1. The Research Process Begins with the PICO QUESTION:
Among the elderly, do those who engage in routine physical activity, compared to those who do not, score higher on quality of life assessments?
Purpose of Presentation: While doing research for another class I became interested in the relationship between physical activity in the elderly and it’s effect on mood/depression/perception of well-being. One way to measure quality of life is through standardized assessment tools. I hypothesize that the loss of physical ability has a direct negative impact on the quality of life of an individual, particularly the elderly.

2. Results of the literature search
Search words
engines Used
Results of search
“Health related quality of life”
“elderly”
“physical activity”
CINAHL
PubMed
Gale PowerSearch
After filtering search to only peer reviewed journals from 2010 to a total of 698 articles were found. Many of these included factors like diet, specific disease or ethnic group.
Search words: health related quality of life, elderly, physical activity
Search engines used: Nursing databases->CINAHL (The Cumulative Index to Nursing and Allied Health Literature) which has access to about 3000 journals;
->Pubmed: largest biomedical database with about 5000 journals! And ->Gale PowerSearch: very large collection with multiple types of sources like podcasts, thesis documents, etc. It is a combination of Academic OneFile and General OneFile
Results of Search:

3. References
ARTICLE #1
Wanderley, F., Silva, A., Marques, C., Oliveira, G., Mota, E., & Carvalho, J. (2011). Associations between objectively assessed physical activity levels and fitness and self-reported health-related quality of life in community-dwelling older adults. Quality of Life Research, 20(9),
ARTICLE #2
Balboa-Castillo, T., Leon-Munoz, L., Graciani, A., Rodriguez-Artalejo, F., & Guallar-Castillon, P. (2011). Longitudinal association of physical activity and sedentary behavior during leisure time with health-related quality of life in community-dwelling older adults. Health and Quality of Life Outcomes, 9, 47.
The first article followed women over seven years, addressing the affect of PA on HRQOL
The second article discussed the definition of HRQOL, what can be done to improve it for people
The third is very helpful as it compares PA to sedentary behavior and both to HRQOL.
Use eyeglasses to access articles, they are hyperlinks

4. Rationale for Articles Chosen
I chose to use these two articles because they both contain the exact elements of my PICO question: Population-elderly, Intervention-PA (physical activity), Control-no (or less) PA, Outcome-higher quality of life. A standardized assessment tool called the SF-36 was used to measure health-related quality of life in both studies which I considered a strong point.
The first article, “Associations between objectively assessed physical activity levels and fitness and self-reported health-related quality of life in community-dwelling older adults” was chosen because Wanderley et al. addressed some of the exact questions I had considered when beginning this project. How do you measure health-related quality of life (HRQoL), and fitness? This study claims to be the first to measure habitual physical activity (PA) objectively by using accelerometers. I liked that the unit of measure for physical activity appeared simple to understand. Also I appreciated that the creators of the study used statistical analysis to account for important variables like “age, BMI, PA levels, 6MWT, hand-grip strength, and HRQoL domains” (Wanderley et al., 2011).
The second article, “Longitudinal association of physical activity and sedentary behavior during leisure time with health-related quality of life in community dwelling older adults” by Balboa-Castillo et al. was chosen because it also studied the relationship between PA in older adults not living in nursing homes. It went a step farther than many studies in looking at PA as a leisure time activity. That made it an original type of study. This study was also valuable as it had a larger sample population and covered a span of seven years.
Both studies attempt to find relationship between PA and HRQOL which is the basis of the PICO question. Both have ‘community dwelling older adults’ as the target population or sample group. Initially I was interested in just the elderly, had to chose more specific population so I chose community dwelling because 1. That is larger group 2. They may one day become LTCF residents 3. Health Promotion aimed at this group will have potential to affect largest age group as it cont. to grow.
I liked that the first article used objective measurement of PA rather than survey information. Also liked that the second article specifically stated sedentary behavior, in other words no PA, which is the control group of the PICO question.
Health-related quality of life was measured by……(compare/contrast)

