 associated with community ambulation of older adults and those with stroke and osteoarthritis. I'd like to introduce our speaker, Dr. Ruth Barkley. She's an associate professor in the Department of Physical Therapy, College of Rehab Sciences at the Raddy Faculty of Health Sciences at the University of Manitoba. A main focus of her research is community ambulation of older adults and people with stroke. She is currently co-principal investigator of a CIHR-funded multisites randomized control trial evaluating two interventions to improve outdoor walking for older adults. So with that, I will pass the ball on to Dr. Barkley. Thank you very much. First, I would like to acknowledge my co-investigators, Sandra Weber and Jackie Ricott and Robert Tate. So, first, I wanted to talk about why walking in the community is important. And so I wanted to show you a few slides of pictures that were taken by participants in a study that we conducted a few years ago with photo voice, where people with stroke took pictures and described what participation in the community meant to them. So as an intro, I'll show you three of the pictures that focused on walking in the community and then why we wanted to focus on community ambulation in future studies. So the first one here, this gentleman took a picture from inside of his apartment looking out into the community. And he said, walking around the living room isn't gonna cut it. The pictures of the outside, that is the world I have to get back into. So he was stressing his wish to be able to walk outside in the community. Another person in the study took this photo of this long straight sidewalk, which is, you know, Winnipeg sidewalks, isn't all that common. Usually they're cracked and broken, but he said walking is difficult. And I was trying to use this to represent the problems. So he was really focusing on the challenge of being able to walk that distance. He said that looks like a really long sidewalk. It's really difficult to walk that distance. So he was really addressing the issue of endurance and being able to walk far enough for a particular walking task. This other picture was taken by a person in the study who said nature picture represents our walks around the block, nature is everywhere, even a walk down a side street. And we have found, looking at the literature, that there is literature regarding walking outdoors and in nature that has suggested positive benefits for both mental and physical health with outdoor walking. So when we're looking at community ambulation, what we're referring to is walking outside of the home in the community. So that could include walking both indoors and outdoors as long as it's outside of an individual's home. So for example, walking at a friend's house, walking outdoors in a park, walking in a shopping mall. And the purpose for walking could vary greatly from person to person. It could be for exercise, for transportation, to walk to a place or to get to the bus. It could be walking for errands or to a social activity or for the purpose of social activity. So for the purpose of today's presentation, I may use the term community ambulation or walking outside or walking outdoors anonymously. In this particular presentation, we are talking about community ambulation that is specifically outside of the house outdoors. So other literature has shown that in older adults, limited community ambulation has been associated with mobility decline and self-care decline. Also with decreased health-related quality of life, with social isolation, sorry, social isolation. And it is considered a markers royalty. People who are ambulating in the community, that's found to be associated with a lower risk of mortality and higher self-reasoned health. And this concept of self-reasoned health, you will see coming up in this presentation as we go along. The objective of this study is to identify factors associated with community ambulation in Canadian adults, aged 45 to 85, those with stroke and those with osteoarthritis. We use the Canadian longitudinal study on aging. We use the baseline tracking data set, version 3.2. We use data from the tracking main wave and from the maintaining contact questionnaire. So we were looking at over 18,000 to almost 19,000 people. So just a few definitions because we did look specifically at people with stroke and people with osteoarthritis. So if people answered yes to any of the following questions, we included them as our definition of someone who had had a stroke. So there are questions that is, has your doctor ever told you that you've experienced a stroke or a CBA? Has the doctor ever told you you've experienced a mini-stroke or TIA? Or if you suffer from the effects of the stroke, CBA, mini-stroke or TIA? So a person answered yes to any of those questions. They were defined in our stroke group. And then for people with osteoarthritis, because we were focusing on community ambulation, we focused on osteoarthritis in a lower extremity. So people answered yes to, has the doctor ever told you that you have osteoarthritis in the knee or osteoarthritis in the hip? Then they were included in our definition of people with osteoarthritis. The outcome that we were looking at again was community ambulation. And there's a question in the CLSA, which is over the last seven days, how often did you take a walk outside your home or yard for any reason? For example, for pleasure or exercise, walking to work, walking the dog, et cetera. And the responses of that is four of them and they're never seldom, sometimes or often. So we decodimized this outcome to sometimes or