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ISSN 0963-8288 print/ISSN 1464-5165 online
Disabil Rehabil, Early Online: 1–9
!2015 Informa UK Ltd. DOI: 10.3109/09638288.2015.1061606
REVIEW ARTICLE
Cultural influences on exercise participation and fall prevention:
a systematic review and narrative synthesis
Haeyoung Jang
1
, Lindy Clemson
1
, Meryl Lovarini
1
, Karen Willis
2
, Stephen R. Lord
3
, and Catherine Sherrington
4
1
Faculty of Health Sciences, The University of Sydney, Sydney, Australia,
2
Faculty of Health Sciences, Australian Catholic University, Melbourne,
Australia,
3
Neuroscience Research Australia, University of New South Wales, Sydney, Australia, and
4
The George Institute for Global Health, The
University of Sydney, Sydney, Australia
Abstract
Purpose: We aim to provide a systematic review of qualitative research evidence relevant to the
experiences and perceptions of program providers and participants from culturally and
linguistically diverse (CALD) backgrounds regarding (i) exercise and (ii) fall prevention programs
for older people. Method: Using a narrative synthesis approach, we reviewed published journal
articles reporting qualitative data. Electronic and manual literature searches were conducted to
identify 19 publications that met the inclusion criteria. Of these, 16 discussed exercise and three
focused on broader fall prevention programs. However, no studies were identified that
explored the perspective of the program providers. Results: An overarching theme emerged
identifying the influence of cultural values and perceptions on program participation. Also,
identified were motivational, social and environmental influences. Conclusion: Exercise and fall
prevention interventions need to be culturally appropriate and utilise the positive influences of
social support, especially from physicians and family. While these findings can be used to
inform the delivery of programs to these population groups, future studies should focus
specifically on experiences and perceptions of older CALD people of fall prevention programs
as well as the perspectives of program providers.
äImplications for Rehabilitation
Program participation is influenced by cultural values and motivational, social and
environmental factors.
The meaning and importance of exercise can vary between and within cultures.
Exercise and fall prevention interventions need to be culturally appropriate and utilise the
positive influences of social support, especially from physicians and family.
Providing information that falls can be prevented and the reasons why behaviours need to
change will be more likely to encourage older people from CALD backgrounds to
contemplate participation.
Keywords
Culturally and linguistically diverse groups,
exercise, fall prevention, older people,
participation, qualitative data
History
Received 21 October 2014
Revised 18 May 2015
Accepted 9 June 2015
Published online 29 June 2015
Introduction
Falls are a major and growing health issue for older people.
One in three older people aged 65 years and over experience at
least one fall each year, contributing to high costs and poor health
outcomes [1]. While generating serious consequences, falls are
preventable. Evidence shows that fall prevention interventions
including exercise effectively reduce falls among older people
living in the community [2,3].
In multicultural societies like Australia, older people from
culturally and linguistically diverse (CALD) backgrounds account
for a significant and growing proportion of the older population.
In Australia in 2006, 35% of older people aged 65 years and over
were born overseas, with 61% of these coming from non-English
speaking countries [4]. The number of older people from non-
English speaking backgrounds is projected to form a greater
proportion of the older population in Australia over the next
decade, posing significant implications for the delivery and
planning of health services and programs [4].
It is not clear whether fall prevention and exercise programs
effectively reach older people from CALD backgrounds and how
such programs are perceived by people from CALD backgrounds.
Older these people are often underrepresented in exercise and fall
prevention programs and research projects [5,6]. Therefore, the
results of such projects are usually most relevant to English-
speaking homogenous groups. Research has shown that partici-
pation in exercise in CALD groups are often constrained by a
range of factors, including cultural and religious beliefs, language
barriers, circumstances of migration, acculturation, socio-eco-
nomic characteristics and perceptional and environmental factors
[7,8]. A wide range of factors should be considered in the quest
for greater understanding of issues specific to the CALD older
Address for correspondence: Haeyoung Jang, Faculty of Health Sciences,
The University of Sydney, Sydney, Australia. Tel: +61 2 9351 9494. Fax:
+61 2 9351 9672. E-mail: h.jang@sydney.edu.au
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population, who may have more diverse and complex health
needs, but probably experience more difficulties accessing health
care, including cultural and religious beliefs, perceptions and
experiences of migration as well as older age.
Evidence from qualitative research can be beneficial for an in-
depth understanding of various experiences and perspectives of
participants in, and providers of, exercise or fall prevention
programs for older people from CALD groups. This knowledge is
critical to ensuring available intervention programs are effective,
relevant and acceptable, but, to the best of our knowledge, have not
yet been addressed in systematic reviews. To address this gap, we
conducted a narrative systematic review of qualitative studies. This
review aimed to provide a comprehensive account of research
evidence relevant to the experiences and perceptions of program
providers and older people from CALD backgrounds with regard to
(i) exercise and (ii) fall prevention programs for older people.
