowich et al., 2017). Men also tend to have a limited awareness of community programs and support available to them and there is an association between age/gender, older men, and lower health literacy (Sudore et al., 2006). In the interviews, most participants discussed how Men on the Move impacted their life. The program enhanced their health and physical activity, a secondary objective of the trial. It also increased awareness of the supports and programs available to them in the community.
Seasonality may have impacted this study, as data were collected during spring months. Flowers and warmer weather are a marker of spring in Vancouver, and this may have influenced the findings on supportive and therapeutic environments. Future studies should endeavor to collect data during two different seasons or at multiple time points throughout the calendar year. All of the participants in this photovoice study were enrolled in the Men on the Move RCT. Although participants in the Men on the Move RCT were not completing a physical activity program prior to recruitment, they did demonstrate a readiness to begin (determined by the PAR-Q+ questionnaire or a letter of recommendation from their physician). It is likely that those men who commit to a program are different from those who do not. Van Heuvelen et al. (2005) found that, at baseline, older adults completing a physical activity RCT were younger, better educated, and had better overall function than nonparticipants. Future studies would benefit from a focus on community-dwelling men who do not participate in programs. For example, future studies may wish to collect data with men who are not willing/able to commit to a 12-week RCT but perhaps might be willing to participate in something less time intensive and/or less physically demanding.
Encouraging men to reach out to their communities, as both active members and those who may need some supports, is crucial to support older men’s health; it is also contrary to culturally constructed norms of hegemonic masculinity (Courtenay, 2000a). In addition to older men reaching out to their communities, findings highlight the need for programs and policies customized to promote physical activity of older men. Given the heterogeneity of older men’s motivations for engaging in physical activity, there is a need to consult older men in program design to ensure its relevance.