Cite Score:
0.65
CITE SCORE SCOPUS

Predictors of Regular Outdoor Walking among Iranian Older Males, Shiraz, 2016

AUTHORS

Ramin Shiraly 1 , Vahid Keshtkar 1 , *

1 Department of Community Medicine, Shiraz University of Medical Sciences, Shiraz, Iran

How to Cite: Shiraly R, Keshtkar V. Predictors of Regular Outdoor Walking among Iranian Older Males, Shiraz, 2016, Shiraz E-Med J. 2018 ; 19(6):e61210. doi: 10.5812/semj.61210.

ARTICLE INFORMATION

Shiraz E-Medical Journal: 19 (6); e61210
Published Online: May 15, 2018
Article Type: Research Article
Received: September 2, 2017
Revised: November 6, 2017
Accepted: November 7, 2017
Crossmark

Crossmark

CHEKING

READ FULL TEXT
Abstract

Background: Walking is the most common type of physical activity among older people. A few studies have specifically investigated factors associated with walking behavior of elderly. The purpose of this study was to determine correlates of regular outdoor walking among Iranian males aged 65 to 75 years, living in Shiraz, Iran.

Methods: This was a cross - sectional study with a control group matched by age and gender, carried out during June to August 2016 in Shiraz, Southern Iran. Interviews with more than 900 elderly people from 11 municipal divisions of Shiraz city were carried out, and 531 eligible males aged 65 to 75 years, including 127 subjects with regular outdoor walking and 404 controls without this activity during the previous year were identified. Using a checklist, socio - demographic and environmental data were collected. Binary logistic regression was used to identify factors associated with regular outdoor walking. Statistical analyses were performed using SPSS version 19. Statistical significance was set at 0.05.

Results: Higher educational level (Adjusted Odds Ratio [AOR] = 2.15, 95% Confidence Interval [CI]: 1.28 - 3.59, P value = 0.004), married status (AOR = 4.10, 95%CI: 1.92 to 8.73, P < 0.001), family support (AOR = 2.48, 95% CI: 1.09 to 5.65, P = 0.029), absence of chronic disease (AOR = 2.07, 95%CI: 1.17 to 2.34, P = 0.004), access to walkable environments (AOR = 3.69, 95%CI: 1.76 to 7.75, P = 0.001) and safe neighborhoods (AOR = 3.11, 95%CI: 1.62 to 5.98, P = 0.001) were significantly associated with regular outdoor walking among Iranian older males.

Conclusions: Being married, having higher education and family support could predict regular outdoor walking among older people. Access to walkable and safe environments are notable environmental factors. Strategies to promote physical activity in older adults should be focused on encouraging regular walking in this age group.

Keywords

Older Adults Physical Activity Walking

Copyright © 2018, Shiraz E-Medical Journal. This is an open-access article distributed under the terms of the Creative Commons Attribution-NonCommercial 4.0 International License (http://creativecommons.org/licenses/by-nc/4.0/) which permits copy and redistribute the material just in noncommercial usages, provided the original work is properly cited

1. Background

Walking is the most common preferred and accessible type of physical activity among older adults (1-4). Walking has beneficial effects on cardiovascular function (5); Studies have shown that regular walking is associated with decreased risk of cardiac events and longer survival in older adults (2, 6). It may also increase muscle strength and improve bone density and psychomotor function (3).

Walking activity may help elderly maintain physical and cognitive independence through the prevention of chronic conditions, such as coronary heart disease, stroke, diabetes, depression, and cancer (6, 7).

The proportion of elderly people, who do not engage in regular walking, often outweighs those, who have regular walking activity. Only about 25% of American elderly walk regularly and 27% meet recommended levels of physical activity, which is 150 minutes of at least moderate - intensity activity per week (3).

Regular walking among older people might be associated with personal, social, and environmental factors (8). Personal factors include demographic characteristics, knowledge, attitude and beliefs regarding walking, self - efficacy, and outcome expectations. Environmental determinants include sidewalks conditions, light, traffic, neighborhood safety, and presence of facilities in the surrounding environment (3).

This study aimed at addressing social and environmental factors associated with regular outdoor walking among Iranian older males aged 65 to 75 years, living in Shiraz, Iran.

