Older people with intellectual disability (ID) are characterized by low physical activity (PA) levels. PA is important for reducing health risks and maintaining adequate fitness levels for performing activities of daily living. The aim of this study was to explore preferences of older adults with ID for specific physical activities, and to gain insight into facilitators and barriers to engaging into PA. Fourteen in-depth interviews and four focus groups were undertaken, with a total of 40 older adults with mild and moderate ID included in the analysis. NVivo software was used for analysing the transcribed verbatim interviews. In total, 30 codes for facilitators and barriers were identified. Themes concerning facilitators to PA were enjoyment, support from others, social contact and friendship, reward, familiarity, and routine of activities. Themes concerning barriers to PA were health and physiological factors, lack of self-confidence, lack of skills, lack of support, transportation problems, costs, and lack of appropriate PA options and materials. The results of the present study suggest that older adults with ID may benefit from specific PA programs, adapted to their individual needs and limitations. Results can be used for developing feasible health promotion programs for older adults with ID.
Being physically active is universally acknowledged as an important factor for health and well-being. Regular moderately intensive physical activity has protective effects for several chronic diseases, including coronary heart disease, hypertension, non–insulin-dependent diabetes mellitus, osteoporosis, and colon cancer (Pate, 1995). It is specifically important for the prevention and reduction of falls and functional limitations in older adults, and for maintaining muscle strength, independent living, mental health, and social well-being (Bouchard & Shephard, 1994; Cress et al., 1999; Spirduso & Cronin, 2001). The World Health Organisation (WHO) recommends adults, including older adults, to be moderately physically active at least five days a week for a minimum of 30 min a day (WHO, 2009).
However, many individuals with intellectual disability (ID) are physically inactive (Peterson, Janz, & Lowe, 2008; Temple, Frey, & Stanish, 2006), and their fitness levels are low (Hilgenkamp, van Wijck, & Evenhuis, 2012b; Stanish & Frey, 2008). The proportion of adults with ID who comply with the WHO guideline ranges from 17.5 to 33% (Temple et al., 2006). In addition, at least 39% of older adults with ID walk less than 5,000 steps per day (Hilgenkamp, Reis, van Wijck, & Evenhuis, 2011), which can be categorized as having a sedentary lifestyle (Tudor-Locke, Hatano, Pangrazi, & Kang, 2008). Immobility, sarcopenia, and frailty form serious threats to this sedentary population as they negatively influence the older adults' health and quality of life (Evenhuis, Hermans, Hilgenkamp, Bastiaanse, & Echteld, 2012). Although the participation of people with ID in activities developed for the general population has increased since the last decade, many people with ID still are not able to participate in such activities as a result of physical and cognitive limitations, insufficient staff for assistance, and structural factors such as financial and transportation problems (Heller, Hsieh, & Rimmer, 2004; Mahy, Shields, Taylor, & Dodd, 2010; Messent, Cooke, & Long, 1999; Temple & Walkley, 2007). Although the importance of increasing the physical activity level of people with ID has been widely recognized, knowledge about effective strategies that appropriately address the unique needs of older adults with ID to accomplish this objective is lacking (Bartlo & Klein, 2011; Heller, McCubbin, Drum, & Peterson, 2011; Stanish, Temple, & Frey, 2006).
The development of such interventions requires insight into facilitators and barriers to physical activity for this group. Research has provided such information about younger adults with ID (Bartlo & Klein, 2011; Stanish & Frey, 2008) and about older people in the general population (Brawley, Rejeski, & King, 2003; King, 2001; Rimmer, Riley, Wang, Rauworth, & Jurkowski, 2004; Sheppard et al., 2003; van Stralen, Lechner, Mudde, de Vries, & Bolman, 2010), but not about older people with ID. We expect that within this target group, determinants for physical inactivity that differ from those for the other groups will be emphasized, because of physical problems (e.g., regarding balance, mobility or strength), cognitive limitations, different living situations, and often limited experiences with physical activity (Frey, Buchanan, & Rosser Sandt, 2005; Hilgenkamp et al., 2012b). In addition, the social networks of older adults with ID are often smaller than the network of their younger peers and include less relatives (Robertson et al., 2001).
