Chapter 3. Literature review
3.3. Benefits of leisure participation to older adults
maintaining participation in a range of activity domains in later life. Establishing supporting systems for caregivers, improving employment and leisure participation among older adults, and increasing lifelong learning systems are all related to promotion of active aging. (李佳綺、胡淑貞、李中一，2015；林嬪嬙，2014；黃品齊、方佩欣、
張少熙，2014)
Activity theory, which has played an important role in the area of gerontology and among public health professionals, echoed the idea of remaining better health condition through participating in meaningful activities. For older adults, active participation in leisure activities is a considerable way to sustain their health and well-being.
3.3. Benefits of leisure participation to older adults
Active engagement in life has profound influences to health in later life (Agahi &
Parker, 2005; Lennartsson & Silverstein, 2001; Singh, 2002; Strain et al., 2002).
Gerontologists and leisure researchers have shared great interest in both physical and mental health benefits of leisure participation in later life, which leisure is viewed from a health promotion perspective. In order to prevent health decline, aside from
medication, participating in leisure activities, both indoor and outdoor, has been found to be beneficial among older populations (Herrera et al., 2011; Lennartsson &
Silverstein, 2001; Simone, 2013; Verghese et al., 2006). Participating in physical activities, such as swimming, using fitness exercise equipment, going mountain
climbing and other outdoor activities, has well documented health benefits. Prevention of chronic diseases, including cardiovascular disease, diabetes mellitus and obesity, are beneficial and can prolong health and preserve quality of life of older adults (Agahi &
Parker, 2005; Singh, 2002; Strain et al., 2002; 趙美玲、江東亮、白豐銘，2011) Among the rising numbers of elderly, prevention of cognitive decline has also been widely acknowledged as a major public health issue worldwide. Frequent engagement in various leisure activities can exercise one’s “mental muscle” (Chao, 2014; Simone, 2013; Schooler & Mulatu, 2001), which has potential benefits in lowering risks of dementia and deteriorating cognitive function among community-dwelling older adults (Sörman et al., 2014; Iwasa et al., 2012). Mental health status is also an important aspect building up one’s well-being. Previous studies indicated that social support may positively affect cognition and mortality in old age (Ellwardt et al., 2013; Glei et al., 2005; Hajek et al., 2015; Holwerda et al., 2012). Participating in leisure activities can provide pleasurable feelings, which can be helpful to lower levels of depression (Cernin
& Lichtenberg, 2009; Chan, Chan, Mok, & Tse, 2009; García-Martín, Gómez-Jacinto,
& Martimportugués-Goyenechea, 2004). The presence of others when participating in leisure activities can also provide social interaction, which may be beneficial to sustain one’s mental health status (Pfeiffer, Heisler, Piette, Rogers, & Valenstein, 2011; Teo, Choi, & Valenstein, 2013). An 18-year follow-up study in Taiwan indicated that
participation in group leisure or social activities was found to be beneficial to mental health status of older adults (Chiao, Weng, & Botticello, 2011). A longitudinal study found that few social connections and infrequent participation in social activities are potential risk factors for cognitive decline among community-dwelling elderly persons (Zunzunegui Mí, Alvarado, Del Ser, & Otero, 2003). These findings suggested that aside from doing solitary activities, the social interaction provided through participating in activities with other people also have additional positive effects, emphasizing the importance of remaining social relationships with others during aging.