Methods
We used systematic review methods for synthesising qualitative
research using available guidance from the Cochrane
Collaboration [9]. Our review sought to investigate experiences
and perception of both program providers and participants. More
specifically, the review was guided by two questions:
(1) What are the experiences, needs and challenges of program
providers in relation to the provision of exercise or fall
prevention programs for older people from CALD groups?
(2) What are the experiences and perceptions of older people
from CALD groups concerning participation in exercise or
fall prevention programs?
Eligibility criteria
Studies were included if they contained qualitative data (a)
reporting the perspectives of older people aged 60 years and over
from CALD groups living in the community or the perspectives of
program providers working with such groups; and (b) were
concerned with the experiences or perceptions of participation in
exercise or fall prevention programs. We defined CALD groups as
comprising persons born in a country where English was not the
main language spoken and who had migrated to an English-
speaking country [10]. Included studies were restricted to
empirical studies published in peer-reviewed journals in the
English language using a qualitative research methodology or data
collection methods such as in-depth interviews, focus groups or
observation. Studies using mixed methods were included if
qualitative data relevant to our review questions were reported.
We excluded studies relating to specific disease-defined
population groups for which we envisaged that participant
perspectives may differ from the general older population, such
as cancer patients, but included studies among participants with
other medical and physiological risk factors for falls including
depression, history of stroke, Parkinson disease, gait problems and
vision impairment [11]. Studies referring to mixed populations
such as older and younger people or CALD and non-CALD
groups or a mix of settings such as community and hospital were
also excluded unless data for each group or setting were clearly
distinguishable. In addition, studies for which the full text was not
available were excluded.
Search strategy
We searched electronic databases and manually searched refer-
ence lists of the included studies, relevant texts (e.g. existing
literature review papers) [7,8,12–14] and relevant journals (e.g.
Journal of Aging & Physical Activity). We also liaised with
researchers with subject expertise or interest including the
authors. We searched Ageline, CINAHL, Embase, Medline,
PsycINFO and Web of Science. Keywords for the search included
terms relevant to essential concepts: older people, qualitative data
collection methods and fall prevention (Supplemental Table S1).
Search terms for fall prevention were selected drawing on findings
from a Cochrane systematic review [2] to include terms relevant
to effective interventions in reducing falls in community-dwelling
older people. They included fall prevention, balance and strength
training, exercise, Tai Chi, home safety/modification, footwear,
vision impairment or vitamin D. To capture ‘‘exercise’’ studies, in
particular, we used a broader range of search terms which
included exercise, balance and strength training, Tai Chi, gait,
physical activity, physical fitness and physical training. As people
from different cultures define exercise differently [15], we wanted
to understand the meaning of exercise among older people from
CALD backgrounds.
The search strategy was first piloted and then refined for each
database. No search terms were used to identify CALD population
groups as our pilot searches revealed that using such terms led
to the exclusion of potentially relevant studies. No study
publication date limit was imposed. The search was completed
in March 2015.
Study selection and quality assessment
The selection of the studies followed a three-stage process of
initial search and screening, preliminary categorisation, and
retrieval and final selection. First, full details of studies yielded
from the initial search were downloaded into Endnote. After
duplicates were removed, each title was reviewed and screened
against the screening checklist (Supplemental Table S2) by one
author to identify potentially eligible studies. Then abstracts of all
the potentially eligible studies identified were screened and
classified into ‘‘Yes (relevant)’’, ‘‘Maybe (potentially relevant)’’
or ‘‘No (not relevant)’’ folders based on the screening checklist.
Finally, the full texts of ‘‘Yes’’ and ‘‘Maybe’’ studies were
assessed independently for eligibility by two authors. This was
conferred with and verified by another two authors.
Final inclusion of studies was based on an assessment of
methodological quality of each relevant study to ensure that we
only synthesised findings from methodologically rigorous studies.
To assess study quality, we used a modified version of the Critical
Appraisal Skills Programme (CASP) [16]. We assigned a score for
each item on the checklist, as adopted by Horne and Tierney [12].
The first two questions of the checklist were marked out of two
(yes ¼1/no ¼2) and the remaining questions were marked out of
three (yes ¼3/somewhat ¼2/no ¼1) for a maximum score of 28.
Studies that scored less than 14 out of 28 on this checklist
were excluded from the review. The quality assessment was
conducted independently by three authors, all experienced
qualitative researchers. Disagreements were resolved through
team discussion.
