Women Playing Golf and Improved Quality of Life

Abstract

The inexorable ageing of the UK population – along with such facets of modern-day lifestyles as more prevalent obesity, increasingly sedentary lifestyles, and the standing of chronic heart disease among the leading causes of death – brings to the fore many health care issues. Foremost among these is the slow progress in bringing down rates of myocardial infarction leading to death. For those nearing retirement or already so idled, more regular and sustained physical activity might be expected to at least slow the deterioration of physical and cognitive faculties, sustain a modicum of social contact, and forestall depression due to being cut off from many activities previously enjoyed.

Since government has had less-than-sterling success inducing the middle aged and elderly to be more active by taking advantage of a free swimming program, this study focused on the signal benefits older women might gain from taking up golf as physical activity. As extensive search of the literature yielded no applicable benchmarks, an exploratory qualitative study supplemented by semi-structured questionnaires administered to the small sample was deemed most appropriate for being heightening validity.

Content analysis and basic cross-tabulations on the supplemental study instrument suggested, among others, that older women who already take up golf recognise the health and social benefits of playing golf into retirement and old age, they feel healthier, believe that golf provides meaningful exercise, but they fail to recognise that possible prodromes of CVD onset (exhaustion, shortness of breath, fatigue and lethargy in every day activities) are anything more than the inevitable decline that old age brings.

Employing the three-element Rowe and Kahn “optimal quality of life” paradigm, other key findings include the fact that exercise minimized symptoms enhanced perceived wellbeing, reduced the incidence of other public health problems like obesity and smoking, and maintained their mobility for other pursuits; that there is a palpable social component to golf that relieves the ennui of the homebound; social networks are broadened; older women are pleasantly surprised that they do not feel their age; and the sense of purpose and accomplishment sustains self-image. Lastly, finances are not a hindrance owing to the availability of municipal golf courses. Policy implications are discussed and guidelines for follow-through quantitative research pointed out.

Introduction

Rationale

The purpose of this study is to understand the personal experiential impact of golf on perceived well-being in women golfers who are nearing retirement age or have already done so. The aim is to test the feasibility of golf as an activity that provides comprehensive health benefits.

One in five women will die from heart disease (Lawlor 2003) – a risk that can be reduced by adhering to the Chief Medical Officer’s recommendation for daily physical activity lasting at least 30 minutes of activity in order to maintain health. Well aware of this recommendation and knowing about the degenerative diseases they are at increased risk for, too many women of advanced years fail to increase their levels of physical activity. While there are many reasons given for reduction in physical activity, many revolve on a declining interest in outdoor activities and a general disinclination for activity of any kind except that needed for the most basic home and personal upkeep.

Older women are not aware of the fact that reduced physical activity can bring on, or aggravate, aging-related illnesses. Cardiovascular disorders (diseases of the heart and circulatory system) are the leading causes of death in the UK, accounting for over 216,000 deaths in 2004. More than one in three people (37 per cent) die from a cardiovascular disorder, with the main forms being coronary heart disease and stroke (Allender, 2006). In 2003, the British Women’s Heart and Health Study found that one in five women between the ages of 60 and 79 had cardiovascular disease (CVD). CVD accounts for more than 40 per cent of all deaths among women of all ages in the UK (Lawlor et al., 2003).

As a national concern CHD costs the health care system in the UK around £3,500 million a year. Hospital care for people who have CHD accounts for about 79% of these costs; buying and dispensing drugs accounts for almost all the rest (16 percent). Looking only at the costs of CHD to the health care system grossly underestimates the total cost of CHD. CHD also costs the UK economy about £3,100 million for days lost due to death, illness and informal care of people with the disease. In total CHD costs the UK economy about £7,900 million a year (British Heart Foundation Statistics 2005).

However, the role of exercise in the prevention of cardiovascular disease in women has been inadequately studied (O’Toole 1993).

This study aims to focus on the link between playing golf and improved quality of life. As an empirical investigation, the research will uncover determinants and barriers for women playing golf. This will be done with a view to investigating the benefits or disadvantages of playing golf for women, and promoting golf as an ancillary activity to ensure a better quality of life. It will also identify possible means by which state intervention might reduce barriers to entry and encourage older women to play golf.

Literature Review

The purpose of this literature review is to highlight current issues and to set out background material and previous research relevant to the study. The review will consider the relevant professional literature in respect of the health and fitness of older women and golf-players. Using a general web-search and these search terms – golf; women; lady golfers; physical activity; exercise; retired; older; fitness; health – in a variety of search engines and online databases (including SportDiscus; Copernic Agent Professional; Google), articles were selected for relevance to golf-playing older women. Articles addressing all golf players and all physically active older adults were included where appropriate.

An Increasingly Important Segment of the Population

Lending urgency to the agenda of this research is the steady ageing of the UK population. The elderly share of the population has greatly increased in the last few decades as life expectancy lengthened whilst birth rates dropped. In 2005, life expectancy at birth for females born in the UK was 80.2 years, compared with 75.2 years for males. This is in contrast to 49 and 45 years, respectively, in 1901.

In order to design effective exercise interventions it is necessary to understand what motivates people to become physically active. However, the body of work has largely concentrated on young and middle aged participants. There is little published research that investigates the motives of those over the age of 60 years. As well, there seems a dearth of studies in the UK that cover older, physically active women as a group and the involvement of women in golf. Diligent search yielded no work that considers the comprehensive benefits that golf has to offer the older woman, especially with regard to its positive effects on the cardio-vascular system.

The Onset of Disease and Degenerative Conditions in Middle Age

Where women are concerned, the focus of medical practitioners has, until recently, been in the areas of reproduction, contraception, and the early screening and diagnosis of cancers – ignoring the need to screen for cardiovascular disease. Both women and their doctors have tended to focus on gynaecological screening, paying little attention to risk assessment, early diagnosis and treatment of cardiovascular disease (Fields et al., 1993).

Cardiovascular disease (CVD) becomes more prevalent in middle age morbidity and coronary heart disease (CHD) is the leading cause of death in the population over the age of 65, accounting for 40% of deaths in women and 42% in men of this age (Statistics.gov.uk). It is noteworthy that there is an increase in cardiovascular events after menopause due to the loss of the protective effects of estrogen. As a result, after the age of 65 the risk of cardiovascular disease is higher among women compared to men.

CHD exemplifies inequalities in health: unskilled male labourers are three times more likely to die prematurely of Coronary Heart Disease than men in professional or managerial occupations. The wives of manual workers bore nearly twice the risk compared to the wives of non-manual workers. Furthermore, angina, heart attack and stroke are all more common amongst those in manual social classes (National Service Framework, 2007). There is a socio-economic aspect to Coronary Heart Disease as the less prosperous are least likely to turn to medical attention with symptoms that they do not believe are life threatening.

In general there is a lack of in-depth studies of older women and the benefits of exercise for their health and well-being. Studies of Coronary Heart Disease in women are often limited to specific cases that come to hospitals to report their condition for treatment (Department of Health, 2008). As a result there is little updated knowledge regarding the development of Coronary Heart Disease in women such as the first appearance of prodromes or vague, indistinct symptoms prior to full-blown Coronary Heart Disease.

Coronary Heart Disease

Coronary heart disease results from the reduction or complete obstruction of blood flow through the coronary arteries by narrowing of the arteries (atherosclerosis) and/or a blood clot (thrombus). There is evidence that if CHD is properly managed, progression of the disease can be slowed down and possibly reversed in some people. If untreated, it is progressive and will lead to death either from a heart attack (acute myocardial infarction) or from heart failure.

CHD causes

• chest pain (angina pectoris)
• heart attack (acute myocardial infarction)
• irregular heart beat (arrhythmia)
• heart failure

Coronary heart disease (CHD) is a preventable disease that kills more than 110,000 people in England every year. More than 1.4 million people suffer from angina and 275,000 people have a heart attack annually. CHD is the biggest killer in the country. Worse it is a major killer of women, in 2003 over 122,000 women died from heart and circulatory disease in the UK (British Heart Foundation 2005).

This is 46,000 more than died from cancer. In comparison to other common medical problems among women the lifetime risk among post-menopausal women for coronary disease is about 31%, as contrasted with 2.8% for hip fracture, 2.8% for breast cancer, and 0.7% for endometrial cancer. That coronary disease is the most prevalent illness affecting older women requires greater dissemination; unless women and their carers realize the high risks of CHD they bear, they will ignore the onset of symptoms until the disease becomes chronic in nature. What makes coronary disease prevention a concern for women is the fact that it has more adverse outcomes for them compared to men once it becomes clinically manifest (Wenger 1993).

Government is committed to reducing the death rate from coronary heart disease and stroke and related diseases in people under 75 by at least 40% (to 83.8 deaths per 100,000 population) by 2010 (Department of Health 2008). In order to accomplish this, the first challenge lies in addressing the awareness gap.

