older people 's participation in leisure activities , such as involvement in cultural , social , and physical activities , is known to be positively associated with health and survival .
it is therefore important to improve the understanding of the risk factors that might cause a decline in such participation .
accordingly , this study aims to investigate the impact that health - related risk factors , such as medical conditions , mobility difficulties , and activity limitations , may have on older people 's engagement in leisure activities .
european countries are currently facing major demographic changes due to substantial increases in longevity ( a large reduction in late life mortality ) and declines in fertility [ 2 , 3 ] . as a consequence ,
this fact has led to a growing interest in understanding how to meet the needs of an ageing population .
it is also a public health priority that includes , among other things , the identification of components that can promote factors to support active and healthy ageing [ 4 , 5 ] . in an aging population ,
the prevalence of health - related risk factors such as medical conditions , mobility related difficulties ( limits in functions ) , and activity limitations ( inability to perform activities ) increase with age .
the relation between the above - mentioned health - related risk factors and health is , however , complex and much discussed .
according to the world health organization , health is a state of complete physical , mental , and social well - being , and to reach this state we must be able to identify and realize aspirations in life , satisfy our needs , and be able to change or cope with the environment . therefore , the relationship between engaging in activities and becoming healthy is an important perspective of health   with a long history . on a general level ,
engagement in leisure activities has demonstrated positive health - related outcomes   and correlates explicitly with increased survival and life expectancies , lower mortality rates [ 1317 ] , and higher levels of happiness [ 18 , 19 ] .
engagement in leisure activities seems therefore to be an important health promoter in the case of older people .
engagement and participation in leisure activities are reported slowly decline over time in later life [ 20 , 21 ] , but how this decline can be promoted is less known .
participation in leisure activities is often studied from the aspect of performing activities as such , while some studies also highlight the importance of incorporating the purpose or motivational aspects for added understanding [ 22 , 23 ] .
being motivated is a crucial component for making the leisure activities meaningful , and therefore the motivation component is an important factor to take into account when conducting research on leisure engagement and its relation to health - related conditions .
earlier research has shown that functional decline could be an important indicator of ill - health in later life [ 24 , 25 ] . however , according to the world health organization , functional decline and limitations might not be the direct cause of the limited ability to perform activities , as the adaptation to the environment or by the person could reduce the negative effect of such decline .
, for example , did not find any associations between medical diseases and activities of daily living ( adl ) , whereas gill et al .   found change in physical performance as independently associated with adl dependency . while maintaining healthy habits is described as preventing the deterioration of functional capacity [ 28 , 29 ] , few studies focus on leisure engagement as a result or indicator of a person enjoying good health .
atchley   found that limitations in performance affected leisure patterns in older people , but if and how this is true also for mobility difficulties and other important health - related risk factors in later life needs further investigation . in this study , we therefore wanted to explore potential health - related risk factors related to leisure engagement decline by studying the impact of medical conditions , mobility difficulties , and activity limitations in relation to leisure engagement .
while studying this relation , it is important to consider the influence of personal characteristics upon these relationships .
for example , it is known that later life health problems seem to vary between genders , to be influenced by socioeconomic aspects , and to vary between countries or geographic regions .
therefore , these potential confounders must be considered as having a possible impact on this relation .
specifically , the research questions for this paper are the following.is there a relationship between medical conditions , mobility difficulties , activity limitations , and leisure engagement in older people?is the relationship influenced by sociodemographic aspects such as gender , age , economy , and geography ? is there a relationship between medical conditions , mobility difficulties , activity limitations , and leisure engagement in older people ?
is the relationship influenced by sociodemographic aspects such as gender , age , economy , and geography ?
the analyses are based on a cross regional survey carried out in 2010 as a part of an interregional eu - funded research project ( gerontological regional database and resource centre , gerda ) .
the overall aim of the multidisciplinary project was to map living and health conditions of older adults ( aged 65 , 70 , 75 , and 80 years ) in the bothnia region , that is , on both sides of the gulf of bothnia , in vsterbotten in sweden and in sterbotten / pohjanmaa in finland ( more information about the project is available at the project website ( http://web.novia.fi/gerda/ ) ) .
although the two regions sterbotten and pohjanmaa belong to the same geographical region , they can in fact be treated as two separate regions due to different linguistic conditions ( the ( technical ) division between sterbotten and pohjanmaa relates to a language stratification of citizens in this particular west - finnish region .