2. Methods

This was a cross - sectional study with a control group matched by age and gender, carried out during June to August 2016 in Shiraz, Southern Iran. Interview with more than 900 elderly people from 11 municipal divisions of Shiraz city, found 531 eligible people including 127 subjects with regular outdoor walking and 404 controls without this activity during the previous year. Regular outdoor walking was defined as walking outside the home with the aim of promoting health at least one day per week during the previous year. Men aged 65 to 75 were enrolled in the study. Study participants were recruited from 16 different neighborhoods, which were selected by cluster random sampling, according to the municipal divisions of Shiraz city (one to two clusters were selected from 11 municipal divisions). Interviewers visited elderly males aged 65 to 75 years at their houses and public parks in every cluster and enrolled them in the study after checking for eligibility. Subjects, who were not willing to participate and those, who were unable to walk, were excluded from the study.

This research used a data collection form, including a checklist of demographic characteristics, self - reported weight and height, history of chronic medical conditions, and self - reported social and environmental factors related to regular walking.

Demographic characteristics included job status, marital status, monthly income, and educational attainment. Body Mass Index (BMI) data were calculated, according to participant’s self - report of body weight and height. Validity of self - reported BMI was investigated and there was a high correlation between self - reported and actual weight and height (9). Body Mass Index was categorized according to the WHO classification: underweight (BMI < 18.5 kg/m2), normal weight (BMI, 18.5 to < 25 kg/m2), overweight (BMI, 25 to < 30 kg/m2) and obese (BMI, ≥ 30 kg/m2) (10), and this study considered two categories of BMI < 25 and ≥ 25.

Smoking status was classified as current, ex- or never - smoker. A current smoker was defined as a subject, who had smoked during the past 30 days. An ex - smoker was defined as one, who had not smoked during the past 30 days.

A chronic medical condition was defined as a prolonged disease state, for which patients received drugs and did not resolve spontaneously and was not be cured completely, such as diabetes mellitus and hypertension (11).

Participants were asked whether there were family and environmental factors that could help them engage in regular walking outside their home. They answered “yes” or “no” to the following questions: Are there walkable environments that are accessible to you for regular walking? Is your neighborhood safe for walking? Do your family and friends encourage and help you walk outdoors? Do you have a companion for outdoor walking?

Face to face interviews were performed by 3 trained interviewers. All data on variables were based on self - reported information and were collected after obtaining informed verbal consent from the study subjects.

Descriptive statistics included frequency distributions of categorical variables, such as educational attainment (< 12 and ≥ 12 years of schooling), marital status (marriedand never married, divorced or widowed), income (< 500 and ≥ 500 US dollar per month), smoking status (current or ex - smoker and never smoked) and Body Mass Index (< 25, ≥ 25).

For univariate analysis, chi - square test was used to determine Odds Ratios (ORs) and 95% Confidence Intervals (CIs).

Backward stepwise logistic regression was used to explore factors associated with engagement in regular outdoor walking among older males after adjustment for potential confounders. The SPSS version 19 was used for statistical analysis. P values of < 0.05 were considered statistically significant. This study was approved by the ethics committee of Shiraz University of Medical Sciences (Code: IR.SUMS.Med.RES.1395.s32).

3. Results

The mean (± SD) age of cases was 68.42 ± 6.15 and of controls was 68.68 ± 6.49 (P = 0.154). Cases were more likely to be retired or housewives and having a BMI of < 25. Controls were more likely to be less - educated, single people with lower income and to be a current or ex - smoker. Less than one - third of participants reported being employed. Also, more than half of both cases and controls had normal BMI and the majority of the remainder were overweight (Table 1).

Table 1. Baseline Characteristics of Study Participants
CharacteristicsTotal Subjects (531), N (%)Cases (127), N (%)Controls (404), N (%)
Male gender531 (100)127 (100)404 (100)
≥ 12 Years of schooling104 (19.60)41 (32.30)63 (15.60)
Working202 (38.00)42 (33.10)160 (39.60)
≥ 500 US Dollar monthly income236 (44.4)73 (57.50)163 (40.30)
Married433 (81.5)118 (92.90)315 (78.00)
BMI ≥ 25209 (39.4)44 (34.60)165 (40.80)
Current or ex - smoker222 (41.80)38 (29.90)184 (45.50)

Table 2 demonstrates univariate analysis of socio - demographic and environmental factors with engagement in regular outdoor walking among the study participants. Most of the study variables, including age, gender, income, educational level, marital and smoking status, chronic conditions, family support and characteristics of environments were potential correlates (P < 0.05), yet there was no significant association between BMI (P = 0.252), job status (P = 0.209), friend’s support (P = 0.252), having a walking companion (P = 0.351), and regular outdoor walking activity.