In the past, the prognosis for women with clinical evidence of coronary heart disease was not adequately appreciated. The Framingham Heart Study even initially defined angina as a relatively benign problem for women. This means that women who experienced early symptoms like angina were less likely to appreciate that CHD had already began to afflict them.

The Framingham Heart Study suggests that one man in four with frank symptoms would develop myocardial infraction within 5 years whereas 86% of women presenting with angina in the Framingham cohort never incurred myocardial infarction. However, a flaw in the Framingham analysis was exposed when data from the Coronary Artery Surgery Study (CASS) Registry – a listing of men and women referred to participating institutions by their treating physicians because of chest pain syndromes of sufficient severity to warrant evaluation by coronary arteriography preparatory to coronary artery bypass surgery) – revealed 50% of the women in this population had little or no obstructive disease in their epicardial coronary arteries (Kennedy 1982).

Essentially, this means that the chest pain reported by many women was not angina pectoris at all but proceeded from other disorder besides CHD. The fact that the chest pain had a non-coronary aetiology for explains why 86% of women in the Framingham cohort did not develop myocardial infarction.

This is not to discount the risks for CHD that women face. The oldest age segment of the Framingham women, those aged 60-69 years, bore the highest risks for CHD than any other female group. This underlines the age-dependency of coronary heart disease in women. On experiencing an initial myocardial infarction episode, secondly, mortality was high at 39%, notwithstanding the substantial reductions in mortality from myocardial infarction achieved by recently developed therapies. Third, cumulative findings from the Myocardial Infarction Triage and Intervention Registry showed that women had a 16% mortality rate overall from myocardial infarction (MI). While the percentage varies somewhat from one series to the next, the ratios remain uniform among all reported series

Further investigation is needed to find out whether female mortality is due to gender per se, or whether it reflects such patient risk factors as more advanced age, greater comorbidity, variable access to care, time to arrive at hospitals or a number of other primary care variables, such as suboptimal access to medical therapies. The Data from the Framingham Study also showed that women were more likely to endure unrecognized or silent myocardial infarction because of unwillingness to acknowledge the problem. It would not be surprising if a similar study made today showed that women with diabetes and hypertension were likely to have silent or unrecognized infarctions – which were also characteristic of the Framingham cohort.

In recent years, the decreases in both total cardiovascular mortality and total coronary mortality have been less pronounced for women; concomitantly, during the past two or three decades, the decrease in coronary risk factors has been less pronounced among women (Eaker 1999). Limitations of these data relate to the traditional exclusion of women and of elderly persons of both genders from many research studies; these problems limit the reliability of the previous studies of both coronary risk attributes in these populations and the efficacy of risk interventions in limiting the chance of developing CHD.

Coronary risk is especially prevalent in elderly women. Even when such risk is recognized and the need for intervention acknowledged, CHD is often ignored as part and parcel of old age. Instead the illness is allowed to take its course when proper therapy and prevention could improve quality of life.

Prevention of CHD is imperative for women as 40% of all coronary events among women will result in death. Had women been properly diagnosed at an early stage, deterioration could have been prevented. Furthermore, 67% of all sudden deaths in women involve those who have undiagnosed coronary disease. Morbidity is also a serious concern among women in the 55-64 year range. One-third (36%) of women with clinically manifest coronary disease are disabled by their illness and this percentage increases to 55% for women with defined coronary disease who are older than 75 years of age.

The importance of education and information dissemination that dissuades women that coronary disease is primarily a disease for men, and that focuses on the primacy of preventive coronary care as a part of women’s health care, is paramount. Coronary heart disease is an equal opportunity killer; women are not immune from this problem. Continued ignorance is fatal to women’s health.

Physical Inactivity

Physical activity has been defined as; “any bodily movement produced by skeletal muscles that results in energy expenditure”. (Bouchard et al., 1990 ). It would appear that the UK population has become rather more sedentary. Overall sports participation has decreased among both men and women since 1996. In 1996, 71% of men had participated in at least one activity, including walking, in the four weeks before interview, compared with 65% in 2002. For women, the four-week participation rate, including walking, fell from 58% in 1996 to 53% by 2002. The overall participation rates, excluding walking, show similar but smaller downward trends indicating that the overall decline in sports participation is partly accounted for by a decline in walking among both sexes.

When considered in conjunction with the burgeoning female population at or approaching retirement age (Population Trends, Winter 2006), two factors become apparent:

• Costs to health and social care services will escalate
• Quality of life for disease sufferers will deteriorate

An extensive set of studies have found positive associations between regular physical activity and health benefits. In June 2008 the UK Government introduced free swimming for people over 60 as a move to encourage older people to stay active. Free swimming for the over 60s will help those who like to swim, but there are many who do not.

Policy makers should address reasons why older women are not as active as men or younger women, and consider areas that would meet their requirements.

The relationship amongst health, fitness and ageing in women has been investigated in combination and independently by many researchers (Allender 2006; Lawlor 2003; Shangold & Mirkin 1994). Among others, it has been found that 24% of the female population take no more physical activity than is necessary for their daily activities. As women age, overall rates of participation in exercise show downward trends – despite involvement in physical exercise being shown to promote positive perceptions of psychological well-being and the latter, in turn, appearing to be an important predictor for staying physically active at an advanced age (Information Centre 2006).

Research following the Allied Dunbar National Fitness Survey (Skelton et al 1999) showed that, among those over the age of 50 in the UK:

• Twenty percent of women do not have the flexibility to wash their hair comfortably.
• Thirty per cent of women aged 50-74 do not have the aerobic capacity to walk comfortably at a 20-minute mile pace.

British Heart Foundation 2003

Physical inactivity is one of the major CHD risk factors which has been targeted in government health strategies since the early 1990s (Health Survey for England 2006). Nearly seven in eight (87%) of those aged 65 to 74 do not achieve the weekly recommended target of physical activity of. (Health Survey for England 2006).

Regular physical exercise is the opposite pole of physical inactivity. It is associated with optimal health and has a positive influence on the cardiovascular system. And the relationship with health is far from ambiguous. Hypertension, obesity, glucose intolerance and hyperlipidemia, all known cardiovascular risk factors, have shown a tendency to be more prevalent in sedentary women (O’Toole, 1993).

By engaging in an active lifestyle, women experience both a decreased incidence and reduced severity of cardiovascular risk factors. Active women have lower blood pressure, lower heart rates, lower cholesterol and triglyceride levels, and higher levels of higher density lipids (HDL) cholesterol than do inactive women.

Yaffe et. al. (2001) indicate that cognitive decline in women might also be associated with lack of physical activity. Cognitive decline ranges from mild impairments to dementia, and is found in at least 10% of those over 65 years and 50% of those over 85 years. Such marked erosion in cognitive functioning could be explained by a decrease in cerebral blood flow, which might increase the risk of cerebrovascular disease.

Physical Inactivity and Depression

With cognitive decline, mental health – including depression and stress-related disorders – is also affected by lack of physical activity. Rethink – the operating name of the National Schizophrenia Fellowship, advocates exercise as an essential part of looking after physical and mental health. The Disability Rights Commission confirmed in 2006 that people with severe mental illness are at higher risk of certain physical health conditions including;

• Obesity – more people with schizophrenia and bipolar disorder are obese compared to the rest of the population
• Coronary heart disease –more common in those with schizophrenia and bipolar disorder than in the rest of the population
• Diabetes is more common in people with schizophrenia and bipolar disorder.
• High blood pressure, respiratory problems, bowel and breast cancer are also more common among people with mental illness.

The consequence of the presence of these diseases in those with severe mental illness (DSM IV) is that they die 10-15 years earlier than the rest of the population. It stands to reason, therefore, that the risk factors of all of these chronic diseases could be reduced by participation in moderate physical activity.

While depression might be brushed off as a weakness, depression is the third most common reason patients in the UK consult with a general practitioner (Tyler et al. 1999). People who are depressed may feel they are ill and visit their GP. Such depression and illness is not merely psychosomatic. In fact, it is often associated with medical comorbidity. Over 45% of patients who are admitted to hospital after a myocardial infarction have depression related symptoms.

In cases where a heart disease patient is also clinically depressed there is a heightened risk of poor medical outcomes such as an increased chance of re-infarction and all-cause mortality. One third of patients who suffer from heart failure also have symptoms of depression.

One study has shown that clinical depression is a significant risk factor for developing CHD (Stewart et Al. 2005). Patients who are depressed in the weeks following an acute coronary episode have a poorer cardiac outcome (Jiang, Glassman, Krishnan, O’Connor and Califf, 2005.). Furthermore, patients suffering from depression demonstrate less significant increases in regaining physical function following coronary bypass surgery.

