Promoting Active and Healthy Ageing at Day Centers for Older People

ABSTRACT

Day centers provide opportunities for older people to achieve active and healthy aging. Staff play a significant role in day centers, although evidence is lacking concerning their role. To explore the experiences of staff in promoting active and healthy aging at social day centers, interviews with 12 staff working at day centers for older people were carried out. The findings present two categories: the actions of the staff and conditions affecting activities at the day centers. Staff at day centers may play an important role in providing opportunities for older people to maintain health and participation in meaningful activities.

KEYWORDS:

• Active aging
• health
• staff
• qualitative study
• day centers

Introduction and literature review

Today, a demographic shift is occurring worldwide, as the number of people over 60 years of age is growing faster than any other age group. This growing population of older people will require different services in the future to support active and healthy aging, according to the World Health Organization (World Health Organization [WHO], 2015). Active aging is a policy framework that the WHO defines as the process “of optimizing opportunities for health, participation and security in order to enhance quality of life as people age” (WHO, 2002, p. 12).

Healthy aging is a related concept developed in the WHO’s World Report on Aging and Health, which defines healthy aging “as the process of developing and maintaining the functional ability that enables well-being in older age” (World Health Organization [WHO], 2015, p. 28). Furthermore, healthy aging is described as a person-environment framework that assumes that functional ability “is made up of the intrinsic capacity of the individual, relevant environmental characteristics and the interactions between the individual and these characteristics” (World Health Organization [WHO], 2015, p. 28). Environmental characteristics are described as comprising all “factors in the extrinsic world that form the context of an individual’s life” (World Health Organization [WHO], 2015, p. 28) such as relationships between people, people’s values and attitudes, the built environment, and social policies and social systems.

Day centers provide services that support active and healthy aging for older people. Day centers are places in the community that provide care, support, and opportunities to engage in various activities (Samuelsson, Malmberg, & Hansson, 1998) with the intention to maintain health and enhance quality of life for older people (Fields, Anderson, & Dabelko-Schoeny, 2014). Visiting a day center to engage in different activities or social gatherings has previously been described as important for older people to sustain and preserve their functions (Anetzberger, 2002; Da Silva & Gameiro, 2021). In previous research, day centers for older people are described as either social or medical day centers (Andersson, Tham, & Borell, 2004; Samuelsson et al., 1998). Medical day centers provide rehabilitation and health services and social day centers provide activities that encourage social interaction among older people (Orellana, Manthorpe, & Tinker, 2020; Samuelsson et al., 1998).

Activities carried out at day centers for older people are diverse, and centers offer a variety of programs (Aday, Wallace, & Krabill, 2019; Kim & Kim, 2021) at different times of the day (Da Silva & Gameiro, 2021). A diverse program of meaningful activities is needed to attract visitors (Eifert, Tappen, & Curtis, 2018) and to cater to various needs in relation to the older person’s health condition, interests, and skills (Hewson, Kwan, Shaw, & Lai, 2018). Furthermore, visitors should have similar cognitive and physical abilities to ensure that an appropriate program of activities suitable to their abilities is scheduled (Eifert et al., 2018).

Social participation can enhance well-being and perceived self-worth among older people (Hewson et al., 2018). Previous research about day centers for older people has concluded that attending a day center creates opportunities to engage in meaningful social interactions (Brataas, Bjugan, Willie, & Helizwen, 2019), experiences of social and emotional support from others (Aday et al., 2019; Gustafsson, Berglund, Faronbi, Barenfeld, & Ottenvall Hammar, 2017), and reducing feelings of loneliness (Kim & Kim, 2021). Furthermore, day centers for older people have been described as places where new friendships can be developed (Aday et al., 2019; Lunt, Dowrik, & Lloyd-Williams, 2018).

Older people who attend a day center may experience an increased quality of life, social participation, a sense of purpose, and feelings of being stimulated and needed by others (Laird, McGurk, Reid, & Ryan, 2017; Orellana et al., 2020). Day centers for older people have also been described to have a prominent role in improving mental and physical health among older people (Aday et al., 2019). Nevertheless, few studies (Lunt et al., 2018), the lack of standardized definition (Fields et al., 2014; Orellana et al., 2020), and different legislative contexts make it difficult to assess the effectiveness of day centers and to generalize previous research (Fields et al., 2014; Lunt et al., 2018; Orellana et al., 2020).

From the perspective of care providers, previous research has pointed out that internal organizational barriers (i.e., constraints regarding spaces, facilities, and staff), and external barriers (i.e., lack of funding for programs) have a negative consequence of what activities could be offered and how these activities could be organized for older people (Hewson et al., 2018). Furthermore, older people attending day centers appreciate being offered choice, being respected, and being empowered through their relationships with staff (Dabelko-Schoeny & King, 2010; Fawcett, 2014). Nevertheless, there is a considerable evidence gap about how day centers are perceived by different stakeholders, such as staff, and those funding or recommending day centers (Orellana et al., 2020). Little is known about staff working at or in relation to day centers for older people (Ellen, Demaio, Lange, & Wilson, 2017) even though staff have been presented as significant stakeholders (Orellana et al., 2020). Furthermore, in active and healthy aging, the role of professional caregivers surrounding older people is described as an extrinsic factor that forms the context of the older person’s life (World Health Organization [WHO], 2015). Therefore, this paper aims to explore how staff experience their work in relation to promoting active and healthy aging at social day centers for older people.

Material and methods

The Swedish context of day centers for older people

In the Swedish context, the National Board of Health and Welfare’s conceptual dictionary states that day services targeting a specific older individual or a group of older people should be separated from each other. Services in the form of day care for individuals must be assessed through a needs assessment process and should be given in accordance with the individual’s needs. Services in the form of day centers targeting older people as a group are open for everyone to attend, so there is no need for any formal application or assessment of the individuals’ needs (National Board of Health and Welfare, n.d.). The current study focuses on social day centers that older people attend without the need for an assessment process.

Data collection

Staff working at day centers for older people in one Swedish municipality were recruited through convenience sampling (Crosby, DiClemente, & Salazar, 2006). Managers for the day centers were informed about the present study. Information was given about the aim, the research procedure, and what was expected of those who choose to participate in the study. The manager agreed that staff working at the day centers for older people could be informed about the present study.

Potential participants were notified by mail and telephone about the study. All day centers in the municipal city center were contacted, and all approached staff agreed to participate. Times and places were determined for interviews.

Before starting the interview, information was given to the participants about the study, confidentiality, and the opportunity to withdraw consent to participate in the present study without justification. Then, written informed consent to participate in the study was given by the participants. All interviews were conducted by the first author who is a senior lecturer and registered occupational therapist with no previous relationship with the participants. She has extensive experience conducting qualitative interviews. The interviews took place at the day center where the participants worked, often between different activities or during the participant’s break. The duration of each interview ranged from 16 to 28 minutes. The interviews were semi-structured and covered different areas from the staff’s perspective about activities at social day centers, the role of the staff, and the meaning and importance of social day centers for older people in relation to active and healthy aging. The topics of the interviews were inspired by the Healthy Aging concept (World Health Organization [WHO], 2015). All interviews were audio-recorded and transcribed verbatim.

Participants

In total, the study included 12 participants working at eight different day centers for older people. All participants were female, mean age was 49 years, and their work experience in day centers ranged from 8 months to 16 years (median 2 years, mean 4.8 years). Half of the participants had a background as assistant nurses or care assistants, and the remaining had various backgrounds such as a cook, dressmaker, or university student. All participants worked as activity leaders at social day centers. The social day centers were visited by older people with different socioeconomic backgrounds living in the same geographical area. Those who visited the social day centers were described by the participants as very old and lonely people often living on their own. Recruitment of participants continued until saturation was met.

Data analysis

The data were analyzed using qualitative content analysis (Graneheim, Lindgren, & Lundman, 2017; Graneheim & Lundman, 2004). To gain a sense of the whole data set, all transcripts were read several times by both authors. The last author identified and extracted text from the transcripts that were relevant to the aim of the study. These extractions were compiled into a single text and constituted the unit of analysis; approximately 70% of the transcribed text was extracted using NVivo©, a software for conducting qualitative analysis. This extracted text was divided into meaning units. Meaning units are words, sentences, or paragraphs that contain aspects related to each other through their context and content (Graneheim & Lundman, 2004). All meaning units were condensed and labeled with a code by the last author. The first author validated all condensed meaning units and codes, and differences were discussed until consensus was reached. At this phase of the data analysis, it was possible to judge that saturation had been reached as no new codes or data were obtained in the final interviews subject to analysis. The first author, using the codes and condensed meaning units, created categories and sub-categories based on similar content. Then, through discussion between both authors, two final categories and six sub-categories were formulated. The analysis of the text was not a linear process. Throughout the analysis process, both authors discussed and reflected on the different phases of the analysis and moved between the whole data set and parts of the text to understand statements in relation to their context (Graneheim et al., 2017; Graneheim & Lundman, 2004).

Ethical considerations

Ethical approval for this study was obtained through the Regional Ethical Review Board (Dnr 2018/188-31).

Findings

The analysis resulted in two categories that describe how staff experienced promoting active and healthy aging. The first category, the actions of the staff, describes how facilitating activities, engaging leadership, and facilitating social interaction enable active and healthy aging for older people. The second category, conditions affecting activities at the day centers, includes conditions in the physical environment, financial conditions, and administrative guidelines and regulations that have an impact on how active and healthy aging can be promoted by staff. Table 1 presents the findings related to categories, sub-categories, and key findings.

Table 1. Presentation of the findings related to categories, sub-categories, and key findings.

Categories	Sub-categories	Key findings
The actions of the staff	Facilitating activities	Staff are a resource in coordinating and organizing activities
	Facilitating social interaction	Staff introduce topics for discussions and create a stimulating atmosphere
	Engaging leadership	Staff supports the visitors and establish a good dynamic in the group
Conditions affecting activities at day centers	Conditions in the physical environment	The premises affect which activities to be offered
	Financial conditions	Activities needs to be at low cost for both the municipality and for the visitors
	Administrative guidelines and regulations	Guidelines hindering staff to offering activities

The actions of the staff

This category describes actions taken by staff at day centers to promote active and healthy aging for older people visiting a day center. It comprises how activities and social interaction at the day center are facilitated and how the staff handle their leadership to encourage the older people to engage themselves in activities at the day center to promote active and healthy aging.

Facilitating activities

The participants perceived that their role at the day centers involved facilitating activities for older people and described themselves as an essential resource in coordinating activities, taking care of administrative duties, keeping the budget, ordering meals, and serving as hosts. Furthermore, the participants perceived that older people who visited day centers expected staff to organize activities but not always to participate in them: “That’s what it is to be an activity leader: to enable, I can say not always to engage in or so but to enable” (participant 1).

Activities at the day centers were scheduled on a monthly basis as part of the program. The activities scheduled were physical activities (e.g., easy gymnastics, balance training, playing table tennis and boule), social activities (e.g., conversations, social coffee breaks, playing board games and reading newspapers or books aloud), and arts and music (e.g., painting and singalongs). The intention when designing the program for upcoming activities, as described by the participants, was that the visitors should plan activities and distribute the responsibility of leading these activities among themselves. Nevertheless, several of the participants expressed that most activities were not led by visitors but by staff. The participants stressed that if staff did not take an active role during the planning or the execution of activities, nothing would be done at the day center:

“My task and the goal of the activity leader is of course to coordinate activities and help volunteers and associations to hold activities and also help the visitors themselves” (participant 4).

Facilitating social interaction

The participants expressed that for many older visitors the day centers provide the only opportunity to socialize. Furthermore, the participants stressed that they experienced social interaction as more important than the type of activities offered at the day center. Thus, they thought that an important task for them as staff was to facilitate social interaction between the visitors: “You have a good group and they really have good social togetherness, here they have this hobby room that they stay [in] after when I go home […] eh for them it is important that they have the social togetherness” (participant 7).

The participants stated that they facilitated social interaction between the visitors at the day centers, for example, by introducing a topic for discussion, posing a question about commonalities of the visitors to stimulate conversation (e.g., topics and questions about politics, news happenings, and history of the city), or gathering all visitors around the same table to avoid people sitting by themselves: “Sometimes there will be discussions and it is seldom that I participate in them in that manner, maybe participate for a while, but when they have started, then I am not needed in the same way” (participant 6).

A positive approach from staff toward visitors creates a stimulating atmosphere that facilitates social interaction at the day center. Staff showing hospitality toward a visitor is stressed as important by several of the participants. The visitors should feel welcome as a part of the day center. According to the participants, to see every person and welcome them with their name, to use physical contact (e.g., a handshake, laying a hand on a shoulder or hugging a visitor) creates a welcoming environment and strengthens the visitor’s identity.

Engaging leadership

The leader’s role, expressed by the participants, is to support the visitors to engage in performing activities, dare to participate, and take on new responsibilities. To achieve this, an important task for the leader is, according to the participants, to create a feeling of security by creating a good dynamic in the group. This was expressed by one participant: “Not that I might participate so much physically, more that they feel quite’ secure if you are with them so they sit and talk” (participant 6).

The participants raised the need for the visitors to feel needed by others. Thus, they tried to engage them in practical chores or to help each other at the day center. Some participants expressed that more physically fit visitors helped others in need of assistance. In relation to this, the participants in their role as staff tailored chores or activities that could be conducted in accordance with each visitor’s abilities. The participants stressed that those helping others blossom as they dared to contribute and were appreciated by others for their contribution by both the staff and the other visitors at the day center:

That they actually dared to help and conduct [activities] that they blossomed in a completely new way, it became lively and they dared to participate in another way so I would probably like them to try because it is great to see that they dare and that all others who participate actually appreciate what you do then you experience feelings of importance and that is significant. (participant 4)

Conditions that affect activities at day centers

This category describes conditions that the participants perceive as influencing their opportunities to organize activities at the day centers to promote active and healthy aging for older people. These conditions include the physical environment, financial conditions, and administrative guidelines and regulations.

Conditions in the physical environment

The participants expressed that the physical environment affects which activities can be performed at day centers for older people. Some day centers had special assets in the physical environment such as an indoor pool or gymnastics facility. These special facilities were described by the participants as an opportunity to offer physical activities such as water gymnastics or table tennis. The participants stated that visitors came from different parts of the municipality to participate in these activities as these were considered to be something extra compared with other social day centers’ activities. Thus, the participants described that they had to limit access to these activities due to a high demand from visitors to participate. However, according to the participants, if the day center did not have a special asset in the physical environment, such as a kitchen or a very small kitchen, this limited the opportunity to offer cooking activities to the visitors: “This little kitchenette, for example, there is no one who can be with me and bake” (participant 1).

Another example described by one participant was that the assembly hall, previously a part of the social day center, was taken away as a resource for them to use, so several group activities were dissolved or moved to other facilities. In this case, the participant stated that the assembly hall had been used by different non-governmental organizations to arrange activities in which the visitors at the social day center were invited to participate as well.

The outdoor environment, when available, was described as a resource being used by staff to organize different activities at the day center; for example, at one day center they had a porch and raised flower and vegetable beds for visitors to use. The vegetables and flowers were used, for example, in a salad or decorations for a party at the day center.

Furthermore, the participants expressed that the location of the day center and its surroundings affected who could participate in the day center activities. The participants stressed that some visitors lived in the same building as the day center and therefore could access the facilities easily. Other visitors were described by the staff as making a greater effort to get to the day center, such as walking outside in different whether conditions or hilly landscapes, which could make it difficult for people with physical restrictions to overcome: “Those who live in the surroundings and manage to get there, at another place, there are only those who live in the building” (participant 3).

Financial conditions

The participants described that financial conditions that govern the day centers had an impact on what activities could be offered. According to the participants, the visitors participating in activities at the day centers wanted activities led by external persons such as musicians or dance instructors. The participants stressed that these activities could not be offered more than once or twice each semester due to financial restrictions. Nevertheless, the perception of the participants was that when these activities were offered at the social day centers the numbers of visitors increased.

Several of the participants stressed that the price to participate in different activities at the day center was an important factor when planning the program. The principle of cost price was applied, which enables participants with fewer financial resources to participate in activities on a daily basis: “Then this is a great alternative, for here it is only at cost price it is very cheap to have coffee here and they also say that, […] but 10 SEK huh it is this cheap for a coffee and bun? Yes, yes it is” (participant 11).

Administrative guidelines and regulations

Guidelines or rules set by politicians and administrators, according to the participants, affect the organization of the day center and which activities are possible to offer visitors. Four different guidelines or rules were mentioned by several participants: staff need to oversee the day center at all times; the visitors should lead activities by themselves; collecting and handling money and procurement rules. There is a balance between the municipality’s guidelines and the visitors’ wishes regarding activities. Many participants described guidelines and regulations governing their work and what could be done at the day center as barriers. These barriers led to meaningful activities not being conducted and therefore the full potential of the day center would not be used. One participant said that they thought a lot about how to circumvent rules or guidelines to offer activities that the older people requested (participant 2).

The participants stressed that they were not allowed to follow the visitors out of the day centers as the day center must be open. That is, according to the participants, one staff member always had to stay behind. Several participants perceived that there had been cutbacks in staffing in recent years. Presently, most day centers are run by one staff member, a barrier according to the participants as to which activities could be offered to the visitors. For example, when there were more than one staff member working, one of them could stay at the social day center and the other could leave the day center together with the visitors to conduct activities in the neighborhood or make daytrips: “They say we can’t do that; we can’t close the day center, we are not allowed to leave it” (participant 9).

The participants perceived that managers and politicians had expressed that the older people themselves should lead the activities at the day centers. According to the participants, when doing this, there were no activities conducted at all at the day centers. The staff listened to the visitors and tried to help them start different activities, but the participants expressed that they had done more than they actually should have in relation to the administrative guidelines. One participant said, “we as activity leaders have had to lead the activities more, more than we maybe should according to our mission” (participant 2).

The participants expressed that as the social day centers are run by the municipality, there are extensive regulations of how to handle money and how to buy commercial goods due to rules about procurement. The participants expressed that they were not allowed to handle or collect the visitors’ money in order to organize activities. This meant that they perceived that they could not buy commercial goods needed for a specific activity; for example, the visitors at a day center wanted to sponsor a godchild, but it was deemed impossible as they could not collect the money themselves. The participants stressed that it is problematic when it concerns money and the municipality, even if the visitors were to pay for activities and products themselves, due to administrative guidelines and regulations. One way to circumvent administrative guidelines and regulations expressed by the participants was if one of the visitors could be responsible for collecting money and conducting the payments each month. Nevertheless, this was described as difficult to manage as the visitors at the social day centers did not want to be responsible for other people’s money.

Procurement rules that govern how commercial goods were to be bought in the municipality made it difficult to organize some activities according to the participants; for example, one activity that had been discussed for several years was wine tasting. According to the participants, this was not possible due to the municipality’s rules for purchasing commercial goods. According to the participants, there are procurement rules to consider, and staff could not collect money from the visitors and buy things themselves. Furthermore, procurement rules did not make it possible to buy just one bottle of wine; instead, they had to buy wine bottles in larger cases and therefore it became too expensive: “As these procurement rules exist, for example, we are not allowed to rattle money and go to the liquor store and buy” (participant 2).

Discussion

In this paper, we explore staff’s experiences promoting active and healthy aging at social day centers for older people. Central to the results of this paper are the actions of the staff and conditions that affect activities at day centers.

In the report on Active Aging by WHO, new ways of providing support are emphasized to meet demographic challenges (World Health Organization [WHO], 2002). Recently, day centers have been thought of as in need of reform to appeal to a new generation of older people, and studies have been conducted to investigate how to reform day centers to meet the wishes and needs of today’s older people (Brunt, Strommen, & Stangl, 2020; Fitzpatrick & McCabe, 2008; Weil, 2014). The results of this paper add a dimension regarding how extrinsic factors, as perceived by staff working at day centers, may impact the organization of day centers for older people. When organizing or re-organizing social day centers for older people, it is not sufficient just to change the activities offered. A wider perspective must be considered such as ensuring the physical environment is suitable for a social day center, securing the financial conditions from the municipality (i.e., number of staff), and revising the principle of cost price in relation to procurement rules.

Active and healthy aging involves optimizing opportunities for health, participation, and security to enhance quality of life and well-being as people age (World Health Organization [WHO], 2015). The results of this paper indicate that staff at day centers might be important actors in providing opportunities for older people to maintain health and participation in meaningful activities and to enhance quality of life. According to our results, staff at day centers create opportunities for older visitors to participate in social interaction with others and to experience feelings of being needed by others. Feelings of being needed by others and interacting with others are important aspects of active and healthy aging (World Health Organization [WHO], 2015).

The physical environment at day centers has previously been described as being in need of reforms and adaptations to serve a new generation of older people (Brunt et al., 2020). Furthermore, the physical environment may have accessibility barriers for those with disabilities (Ellen et al., 2017). Staff who participated in the current study stated that the physical environment is not always well-suited for activities that the visitors at the day centers wanted. Thus, the physical environment could be a barrier that staff has to tackle to provide the visitors with activities they wish to participate in at the day center. Often staff have to compromise and do the best with what they have. On the other hand, the result of the present paper shows that special assets at day centers made it possible to offer activities that appealed to many older people who were mobile and managed to travel to day centers located at another part of the city. These facilities often provided the opportunity to conduct physical activities. If day centers are located at community-buildings, it might increase opportunities for older people to attend a day center (Laird et al., 2017). Reforming day centers for older people could include using existing facilities in a municipality such as libraries, cafes, or gymnasiums to organize seminars, social activities, or water gymnastics. Attention should also be paid to the outdoor environment and the homeliness and atmosphere, areas that have been more discussed in relation to care homes (Fleming, Kydd, & Stewart, 2017).

Previously, it has been argued that older people want physical activities such as dancing, golfing, aquatic exercise, technology, and science and wellness classes (Brunt et al., 2020). Staff who participated in the current study stressed that the activity itself was not the most important thing; the most important part of the day centers is providing opportunities for older people to meet and socialize. Brunt et al. (2020) had an inclusion criterion in their study of people between 55 and 70 years of age. Older people are not a homogenous group (Österholm & Larsson Ranada, 2020), younger older people today are concerned with aging well, developing or maintaining a healthy lifestyle, and life-long learning (Brunt et al., 2020; Fitzpatrick & McCabe, 2008; Malone Beach & Langeland, 2011). Most visitors at the day centers participating in the present study were described by the staff as very old and as living by themselves. As there is a lack of a standardized definition of day centers, this makes it difficult to compare results between studies (Fields et al., 2014; Orellana et al., 2020). Further scholarly attention is needed to understand potential different needs and wants of different groups of older people at social day centers.

Financial limitations of day centers constrain what is done at day centers for older people (Fitzpatrick & McCabe, 2008), a finding in present results as well. Furthermore, it is stressed in the results that the principle of cost price and procurement rules have an impact on how and whether an activity is conducted. The findings also suggest that staff working at day centers for older people have limited discretion in their work due to different guidelines and regulations governed by politicians and administrators. Consequently, staff use their creativity to find ways to circumvent guidelines and regulations to meet the visitors’ wishes for different activities. When it is not possible to circumvent guidelines and regulations, staff make the best with what they have. For example, the findings of this paper suggest that it is out of the staff’s hands to decide which facilities are at their disposal and therefore they cannot offer some activities that the visitors request. Further studies with other stakeholders such as politicians and administrators for day centers for older people are needed to gain more knowledge of their perspectives about guidelines and regulations governing day centers for older people.

Limitations

There are some limitations with the present study. When using a convenience sample, as in this study, there is a risk that the participants may provide a skewed view of the studied phenomenon (Crosby et al., 2006), and there may be differences between how day centers for older people are organized and experienced in other municipalities. The participants in this study have the same employer and work under the same financial circumstances, but each day center is different with different possibilities for organizing their daily programs in accordance with the visitors wishes and preferences for activities. That is, the collected data are heterogeneous as they reflect different experiences and the day centers are located in different urban districts within the municipality with different socioeconomic conditions and cultural backgrounds, which also contribute to a variety of experiences.

The interviews conducted for this study were rather short. Nevertheless, the amount of extracted text in the analysis that was relevant in relation to the study’s aim is rather high, as 70% (according to NVivo®) of the total material was used in the analysis; therefore, it is reasonable to assume that questions asked were appropriate in relation to the study’s aim.

Disclosure statement

Ethical approval for this study was obtained through the Regional Ethical Review Board (Dnr 2018/188-31) Linköping university Sweden.

Additional information

Funding

This research was founded by Linköping university, unit of occupational therapy.