elderly swedish - speaking inhabitants were coded as belonging to sterbotten and those with finnish as their mother tongue were coded as belonging to pohjanmaa ) . in this paper , however , we do not separate these two areas from each other , since the linguistic characteristics of the finnish population are controlled for by the language variable . in 2010 ,
the swedish region vsterbotten consisted of 15 municipalities , including two more densely populated areas ( ume and skellefte ) , with an overall population of approximately 260,000 inhabitants .
the overall population in the west - finnish region sterbotten / pohjanmaa ( including the town of vaasa ) consisted of approximately 178,000 inhabitants .
although the above - mentioned regions share several common structural features , such as common cultural characteristics and common historical bonds , there are also noticeable differences between them , such as differing linguistic conditions .
finland is an officially bilingual state with a large finnish - speaking majority and a small swedish - speaking minority of approximately 6 percent .
however , in sterbotten / pohjanmaa , 51 percent of the population belong to the swedish - speaking group and form to some extent a majority at the local level . in 2010 ,
three out of 17 municipalities in sterbotten / pohjanmaa were officially monolingual ( finnish ) whereas swedish - speakers formed the local majority in nine municipalities .
a total sample of 10,696 was selected from the national tax board in sweden and the population register centre in finland .
questionnaires were sent to all people that in 2010 were 65 , 70 , 75 , and 80 years old in rural municipalities , to every second person in the most populous town in finland and to every third person residing in the two most populous towns in vsterbotten . in total , 6  838 persons ( 64% ) replied .
the response rate varied between the regions , with 70% responding in vsterbotten , 62% in sterbotten , and 53% in pohjanmaa .
the response rate was somewhat higher amongst the two younger age groups ( 66% ) than those aged 75 and 80 years ( 61.9 and 59.2% , resp . ) . in order to be selected as a part of the sample , valid responses on leisure engagement were required .
a posted questionnaire was sent out during late 2010 and included a broad range of questions related to aspects of societal engagement , medical history , health , and sociodemography .
the battery of questions was developed by the multidisciplinary team of researchers included in the gerda , and for this paper we analyzed medical conditions ( integrating 5 pharmaceutical drugs , stroke , heart disease , cancer , and hospital stays during the last 12 months into an index ) ; mobility difficulties ( integrating fear of falling and mobility device into an index ) ; activity limitations ( integrating independent bathing and independent cleaning into an index ) ; and leisure engagement .
the sociodemographic variables included in the analysis were age ( 65/70/75/80  yrs ) , language ( swedish / finnish and other languages ) , gender ( man / women ) , civil status ( single / together ) , income ( 1000/>1000  ) , education ( 9  yrs/10  yrs ) , and country ( finland / sweden ) .
leisure engagement was measured by asking about two aspects of 20 different leisure activities ( task ) : first if the participant had a habit of performing the task and then if the participant was motivated to perform the said task .
these questions were a part of the mnps leisure checklist that has been used in previous similar samples and that has been evaluated for its validity [ 23 , 34 ] .
firstly , we calculated the extension of medical conditions , mobility difficulties , and activity limitations in every person by adding up each component in the index into a number .
more specifically , each person was assigned a number that put their medical condition between 0 and 5 based on if they reported using 5 pharmaceutical drugs , personal incidence of stroke , heart disease , cancer , or / and hospital stays during the last 12 months .
similarly , a number between 0 and 2 was assigned for mobility difficulties ( adding a fear of falling , dependency on mobility devices ) and activity limitations ( dependency on help for bathing , dependency on help for cleaning ) .
a higher number was interpreted as showing a more severe medical condition , mobility difficulties , or activity limitations . secondly , to generate the measures of leisure engagement ,
the raw data of leisure performance and the raw data of leisure motivation were combined and subjected to the rasch rating scale analysis by using the winsteps program . this procedure has been used and found to be a valid measurement for groups of older people .
the generated data was treated as valid if it met the common criteria for surveys of mnsq  1.5 and z  2.0 . to be included in the study ,
a valid response regarding leisure engagement was required . in total , data from 1  403 respondents was excluded due to invalid responses . a major reason for this error was that many participants had not answered the question about leisure motivation (  do you want to perform this activity ?  ) .
lastly , we exported the leisure engagement scale measures to ibm spss statistics , version 20 , for continued analysis .
the relationship between the engagement in leisure activities of older adults , different health indicators and sociodemographic control variables was assessed by using ordinary least squares ( ols ) multivariate regression .