5. Theory
Wanderley et al.’s study was conducted to test their theory that there is a direct relationship between routine or habitual physical activity and physical fitness on an older adult’s subjective HRQoL.
The study by Balboa-Castillo et al. theorized that the more time an elderly person spends being sedentary the lower HRQoL they will have.
Type of Study
Both of these studies collected qualitative data and used it to complete qualitative statistical analysis.
Design
Wanderley et. al conducted a descriptive study that used numerical data to analyze the relationship between PA, fitness, and HRQoL, while also accounting for confounding variables like BMI and number of chronic conditions. This was a cross-sectional one-shot case study that gathered data once. It was reliable in it’s use of measuring instruments. It accounted for many variables that could affect the outcome which supports internal validity. External validity was not strong based on the small sample group.
Balboa-Castillo et. al conducted a prospective cohort study by following up with a large group after seven years. This is a posttest-only control group design as the HRQoL was only assessed at the end of the study. The sample population was randomized by “probabilistic sampling within multistage clusters” (2011, p. 2). Internal validity may be weakened by the effect of time on the elderly; as they aged HRQoL decreased. External validity may have been effected
by the Hawthorne effect; did the subjects exercise during leisure time knowing it was positively viewed by the authors of the study?
Further discuss the variables accounted for in the Wanderley study. Mention types of analysis used for particular variables.
Both studies are prospective as they gathered current data and are using it in an attempt to predict
Both used linear regression and were adjusted (for main cofounders??)

6. Physical Activity Health-related Quality of LifeFi
Methods and Findings
The study conducted by Waverley et al. had a sample of 85 older adults. The individuals were assessed for three things. First they were tested for physical fitness by completing a six-minute walk test (6MWT). Next researchers measured hand-grip. Third, they were asked to wear an accelerometer for seven days. These devices were analyzed by computer which was able to obtain “amount, frequency, duration, and intensity of PA” (Waverley et al., 2011, p. 1372). Participants also gave a health history. Researchers used statistical analysis to find relationships between physical activity levels, fitness and HRQoL. They were also able to adjust for variables including “BMI, number of chronic conditions, and education” (p. 1375).
The study found those who tested higher in physical fitness and PA reported a higher HRQoL.
Accelerometer sounds like a fitbit. This test was conducted in Portugal. These folks were generally healthy, it was shown that the most active and fit older adults have approximately twice as much chance of scoring higher on physical functioning and vitality in particular.
Physical Activity Health-related Quality of Life

7. Methods and Findings Cont.
In 2003 the Longitudinal association of physical activity and sedentary behavior during leisure time with health-related quality of life in community dwelling older adults researchers contacted almost three thousand older adults in Spain. Volunteers underwent a physical exam. The subjects also completed the “Nurses’ Health Study and the Health Professionals’ Follow-Up Study” (Balboa-Castillo et al., 2011, p. 2). which measured participation in sixteen different physical activities. Physical activity was calculated in minutes per week. Also metabolic equivalents for each activity were calculated. Sedentary behavior data was gathered in hours per week. Participants were contacted again in The 1,608 remaining subjects completed the SF-36. Study results show an inverse relationship between LTSB and PA. Also replacing sedentary behavior with PA can increase HRQoL.
Further discuss methods and findings

8. Ethical Considerations
Both studies used volunteers. There is no mention of benefit to the subjects for their participation. In both studies trained interviewers conducted the tests which should minimize the transference of expectations onto the subjects. The experiments were approved by the “Institutional Scientific Board” (Wanderley et al., 2011, p.1372) and the “Clinical Research Ethics Committee of the ‘La Paz’ University Hospital in Madrid, Spain” (Balboa-Castillo et al., 2011, p.2). Balboa-Castillo et al. report no conflicting interests nor influence by funding sources. They were funded by FIS grants. Wanderley et al. do not address conflicting interests. It was noted Wanderley is affiliated with the Research Centre in Physical Activity at the University of Porto. The authors acknowledge funding by the Portuguese Foundation of Science and Technology.
Very Limited exposure between subjects and researchers minimized risk of influence or harm. Not sure what FIS grants are.

9. Strengths and Weaknesses of each study
The study by Wanderley et al., Associations between objectively assessed
physical activity levels and fitness and self-reported health-related quality of
life in community-dwelling older adults has strengths and weaknesses. One of
it’s strengths is it’s reliability. All of the measurements gathered were done so
with precise instruments or respected standardized tests.
The study has face validity and construct validity. External validity is weakened by the inclusion of only healthy people into the sample group. There is no reason to doubt the credibility of the study. Unlike the second study, there is no evidence of training of those collecting data putting quality in question.
Limitations of the study relate mainly to generalizability. The sample group was small, consisted of similar type individuals who were generally healthy.
Accelerators worn at the waist measured “amount, frequency, duration, and intensity of PA” (Wanderley, 2011, p.1372). Also used “Medical Outcomes Study 36-Item Short-Form Health Study” survey. “Hand-grip strength was isometrically measured using an electronic hand-grip dynanmometer”. It has face validity because the data and measurement units are appropriate (how much and what kind of exercise, standardized health related aspects of life. It has construct validity if all of the equipment used was properly calibrated and used the same by each person taking measurements. External validity is weakened by the inclusion of only healthy people into the study population. They used a list of over 11 health issues to exclude people. Also subject-treatment interaction must be considered. Perhaps the type of people who volunteer for research studies are the same type who are more physically active. I feel the authors made a good effort at trying to account for the most obvious variables including BMI, smoking status, education level, number of chronic conditions. The authors did a good job of pointing out their limitations in the discussion section-all white, only one smoker.