Therefore, our purpose was to explore preferences of older adults with ID for specific physical activities, facilitators, and barriers to physical activity. Research questions were (a) In what kind of physical activities do older people with mild and moderate ID participate? and (b) What barriers and facilitators do older people with mild and moderate ID perceive with regard to participation in physical activities?
This was a qualitative interview study based on interviews and focus groups. It was part of the development of the program in the study Healthy Ageing-Physical Activity Programme, for which ethical approval was obtained (number NL29573.078.09) from the Ethics Committee of the Erasmus Medical Center at Rotterdam, the Netherlands.
Fourteen people age 50 years and over with moderate or mild ID were selected for individual interviews in seven day-activity centers of three Dutch care provider services for people with ID. We expected this amount of interviews to be sufficient to achieve saturation of the data. If not, additional persons could be selected. Managers were asked to select persons age 50 years and over who walked independently, who walked with aids or were dependent on a wheelchair, who liked being physically active, or who disliked being physically active. Preference was given to persons who were likely to enjoy participating in interviews. The day-activity centers' staff explained the purpose of the interview to the potential respondents and invited them to participate. All 14 invited persons were willing to participate in the interviews. Information about the participant characteristics was provided by the managers.
In the interest of the Healthy Ageing study, four groups of older adults with ID were set to provide information about the research topics in focus groups. These groups, which were chosen from different geographical locations, consisted of members of client boards of the three participating organizations. Support workers who coached these client boards were also involved in the construction of the groups. They explained the purpose of the groups and invited the clients age 50 years and over to participate. In total, 26 clients signed up to participate and were consulted for the current study in the four focus groups to gain information about barriers and facilitators to physical activity. The focus group interviews were conducted with 5–11 participants per interview.
The 40 interview and focus group participants ranged in age from 50 to 80 years (see Table 1). Most participants (n = 28) had mild ID. Seven used a walking aid, and four used a wheelchair. Participants received support in their living situation from ID-care organizations and mostly participated in activities organized by day-activity centers.
In both interviews and focus groups, the interviewer started with general questions about the respondents' physical activities. Subsequently, questions were asked about respondents' positive and negative experiences with their physical activities, in order to gain insight in experienced facilitators and barriers. For example we asked what the respondents liked or disliked about the activities they performed. Because in earlier research the importance of social support and physical barriers for participation in physical activities was emphasized (Frey et al., 2005; Heller, Ying Gs, Rimmer, & Marks, 2002; Mahy et al., 2010; Messent et al., 1999; Temple & Stanish, 2009; Temple & Walkley, 2007), we specifically drafted questions about these concepts. For example, we asked whether the older adults received support from others to perform physical activities and whether they suffered from physical complaints when they performed physical activities. The support workers were asked to check terminology appropriateness of the questions using their professional experiences with the target group. The core questions and prompting questions used in the interviews are presented in Table 2.
Fourteen individual semistandardized interviews and four semistandardized focus group interviews were undertaken. The individual interviews provided the opportunity to gain information about preferences for or barriers to physical activity. The advantage of focus groups is that participants can interact, which can lead to a broader range of information about the study's subject. In addition, this method makes it possible to explore related but unanticipated topics as they arise in the course of the groups' discussion (Berg & Lune, 2011).