Data extraction and synthesis
We used a narrative synthesis approach guided by Popay et al.
[17] to analyse and synthesise the findings from each included
study. By ‘‘telling the story’’ of the findings, this method allowed
us to focus on a wide range of factors relating to program
participation among older people from CALD groups and develop
a new conceptual framework about how to improve their
participation. First, all the included studies were read and re-
read by one author to establish familiarity with the findings,
generate initial codes and extract the data, which were carried out
at the same time. A list of initial codes was developed from
themes identified from the data, such as ‘‘facilitators to partici-
pation’’ and ‘‘barriers’’. Data extraction was based on inclusive
approaches as per the review questions, in which all relevant data
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presented in a study were extracted from the sections of results,
discussion and conclusion including participant quotes of each
study. Data extracted from each study were summarised into
evidence tables in accordance with the initial categories, which
were entered into Nvivo (version 10 produced by QSR
International, Melbourne, VIC, Australia) for line-by-line
coding, comparison of similarities and differences between
studies, categorisation and the preliminary synthesis of the
findings. The preliminary synthesis was then reviewed independ-
ently by another three authors for focused coding, leading to the
development of key themes and sub-themes through team
discussion. Diagrams were used to identify links and inter-
relationships between themes. The final thematic framework was
refined through team discussion and consensus.
Results
Description of included studies
The initial searches yielded a total of 59 638 records including
duplicates (Figure 1). Of those, after the three-stage process of
screening, 20 studies were selected for the assessment of study
quality. The reasons for exclusion of 207 relevant study reports for
which the full text was examined are listed in Supplemental Table
S3. After quality assessment, one further study was excluded due
to poor quality, leaving 19 publications included in the synthesis.
Of 19 included studies, 16 studies focused on physical activity
or exercise, two related to fall prevention in general [18,19] while
one focused on the use of mobility aids for fall prevention [20]
(Figure 1). Exercise is generally considered to be a type of
physical activity that is planned and structured [21]. In most of the
included studies, the terms physical activity (PA) and exercise
were not clearly defined, but used interchangeably to refer to a
broad range of activities undertaken in various domains, making it
not possible for us to identify the types of exercise or PA and to
focus only on exercise for fall prevention. For example, sometimes
Tai Chi was referred to as PA while walking or dancing was
perceived as exercise. Only one study examined one type of
program and this was a walking group [22]. Prior evidence
suggests that the use and understanding of the terms PA and
exercise can vary with different languages and cultures and they
should be explored in ‘‘culturally bound ways’’ [15]. Therefore,
throughout our results and discussion we used the term exercise to
mean exercise, physical activity or physical fitness. We found no
studies exploring the perceptions or experiences of service
providers in providing programs for older people from CALD
backgrounds (review question 1). All included studies related to
the perceptions or experiences of older people from CALD groups
(review question 2). Key characteristics of each study including
author, study aim, location, population, type of intervention
program, sampling method and data collection and analysis
methods are provided in Supplemental Table S4. Of 19 included
studies, 18 were qualitative and one study [23] used a mixed
methods approach. Studies were conducted in the US (n¼10),
Australia (n¼3), Canada (n¼3), UK (n¼2) and New Zealand
(n¼1). Three studies were conducted with multicultural popu-
lation groups while most focused on specific cultural groups
including Chinese (n¼6), Latino (n¼4), South Asian (n¼2),
Filipino (n¼1), Indian (n¼1), Slavic (n¼1) and Tongan (n¼1).
Both fall prevention studies were conducted with Chinese older
immigrants and the study on mobility aids included Italian
immigrants. Quality assessment scores ranged from 17 to 28
(Supplemental Table S5).
Figure 1. Flow chart summarizing the study
selection process.
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Synthesis of findings
Two key themes were identified: (1) the role of culture in shaping
perceptions, values and beliefs, and (2) motivational, social and
environmental influences. For each theme and subtheme, we first
describe the findings for exercise and then follow with further
discussion if the theme was also reported in relation to any fall
prevention intervention. Supplemental Table S6 provides a
summary of themes and subthemes identified and supporting
interview quotations.
Theme 1: the cultural shaping of experiences,
values and beliefs
Cultural values and beliefs clearly shaped the experiences and
perceptions of older people and their participation in exercise or
fall prevention programs.
Cultural perceptions of ageing and the ageing body
The perceptions of older people from CALD groups, especially
the attitudes, expectations and values of the society in which they
grew up in, had an important impact on program participation.
