Introduction
Importance of Physical Activity in Aging
The importance of regular physical activity as a person ages is well known; it is associated with improved health, function, and quality of life (Anokye, Trueman, Green, Pavey, & Taylor, Reference Anokye, Trueman, Green, Pavey and Taylor2012; Fletcher, et al., Reference Fletcher, Landolfo, Niebauer, Ozemek, Arena and Lavie2018; Manini & Pahor, Reference Manini and Pahor2009). Having an active lifestyle decreases one’s risk for cardiovascular disease, type 2 diabetes, and many types of cancer (Bushman, Reference Bushman2020). Improved cognition, decreased risk for dementia, reduced anxiety and depression, and improved sleep are also benefits associated with physical activity (Bushman, Reference Bushman2020). Remaining active while aging, which can be contributed to by walking regularly, has many benefits. It helps maintain and increase bone density, allowing older adults to maintain physical function and independence as they age; it also decreases the risk for falls and injuries associated with these falls (Bushman, Reference Bushman2020). As a result of the many benefits of active aging that can be achieved through walking, it is important to consider what the facilitators or barriers are to walking in older adults.
Older adults may choose to walk for many reasons. Krogstad, Hjorthol, & Tennoy (Reference Krogstad, Hjorthol and Tennoy2015) identified three main categorical reasons why older adults may choose to walk: to accomplish necessary activities, because they have the ability to, and because they find it to be an enjoyable leisure activity. As a result, walking plays a role in accomplishing daily living activities, expressing and maintaining independence, and improving physical and mental functioning for older adults (Krogstad et al., Reference Krogstad, Hjorthol and Tennoy2015). Warm summer months evidently provide good conditions for walking, but seasonal changes can bring many environmental challenges to winter walking for older adults. In the winter months social isolation can occur if walking outdoors becomes limited, as older adults use walking as a means of transportation (Krogstad et al., Reference Krogstad, Hjorthol and Tennoy2015; Choi & DiNitto, Reference Choi and DiNitto2016). An older adult may normally walk to a local drop-in centre once a week, but this may be reduced or limited as a result of factors affecting their ability to walk outdoors in the winter. This may decrease their engagement and participation in their social community.
Seasonal changes impact gait speed (Montufar, Arango, Porter., & Nakagawa, Reference Montufar, Arango, Porter and Nakagawa2007). Assessed in real life conditions, walking speeds of both younger and older adults were reduced in winter compared with summer (Montufar et al., Reference Montufar, Arango, Porter and Nakagawa2007). This is an important factor, as increased gait speed in older adults is related to survival (Studenski et al., Reference Studenski, Perera, Patel, Rosano, Faulkner and Inzitari2011). A reduction in gait speed is a risk factor for a variety of outcomes such as falls, cognitive impairment, institutionalisation, and death (Abellan van Kan et al., Reference Abellan van Kan, Rolland, Anieu, Bauer, Beauchet and Bonnefoy2009). Understanding more clearly the factors facilitating or preventing outdoor winter walking among older adults could help develop better strategies to deliver the benefits that walking, as a type of physical activity, can provide during the winter months. Factors may be described as internal to the person, such as physical function, perceptions, or beliefs; or external, which refers to factors outside of the person such as neighbourhood or environment.
Winter and Reduced Activity
The geographical lens of this scoping review is the climate conditions experienced by residents of Winnipeg, Manitoba in Canada. Canadian winters are some of the most severe in the world (Government of Canada, 2013). For example, in Winnipeg, Manitoba, the average ambient temperature between December and February is -14.2 degrees Celsius and the extreme minimum temperature is -45.0 degrees Celsius (Government of Canada, 2019a). Wind chill greatly amplifies the cold weather that Canadians experience. In Winnipeg, the average number of days per year with a wind chill below -20 degrees Celsius is 85.1, with 43.9 of these days being below -30 degrees Celsius and 12.1 of these days being below -40 degrees Celsius (Government of Canada, 2019a). The snow, ice, wind, decreased daylight hours, and cold weather experienced during Canadian winters can make outdoor winter walking challenging for older adults.