SSRIs (selective serotonin reuptake inhibitors) have proved to be effective in the treatment of depressive symptoms in cardiac patients and are also safe from the cardiovascular point of view (BMJ 2004). But while anti-depressant treatments are effective in treating depression in medically ill patients, their impact on medical outcomes has yet to be quantified (Curr Opin Psychiatry 2006).

Many studies have shown that clinical depression or depressive symptoms are a risk factor for all-cause mortality and mortality due to cardio-vascular disease (Penninx et al., 1998) at all stages of adulthood. There are a variety of results found in studies using measures of depression in clinical and community samples. In non-psychiatric samples factors shown to mediate the effect of depression on mortality include chronic physical illness, low body mass index (BMI), cancer, heart disease, smoking, and alcohol abuse (Wulsin et al., 1999)

Research also shows that among the elderly, depression is more prevalent in women. Although studies in this respect vary with regard to the mortality effects of depression, discrepancies in the findings may in part be caused by the differences in sample selection, composition or age, and the explanatory variables analyzed. It is possible that the different explanatory variables are only valid at different ages.

For example, depression predicts coronary heart disease more consistently in middle-aged than in elderly populations (Mendes 1998). Another possibility is that because depression is a fluctuating illness, single measurable occurrences do not always concur with a series of longitudinal measurements that more accurately reflect the chronic aspect of depression. One of the few studies that examined change in depressive status in relation to mortality (Bittner 1993) found that neither incident nor chronic depression, as measured on the CES-D (Centre for Epidemiologic Studies Depression) Scale at baseline and after 2 years was associated with mortality over a 12-month follow-up period. Although based on a large community sample, however, the follow-up period was relatively short.

It should be noted that no study has shown conclusively depression is associated with increased risk of mortality. The findings suggest that a high depression score in a single isolated instance does not automatically lend itself to a risk of mortality; however, improvement in depression may reduce morbidity and mortality. It may also partially explain the equivocal findings on the mortality of depression coming from studies using occasional single measurement. Longitudinal community-based studies including successive measurements of depression are required to clarify the general findings relating depression and gender to mortality.

There are quite a few reasons why incidental depression in the very old may be a risk factor for mortality. It is possible that depression is the prodrome of cardiovascular events or dementia or that such occurs in concurrence with these conditions. Depression may be an early sign of impending physical decline (O’Toole 1993) or incur a physiological response that predisposes individuals to cardiovascular disease or other illness, such as cancer (Greenland et al. 1991).

It also seems that incident depression and gender interact in old age. For example, Penninx et al. (1998) argued for newly-depressed moods in women being associated with impending cardiovascular events, whereas chronically depressed men were not at increased risk of cardiovascular events or mortality. The same study did not find that incident depression in women increased the risk of mortality. Hence the physiological impact of depression may be greater for men than for women despite the greater prevalence of depression among women. One difficulty inherent in longitudinal studies is that depression may be associated with non-response, leading to underestimation of chronic depression.

Weight Gain and Illness

Obesity is defined as an excess of body fat associated with an increased fat cell size. Cardiovascular health is thought to be influenced by the distribution of body fat. (Spelsburg, 1993). The waist-to-hip ratio measurement is believed to be an estimate for obesity. Hip, buttocks and thigh fat accumulation is believed to be less metabolically active than in the waist, abdomen and upper body. Fat accumulation in the abdomen is especially important in predicting non-insulin dependent diabetes, hypertry-glyceridemia, hypertension, and coronary heart disease in women (LaRosa 1994).

Some possible reasons for this relationship are the increased sensitivity of the abdominal fat cells to lipolytic stimuli and direct delivery of fatty acids and glycerol to the liver with subsequent insulin resistance. Higher hip-to-waist ratios are correlated with lower HDL levels and higher Low-Density Lipids (LDL) levels. One author contends that obesity should be elevated from the status of minor to major risk factor in women because weight gain and obesity are associated with an overall deterioration of the cardiovascular risk profile (Kannel 1987).

There is an established normal weight range for woman. Due to the increasingly sedentary lifestyles of people today the tendency is to gain weight. As a result of this weight gain the risk of coronary heart disease increases (Willett 1995). One of the easiest means to establish if a person is overweight is to use the Body Mass Index (BMI).

A 1976 study conducted in the USA tested the validity of this hypothetical relationship between the recommended range of body mass index (BMI) and coronary heart disease. The American study used 115,818 women aged 30-55 with no history of CHD (Counchman 1995).

A follow up of the same study 14 years later, on 1292 cases of CHD, showed a covariate-adjusted hazard ratio for CHD of 1.19 for a BMI of 21-22.9 kg/m², (using as reference women with a BMI of less than 21 kilogram weight per meter of height squared [or <21kg/m²]),1.46 for a BMI of 23-24.9kg/m², 2.06 for a BMI of 25-28.9kg/m², and 3.56 for a BMI of 29kg/m² or above. The Covariate-adjusted hazard ratio is the number used to represent the survival curves to explain the risk of an event, in this case CHD. Evidently, higher BMIs result in higher risks of CHD (Willett 1995).

It was also established that women who gained their weight later in life were at greater risk of CHD. Women who had stable weight (+/- 5kg) had lower risks of CHD than those who had greater weight gain over the course of their lives. Relative risk for those who gained 5 – 7.9kg is 1.25%, which goes up to 1.64% for those who gained 8-10.9, then 1.92% for an 11-19kg gain and 2.65% for a weight gain of 20kg (Couchman 1995).

In recent years there has been an increase in the prevalence of obesity among both genders. Obesity in the Framingham Study population was a significant independent predictor of cardiovascular risk, especially among women. Specifically, the associated risk factors identified by Kannel (1986) for a certain type of plaque in arteries and for CHD generally in women included LDL cholesterol, low HDL cholesterol, triglycerides (particularly in older women), impaired glucose tolerance, the upper-body obesity typical of older women, fibrinogen, and simply being post menopausal.

Golf

The word Golf is first mentioned in a 1457 Scottish statute on forbidden games. Gouf (Wikipedia 2008), as it was called then, was the Scottish name for the sport derived from the world goulf which meant “to strike or to cuff”. The Scottish term itself maybe derived from the Dutch term “kolf” which meant “bat” or “club”. Indeed there was a contemporary Dutch sport of the same name. It is often claimed that the true origin of the word Golf is as an acronym for “gentlemen only, ladies forbidden” although this has long been disproved as a false etymology (Snopes, 2006).

From its medieval roots, Golf today has evolved into a sport in which a player uses several different types of clubs, such as the iron, driver, and putter, to make a ball go into a hole with the fewest number of strokes. It is rare as a ball game as it does not use a standardized playing area. Instead the game played on a golf “course” which often has a unique series of challenges and obstacles around the 9 to 18 holes. Simply put; Golf is playing with a club from the teeing ground into the hole by a stroke or successive strokes.

The first recorded game of Golf was played at Bruntsfield Links in Edinburgh in 1456. (Wikipedia 2008). These records were found in the archives of the Edinburgh Burgess Golfing Society, a.k.a. The Royal Burgess Golfing Society. Since those early games in Scotland and England the game has spread to the rest of the world. Most nations today feature golf courses where the game is played.

Golf and the Benefits of Exercise

The benefits of physical activity have been extensively researched and are consistent with studies that have identified physical activity is an important factor for reducing the risk of atherosclerotic vascular disease, lipid and glucose levels, obesity, and hypertension. In addition to these factors physical activity is known to reduce the risk of cancer of the breast and colon; osteoporosis, and depression. (Fletcher and Trejo, 2005).

Through participation in an active lifestyle women have experienced a decrease in the incidence and severity of cardiovascular risk factors. Active women have lower blood pressure, lower heart rates lower cholesterol and triglyceride levels and higher levels of HDLs than inactive women (Holm et al. 1993).

While participation in other sports is biased towards adolescents and young adults, participation in golf holds up to about age 69, the median age of participants being 42. (General Household Survey for England, 2001).

It has recently been found that golfers can expect a life expectancy longer by five years compared to reference populations with age, sex and socio-economic status held constant. A study of 300,000 Swedish golfers found the “death rate for golfers is 40 per cent lower than for other people of the same sex, age and socioeconomic status.” (Farahmand et al., 2008). Farahmand found that Swedish golfers, men and women both, boast mortality rates about 60% that of the general population and that the lower the handicap (a measure that reflects the level of play), the lower the mortality level.

The majority of studies on associations between physical activity and health risk operationalise physical activity in terms of both energy expenditure and time devoted to the sport or brisk activity.

Dynamic aerobic exercise increases systolic and lowers diastolic blood pressure, whereas isometric exercise increases both systolic and diastolic blood pressures. An abnormal increase in blood pressure during exercise has been reported in borderline hypertensive individuals, but the rate of rise in blood pressure is similar to that observed in normotensive subjects (Drory et al. 1990). Exercise improves well-being and improves insulin sensitivity.

