A participatory evaluation of the health promotion programme “more healthy years of life” programme among senior citizens in Sweden

Abstract Background: Older adults have, in general, been sparsely involved in development and evaluation of programmes intended to promote their health. Aim: To describe older adults’ reflections on and involvement in the development and evaluation of a health promotion programme. Material and Method: Ten older persons participated in a health promotion programme (HPP) focusing on activity during four sessions. After each HPP session, focus group discussions were held, analysed through qualitative content analysis. Results: The main theme; “Being involved adds value and new experiences to life“, were built from sub-themes; “From sceptical individual to engaged group member”, “From beholder to active co-creator”, and “From individual knowledge recipient to collective knowledge sharer”. Conclusions: Having a leader with a gerontological competence was mentioned as important, as well as to integrate existential topics into the HPP. Social inclusion together with the possibility to influence the HPP had a positive effect on the participants and provided a sense of belonging. Significance: Several contributions to the development of the HPP were given, that would not have been captured without the reflections and involvement of the participants. However, more and larger studies are needed to develop strategies that enable older adult’s involvement in the development of HHP.

Abstract: Background: Older adults have, in general, been sparsely involved in development and evaluation of programmes intended to promote their health. Aim: To describe older adults' reflections on and involvement in the development and evaluation of a health promotion programme. Material and Method: Ten older persons participated in a health promotion programme (HPP) focusing on activity during four sessions. After each HPP session, focus group discussions were held, analysed through qualitative content analysis. Results: The main theme; "Being involved adds value and new experiences to life", were built from sub-themes; "From sceptical individual to engaged group member", "From beholder to active cocreator", and "From individual knowledge recipient to collective knowledge sharer". Conclusions: Having a leader with a gerontological competence was mentioned as important, as well as to integrate existential topics into the HPP. Social inclusion together with the possibility to influence the HPP had a positive effect on the participants and provided a sense of belonging. Significance: Several contributions to the development of the HPP were given, that would not have been captured without the reflections and involvement of the participants. However, more and ABOUT THE AUTHOR Sofi Fristedt The present article is written by an interdisciplinary group of researchers within health sciences, representing public health, nursing, as well as occupational therapy and science. When conducting the data collection of the present study all five researchers were also involved in the Ageing Research Network -Jönköping at Jönköping University, School of Health and Welfare. Several in our group have a special interest in health promotion and have conducted previous studies on similar topic. Moreover, the knowledge gained from the present study will inform future studies on activityrelated health promotion programmes or interventions.

PUBLIC INTEREST STATEMENT
Health promotion programmes (HPPs) have positive effects on health and well-being in later life. However, few of these previous research studies have involved older adults' in the development and evaluation of a health promotion programme. Thus, it is important to gain more knowledge about these programmes from the participants' perspective. In this study ten older persons participated in a HPP focusing on activities. After each HPP session, the same persons were interviewed in group about their thoughts on and experiences about the HPP: The interviews revealed that the participants wanted the groups to be led by persons with knowledge on ageing. They also wished to integrate existential topics (including death and dying) into the HPP. Social inclusion together with the possibility to influence the HPP had a positive effect on the participants and gave them a sense of belonging. larger studies are needed to develop strategies that enable older adult's involvement in the development of HHP. Subjects: Allied Health; Occupational Therapy; Nursing Older People; Public Health Policy and Practice Keywords: belonging; education; health promotion; older adults

