What do older women want from a physical activity program? Stakeholder consultation to optimise design and recruitment for the Active Women over 50 trial | BMC Public Health

A total of 21 women participated in this consultation. Ages ranged from 50 to 80 with an average of 62 years. Eleven participants were currently working and ten had carer responsibilities (seven had both). Ten participants lived in or near a major city, seven lived in inner regional areas, three in outer regional areas and one in a remote area as classified by the Australian Statistical Geography Standard.

which divides Australia into areas of remoteness according to relative access to services [56]. Thirteen participants lived in higher income areas, four in medium income area, and four in low income areas as defined by the Australian Bureau of Statistics’ Socio-Economic Indexes for Areas [57]. Ten participants reported physical conditions which affected their ability to engage in physical activity. Three said they did no physical activity at all but wished they did. Four described themselves as somewhat active. Fourteen considered themselves to be physically active, but in conversation most did not seem to be meeting the WHO physical activity guidelines [58]. Three spoke English as a second language. Three had participated in the AWo50 pilot trial two years previously.

The focus group for women living in regional and rural areas included four people and lasted 83 min, and the 17 interviews lasted between 28 and 59 min, with an average of 44 min.

Feedback and advice about trial recruitment

Five themes were identified in relation to recruitment, focused on a review of four draft recruitment flyers.

I want to see (women like) myself

Many women commented on the power of well-chosen photographs to capture attention (“they hit you in the face”) and to convey the ‘flavour’ of the program while also making a persuasive case about its potential value and its inclusivity. The explicit diversity of women in photos was strongly appreciated, “It’s good to see women of colour and with different shapes and sizes”. The photo of a woman exercising with a walking frame was valued for its clear message that the program aimed to include people living with disability.

But photos could convey misinformation too. Photos of women taking part in yoga and using hula hoops alarmed some who thought these might be mandatory program activities, and one interviewee said the emphasis on photos of women laughing during communal activities was off-putting because, “It makes you feel like you have to be in a group, like you have to have fun rather than maybe do things for stress, or just feeling better in yourself. It’s very extrovert.” Several women mentioned they liked seeing the LGBTQIA + Progress Pride flag on the flyers, but a few questioned how other marginalised groups might feel about their absence.

Keep it real

Some felt that the photos verged on exaggeration. The ubiquity of smiles and laughter in the photos prompted one woman to state that “Everyone looks happy to be exercising – maybe too happy to be convincing?” Several expressed surprise at the photo of women using hula hoops, “Would women over 50 really do that?” and another felt the photos looked American rather than Australian. ‘Real’ attributes that were valued included diversity, less-than-glamorous exercise wear and visible sweat.

Readability is for everyone

Many women made the point that good readability enhances engagement more broadly. Aspects they identified as increasing readability included the use of icons and subheadings which helped to break up the text and make it more scannable, and a plain background and lots of white space. The uncluttered look of the flyers was important so the relatively limited information about the trial, and range of options for finding out more using different strategies—telephone, website and a QR—was felt by most to be a good balance. They noted that photos with clear contrast were important for those with visual impairment.

Why should I do it?

Most, but not all, argued that no explicit statement about why exercise is beneficial was required since “we all know that nowadays”, and the pleasures of the program were largely conveyed by the photographs which emphasised women enjoying being active. However, conveying the “non-threatening” nature of the program was regarded as essential. This included making it clear that the program was flexible in terms of physical activities (what, when and who with) and also in choice of program components. Concerns were raised particularly about perceptions that Facebook might be a requirement because, “there’ll be women out there who don’t want to have anything to do with Facebook”.

The program’s credibility was considered to be especially important in an era when self-appointed wellness gurus abound. The university logo and statement that health coaching was provided by physiotherapists gave women confidence they could trust what was on offer. Several pointed out that we had failed to mention that participation was free—and that this was likely to be a deal-maker for many—or to explain the timeframe. Both of these were considered essential information.