often or never or seldom. The explanatory variables that we used in the study were chosen based on the published literature. So we included the following self-rated health, a depression, number of chronic conditions, the ability to walk independently without health, being able to walk two to three blocks really reflecting endurance, the ability to stand up from a chair, pain, number of falls in the previous year, the month of the interview, which we felt reflected the weather, also age and sex. Control variables, we were looking at province, income, education, neural status, and whether the person was in an urban or rural setting. For our models, what we did was for all models, we used univariate binary and logistic regression with community ambulation as the outcome and each explanatory variable individually. All variables were statistically smoothened. So all variables were added to the multivariable binary logistic regression models. So for older adults, for people with stroke and people with osteoarthritis, we did models of all ages. We did a model for male, model for females. And then for the older adult group, we also did models for the various age categories that you see there on the slide. For weighting, if we did weighted frequencies, we used trimmed weights and for the modeling, we used analytic weights. So looking at some of the characteristics of the all ages group, so the ages 45 to 85, the mean age was 60.5. And just picked out a few things just to give you an idea of this group. People that describe themselves as walking outside the home never seldom in the past week, that was 34%. 51% were female, 3% had two or more falls in the last 12 months. We chose to look at two or more falls because people are at a higher risk for future falls. And we looked at number of chronic conditions. So the number of people who had seven or more chronic conditions was at 18%. So look at this slide. These are the variables or factors that were associated with being less likely to walk outside sometimes or often versus never seldom. So if self-rated health was lower relative to being excellent, so poor, very good or very good, people were less likely to walk outside sometimes or often. If people were unable to or had difficulty walking two to three blocks, they were also less likely to walk outside. And I just wanna point out that, again, the walking two to three blocks represents insurance. Unable doesn't mean that a person can't walk at all. It does refer to the inability to walk the distance of two to three blocks. That's too far to walk. The also being female, you're less likely to walk outside. And then if a person had severe pain or moderate pain versus being pain-free, less likely to walk outside as well. So looking at the factors related to being more likely to walk outside, certainly we found in general, the younger age categories, people were more likely to walk outside than people in the older age category. And then in months that tend to be better weather, people appear to be more likely to walk relative to January. When we looked at the age categories separately, sorry, when we looked at not age at gender, sex, females versus males, in females, they were less likely to walk if they had decreased self-rated health related to excellence, if they had severe or moderate pain, and then if they had difficulty or were unable to walk two to three blocks. More likely to walk outside in the younger age categories and in months with a better weather. Males were less likely to walk outside very similar to the females. And for the reasons of more likely to walk outside, 65 to 74 year age group, people were more likely to walk outside than the older age group, also the weather, but then an addition of chronic conditions. So males that had a lower number of chronic conditions relative to seven or more, were more likely to walk outside. We also further looked at age categories, and you can see there are a number of similarities across the age categories. Some things that are common, also some differences. When we look across, we see self-rated health is relatively common, except for one category, and that endurance or being able to walk that distance of two to three blocks is common across the age group, as well as the issue of pain. People with severe or moderate pain are being less likely to walk outdoors in the three lower age categories. In the, so some interesting things to note, in the 65 to 74 year age group, people were more likely to walk outside. Again, if they had this decreased number of chronic conditions relative to having seven or more. In the age 75 to 85 category, difficulty or inability to stand up independently was associated with being less likely to walk outdoors, and that being able to stand up independently is a reflection of leg strength. So you could possibly interpret that as having decreased leg strength. People would be less likely to walk outside. For the age group 45 to 54, being sometimes depressed versus being rarely depressed was also associated with being less likely to walk outdoors. And we see that females were less likely to walk outdoors in the two older age categories. When we look at new to the model of people with stroke and look at some of the characteristics there, we had a smaller number of people, of course, that we were looking at. So there was 866 people in this model, and the new age was a bit older at 68.3. And so here I've got some of the same characteristics describing the population. And in brackets in red, you can see that comparison to the whole group of the age 45 to 85. So 41% of people describe themselves