Difficulties and motivations for physical exercise in women older than 65 years. A qualitative study

ABSTRACT Objective: to identify difficulties and motivations for the practice of physical exercise in women older than 65 years. Method: qualitative study based on the phenomenological theory, with focus groups and in-depth interviews. The nursing staff selected 15 women by intentional sampling using the following criteria: age, time dedicated to physical exercise, independence, and absence of cognitive impairment and contraindication for this activity. Two focus groups were formed (one of them did physical exercise for less than 150 minutes per week and the other at least 150 minutes per week) in addition to conducting five in-depth interviews. Qualitative analysis of the data was performed through transcription, coding, categorization, and verification of results. Results: the difficulties to start and develop physical exercise were circumscribed to the perception of poor health and lack of free time; both circumstances result from care obligation, being represented as a gender imposition. However, the motivations are related to perception of strength, need for socialization, and perception of autonomy and freedom. Conclusions: the ideological representation of gender determines the women’s decision to exercise. Knowing the meaning and significance that women give to health and their role in the socio-family environment allows nurses to develop relationships and interventions to encourage the practice of physical exercise.

Sedentary lifestyle is the fourth most important mortality risk factor worldwide, causing both the appearance of chronic degenerative diseases and installation of incapacitating processes (12)(13) . Some international studies confirm that women of advanced age are more sedentary than men of the same age group (14)(15)(16)(17) . The National Health Survey in Spain (2011)(2012) indicates that 58.4% of the population with more than 65 years old referred to be sedentary, with a higher percentage in women (63.6%) (13) , and 52% of those over 16 years of age lived in Murcia (18) .
The gender role and family responsibilities are the main causes of non performing PE (19)(20) . According to the Institute for Women in Spain, these findings lead us to suppose that 17.3% of older women do not exercise (21) .
Most of the female population does not have the time necessary to dedicate to occupations not related to the procreation role. Therefore, the activities developed in the social life do not have as much importance as those derived from gender impositions. The wife, mother, and caregiver roles obtain more social value and time than activities related to PE or recreation (22) .
If sport, which follows a model of androcentric values, is added to this lack of time and valuation of PE, the barriers for women to open a space for such activity are increased. The PE is so oriented to men, that women have to understand it within the male model and "re-socialize" to be integrated, accepting these customs that do not take into account half the population (23) .
For this reason, it is important to explore these socially-established conceptions and design interventions that promote health and physical activity, considering the gender perspective (14,17,24) .
We conducted a literature review of the existing scientific evidence about studies related to barriers and motivations to do PE. Eight references were then included: six reviews (systematic or integrative) (8,(19)(20)(25)(26)(27) and two original articles (7,9) . In Figure 1  is expected to provide opportunities to choose healthy lifestyles, within the expectations of older adults (28) .
For this reason, our objective was to identify and understand the difficulties and motivations for the practice of PE in women over 65, in a Basic Health Area (BHA), taking into account the following aspects of this group: personal experiences, idiosyncrasies of health, family, and sociocultural context (29) .

Method
This is a qualitative study based on the phenomenological theory. In November 2015, two focus groups (FG) were formed as a tool for data extraction.
They were organized as a function of the weekly time dedicated to PE as recommended by WHO (6) . A group of 8 women who did PE for ≥ 150 minutes (min) per week (FGA) and another group of 7 women who did PE for < 150 min per week (FGB). A thematic guide was used as a stimulus for the debate (30) , which contained the following aspects: a) what they understood by doing PE; b) benefits of PE; c) motivations to do it; and d) difficulties in doing it.
The inclusion criteria were circumscribed to homogeneity and heterogeneity, as shown in Figure 3.   Once all statements were recorded and the data were transcript, we proceeded to analyze its content.
The information obtained was segmented into basic units of meaning (coding process). Subsequently, these units were grouped into broader categories (categorization process). The transcripts were coded by four researchers in an independent way. At all times, anonymity and confidentiality of participants' identity were assured (31) . The MAXQDA10 software was used to analyze the data.
The methodological procedure followed in this study can be observed in figure 4.  It is understood that for these people, being able to go at their own pace is an element that adds to others, increasing the appeal of developing a physical activity.

Discussion
For the women who participated in the study, PE is represented in a polysemic way. While for the group that did not exercise regularly any activity developed in the domestic sphere was understood as PE, for the group that developed PE regularly, it was understood as a planned and organized activity, that took place outside of the family home, not related to domestic tasks. This way of conceptualizing PE agrees with the concept that the international and Spanish organizations have; they emphasize the idea that PE should be planned, structured, and done on regular basis, aiming to maintain or improve the physical conditions (32)(33) .
Despite this definition, there is a widespread conviction among women that "any physical activity they perform would fit within the PE concept" and, as such, would contribute in a beneficial way to their health.
The perception of a bad state of health, which women with advanced age have, is supposed to be a great limitation to start and maintain PE. The López-Benavente Y, Arnau-Sánchez J, Ros-Sánchez T, Lidón-Cerezuela MB, Serrano-Noguera A, Medina-Abellán MD.
women who participated in the study perceived limitations in their own bodies, which generated a great distrust in the response that it would have after doing PE. With reference to the above, some international investigations highlight the power of negative stereotypes associated with old age and their connection with PE. These same studies emphasize that, in the context of physical activity, women represent old age as a lack of adequate response of the body to face the challenge of PE; this would be due to a decrease in their physical abilities (7,(19)(20)34) .
However, in this BHA, the ideological representations of senescence and limitations that it imposes to the body, did not present as a great obstacle to start a new activity. Differently, other studies point out the slowness of the recovery process after doing PE and the concern about suffering injuries in this age group as the main barriers to its development (35) .
Gender is another analysis category that emerges in the results of this study. The statements show that women were educated and socialized during their maturity to take care of previous and future generations by cultural and social imposition of gender (36) , which leads them to identify themselves as a "being for others" and "omnipresent", defining them as health preservation agents of the other members of the family. This circumstance makes them adopt a role that is difficult to change, not only by the cultural force, but also due to the conflicts they suffer when they try to break the behavior rules imposed by culture. initiate themselves in sports, activities that acquire more relevance as they age (7,(20)(21)35,40) . It is reasonable to assume that, although elderly women recognize their bad health, their perception of feeling able to do PE and the feeling of well-being (when they overcome the limitations of their own bodies) contribute to their initiation and continuity in PE.
Inversely, other international investigations claim that despite the benefits brought by PE, it has not power enough to start and sustain this activity (41) .
According to the factors that motivate the development of PE in elderly women, their need to socialize is a remarkable influence, both to start and maintain this activity. In this perspective, some studies reveal that women generally feel uncomfortable when they walk alone, feeling better when doing it with a company, as this activity allows to create and reaffirm links (7)(8)42) . The importance of a companion is significant because it allows women not only to enjoy the benefit of the company itself, but also to establish and reaffirm social ties that become support and Similarly, the study of the Women's Institute also establishes a relationship between freedom, autonomy and physical exercise, by stating that independence of their children, health, widowhood, and availability of time for retirement are found among the reasons for women older than 65 initiate sports practice (21) . This relationship allows them take the incomes of their life, being freer and happier at this moment of their life cycle (39) . On the other hand, in the group of women who do less exercise, the responsibility of family care, a consequence of being a connection between the previous and subsequent generations (44) , decreases freedom and autonomy to do exercise due to the absence of free time.