Positive impacts related to the belief that health and physical
independence increased in importance with age, which facilitated
participation in exercise. Evident in many studies were negative
attitudes or stigma towards ageing and the ageing body, such as a
fear of dependency, where the effects on exercise participation
were detrimental rather than beneficial. In many studies, the value
of exercising in older age was questioned with participation
considered by some as inappropriate, incompatible or useless
[23–27]. Many Latino older people, for example, perceived
exercise not ‘‘fitting’’ for older people and expressed ‘‘shame’’,
‘‘acting foolish’’ or ‘‘a waste of time’’of doing exercise in old age
[27]. In addition, the concept of old age as a time to rest or relax
was widespread among Asian Indian, Chinese and Latino
immigrant older peoples [23,25–27].
Perceptions about participation specifically in fall prevention
programs were influenced by negative cultural perceptions
associated with a fear of frailty, lost function and becoming an
embarrassment or burden in old age [18–20]. In two fall
prevention studies [18,19], fear of falling was common among
Chinese older immigrants, who were inclined to hide falls from
their adult children in order to avoid worrying them or becoming a
burden to them. Similarly, the use of mobility aids, especially
walking canes, among Italian older immigrants was hampered by
strong socio-cultural stigma towards ageing and falls and the
identification of these devices as symbols of frailty and lost
function [20].
The role of health beliefs and health status
Health beliefs were a strong influence, both facilitating and
impeding participation in exercise. In many studies, there was a
widespread belief that exercise had beneficial effects related to
physical health, well-being and independence in old age, which
translated to participation in exercise [24,26–34]. In some,
however, traditional health beliefs impeded the perceived need
for exercise among older people. For example, many Chinese
older immigrants believed that proper care of the body and mind
or ying and yang was possible through the use of (traditional
Chinese) medicine and dietary practices more than through
exercise [18,24,26]. High levels of fatalism were also commonly
reported among Chinese older immigrants. With an acceptance of
illness and physical decline in old age, many Chinese older people
understood health by the concept of ‘‘luck’’ [25,26] such that:
‘‘Good health means good luck’’ [26]. For them, there was little
sense in trying to change the processes of ageing by engaging
in exercise.
Alongside these cultural health beliefs, health status also
influenced exercise participation. For some, health problems and
chronic conditions served as a key motivator for the initiation or
continuation of exercise [23–26,28,32,33]. Conversely, not being
sick or having no health problems was an indication of no need for
exercise [25,26]. For many others, however, physical health
limitations and poor health served as a barrier to exercise [23–
26,28,31,32,34–36]. The fear of detrimental effects (e.g. worsen-
ing pain or health problems) often outweighed the potential
benefits of exercise [23,24,27,28,36].
In the study on the use of mobility aids, perceived health
benefits (e.g. functional and safety gains) did not necessarily
enhance perceived need among Italian older immigrants [20].
Perceived risks, however, were associated with not using mobility
aids as one study participant said: ‘‘I wouldn’t feel secure with a
cane’’ [20]. Fatalistic health beliefs had important implications
for Chinese older immigrants’ understanding and experience of
falls and fall prevention [18,19]. Similarly with the findings
regarding exercise, having a fall and finding suitable fall
prevention programs was also explained by the concept of luck.
Chinese older people with fatalistic beliefs were less likely to
view falls as preventable, interventions as effective or worth
participating in, or to change behaviours to improve their health as
reflected in the following statement: ‘‘There is no prevention for
falls as falls always happen suddenly’’ [19]. Chinese older people
demonstrated some understanding on the impacts of some specific
health conditions (e.g. poor vision and Parkinson’s disease) on
falls risk, but this was not explored in relation to their
participation in fall prevention [19].
The need for culturally appropriate programs
There was a strong preference for programs that were culturally
relevant and appropriate. The need for programs that catered to
specific rather than mixed cultures was highlighted as well as
programs conducted in culture-specific languages [24–31,33–35].
The promotion of cultural unity was also seen as important.
Having a place ‘‘to exercise and congregate in’’ with people of the
same cultural background, same language or similar age
motivated participation in exercise [22,27,28,30,36] and helped
immigrant older people to mediate not just language, but most
importantly, the cultural barriers they experienced within their
adopted country [28]. There was a recognition that this may rest
on an organisation’s ability to secure sufficient funds to deliver
and maintain such programs over time [28].
Older people from certain CALD groups faced various
religious or cultural expectations in relation to their social
and physical behaviours such as clothing, which limited their
exercise participation and choices throughout their life. Cultural
barriers to participation were a particular concern of older
women [24,25,29,37], with many older women expressing a
preference for gender-segregated activities [25,29] and feelings of
embarrassment or concerns about mixed-gender programs
[24,25,35,37]. Expectations in appropriate exercise attire also
were of concern. In addition, limited English and a lack of
program information in their own language were reported as
barriers to exercise [25,29]. Hence, older people often lacked
information about the necessities and benefits of exercise [25,35]
and some were dependent on ethnic organisations or ethnic media
as a source of health information [34]. The importance of
health education interventions was commonly emphasised as
an effective way to positively influence perceptions and
uptake of exercise among older people from CALD groups
[25,28,30,31,34,36].