we used the above - mentioned measure for leisure engagement as our dependent variable as well as three indexes measuring medical condition , mobility difficulties , and activity limitations as independent variables .
the first model calculated a bivariate regression coefficient for each separate health indicator index on leisure engagement .
the second model consisted of multivariate regressions of the above - mentioned health indicator indexes on leisure engagement .
the third model was a full model assessing the association between leisure engagement and health indicators while controlling for sociodemographic characteristics .
in this study a total of 5435 participants met the inclusion criteria , 1375 from sterbotten ( 25.3% ) , 845 from pohjanmaa ( 15.5% ) , and 3215 from vsterbotten ( 59.2% ) .
the most dominant type of person found in the sample was a 65-year - old ( 40.2% ) women ( 55.5% ) living in vsterbotten , sweden ( 59.2% ) , together with someone ( 74% ) and earning more than 1000  a month ( 72.8% ) .
the basic characteristics were similarly distributed in finland and sweden . of the total sample 59.2% were swedes ( from vsterbotten , sweden ) , 25.3% were swedish - speaking finns ( from sterbotten , finland ) and 15.5% were finnish - speaking finns ( from pohjanmaa , finland ) .
leisure engagement varied in the sample between the most engaged ( 5.10 ) and the least engaged ( 4.60 ) with a mean 0.28 ( sd 0.99 ) . every fifth participant ( about 20% ) used 5 or more pharmaceutical drugs and reported a hospital stay during the last 12 months .
the most frequently reported medical diagnosis was ( some form of ) cancer ( 15% ) .
one quarter of the participants ( about 25% ) reported a fear of falling and about 14% needed help with cleaning .
more details about medical diagnoses , mobility difficulties , and activity limitations are described in table 2 .
the first two models of the ols regression ( see table 3 ) indicate that medical conditions , mobility difficulties , and activity limitations all have hampering effects on the leisure engagement of older adults , both when we consider the bivariate associations between each of the three indicators and leisure engagement ( model 1 ) and when their relative importance for leisure engagement ( model 2 ) is taken into consideration .
as is shown in the table , the indicator having the biggest impact on the leisure engagement of older adults is activity limitations , while the two other health status indexes play somewhat lesser roles .
interestingly , the strong negative association between activity limitations and leisure engagement remains significant ( which is also the case with mobility difficulties ) even after we control for individual , sociodemographic characteristics , and country ( model 3 ) .
this suggests an independent association between activity limitations , mobility difficulties , and leisure engagement .
the table also shows that leisure engagement tends to decline with old age and that leisure engagement is higher among swedish - speaking older adults than among finnish - speakers and persons with other mother tongues .
it is intriguing to note that one 's mother tongue seems to play an important role in this respect , although the country variable does not seem to matter a great deal .
as it is revealed in the figure , the swedish - speakers in finland also show a high rate of leisure engagement , which may explain why the country variable remains insignificant ( see figure 1 ) .
furthermore , table 3 shows that leisure engagement is higher among women , persons living together with someone else , persons with high incomes ( pensions ) , and persons with higher levels of education .
in this paper , we have analyzed the relationship between leisure engagement and medical conditions , mobility difficulties , and activity limitations .
this study demonstrates that having a fear of falling , using mobility devices , and needing help with bathing and/or cleaning all have a significant impact on the level of leisure engagement in the case of older people .
this impact remains significant even after controlling for variables such as gender , age , civil status , income , education , and language group affiliation .
for the purpose of this study , we operationalized mobility difficulties and activity limitations as an index that assessed whether older persons were experiencing a fear of falling and using mobility devices or if they were in need of help in order to bathe or clean themselves , respectively .
even though this is only one way of operationalizing mobility difficulties and activity limitations , it still gives an insight into how mobility issues as well as ability factors influence the extent to which older persons engage in leisure activities .
mobility issues and particularly a fear of falling have previously been studied and found to influence physical leisure activities negatively [ 38 , 39 ] .
this variable does not seem to play a role as big as that of mobility difficulties and activity limitations .
moreover , the variable of medical conditions loses its strength after controlling for sociodemographic variables .
these results are somewhat supported by earlier findings [ 6 , 40 ] , which report that older people may view themselves as healthy despite suffering from chronic illnesses and disabilities .