Background
As commonly known, older adults face an increased risk of age-related changes (Jivraj, Nazroo, Vanhoutte, & Chandola, 2014), with potentially negative consequences to activities, participation and health. To successfully target these consequences, authorities and policy-makers need to develop preventive strategies, focusing on promotion of activity, health, safety and security in later life (European Commission, 2012). Such strategies should, of course, build on scientific evidence. For example, the correlation between physical activity and health (Bauman et al., 2016) is well known. But also social activities are important for older adults' mental health and well-being, and social networks are vital in order to give life meaning and create new social roles (Forsman, Schierenbeck, & Wahlbeck, 2011). Wilcock and Hocking (Wilcock & Hocking, 2015) concludes that health is dependent on doing activities that support the person's being, generates becoming and provides belonging throughout life. Moreover, empowerment is essential for the experience of health, and can be stimulated if older adults can take control of their daily lives through health promotion interventions and strategies (Toofany, 2007;Warren & Cook, 2005).
Thus, health-promotion strategies should support older adults in taking personal responsibility for an active life, to remain in control of their everyday lives, as well as social participation (2014). Additionally, it is important to individually customize health promotion initiatives and establish supporting social structures, since older adults' abilities and opportunities to take responsibility for their health may vary (Kjellström & Ross, 2011).
Health promotion programmes are considered vital to promote older adults' health through healthy life styles and occupational participation (World Health Organisation, 2012). Health promotion programmes, building thoughts in line with occupational science (Pierce, 2014) and occupational therapy have been designed and successfully evaluated worldwide, for example, in the United States, Japan and Sweden (Clark, Jackson, & Carlson et al., 2012;Clarke, Azen, & Zemke et al., 1997;Johansson & Björklund, 2016, Yamada, Kawamata, Kobayashi, Kielhofner, & Taylor, 2010, Zingmark, Fisher, Rocklöv, & Nilsson, 2014. However, participatory evaluations of these health promotion programmes, involving older adults beyond being subjects of the research, have been scarce (Fudge, Wolfe, & McKevitt, 2007). Thus programmes risk to be less successful by not fully addressing the experienced health needs (Lewes & Hulatt, 2005).
Older adults' reflections on taking part in these programmes are vital for further development of programmes and are likely to generate positive outcomes and user satisfaction (Lewes & Hulatt, 2005). Moreover, it is a shortcoming that the participants' perspectives on content and programme implementation seldom are described in research articles. This is surprising since health promotion programmes intend to empower their participants. Empowerment, defined as: " a multidimensional social process that helps people to gain control over their lives", (Page & Czuba, 1999, p. 1), is one benefit described from involving older adults in research as users (Fudge et al., 2007).
User involvement in research can take different forms. Arnstein´s (1969) ladder, reported in (Nolan, Hanson, & Magnusson, 2011), illustrates different levels of participation and can be used for discussing user involvement in research. The lowest level of participation is manipulation and therapy, followed by three forms of tokenism (symbolic efforts), where the participants can be informed or advised. In the top of the ladder is partnership, delegated power and citizens' control respectively. Our project aimed to reach the higher steps of user involvement, that is beyond the steps of tokenism. Therefore, the aim of this study was to describe older adults' reflections on and involvement in the development and evaluation of a health promotion programme.

Material and methods
A descriptive, qualitative design was performed using focus group discussions involving older adults, to respond to the study aim (Krueger & Casey, 2015).

Participants
Older adults living in a small town (with in total 1500 inhabitants) were invited to participate in a health promotion programme (HPP). They were also asked to reflect on and be involved in the development and evaluation of the health promotion programme. The participants were recruited through convenience sampling (Polit, 2016). Community-dwelling men and women, above 65 years of age, were contacted.
One member of a senior organization initiated the first contact with the participants (who did not have to be member of the same organisation), and asked each person individually about their interest in participating in the project. Those interested received an information letter in line with the ethical guidelines for research. The group leaders collected the consent forms before the first session started and questions could be asked.
Finally, ten persons including four women and six men, mean age 75.7 years (66 years−89 years), gave their written informed consent to take part in both the HPP and the data collection for this study.

The health promotion programme
The HPP-meetings were held in a public facility in the participants' home town, but in rooms available only for the participants, lecturers, group leaders and focus group moderators during the sessions. The data collection followed in direct connection to each of the four sessions of the HPP, using the sessions as a starting point for focus group discussions. The HPP sessions were inspired by Lifestyle Redesign (LR) © -methodology (Clark, Blanchard, & Sleight et al., 2015;Mandel, Jackson, & Zemke et al., 1999). The four sessions, held every other week, had separate themes: (1) introduction and information about the project. Public health and activity in later life. (2) The natural aging and changing patterns of activity. (3) Physical activity and nutrition and their links to health. (4) Mental activity and its links to health (web lecture).
Firstly, these fours sessions included lectures focusing on the specific theme for the session and everyday activities were given. Secondly, discussion and exchange of experiences among participants related to the themes were held. The intention was that participants should discover the potential and power of activities, and analyse their needs for activity, and if relevant, change their own activity patterns (Mandel et al., 1999). These group sessions were led by a university lecturer/ occupational therapist together with a public health planner/occupational therapist. Both leaders had previous experience of leading health promotion group activities. After each session, the participants received a written summary based on that day's content.