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In fall prevention studies, the need for language-specific
programs was also reported. For older Chinese people, it was vital
that these programs were conducted in Chinese as stated by one
study participant: ‘‘It is good that we have it [the Tai Chi class] in
Chinese. I will not attend if it’s not in Chinese’’ [18]. Language
problems included not just limited English but also a lack of
literacy in their first language [18]. Therefore, there was a
preference to also receive information via visual media such as
TV or DVD [18,19]. The lack of information was an even more
common issue. Older people from CALD groups received little
reliable information on fall risk factors and consequences or fall
prevention interventions [18–20]. Their understanding of falls and
fall prevention was often reliant on sources such as family
members or friends [19] and strongly affected by traditional
cultural views of health and illness [18]. Many Chinese older
people, for example, were aware of Tai Chi as a beneficial
exercise, but not necessarily as a fall prevention intervention [19].
The lack of information contributed to reduced understanding of
the necessities or benefits of fall prevention interventions; the lack
of interest or motivation for them; the lack of awareness of the
potential impact of medication use on falls risk; preference for
seeing a doctor and taking medications over doing exercise even
after having an injurious fall [18–20]; and the need for education
interventions for preventing falls [20].
The importance of family roles and responsibilities
Older people from CALD groups commonly placed great
importance on their family roles and responsibilities but had
divergent views about how this would influence their engagement
in exercise. For example, some people perceived grandparenting
as an important motivation for increased exercise in old age as
indicated by one study participant: ‘‘Do everything that children
doðwalk, run, play’’ [31]. Others, however, considered a lack of
time stemming from housework as a key barrier to exercise,
which was particularly apparent amongst older women from
Asian Indian [23], Chinese [25], Filipino [28,32], Mexican [33],
Vietnamese [30] and Tongan [35] backgrounds. Many older
women echoed comments like the following; ‘‘My full day goes
in housework. So, I have no time for anything else’’ [23]. A lack
of established routines for exercise due to work or family
obligations during adulthood often led to a lack of exercise later
in life [23,24,26,29].
For some, traditional gender role expectations lessened after
migration as a result of acculturation to western society [34] or
individual older women learned to effectively ‘‘go against
tradition’’ [37] and use social, cultural and environmental
resources available to structure their choice of exercise and
continue their engagement in it [24,26,27,29,31,33,37]. One
Mexican woman explained: ‘‘I can give up running for something
that I have to do, but if there is a tense situation, I will give up
what I have to do to tend to that situation. But if I can go run well
just let me out the door you know just to get that relief’’ [37].
Various personal strategies were used by older people to balance
their duties and need for exercise in everyday life including: doing
exercises along with their sick mother [37]; practicing Tai Chi at
home guided by a DVD while taking care of a sick husband [24];
or walking to the local shops, taking grandchildren to and from
school, performing prayer as exercise [29]. No study explored how
cultural beliefs regarding family responsibilities influenced par-
ticipation in fall prevention programs.
Cultural perceptions of PA, exercise and fall preventions
The meaning of PA or exercise varied within and across cultures,
which exerted an important influence on an individual’s partici-
pation in these activities. For example, in Chinese and Latino
groups, PA or exercise was often considered an age-based activity,
defined as a leisure activity during young-adulthood and a way to
achieve physical and mental health in older age [24–28]. In Indian
and Tongan cultures, activities such as dancing, fishing, cooking,
art-making or yoga were an integrated part of everyday life, but
not necessarily related to promoting health [23,29,35,36]. In
addition, PA or exercise as an activity was typically viewed in
terms of gender appropriateness. That is, older men typically
participated in leisure activities, while older women typically
participated in household activities [25,31,36].
Accordingly, the importance of having a daily physical activity
routine rather than organised or structured exercise was
emphasised in various CALD groups [27]. Often with limited
choices, daily activities like housework or gardening were
regarded as forms of exercise [23,25–27,31,32,34–36]. Low- to
moderate-intense exercises were preferred and walking was often
the most frequent or preferred form of exercise reported
[22,25,27,28,31,32,34,36]. Reasons to walk or preferences to
walk, although closely linked to health incentives in a few studies
[22,31], involved varied social, cultural or economic motives
including: (a) being accessible, familiar and convenient [25,36];
(b) the only transport option both in home and host countries
[31,34,36]; (c) a form of leisure or socialisation [31,36]; (d) a way
to maintain independence and to help others [31]; (f) an integrated
part of daily lives [32]; and/or (g) no cost [31,36].
