Functional Mobility of Community-Dwelling Older Persons: An Ethnographic Pre-Feasibility Study by Uirá Duarte Wisnesky A thesis submitted in partial fulfillment of the requirements for the degree of Doctor of Philosophy Faculty of Nursing University of Alberta © Uirá Duarte Wisnesky, 2019 Abstract The purpose of this pre-feasibility study was two-fold: first, to examine perceptions and experiences of mobility challenges in the urban Brazilian community-dwelling older persons; second, to examine study participants’ perceptions about a sit-to-stand activity. The method of exploration was qualitative focused ethnography. Convenience and purposive sampling were used to recruit 23 older persons living in Paquetá, Rio de Janeiro, Brazil. Data was collected via observant participation and semi-structured interviews. Data analysis utilized qualitative content analysis to describe and interpret the phenomena under study. Findings revealed that perceptions of urban Brazilian community-dwelling older persons with mobility are culturally transmitted and influenced by the social, physical and health environments they are part. Older persons’ experiences with mobility challenges was an integral part of sense of self and strongly related to contextual factors. Accordingly, the experience of mobility challenged older persons with the sit- to-stand activity was dependent on their mobility expectations involving many factors that worked together to influence their activity beliefs and attitudes, preferences, behaviors, and cultural perceptions; however, the most noticeable shortcomings for participants’ engagement in the sit-to-stand activity emerged as gaps in their personal and intrapersonal needs. The recommendations generated from my findings call for the design of implementation strategies of the sit-to-stand intervention that are tailored to this particular population’s needs. This study contributes new information to the field of inquiry on mobility of older persons as it focuses on the perceptions of a specific age group, and attends to the interrelationships between health conditions and contextual factors affecting the mobility of older persons. ii Preface This thesis is an original work by Uirá Duarte Wisnesky. The research project, of which this thesis is a part, received research ethics approval from the University of Alberta Research Ethics Board, Project Name “ Functional Mobility of Community-Dwelling Older Persons: An Ethnographic Pre-Feasibility Study”, No. 00081957, 20/06/2018. iii Acknowledgements I am grateful to all of those with whom I have had the pleasure to work during this and other related projects. Many members of the scholastic community enriched my thinking and stimulated discursive deliberation over the course of this academic journey, I am deeply appreciative of each one of you. I am very thankful for the support and assistance of my supervisors, Dr. Joanne Olson and Dr. Pauline Paul, who believed in my potential and provided me guidance, encouragement and advice. I am deeply indebted to both of you for your great patience, immense support, and constant care. I wish to extend my sincere appreciation to my committee member, Dr. Sherry Dahlke, who also supported my development. I also wish to thank my internal examiners, Dr. Kathleen Hunter and Dr. Solina Richter, as well as my external examiner Dr. Jenny Ploeg from McMaster University. A special thank you to Dr. Karin Olson who chaired my examination. This work would not have been possible without the financial support of the Conselho Nacional de Desenvolvimento Científico e Tecnológico (CNPq), Mu Sigma Chapter of Sigma Theta Tau International Honor Society of Nursing, the Legacy Fund from the Canadian Association of Gerontology, the Education Abroad Individual Scholarship from the University of Alberta, and the Innovations in Seniors Care Research Unit Strategic Plan. I also would like to acknowledge the participants and gate keepers who made this project possible by opening their doors and sharing their experiences and stories with me. No one has been more important to me in the pursuit of this project than the members of my family. This thesis is especially dedicated to my mother, Neuza Duarte; to my father, João Carlos Campos Wisnesky; and to my brother, João Carlos Duarte Wisnesky. iv Table of Contents CHAPTER ONE: INTRODUCTION 1 RESEARCHER POSITIONALITY 1 BACKGROUND 4 STUDY PURPOSE 8 RESEARCH QUESTIONS 8 SIGNIFICANCE OF THE STUDY 9 KEY TERMS 10 SUMMARY 14 CHAPTER TWO: LITERATURE REVIEW 15 AGING 17 Functional Capacity and Aging 18 MOBILITY 19 Mobility Spectrum 20 Bed mobility 25 Breadth of transfer skills 26 Travel 26 MOBILITY AND THE INTERNATIONAL CLASSIFICATION OF FUNCTIONING, DISABILITY AND HEALTH 28 Mobility as an Activity 32 Participation