Environmental factors have been identified as both facilitators and barriers in relation to activity and participation (Schneidert, Hurst, Miller, Ustun, Reference Schneidert, Hurst, Miller and Ustun2003). For example, snow-covered sidewalks could be a barrier to walking outdoors, whereas snow clearing and sanding could be a facilitator of outdoor walking. The model developed by Patla and Shumway-Cook (Reference Patla and Shumway-Cook1999) identifies ambient conditions and terrain characteristics as two of eight factors that may limit mobility in older adults. They discuss two aspects in regard to ambient conditions: weather conditions and light level. In the winter months, Canada has decreased daylight hours and snowfall that can reduce visibility, wind that can affect balance, and cold weather, which requires warmer, bulkier clothing (Government of Canada, 2013; 2019a, 2019b). Terrain characteristics associated with winter, such as ice and snow, add to the complexity of winter walking for older adults in addition to the usual obstacles such as curbs and inclines (Patla & Shumway-Cook, Reference Patla and Shumway-Cook1999). Environmental factors can pose challenges to mobility for older adults, and if they have difficulty overcoming these challenges, inactivity can result (Patla & Shumway-Cook, Reference Patla and Shumway-Cook1999).
In order to address the barriers to walking outdoors in winter and the resultant influence on physical activity, mobility, and safety, we need to have a comprehensive understanding of the associated factors that appear in the literature. As a result of the review, we hope to develop a basis for further research and strategies that will identify barriers as well as the factors that could facilitate participation in safe winter walking.
Objective
The purpose of this study was to identify the internal and external factors associated with outdoor winter walking in older adults. The protocol for this scoping review was published in Open Science Framework (https://osf.io/xebgd/).
Methods
Approach
Scoping reviews provide an avenue to comprehensively map areas of interest and do so in a clear and transparent way so that it may be replicated by others (Arksey & O’Malley, Reference Arksey and O’Malley2005). By consolidating many study designs, the scoping review has the advantage of retrieving all literature that is pertinent to the research (Arksey & O’Malley, Reference Arksey and O’Malley2005). Through this method of knowledge synthesis, scoping reviews can summarize research, identify current gaps, inform future directions, and be a source of information for programs and policies (Arksey & O’Malley, Reference Arksey and O’Malley2005). Our review followed the foundational steps of the methodological framework produced by Arksey and O’Malley (Reference Arksey and O’Malley2005) in conducting a scoping review as well as following the recommendations proposed by Levac, Colquhoun, and O’Brien (Reference Levac, Colquhoun and O’Brien2010) to enhance each stage. Covidence was used to manage search results, develop a Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) flow chart, and manage article screening and data extraction (Covidence systematic review software, Veritas Health Innovation, Melbourne, Australia, available at www.covidence.org). The PRISMA extension for scoping reviews checklist was used in planning the review (www.equator-network.org/reporting-guidelines/prisma-scr/).
The research topic was created by the 11 members of the “Winter-Walk” team. This team included: seven researchers encompassing professional backgrounds of physical therapy, occupational therapy, kinesiology, geography, and library sciences. The team also included two older adult members of the community from the Manitoba Association of Seniors Centres and Active Aging in Manitoba, and two graduate student trainees. These members had diverse and unique experiences in areas of older adults, physical activity, and winter walking. The team had two, 5-hour meetings in which there were presentations from all the team members, roundtable discussions, and two rounds of voting to determine the team research priorities related to older adults and outdoor winter walking. The team identified and voted on 14 topics. The topic with the highest priority was “identifying internal and external factors associated with outdoor winter walking for older adults”. This review will add to the literature of outdoor winter walking barriers and facilitators for older adults and assist as a basis for future winter walking studies.
Study Eligibility
The scoping review included all study designs and all years published within the utilized databases. To be included, studies had to evaluate one or more factors associated with outdoor winter walking and be written in the English language, and the study population had to be 65 years of age or older or contain a sub-group analysis of adults 65 years of age or older. Studies that contain mixed ages were included if 80 per cent or more of the study sample was over 65 years old.
Articles were excluded if participants did not walk outdoors (e.g., used wheeled mobility) or if the study population examined was homogenous of a specific health condition.