In line with these findings, participation in formal exercise was
viewed as a low priority or even unnecessary as was participation
in fall prevention programs [19,20,23,25,29]. Participation in
exercise was not understood as a fall preventive measure, rather,
the use of personal strategies to prevent falls such as being
careful, wearing appropriate shoes or using assistive devices such
as a walking stick were emphasised [18,19]. In two studies on PA
or exercise [28,31], fear of falling was discussed as a barrier to
exercise.
Theme 2: motivational, social and environmental
influences
Program participation among older people from CALD groups
was also influenced by motivational, social and environmental
factors, on which post-migration experiences had a profound
effect.
Motivation and intent
Motivational factors including self-motivation, personal deter-
mination, enjoyment, interests and self-efficacy were important
factors encouraging initiation and continuation of exercise
[22,23,25–29,34,36,37]. One older person said: ‘‘Even though
my doctor recommended doing so, I still need to be determined.
But the limitation is your motivation. If you are lazy and
unmotivated, you cannot do it’’ [28]. Self-motivation and self-
efficacy were often contingent on the cultural and family values
placed on exercise in old age. They were strengthened through
various resources and experiences such as a sense of achievement
(e.g. from mastering a specific activity), encouragement
from others, parenting or work experiences [22,25–27,30,37].
Education and an emphasis on self-monitoring of health also
increased motivation [24,31].
On the other hand, a lack of motivation, interest or desire to
participate, fear of making a commitment or certain personality
traits, such as being introverted or having a sense of inferiority,
were reported as barriers to participation in exercise and the use
of mobility aids [20,23,25–28,31,32,35]. A lack of motivation,
desire or need for these interventions was often prompted or
exacerbated by language barriers, a lack of information and know-
ledge, social isolation and/or other socio-cultural disadvantages
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faced by older people from CALD groups [20,24,25,28,33] as
explained by one Chinese woman: ‘‘I am very introverted. I don’t
know English. I don’t know how to communicate with other
people. I’m afraid of saying something wrong. I enjoy staying at
home and doing indoor activities’’ [25]. However, no study
explored how motivation or lack of motivation influenced
participation in fall prevention programs.
The importance of social support
Physicians or health professionals played an important role in
supporting, encouraging and recommending exercise in a range of
CALD groups [22–24,27,29,35]. Receiving advice and support
from health care providers of the same cultural or language
background was reported to be crucial [27,29,35]. Many Chinese
older immigrants chose traditional body exercise (e.g. Tai Chi or
Luk Tung Kuen) in accordance with physicians’ recommendations
[24–26]. For some however, advice was not supportive. Some
Korean older immigrants did not walk for exercise because their
health care providers recommended against this due to their age or
health condition [28].
Families were also an important influence on participation in
exercise. Older people were encouraged by their families to
participate in exercise as a way of maintaining health
[23,25,28,29,34]. For Chinese older immigrants, the family was
more important than friends in this regard, often due to an
increased emphasis on looking after oneself after migration and
lack of friends or relatives in a new country [34]. The Chinese
cultural emphasis on graceful interaction (not causing trouble)
with others or cultural embarrassment of requesting help was also
identified as a significant factor [25]. Familial influence also had
adverse effects. In some studies, the influence of family was an
important reason for not exercising [23,25,35] as explained in the
following: ‘‘Last week I asked my son to buy me a bike for my
exercise, but my son was very scared that I might have an
accident. Our children sometimes prevent us from doing exercise
or physical activity’’ [35].
Support from the community such as community resources and
group support also played an important role. Religious organisa-
tions and leaders were influential in organising appropriate
exercise programs and promoting them among various CALD
communities [28,31,35,36]. Government was also seen as an
important provider of such programs [30,35]. Friends or the peer
group were important sources of support [29,34,37] or role
models for exercise [23]. Exercising in a group was particularly
influential, providing a sense of commitment and belonging;
companionship, opportunities to share knowledge or experiences
resulting in improvements in self-confidence or self-efficacy
[22,27,29–31,34,36,37]. Participation in group-based exercise
resulted in social benefits such as a socially active life, social
recognition and a sense of community as well individual benefits
such as a sense of achievement and personal accomplishment,
which were important facilitators for participation [28,29,36]. A
lack of social support, including having no one to provide
encouragement or to exercise with, was closely related to low
levels of exercise participation among a number of CALD groups
including Indian, Latino and Chinese [23,25–28,33].