and Mobility 35 Body Function and Structures and Mobility 37 Health Conditions and Mobility 39 v Contextual Factors and Mobility 42 Personal Factors Influencing Mobility 42 Environmental Factors Influencing Mobility 49 PHYSICAL ACTIVITY AND MOBILITY 57 Physical Activity and Older Persons 58 Sit-to-stand Activity: An Activity to Improve Mobility in Older Persons 60 CONCLUSION 67 CHAPTER THREE: METHODS 70 STUDY APPROACH 70 METHODOLOGICAL PERSPECTIVE 72 Methodological Origins 72 Focused Ethnography 74 STUDY ASSUMPTIONS 76 Ethnography and the Constructivist Worldview 76 Ontological Assumptions 76 Epistemological Assumptions 78 STUDY DESIGN 78 Setting 79 Participants 83 Sampling 86 Data Making 87 Ethnographic interview 89 The sit-to-stand activity 92 vi Participant observation 93 Data Management Procedures 95 Data Analysis 96 Content analysis 96 Data Translation 99 The translation procedure: step-by-step 101 Writing an Ethnography 103 ETHNOGRAPHY AND ETHICAL CONSIDERATIONS 104 Risks and Benefits for Vulnerable Participants 104 Confidentiality 105 Autonomy of Participant Involvement 106 Informed Consent 106 Researcher’s Safety 107 ESTABLISHING RIGOR 108 SUMMARY 111 CHAPTER FOUR: FIELD ACCESS AND STUDY CONTEXT 113 PRELIMINARY FIELDWORK 113 Pre-Entry Phase 115 Contextualizing the field 115 Participant Recruitment and Selection 139 Participants socio-demographic characteristics 141 CHAPTER FIVE: FINDINGS OF OLDER PERSONS’ PERCEPTIONS AND EXPERIENCES OF MOBILITY CHALLENGES 147 vii THEME ONE: MY PAST, MY IDENTITY 147 Family-life Experiences 148 Past Experiences with Mobility 154 THEME TWO: MIRROR, MIRROR ON THE WALL, WHO AM I AFTER ALL? 161 I am Affect 162 I am Cognition 168 I am my Body 173 THEME THREE: CONTEXT MATTERS 179 Environmental Factors 180 Socio-Economic Factors 202 THEME FOUR: EXPECTATIONS AND NEEDS FOR MOBILITY 212 Expectations 213 Needs 216 SUMMARY 220 CHAPTER SIX: FINDINGS OF OLDER PERSONS’ EXPERIENCES WITH THE SIT-TO-STAND ACTIVITY 222 THEME ONE: TO JOIN, OR NOT TO JOIN: THAT IS THE QUESTION 222 Structural Aspects 223 Individual Influence 225 THEME TWO: HOW DID IT GO? 228 Drivers 229 Obstacles 236 SIT-TO-STAND ACTIVITY WITHIN THE INTERNATIONAL viii CLASSIFICATION OF FUNCTIONING, DISABILITY AND HEALTH 242 SUMMARY 247 CHAPTER SEVEN: DISCUSSION 249 PERCEPTIONS AND EXPERIENCES WITH MOBILITY CHALLENGES 250 Culturally Transmitted Perceptions of Mobility 250 Mobility is an Integral Part of Sense of Self 253 (Dis)abling Contexts 256 Mobility Expectancies 261 EXPERIENCES WITH THE SIT-TO-STAND ACTIVITY 264 Establishing Intentions 264 The Experience with the Components of the Activity 267 The Personal Experience with the Activity 269 The Interpersonal Experience with the Activity 271 FINDINGS IN LIGHT OF THE INTERNATIONAL CLASSIFICATION OF FUNCTIONING, DISABILITY AND HEALTH 272 IMPLICATIONS 274 Implications for Patient Care and Nursing Practice 274 Implications for Nursing Education 277 Implications for Nursing Research 278 KNOWLEDGE SHARING STRATEGIES 279 STUDY STRENGTHS AND LIMITATION 280 REFERENCES 282 APPENDICES 373 ix List of Tables Table 1 Participants’ demographic data ………………………………………….…… 144 Table 2 Participants’ age distribution ……………………………………………….....146 Table 3 My past, my identity ……………………………………………………….….148 Table 4 Mirror, mirror on the wall who am I after all? ……………………………..….162 Table 5 Context matters ………………………………………………….…………….179 Table 6 Expectations and needs ………………………………………………….….….214 Table 7 To join, or not to join: that is the question ………………………………...…..224 Table 8 How did it go? …………………………………………………………………230 Table 9 Sit-to-stand activity within International Classification of Functioning, Disability and Health …………………………………………………………………..….245 x List of Figures Figure 1 International Classification of Functioning, Disability and Health and Mobility ………………………………………………………………………...30 Figure 2 Wave two participants housing ……………………………………………..…182 Figure 3 Outdoor space of participants from wave three ……………………………….184 Figure 4 Gravel and holes due to rain …………………………………………………..191 Figure 5 Rubble on the streets of Paquetá Island ………………………………….……192 Figure 6 Holes in the sidewalk …………………………………………………….…....193 Figure 7 Holes in the streets of Paquetá Island ……………………………………....….194 Figure 8 Sidewalks damaged by roots of a tree ……………………………………....…195 Figure 9 Ramps on the sidewalks …………………………………………………….…196 Figure 10 Model of the sit-to-stand activity within International Classification of Functioning, Disability and Health and Mobility ……………………………...243 xi List of Appendices Appendix A Health Care Center Consent to Participate in the Study ……………………....374 Appendix B Information Sheet and Consent Form …………………………………………376 Appendix C Demographic Data Survey …………………………………………………….383 Appendix D 1st Interview Guide