An eligibility checklist was developed based on these criteria within Covidence and applied to the articles during the screening process to exclude those that did not meet the criteria for inclusion.
Search Strategy
The search was conducted using the subject headings: Geriatrics, Aging, Aged, Retirement, Walking, and Cold Temperature; along with appropriate keywords and free-text words. Databases searched included Ovid MEDLINE® 1946–August 21, 2020; Cumulative Index to Nursing and Allied Health Literature (CINAHL)1937–August 21, 2020; Scopus 2004–August 21, 2020; AgeLine 1978– August 21, 202; Embase 1947–August 21, 2020; Sportdiscus 1937–August 21, 2020; Cochrane Central 1996–August 21, 202; ClinicalTrials.gov 2000–August 21, 2020; the International Clinical Trials Registry Platform 2004–August 21, 2020, and the Joanna Briggs Institute Evidence-Based Practice Database 1996–August 21, 2020. Grey literature was not included in this scoping review. The reference list of included articles was examined to identify other relevant literature. Deduplication and references were managed in EndNote. Further deduplication was additionally completed in Covidence. The initial search strategy was conducted in Ovid MEDLINE and then applied within the other databases. See Table 1 for the full search strategy conducted on Ovid MEDLINE.
Table 1. Search Strategy Ovid MEDLINE(R) and Epub ahead of print, in-process, and other non-indexed citations
Study Selection
The health sciences librarian (H.L.) aided in the development of the search and offered search strategy suggestions. After conducting the search, titles and abstracts were screened and then selected using the inclusion and exclusion criteria checklist, which is available in Covidence. This involved each title and abstract being assessed by two authors for eligibility (K.B., M.J., K.S., E.S., S.M.). Lack of agreement on titles and abstracts at this stage resulted in carrying the study forward to the next stage. Two authors then applied the same inclusion and exclusion criteria to each full text article that passed the first stage. Lack of agreement between reviewers resulted in further analysing the article until a consensus was reached. Once this was completed, the reference lists of included studies were analysed to determine if any additional studies met the inclusion and exclusion criteria that were not covered by the databases. Covidence was used for citation management and the screening process.
Data Extraction and Data Charting
Data was extracted in Covidence independently by the first four authors, ensuring that at least two authors addressed each source and compared results. After extracting data from two articles, minor revisions were made to the extraction chart format based on team member experience and discussion. In cases for which there was a lack of agreement, the two individuals who had extracted the data of the study met and formed a consensus on the final data extracted. Data were exported from Covidence to Microsoft Excel. Tables were created from the following information that was extracted: author, title, publication year, country, study design, study purpose, age, sex, health conditions or physical function, number of participants in the study, statistical methods used, outcome measures used, how the study measured winter walking, the factors described in the study, and the factors that are associated with winter outdoor walking or are predictors of winter outdoor walking.
Synthesis of Results
The first four authors and R.B. of the “Winter-Walk” team analysed the results of the final studies included. For each study, the factors associated with outdoor winter walking in older adults were classified as either facilitators or barriers and then categorized as either internal or external in nature. Furthermore, the factors identified were classified into body functions, activity, or participation, according to the International Classification of Functioning Disability and Health (ICF) (World Health Organization, 2002). Once the factors affecting outdoor winter walking from all the studies were organized together in tables, factors were grouped into categories.
A stage of consultation occurred to offer additional knowledge and perspectives, as well as relevance and applicability to the scoping review (Levac et al., Reference Levac, Colquhoun and O’Brien2010). A consultation occurred with the two older adult community members of the “Winter-Walk” team, who represented two community organizations which support senior centres and active aging. Scoping review results were shared with these team members, and their impressions of the results and next steps are included in the discussion.
Results
The database searches resulted in 6,843 studies, with 1,893 duplicates removed via EndNote. The remaining 4,950 studies were imported to Covidence for screening. Further deduplication occurred in Covidence where five more studies were removed. After reviewing the titles and abstracts of 4945 studies, 4,789 were excluded for reasons including being unrelated to the review topic or because the study focused on a specific health condition. This resulted in 156 full-text studies that were assessed for eligibility. We excluded 148 of these, with the main reason for exclusion being that the study did not evaluate factors associated with outdoor winter walking. Other reasons for exclusion can be seen in Figure 1. Following full-text screening, eight studies were included in the scoping review.