3.4. Leisure participation of older adults
The transitions of social environment and improvement of public health are possible reasons why older adults gradually put more emphasis on participating in leisure activities. Also, after retirement, they have more spare time and opportunity to participate in leisure activities. According to past research in Taiwan, the most common leisure activities older adults participate in tend to be more static or recreational, such as watching TV, chatting with others, listening to radio and other indoor leisure activities;
as to physical leisure activities, older adults tend to go take a stroll. (吳秀汝等人，2012；
李維靈等人，2007；李錦東、張峻嘉，2009；莊婷婷，2013；陳宇嘉、吳美玲，
1984；陳畹蘭，1991；蔡長清，2001；陳肇男，2003；陳娟娟，2005；陳俊宏、
陳鎰明，2008；高菁如、陳燕禎，2009). A study investigating the time usage and quality
of life of community-dwelling older adults found that aside from sleeping, older adults spend over 3 hours per week watching television, which is the most common activity participated (蔡蜜西，2003). Chen & Fu (2008) discussed about the relationship between leisure participation and leisure benefits, discovering that among the 499 interviewed older adults, over 80% of them watch television every day.
As to foreign countries, there are also some findings in common. Strain, Grabusic, Searle & Dunn (2002) investigated leisure participation differences between 1985 and 1993, among the 380 Canadian older adults, the most frequently participated leisure activities are watching television, reading and shopping. A research held in Korea found that out of the 155 participants over 60 years old, the most time spent was use of media, of which the most time was spent in watching television (Lee et al., 2014). Some leisure activities, such as gardening, are also common in Taiwan, yet not as popular as other western countries. Silverstein & Parker (2002) analyzed the data to investigate the variation between leisure participation of 1981 and 1992, and found that gardening and reading are the most frequently participated leisure activities. Minhat & Amin (2011) discovered that the most frequently daily done leisure activities were having
conversations while relaxing, watching television, and reading among older adults in Malaysia. The results also showed that the Malaysian older adults were more likely to participate in passive and sedentary leisure activities compared to physical activities
(Minhat & Amin, 2012). Due to the cultural and environmental differences, some leisure activities commonly listed in studies from western countries, including Sweden, Finland and America, are seldom seen in Taiwan, for example, hunting and fishing
(Hyyppä, Mäki, Impivaara & Aromaa, 2006; Agahi et al., 2006; Nilsson & Fisher, 2006;
Nilsson et al., 2015).
Both older adults of Taiwan and foreign countries tend to participate in sedentary indoor leisure activities, and interact mostly with their own family and friends, limiting their social internet. In order to decrease social isolation and promote active aging, encouraging more participation in various leisure activities is of great importance among older adults (Hyyppa et al., 2006; Karp et al., 2006; Minhat & Amin, 2012;
Nummela et al., 2008; Pressman et al., 2009; 柳立偉、王嘉淳，2009).
3.5. Measures of leisure participation for older adults
In spite of the far-reaching interest in leisure participation among older adults, there is a lack of valid tools for evaluating leisure participation. There is great inconsistency and variability in the contents of leisure participation measurement (Agahi & Parker, 2005; Fallahpour et al., 2015; Iwasa et al., 2012; Maselko et al., 2014;
Morrow-Howell et al., 2014; Nilsson & Fisher, 2006; 陳肇堯，2015). Under a thorough literature review, we found 37 studies investigating leisure participation among older
adults (Appendix 1).The following paragraphs illustrate how past research measures leisure participation of older adults, including the classification of leisure activities and the measured dimensions.
3.5.1. Formats of leisure participation questionnaire
Studies of leisure participation among older adults mostly used self-designed questionnaires to investigate the frequency and diversity of participating in leisure activities (Menec, 2003; Nilsson & Fisher, 2006; Wang et al., 2002). 34(92%) of them used questionnaires (Agahi et al., 2006; Agahi & Parker, 2008; Chen & Fu, 2008; Ferrer et al., 2015; Herrera et al., 2011; Hyyppa et al., 2006; Iwasa et al., 2012; Lennartsson &
Silverstein, 2001; Minhat & Amin, 2012; Morrow-Howell et al., 2014; Nilsson & Fisher, 2006; I. Nilsson et al., 2015; Nummela et al., 2008; Pressman et al., 2009; Scarmeas et al., 2001; van der Meer, 2008; 吳秀汝等人，2012；李維靈等人，2007；李錦東、張 峻嘉，2009；林聰哲、李世昌，2008；柳立偉、王嘉淳，2009；張俊一、許建民，
2012；陳俊宏、陳鎰明，2008；陳祥慈，2012；陳肇堯，2015；湯幸芬等人，2010；
黃淑貞，2011；盧俊吉、蕭崑杉、林如森、王春熙，2011；莊婷婷，2013；李素箱 等人，2013), one (3%) used time diary(Lee et al., 2014), and 2 (5%) used interviews
(Verghese et al., 2006; Verghese et al., 2003). Since open-ended questions may be too complicated and difficult for older adults to respond, the leisure participation
questionnaire developed in our study was in the format of multiple choices, as most of
the studies do.