as walking outside the home never saw them in the past week. 45% were female, 8% describes two or more falls in the last 12 months, and 43% of people had seven or more chronic conditions. And we counted those not including the definition of stroke that we used. So for people with stroke, we found that people were less likely to walk outside. Sometimes they're often versus never saw them if they were unable or had difficulty walking two to three walks. So that we see it consistent with the other model that we've looked at. And then people were more likely to walk outside sometimes or often if they were in the 55 to 64 year age group versus the older age group. And then having mild pain versus pain-free. So we're gonna talk a bit about why this might be. And then also looking at the months of selecting the weather. So you can see the sort of better weather months that people would be more likely to walk outside. When we looked at people with stroke and looking at males and females separately, we see similarities in less likely to walk outdoors when we begin that endurance or ability to walk two to three blocks. For men, we also see that being sometimes depressed versus rarely depressed, men were less likely to walk outdoors. And then when you look at reasons for being, for factors associated with being more likely to walk outside, again, we see that 55 to 64 year age group in women more likely to walk outdoors than the oldest group. Also the better weather months. But those we don't see in the male group. And then we see the more likely to walk with pain in both age groups, which again, we didn't really expect to see. When we look at people with osteoarthritis, we have a larger group than stroke. So we had just over, well, over 3,800 people, almost 3,900. And the mean age was 64.5, so similar to the overall age group for more females. Walking outside, 38% described walking outdoors so them were never in the last week. 60% were female. 5% of people described two or more falls in the last 12 months. And 30% of people described having seven or more chronic health conditions, not including osteoarthritis. So when we look at some of the reasons for being less likely to walk outdoors, we see, again, some similarities with the old model of all age groups. We see self-rated health again, which we didn't see with the stroke group. So poor self-rated health versus excellent or good self-rated health, people were less likely to walk outside, sometimes they're often. Also, again, we see there's endurance, walking two to three blocks. We see pain limiting, perhaps, outdoor walking and then females less likely to walk outside sometimes. And then looking at some of the reasons for being more likely to walk outdoors, again, we see younger age groups. Here again, we see number of chronic conditions. So a lower number versus a higher number of people being more likely to walk outdoors than again the, in general, better weather months. For the osteoarthritis group, we also looked at females and males separately. And with females, they were less likely to walk outside and more likely to walk outside for reasons similar to the whole group of people with osteoarthritis. And for males, interestingly, quite different. The only variables that are factors that were associated with the outdoor walking which meandulation was a decreased number of chronic conditions would be more likely to walk outside. So I'll just show you a summary across all the different groups for the full models of people of all ages and both sexes. So we have the older adult, the osteoarthritis and the stroke groups. And you can see that self-rated health is associated with being less likely to walk outside for both the older adults and people with osteoarthritis. The walking to the street blocks or endurance consistent across all groups or sex, females were less likely to walk outdoors in the older adults and osteoarthritis groups. It didn't come up in the stroke group. And then pain for the older adults and osteoarthritis groups came up as being related to less likely to walk outside. Or again, looking at more likely to walk outside, we see some similarity across groups related to a younger age group, relative to the oldest age group. And then some differences among us but all better weather months, we see in strokes July and August aren't there. We have had people told us that sometimes it's too hot to walk in those months. So whether that's a factor or not possible, but generally walking outdoors is more likely associated with better weather months. And then again, what we hadn't expected was seeing mild pain being associated with more likely to walk outside and people with stroke and number of chronic conditions came up in the osteoarthritis group. So a lower number of chronic conditions relative to a higher number were more likely to walk outdoors away. So looking at overall some of the limitations in the study, we don't know the type and location of pain. So that was one thing that we'd like to know more about. We didn't use the physical test data because we were using the tracking data. And also it's not a causing model. You could say that factors are associated but not that one causes another. What we did find interesting was that in none of the models did we find number of falls in the last year being associated with the frequency of walking outdoors, which we had expected that we might see. As you saw, there was certainly differences between the models of male and female in the different models and also among the ages as well in each category. So for example, women were less likely to walk