The individual interviews were conducted on site in the activity center by the first author, who is experienced in interviewing people with ID. If necessary, a staff member was present if the respondents' pronunciation was not clear to someone who did not know him or her well. The individual interviews lasted between 15 and 30 minutes; in two interviews a staff member was present. Most respondents were a little anxious about the interview but felt more at ease after a cup of coffee and a general “warming up” talk about their living situation and daily activities. The researcher explained the purpose of the interview and asked permission to tape the conservation with an audio recorder. Not all questions were posed in each interview, and depending on the answers of the respondents, some subjects were given more attention than others to gain more in-depth information about those subjects. Respondents received a small gift to thank them for their participation.
The support workers participated in preparing and conducting the focus group interviews. They checked the appropriateness of the terminology of the questions using their professional experience with the target group and provided pictograms that were used to support the discussion. Before the start of the focus group discussions, the support workers communicated with the respondents about the content, time, and location of the interviews. The support workers were trained by the researcher to participate as second mediators. The first author served as principal mediator and played a key role in ensuring that the core questions and prompts were covered. The second mediator supported the principal mediator to explain or rephrase the question to participants if needed and ensured that everyone was included in the discussion. The focus groups took place at the day-activity center. Because the support workers were familiar with the respondents, they could help them to feel at ease. The focus group discussions were video- and audio-recorded. A researcher took field notes. The duration of the focus group interviews ranged from 70 to 95 minutes.
The interviews and focus group discussions were transcribed verbatim by a researcher and two secretaries, who were well instructed by the researcher to write down what was said in the interview by both the interviewer and respondents. If the quality of the audiotape was not sufficient for transcription of the focus groups, the videotapes were used. If a transcriber could not hear a sentence clearly enough, the transcriber placed a remark. The researcher checked these remarks by listening to the audiotape and/or the videotape again. Then the correct text was written down, or, if the sentence remained unclear, it was not transcribed and was excluded from the analysis.
To indicate preferences for physical activities and the facilitators and barriers to physical activity, one researcher started the process of coding using Nvivo software (QSR International, Melbourne Australia). Each text fragment—sometimes containing one sentence about one topic and sometimes five to six sentences—was given a code. The first author and two colleague researchers independently coded the text fragments of two interviews. A peer review was undertaken to compare the codes of the three coders. Subsequently, the first author coded the other interviews. New codes were defined until saturation of the data was achieved (Berg & Lune, 2011).
After open coding was completed, data were organized by the use of coding frames (Berg & Lune, 2011). Following the method of van Stralen et al. (2010), we clustered determinants of physical activity into four coding frames: (a) social and cultural determinants, (b) psychological determinants, (c) personal determinants, and (d) physical environmental determinants. We applied these four coding frames because they give direction to the nature of strategies that can be developed as part of a physical activity intervention (van Stralen et al). In addition, a distinction was made between facilitators and barriers.
The interviewees were often not able to explain what they specifically liked or disliked about a certain activity, which made clustering of the codes not always easy. For example: “coffee break” was one of the answers to the question about what the interviewees liked about a certain activity. Therefore we assigned this label to the “physical activity and preferences” coding frame, although it could also have been clustered within “psychological” determinants or “social and cultural” determinants. Thus we chose the coding frame that was most directly linked to the context in which the determinant was described by the respondent. Two medical students, a co-author and the first author, clustered the codes independently and subsequently discussed the results and differences in cluster process.
Most of the codes appeared in both interviews and focus groups. Because the aim and the interview schedule used were comparable for both interviews and focus groups, we judged that possible differences in results from the two methods did not have an impact on the interpretation of the results. In favor of the readability of this manuscript, we therefore made no distinction between codes revealed in interviews and codes revealed in focus groups when describing the results of this study.
Physical Activities and Preferences
The older adults participated in various physical activities. Walking was the most cited activity, but dancing, gymnastics for older adults, cycling, cycling on a home trainer, swimming, and household activities were also frequently mentioned. Participants walked and cycleed to their work and for fun in their free time. Other activities were mostly part of the participants' day-activity program, provided by the care provider services. Enjoying or disliking an activity were coded as separate facilitator and barriers for being physically active (see Table 3). It appeared that music made it fun to be active. Several interviewees liked dancing, individually or in a group. Disco or folk dancing were frequently cited as favorite activities. In addition, making music with others and singing appeared to motivate interviewees' participation in physical activity. Some examples of remarks about music:
Participant 1: Music makes me happy.