3.5.2. Classification of leisure activities
Leisure activities may have different meanings among each person, therefore, it is quite difficult to classify an activity into one specific domain. Classification of leisure activities varies among past research, the numbers of activity domain range from two to eight, while some didn’t classify activity items into different domains(Agahi et al., 2006;
Agahi & Parker, 2008; Chen & Fu, 2008; Nummela et al., 2008; Pressman et al., 2009;
van der Meer, 2008; 李月萍、陳清惠，2010). A study investigating the relationship between leisure participation, self-worth and well-being, listed only two domains of leisure activity, sedentary and non-sedentary, and included only 10 items, limiting the results of research findings(陳祥慈，2012). Another study focusing on the relationship between leisure participation and mental health among older adults, also listed two domains of leisure activities but from a different perspective, i.e., physical and recreational, including less than 10 items. In addition, it only investigated how many activities the older adults participated in, without a comprehensive approach to the leisure participation profile of older adults(盧俊吉等人，2011). Most studies on participation in leisure activities among older adults classified activities into four domains, i.e., social, recreation, physical and self-improvement activities (Fallahpour et al., 2015；張家妤、曾美惠，2015). Aside from these four commonly seen activity
domains from literature review, Lawton (1993) proposed a classification that
discriminates best between activities based on the meaning of the activity. Therefore, Lawton classified activities into three domains, including Social, Experiential and Developmental activities (Lawton, 1993; Aartsen et al.,2002). Social activities include social interaction and services, such as volunteering. Experiential activities are
characterized by the intrinsic satisfaction of the activity, including activities that people are engaged to find relaxation or relief. Developmental activities are to help oneself become something, or change in some way, such as intellectual-related activities.
3.5.3. Naming of activity domains and activity items
In addition to the differences in activity classification among literatures, there are also inconsistencies in the naming of activity domains, though they include similar
activity items. For example, different studies used “exercise”, “physical activities”,
“sports and outdoor activities” and “fitness exercise” as the name of the domain for
leisure activities like jogging, mountain climbing, and swimming (Iwasa et al., 2012;
Lee et al., 2014; Morrow-Howell et al., 2014; 吳秀汝等人，2012；李維靈等人，2007；
盧俊吉等人，2011；莊婷婷，2013).
To sum up, a considerable multitude of research has shown that participating in various leisure activities have positive effects on physical and mental health among older adults, delaying cognitive decline, increasing social connectedness, thus
improving quality of life (Sörman et al., 2014; Iwasa et al., 2012; Maselko et al., 2014;
Scarmeas et al., 2001; Takeda et al., 2015; Toepoel, 2013; Verghese et al., 2006；李素箱 等人，2013；盧俊吉等人，2011). Due to cultural differences, it is not suggested to apply leisure participation questionnaires translated from foreign countries(李月萍、陳清惠，
2010；Iwasa et al., 2012; Maselko et al., 2014). However, the leisure participation questionnaires used in the reviewed literature have failed to consider social,
environmental and personal perspective altogether. Through the combining scope of active aging and occupational therapy, we are guided to develop a more comprehensive leisure participation questionnaire, in order to comprehensively profile older adults’
leisure participation in depth and for further leisure-related health research application in the future.