In fall prevention studies, the role of social support was also
noteworthy. A physician’s recommendation was the most import-
ant factor influencing the decision to use mobility aids among
Italian older immigrants in contrast to their British counterparts
who tended to make their own decisions [20]. In addition,
physicians were the most important and influential source of
information on fall prevention among Chinese older immigrants
in Australia, who reported low awareness of the problem of falls
and utilisation of other health services and professionals [19].
Similar to the findings regarding exercise participation, the
impact of family on participation in fall prevention interventions
was significant, but not always favourable. For example, an older
person’s decision to use a walking cane was disapproved by family
members who had negative perceptions about the use of such
devices [20]. The group environment also had a positive impact
on participation in fall prevention programs. Chinese older
immigrants attending Tai Chi classes in the UK highly valued
the social aspects of the program such as ‘‘making friends’’ and
‘‘having the Chinese food together after’’ [18].
Changes in the living environments and life circumstances
Participation in exercise among older people from CALD groups
was also affected by changes in the living environment between
their country of origin and their current location. Differences or
changes in the physical environment which could affect program
participation related to weather conditions [23,28,31,35,36];
transport availability [23,25,27,28,31,35]; community safety con-
cerns [23,28,35,36]; availability of facilities [24,35]; geographical
isolation [28]; or community design [30]. Changes in life
circumstances in the new country also made it difficult to find
the time or resources needed for exercise. Such changes often
involved negative life experiences including: (i) a less active or
sedentary lifestyle in the new country; (ii) social isolation; (iii)
cultural disconnection with exercise available in the new country
(e.g. older South Asians’ unfamiliarity with Canadian winter
sports); (iv) personal safety concerns experienced as an old
minority in the new country; (v) limited housing options for large
immigrant families in the new country, restricting indoor exercise;
(vi) frequent visits to the home country; (vii) financial difficulties
stemming from lower socio-economic status in the new country
and/or (viii) resettlement disruptions, family separation and long
work hours [23,26,28,30,33,35,36]. Given these post-migration
experiences, older people were less likely to perceive exercise as
convenient or to fit into their new lifestyles after migration [30]
and also more likely to lose motivation for exercise and pay less
attention to it in the new country [26]. The effects of lifestyle
changes were more detrimental for recent immigrants with low
levels of English-proficiency, education and income [30]. Cost or
the expenses associated with program participation was regarded
as an issue not only to exercise [24,28] but also to fall prevention
programs and the use of mobility aids [18,20] as suggested in the
following statement: ‘‘I wouldn’t mind paying the odd pound but I
guess it can mount up if you come twice a week, every week in
the month’’ [18].
Discussion
Our systematic review revealed limited qualitative research on the
perspectives of the key stakeholders in fall prevention programs
for older people from CALD backgrounds, finding no study
exploring the perceptions or experiences of service providers. The
majority examined perceptions and experiences of older people
from CALD groups relating to participation in exercise. Only
three studies focused on fall prevention approaches, with one of
these exploring the use of mobility aids.
Despite the limits posed by the shortage of primary qualitative
studies on effective knowledge generation and synthesis, our
review had some important findings. Our review, in particular,
highlights the impacts of culture and other life circumstances and
experiences, often related to post-migration experiences, as
important factors that could have detrimental rather than bene-
ficial effects on participation in exercise and fall prevention
among older people from CALD groups. Similar with the general
older population, attitudes, expectations and values play an
important role among these older populations. Noticeable was the
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prolonged impacts of cultural values and beliefs on the ways they
perceived and defined ageing and health, their perspectives of
cultural appropriateness, family duties and gender roles and the
meanings they ascribed to exercise and fall prevention measures.
We found that, despite an increased desire for autonomy
and independence, a sense of inevitability about becoming frail,
dependent or sedentary in old age was common and had
significant negative effects on exercise participation as it
weakened self-efficacy and motivation to undertake exercise. In
addition, cultural norms attached to traditional family responsi-
bilities were deeply embedded and reinforced even after migra-
tion. While these norms often posed a barrier to exercise, there
was some evidence that they were renegotiated to facilitate
changes among older people.
We also found that participation in exercise or fall prevention
differed not only between but also within CALD groups and in
many studies it was complex and complicated due to diverse issues
facing individual older immigrants. Physicians and family played
an important role in encouraging or discouraging adaptation of
exercise or fall prevention, which signified not only family centred
culture among CALD groups but also the lack of social support and
the interdependent nature of family relationships in CALD
households. Difficulties in adapting to new living environments,
circumstances and/or language contributed to the lack of informa-
tion and knowledge of fall prevention programs and deterred
participation in these programs or discouraged seeking social
support outside the family. The detrimental effect of acculturation
and language barriers has been also addressed in recent literature
reviews on PA or exercise participation in CALD groups [7,8,12].