Participant 2: I like to dance, if I know all the songs very well.
Participant 3: I put on a CD [when on a home trainer]. That is important. To put on the music when I cycle.
Walking, cycling, and gardening were favorite activities, mostly because the participants enjoyed being outside. Some told us that these opportunities were limited because they were not allowed to go outside without accompaniment. Also household activities, especially shopping for groceries, were appreciated activities. The opinions about swimming and about gymnastic games for elderly varied. Some loved being in the warm water, others were afraid of drowning. Four older adults mentioned explicitly that they did not like throwing a ball because they found it difficult or stupid. Three participants did horseback riding and loved the contact with the animals. The necessary change of clothes to perform an activity was not appreciated and could be a barrier to becoming physically active. Several older adults did not mention features of the activity itself, but the coffee and cigarette breaks in between as their favourite part of the activity.
Facilitators and Barriers to Physical Activity
In total, 30 labels for facilitators and barriers were identified (see Table 3). No new labels were indicated after analysing the ninth interview, which implies that saturation of the data was achieved. Several citations are added to provide insight into the level of the information that was provided by participants and to provide more detailed information about the described labels.
Interviewees noted that they liked a certain activity because they enjoyed participating in it. Three participants mentioned that they performed a certain activity simply because it was part of their day program. Disruption of the program, for example because staff was on vacation, was not appreciated.
Others performed so-called useful activities and liked them because it enabled them to help others, such as walking with someone in a wheelchair, cycling to the reception to get the mail, or household activities.
Man, 58 years old, mild ID, walks independently. Works in neighborhood where mainly older people without ID live.
Interviewer: Does someone do activities in the garden?
Participant: I keep the neighborhood clean. I sweep and I pick up rubbish.
Interviewer : Do you like to do that?
Participant: Nahh like it … that's not the word. I just want to keep it clean!
Interviewer: That's a nice task.
Participant: Yeah, the oldies like it. They like that I keep their neighborhood clean.
Four older adults said that they did physical activities because it was good for their body, their health, and their weight. Others were aware of the positive effects of physical activity on their body, such as feeling more flexible, relaxed, energetic and cheerful, and mentioned this in the context of why they liked to be physically active.
Social and cultural facilitators
Support from staff or relatives who stimulate physical activity was considered an important facilitator for physical activity. Four older adults with ID noted that they liked walking or cycling together with family members on the weekend. Staff also supported physiotherapy exercises, which had to be executed at home. Two interviewees considered an activity to be fun because of a specific staff member who guided the activity.
Male, 52 years old, moderate ID, walks independently but with limitations.
Participant: In the morning I do exercises.
Interviewer: In the morning you do exercises. For physical therapy?
Participant: Yes, for my back.
Interviewer: Do you have back complaints?
Participant: Now and then…..now and then it is. Don't carry things!!!! That's what … [physical therapist] says. Do your exercises!.
Interviewer: Do you do your exercises with help from your staff?
Participant: I do them alone, but the staff is watching.
Receiving a reward for participating in physical activities (e.g., a medal) made older adults with ID feel proud of their performance and valuable to others. Some physical activities were categorized as “cool,” such as Nintendo Wii, bowling, and billiards. Performing physical activities with peers in a pleasant atmosphere also made it more fun to participate.
Participants mentioned that they were confronted with physical discomfort, such as being tired quickly and having pain. Increasing physical limitations hampered their performance of certain physical activities they were used to, such as cycling and horseback riding. Risk of falling also played a role within this context (see next paragraph). Unfortunately, according to the interviewees, these activities were not always replaced by more appropriate activities. Participants who lived in the community spoke about their dependency on staff to go outside, because of the traffic or risk of falling.