Table 2. Univariate Odds Ratios and 95% Confidence Intervals for Potential Factors Associated with Engagement in Regular Outdoor Walking among Iranian Older Males, Aged 65 to 75 Years in Shiraz (Unadjusted Benefit)
VariableCases (N = 127), N (%)Controls (N = 404), N (%)OR (95% CI)P Value
Education (years of schooling)< 0.001
< 1286 (67.70)341 (84.40)1
≥ 1241 (32.30)63 (15.60)2.58 (1.63 - 4.08)
Job status0.209
Working42 (33.10)160 (39.60)0.75 (0.49 - 1.14)
Retired or housewife85 (66.90)244 (60.40)1
Monthly income (US Dollar)0.001
< 50054 (42.50)241 (59.70)1
≥ 50073 (57.50)163 (40.30)1.99 ( 1.33 - 2.99)
Marital status< 0.001
Married118 (92.90)315 (78.00)3.70 (1.81 - 7.59)
Single/Divorced/Widowed9 (7.10)89 (22.00)1
BMI0.252
< 2583 (65.40)239 (59.20)1.30 ( 0.86 - 1.97)
≥ 2544 (34.60)165 (40.80)1
Chronic disease< 0.001
Yes36 (28.30)186 (46.00)1
No91 (71.70)218 (54.00)2.16 (1.39 - 3.32)
Smoking status0.002
Current or ex - smoker38 (29.90)184 (45.50)1
Never smoker89 (70.10)220 (54.50)1.96 (1.28 - 3.00)
Access towalkable environment< 0.001
Yes116 (91.30)254 (62.90)6.23 (3.25 - 9.94)
No11 (8.70)150 (37.10)1
Safety of neighborhood< 0.001
Yes111 (87.40)236 (58.40)4.93 (2.82 - 8.65)
No16 (12.60)168 (41.60)1
Family support0.026
Yes15 (11.80)22 (5.4)2.32 (1.17 - 4.64)
No112 (88.20)382 (94.6)1
Friends’ support0.252
Yes13 (10.20)28 (6.9)1.53 (0.77 - 3.05)
No114 (89.80)376 (93.1)1
Having a walking companion0.351
Yes12 (9.40)52 (12.90)1.42 (0.73 - 2.74)
No115 (90.60)352 (87.10)1

Abbreviations: CI, confidence interval; OR, odds ratio.

When adjusted for socio - demographic and environmental characteristics, there was a significant association between higher educational level (AOR = 2.15, 95%CI: 1.28 to 3.59, P = 0.004), marital status (AOR = 4.10, 95%CI: 1.92 - 8.73 , P < 0.001), family support (AOR = 2.48, 95%CI: 1.09 - 5.65, P = 0.029), absence of chronic disease (AOR = 2.07, 95%CI: 1.17 - 2.34 , P = 0.004), access to walkable environments (AOR = 3.69, 95%CI: 1.76 - 7.75 , P = 0.001), and safe neighborhoods (AOR = 3.11, 95%CI: 1.62 - 5.98 , P = 0.001) and regular outdoor walking among Iranian older adults (Pseudo R2 was 0.29 and correctly predicted percentage was 76.1%) (Table 3).