outside in the 65 to 74, 75 to 85 near each room. Looking at some again, thinking about the factors associated with being less likely to walk outdoors. Again, that limited walking endurance seems to be common across all models. It came up in all models except for males with OA. That was the only exception. So certainly that endurance or difficulties or inability to walk two to three blocks would limit people in walk-up fighters associated with less likely to walk outdoors. Also be less likely to walk outdoors is associated with mild severe pain in the all age group and its males with osteoarthritis. Lower self-rated health, we saw in the osteoarthritis model and the all ages model, but when we looked separately at sexes, we saw it only in the females with osteoarthritis model. So that was common across the groups except for a stroke that didn't appear in people's stroke. Being female, this associated with being less likely to walk outside again in the all age model and people with OA. And then we saw in some models being depressed sometimes versus being rarely depressed, maybe less likely to walk outside. And we saw that in males with stroke and in adults in a younger age group. So then summarizing then looking at factors being associated with being more likely to walk outside. Again, the younger age groups we saw in all of the school models, we saw that again, the mild to moderate pain in people with stroke being associated with being more likely to walk outside, which seems sort of backwards or opposite to what we might have expected. So we've been thinking about this a bit and we know that we don't know the location or cause of pain. We know that sometimes people with stroke may have hemoplegic shoulder pain, which probably in most cases would not be likely to cause decreased walking. And then also a question of were people purposefully walking for exercise? Because we know that a number of people with stroke do walk for exercise. So that doesn't really explain it, but it brings us a few more questions. So that's certainly something that we could further investigate in the future. We saw that it was common across all models except for males, the osteoarthritis and male to stroke that people associated to be more likely to walk outside in good weather months, which certainly makes sense. And the weather that we have in Canada from some other research that has been done across Canada and other countries. And then we saw that a lower number of chronic conditions associated with being more likely to walk outdoors in males, all ages in males with osteoarthritis and in the 65 to 74 year age group. So we're always trying to think of what potential clinical applications could be to our work as speaking therapists and occupational therapists. And certainly we know that pain and walking endurance are factors which are amenable to improvement if we have intervention. So we may assume or think that being able to decrease pain and improve walking endurance, people might then be more likely to walk outdoors for exercise or leisure activities and for transportation in the future. Colonically, we know that addressing walking endurance may assist people again in communal information for all groups. And the other thing that we wanna consider for future potential application is that safe locations and strategies for walking in poor weather months should be addressed. So if people aren't walking outdoors in poor weather months, are they not walking outdoors at all? Or are there other locations that people can walk if they choose to walk for exercise and leisure? Other places that people can walk other strategies to maintain mobility for a moment or time. Yeah, excuse me. Looking at next steps for future research, we are gonna be taking us a step further. We're going to be repeating some of the analysis that we have done using the comprehensive data sets and using some of the physical measures and related to strengthen walking and gate speed, et cetera. And we will also be testing existing models of community ambulation. So the one on the left is a model of community ambulation for people with stroke. We're going to be testing that model using the comprehensive data. And the model on the right is a model of community mobility for older adults. And we're also going to be testing that with the comprehensive data using structural inclusion logic. So that is our next step in our research. And I would like to acknowledge that this study was funded by the Endowment Fund of the College of Resilitation Sciences at the University of Manitoba. And I'd like to thank Scott Nolicky or data analyst as well. Thank you. Great, well, thank you for the excellent presentation. I know I learned a lot. And I'd like to open it up to any questions. Just a reminder that muting will remain on, but you can enter your questions into the chat box in the bottom right corner at the end of the WebEx window at any time. I don't think anyone's posted any questions yet, but so maybe I'll start off by one of my funny ads. I always, I tend to sort of drop questions down and as presentations go, they usually get answered, which is, I guess, a good sign that I'm asking the right questions and you're answering what people would want to know. But when it comes to, I think you outlined in your future work the two different models that you'll be looking at or using to guide your research as you use the CLSA's comprehensive data set. But do you have any hypotheses, maybe on a smaller scale, maybe if we just think of the depressed, the men with stroke who are, who self, the men with stroke who indicated they