Figure 1. PRISMA diagram.
Study Characteristics
As seen in Table 2, the largest number of studies (three) came from Canada (Clarke et al., Reference Clarke, Hirsch, Melendez, Winters, Gould and Ashe2017; Li, Hsu, & Fernie, Reference Li, Hsu and Fernie2013; Schmidt, Rempel, Murray, McHugh, & Vallance, Reference Schmidt, Rempel, Murray, McHugh and Vallance2016). The remainder were conducted in Finland (Sakari et al., Reference Sakari, Rantakokko, Portegijs, Iwarsson, Sipila and Viljanen2017), Iceland (Bjornsdottir, Arnadottir, & Halldorsdottir, Reference Bjornsdottir, Arnadottir and Halldorsdottir2012), Sweden (Wennberg, Stahl, & Hyden Reference Wennberg, Stahl and Hyden2009), the United States (Finlay, Reference Finlay2018) and England (Wu, Luben, & Jones, Reference Wu, Luben and Jones2017). Average temperature in the month of January ranged from -15 to +5 degrees Celsius at the included study sites. In total, these studies collectively included 5,484 older adults with ages ranging from 49 to 100.
Table 2. Included study characteristics
Note.
a January mean temperature from https://www.timeanddate.com/weather
NP = not provided in the study; SD = standard deviation; SPPB = Short Physical Performance Battery, estimating physical function
On average, 70 per cent of the participants were female. As is common in sport medicine literature (Parsons, Coen, & Bekker, Reference Parsons, Coen and Bekker2021), the terms “sex” and “gender” were used interchangeably with male/female and man/woman in a number of the included studies. In most of the eight included studies, the description appeared to be related to the biological description of males and females, as opposed to gender identities. How the determination of male/female or man/woman was made was not clear in all studies. Therefore, we chose to use the term “sex” along with male/female in the description of study participants, as described elsewhere (Government of Canada, Canadian Institutes of Health Research, 2015).
Although our inclusion criterion was age 65 or older, two studies (Li et al., Reference Li, Hsu and Fernie2013; Wu et al., Reference Wu, Luben and Jones2017) included participants outside the age range of this review, but either completed sub-group analysis or had more than 80 per cent of participants within the age range criterion for inclusion. Health conditions and physical function of the participants were described very differently across studies. For example: by walking aid use (Bjornsdottir et al., Reference Bjornsdottir, Arnadottir and Halldorsdottir2012), physical function assessment (Clarke et al., Reference Clarke, Hirsch, Melendez, Winters, Gould and Ashe2017; Sakari et al., Reference Sakari, Rantakokko, Portegijs, Iwarsson, Sipila and Viljanen2017), number of chronic conditions (Li et al., Reference Li, Hsu and Fernie2013; Sakari et al., Reference Sakari, Rantakokko, Portegijs, Iwarsson, Sipila and Viljanen2017, Wennberg et al., Reference Wennberg, Stahl and Hyden2009) or self-rated health (Wu et al., Reference Wu, Luben and Jones2017). The study designs encompassed qualitative approaches including surveys (Li et al., Reference Li, Hsu and Fernie2013), interviews (Finlay, Reference Finlay2018; Schmidt et al., Reference Schmidt, Rempel, Murray, McHugh and Vallance2016; Bjornsdottir et al., Reference Bjornsdottir, Arnadottir and Halldorsdottir2012) and focus groups (Wennberg et al., Reference Wennberg, Stahl and Hyden2009). Other study types included cross-sectional studies (Clarke et al., Reference Clarke, Hirsch, Melendez, Winters, Gould and Ashe2017; Sakari et al., Reference Sakari, Rantakokko, Portegijs, Iwarsson, Sipila and Viljanen2017), exploratory mixed methods (Wennberg et al., Reference Wennberg, Stahl and Hyden2009) and a prospective cohort study (Wu et al, Reference Wu, Luben and Jones2017).