Woman, 72 years old, mild ID, walks with aid.
Participant: I used to walk very often. We went to the park.
Interviewer: Don't you walk anymore?
Participant: No. I have problems breathing. I can't walk far. It is such a shame I can't go walking anymore. Now staff members sometimes walk with me in the hallway.
Whereas participants liked certain activities, they disliked others, sometimes without being able to articulate why they did not like the activity. Three older adults did not want to participate in game-like activities that were specifically organized for older individuals with ID, such as passing a hoop around, because they did not see their usefulness or thought the activities rather dull. Also, cycling on a tricycle was not attractive for everyone: “I really would like to cycle again, but I am afraid to fall. And I don't want to cycle on a stupid tricycle.”
Several older adults thought they were not able to perform certain activities because these were too difficult for them or because they were afraid to fall. They did not want to look stupid or be laughed at by others (see code in Table 3: feeling insecure social context ).
Uncomfortable feelings that co-occur with being active, such as getting tired and sweaty, were not appreciated. “When I get tired, I quit the activity.” One participant said she would retire soon and from that point onward she would relax all day.
Social and cultural barriers
Staff members did not always seem to encourage older adults with ID to be physically active. Indeed, according to some older adults, they told their clients to relax and take it easy, because of their age.
Physical environmental barriers
Lastly, we identified some physical environmental determinants that hamper physical activity for older adults with ID. Like most of us, they did not like walking in bad weather. Moreover, they did not appreciate a transfer to another location where the activity took place.
When older adults were dependent on a taxi to go to an activity, the taxis often arrived too late or too early, which caused a lot of stress and discomfort. Besides, transportation entailed costs that most of the older adults could not afford. Lack of money sometimes forced older adults to stop an activity they enjoyed very much. Mentioned examples were activities, organized in the community—and thus more expensive—such as horseback riding, bowling, and fitness. Three older adults told us they wanted to tandem bike, but the problem was that they had none. One participant noted, “I had a bike. But since I moved, I do not have a bike anymore. I had to leave my bike behind. I loved cycling. Now I have no hobby.”
As mentioned before, participants told us they were dependent on staff or their relatives to go outside or to take part in an activity. However, staff members did not always have enough time to support them in physical activities.
Woman, 72 years old, moderate ID, wheelchair dependent.
Participant: You have to be patient.
Interviewer: What do you mean?
Participant: You have to be patient. Staff members never have time to walk with you, to go outside. They always write and sit in their office.
This qualitative interview and focus group study provides insight into preferences as well as facilitators and barriers to physical activity among older adults with ID. Participants frequently mentioned walking, dancing, gymnastics for older adults, cycling, cycling on a home trainer, swimming, and household activities as preferred activities. They especially enjoyed activities with music and outside activities, and coffee breaks were also appreciated. Identified psychological facilitators for participating in physical activity were (a) enjoyment, (b) perceived benefits for physical comfort, (c) knowledge about benefits for health, (d) physical activities as part of the daily routine, and (e) being active for a useful purpose. Social support from relatives, staff, and peers seemed to be a prerequisite as well as a motivation for many older adults to perform physical activities. It was appreciated when staff members created a pleasant atmosphere in which people with ID could feel at ease. For some older adults, activities with a certain status (activities that are popular in the group), were more appreciated, for example, Nintendo Wii or billiard. Receiving a reward and positive feedback from others may contribute to the participants feeling proud and appreciated.