slightly, maybe depressed or the younger group who slightly indicated that depression is, there might be some signs of depression there. Any hypotheses there as to why that might be happening for those groups? Well, depression is fairly common after stroke. So it could be related to the stroke. We do know that from some of the other work that we've done, then with this model on the left, looking at community ambulation in people with stroke, we had developed a model with structural equation modeling based on data that we had available to us, so secondary data analysis. But then we also interviewed, did focus groups of people with stroke and asked them about barriers and facilitators and how they felt with walking and that sort of outdoors, that sort of thing. And they told us about how mood was very important and that walking may help to increase their mood. And if they had decreased mood, then they might be less likely to walk, but if they did walk it helped them feel better. So there's definitely a relationship. We know there's a relationship between depression and exercise. So that exercise may help to decrease depression. So certainly we see that relationship there in an earlier model that we did. So we are expecting that we will see that again with our using this other data. I think one of the first questions we have from a participant relates to that is why were the men with stroke and osteoarthritis less likely to walk outside regardless of nice weather? That's a good question. That touches on maybe the depression. Maybe that was there, or I'll let you. Oh, yeah. I mean, that was the other difference with men, too, that we saw. So I guess that is another question just for any research. But certainly with this, we had a lot of interesting answers. And then also a few other interesting questions that we think that pursue more in the future. But that is an interesting question. I unfortunately don't know the answer to that. Oh, you should know. Have all the answers. I guess that's the beauty of this sort of research. Okay, so another question we have is any consideration to socioeconomic status and the importance of socioeconomic status in health behavior theory? Or the SES differential? We did use income as a control variable. So we did control for that, but we have not investigated that specifically or further. So I think that would be a good aspect to study on specifically for a future project. And then we have another question. Why are women, I think you might have touched on, oh, maybe not. Why are women less likely than men to actually walk outside? And is this consistent with other studies? We did, when we did our literature review prior to doing the study, we did see some studies that suggested that women could be less likely to walk or walk outdoors for exercise. And so we certainly did see that in some of our results, although not for people's stroke though. So it seemed like our stroke group was quite different in a lot of ways, which is interesting. So it does fit with some other literature that we have seen. And next question is, what do you expect to get from the application of the structural equation modeling that is different from the regression analyses that you already did? I think with the structural equation modeling, we had done that with a group of people with stroke. So we also want to identify if that model can be verified with people with bluster arthritis as well and with older adults in general. Most of the variables are available to us that we should be able to replicate the model. So we're hoping, we're gonna see if there's any differences to the original model. And that's the main thing is to really try to also expand on the model in a way, because again, I'd mentioned we did structural equation modeling and then also spoke to people who had experience with stroke and walking outdoors. And so some of the additions to the model to see it on the screen, anything with the dodge lines are things that we added from what people told us. So some of these things that people told us, we do have some variables for that in the CLSA data and we can also add that into the model. So hopefully the model will be expanded and show us some additional information. So it may be a bit different than our regression models, although it should match, but then in addition, I think it will give us some more information about how things relate together. So I don't think the variables that are associated with community ambulation aren't gonna be different, but we will see how they fit together in the SEM model. It's always good to use multiple methods and analyses, which I'll ask another question that I had noted as well. Yeah, obviously there's lots of information you can get from the CLSA data and you're involved in this area of research, but do you have any other plans outside of using the CLSA data to complement this work and doing any more qualitative type research and finding out a little bit more about the reasons maybe why self-rated health is a factor. There's a few other things that you mentioned that I thought could be explored with a complementary qualitative type study. Well, right now, as you've mentioned at the beginning, we're doing a study called Go Out, which is focusing on outdoor walking for older adults. And we are looking at intervention specifically, focusing on what barriers that some older adults may have to walking outdoors based on a mobility framework by Shumway Cook and Patla. And with that study, we also have, so we'll have all the data from our follow-up evaluations after our walking intervention, but we also