The included studies utilized multiple methods to identify outdoor winter walking including: surveys/questionnaires (Clarke et al., Reference Clarke, Hirsch, Melendez, Winters, Gould and Ashe2017; Li et al., Reference Li, Hsu and Fernie2013; Wu et al., Reference Wu, Luben and Jones2017), accelerometry (Wu et al., Reference Wu, Luben and Jones2017), interviews (Bjornsdottir et al., Reference Bjornsdottir, Arnadottir and Halldorsdottir2012; Finlay, Reference Finlay2018; Sakari et al., Reference Sakari, Rantakokko, Portegijs, Iwarsson, Sipila and Viljanen2017; Schmidt et al., Reference Schmidt, Rempel, Murray, McHugh and Vallance2016; Wennberg et al., Reference Wennberg, Stahl and Hyden2009), focus groups (Wennberg et al., Reference Wennberg, Stahl and Hyden2009) and participant observation (Finlay, Reference Finlay2018; Wennberg et al., Reference Wennberg, Stahl and Hyden2009). Weather conditions and weather data were also collected in some studies (Clarke et al, Reference Clarke, Hirsch, Melendez, Winters, Gould and Ashe2017; Wu et al., Reference Wu, Luben and Jones2017). Multiple studies used a combination of methods; for example, the Neighbourhood Environmental Walkability Survey was utilized by Clarke et al. (Reference Clarke, Hirsch, Melendez, Winters, Gould and Ashe2017), the results of which were connected to archived weather information. Wennberg et al. (Reference Wennberg, Stahl and Hyden2009) used a combination of focus groups, a questionnaire, and participant observation to measure outdoor winter walking, and Finlay (Reference Finlay2018) used both interviews and participant observation. Two studies focused on the rural setting (Schmidt et al., Reference Schmidt, Rempel, Murray, McHugh and Vallance2016; Wu et al., Reference Wu, Luben and Jones2017), one study included both urban and rural settings (Sakari et al., Reference Sakari, Rantakokko, Portegijs, Iwarsson, Sipila and Viljanen2017), whereas the remainder of studies focused on the urban setting.
Within these eight studies, factors that were associated with outdoor winter walking were described as barriers or facilitators (Table 3). The barriers and facilitators were then further divided into internal or external factors and categorized using the ICF (Table 4). Internal factors were considered to be person-related, such as one’s physical capacities, perceptions, beliefs, and fears, whereas external factors referred to those factors apart from the person such as weather, ice, snow, neighbourhood, and environment. Factors were aligned with the ICF classifications of body function, activity, participation, and the environment. Common categories emerged in the results that allowed an understanding of the categories of factors that were relevant to the study population, both internal and external, that impacted walking outdoors in winter. These categories were physical function, perceptions and fears relating to winter walking conditions (internal factors), and adverse weather conditions and physical environmental conditions (external factors). See Table 4.
Table 3. Included study methods and barriers to / facilitators of outdoor winter walking
Table 4. Synthesis of results – ICF categorization of factors associated with outdoor winter walking
Discussion
The objective of this scoping review was to identify internal and external factors associated with outdoor winter walking in older adults. The eight included studies revealed many different factors that were described as external or internal barriers or facilitators. These factors were further summarized into four categories: adverse weather conditions (external), physical environmental conditions (external), physical function (internal), and perceptions and fears relating to winter walking conditions (internal).