Regular aerobic physical activity of moderate intensity decreases systolic and diastolic blood pressures by an average of 10mm Hg. Brisk walking for 30-45 min or low intensity exercises, such as playing Golf, at least 3 – 4 times a week is at least as effective in lowering blood pressure as regular aerobic exercise (American College of Sports Medicine Position Stand, 2005). Exercise will also reduce sympathetic outflow activity which is the mechanism by which exercise-induced blood pressure reduction occurs.

The effects of dynamic exercise on haemodynamics vary by age. However, the difference is negligible among women. An abnormal rise in systemic vascular resistance and decrease in cardiac output may account for reduced effort tolerance in the elderly; antihypertensive drug treatment may be required prior to instituting an exercise program in older patients.

Blood pressure control is related to a reduction in the incidence of stroke and heart failure. For those women with severe hypertension, exercise as part of their program of treatment can help control elevated blood pressure. In mild to moderate hypertension, common among older women, weight control with diet and an increase in physical activity produce a moderate reduction in blood pressure. When nonpharmacologic efforts fail, drug therapy is indicated and has to be individualized. Although recent drug trials have included women, sample sizes have been too small to adequately address the impact of treatment on cardiovascular mortality.

To summarize, there is substantial evidence that moderate-intensity leisure exercise, as a means of imparting physical fitness, has widespread and powerful survival benefits. The efficacy of lipid-lowering interventions has not yet been documented extensively, the extent of cholesterol lowering and resultant decline in rates of coronary heart disease is often beneficial for both genders. Given the higher tendency for obesity among women it is even more important for women to participate in moderate exercise. After all, a modest investment in time and energy playing golf could have significant benefits in preserving the health of older women.

Social Adjuncts and Psychological Rewards of Golf

Golf is a social sport. The high cost of maintaining golf courses means that is it not simply a pick-up sport like football which can be played anywhere. Instead, golf requires well maintained courses and lawns which are costly to support. As a result, golf clubs are organized around the care and maintenance of these courses. In order to play golf, one is normally required to be a member of these clubs or at least sponsored by a member of the club. In fact, golf club memberships cost a minimum of £250.00 for a yearly membership or £25 for a pay for play arrangement.

A social structure then forms around these golf clubs not only with respect to playing itself but also around operations and maintenance of the facilities. Other social activities can also be held in a Golf club. Membership in a Golf club does not only provide a light sport which can provide healthful exercise but also social activity that can benefit psychological health. You have ignored my comment that this section needs to link into the literature on social support and health.

A further benefit of being around other people and interacting with them is the development of self-esteem. In the close knit community of a golf club, friendly competition encourages people to do better and practice is rewarded with recognition, all of which can help raise self-esteem in the golf club member. In the context of older, retiring women this becomes even more important. As women get older and feel their bodies, figures and looks begin to change with age, many suffer declining or even poor, self-esteem.

Again – ignored my request to link into the literature.

Older Women and Golf

Moderate physical activity in elderly women can reduce mortality, whether from other causes of death or from CHD – moderate physical activity can also improve bone mineral density and reduce the risk of osteoporotic fractures. Playing golf regularly has been found to increase aerobic performance and trunk muscle performance in addition to accelerating weight loss, trimming waist circumference and abdominal skin fold thickness.

Yaffe’s (2001) definition of moderate physical activity included eighteen holes of golf played once weekly. Regular walking on a golf course could beneficially affect cardiovascular risk factors.

In a study of physical activity (including 18 holes of golf once weekly) and cognitive decline in elderly women it was found that moderate physical activity reduced the mortality rate from CHD (and overall mortality), as well as improving bone mineral density and reducing risk of osteoporotic fractures.

Bouchard (1990) described exercise as: “Leisure time physical activity which is planned and structured, and repetitive bodily movement undertaken to improve or maintain one or more components of physical fitness”.

Moderate intensity physical activities have an energy cost of at least 5 kcal/min but less than 7.5 kcal/min and include heavy housework or gardening and sports which make the individual breathe heavily or become sweaty. (NHS Information Centre, 2008)

Brown et al (2001) found no evidence of additional health benefits from “vigorous-intensity” physical activity over and above those achieved from walking or other moderate-intensity physical activities. For the purposes of this study, physical activity is used as a specific type of activity, closely identified with active living.

Participation in exercise and physical activity declines with age from 65% of women aged 16-19, to 10% of those aged 70 and over. Women aged 60 and over have very low levels of physical activity participation, with only 12 per cent of women aged 65-74 and 3 per cent of women aged 75 and over achieving current government targets for physical activity (Women’s Sports Foundation UK, 2004). Orsini et al (2007) found that among middle-aged and elderly women, the likelihood of engaging in higher total daily physical activity levels decreased with age, body mass index, educational level, smoking, drinking, and growing up in urban places.

Since engaging and maintaining regular physical activity plays a key role in reducing several public health problems, the identification of these significant correlates may help researchers, clinicians, and health policy makers design gender and age-specific interventions.

While walking remains the most popular physical activity for women of all ages, golf does not register in the top ten popular activities for women. (General Household Survey, 2002). The impact of walking on activity levels is so important to women over 50 that if included in statistics it doubles the participation rate of physical activity in women over the age of 60. For women in Yorkshire, on the other hand, recreational walking is top of the sports participated in by those over 16 years; while walking is similarly at the top of Yorkshire men’s sporting activity, golf takes fifth position for men, but does not appear in the top ten for women. (WSF 2006).

Hollman et al (2007) found that women with higher physical activity showed significantly lower age-related reduction of cognitive abilities, pointing to the fact that physical activity counters the age-related erosion of cognitive capabilities.

Methodology

Statement of the Problem

At the core, the current study constitutes an exploratory investigation into the question: how might older women be motivated to commence a regimen of physical activity that will tangibly reduce their risk of CVD and CHD? What are the hindrances to attaining the self-evident benefits of golf?

Hypothesis

The more prominent barriers to taking up golf have to do with unrecognised need, accessibility of golf courses, ownership of a golf set and time constraints. In turn, the lack of motivation (“unrecognised need”) covers:

1. Being totally asymptomatic, presenting no pre-existing cardiovascular condition ;
2. Lack of awareness that a program of regular physical activity materially prevents or delays the onset of degenerative diseases;
3. Not knowing that symptoms already felt indicate CVD or CHD;
4. Not realising that golf is a valid form of brisk physical activity with enjoyable sidelights.

Research Objectives

Given the low incidence of participation by older women in general physical activity and in the intervention sport of interest, golf, this research investigated attitudes, beliefs and perceptions preparatory to formulating a strategy for persuading target women to take up golf.

The key research objectives were as follows:

1. Investigate, first of all, the state of target public (older women aged 55 to 70) awareness of the risk they face for CVD and CVD.
2. Assess their awareness of the associated risk factors such as little/no physical activity, above-average BMI, and diabetes.
3. If awareness of CHD and CVD morbidity and mortality risk is tangible, investigate the degree of conviction about being able to forestall the further progress and deterioration of the disease through time.
4. Explore the medical and fitness options target women are aware of and believe they should undertake.
5. Investigate the reasons for resistance, if any.
6. Elicit what benefits and drawbacks are known in respect of taking up golf as therapeutic activity.
7. Investigate acceptance of the sport even among women who remain asymptomatic for CHD and CVD but who present with associated risk factors.

Research Design and Study Instrument

Research is guided by epistemology – the theory of the nature and scope of knowledge. This research study involved an examination of fairly complex social phenomena. Using quantitative methodologies only would give poor representation and a generalisation of data, and could exclude discovery. The primary task of quantitative research is to ensure validity and reliability of results (Dingwall et al, 1998).

Quantitative research implies questionnaires and data analysis. In the social sciences formal quantitative methods include laboratory experiments, survey methods and mathematical modelling. Quantitative research is measurable, reliable and valid, but the drawback is that quantitative methods do not take in to account the variables of the real world. Qualitative research methods are designed to provide researchers with data explaining the perceptions and understanding of various phenomena and experiences of the participants. The most common methods of gathering qualitative data include participant observation, interviewing and analysis of written data. These methods produce rich and detailed data from the context in which it was gathered.

Since a sedulous search of the literature had yielded no prior investigation of the relationship between the independent variable (golf as self-managed physical activity intervention) and the dependent variable (whether general well-being for asymptomatic women or slowing the progress of CVD for those already symptomatic and so diagnosed), the present research took on the nature of an exploratory motivational study.

As such, the classic follow-through for a literature survey consists of qualitative research, for which the applicable techniques include in-depth individual interviews, direct observation, focused group discussions, role play and simulation, projective techniques, case study, grounded theory, projective techniques, and the diary method.