10. Strengths and Weaknesses of each study cont.
The study by Balboa-Castillo et al., Longitudinal association of physical activity and sedentary behavior during leisure time with health-related quality of life in community-dwelling older adults, has strengths and weaknesses as well.
The researchers gave the research face validity when they chose appropriate tests to measure HRQoL , LTPA and LTSB. The authors stress the specialized training of those giving interviews and conducting physical assessments. This supports the reliability of the study. The subjects self reported on their level of activity which could have a negative effect on reliability.
Internal validity was effected by attrition as after seven years some of the sample population had died. The authors made a strong effort to calculate for a large number of variables which gives the study increased external validity. Their calculations accounted for more variables than the previous study.
No credibility issues were noted in this study.
Those who did physical assessment had been trained and were certified. The SF-36 was conducted by telephone, “There is evidence in Spain that validity and reliability of information obtained by telephone interview on lifestyles and HRQoL is similar to that obtained in face-to-face interview” (pg. 2). Used “Nurses’ Health Study and the Health Professionals’ Follow-up Study”.
Interrater reliability is could be affected by the self reporting of activity. Don’t we often feel like we worked harder or longer than we really did? The authors reported that at the end of the study the cohorts were younger. The authors included all the variables as the other study Plus six different health conditions and variations of alcohol consumption.

11. Contributions to Evidence Based Practice
Wanderley et al.’s research has limited usefulness for future clinical practice due to it’s highly selective and small sample population. This study did show that there are objective ways to measure physical activity that could be useful for future studies.
Balboa-Castillo et al.’s research found proof of positive outcomes when one hour of sedentary behavior is replaced by physical activity. Future studies can compare different durations of PA to find the least amount needed to obtain same results.
Both studies state the need for further research to better understand the complexities of health, self reported quality of life and physical fitness.
As the authors point out, there are many factors that can affect health and quality of life. In future other factors could be studied along with measuring PA using the accelorometers, like marital status, financial status, etc. This will over time draw a better picture of who is getting enough PA. Assessments or studies must be done before accurate interventions can be devised.

12. Relevance to Clinical Practice: Communication
The findings of these two studies both support the relationship between being physically active and having a higher health related quality of life. This could be applied to a variety of settings where older adults live.
In the community organizations like the AAA or those in home health could use client education as a health promotion tool.
While studies were completed on community members it would be beneficial to those in health care facilities as well. Include as part of discharge education.
No reason these findings could not be shared with those in long term care setting as well. Remind residents and staff that staying active has positive outcomes for overall health.
Discuss implications for health promotion by hand outs, part of seminar or inservice, community service messages on radio, newspaper, TV. Doctors offices can have informational pamphlet.
In assisted living and LTCF short informational flyers in breakrooms, bathrooms, assignment books can be effective.

13. Relevance to Clinical Practice: Implications for Change
These studies did not provide any groundbreaking new evidence. Rather their findings support ideas that are commonly held by the medical community-Being active keeps you healthy.
The quality of the studies was sound. The generalizability was limited in some aspects. Therefore I don’t predict any changes in practice resulting from these particular studies.
They do provide methods that can be duplicated as part of future studies.
Results can be used to support claims of importance of physical activity.
Potential Barriers to implications for change include lack of new information, inability to generalize to less healthy populations.
Policy makers generally like to see significant change before putting forth resources like time and money toward any type of change. If the studies had found that physical activity reversed depression for example the entire health care community would get excited and do something like prescribe specific amount and frequency of activity.

14. Relevance to Clinical Practice: More PICO questions
For future study the original PICO question could be modified. Populations could be adults over the age of eighty years old or older adults with more than one chronic disease or older married adults Interventions could be attend structured physical activities or have a fitness buddy Control remains without the intervention of course Outcome could be more specific, like improve mental health or decrease bodily pain

15. Conclusion
Researching a question critically is a valuable skill. It provides the means to continue learning about any topic of interest. From the initial query of the subject, to forming a PICO question, and finally reaching an educated conclusion the process of analyzing research information empowers us. In this particular project it was concluded that physical activity does in fact contribute strongly to having a high health-related quality of life. This general information can be used as the basis to which further research may be done. The use of standardized testing for all of the variables was indicated as an important factor in both studies. It was interesting to compare the similarities and differences in the two studies, as well as the strengths and weaknesses. This has been a very useful exercise in research analysis.