Find us where we live

Many expressed interest in where these flyers would be displayed and argued that women should encounter them in everyday settings. In addition to social media, suggestions included placing flyers in libraries, on shopping mall boards and medical centre walls. They advised us to contact local councils, many of which run activity and healthy ageing / healthy community programs and could email residents or post information on their website. They also suggested specialist groups who have reach into the targeted demographic such as the NSW Country Women’s Association, Menopause Society, BreastScreen, seniors’ groups and community groups such as Probus. Participants emphasised the power of word-of-mouth recommendations and suggested we build that into the recruitment process by asking women who consent to the trial to pass on information to eligible friends and family.

Component-specific feedback and advice about the AWo50 program

Participants gave feedback about the value of each of the four proposed program components: health coaching, access to online resources via the AWo50 website, a private Facebook group, and messaging (by text and/or email). When asked to rank these components in terms of value, most participants said they were unable to rank them because the components were complementary and were likely to function synergistically as a whole package. The assumption was that women could benefit even if they did not make use of the whole program.

Health coaching

There was universal feedback about the value of health coaching which was emphasised by participants in rural and regional areas where access to health services, especially at low cost, was very poor. The draft program design stated that there would be two up-to-40 min sessions of health coaching for each participant. Many participants felt it was “a shame there can’t be more” but acknowledged that cost-effectiveness was an important consideration. However, several women suggested we find ways to do “mini check-ups” or build alternative accountability mechanisms into later stages of the program because, “… there’s a danger that everything is happening at the beginning whereas sustaining the program might be the hard thing” so “Some later check-in mechanism might keep people’s eyes on the horizon”. Two suggested breaking up the health coaching sessions, “Would 4 sessions of 20 minutes be better? You could give people the choice. People who don’t have support may need more input over time.”

The timing and mode of health coaching sessions attracted strong feedback. Participants agreed that the first session should take place at the beginning of the program (as currently planned) to help women think about how to be active, set goals and problem-solve. Most felt the second session should take place approximately 4 weeks later, but many argued that this should be flexible.

Choice was also important regarding the mode of the health coaching: specifically, the opportunity to choose telephone or videoconferencing sessions, the latter of which might enhance rapport and individualised feedback from the health coach, “Zoom would be better for feeling they had seen me, looked at my body and really seen who I am. But others may prefer phone – we’re Zoomed out”.

There was positive feedback about the credibility and suitability of the proposed health coaches who were to be mature women who were experienced physiotherapists trained in motivational health coaching. Participants urged us to highlight this in promotional materials to instil confidence,

You should explain the coaches are women over 50 too – that’s fabulous. I was talking to a friend recently about having her makeup done and how she didn’t want a 20-year-old doing it. She wanted a 50 + woman who would understand her. So let women know that it won’t be a 20-year-old looking gorgeous in Lycra because that would put people off, especially if they are more self-conscious.

AWo50 website

The AWo50 website generated the most feedback, probably because the draft site had different sections with a wide range of resources, and we guided participants to comment on different aspects of the site: content, usability and visual appeal. These findings are reported according to constructs from the Adapted Mobile App Rating Scale (Table 1) which is used to evaluate health websites [50].

Private facebook group

All participants agreed it was worthwhile to offer a private, moderated Facebook group as part of the AWo50 program mix, seeing it as an opportunity for social connection, information sharing, inspiration and motivation, “I love the idea! People can share goals, set each other challenges, check in with each other, ask questions, share tips, feel accountable to the group”.