Data collection
Directly after each of the four HPP-sessions, the participants took part in focus group discussions (Krueger & Casey, 2015), that is the data collection for the present study. The grouping was made spontaneously by the participants, so that both groups included five participants. The same groups were kept during all four focus group sessions. The discussions lasted about one hour under the guidance of a moderator in each group, and were held in two different room at the same place as the HPP sessions. Both moderators were researchers in the field of gerontology and did not participate in the HPP group sessions. One of them also had a background in public health and the other person in nursing.
The discussions were recorded using a digital voice recorder. A semi-structured interview guide was followed to allow a deeper understanding of participant's reflections on participation in a HPP. The first focus group discussion also focused on the participants' own expectations, and what they thought older adults (in general) would expect from a HPP. The remaining three focus group discussions all started with a résumé of the content in the previous focus group. After that, the significance of the current session theme for a good later life was discussed, and whether the content would be likely to affect older adults' lives. Also, issues related to content and structure of the programme were covered, for example complexity, relevance, performance of presenters, media used for presentation etc. All focus groups included discussions of who would benefit from listening to the information, and how this target group could be reached. At the end of each focus group, perceptions were summarised and reported back to the participants for member checking in order to promote trustworthiness (Creswell, 2013). These are examples of questions asked: What expectations do you, and people in your own age group have, about health related program for elderly? Do you think the topic of today is of importance for "healthy aging"? To what extent was useful for you and why/why not? How does the content of the session worked? For whom is this knowledge you have got today important and why? How can we reach (other) people who need this knowledge? What characteristics are required from a person leading such session?
To summarise all sessions followed the same order; that is started with a lecture (30 mins), followed by a group sessions lead by same group leaders each session (1.5 h) and finally (for the purpose of the present study) focus group discussions (1 h) were held.

Data analysis
The transcript of the focus group discussions was analysed in accordance with the steps of the content analysis (Elo & Kyngäs, 2007). Data were analysed inductively, that is the starting point was the interviews and themes that emerged from this material (Elo & Kyngäs, 2007). The first step in the analysis was reading the transcribed interviews, that is the unit of analysis. Then words, sentences or paragraphs containing aspects related to each other through their content and context, that is the meaning units, were marked in the text and placed in a table for analysis (Table 1).
The meaning units were then condensed into smaller units (condensed meaning units) to make the body of the text more manageable. The condensed meaning units were then given descriptive code names that were as close to the original text as possible. Codes with similar content, which could be said to belong together, were then placed together and given a content-describing sub- Too early to answer the first time, if it's good. Not enthusiastic, but want to try. Has been a good group and the discussion afterwards is important.
Initial scepticism Group/discussion to community From sceptical individual to engaged group member theme name. Sub-themes and codes were constantly compared to each other and the original text. In that way, their relation to each other and the overall main theme was checked, and whether the selected overall theme described information as expressed in the data.
Until the formation of the codes, the analysis was conducted by the two researchers who moderated the focus group interviews. When grouping codes as well as forming the subthemes and themes, three more researchers and also the project manager took part in the analysis in order to increase credibility (Creswell, 2013).

Ethical considerations
The study was approved by the Regional Ethical Committee in Linköping, (2014/266-31). The fundamental ethical requirements regarding information, consent, use and confidentiality were considered (the Swedish Research Council, 2002) in the project.

