Improving Physical Activity and Health of Older People Involved in a Social Farming Regional Preventative Multidimensional Programme in Italy

Aging population and health related issues

The world population continues to age precipitously. It is estimated, in fact, that in 2019, the number of subjects aged 65 or over was 703 million, with the forecast of increasing to 1.5 billion in 2050 (Guo et al., 2022). The aging process is associated with a decline in functional abilities, a greater frailty, and longevity does not always correspond to a good quality of life (Merchant et al., 2021). The World Health Organization (WHO) considers the process of healthy aging to be the process during which the functional skills and abilities for one’s well-being are developed or maintained (Beard et al., 2016). According to the scientific literature, physical exercise and social activities play a role of primary importance in the prevention of diseases and in maintaining functional abilities in later life (Merchant et al., 2021). Keeping physically active is not only good for the body, but also for the mind. In fact, physical activity is considered a very valuable tool in the prevention and reversal of depressive diseases, even among seniors (Zhang et al., 2021).

The World Health Organization suggests that people over the age of 65 to do at least 150–300 minutes of moderate-intensity aerobic physical activity or at least 75–150 minutes of vigorous-intensity physical activity; nevertheless, the WHO clarifies that replacing sedentary time with physical activity of any intensity (including light intensity) is always better than doing none (WHO 2020). The multicenter, randomized, controlled LIFE study (Pahor et al., 2014) demonstrated that a program of moderate-intensity physical activity (compared to a health education program) significantly reduced motor disability in older adults with mild physical limitations.

Nevertheless, maintaining a regular habit of exercise is considered a challenge during the aging process (Rivera-Torres et al., 2019): the UK ELSA study reported, for instance, people aged 70–79 years being about 50% less likely than those aged 50 to 59 years to be engaged in exercise and physical activity, adding emphasis on the importance of promotion aimed at obtaining constant practice intervening on mediating variables (Stevens et al., 2003).

Previous literature highlighted the way individual’s level of physical activity is affected by a number of correlated personal characteristics such as age, sex, social support and one’s health status and self-efficacy, the last two being the most recurrent in older adults (Bauman et al., 2012).

This is an important factor to consider is the motivation to start and maintain physical activity and exercise (Ryan and Deci, 2000; Teixeira et al., 2006). Devereux et al. 2016 have highlighted that in older people motivation can be affected by the poor prospect of achieving major physical improvements. Their research pointed out that rather than promoting physical activity programs based on health improvements, many people will be more interested in activities that will be intrinsically pleasurable, such as interactions with other people who are also performing the activities (Devereux-Fitzgerald et al., 2016).

In this perspective, preventative multidimensional interventions combining social participation with physical activity (e.g. leisure time activities that include a physical activity component) might be of help in promoting healthy ageing in the elderly population (Tcymbal et al., 2022).

Factors correlated to physical activity in older people

Scientific literature confirms that high levels of physical activity are linked to high levels of self-esteem and self- efficacy (McAuley et al., 2005). One of the main deterrents of preventive activities, such as physical activity, is the “ageism” (Menkin et al., 2022) negative or positive stereotypes, prejudice and/or discrimination against (or for the benefit) of the elderly on the basis of based on their chronological age or on the basis of their perception as “old” or “elderly” (Iversen et al., 2009).

Often, older people themselves tend to endorse the belief that functional decline is unavoidable in later life and this can lead them to be less open to preventative health behaviours (Nelson, 2016). Fighting ageism is necessary and the most effective weapons are activities that improve self-esteem and body image (Bergman, 2022). For this purpose, it is considered useful to encourage the perception of oneself in the elderly as able to face new or challenging experiences in different areas of life. This type of attitude towards problems and stressful events, or simply towards new goals, implies the achievement or recovery of a sense of self-efficacy, a psychological dimension strongly linked to that of self-esteem. A high level of self-efficacy, in fact, is considered a facilitating element in the pursuit and achievement of one’s goals and is connected to persistence in the face of obstacles and the ability to recover quickly in the face of a stressful event (Bandura, 1977).

Functional limitations affect adherence to exercise (Aartolahti et al., 2015). One of the most used and trusted tool evaluating functional impairment is the “Short Physical Performance Battery (SPPB)” test (Bruyère et al., 2017; Pel-Littel et al., 2009; Perracini et al., 2020; Van Kan et al., 2008) created by Dr. Guralnik that includes a series of exercises for assessing balance, strength and endurance (Guralnik et al., 1994). The three dimensions are often used in a number of studies. For instance, poorer walking speed (Timed Up and Go) at 9-year follow-up was linked to a reduction of mobility in a sample of older women (Idland et al., 2013). Karinkanta et al. (2005) showed that dynamic balance is an independent predictor of a standardized quality of life in home-dwelling elderly women. This is because balance issues in elderly people are really affecting quality of life, causing isolation, injuries, functional limitations, psychological difficulties, decreased everyday activities and increase admission to nursing homes (Kovács et al., 2013).

