The aim of this realist review is to develop a programme theory that explains how, why, for whom, and under which circumstances group-based PA programs work when delivered to older immigrants. For the purposes of this review, we define older adults as individuals who are 55 years of age or older, while an immigrant is an individual born in a country other than their current country of residence. Group-based PA programs are any programs that target PA, are located within a community setting and are delivered in an in-person group environment. The key questions for this review are:
How, why, for whom, and under which circumstances do group-based PA programs work when delivered to older immigrants?
How do PROGRESS-Plus factors interact to influence variations in participation and effectiveness of these programs?
What types of recommendations can ensure equitable opportunities and outcomes for older immigrants participating in these programs?
Equity-deserving populations are less likely to participate and benefit from health-promoting interventions which further exacerbates pre-existing inequities . An intersectional lens will be utilized to sensitize the team to the roles of intersecting identities and social locations in the uptake and effectiveness of PA programs. Intersectionality posits that social constructions such as race, gender, disability, and age create interacting and interdependent systems of oppression [28, 29]. Structural inequities are thus sustained, and, for older immigrants, are reflected in limited access to health-promoting resources [14, 30]. PROGRESS-Plus factors are used to evaluate inequities within and across interventions and include Place of residence, Race, Occupation, Gender, Religion, Education, Socioeconomic status, and Social capital in addition to Plus factors such as personal and group characteristics . Not all of these factors are relevant for every intervention but, rather, these factors differ in importance based on the type and context of the intervention. We identified, based on key literature [18, 32], factors that shape PA in immigrants and aligned these factors to the PROGRESS-Plus list: Place of residence (ethnocultural density, rural/urban region, availability and appropriateness of PA facilities), Race/culture/language (migration status, time since migration, discrimination, language), Gender (gender norms, gender expectations, gender roles), Religion (PA beliefs & attitudes), Education (PA literacy, years of education), Socioeconomic status (financial resources for engaging in PA), Social capital (social support, social norms, & social environment influencing PA), and Plus factors: health (access to healthcare, health care system adaptation, health status), motivation, age. Only Occupation did not seem to be immediately relevant to PA programming for older adults but would be relevant to overall levels and types of PA . An intersectional approach using these factors will be integrated into all phases of the realist review to ensure an equity lens informs recommendations on PA program design .
This review will not require ethics approval by the University of Alberta because all documents are in the public domain. The protocol has been submitted to PROSPERO for registration (ID#258179, Date submitted May 30th, 2021).
A realist review is an approach to synthesis that aims to explain why an intervention works or does not work in particular circumstances, by asking what works for whom, in what context, and how . PA programs are complex interventions in that they are contingent for success on a set of interacting personal, interpersonal, and structural factors with a range of potential outcomes [5, 23]. PA programs in the community are rarely successful at increasing PA in immigrant populations and ways to increase participation are unclear [15, 16, 17, 18]. A realist review posits that it is only possible to achieve an understanding of the social world by identifying underlying causal mechanisms and their functions under different conditions . Hence, this realist review will generate hypotheses in the form of “programme theories” or “explanations of how things work” to explore the features and conditions necessary for a successful group-based PA program for immigrant older adults . Central to a realist review is the identification of contexts (C), mechanisms (M), and outcomes(O) from which programme theories are developed in the form of C-M-O configurations (Table 1).
This review will follow established realist quality and publication standards (RAMSES) , Pawson’s realist methodology [34, 36] and PRISMA-equity reporting guidelines . A PRISMA-P checklist has been completed for this protocol (Appendix A). Realist reviews have included primary data to aid with triangulating evidence with secondary sources and enhance the contextual relevance of findings . Each stage will incorporate stakeholder consultations:
Develop an equity-focused initial programme theory (IPT) that explains tentatively how, why and for whom PA group-based programs work.
Test and refine the IPT for the target population of immigrant older adults using a systematic realist review process.
1. Developing the Initial Program Theory (IPT)
An IPT is an abstract description of how and why an intervention is assumed to work in a particular circumstance and drives the direction of empirical testing during the realist review . IPTs for this study will be built from: (a) a literature search on existing theories that explain older adults’ PA uptake and adherence in group-based PA programs, (b) a theory (intersectionality) not directly related to PA but relevant to the equity lens of this study, and (c) tacit theories on what is working, how and why from stakeholder consultations .
1.1 Searching the Literature
The literature search will examine existing theoretical evidence on group-based PA programs in older adults (Table 2). As the literature on older immigrants and PA is sparse and the theoretical development in this field minimal, we will need to expand our search to include all populations of older adults for initial theory development. Search terms of electronic databases will include combinations of: “theory, concept, framework” AND “physical activity, exercise” AND “interventions, programs'' AND “older adult”. As we move through the search process and begin to identify relevant literature that can illuminate mechanistic dimensions of PA programs, we will conduct additional searches to target particular theories/concepts (see sample search strategy: Appendix B). This phase will, also, be informed by iterative one-on-one consultations with the PA theorist (JP) and practitioner (AJ) on our team.