Results
The participants' reflections on their involvement in the development and evaluation of the HPP can be described through three sub-themes; "From sceptical individual to engaged group member", "From beholder to active co-creator", and finally "From individual knowledge recipient to collective knowledge sharer" (Table 2).
From the subthemes a main theme; "Being involved adds value and new experiences to life" emerged. Thus the main theme suggests that being involved in developing the HPP, alongside taking part in it, added value and new experiences to life. The results will be presented below with the sub-themes as headings . Gender and participant number (e.g. P3, woman) are found behind each quote, to illustrate the source of each statement.

From sceptical individual to engaged group member
At the first session(s), the participants expressed themselves as individual persons, but during the later sessions of the HPP the participants experienced themselves more and more as part of the group, and felt they had been exclusively selected and were important to the research.
Since they lived in a small, urban town, they knew each other by name, but had no former social contacts. They were invited or summoned to a meeting by a common acquaintance, also the initiator of the programme sessions, without really knowing what the programme would include. They expressed initial scepticism concerning this invitation procedure, and concluded that initiatives like the HPP should be marketed by care professionals rather than lay persons from the community. Nevertheless, they said they had time for these kind of activities as they were retired. Some felt obliged to take part on the first occasion, even if they lacked the motivation for doing so. "I must confess, I don't feel so motivated, but you should never give up at first. . ." (P3, woman).
However, usually nothing much is happening in the small town, so the participants also admitted being curious and wanting to learn more about what was going to happen in the HPP. They have heard others talking about the initiative as an education for older adults, and consider this to be positive for people in their small town. "Yes, I thought it would be exciting to attend. . .and find out what this was. Yes, and we didn't know who were coming. . .either. . .but I need to say that so far [the first session] this has been positive" (P6, man). Participants also concluded that older adults tend to keep the same friends and relationships, and sometimes have difficulties in changing these relational patterns, because they live in a small town. The invitation to the HPP was from this perspective an exciting possibility of gaining new acquaintances. "Yes, that's the problem commonly. . .in later life we often stick to the same people, and we don't dare to change. . ." (P2, woman). These new, rather than old, relationships and thus not being "stuck in a rut", were also considered to enable fruitful and constructive discussions in the group.
"Very exciting to be part of group where participants recognise but do not know each other. . . This way new ideas developed each time. If we had known each other (before], we would have dwelled on subjects as they do in sewing circles" (P5, man).
To further facilitate their active participation throughout the programme, the participants considered it important that an introduction was given on a general level and that the subsequent meetings illustrated health and health promotion from different perspectives. They found the HPP content interesting and important, but emphasized that more people should have the possibility to take part in such a programme, since health issues are relevant for everyone, regardless of age, gender or political opinion, etc. In addition, they stated that HPPs should be open to more older adults and younger persons, since knowledge of health promotion is relevant for everyone during their whole life span.
The participants felt encouraged to express their views on the HPP content, and consequently were happy to provide such. This contributed to yet another positive experience from being an active and important member in this group. "Oh yes, it has been so encouraging. . .whatever we have said [leaders and presenters] has been encouraging. . .It is remarkable [laughing] that we are pioneers. . .I mean, in this small town" (P4, man).
Obviously, participants felt privileged at having been selected to take part in the HPP, and the focus groups. "Don't you agree? We are in fact selected, we're not just anyone. We became part of this group since we were selected" (P7, woman).
Taken together, their motivation developed and increased over time through their involvement, and participants expressed looking forward to the later programme sessions, since they considered these occasions to be an important meeting place for these new relationships. During this process, people who started out as individuals, thus became significant and important parts of a community.