In the event, focus groups (FGD’s) seemed the most prudent and valid research technique since:

1. The synergy of interaction and group dynamics maximised the range of feedback generated, a very important consideration for an exploratory study
2. The dynamic nature of FGD procedures permitted the researcher to respond to unexpected answers, develop new hypotheses and float new questions while the group remained in session.
3. There being no hard-and-fast guidelines for number of panels, the researcher had the flexibility to recruit any number of panels that would allow for inter-group analysis.
4. Like observation techniques, content analysis could take into account non-verbal response that amplified on, or qualified, verbal statements. Hence, the researcher had significantly more visibility to attitudes, perceptions, hindrances, and degree of conviction.

Sample

A minimum of 12 FGD sessions were required to account for the independent variables in this study: being symptomatic or not for CVD and associated syndromes, financial means for taking up golf, ready access to a golf course, and meeting the minimum threshold of physical activity.

Field Implementation

Convenience sampling was carried out from relevant populations of women aged 50 and up in North and West Yorkshire. Face validity was ensured by explaining to prospective respondents they were being invited for tea with a group of from seven to 11 like-minded women at which they would participate in an ongoing NHS study of personal wellbeing.

Recruitment Method

Letters were issued to participants in the group (Appendix 1) fully informing them of the purpose, methods and intended outcomes of the research; participants were made aware of: their rights to data protection; to withdraw from the project at any time; and of any risks involved – although none were foreseen. Participants were also reassured regarding storage and final destruction of data.

Following written consent and prior to the FGD’s, prospective participants completed questionnaires examining levels of physical activity and awareness of heart disease. Prior to use, a pilot was conducted amongst one dozen women to detect any flaws in the questioning with a view to correcting them prior to the main survey.

All sessions were held at a flat leased for the month by the researcher in order to ensure privacy and maximise the productivity. The study proponent facilitated the sessions, assisted by a clinical psychologist with experience in therapy groups and a stenographer to take notes.

The researcher-facilitator employed extensive probing to clarify vague verbalisations and role-playing to stimulate panellist participation. All sessions were taped for later review and content analysis.

Ethics Concerns

Unlike research studies in other fields, studies in health and social sciences involve the use of human subjects and require greater caution. The Helsinki Declaration of the World Medical Association declares that, though progress in health-related fields requires research and experimentation involving the use of human subjects, considerations related to the “well being of the human subjects should take precedence over science and the society”; and that the primary objective of such studies, involving human subjects, is to understand better and improve on diagnostic and therapeutic procedures, and to increase knowledge of the causes and progression of diseases (WMA, 2000).

Having considered my research plan against the University Codes of conduct for ethical research there did not appear to be any areas in the process that might cause harm to those participating, and ethical approval was received. Subjective data based on the subject’s own testimony was taken.

Study Instruments

Various pre-written questionnaires were considered including the Treatment Self-Regulation Questionnaire (TSRQ). Using the TSRQ as a starting point, a customised version was developed to consider the motives and perceived benefits of golf to middle-aged and elderly women.

The TSRQ was considered as it assesses motives for healthy behaviour (Williams, Grow, Freedman, Ryan and Deci 1996). The TSRQ has been shown to be a reliable and valid tool that can assess both motivation and self-regulation – fundamental aspects of health promotion interventions (Levesque et al., 2006). However the TSRQ assesses autonomous self-regulation considering only why people do or would do a healthy behaviour or would try to change an unhealthy behaviour. For this study questions were changed, examining not only why the behaviour (playing golf) was practised, but also included open, subjective questions allowing opinions and feelings to be addressed.

While a TSRQ was the starting point for the study, it was decided that it would be more efficient to employ a focus group discussion (FGD) instead. Not only was this more cost effective and less time consuming but by allowing the women to meet and discuss the benefits of physical activity and golf, it was possible to obtain more information and encourage them to speak freely and reinforce each other’s views. Individual interviews were also determined to require more work when the same results, if not better, could be had from an FGD.

Socio-demographic background information, including details about extent of physical activity and golf playing (e.g. handicap), was collected. Some golfing participants were asked to participate in an interview which aimed to capture the rationale and perceived benefits of golf participation.

Perceptions of whether (and how) golf could be considered as a way of promoting physical activity in older adults were evaluated. The focus group discussion will be conducted and guided by a Discussion Guide (see Appendix 2), designed to direct the participants into giving answers that will shed light on the research objectives.

The following are the questions to be used in the focus group which are designed to provide useful learning that might help shape policy:

Q1: Age group, Q2: Age did you start to play golf? Q4: For how long have you have been playing golf?

These questions identify the demographic group. Ideally the target group will be between 50 – 70 years old as these will be retired or about to retire aged women who are most likely to benefit from the program. The question of when the person started to play golf will help establish if the persons involved are the ones that the study is targeting. After all, it is predicted that a life-time golfer or one who has been playing for 10 or more years is less likely to feel the benefits of playing golf as a function of graceful aging. The question on how long a golfer has been playing ties in with Q2 as it helps establish the length of time the subject has played golf vis-à-vis the age of the respondent

Q3: Do you take any other form of exercise? E.g. walking, gym, dancing, home equipment, team games, swimming etc.

By asking if there are other exercises that the participant takes part in the study will attempt to isolate golf as the reason the subject feels that she is healthy. Intervening sports will dilute the results since if they are participating in these it is possible to attribute the improved health to these factors.

Q5: Are you retired from full time work? Q6: If you are still working do you intend to continue playing golf on retirement?

This is another demographical question which aims to establish that a person who has retired from full time work will stand to benefit more from playing golf. The idea is that if a person no longer has full-time work they are even less likely to leave home, further reducing the amount of exercise that they get. Furthermore, a retired person not only gets less exercise but also less interaction with her fellows increasing the likelihood of psychosomatic illness or a feeling that one is sick when she is not and depression as a result of isolation.

Q7: Are you a member of a golf club?

This question aims to establish a correlation between membership in golf clubs and additional benefits that the subject may gain from being a member. It will also play into the theory that membership in a golf club provides additional health benefits.

Q8: What were your reasons for starting golf?

Question Eight is subjective information gathering as to the reasons why the person started golf. Such information may give insight into how golf can be promoted as a healthful activity for older women.

Q9: During the months of April – September, how often do you play golf? Q10: During the months of April – September, how often do you use a golf driving range or practice area? Q11: During the months of October – March, how often do you play golf? Q12: During the months of October – March, how often do you use a golf driving range or practice area? Q13: Are you a ‘fair weather only’ golfer?

These questions will help plot the seasonality of golf players. By knowing when these women play golf most often it will be possible to plot when it would be most beneficial to organize golfing tourneys and other events which will encourage other women to take up the sport.

Q14: Does golf play a part in your social life?

A subjective question designed to measure the effects of golfing on the social life of the participant. The impact of golf on their social life will lead to using this information as a means of determining the extent of the helpfulness of golf in improving the quality of life of the woman golfer.

Q15: Is your physical health affected by playing golf? (e.g. palpitations, breathlessness, joint pains, increasing or retaining stamina, suppleness etc) Q16: Is your emotional health affected by playing golf? (e.g. pressure from competition, friendship network etc) Q17: Is your mental health affected from playing golf? (e.g. anxiety, security, contented, relaxation, stress relief) Q18: Has your medical practitioner told you of any positive or negative changes to your health since you started playing golf? Please give details. Q19: What benefits do you think that you gain from playing golf? Q20: Are you affected in any way if you do not play golf for an unusual (for you) length of time?

These questions specifically address the healthful effect of playing golf upon the physical, mental and emotional well-being of the golf player. They also aim to establish a self-assessment of the benefits they receive from the sport including questions on any possible ‘withdrawal’ symptoms of not playing golf. The section on whether or not they have been informed of the benefits hopes to help support research that shows the lack of information women have on their health.

Q21: Can you envisage a time when you might retire from playing golf? Q22: What reasons would make you consider stop playing golf? Q23: What prevents you from playing golf?

In order to find the determinants of how a woman might be prevented from playing golf and how a woman might be discouraged from playing golf these questions were included. After all, this information can play into the factors behind why women are not playing golf despite the positive impact is has on their health.

A survey was the original plan for information gathering. Due to the lack of time and resources for tracking down possible respondents, even with the blessing of the Lady Captain, it was decided that one-on-one interviews would be overly time-consuming and counter-productive. A Focused Group Discussion (FGD) was developed instead. The FGD would have the advantage of having all the participants available for questioning at once saving time. In addition, by having them all together it would encourage them to speak up. Furthermore, an FGD would open the gates to a more in depth discussion as the lady golfers would be able to reinforce each others opinions. A final advantage sought is that the women will be able to reinforce their opinions and affirm each other’s responses saving the time and effort to ferret out these opinions.

Data Analysis

The researcher employed content analysis to identity common themes underlying respondent opinions and other feedback. Themes that emerged and were relevant to the study objectives were then subjected to simple descriptive statistics.