3.5.4. Leisure participation dimensions
Leisure participation was operationalized and measured as engagement or
involvement in the diversity of leisure activities by 19 studies (51%)(Agahi et al., 2006;
Agahi & Parker, 2008; Chen & Fu, 2008; Ferrer et al., 2015; Herrera et al., 2011;
Hyyppa et al., 2006; Iwasa et al., 2012; Lennartsson & Silverstein, 2001; Minhat &
Amin, 2012; Morrow-Howell et al., 2014; Nilsson & Fisher, 2006; I. Nilsson et al., 2015; Nummela et al., 2008; Pressman et al., 2009; Scarmeas et al., 2001; van der Meer, 2008; 吳秀汝等人，2012；李維靈等人，2007；李錦東、張峻嘉，2009；林聰哲、
李世昌，2008；柳立偉、王嘉淳，2009；張俊一、許建民，2012；陳俊宏、陳鎰 明，2008；陳祥慈，2012；陳肇堯，2015；湯幸芬等人，2010；黃淑貞，2011；
盧俊吉、蕭崑杉、林如森、王春熙，2011；莊婷婷，2013；李素箱等人，2013), frequency
of participation by 26 studies (70%)(Agahi et al., 2006; Agahi & Parker, 2008; Chen &
Fu, 2008; Herrera et al., 2011; Hyyppa et al., 2006; Iwasa et al., 2012; Lee et al., 2014;
Lennartsson & Silverstein, 2001; Maselko et al., 2014; Minhat & Amin, 2012;
Nummela et al., 2008; Pressman et al., 2009; 吳秀汝等人，2012；李維靈等人，2007；
李錦東、張峻嘉，2009；林聰哲、李世昌，2008；柳立偉、王嘉淳，2009；張俊 一、許建民，2012；陳俊宏、陳鎰明，2008；陳祥慈，2012；黃淑貞，2011；李 素箱等人，2013), with whom the older adult was being accompanied by in 2 studies (5%)(李錦東、張峻嘉，2009；陳祥慈，2012), and perceived value of leisure activity in 1 studies (2.7%)(張俊一、許建民，2012). Among the aforementioned four dimensions of leisure participation, some of the studies measured only frequency, some only
focused on the diversity of leisure activities, and some a combination of these two.
Each study focused on a specific dimension of leisure participation, yet none of the above studies has included all dimensions simultaneously to comprehensively profile leisure participation among older adults. Under such circumstances, we do not know much about the details of their leisure participation altogether, such as what leisure activities they prefer, who they do them with, how much they value them and whether
these activities are at home or community-based (Law, 2002). In considering whom they do them with, environment, and the leisure activities, we will be able to capture the profile of how older adults participate in leisure activities comprehensively. Thus, the combination of each dimension of participation, including frequency, social
environment, physical environment and preference of leisure participation, is
recommended, so as to form a leisure participation questionnaire to comprehensively profile how older adults participate in leisure activities.
Chapter 4. Phase I: Development of Leisure Participation Questionnaire
The questionnaire was developed through five steps: (a) literature review, (b) preliminary item development, (c) expert validation, (d) pilot testing, (e) internal consistency and test-retest reliability of the questionnaire. The development procedure of the questionnaire is shown in figure 1.
Figure 1. Flow chart of research phase I
4.1. Methods
4.1.1. Literature review
Electronic databases including PubMed, Medline, and Airiti were searched for literatures about measures of leisure participation used in samples of older adults. The keywords included are “leisure participation, leisure activity, leisure, older adults, elderly, old people, aging”. Domains and items of leisure activities, dimensions of leisure participation and the scaling were all investigated within extensive literature review. Literatures from both Taiwan and western countries, written in Chinese or
Reliability of the questionnaire (n=30)
English, were included.
4.1.2. Preliminary item development
Based on literature review, we recruited 33 activity items in the initial version of leisure participation questionnaire, according to Lawton’s classification of activities, including three domains, Social, Experiential and Developmental activities, and an additional domain, Physical activity, which is often adopted in the studies of leisure participation, resulting in four activity domains.