The first category that emerged was the impact that weather conditions had on outdoor winter walking in older adults. All of the included studies described at least one weather-related factor that was described as a barrier to or facilitator of outdoor winter walking. These included conditions producing ice, slush, and strong winds (Bjornsdottir et al., Reference Bjornsdottir, Arnadottir and Halldorsdottir2012; Schmidt et al., Reference Schmidt, Rempel, Murray, McHugh and Vallance2016), cold temperatures (Bjornsdottir et al., Reference Bjornsdottir, Arnadottir and Halldorsdottir2012), and higher levels of snow (Clarke et al., Reference Clarke, Hirsch, Melendez, Winters, Gould and Ashe2017) or precipitation (Wu et al., Reference Wu, Luben and Jones2017), which were all negatively associated with outdoor walking. These results were perhaps unsurprising, as it seems sensible that harsh weather would tend to decrease older adults’ participation in outdoor walking, and this was confirmed by the results. These results appear to confirm that it is realistic to think that, as a general principle, categorically harsher winter days will result in less outdoor winter walking whereas more pleasant winter days will result in more outdoor winter walking. This appears to be consistent with literature that describes decreased gait speed (Montufar et al., Reference Montufar, Arango, Porter and Nakagawa2007) and steps per day in winter (Kimura, Kobayashi, Nakayama, & Kakihana, Reference Kimura, Kobayashi, Nakayama and Kakihana2015). Beyond examining weather variables in isolation, Clarke et al. (Reference Clarke, Hirsch, Melendez, Winters, Gould and Ashe2017) examined the interplay among neighbourhood walkability, vehicle dependency, and weather conditions. Walkable neighbourhoods encompassed those with shorter block lengths, a greater mix of land use, and more street connectivity (Clarke et al., Reference Clarke, Hirsch, Melendez, Winters, Gould and Ashe2017). Snow was found to be negatively associated with outdoor walking in general but much more strongly so in car-dependent neighbourhoods. This implies that properly designed, built environments can attenuate some of the negative associations between winter weather and outdoor walking. These results highlight the important overlap between winter-related factors and the built, physical environment, pointing to the relevancy of considering how the physical environment an older adult lives in can affect their outdoor winter walking. This is exemplified by the second category.
The second category that emerged were factors related to the physical environment. These factors included conditions of the walking terrain, such as ice-covered surfaces (Bjornsdottir et al., Reference Bjornsdottir, Arnadottir and Halldorsdottir2012; Finlay, Reference Finlay2018; Li et al., Reference Li, Hsu and Fernie2013; Schmidt et al., Reference Schmidt, Rempel, Murray, McHugh and Vallance2016; Wennberg et al., Reference Wennberg, Stahl and Hyden2009) and lack of snow removal (Finlay, Reference Finlay2018). Li et al. (Reference Li, Hsu and Fernie2013) examined what specific areas of the physical environment were of most concern to outdoor walkers. The most problematic were sidewalks, followed by street crossings and curb ramps. In these three areas, commonly reported barriers were ice, snow, and slush accumulation that made walking difficult. These physical environmental barriers led to winter coping strategies that were explored further by Li et al. (Reference Li, Hsu and Fernie2013) who found that 16 (59%) of the older adult participants coped with these winter challenges by going out less, and consequently reducing outdoor winter walking. Therefore, we see how the physical environment, as affected by winter weather, can be a barrier to outdoor walking.
The third category that emerged was participants’ physical function acting as a barrier or facilitator to outdoor winter walking. Older adults with a higher physical function were more likely to walk outdoors in the winter than those with poorer physical function (Clarke et al., Reference Clarke, Hirsch, Melendez, Winters, Gould and Ashe2017), as measured using the Short Physical Performance Battery (SPPB). Sakari et al. (Reference Sakari, Rantakokko, Portegijs, Iwarsson, Sipila and Viljanen2017) also measured physical function through assessment of the lower extremities using the SPPB, which examines functional strength through walking, sit-to-stand, and standing activities. Sakari et al. (Reference Sakari, Rantakokko, Portegijs, Iwarsson, Sipila and Viljanen2017) discussed that for older adults with poor lower extremity performance, fear stemming from safety issues was a major barrier. These barriers for those with intact lower extremity performance focused on aspects of outdoor walking such as the distance required to walk, and less so on fears or safety concerns (Sakari et al., Reference Sakari, Rantakokko, Portegijs, Iwarsson, Sipila and Viljanen2017). This finding indicated that older adults with poorer physical function may walk less, simply because of their perceptions of winter as a dangerous time to walk. Other functional limitations, including mobility, vision, and hearing impairments, were also found to be barriers to outdoor winter walking for older adults (Li et al., Reference Li, Hsu and Fernie2013). Many of the aforementioned barriers to outdoor winter walking have also been identified as barriers to outdoor walking in general in a conceptual framework for an outdoor walking intervention, including various aspects of physical function as well as fear and self-efficacy (Salbach et al., Reference Salbach, Barclay, Webber, Jones, Mayo and Lix2019).