Given the exploratory nature of the study and modest sample size, data interpretation focused on the subjective and marginal benefits for physical activity generally and playing golf in particular. After all, it is the opinion of the subject about their health that mattered most.

Results

Rowe and Kahn (1999) propose that maintaining a satisfactory quality of life comprised three aspects: freedom from disease, engagement with life, and physical and mental competence. “High quality of life” means that individuals feel better, function better on a daily basis, and for most part, live independently. Quality of life is subjective, and the value of various components of aging gracefully differs not only among individuals but within individuals at different stages of life.

There is more to health than physical function. Even an otherwise healthy individual may feel that she is unhealthy if she is psychologically depressed. On the other hand, people can be made to believe they are healthy or getting better even if in fact they are not. An example of this is the placebo effect where the ‘patient’ is convinced that the drug she is taking is actually doing him some good. Golf, however, does not create a placebo effect and does indeed create a measurable, if subjective, improvement in the health of the elderly. The fact that the elderly themselves feel subjectively better is already a positive result. The additional fact that research has shown that mild exercise, such as can be had by playing golf, has measurable benefits upon a person’s well being supports these results.

Older people tend to have less access than other demographic groups to physical activity information and programming. Many senior citizens are no longer capable of participating in high impact sports like basketball or football because the aging process has atrophied their athletic capabilities. Furthermore, they no longer feel comfortable in playing most sports with those of the younger generation. Likewise the young do not feel that older people can play competitive sports with them. Old people, in contrast, have relatively more contact with their health care providers who will urge them to actually attempt some form of exercise to supplement therapy and medication that they take to help them age gracefully.

“Starting an exercise program later in life can significantly modify risk factors, even if a person has been sedentary in prior years,” McDermott concludes. “Health care providers can play a major role in offering effective and inexpensive primary or adjunct therapies, encourage appropriate physical activity, and dispel myths that persist as barriers to exercise in the elderly.” Research shows that exercise can have a drastic impact on the health and well being of the elderly, not only physically but mentally and emotionally as well.

The women interviewed were in the 55-70 yr old range. As discussed earlier at this age group many age related diseases are beginning to manifest themselves first as prodromes and later as full-blown maladies that start to strip away the quality of life of those afflicted. Those interviewed showed surprisingly few prodromes or undefined symptoms that may be caused by early symptoms of serious disease or may simply be minor ailments.

Possible prodromes like migraine, exhaustion, shortness of breath, fatigue and lethargy in every day activities were not seen as a problem by these women. It is believed that this is a function of the exercise received during the play of golf. By exerting effort to walk to the lawn and play they increase their metabolism and subsequently their energy levels so as to cope with the other demands of their lifestyle better.

Even those that already exhibited symptoms of disease or infirmity have found that their symptoms were reduced. Exercise appeared to minimize their symptoms and make them feel better overall. This ties in with the belief that proper exercise can help arrest the degradation of a person’s physical health and may even reduce the possibility of ageing related diseases from become chronic.

Engagement with life is important for older persons. With the decline in the number of activities they can actually participate in, older women believe that they are slowly being cut off from life. This leads to depression which aggravates their physical well-being. However, this is not the case for women who play golf. With their sport being a highly social activity, the women who play golf are often interacting with their peers in the sport.

In addition to this there are numerous meetings and social gatherings which the women can participate in over the course of their membership in the golf club which increases the amount of human interaction that the women can do. Not surprisingly, the results show that women who are playing golf have significantly higher levels of engagement with life due to their numerous social activities.

Maintenance of physical and mental competence make up the third aspect of graceful aging. Simple tasks like walking to the grocery or cleaning house which may become difficult for older women who have no exercise are not obstacles to them.

The women are more physically active. This ability to maintain physical competence is ascribed by the women to exercise and golf. With respect to mental competence there is no major correlation between playing golf and keeping mental faculties vibrant. What can be said is that being active in golf results in the women remaining mentally active and thinking. Whether or not this trend is actually more helpful than simply remaining at home or not having any physical activity is subjective. However as this study was undertaken with a view to the subjective interpretation of the women surveyed , it is worth noting that the women themselves think that playing golf is in fact helpful in keeping their mental competence.

With such information in mind it is time to move on to the results of the focus group discussion.

Demographics Q1, Q2, Q4

Due to the highly targeted nature of the study all 120 women fell within the 50-70 year age bracket. The minority (46) fell in the pre-retired or 50 – 60 years age group will the rest (74) were 60 – 70 years of age. The average starting age for playing golf was 58 with most in the 50-60 range. Years playing golf ranged from 1 – 30 years with an average of about 5 years. The demographic information was obtained prior to the focus group discussion

Other forms of Exercise Q3

When this question was asked most women responded no, or that they did not participate in any other exercise. Only upon prompting and enumeration of the types of exercise contemplated were any results gleaned. Some women go jogging while others enrolled in a dance class. This would suggest that 15% of the sample (18 out of 120) gain benefits from exercise other than golf. However, since the majority (85%) still has golf as their only form of exercise the results of the study will still be valid.

Work Status Q5, Q6

Nearly all the women aged 50 – 60 (30) are still working while all the women aged 60-70 are retired. Such results are concluded but not further questioned as it may be too invasive to ask them what their occupations are or why they are not working or why they are retired. This question was only asked to establish what percent of the population surveyed was still working (25%). All respondents replied in the affirmative that they would continue playing golf even after retirement. However, this response must be weighed with the fact that some who might not actually continue simply said yes to affirm the group stand. In other words, group think led them to say, “yes”.

Golf Club Membership Q7

Of the one hundred and twenty women involved in the survey, 84 were members of the golf club. However, this may be attributable to the fact that the women were recommended by the Lady Captain and her bias in recommending members of the club becomes apparent.

Reason for starting Q8

As a purely subjective question, the main relevance is to see what reasons there are for playing golf and how these reasons can be turned into ways to encourage other women to begin playing golf. Ninety-six women said they started because their friends recommended the sport to them. Again this may be a function of group pressure because after one person suggested this answer most concurred with it and no other responses were received.

Frequency of play Q9, Q10, Q11, Q12, Q13

The general response to summer golfing averaged at 3.5 times each week with only one visit to the driving range. Winter play was both once on the course and once on the range each week. Despite denials that they were fair weather golfers this would show that the surveyed women are in fact infrequent golfers.

Social impact Q14

Of all the questions asked in the focus group this question was the most vulnerable to group bias. All the participants can hear one another’s responses. Therefore, there will be a tendency to overplay or exaggerate the social impact of the group activities of the golf club. However, there is still value in the responses as they each substantiate their responses. Significantly most of the respondent retirees said that golf helps lessen the boredom of not doing anything at home. Furthermore, some women said that playing golf enabled them to meet people with whom they would not otherwise interact.

Health Impact Q15, Q16, Q17, Q18, Q19, Q20

Many health benefits were attributed to playing golf. In general the responses point to improved fitness and mobility despite their advancing age. Responses also indicated that the focus group women considered their general well-being and levels of physical activity to be greater than their peers. Positive responses were garnered for mental and emotional health. Perhaps the most significant benefit they are receiving, according to one respondent, is that they do not feel their age. As expected there is no information from their doctors about the benefits of golf to their health.

Retiring from play Q21, Q22, Q23c

The general response to when they will retire from golf is when they are too old to play golf or when they are no longer capable of playing. For those who presently have the means to afford club and green fees at the frequency they play, one can confidently predict that they will continue playing for the foreseeable future. And, as lower-income participants pointed out, there are always municipal golf courses where a round or day ticket may cost as little as £5 or even less.

Discussion

Need to include some discussion regarding the broad range of participant’s ages and therefore range of physical capabilities.

It is well established that exercise is beneficial to the health of an individual. As a matter of fact, the Mental Health Foundation Suggests that exercise is beneficial because;

• Exercise leads to an increased release of endorphins in the body. These chemicals may help combat depression and make us feel happier.
• Exercise helps us to get active and meet new people. This stops us from feeling isolated and unsupported.
• Exercise can give us new goals and a sense of purpose – we have something positive to focus on and aim for.
• Exercise can boost our self-esteem – it can improve the way we look and how we feel about ourselves.

Given the benefits that exercise can give depending on the doctor’s recommendation on suitability of an exercise program for a patient, the Mental Health Foundation can refer the patient to one of 1300 schemes where they can have access to a qualified trainer at a significantly discounted price. These schemes might incorporate swimming, yoga, gym sessions or even dancing. Such schemes will not only promote physical health but also mental and emotional well being as well. Although golf is not yet included in these recommended schemes, the Mental Health Foundation recognizes that exercise will not only improve the physical fitness of a person but will also have an impact on the mental and emotional well-being.