Although these women agreed that Facebook was “the right platform for this demographic”, the question of whether they would have joined the AWo50 Facebook group if they were trial participants was polarising. Those who currently engaged with Facebook, and were often members of shared interest groups, reported that they generally found it to be a supportive space with useful exchange of information and resources, “I like to know what others are doing. I like to be able to ask questions and offer ideas”. These women were enthusiastic and said they would definitely join a Facebook group like this and would be likely to benefit from it, “Absolutely! People can feed off of Facebook. If they’re feeling down they can put it out there and other people will help lift them up. That’s what we should be doing – helping and inspiring each other”. However, a minority of others were sceptical and two said they would definitely not join it because it could undermine confidence rather than boosting it,

I wouldn’t be persuaded to join the Facebook group. I don’t want to hear a bunch of women sitting around and talking about fitness. It creates comparisons with other women…. You don’t want to hear that someone’s run 10 K if you are feeling bad about yourself.

Two participants raised concerns about the possibility that Facebook could present cyber-threats, “I would be worried about phishing and pressing the wrong link which could download a virus or something”. They stated the research team needed to investigate and address this possibility and “…reassure people that this is not a risk”.

Everyone agreed that the group must be moderated, ideally by one or more women aged 50 + who are somewhat active. Careful moderation with clear group rules was essential because, “You don’t know what direction it will go in. That’s the problem with social media, it’s not in your control”.

They advised that the research team, “will need very clear rules and protocols” in order to manage the tone and to “…keep advertising and inappropriate or irrelevant content off it. Weight loss supplements and the whole wellness movement could hijack it!”. Some participants suggested the moderator could help different voices to be heard, including making sure the group “doesn’t get taken over by the over-achievers who want to tell you they’ve run a marathon”. Importantly, “‘No body shaming should be a rule”. The focus group argued that the Facebook group would probably need multiple moderators who are working with rules devised (and refined as required) by the wider team. They advised us not to delay participants’ contributions by checking them pre-posting because immediacy is a drawcard with Facebook posts; rather, we should remove unsuitable posts periodically and reassert the rules when needed.

Participants agreed that the AWo50 Facebook moderator should also provide content, “e.g., a weekly tip or story”, “using humour and sharing ideas”. And they envisaged the role as someone who engages and interacts with the community authentically as a “real person”; “She should be personally involved so we could get to know her and she should lead the sharing, especially early on”. This was regarded as a strategy for creating a safe space and building rapport,

I’m in a private Facebook group re my [health condition] and it feels very safe. I’m willing to share personal info there. We get to know the moderator as she tells us about herself too, and that is reassuring that we can trust her.

The rural focus group was asked if we should consider offering separate groups for women living in rural/regional and metropolitan areas. The group said no, “they have things to offer each other” but the moderator would “… need to be sensitive to needs/experiences of country women as well as urban”. Two participants asked about the possibility of local Facebook groups, “I want something that makes me feel ‘This is my place’”, but acknowledged that local connections with subgroups might develop organically.

Additional feedback focused on the need for strong, early reassurance about the psychological safety of the forum “so people don’t just dismiss it without considering it”.

Text and email messaging

In general, messaging was regarded as a positive component of the program with potential to increase engagement, knowledge and motivation, “Keeping in touch is good – when you get a text or an email it feels like the researchers are thinking of you”. Women highlighted the limitations of generalised unidirectional messaging, but argued that this was reasonable within the program-as-a-whole if expectations were managed, “Unidirectionality is okay because you have other options for asking questions and getting feedback (I’m thinking of the coaching and Facebook page), and I wouldn’t expect it be two-way anyway”. Strategies for making messages feel more personal included signing emails with the coach’s name and targeting message content at specific points in the program, “You may not be able to individualise the messages, but you could at least say ‘Now you’re in week 6 of the program’ so people feel the program knows what they are doing”.

Choice was, again, a central concern. Participants liked that women in the AWo50 trial could choose either texts or emails or no messaging, and had some say in how often they were received, “It’s great that people can choose frequency because there will be a lot of diversity in preferences”. This was viewed as a way to minimise irritation, “texts will quickly lose impact and become annoying and will be ignored.” Women suggested that messages would be more effective if trial participants could choose which days and at what time they receive them as this could help the messages stand out against “the constant junk on all our phones”. Timing could be selected to align with exercise preferences too, “the time of day may be a factor – if I don’t exercise first thing it won’t happen”. We were advised to check participants’ preferences throughout the trial so they could adjust timing and frequency, “You may need to change it during the program too as life circumstances and your message-tolerance changes.”