Older adults reported physical complaints such as feeling tired more quickly, having less energy to become active, and sometimes being afraid to fall. Participants told us that they received support from others to perform physical activities. In addition, they often needed help to replace activities that became infeasible, such as horseback riding or cycling, by more appropriate ones, such as cycling on a tricycle or walking. However, some staff members seemed to be concerned about their clients being active and, according to participants in our study, even discouraged them from being more active. Barriers such as a lack of self-confidence, fear of activities being too difficult, and fear of falling, prevented older adults with ID from engaging in activities. These psychological barriers seemed to negatively influence the belief that they were able to perform the activities. Finally, physical environmental barriers, such as transportation problems and costs, seemed to influence participation in physical activities negatively. Older adults with ID are often not able to use the road safely, have to deal with mobility problems, and have a high risk of falling (Smulders, Enkelaar, Weerdesteyn, Geurts, & van Schrojenstein Lantman-de Valk, 2012). Moreover, older people with ID in general have less contact with their relatives than younger adults with ID. Most of their parents have died, and brothers and sisters are not always committed to their relative with ID or do not live nearby (Dagnan, Look, Ruddick, & Jones, 1995; Peterson, Lowe, et al., 2008; Ryan, Taggart, Truesdale-Kennedy, & Slevin, 2013).
In conclusion, factors that make older adults with ID feel happy, comfortable, and self-confident may positively contribute to their participation in physical activities. The lack of preconditions, such as support from others, transportation, suitable activities, and appropriate materials can prevent older adults from being physically active. Also, physical and psychological limitations were mentioned within the context of barriers to physical activity.
Comparison With Younger Adults With ID and Older Adults Without ID
A substantial number of factors identified in this qualitative study correspond with facilitators and barriers found by research in (younger) adults with ID (Frey et al., 2005; Heller et al., 2002; Hilgenkamp et al., 2012b; Mahy et al., 2010; Messent et al., 1999; Temple & Stanish, 2009; Temple & Walkley, 2007) and by research in older adults without ID (King, Rejeski, & Buchner, 1998; Phillips, Schneider, & Mercer, 2004; Rimmer et al., 2004; van Stralen et al., 2010). Facilitators to physical activity were support from others, social contact and friendship, positive feedback and reward, familiarity, routine of activities, and having fun. Barriers to physical activity were health and physiological factors, lack of self-confidence, lack of skills, lack of support, transportation problems, costs of physical activity and lack of appropriate physical activities and materials. Factors that were identified in these populations, but not in the current study, concerned information-related barriers and knowledge and skills of the professional coaches (Phillips et al., 2004; van Stralen et al., 2010). We hypothesize that these barriers may indeed be applicable to older adults with ID as well, but they are beyond the scope of the target population.
However, the results of this study highlight some elements that are specifically important when promoting physical activity among older adults with ID, as compared with younger adults with ID and older adults without ID. Support by family of older adults with ID is often not available. More than younger adults with ID and older adults without ID, older adults with ID are dependent on professionals to stimulate or support them in being physically active. Staff members could receive training to increase their awareness of the importance of sufficient physical activity for older adults with ID and to consider support of physical activity as their responsibility (Frey et al., 2005; Temple, 2007; Temple et al., 2006). Secondly, older adults with ID are in need of suitable activities, adapted to age-related decrease of physical functioning, which in this group starts at younger age compared with older adults without ID (Evenhuis et al., 2012). Physical limitations such as balance and coordination problems, decrease in mobility and muscle strength (Hilgenkamp, van Wijck, & Evenhuis, 2010), and pain, combined with limited understanding and often limited experiences with physical activity (Frey et al., 2005), indicate a need for professional support to create a safe environment and to choose appropriate activities for the target group.
In conclusion, physical decline at younger age, lifelong multimorbidity (Robertson et al., 2000), and dependence on staff to be physically active probably place older adults with ID at risk for low physical activity levels compared with younger people with ID and older adults without ID. The results of the present study suggest that older adults with ID may benefit from specific physical activity programs, adapted to their individual needs and limitations.