Given the broad age range of the participants, from 50 years to 86, senescence and degenerative diseases had already made themselves felt. Some FGD panellists attested that the disabilities they were increasingly heir to, such as hearing loss, did not materially affect their game.

Other disabilities, such as nearsightedness, could be remedied with glasses and the latest surgery. Those in their 70s and even late 60s had already begun to experience loss of skin sensitivity, dryness, the need to cover up better and hydrate more frequently. Managing diabetes seemed more difficult for those who experienced the onset in middle age than much later. Still, the only serious hindrance to walking and golf the panellists could mention offhand was rheumatoid arthritis when an inflammatory episode prevented them from gripping their clubs properly.

Heartstats.org (2008) concur with the Mental Health Foundation in the belief that people who are physically active have a lower risk of CHD. As already established, CHD is one of the major killers among the elderly today. In order to produce the maximum benefits, however, the activity needs to be regular and aerobic. Aerobic activity involves using the large muscle groups in the arms, legs and back steadily and rhythmically so that breathing and heart rate are significantly increased.

Recent research from the World Health Organization (2002) highlighted the importance of physical inactivity as a major risk factor for CHD. The 2002 World Health Report estimated that around 3% of the disease burden in developed countries was caused by physical inactivity, that over 20% of CHD and 10% of stroke in developed countries was due to physical inactivity (less than 2.5 hours per week moderate intensity activity or 1 hour per week vigorous activity). Thus, the increase in activity brought about by playing golf will have significant effects on the health and wellbeing of the subjects.

Prevalence of CVD in women

In the United Kingdom, coronary heart disease causes almost 114 000 deaths a year and one in six occurs in women (British Heart Foundation 2006). This indicated that there is a significant incidence of coronary disease among women for such prevalence is greater than other medical problems common to women: the lifetime risk among postmenopausal women for coronary disease is about 31%, as contrasted with 2.8% for hip fracture, 2.8% for breast cancer, and 0.7% for endometrial cancer. Women who are in the 55-70 age range are in the postmenopausal stage and thus comprised the participants in the FGD’s.

That coronary disease is the most prevalent illness affecting older women requires greater dissemination. Unless women perceive that coronary disease is actually part and parcel of their illness experience, they may not believe they are at risk for CHD and are not likely to heed coronary disease preventive measures. Instead they will ignore the symptoms until they become chronic in nature and are far more difficult to treat.

In addition, more than 1.4 million people suffer from angina and 275,000 people have a heart attack annually. CHD is the biggest killer in the country. Worse it is a major killer of women, in 2003 alone over 122,000 women died from heart and circulatory disease in the UK (British Heart Foundation 2005), making it a major threat to elderly women. And yet, CHD is preventable.

In Relation to the Research Objectives

The expectation that playing golf has a positive impact on the health and well-being of pre-retirement or retirement age women was strongly borne out, at least to the extent that is possible in a qualitative exploratory investigation. In addition, the other findings reinforce what is known about the women who play golf.

The demographics are as expected, the women in question were targeted specifically for their age. It was established that many of the women took up golf towards the end of their working careers, reinforcing the perception that women saw golf as a leisure activity for later life rather than a competitive sport. The relatively short average period of play of five years is consistent with this perception, that golf is an older person’s sport. Another reinforcement of this perception is the fact that most of the women in the FGD were already retired. Only a few were still working.

As expected the women were not physically active, they did not have any other form of exercise besides golf. Only a minority went against this trend. This confirms the research, which shows a trend of declining activity towards old age.

The finding that a good number of the women in the FGD were members of the Golf club is the result of the bias in the selection process used by the Lady Captain. This bias in turn may be the result of her familiarity with these women versus any other women who play in the golf club infrequently or are not part of the club.

The main reason that the women started playing golf is due to a personal invitation or testimony from another golfer. This suggests that the best way to entice non-golfers to play is to invite them to events at the club. Such finding can also be attributed to the fact that retired women are not as active as they used to be and are not as open to new activities as before. As a result, they need to be invited to an activity before they are willing to try it out. According to the FGD, they will cease play when they are too old to continue playing.

The findings reinforce each other in respect of significant physical, emotional, and social benefits for women who play golf. Since this is a subjective study their personal testimony is given considerable weight. The fact that they feel better is benefit enough for them. The women in the study also reported social and emotional benefits from playing on the course with their peers. Playing golf then helps reduce the feeling of loneliness and isolation associated with being retired. Perhaps the most significant finding is that the women agree that they do not feel their age because they play golf

The results suggest the women who play golf feel they are healthy and fit. The results of the focus group show that the women believe that golf is beneficial to their health. As the FGD focused on subjective assessments this would lead to a positive finding based on their own opinions. This conclusion is somewhat belied by the fact that most of the women who play golf do so very infrequently.

Determinants and Barriers

The main barrier to playing golf for women is the lack of interest and knowledge of the benefits that can be derived from playing golf. Once awareness is established the next determinant/barrier is the cost of playing golf. While it is possible to play for as little as £10 for a 9-hole game in order to access golf and gain its maximum benefits a potential lady golfer needs to invest £250-300 to join a golf club. In addition there may be a need to purchase golfing clothes, shoes and even golf clubs, all of which are expensive. Such expenditure may be beyond the capacity of those who are retired and no longer have stable incomes.

However, the cost of joining a Golf Club will pale in comparison to the cost of heart bypass surgery or reliance upon statins or drugs designed to mitigate the progression of CHD. Once older women are properly informed of the benefits that can be derived from playing golf they should be able to look beyond the monetary costs of the moment and see the benefits and the potential to age gracefully while playing golf.

Costs

As a national concern, CHD costs the health care system in the UK around £3,500 million a year. In fact, health care for people who suffer from CHD — the most costly factor being buying and administering drugs that will ameliorate symptoms – accounts for 79% of these costs;.

Indirect costs to the economy are estimated at about £3,100 million because of days lost due to death, illness and informal care of people with the disease. In total, CHD costs the UK economy about £7,900 million a year (British Heart Foundation Statistics 2005). With this in mind is it not surprising that CHD has a grave economic cost and there is considerable benefit to the country as a whole in addressing it.

Women and Golf

What makes golf such a beneficial activity for women? The research is limited, with few studies designed specifically with women in mind. A Controlled Trial of the Health Benefits of Regular Walking on a Golf Course (Parkkari et al 2000) while aimed specifically at those aged 48 to 64 years, and identifying that the game of golf is a good form of health enhancing physical activity, only considered men. There is yet to be a similar study aimed exclusively at women.

Given that CHD is such a major risk among elderly women it is gratifying to know that moderate physical activity in elderly women can reduce mortality. Moderate physical activity can also improve bone mineral density and reduce the risk of osteoporotic fractures. Osteoporotic fractures are caused by the onset of osteoporosis which is in turn often the result of advanced years. Increased activity encourages the bones to continue the healing process and reduces the risks caused by the loss of calcium in the bones.

Regular golf playing has been found to increase aerobic performance and trunk muscle performance in addition to increasing reductions in weight, waist circumference and abdominal skin fold thickness. Yaffe’s (2001) definition of moderate physical activity included eighteen holes of golf played once weekly. Regular walking on a golf course could beneficially affect cardiovascular risk factors.

Bouchard (1990) described exercise as: “Leisure time physical activity which is planned and structured, and repetitive bodily movement undertaken to improve or maintain one or more components of physical fitness”. By employing such leisure time in playing Golf women will be able to arrest the decline of their physical fitness brought on by ageing.

Brown et al (2001) found no evidence of additional health benefits from vigorous-intensity physical activity over and above those achieved from walking or from moderate-intensity physical activity. Therefore, moderate physical exercise such as playing golf is just as effective at promoting health as demanding, high-intensity exercise such as basketball or football. Given the overall lack of fitness of older women it would be counter-productive and possibly harmful to make then partake of more vigorous exercises.

Unfortunately, participation in exercise and physical activity declines with age from 65% of women aged 16-19, to 10% of those aged 70 and over. Women aged 60 and over have very low levels of physical activity participation with only 12 per cent of women aged 65-74 and 3 per cent of women aged 75 having any significant aerobic activity (Women’s Sports Foundation UK, 2004). Orsini et al (2007) found that among middle-aged and elderly women, the likelihood of engaging in higher total daily physical activity levels decreased with age, body mass index, educational level, smoking, drinking, and growing up in urban places.

Since engaging and maintaining regular physical activity plays a key role in reducing several public health problems, the identification of these significant correlates may help researchers, clinicians, and health policy makers design gender and age-specific interventions.

Although walking remains the most popular physical activity for women of all ages, golf does not register in the top ten popular activities for women. (General Household Survey, 2002). The impact of walking on activity levels is so important to women over 50 that if included in statistics it doubles the participation rate of physical activity in women over the age of 60. For women in Yorkshire, recreational walking is top of the sports participated in by those over 16 years – while walking is similarly top of Yorkshire men’s sporting activity, golf takes fifth position for men, but does not appear in the top ten for women (WSF 2006).