1.2 Data Extraction and Synthesizing Evidence
We will use Covidence, a systematic review management system, to facilitate the screening process which will be implemented by the two team members (JS) and (SA) with a third team member (AJ) resolving disagreements. Initial data extraction will be completed by two members of the research team (JS & SA) and followed by a detailed discussion to ensure consensus during team meetings. The team will collaboratively identify recurrent patterns of contexts and outcomes (demi-regularities) in the data and synthesize explanations (mechanisms) of these patterns . The team will explore whether and how PROGRESS-Plus factors can be featured in each C-M-O statement by asking the following questions (Table 3):
Which PROGRESS-Plus factors are taken into consideration in this paper/study?
Are these factors looked at individually or has an intersectional lens been applied?
What are the factors or intersections of factors that must be considered in community-based group PA programs?
1.3 Stakeholder Consultations
Once the IPTs are configured, we will present the IPTs to stakeholders for review. Stakeholders will be service providers at immigrant serving agencies (Multicultural Health Brokers), seniors’ organizations (SAGE; West End Seniors Activity Centre), and ethnocultural community organizations (Al-Rashid Mosque, SHAAMA Center). We will focus on stakeholders within our existing networks who are known to run PA programs in their organizations or have intimate working knowledge of the lived experiences of immigrant older adults in Alberta, Canada. We will conduct 8-10 stakeholder consultations to draw on this expertise using questions (Table 4) developed with a realist lens . Consultations will be 30 minutes to one hour in length and will occur at locations convenient to participants (via telephone or zoom for the duration of COVID-19 pandemic restrictions). Notes will be taken and organized in an excel spreadsheet as they correspond to particular IPTs and will be used by the research team to refine theoretical conceptualizations.
2. Testing and Refining the Programme Theory
This phase will include a systematic search, appraisal, extraction, and synthesis of evidence to test and refine the initial programme theories.
2.1 Searching the Literature and Appraisal
A systematic literature search will be conducted by a team member who is a health librarian (MK) using the PRISMA-Equity Reporting Guidelines for Systematic Reviews . Searches will be performed in the following electronic databases MEDLINE via OVID; EMBASE via OVID; CINAHL via EBSCOhost; Scopus via Elsevier; Cochrane Library via Wiley; Sports Medicine & Education Index via ProQuest; SPORTDiscus via EBSCOhost, in addition to grey literature and hand searches of the reference lists of papers to be synthesized in the review. We expect the following main types of studies to be included in the review: Studies that (a) describe group-based PA programs for immigrant older adults and (b) studies exploring motivators and barriers to PA in this population (Table 5). In keeping with a realist review methodology, studies will not be excluded based on design and will be selected based on their relevance; meaning their ability to address the research questions and inform the programme theories [34, 38]. The team will assess each study for final inclusion using screening criteria for relevance (Table 6) by ranking studies as conceptually rich (high), moderate or low based on their explanatory power . We will automatically include conceptually high and moderate studies ranked by two independent reviewers on the team and exclude non-relevant studies. Conceptually low studies will be included based on team deliberations. Studies included in the review at this stage will be evaluated for rigor to inform the trustworthiness of final programme theories . We will adopt the Mixed Methods Appraisal Tool (MMAT) which can be used for qualitative, quantitative, and mixed methods studies .
2.2 Data Extraction & Synthesizing Evidence
Two research assistants will independently extract relevant data from included studies using an excel spreadsheet. The extracted data will consist of descriptions of interventions (type of PA program, location, population, personal/interpersonal/organizational features of the program) and findings (barriers/facilitators to adherence, outcomes of interest). Data extraction will also include PROGRESS-Plus indicators to identify ways the programme theories are shaped or altered by these factors . A working session where the research assistants conduct extractions with the team will allow for agreement on the extraction process early on. In co-working sessions the team will seek evidence that adds proof or refutes aspects of the overall programme theories under investigation . The team will explore the literature for the contextual (C) influences that are hypothesized to have triggered the relevant mechanism(s) (M) around PA program participation to generate the outcome(s) (O) of interest observed in older immigrants. For example, a C-M-O configuration could provide a nuanced explanation of how gender, religion, and age intersect to influence participation in PA programs and an equity-focused recommendation would be developed from this observation. A flow diagram will be used to track the flow of documents included in the review, reasons for inclusion at each stage, and key findings.
2.3 Final Stakeholder Consultations
We will invite the stakeholders again to a group discussion of the final programme theory and ask for input on the usefulness and authenticity of the theory based on their experiences within immigrant communities . We will record and transcribe the content of this 2-3-hour group discussion, and we will use NVivo 12 qualitative software to thematically link stakeholder input with relevant programme dimensions for final refinement.
2.4 Knowledge Translation Tools
Outputs from the review will include a refined programme theory and an outline of recommendations in the form of best practices for developing group-based PA programs targeting immigrant older adults. The review methodology and resulting programme theory will be published in a peer-review journal. Recommendations will be disseminated to community stakeholders (including City of Edmonton, Multicultural Liaison Office, Seniors Clinical Network, Edmonton Seniors Coordinating Council, immigrant service agencies, ethnocultural organizations).