Support currently received by family and friends is considered a strong predictor of exercise adherence (Oka et al., 1995). In particular, positive support from others can increase self-efficacy to perform physical activity, through imitation and social learning (e.g., being an exercise partner) and verbal persuasion (e.g., reminding, encouraging, and reinforcing) (Bandura, 1977). More generally, a solid social network helps to take better care of one’s health, at all levels: elderly people who suffer from social isolation are more at risk of lacking of motivation to change (Seeman, 1996).

Subjective health perception is another factor associated to physical activity. Describing a state of how one feels and evaluates his or her state of health is correlated with objective health outcomes, such as functional status (Dostálová et al., 2021; Idland et al., 2013).

Social farming and the project Social Agriculture for active longevity of the Marche Region

In this framework the project named “Social Agriculture for active longevity” started in 2019 from the will of the Marche Region (Italy) to experiment innovative initiatives and services aimed at the elderly population in order to enhance social participation and well- being in peri-urban and disadvantaged areas of the territory lacking services to support the elderly population.

Three family-run farms, distributed throughout the Marche region, took part in this programme. The strategies used were focused on promoting physical activity, self-efficacy, social participation in the context of a natural environment. The programme scheduled a minimum of 50 days distributed in horticultural and occupational activities, socializing and a programme of physical exercise.

Research Hypothesis

Based on the collected scientific literature, the authors believe that a program of social farming, where older adults are involved in social events, group learning and physical activities, would be ideal to engage their interests in developing new skills, to socialise, to adhere to exercise programs and finally to improve the quality of life.

Participants’ recruitment and study design

The participants were recruited through a public recruitment campaign promoted by the Marche Region Agriculture Bureau and the farms. Recruitment was conducted by means of voluntary associations and personal contacts, day care centres, facilities for older people and municipalities. The participants lived in urban and rural environment and freely decided to participate after being informed of the study objectives, the programme activities, and the outcome monitoring. The presence of one or more disease was not considered a reason for exclusion, which is supported by the literature (Young et al., 2009). For this study, the authors selected a single group pre-test post –test design. Ethical approval was not mandatory for this study according to the Italian law. Data protection and privacy were granted through a consent letter that was signed by the participants to allow the processing of personal data. Potential participants that showed impossibility or unwillingness to sign the written consent; or with neoplastic disease or life expectancy <1 year, presence of cognitive disorders and other impediments that do not guarantee correctness adherence the programme were excluded. Selection and recruitment of participating subjects contemplated the signature of informed consent, the verification of the inclusion/exclusion criteria, the enrolment.

Study objectives and evaluation protocol

The objective of the study was to evaluate if the participant of the programme increased their level of physical activity at follow up.

The respondents were asked to answer to the question “Do you exercised regularly past year? “(no/yes with long interruptions/yes with short interruptions/yes without interruptions). Then the modalities “yes with short interruptions” and yes “without interruptions” were summed up into a single variable named Physical activity past year.

The authors are aware that answering questions does not provide an objective measurement of physical activity; on the other hand, physical fitness perception is positively correlated to physical activity levels and it has been previously used as marker of health-related fitness (Flanagan and Perry, 2018; Shephard and Bouchard, 1995).

Demographic characteristics aside (Sex, Age, living alone, Education), the research team established 5 main variables to consider as correlates of physical potential improvements based on the literature, Self-efficacy, Social network and support, Physical performance/Frailty, Quality of life, Perceived health.

Statistical analysis

The authors provided descriptive analysis of the study population grouped according to physical activity intensity at baseline. In the sub-sample of physically inactive population, significant variations in the potential correlates at follow-up were analysed. Continuous data were expressed by mean ± standard deviation, while categorical ones were reported as number (percentage). Chi-square test was used to analyse categorical variables, while t-test for independent samples was used for continuous ones. In order to study the correlates of physical activity improvement at follow-up, logistic regression model adjusted for confounders was built and fully adjusted model with age and balance test score was created. Statistical analysis was carried out using SPSS for Win V24.0 (SPSS Inc., Chicago, IL, USA). A p-value < 0.05 was considered statistically significant.