The fourth category that emerged was how participants perceived that environmental conditions influenced their decision to walk outdoors. Specifically, fear of falling was a consistent subject across many of the included studies, which led to avoidance of outdoor winter walking among older adults (Bjornsdottir et al., Reference Bjornsdottir, Arnadottir and Halldorsdottir2012; Finlay, Reference Finlay2018; Sakari et al., Reference Sakari, Rantakokko, Portegijs, Iwarsson, Sipila and Viljanen2017; Schmidt et al., Reference Schmidt, Rempel, Murray, McHugh and Vallance2016;). This consistent factor indicated that older adults may perceive the risk of walking outdoors in winter to be greater than the benefit and choose to avoid doing so. Individuals with poor lower extremity performance had higher fear of falls (Sakari et al., Reference Sakari, Rantakokko, Portegijs, Iwarsson, Sipila and Viljanen2017).
The results of this scoping review have important implications for our study population, as well as other key stakeholders. As active aging, functional independence, and social participation are all impacted by maintaining one’s mobility (Krogstad et al., Reference Krogstad, Hjorthol and Tennoy2015), being able to walk year-round in a safe and self-directed manner are important goals. By identifying the known facilitators of and barriers to outdoor winter walking in older adults, there can be knowledge regarding why older adults may walk less in the winter, what factors surrounding winter pose difficulties for them, and how policy, programs, or other strategies may assist in facilitating walking in winter. Understanding that ice, snow, or slush-covered walkways will negatively impact walking for older adults identifies that prioritizing walkway clearance, sanding iced pathways, and removing snow from benches, as examples, are important tasks in the built environment. Specifically, Li et al. (Reference Li, Hsu and Fernie2013) and Finlay (Reference Finlay2018) identified snow at locations such as curb ramps, bus stops, crosswalks, and sidewalks as barriers to outdoor walking. To support this as a priority, Wennberg et al. (Reference Wennberg, Stahl and Hyden2009) found that a facilitator to walking was prompt snow removal so that walking surfaces were visible. Departments in cities or towns can benefit from this information by utilizing it to focus resources on tasks that can reduce barriers to outdoor walking for older adults. The finding that poorer physical function will negatively affect outdoor winter walking (Sakari et al., Reference Sakari, Rantakokko, Portegijs, Iwarsson, Sipila and Viljanen2017) through fear identifies that interventions to improve physical function in older adults could potentially facilitate walking. This is supported by Clarke et al. (2013), who found that higher physical function was positively associated with the number of destinations walked to in winter among their older adult participants.
A number of studies were excluded, as they evaluated outdoor physical activity, but did not specifically identify walking. All eight studies used interviews and questionnaires to identify outdoor walking in this scoping review. One study also used accelerometry (Wu et al., Reference Wu, Luben and Jones2017), while two used observation (Finlay, Reference Finlay2018; Wennberg et al., Reference Wennberg, Stahl and Hyden2009). It should be noted that although an older adult may be less physically active and walk outdoors in winter less, indoor walking alternatives may be used as a compensatory strategy to allow older adults to remain physically active (Li et al., Reference Li, Hsu and Fernie2013).
Consultation
Consultation was had with the older adult community members of the Winter Walk Team. Both team members agreed that the results of this study were applicable to their association members. It was noted that much of the information applies to people of all ages. The importance of public works and others to be able to remove snow, ice, and slush was supported. Experience was shared that when this occurs, it makes older adults feel safer and more able to have a good walking experience. It was also supported that planning for green space, trails, and benches is very important. It was noted that in the previous year with COVID-19, an increase in dog ownership and experiences with isolation and physical distancing may be motivations for older adults to get outdoors more; the importance of addressing fear of falling and interventions for fall prevention are essential.
It was stressed that it will be important to address other knowledge translation strategies of this project; for example, creating an infographic showing the need for cities/municipalities to clear snow from walking paths and sidewalks, which could convince municipal decision makers of the value of clean streets and sidewalks in winter. It is also important to make the connection between walking and one’s own health; winter walking is hampered because municipalities do not connect snow with walking and health.