Table 3. Multivariate Stepwise (Backward Elimination) Logistic Regression of the Factors Associated with Regular Outdoor Walking among Iranian Older Males Aged 65 to 75 Years in Shiraz City (Adjusted Benefit)
VariableβSEWalddfOR (95% CI)P Value
Educational attainment0.004
> 12 (years of schooling)0.7650.2638.45612.15 (1.28 - 3.59)
≤ 121
Job status0.189
Working- 0.3480.2471.98110.72 (0.45 - 1.17)
Retired or housewife10.744
Monthly income
≥ 500 (US dollar)0.0840.2580.10611.08 (0.66 - 1.80)
< 5001
Marital status< 0.001
Married1.4110.38613.38114.10 (1.92 - 8.73)
Single/Divorced/Widowed1
BMI0.242
< 250.2860.2451.36711.33 (0.82 - 2.15)
≥ 251
Chronic disease0.004
No0.7300.2439.04512.07 (1.17 - 2.34)
Yes1
Smoking status0.068
Never smoker0.4430.2423.34311.56 ( 0.96 - 2.50)
Current smoker/Ex - smoker1
Family support0.029
Yes0.9110.4194.73912.48 (1.09 - 5.65)
No1
Friends’ support0.936
Yes0.0080.4720.00010.96 ( 0.38 - 2.43)
No1
Access to walkable environments0.001
Yes1.3070.37811.93213.69 (1.76 - 7.75)
No1
Safe neighborhoods0.001
Yes1.1370.33311.66813.11 (1.62 - 5.98)
No1
Having a walking companion0.111
Yes0.5990.3752.54711.82 (0.87 - 3.79)
No1
Constant- 5.7800.65877.136< 0.001

Abbreviations: CI, confidence Interval; df, degrees of freedom; OR, odds ratio; SE, standard error.

4. Discussion

Our findings indicate that educational attainment and marital status are important social determinants of regular outdoor walking among Iranian older males. Some other studies have also shown a relationship between social class and physical activity of older adults. These findings support the popular concept of social determinants of health (12-14).

Disparities between walking behavior of cases and controls cannot be explained by disparity of educational levels. Indeed, low social levels may promote the kind of lifestyle that predisposes to unhealthy behaviors, including low physical activity (15).

In the present study, married elders more commonly engaged in regular walking than did single, divorced or widowed elderly. One study also showed that married older people had higher average physical activity and exercise than those, who were single (16).

There are some reports that married and highly educated people have an increased sense of confidence, which can act as a driving force to manage health behaviors and achieve better health outcomes (17-19).

Moreover, the current study demonstrated that the presence of a chronic medical condition might have a negative effect on regular walking. Chronic diseases are associated with inadequate physical activity in older adults (20). There may be a reciprocal cause and effect relationship between physical activity and chronic medical conditions, as regular exercise correlates with a reduced risk of chronic diseases, while the latter can restrict physical activity (21, 22).

Family support was another factor that could predict engagement of older adults in regular outdoor walking. The present study showed that elderly people with positive family support had higher outdoor walking activity levels than those without, yet friends’ support and need to have a walking companion were not associated with this outcome. Effect of family support on physical activity levels of older adults have been suggested in other studies (23, 24). This effect may be mediated by marital status, as physically active, married elders usually have a physically active spouse and are more likely to have family support than single, divorced or widowed elders (16). Some studies have also shown the positive influence of important others, such as friends (23, 25), yet this study did not find a significant association.

Both access to walkable environments and safe neighborhoods had a positive effect on engagement in regular outdoor walking. These findings are consistent with many other studies, which showed that characteristics of the environment is associated with physical activity levels in older adults. More walkable environments are associated with more walking and better health outcomes among elderly people (26-30).

In parallel with the current findings, it has been suggested that unsafe neighborhoods due to factors, such as traffic, excessive noise, unsafe sidewalks, and crime are more likely to be associated with lower tendency of older people to walk outdoors (31). One study showed no association between neighborhood safety and physical activity in older adults (32); yet many studies showed that perceptions of safety for walking is positively related to higher levels of walking activity (33-35).

Life expectancy has been lengthened almost linearly over the past century in most developing and developed countries and this trend is expected to be continued in the future (36). According to the national population and housing census, the proportion of Iranian elderly has increased from 7.2% in 2006 to 8.2% in 2011 and it is expected that in the coming years the elderly population will grow more rapidly (37). In the light of this trend, public health strategies should target factors contributing to positive health outcomes among older adults. Thus, promotion of adequate physical activity, especially of walking outdoors, should be a major aim of health policy.

There were some potential limitations to this study. This research recruited cases from some limited areas of the city and this may restrict the generalizability of the results. The validity of self - reported data cannot be established and hence the collected information may be subject to bias.