In order to have a comprehensive profile of the leisure participation among older adults, five dimensions were included in the questionnaire, comprising Diversity,
Frequency, With whom, Where and Preference. Each leisure activity that the older adult has participated in the past three months was followed by these questions related to the other four dimensions: How often do you do this activity? Who do you usually do this
with? Where do you usually do this activity? How much do you like this activity?
4.1.3. Expert validation
Three occupational therapy experts with master’s and doctoral degrees in the field of geriatric care were invited to form an expert panel. They were given a questionnaire
with 3-point scale to evaluate each item in terms of suitability and clarity. As for the suitability, there were three categories, i.e., “suitable”, “unsuitable and requiring further revision,” and “unsuitable and should be deleted”. A column was also included in the
questionnaire for experts to provide comments and suggestions regarding the
descriptions of each question and activity, five diverse dimensions of participation, and
the structure of the preliminary questionnaire.
Based on experts’ comments and suggestions the naming and description of 6
activity items were revised for easy understanding, i.e., the items of “Going shopping (外出購物)” and “Going window-shopping(逛街)” were combined together into
“Going shopping (including shopping malls and markets) (逛街購物(含購物中心、傳統 市場)”, since they are similar activities. The item of “Going camping (露營)” was a
less common leisure activity for older adults in Taiwan, so this item was deleted. The item of “Going to the gym” was changed to “Going to the gym or sports center
(including using fitness exercise equipment)(去健身房、運動中心(含使用健身器材)”, since in Taiwanese society “going to the gym(去健身房)” implies a leisure activity for people with higher economic status. Therefore, “using fitness exercise equipment (使用 健身器材),” which described an activity for the common people, was added to the item.
“Attending activities and classes held by senior associations and communities(參加里 民及社區關懷據點活動)” was added to the item of “going to community colleges”,
since senior associations and communities also hold a wide range of lifelong learning classes or activities for older adults. “Going to exhibitions and shows (參觀表演和展 覽)” was recommended to be added to the item of “going to concerts(欣賞音樂會)” to
give a clearer description of this activity item.
Second, “frequency” was changed from a 5-point scale to a 9-point scale for a more continued timeline, with ratings from “once per three months(三個月一次)” to
“more than once per day(一天多次)”. Out of the 5 point scaling of Where, two of the ratings: “in your community(在自己的社區)” and “out of your community(在自己的 社區之外)” were changed into “takes less than 30 minutes(30分鐘以內可到)” and
“takes more than 30 minutes(30分鐘以上才可到)”, to be more specific about the
differences of the distance. A new dimension of leisure participation, “How important is this activity to you?” was also added. The structure of the questionnaire was also
revised into a clearer way for older adults to read. An additional open-ended question was added for older adults to fill in the leisure activity that they often do which was not mentioned above. The structure of the questionnaire was also revised into a clearer way for older adults to read. After revision, the first version of the preliminary questionnaire was then used for pilot testing.
4.1.4. Pilot testing
The first version of the preliminary questionnaire was tested on 15 participants (mean age=66.3, SD=3.59, range: 60-73, 3males, 12 females), recruited from an elderly community service site in Northern Taiwan. The education level of the participants ranged from elementary school to Master’s degree, with a majority of senior high
school graduates (n=6, 40%). Only one of them lived alone, the others lived with their families. Eight of the participants have no chronic disease; the others have at least two types of chronic diseases, such as hypertension and heart disease.
The participants filled out the preliminary questionnaire with the assistance of the researcher. After filling out the questionnaire, the participants were asked to give suggestions about the wordings and structure of the first version of the preliminary
The participants filled out the preliminary questionnaire with the assistance of the researcher. After filling out the questionnaire, the participants were asked to give suggestions about the wordings and structure of the first version of the preliminary