Although the impact on program adherence and retention was
not included in major themes that we identified from our review,
there were a few studies that explored factors promoting program
adherence [26,29,37]. Findings from these studies suggest that
factors promoting program adherence can be different from those
influencing program initiation. In these studies, factors that were
most significant in promoting adherence were having appropriate
social support [29] and intrapersonal mechanisms (such as
perseverance, personal interest and the development of self-
confidence, self-determination or self-efficacy) [26,37] while
health-related factors played the biggest role in program initiation.
We also found that cultural values and beliefs were often negotiated
to incorporate people’s choice of exercise and continued engage-
ment and adherence.
Our findings support previous systematic review findings on
participation [13] and implementation [14] of fall prevention
interventions in the general population, adding to the understand-
ing that program participation is complex and multifactorial.
Similar findings have been made to suggest that older people’s
participation in intervention programs are influenced not only by
cultural and individual beliefs and perceptions but also by health,
social, psychological, economic and environmental factors. For
example, as in the general population, health status is one of the
strongest predictors of engaging in exercise.
With these influences impacting through the individual, a large
number of the participants in the primary studies were not
physically active, not involved in organised exercise or any fall
prevention interventions, not informed or under-informed about the
benefits of these programs and the consequences of not participat-
ing in them, and, more importantly, not motivated to participate in
these. Many preferred walking and low- to moderately intense
exercise, and were unaware of exercise regimes that are effective
for fall prevention. Viewing behaviour change as a process
occurring over time, the transtheoretical model (TTM) of health
behaviour change recognises that individuals differ in their
readiness to overcome barriers and change health behaviours and
therefore that different interventions are needed for those at
different stages [38]. The findings of this review support the notion
that the majority of people are at an earlier stage of change and are
not intending to take action in the foreseeable future. As such,
approaches to engage older people must be tailored differently than
if they are contemplating or ready for action. TTM may be a useful
perspective in helping frame the messages relevant to their beliefs
and stage of action as well as personal benefits and activities that
provide a continued sense of mastery [39,40]. Although there is
work to be done, the relationship between behaviour change and
improvement in PA and exercise in different cultural groups has
been demonstrated [41–44].
To promote uptake and maintenance of fall prevention
programs or exercise programs effective for fall prevention
among those who are not ready for immediate or long-term
change, programs need to be designed to match individual and
community needs, suggesting that there would be no ‘‘one-size-
fits-all’’ solution. Our findings suggest that, without specific
targeting, the reach of fall prevention programs to older people
from CALD backgrounds is likely to be poor. Exercise and fall
prevention interventions need to be culturally appropriate and
maximise beneficial effects of educational interventions and the
positive influence of social support, especially from physicians and
family. More attention should be paid to education with regard to
raising awareness of fall prevention and the important components
of exercise effective for fall prevention (e.g. challenging balance
and regular long-term participation [3]). Having some materials in
the language and leadership from within the CALD community is
preferred and makes sense as language, communication, meaning
and acceptance are inextricably linked. Increased exposure to
information and knowledge about the program and the program
benefits will ease social isolation and encourage engagement in
community-based programs. This highlights the important role of
partnerships between CALD-specific and mainstream health care
organisations in working together to reach older CALD people,
providing culture-sensitive and relevant information and adapting
programs and approaches.
Healthcare professionals require an understanding of the
community and its diversity. There are a range of strategies that
can be used to enhance cultural appropriateness and relevance in
addition to culturally appropriate materials. These include, for
example, drawing directly on the experience of members of the
CALD group and engaging them as advisors and volunteers,
understanding the collective community shared practices for
health beliefs, support and practices, building on strong familial
and community ties and working within the broader social and
cultural values when designing messages about participation and
prevention, as well as tailoring to individual diversity [45,46].
The absence of literature on the perspectives of program
providers and other stakeholders in fall prevention represents an
important lack of knowledge. Also, the few studies on fall
prevention and participation have limited our ability to identify
and compare experiences and perceptions of older CALD people.
In addition, we included only empirical studies published in peer-
reviewed journals, excluding the grey and non-English literature,
which may have excluded some relevant studies. While these
findings can be used to inform the delivery of programs to this
population group, future studies should focus specifically on
experiences and perceptions of older CALD people to fall
prevention programs as well as the perspectives of program
providers.
Declaration of interest
The authors have no declaration of interest to report. This study
was supported by a National Health and Medical Research
Council (NHMRC) Partnership Projects Grant.
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Supplementary material available online
Supplemental Tables S1–S6.
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