Sequential development of both emails and text messages was suggested to help build progress week-by-week, and help participants connect with other parts of the program in a logical order. This included “exit planning”: “You will need an email near the end to help people think about planning their exit and how to sustain being active – ask ‘What’s your plan?’ ‘What have you learnt that you can use?’”.

Text messages were liked for their succinct prompts, hyperlinks to resources, and their encouraging tone, “They’re inquiring, reaching out. It invites participation without being preachy”. This was regarded as essential because “… it’s so easy to feel bad and a failure”. But some suggested that the content should function less like reminders and more like “a call to action” which encouraged women to reflect by asking them questions, e.g., “What can you squeeze in today?”, ‘What could you do differently next week?’. Some advised we should not use negative phrasing (e.g., ‘Feeling a bit down?’), but rather, “Make it positive. Say something like, ‘Get those good feeling endorphins going!’” Others suggested we “mix it up”: “Sometimes a tip, sometimes a quote. You want to have variety in the content to prevent text fatigue.” Most women agreed that clear branding with an AWo50 logo was important “… so I can trust it’s from AWo50 and not yet another scam”.

Emails were liked for their “deeper information”, but many felt they were too long (“a slab of text”) with layouts that were dense and lacked visual interest, “They’re way too long. It’s daunting. You think ‘Oh no, this is a lot of work I’ve got to do’”. The language was reasonable, “I like the wording – nothing technical or jargony. I don’t speak English as first language but could read it all with no problem”; however, many felt it could be “chattier”, “snappier” and more engaging. Hyperlinks to quality resources and interactive tools such as quizzes was highly valued as a “hook” for engagement. Suggestions for improving the emails included: shorter paragraphs with more white space; breaking up the text with headings, text boxes, bullet points and infographics; using headings to generate interest (e.g., “Quick tips” and “How active are you?”); focusing on one key message per email; careful phrasing so messages are succinct and “punch home the key message in the first paragraph” with no repetition.

Accessibility was a concern for emails. Women suggested using larger typeface, formatting so they would display clearly on different devices and being mindful of including content such as images that might affect downloadability and readability, “Be careful of making them too busy – people will be reading it on their phone. I want things to be easy to read. I often differ from my colleagues on this as they want cute graphics and all sorts on our newsletters – but it can be too much.”

Ranking components

When asked the question, “If we had to drop one of these components, which would you choose?”, most women said the text messages, with the two who shunned Facebook nominating that component. However, everyone pointed out that women over 50 were a highly heterogeneous population and a successful program should use a range of engagement strategies that target different needs and preferences, and function complementarily, “It’s all useful because different bits will work for different women”.

Using consultation data to review our program theory

The inclusion of all constructs was supported by the consultation data as outlined briefly below.

Autonomy

As is evident in the findings above, choice was a dominant theme in the data. Person-centred coaching that supported self-directed goals and individualised physical activity programs, combined with the ability to pick and choose between components, and to engage with those components differently (e.g. choice of messaging type and frequency), was considered likely to broaden uptake of the AWo50 program, increase women’s confidence and sense of ownership in physical activity and their likelihood of maintenance. This strongly supports the inclusion of autonomy as a driver for program success in our program theory.

Relatedness

Consultation data confirmed that relatedness was highly valued in supporting physical activity, but suggested that this could be the weakest aspect of the AWo50 program. This was because of limited health coaching sessions, unidirectional messaging, and the antipathy some women will feel about Facebook. However, participants were realistic about cost/benefit considerations, noting that, “Two sessions [of heath coaching] isn’t long enough to build a relationship but it could still be very helpful”. They offered suggestions for building rapport in these sessions, explaining that coaching should be “kind” “encouraging” and “demonstrate understanding and empathy around challenges and lack of services in regional areas”. Coaches were also advised to, “… think about how best to connect with people over Zoom. Make sure you use it well. You may need to think creatively about that”.