It is suggested for future studies to determine factors affecting walking behavior of the eldest elderly, those aged 80 or older, who seem to be least involved in outdoor walking.

4.1. Conclusions

Being married, having higher education, and family support can predict regular outdoor walking among older people. Access to walkable and safe environments are notable environmental factors. Strategies to promote physical activity in older adults should be focused on encouraging regular walking in this age group.

Acknowledgements

Footnote

References

  • 1.

    Notthoff N, Carstensen LL. Positive messaging promotes walking in older adults. Psychol Aging. 2014;29(2):329-41. doi: 10.1037/a0036748. [PubMed: 24956001]. [PubMed Central: PMC4069032].

  • 2.

    Diehr P, Hirsch C. Health benefits of increased walking for sedentary, generally healthy older adults: using longitudinal data to approximate an intervention trial. J Gerontol A Biol Sci Med Sci. 2010;65(9):982-9. doi: 10.1093/gerona/glq070. [PubMed: 20484337]. [PubMed Central: PMC2920578].

  • 3.

    Gallagher NA, Gretebeck KA, Robinson JC, Torres ER, Murphy SL, Martyn KK. Neighborhood factors relevant for walking in older, urban, African American adults. J Aging Phys Act. 2010;18(1):99-115. [PubMed: 20181997]. [PubMed Central: PMC2843394].

  • 4.

    Lin YC, Huang LH, Yeh MC, Tai JJ. Leisure-time physical activities for community older people with chronic diseases. J Clin Nurs. 2011;20(7-8):940-9. doi: 10.1111/j.1365-2702.2009.02877.x. [PubMed: 20586832].

  • 5.

    Saevereid HA, Schnohr P, Prescott E. Speed and duration of walking and other leisure time physical activity and the risk of heart failure: a prospective cohort study from the Copenhagen City Heart Study. PLoS One. 2014;9(3). e89909. doi: 10.1371/journal.pone.0089909. [PubMed: 24621514]. [PubMed Central: PMC3951187].

  • 6.

    Samawi HM. Daily walking and life expectancy of elderly people in the iowa 65+ rural health study. Front Public Health. 2013;1:11. doi: 10.3389/fpubh.2013.00011. [PubMed: 24350181]. [PubMed Central: PMC3854856].

  • 7.

    Prins RG, Kamphuis CB, de Graaf JM, Oenema A, van Lenthe FJ. Physical and social environmental changes to promote walking among Dutch older adults in deprived neighbourhoods: the NEW.ROADS study. BMC Public Health. 2016;16:907. doi: 10.1186/s12889-016-3563-2. [PubMed: 27576484]. [PubMed Central: PMC5006535].

  • 8.

    Gallagher NA, Clarke PJ, Ronis DL, Cherry CL, Nyquist L, Gretebeck KA. Influences on neighborhood walking in older adults. Res Gerontol Nurs. 2012;5(4):238-50. doi: 10.3928/19404921-20120906-05. [PubMed: 22998660]. [PubMed Central: PMC3951905].

  • 9.

    Flint AJ, Rexrode KM, Hu FB, Glynn RJ, Caspard H, Manson JE, et al. Body mass index, waist circumference, and risk of coronary heart disease: a prospective study among men and women. Obes Res Clin Pract. 2010;4(3):e171-81. doi: 10.1016/j.orcp.2010.01.001. [PubMed: 21116472]. [PubMed Central: PMC2992336].

  • 10.

    Dzakpasu S, Duggan J, Fahey J, Kirby RS. Estimating bias in derived body mass index in the Maternity Experiences Survey. Health Promot Chronic Dis Prev Can. 2016;36(9):185-93. [PubMed: 27670921]. [PubMed Central: PMC5129777].

  • 11.

    Stellefson M, Chaney B, Barry AE, Chavarria E, Tennant B, Walsh-Childers K, et al. Web 2.0 chronic disease self-management for older adults: a systematic review. J Med Internet Res. 2013;15(2). e35. doi: 10.2196/jmir.2439. [PubMed: 23410671]. [PubMed Central: PMC3636299].

  • 12.