are incorporating a qualitative component as well. So we will, among our qualitative questions are things like barriers and facilitators and whether the program is beneficial or not, so a wide range of questions. We're gonna have a lot more information about walking outdoors from that study. So partly from the quantitative, partly from the qualitative. We're also looking at trying to look at some weather issues specifically. So we're just starting to do, rather we're just finishing analysis on a study looking at participation in activity and people with stroke in different seasons. So people were interviewed in the summer and in the winter talking about barriers and facilitators to participation in activity based on weather conditions. And so we're just finishing analyzing that right now. And we've just put together a team to look at winter walking and issues regarding outdoor winter walking and safety and risk of falls, et cetera, for older adults. And so our team will be meeting soon and discussing what our research priorities will be moving forward. So actually the last question that was posted relates to weather. How are you accounting for climate change affecting the research? If at all. Yeah, well if at all we haven't to date, but that's a really good question because as I was going through this, I was thinking about that because certainly we are seeing changes in weather and that's something that we need to start considering. And certainly in our outdoor walking study during the intervention, we have held it in city parks, outdoors in summer months. And sometimes we have to counsel because of rain or what have you, but we've also had to counsel because of poor weather quality conditions or because there was forest fires in an area nearby and it was too smoky to be safely walking outdoors. So we are seeing that the weather changes are affecting our ability to do the research and that certainly will be affecting our outcomes and ability to walk outdoors. So something we need to be focusing on in the future for sure. And I'm just gonna ask one last question since we have some time and then perhaps we'll wrap it up after that if we don't get any more. That also speaks to, when I was hearing some of your results, I thought this would be very important information for municipal, local decision makers to have too in terms of the importance of walking facilities for older adults. And so have you, do you have any plans to, and I'm also by background knowledge translation researchers. So like I'm just curious, have you thought of communicating some of those results to local decision makers to feed into their processes for developing indoor walking tracks or developing partnerships in that respect? That's certainly part of our plan with our go out study. My co-PI is now to sell back at University of Toronto and so a big focus of that project is on knowledge translation and being able to, of course depending on our results incorporate the intervention into the community. So that will be a big part of it and working with different community groups. So it could be at a civic level for example and with our outdoor walking team that we're developing, we do have some members on the team who are community members and who will be associated with publicly municipal representatives as well with the results of our research. So I'll just turn it back to you finally and just say, was there anything else you wanted to address to the group before I do our closing remarks and we ask participants to complete their exit survey? I don't think anything specifically I'd want to add but just I guess to consider in your research or clinical practice the importance of outdoor walking and community ambulation for your current group. Well thank you again for a great presentation. We appreciate your participation in the CLSA webinar series. I'd like to remind everyone that the CLSA has data access request applications and that are ongoing. The next deadline for applications is February 12th of 2020. If you want more information please visit the CLSA website under the data access to review what data is available and the other further information and details about the application process. I'd also like to remind everyone to complete their survey that's located under the polling option. If you don't see it besides the chat button please click the drop down arrow and I think it was just, it did just pop, should have just popped up. And for our first webinar of 2020 it will take place on January 29th at noon. Dr. Sarah Hugo who's an assistant professor in the Department of Applied Human Sciences at the University of Prince Edward Island will present her presentation entitled The Early Retiree Divests the Workforce A Quantitative Analysis of Early Retirement Among Health Professionals Using CLSA Data and you can register for that starting now, I believe it's open. And finally graduate students and post-doctoral fellows with an interest in longitudinal studies on aging are encouraged to save the date for our summer program in aging which is called SPAW for short. This innovative five day training program will take place next June at the Hawkely Valley Resort in southwestern Ontario. More details will be available in January 2020 when the program launches on CIHR's research net. And also remember the CLSA Promotes this webinar series using the hashtag CLSA webinar. We invite you all to follow us on Twitter at CLSA underscore ELCV. And I think those are all the key points so thank you again to everyone for attending today's presentation and to our speakers and we'll see you in January.