Similarly, Facebook moderators were advised to be interactive and authentic to foster trust, but we were warned not to treat Facebook as a substitute for real world social engagement, “there’s an assumption that social media fills the gap of social connection, but it really doesn’t”. To this end, women asked us to use all the program components to “encourage women to make real world connections in their communities to support being physically active”. Suggestions included seeking “local representatives” via Facebook who could “volunteer as an AWo50 ambassador” and organise community activities such as walking groups. Participants also suggested a greater focus on social connection on the website, including tips for finding an exercise buddy and making use of community programs like Park Run.

Capability / competence

The importance of building women’s capabilities and self-efficacy was evident in participants’ discussion of the need for encouragement that, “You can do it!”. They asserted that goals must be “modest”, “realistic” and incrementally progressive, and recommended we provide more resources that “[Target] where people are starting from: Are you a beginner? Are you trying to get back to exercise? Are you looking for ways to expand your exercise routine? Are you dealing with an injury?”. Reassurance about the “non-threatening” nature of the AWo50 program was regarded as essential in recruitment given that poor self-efficacy could be a major deterrent.

Opportunity

The AWo50 program was regarded as offering opportunities directly via health coaching and, indirectly, by ‘pointing’ to other opportunities in the website resources. For example, some had tested the activity directories and sourced local opportunities for themselves, “I found a walking group in my area which I’m going to follow up”. They thought the Facebook group might generate information about further opportunities. Several pointed out that offering the free trial opened opportunities up to some women who might otherwise not be able to afford a physical activity program.

Motivation

All participants acknowledged that motivation was a major challenge for many women aged 50 + and that the AWo50 program had to tackle this. Several participants advocated stronger messaging about the benefits of PA in coaching, on the website and in recruitment, “Maybe sell the message that the more active you are the longer and better your life will be. Your body and brain will both work far better. Your psychology will be affected”. However many advocated for encouragement while also warning us about the potential for women to feel hectored or shamed by messaging which could alienate rather than motivate them. For example, website content was appreciated because, “The tone, the encouragement and positivity is great. It’s normalising the challenges of time, caring, fatigue, etc. so there’s nothing guilt inducing. We have enough guilt already!”. Photos and videos on the website were generally considered to be “very motivational” because they depicted ‘real’ women who modelled being physically active in achievable ways. They noted that the program was using a range of strategies and felt this was appropriate given that women will be motivated by different things. For example, some felt motivated by activity tracking (e.g. monitoring step counts), and enjoyed ‘rewards’ for achievement, but they cautioned against building a dashboard into the website that would encourage data sharing and competition, “I don’t want to compare. I want to listen to myself and find my own rhythm”.

Competing priorities

The flexibility of the AWo50 program was regarded as essential given the limited time and energy that many women aged 50 + struggle with. We were encouraged to confront this head-on in recruitment, for example, rather than ask “Do you want support to be more active?” on every flyer we could ask “Are you struggling to get exercise into your busy life?”. The focus group highlighted how competing priorities could play out differently for some women in rural areas when, “During harvest people have weeks when they’re completely unable to fit anything else in”.

However, we also identified two prominent concepts in the data that were not well captured by the current program theory. First, the need for reassurance about online safety: psychological and technological. We are conceptualising this as A safe enough space in our revised program theory model (Fig. 2) and see this as potentially extending to experiences of social and physical safety in environments in which participants exercise.

Revised program theory for further testing and refinement during the planned AWo50 RCT

Second, women in our consultation often reflected on the enduring question of how women can be supported to make physical activity a priority without triggering guilt and inadequacy when plans go awry. We conceptualised this as Responsibility without blame. Given its salience, we also added this construct to our program theory as another condition which should be addressed in the AWo50 program evaluation.