    Beenackers MA, Kamphuis CB, Giskes K, Brug J, Kunst AE, Burdorf A, et al. Socioeconomic inequalities in occupational, leisure-time, and transport related physical activity among European adults: a systematic review. Int J Behav Nutr Phys Act. 2012;9:116. doi: 10.1186/1479-5868-9-116. [PubMed: 22992350]. [PubMed Central: PMC3491027].

  • 13.

    Mourao AR, Novais FV, Andreoni S, Ramos LR. [Physical activity in the older adults related to commuting and leisure, Maceio, Brazil]. Rev Saude Publica. 2013;47(6):1112-22. [PubMed: 24626549]. [PubMed Central: PMC4206094].

  • 14.

    Kamphuis CB, Van Lenthe FJ, Giskes K, Huisman M, Brug J, Mackenbach JP. Socioeconomic status, environmental and individual factors, and sports participation. Med Sci Sports Exerc. 2008;40(1):71-81. doi: 10.1249/mss.0b013e318158e467. [PubMed: 18182936].

  • 15.

    Pampel FC, Krueger PM, Denney JT. Socioeconomic Disparities in Health Behaviors. Annu Rev Sociol. 2010;36:349-70. doi: 10.1146/annurev.soc.012809.102529. [PubMed: 21909182]. [PubMed Central: PMC3169799].

  • 16.

    Pettee KK, Brach JS, Kriska AM, Boudreau R, Richardson CR, Colbert LH, et al. Influence of marital status on physical activity levels among older adults. Med Sci Sports Exerc. 2006;38(3):541-6. doi: 10.1249/01.mss.0000191346.95244.f7. [PubMed: 16540843].

  • 17.

    Zahodne LB, Nowinski CJ, Gershon RC, Manly JJ. Self-Efficacy Buffers the Relationship between Educational Disadvantage and Executive Functioning. J Int Neuropsychol Soc. 2015;21(4):297-304. doi: 10.1017/S1355617715000193. [PubMed: 25877284]. [PubMed Central: PMC4871130].

  • 18.

    Yim HJ, Park HA, Kang JH, Kim KW, Cho YG, Hur YI, et al. Marital Status and Health Behavior in Middle-aged Korean Adults. Korean J Fam Med. 2012;33(6):390-7. doi: 10.4082/kjfm.2012.33.6.390. [PubMed: 23267425]. [PubMed Central: PMC3526722].

  • 19.

    Umberson D, Crosnoe R, Reczek C. Social Relationships and Health Behavior Across Life Course. Annu Rev Sociol. 2010;36:139-57. doi: 10.1146/annurev-soc-070308-120011. [PubMed: 21921974]. [PubMed Central: PMC3171805].

  • 20.

    Ashe MC, Miller WC, Eng JJ, Noreau L, Physical A, Chronic Conditions Research T. Older adults, chronic disease and leisure-time physical activity. Gerontology. 2009;55(1):64-72. doi: 10.1159/000141518. [PubMed: 18566534]. [PubMed Central: PMC3167824].

  • 21.

    Warburton DE, Nicol CW, Bredin SS. Health benefits of physical activity: the evidence. CMAJ. 2006;174(6):801-9. doi: 10.1503/cmaj.051351. [PubMed: 16534088]. [PubMed Central: PMC1402378].

  • 22.

    Booth FW, Roberts CK, Laye MJ. Lack of exercise is a major cause of chronic diseases. Compr Physiol. 2012;2(2):1143-211. doi: 10.1002/cphy.c110025. [PubMed: 23798298]. [PubMed Central: PMC4241367].

  • 23.

    Park CH, Elavsky S, Koo KM. Factors influencing physical activity in older adults. J Exerc Rehabil. 2014;10(1):45-52. doi: 10.12965/jer.140089. [PubMed: 24678504]. [PubMed Central: PMC3952835].

  • 24.

    Plonczynski DJ, Wilbur J, Larson JL, Thiede K. Lifestyle physical activity of older rural women. Res Nurs Health. 2008;31(5):501-13. doi: 10.1002/nur.20282. [PubMed: 18384050]. [PubMed Central: PMC2574920].

  • 25.