Hollman et al. (2007) found that women with higher physical activity showed significantly lower age-related reduction of cognitive abilities, pointing to the fact that physical activity counters the age-related reduction of cognitive performance capabilities.

Mere walking does not provide upper body exercise that golf provides. Furthermore, while is possible to form sport-walking clubs there is little social activity in sports walking. Walking develops the endurance of the participant and this can have healthful effects. A golf club on the other hand can ensure that there will be considerable social interaction during and after one plays golf. For as little as £5 a person can begin playing golf and enjoy the benefits derived from it.

Conclusions

There are no extant studies on lady golfers; given the physical and psychological benefits of regular golf playing, this is an area that bears validation and support as another activity that will encourage women to remain active, fit and healthy. While admittedly based on qualitative research, this study discovered such widely-held perceptions and depth of feeling about the multiple benefits of the sport that it is, at the very least, a firm foundation for more reliable quantitative analyses in other areas around the country.

The affirmation of multiple physical, psychological and emotional benefits is also valid enough to begin evaluating NHS patients for their suitability for adding golf to a repertoire that will reduce the risk of CHD and other degenerative diseases. Further down the road, one logical quantitative extension could be a longitudinal study comparing the triad of benefits and general health status of a cohort of women golfers with control groups that are sedentary or engage in other regular activities.

Ageing is unavoidable, but its effects can be counteracted. Through proper diet and exercise women can expect to enter their retirement years gracefully and be free of the risk of CHD. Just a few preventive steps could prevent severe economic strains. Even the £300 yearly membership costs of joining a Golf Club will pale in comparison to the cost of heart bypass surgery or reliance upon statins and other drugs designed to mitigate the progression of CHD. Moreover, as a preventive exercise, playing golf could also delay, if not stop altogether, the onset of other aging / inactivity-related maladies such as osteoporosis and depression.

Even minor increases in the level of physical activity can drastically improve a person’s physical and emotional well-being. Golf only involves moderate physical activity, it does not entail running, jumping or other heavy physical exertions that might endanger the women exercising. At most playing golf will require the subject to walk to the ball and swing a club. Such moderate exercise will prove most beneficial to women in their retirement years.

In addition to direct physical health benefits, playing golf has also been established as helpful to the psychology and self-esteem of the player. Given that a number of i.e. psychosocial factors are associated with an increased risk of CHD it is important for an aging potential CHD patient not only to be physically healthy but also emotionally and mentally healthy. This is a good reason to provide the psychosocial support offered by a golf club to retiring women.

Although only 10% of women may claim to report a lack of social support (Heart Stats.org 2008), this number rises dramatically among women who perform semi-routine or routine jobs who are more than twice as likely to suffer from this perceived lack of social support. Such women include those who are nearing retirement or are already retired. Cut off from their old working environment, these women are relatively isolated from their social structures and without a job their financial means to go out and be more active is impaired as is their emotional health.

Fortunately, the women involved in the study seem to have found a solution to the looming problem of CHD. They have found that playing golf reduced the chances of their developing the symptoms of CHD because of the exercise they gain from it. Furthermore, the increased interpersonal interaction that they get from playing Golf relieves some of the psycho-emotional burden that they would have felt after they attained retirement age. Although not as pronounced as it was in the previous generation the fact that they would ordinarily no longer be as active after ending work still imposes undue suffering upon them.

One important example of such undue suffering is that fact that many of the retired women no longer have set day-to-day activities which require any notable amount of aerobic exercise. Based on their own testimony, playing golf is the only activity they have to which they attribute ability to remain active despite their advancing age.

To conclude, this study aims to uncover the link between playing golf and improved quality of life. It is an Investigation into the benefits, determinants and barriers of golf playing for women of pre-retirement and retirement age. The results, as mentioned above, show that the women experience a quality of life that is not available to women who do not have access to golf or other light exercise. The connections established in the golf club with their peers help replace the social connections they lost when they stopped working. As a whole the physical, psychological and emotional benefits of playing golf results in an improved quality of life for these women. The primary barrier that prevents more women from taking up golf is the high cost of playing this sport.

The study’s sample size is small. In order for the findings to become more authoritative it will be desirable for a future study to have a larger sample size and one that is based over a range of golf courses. The current study’s findings coupled with the encouraging results merit a wider, more far reaching study to verify and expound upon its findings.

Recommendations

Given the level of benefits that can be achieved in playing golf it is imperative that older retiring women are encouraged to play golf. Beyond ignorance and lack of information, the primary barrier is the cost of actually starting to play golf. Such barrier is addressed by two possibilities; first government subsidy for public golf courses and second time-sharing agreements.

Public golf courses

£250-300 is a lot of money for the average retiree. With only a pension to rely upon the target audience could suffer unduly from the high cost of entry. Furthermore, other expenses needed to play golf with discourage them from even starting. The solution to this would be to take advantage of public/municipal golf courses with days and times specifically addressed to older men and women. With the potential health benefits being considerable there is reason to believe that such a program should be pursued.

As for feasibility, significant benefits can be achieved by public golf courses. Given the extraordinarily high costs of CHD medications and health care of CHD sufferers and the fact that it is the government that is often forced to foot the bill, it will be cost effective for the government to use the money instead to maintain the golf course. The cost of maintaining a golf course is drastically smaller than the £7,900 million spent in 2005 alone for the treatment of CHD, which again largely came from the government health care budget.

Time Sharing Agreements

Time share agreements are more common in the US but are beginning to gain interest in Europe. In general, time-sharing revolves around expensive property such as Country Clubs, Vacation Homes or Yachts which are ordinarily out of reach of the participants pockets. By entering into a time share agreement two or more parties the parties bind themselves to use the property only at certain times of the year and pool their resources to purchase it. The idea is not unlike share holders in a corporation. Part ownership of the property allows them to use the property without having to invest in the full amount.

While the principle is still currently limited to real estate and yacht clubs, the same idea can be applied to golf club memberships. By sharing the financial burden the parties will be able to enjoy the benefits of golfing at reduced cost.

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Kobriger, S.L. Smith, J. Hollman, J.H. Smith, A.M. (2006) The Contribution of Golf to Daily Physical Activity Recommendations: How Many Steps Does It Take to Complete a Round of Golf? Mayo Clinic Proc. 81 (8), 1041-1043.

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Hermanson, B., G. S. Omenn, R. A. Kronmal, B. J. Gersh, and Participants in the Coronary Artery Surgery Study. Beneficial six-year outcome of smoking cessation in older men and women with coronary artery disease. Results from the CASS Registry. N. Engl. J. Med. 319:1365-1369, 1988.

Hubert, H. B., M. Feinleib, P. M. McNamara, and W. P. Castelli. Obesity as an independent risk factor for cardiovascular disease: a 26-year follow-up of participants in the Framingham Heart Study.Circulation 67:968-977, 1983.

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Kannel, W. B., R. J. Garrison, and P. W. F. Wilson. Obesity and nutrition in elderly diabetic patients. Am. J. Med. 80(Suppl. 5A): 22-30, 1986.

Kaplan, N. M. The deadly quartet. Upper-body obesity, glucose intolerance, hypertriglyceridemia, and hypertension. Arch. Intern. Med. 149:1514-1520, 1989.

Kawachi, I., G. A. Colditz, M. J. Stampfer, et al. Smoking cessation in relation to total mortality rates in women. A prospective cohort study. Ann. Intern. Med. 119:992-1000, 1993.

Kennedy, J. W., T. Killip, L. D. Fisher, E. L. Alderman, M. J. Gillespie, and M. B. Mock. The clinical spectrum of coronary artery disease and its surgical and medical management, 1974-1979. The Coronary Artery Surgery Study. Circulation 66(Suppl. III): 16-23, 1982.

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National Center For Health Statistics. Health: United States, 1990.

Hyattsville, MD: U.S. Public Health Service, Centers for Disease Control, 1991.

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Perkins, J. and T. B. S. Dick. Smoking and myocardial infarction. Secondary prevention. Postgrad. Med. J. 61:295-300, 1985.

Rosenberg, L., D. W. Kaufman, S. P. Helmrich, D. R. Miller, P. D. Stolley, and S. Shapiro. Myocardial infarction and cigarette smoking in women younger than 50 years of age. J.A.M.A. 253:2965-2969, 1985. Link To Full Text Bibliographic Links.

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Wenger, N. K., L. Speroff, and B. Packard. Cardiovascular health and disease in women. N. Engl. J. Med. 329:247-256, 1993.

Willett, W. C., A. Green, M. J. Stampfer, et al. Relative and absolute excess risks of coronary heart disease among women who smoke cigarettes. N. Engl. J. Med. 317:1303-1309, 1987.

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