Strengths and Limitations
The strength of this study was that a self-report paradigm was used, allowing clients' personal views to be obtained instead of proxies for clients' personal views. An elaborate qualitative design was used to capture these personal views. Relatively few people with ID are able to read and write and to fill in written questionnaires. Therefore, the most appropriate method to gain subjective information from people with ID is interviewing (Felce & Perry, 1995). Data about the clients' personal views were obtained using a careful qualitative design. Participants with varying levels of mobility and in various age groups were included in the study, which supports the diversity of the findings. The comprehensiveness of the data was underlined by the fact that data saturation was achieved. Published studies of determinants of physical activity have involved younger adults with ID or have not been based on interviews with the participants with ID (Frey et al., 2005; Heller et al., 2002; Hilgenkamp, van Wijck, & Evenhuis, 2012a; Mahy et al., 2010; Messent et al., 1999; Temple & Stanish, 2009; Temple & Walkley, 2007).
On the other hand, restriction to the perspective of the older adults themselves is a limitation. Although we considered interviewing as the most appropriate method, interviewing people with ID also raises some significant and challenging methodological issues such as acquiescence and response bias (Finlay & Lyons, 2001; Perry & Felce, 2002). We acknowledge that these issues may have had an impact on the answers of participants and thus on the study results. It appeared difficult to gain information about factors of a higher abstraction level without asking suggestive questions. This resulted in relatively superficial information and limited information about underlying factors. Triangulation, for example by interviewing staff and family members, could provide more in-depth information about facilitators and barriers to physical activity among older adults with ID.
We included older adults who varied in age, mobility, motivation for physical activity, and severity of ID. However, we did not register other biological, physiological, or cognitive markers of aging. Inherent to the methodology of the focus group itself, data gathered with this method are not representative of the larger population from which the sample is drawn. The 40 participants in this study were not representative of all older adults with mild and moderate ID; most participants had a mild ID, and participants who could not communicate were not included. Caution is needed when generalizing the results of this study to all older adults with mild and moderate ID. The current study had an explorative nature; no conclusions can be drawn about the prevalence of barriers and facilitators indicated in this study.
Recommendations for Physical Activity Promotion and Research
Involving the target group itself when developing health promotion programs and tailoring the activities to their needs, interests, and abilities is of extreme importance for participation and adherence to the program (Brawley et al., 2003; King, 2001). Results from the current study can be used for developing effective programs aimed at promoting and improving physical activity among older adults with ID. Identified facilitators and barriers influencing physical activity among this target group can be translated into effective, evidence-based strategies. It is recommended to tailor the physical activities, including appropriate materials, to the interests of the older adults in order for them to enjoy participating in them. Walking and activities with music seem to be popular activities, and coffee breaks were very appreciated by our participants. However, like everyone else, older adults with ID have their individual preferences for certain activities, which could be addressed in order to develop a successful program. Support from experts, such as movement scientists and physical therapists, in specific activity games to create a safe environment is recommended. Positive experiences with simple physical activities may increase the older adults' confidence, reduce their fear of falling, and motivate them to continue. Education about physical activity and bodily reactions could also increase the motivation for more active participation. The challenge will be to draft an effective program that is suitable to older adults with ID that corresponds with their physical activity level, physical limitations, and personal preferences, in order for them to participate actively over time. To increase the consciousness of the importance of physical activity, we recommend using strategies that address both older adults with ID and their staff. Further research about the staff's attitude towards promoting physical activity could additionally provide insight in which strategies should be used to implement physical activity programs effectively.
The authors thank The Netherlands Organization for Health Research and Development (nr 57000003) and the participating Dutch provider services Abrona, Amarant and Ipse de Bruggen for their financial support. Moreover we thank all the participants and support workers who participated in and provided support for this project.
Marieke van Schijndel-Speet and Heleen M. Evenhuis, Erasmus University Medical Center, Rotterdam, the Netherlands; Ruud van Wijck, University of Groningen, the Netherlands; Pepijn van Empelen, TNO Research Group, Leiden, the Netherlands; and Michael A. Echteld, Erasmus University Medical Center.