A Realist Review Protocol of Community Group-Based Programs to Promote Physical Activity in Immigrant Older Adults. Rachel Flynn University of Alberta Faculty of Nursing Jordana Salma ( [email protected] ) Faculty of Nursing, University of Alberta and Faculty of Nursing, level 3, Edmonton Clinic Health Academy Sonam Ali University of Alberta Faculty of Nursing https://orcid.org/0000-0001-9610-9251 Stephanie Chamberlain University of Alberta Faculty of Nursing Megan Kennedy University of Alberta Faculty of Nursing Hongmei Tong MacEwan University Salima Meherali University of Alberta Faculty of Nursing John Spence University of Alberta Faculty of Kinesiology Sport and Recreation Allyson Jones University of Alberta Faculty of Rehabilitation Medicine Protocol Keywords: Immigrant, older adult, physical activity, program, realist review, intersectionality, equity Posted Date: August 2nd, 2021 DOI: https://doi.org/10.21203/rs.3.rs-746376/v1 License: This work is licensed under a Creative Commons Attribution 4.0 International License. Read Full License Page 1/10 Abstract Background: Immigrants constitute 30% of Canada’s older adult population. Immigrant older adults have low levels of physical activity coupled with higher risks for cardiovascular disease and obesity in some sub-populations. Community group-based physical activity programs combine both physical and social benets and are well received by older adults. These programs often lack sensitivity to the needs of equity-deserving groups, such as immigrants, who continue to experience lower levels of participation. Local, accessible, and culturally informed approaches are required to remedy these well documented inequities in who has access to and benets from such programs. There is a gap, however, in our understanding of the characteristics and conditions for effective program design and delivery when the target population is immigrant older adults. Methods: The aim of this equity-focused realist review is to develop a programme theory that explains how, why, for whom, and under which circumstances community group-based physical activity programs work when delivered to older immigrants. We will rst articulate an initial programme theory that explains tentatively how, why and for whom such programs work and then test and rene the programme theory using a systematic realist review process. The initial programme theory will draw from existing theories that inform group-based physical activity programs for older adults, intersectional theory, and stakeholder insights. PROGRESS-Plus factors will be explored in relation to relevance and impact for physical activity interventions. Stakeholders will include service providers, community volunteers and leaders who have extensive knowledge and interactions with immigrant communities. The initial programme theory will then be tested and rened using a systematic process of searching, retrieving, and reviewing literature on physical activity in immigrant populations. The nal programme theory will be validated using stakeholder input and the research team’s expertise in aging, health equity, and physical activity. Discussion: Physical activity improves the wellbeing of older adults, decreases frailty, and supports aging in place. Ensuring that all older adults can participate in such programs entails understanding what works for whom, when and under which circumstances. This review will provide recommendations on best practices to support immigrant older adults’ participation in group-based physical activity programs. Systematic review registration: The protocol has been submitted to PROSPERO for registration (ID#258179, Date submitted May 30th, 2021. Background Physical activity (PA) protects against and supports the management of non-communicable diseases, improves physical and mental health, and enhances overall quality of life and wellbeing [1]. Regular participation in PA and exercise preserves mobility, decreases frailty and reduces falls in older adults [2]. Despite these well-known benets, PA levels amongst older adults remain below the recommended 150 min/week of vigorous to moderate intensity activity [3, 4]. Community group-based PA interventions, such as group walking and aerobic programs, provide opportunities for enjoyment, fostering belonging, and building friendships which can increase PA in older adults [5, 6, 7]. Canada has the second-highest percentage (21.9%) of foreign-born nationals in the world and immigrants will soon constitute 30–50% of Canada’s aging population [8]. Immigrants are at a higher risk than the general population for inactivity and sedentary behavior [9, 10, 11, 12, 13]. Older immigrants, especially those who are low-income, racialized, or family-sponsored, experience signicant barriers to accessing health, recreation, and social programs [14]. Lack of PA and lack of participation in PA programs in immigrants has been attributed to cultural and religious preferences, lack of social support, acculturation stressors, environmental and language barriers, perceptions of health and injury, and safety concerns [15, 16, 17, 18]. A systematic review of the literature identied 44 correlates of PA for immigrants including age, gender, religion, ethnicity, and health status [19] while another identied 183 correlates of PA and sedentary behavior [18]. Although not focused exclusively on older adults, these studies conclude that mainstream theoretical conceptualizations of PA motivators and barriers are not always relevant to immigrants and that an exploration of intersecting factors inuencing PA is required to further understand how to best improve PA uptake in this population. Additionally, there has been minimal discussion in the literature on the particular ways such factors intersect to inuence older immigrants’ PA participation in the community [20, 21]. Despite reviews of PA programs for older adults being reported in the literature [22, 23], identied guidelines and best practices fail to address the specic needs of older immigrants. Improving PA in older immigrants entails the development of local, accessible, and culturally responsive programs that address both the physical and social needs of this population but there is limited guidance on successful evidence-based design and delivery models [24, 25, 26]. Methods Aim 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 dene 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 inuence 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? Theoretical Lens Equity-deserving populations are less likely to participate and benet from health-promoting interventions which further exacerbates pre-existing inequities [27]. 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 Page 2/10 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 reected 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 [31]. 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 identied, 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 (nancial resources for engaging in PA), Social capital (social support, social norms, & social environment inuencing 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 [19]. 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 [33]. Ethical Considerations This review will not require ethics approval by the University of Alberta because all documents