however , the negative link between illnesses or diagnoses and activities is often taken for granted or regarded as obvious ( e.g. , [ 4143 ] ) even though other researchers found that engagement in activities is affected by more than just diseases .
life style factors as well as persons ' physical and social environment , for example , have been noted to play a role in the level of engagement in such activities [ 4447 ] . with a regression model explaining about 10% of the variance in leisure engagement , this study demonstrates the need to examine leisure engagement no matter medical conditions , mobility difficulties , or activity limitations .
moreover , this study supports the need to consider age , gender , civil status , and socioeconomic status in terms of income and educational level when examining leisure engagement in the case of older people . in this study ,
leisure engagement varied between finnish- and swedish - speakers , but the country variable as such showed no impact on their engagement in leisure activities .
this is an interesting finding that seems to separate the effects of language group affiliation from those of the geographic region where a person is resident ( e.g. , ) .
the results found in this paper also corroborate the findings from a recent study , which found that good self - rated health was high among swedish - speakers in sweden and finland , respectively , but lower among finnish - speakers in finland .
further , being in line with previous research , it seems like historical , social , and cultural differences attributed to belonging to a specific language group in finland are playing an important role in explaining language group differences in leisure engagement .
it has been suggested that the swedish - speaking community in finland live in tighter social networks as compared to the finnish - speaking community   which might explain the high levels of leisure engagement among the swedish - speakers in finland in our study . to
what extent does leisure engagement of older persons depend on their level of activity limitations , their level of mobility difficulties , or their medical diagnoses , and to what may such engagement be related to other factors not examined in the present study ?
environmental issues and physical and social factors may also be important here , as suggested in many theories [ 5052 ] .
supports and barriers in the social , physical , or societal environment could , for example , be a part of interventions   but are also shown to influence physical activities and suggested to be used as predicting factors .
there might also be other , yet unknown , factors of importance to identify and incorporate into future evaluations of leisure engagement .
earlier research supports a relationship between self - rated health , seen as an overall measure of health , and leisure engagement [ 55 , 56 ] and this needs to be investigated further .
perhaps self - rated health could go together with medical conditions , mobility difficulties , and activity limitations to create a broader understanding of factors influencing the engagement in leisure activities .
based on the results , we can question whether medical conditions have a great impact on leisure engagement .
other findings similarly reveal limitations in using medical conditions to predict a decline in the activities of daily living .
hence , it is important to remember that only a few diagnoses and signs of medical conditions were included in this study 's medical condition variable .
if other diagnoses or signs , such as symptoms of depression and cognitive limitations , were included , the predictive strength of the regression models might be improved in terms of leisure engagement .
another limitation of this study is that self - reports of diseases are prone to be influenced by individual bias , particularly in the case of illnesses perceived as nonthreatening and that do not hamper a person 's ability to live normally .
these illnesses may nevertheless increase the risks for a decline of a person 's ability to function normally and need therefore to be considered .
although we used a population - based cohort , the exclusion from the analyses of participants with invalid responses on leisure engagement measures may have introduced bias and reduced the generalizability of the results . however , as the study is not limited to include only the performance of leisure activities , but also the motivational aspect of these activities , our measure on leisure engagement can arguably be seen as robust .
this study is based on self - reports , that is , on the accounts of older people assessing their engagement in leisure activities as well as their experienced medical diagnoses , mobility difficulties , and activity limitations .
there is however a great need to study also other variables in the complex field of leisure engagement .
 
 objectives . this study aims to investigate the impact of medical conditions , mobility difficulties , and activity limitations on older people 's engagement in leisure activities . methods . 
 the analyses are based on a cross regional survey carried out in 2010 in the bothnia region ( northern sweden and western finland ) . 
 a posted questionnaire , which included questions on different aspects of leisure engagement , medical history , and health , was sent out to older persons in the region . the final sample consisted of 
 5435 persons aged 65 , 70 , 75 , and 80 years . 
 the data was analyzed by using ordinary least squares ( ols ) multivariate regression . 
 results . 
 the most important predictor of leisure engagement abstention among older people is the prevalence of activity limitations , whereas mobility difficulties and medical conditions play less important roles . 
 the strong negative association between activity limitations and leisure engagement remains significant even after we control for individual , sociodemographic characteristics , and country . 
 discussion . 
 this study provides a window into leisure engagement in later life and factors influencing the magnitude of engagement in leisure activities . 
1. Introduction
2. Data and Methods
3. Results
4. Discussion