    Moschny A, Platen P, Klaassen-Mielke R, Trampisch U, Hinrichs T. Barriers to physical activity in older adults in Germany: a cross-sectional study. Int J Behav Nutr Phys Act. 2011;8:121. doi: 10.1186/1479-5868-8-121. [PubMed: 22047024]. [PubMed Central: PMC3225299].

  • 26.

    Cain KL, Millstein RA, Sallis JF, Conway TL, Gavand KA, Frank LD, et al. Contribution of streetscape audits to explanation of physical activity in four age groups based on the Microscale Audit of Pedestrian Streetscapes (MAPS). Soc Sci Med. 2014;116:82-92. doi: 10.1016/j.socscimed.2014.06.042. [PubMed: 24983701]. [PubMed Central: PMC4153433].

  • 27.

    King AC, Sallis JF, Frank LD, Saelens BE, Cain K, Conway TL, et al. Aging in neighborhoods differing in walkability and income: associations with physical activity and obesity in older adults. Soc Sci Med. 2011;73(10):1525-33. doi: 10.1016/j.socscimed.2011.08.032. [PubMed: 21975025]. [PubMed Central: PMC3637547].

  • 28.

    Gauvin L, Richard L, Kestens Y, Shatenstein B, Daniel M, Moore SD, et al. Living in a well-serviced urban area is associated with maintenance of frequent walking among seniors in the VoisiNuAge study. J Gerontol B Psychol Sci Soc Sci. 2012;67(1):76-88. doi: 10.1093/geronb/gbr134. [PubMed: 22227735].

  • 29.

    Winters M, Voss C, Ashe MC, Gutteridge K, McKay H, Sims-Gould J. Where do they go and how do they get there? Older adults' travel behaviour in a highly walkable environment. Soc Sci Med. 2015;133:304-12. doi: 10.1016/j.socscimed.2014.07.006. [PubMed: 25017579].

  • 30.

    Saelens BE, Handy SL. Built environment correlates of walking: a review. Med Sci Sports Exerc. 2008;40(7 Suppl):S550-66. doi: 10.1249/MSS.0b013e31817c67a4. [PubMed: 18562973]. [PubMed Central: PMC2921187].

  • 31.

    Fox KR, Hillsdon M, Sharp D, Cooper AR, Coulson JC, Davis M, et al. Neighbourhood deprivation and physical activity in UK older adults. Health Place. 2011;17(2):633-40. doi: 10.1016/j.healthplace.2011.01.002. [PubMed: 21292536].

  • 32.

    Won J, Lee C, Forjuoh SN, Ory MG. Neighborhood safety factors associated with older adults' health-related outcomes: A systematic literature review. Soc Sci Med. 2016;165:177-86. doi: 10.1016/j.socscimed.2016.07.024. [PubMed: 27484353].

  • 33.

    Bennett GG, McNeill LH, Wolin KY, Duncan DT, Puleo E, Emmons KM. Safe to walk? Neighborhood safety and physical activity among public housing residents. PLoS Med. 2007;4(10):1599-606. discussion 1607. doi: 10.1371/journal.pmed.0040306. [PubMed: 17958465]. [PubMed Central: PMC2039759].

  • 34.

    Winters M, Barnes R, Venners S, Ste-Marie N, McKay H, Sims-Gould J, et al. Older adults' outdoor walking and the built environment: does income matter? BMC Public Health. 2015;15:876. doi: 10.1186/s12889-015-2224-1. [PubMed: 26359159]. [PubMed Central: PMC4566863].

  • 35.

    Tucker-Seeley RD, Subramanian SV, Li Y, Sorensen G. Neighborhood safety, socioeconomic status, and physical activity in older adults. Am J Prev Med. 2009;37(3):207-13. doi: 10.1016/j.amepre.2009.06.005. [PubMed: 19595554]. [PubMed Central: PMC3685411].

  • 36.

    Christensen K, Doblhammer G, Rau R, Vaupel JW. Ageing populations: the challenges ahead. Lancet. 2009;374(9696):1196-208. doi: 10.1016/s0140-6736(09)61460-4.

  • 37.

    Noroozian M. The elderly population in iran: an ever growing concern in the health system. Iran J Psychiatry Behav Sci. 2012;6(2):1-6. [PubMed: 24644476]. [PubMed Central: PMC3940007].

  • COMMENTS

    LEAVE A COMMENT HERE: