Background
The number of older adults living with disabilities is increasing worldwide. Current predictions indicate that by 2050, one in six people in the world will be over 65 years old [
1]. The fastest increase is projected for the oldest old (85 years and over) [
2]. In mid-2016, there were 1.6 million people aged 85 years and over (2% of the UK population), by mid-2041 this is projected to double to 3.2 million (4% of the population) [
3]. Thus, maintaining physical and cognitive function, daily living independence, and quality of life in older adults are public health priorities [
4] with evidence suggesting a protective and beneficial effect of physical activity (PA) on different physical and mental health outcomes [
5]. However, a consistent decline in PA participation has been noted with increasing age, with older adults consistently being reported as the least physically active age group [
6]. Data from the Active Lives Adult Survey in England from November 2015 to November 2019 classified 29% of older adults aged 65–74 and 47% of people aged 75 + as inactive (less than 30 min a week of moderate PA) [
7]. In addition, the oldest old are 50% less likely than those in their 50 s to engage in exercise or to want to increase their activity levels [
8].Given that physical inactivity is recognised as one of the main risk factors for non-communicable diseases [
9] and mortality [
10], interventions which focus on promoting PA in older adults that can support healthy ageing and slow progression of diseases and disability are a global priority [
7].
Dance is a mind–body activity characterised by rhythmic movements to music and can be performed according to different types of dancing [
11]. Previous evidence showed that dance was a motivator for older adults to engage in PA due to the potential to overcome some of the most common barriers to PA participation. Dance can be adjusted to the target population’s age, physical condition, and ability [
12,
13]. In addition, it can be performed in different settings without high-cost equipment and the variation in dance styles makes it a popular form of activity across different backgrounds and cultures [
14]. Finally, dancing allows older adults to maintain a connection with previous experiences of dance when they were younger, encouraging enjoyment and a sense of community [
15]. Previous evidence from both quantitative and qualitative studies highlighted the importance of the aesthetic forms of artistic expression included in dancing. These forms of expression contributed to older adults’ physical, intellectual, and social development [
16]. Previous studies mainly focused on types of dancing with didactic and pre-determined movements [
11]. However, it has been observed that the option to be creative (lack of pre-determined performance standards) in dance sessions was positively associated with enjoyment and ability to control and coordinate bodies over time [
17]. It is also important to consider a flexible approach to dance with the possibility to integrate core components of physical health behaviours such as aerobic activity, strength training, balance and coordination [
18]. Therefore, a more creative dance approach based on the fundamental PA components can emphasize the process of being physically active, support interaction within the class and enjoyment in older adults.
Overall, studies on the effectiveness of dance interventions in older adults have demonstrated a wide range of health benefits. Contemporary dance showed potential effects to modify physical and psychosocial risk factors of falling in older adults [
12]. A previous cluster randomised controlled trial suggested that a social dance programme including structured exercises for training specific aspects such as balance can be beneficial for fall prevention strategies [
19]. Thus, future interventions should also include structured exercises based on PA guidelines for older adults. A previous dance programme involving older adults, reported improvements in physical, mental, and social wellbeing with increased interest in dance and confidence to engage in creative movements through dance [
18]. However, a study on intergenerational dance showed improvements in older adults’ wellbeing over time, but the results were not statistically significant [
20]. This was potentially due to methodological challenges such as difficulties in recruiting sufficient numbers of both experimental and control groups [
20]. A recent systematic review showed that dance improved physical function, mobility, and endurance in healthy older adults [
21]. While research shows the social benefits of taking part in group dance interventions with improvements in older adults’ wellbeing attributed to the interaction with others and the possibility to reconnect with youth [
22,
23], the long-term effect of dance on quality of life in older adults is less well established.
Thus, published work shows the positive effect of dance on PA engagement and different health outcomes in older adults. However, most studies have relatively small sample sizes and engage people from a narrow socioeconomic status range [
24]. Additionally, few studies explored the long-term benefits of dance interventions on PA and wellbeing [
24]. Therefore, the aims of this study were to assess the impact of engaging in regular dance sessions on physical (PA levels) as well as wellbeing (perceived health) in a large sample of older adults from socially economically diverse communities. Firstly, our research questions related to the acceptability and effectiveness of a creative dance intervention (using a range of genres of dance) to increase PA levels and wellbeing in adults and older adults. Lastly, we explored these outcomes across different age groups. The intervention acceptability and feasibility were addressed by documenting adherence rates, and the efficacy of the programme by evaluating changes in PA and self-rated health. Furthermore, we used focus groups to document participants’ views of the dance intervention and how it had affected them. Based on previous evidence, we hypothesised that the dance intervention could be an acceptable and suitable approach to increase PA levels and wellbeing in community-dwelling older adults.
Discussion
The aim of this study was to assess the impact of engaging in regular dance sessions on PA levels and well-being in a large sample of older adults from socially economically diverse communities in Yorkshire and understand participants’ views of the dance intervention. We have shown that adult and older adults participation in a community-based dance programme once a week was high with an adherence rate > 70% across 12 months, leading to significant increases in PA levels maintained over time during the intervention and in perceived health state. The increase in PA contributed to a greater number of older adults classified as active at 12 months compared to baseline (Table
2). Out of 680 participants, a total of 67 participants (60 females, 7 males) had complete PA data for the 12 months intervention with the majority of them belonging to the “Older Adult” group (
n = 43), followed by “Oldest Old” and “Adult” groups (
n = 10 and
n = 7, respectively). However, a significant increase in PA and perceived health state across time points was observed.
The main finding was that over 12 months, participants reported a significant increase in total minutes of PA and a greater number of individuals were classified as being active compared to baseline. Specifically, when age groups (Adult, Older adult, Oldest old) were considered, “Older adult” displayed a statistically significant increase in minutes of PA from baseline at 6 months while the “Oldest old” showed a significant increase in PA at 12 months. Evidence from a previous review and meta-analysis revealed that undertaking dance of any genre was equivalent to and occasionally more effective than other types of structured exercise for improving health outcome measures [
11]. Our findings agree with previous evidence highlighting dance as a suitable form of PA for older adults with high adherence rate (84%) and increase in moderate and vigorous physical activity patterns [
12]. Similarly, the adherence rate was high and consistent across the 12 months of intervention in our study (70%). In addition, qualitative data indicated that participants regarded the dance intervention favourably, noting both physical and psychological benefits such as increased mobility and flexibility as well as improvements in mood and wellbeing. Previous qualitative studies identified improved social interactions, enjoyment, increased confidence and improvements in movements and mobility as mediating factors to the impact of dancing on physical and subjective health [
36]. In these studies, older people reported how the dance programme made them feel better, giving them a sense of wellbeing [
36].Overall, in line with previous research, our qualitative data showed that participants reported facilitators to participation being the possibility to adaptability of the programme, variety of music, quality of instruction and the group nature of the programme. Thus, future studies should consider the peculiarities and characteristics highlighted by the participants into the design of dance interventions to possibly increase adherence and participation.
In this study, we were able to recruit people aged above 85 years (
n = 104). In general, systematic reviews and studies focusing on older people aged 85 + years are scarce [
37]. The ‘Oldest old’ group showed a significant increase in the amount of PA at the end of the 12 months programme suggesting dance is an appropriate form of PA also for ‘oldest old’ people. This could be explained by the fact that dancing may be less threatening to many older adults than other exercise modes [
38]. Indeed, previous evidence demonstrated the efficacy of dance intervention in reducing fear of falling and falls [
12,
18] and another study on dance involving older adults 75 + reported enjoyment and improvements in balance, walking, and strength [
39]. Additionally, dance could allow older adults to maintain a connection with past experiences [
40] promoting health and mobility. Therefore, our dance programme appears to be an appropriate form of intervention to promote and encourage a sustainable approach to being physically active in the oldest old.
Across the different time points, each age group had a significant increase in the time spent in fitness activities (sport, gym, classes and dance, not including walking) that was maintained throughout the programme. However, when considering participants (“Older adult” and “Oldest old” group) with observations carried forward, a significant increase in walking was observed, which was maintained at the end of the programme (12 months, + 114 min/week of walking for “Older adult” and + 223 min/week of walking for “Oldest old”). Similar findings have been reported previously [
19] noticing an increase in incidental PA in older adults enrolled on dancing programmes. Different organisations, including the UK CMO, have recommended guidelines for PA for older people suggesting at least 150 min of moderate-to-vigorous PA intensity per week. In our study, participants attended once-a-week dancing classes, with the possibility of CMO guidelines exceeding the duration of the time spent dancing as PA. However, we observed an increase in prevalence of participants classified as active from 25% at baseline to 55% at 12 months. Taken together, one of the reasons could be that participation in the programme could directly (dance sessions) and indirectly (walking) support older adults becoming physically more active and to reach the PA CMO recommendations [
28]. However, these results should be interpreted with caution. Firstly, the possibility of different results should be considered if the whole sample was retained until the end of the intervention. Secondly, PA was measured with a self-reported questionnaire not previously used in older adults aged 85 + years. In addition, self-reported measures of PA could be influenced by recall and social desirability bias [
41]. Therefore, future studies should consider the use of objective measures for PA (body-worn accelerometers) and of a validated PA questionnaire such as the Newcastle 85 + Physical Activity Questionnaire [
42].
In this study, 54% of the participants who attended “Dance On” classes were from areas with a high index of deprivation (1
st and 2
nd IMD quintile). This finding showed that our dance intervention largely attracted participants from deprived areas. Indeed, this programme was with minimal costs to participants, arranged in a safe, indoor environment. In addition, dance classes did not require high expense or equipment. Previous evidence supports the idea that SES may have a significant influence on leisure PA participation [
43]. The physical environment can influence PA participation with seasonality, safety, and proximity and accessibility of recreational facilities and services [
44] with inequitable distributions accounting for lower engagement in PA. The social environment refers to the kind of social networks and support available and systematic review showed that high levels of social support and having companions with whom to participate in PA were the factors most consistently associated with high levels of PA [
45]. A previous study showed that dance classes are safe, cost-effective and have a good value for money investment benefiting national health services through a reduction in the share of people `at risk’ of falls and associated utilisation of services [
46]. With our dance programme, we have been able to promote leisure PA participation among a wide range of older adults.
We found a statistically significant increase in self-rated health in our sample at 3-month, 6-month, 12-month follow-up compared to baseline. This finding highlights the impact of our dance intervention on perceived self-rated health with an initial increase that was maintained throughout the programme. In addition, self-rated health state at follow-ups had a significantly higher score than baseline in the adult group. However, no significant changes were found for older adult and oldest old group. Previous evidence reported dance as highly enjoyable for older adults [
47], with important wellbeing benefits due to the social aspects of recreational and creative dance [
17]. Thus, our work further supports the idea that dance could enhance perceived health state. This finding is additionally supported by qualitative data suggesting the role of the dance programme in providing psychological benefits and creating a sense of connectedness and belonging to a group feeling, with positive impacts on mood and mental wellbeing. A previous systematic review reported a positive effect of dance on the older adults’ sense of belonging [
48] with improvements in depression, loneliness, and negative emotions in older people [
47]. In addition, previous evidence demonstrated that variety of music, reported as facilitator in our programme, satisfies older adults psychological needs [
49], and that group dance has the capacity to preserve psychological well-being in aging as well as counteracting loneliness and social isolation [
24,
50].
Strength and limitations
Interpretations of study findings were based on both the participants who completed (completers) the programme and participants with observation carried forward (non-completers). While the direction of the effects was the same across our findings, due to the small sample size, the completers’ group data had reduced statistical power. Data collection was impacted by the pandemic, and classes and data collection ceasing through the remainder of 2020. This is supported by the fact that most of the participants were recruited during winter 2019 (38%) leading to a loss of follow-up data at 6 and 12 months. However, analyses showed that the population characteristics of those who remained in the programme for 12 months were not significantly different to those who were not able to complete the intervention. Further work should consider objective evaluation methods and employing a treatment-as-usual control group. Indeed, the use of questionnaires may be subject to a bias with participants reporting better health status being more likely to answer questions, but also a recall bias and inaccuracy in older adults, with changes in cognitive and communicative functioning affecting question answering [
51]. The dance intervention was initially designed for women. However, to ensure inclusivity, we also invited men to participate. The majority of our participants were females, and the benefits of our dance intervention may only be true for this group. There is an increasing need for health promotion strategies that effectively target men, that specifically focus on masculine ideals of physical activity, and it is possible that this is not well suited to dance, thus further work is required to make this intervention attractive to both genders. In addition, only 58% of participants at baseline were classed as inactive with the remaining all classified as either active or fairly active [
28], suggesting the possible presence of a self-selection bias and this can confound data generalisation and interpretation. It is often the case that older adults who are inclined to participate in an exercise study are at least partially fitter and with higher volumes of PA than ones who are not inclined to participate [
52]. It could also be that participants chose to take part in the “Dance On” programme, as they have a high affinity to dancing, and while we ascertained baseline PA, we did not ask about prior engagement in dancing. Therefore, future studies should consider the possibility to collect information on PA background.
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