Limitations
There were some limitations to the current scoping review. Our methodology did not evaluate the quality of the studies included, as is common in a scoping review. In a scoping review of 344 scoping reviews, Pham et al. (Reference Pham, Rajic, Greig, Sargeant, Papadopoulos and McEwen2014) found that only 22 per cent assessed the methodological quality of their respective included studies, with the majority stating that scoping reviews do not prioritize quality assessment or that quality assessment is not commonly a part of their methodology. Second, including only studies in English excluded potential research conducted in other cultures or languages. Third, the choice to limit the scope of this review to focus on walking was beneficial for assessing a specific facet of physical activity in older adults. The limitation of this approach was that there were a large number of studies in the screening stages that were excluded because the outcomes examined were physical activity levels and not specifically walking. This identified that there was an abundance of research surrounding winter and its effect on physical activity in older adults in general. Some factors may have been missed by this scoping review by way of studies that discussed walking as a type of physical activity among participants in the study, but in measuring physical activity did not distinguish between types of physical activity, specifically walking, in the results. It was unclear in some studies whether the winter walking challenges were reported during the winter season or if winter weather was reflected upon at another time, in interviews or with questionnaires. Another potential limitation was that most studies focused on the urban setting; challenges specific to rural settings were not identified in the analysis. Perhaps this scoping review may spark interest in more in-depth examinations of walking as a specific type of physical activity in the winter months among older adults.
Conclusions
This scoping review identified the factors associated with outdoor winter walking for older adults. The studies in the review included both observed and perceived facilitators and barriers to winter walking that were internal and external in nature. Four main commonalities were found in the results: the impact of adverse weather conditions, the physical environment, physical function, and perceptions and fears relating to winter walking conditions. Overall, the studies cumulatively and consistently found that harsh winter weather conditions producing snow, ice, wind, and cold temperature decreased outdoor winter walking for older adults (Bjornsdottir et al., Reference Bjornsdottir, Arnadottir and Halldorsdottir2012; Clarke et al., Reference Clarke, Hirsch, Melendez, Winters, Gould and Ashe2017; Schmidt et al., Reference Schmidt, Rempel, Murray, McHugh and Vallance2016; Wu et al., Reference Wu, Luben and Jones2017). Fear of falls was consistently a barrier for older adults, especially those with poorer lower extremity performance (Sakari et al., Reference Sakari, Rantakokko, Portegijs, Iwarsson, Sipila and Viljanen2017).
Additional questions result from this review. For example, are challenges in outdoor winter walking for pleasure or exercise different from the requirements for and challenges to safe outdoor walking necessary for transport, to get to and from vehicles for transportation to other activities outside the home? This may assist in the development of indoor programs focusing on skills necessary for safe outdoor winter walking, as determined by the purpose that older adults may identify.
Research findings from this study and further research studies could be used in developing public education strategies geared towards older adults. Rehabilitation and exercise professionals can use the information from this article to educate their clients about the facilitators of and barriers to outdoor winter walking. Being aware of the barriers can assist health care professionals in implementing alternatives and solutions to these barriers, such as home and community exercise programs.
Acknowledgments
We thank the Winter Walk Team: Olayinka Akinrolie, graduate student trainee, University of Manitoba; Ruth Barclay, Department of Physical Therapy, University of Manitoba; Hal Loewen, Neil John McLean Health Sciences Library, University of Manitoba; Sue Mackenzie, coordinator, Active Aging in Manitoba; Connie Newman, Executive Director, Manitoba Association of Senior Centres & Age Friendly Manitoba Initiative; Jacquie Ripat, Department of Occupational Therapy, University of Manitoba; Nancy Salbach, Department of Physical Therapy, University of Toronto; Becky Schorr, graduate student trainee, University of Manitoba; Shaelyn Strachan, Faculty of Kinesiology and Recreation Management, University of Manitoba; Gina Sylvestre, Department of Geography, University of Winnipeg; and Sandra Webber, Department of Physical Therapy, University of Manitoba.
Funding
Funding was received from the Centre on Aging Research Team Small Grant, University of Manitoba.
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