From beholder to active co-creator
Through the programme, the relationships in the group become deepened, suggesting that the discussions and the confirmation of recognizing their own situation in others engenders trust in each other. The focus group attained a main role in the HPP. In the beginning of the HPP the participant experienced themselves as more inactive but as the HPP proceeded their engagement increased. It could be described as that they went from beholder to active co-creators.
Throughout the HPP, the group leader was considered as important and played a significant role. For example, the leader was considered important since they kept the structure and ensured that all participants played an equally important role in the discussion. However, the knowledge communicated by each guest lecturer in the HPP was considered important since they mediated expert knowledge. The participants also appreciated being invited to ask questions during the lecturers, since that were considered to facilitate the learning and understanding of each programme session.
"Time flies! But that is probably because the lecturers do not speak all the time, and what´s makes it so good is that we also are encouraged to speak; that's probably what makes it so good. It is positive, absolutely" (P8, man).
The participants put great value on recognizing themselves in others and that the questions they were urged to ask were never perceived of as being stupid. Furthermore, worries that one person had were also recognizable to others, which was perceived as being an important confirmation during the HPP. The focus groups that were held in smaller groups after each programme session gained a major role. The participants found the focus group discussions to be an important arena for discussion, but also for reflections. Participants listened, spoke to each other and reflected on their own and other persons´situations. "Yes, but this focus group where we can talk afterwards . . . it has become the best part in fact, I think so. [several says yes]. It's very important, I think so. Yes, you really look forward to this" (P6, man).
Among other things, participants highlighted the importance of speaking about death as a natural part in the HPP. They therefore suggested adding existential health to the programme, as long as this aspect was led by a professional lecturer. During the HPP, the participants instantly described themselves as being seen and respected by others, leading to an increased trust in both leaders and the other participants. This trust was said to be built from a good group design in which participants could recognize each other, but also facilitated by the small size of their town.
"Yes, we've had it so nice, and it is probably because we live in a small town where everyone knows each other. It is not sure that we'd have talked this much in a big city, where you are less familiar with others" (P4, man).
In this sub-theme, a change over time was described, where the participants were rather inactive to start with, but increased their engagement as the HPP proceeded.

From individual knowledge recipient to collective knowledge sharer
Although most information given in the HPP was new to some participants, others experienced it as common knowledge. On the other hand, they received confirmation that their knowledge was up to date. "So far it has involved knowledge about nutrition, something that we already knew about. But, though it is clear for us, it shows that you are eating right". (P8, man) The various programme sessions initiated different kinds of questions and reflections according to the participants. Health advice together with the participant's individual health condition ended up in lively discussions within the group. Sometimes, the lively discussions questioned the message given by the lecturer. For example, the common advice of being physically active was brought up by the group, and considered problematic from potentially causing bad conscience for participants with limited ability to exercise due to disabilities. Consequently, the participants sometimes regarded the knowledge and the health advice given in the HPP as too demanding and stressful. The awareness that you ought to improve your health was considered to increase the risk of feeling excluded.
"For example, she can´t do the same exercise as us since she is disabled; she can´t move. It isn´t easy to be told that you should exercise because it tends to give you bad conscience since not all of us can do it! But are the disabled ones supposed to accept declining health just because they are unable. . .? " (P6, man).
Some participants considered health information on for example nutrition to be judgemental, while others did not agree on that. Medications were considered another problematic area. Participants were ambivalent as to whether it was beneficial or negative to stop taking any of the different medications they were prescribed. One the one hand, it was commonly known, that they should not take too many medications, on the other hand they thought that health limitations could perhaps increase if you stopped taking them.
"I am a bit ambivalent related to medication. . .Maybe you could improve your health now, so you don't have to take so much medication. . .but on the other hand you don't dare stop taking those [medications] either" (P9, man).
The participants considered that their lived experience facilitated them in sometimes taking the knowledge presented in the HPP with a pinch of salt. The HPP, according to the participants, should focus on promoting one's individual health rather than that of the group. They also acknowledged a risk of feeling guilty because of the health choices they had made, or not made, in life. As long as the health information was given on an individual level, each individual could adapt it to their own situation. Information given under these circumstances, was also considered inspiring and encouraging, as illustrated in this dialogue between three participants: (P9, man) "-You are happy if you are able to get out of bed! (P6, man) -Yes, I have been able to walk without any problems at all, 30 minutes each day, but that doesn't work now! No, at least not in wintertime when it is cold.
(P7, woman)-No, but I don't think we should compare.
Based on their different views and individual prerequisites, they considered it important that presenters had gerontological knowledge and adapted their presentations to the different needs of the participants. Being in a group, led by a person that gave everyone the chance to speak and be heard was then considered to be the key components of a HPP.
To summarise this sub-theme, the knowledge presented was gradually more and more questioned by the participants, and this was described as a development influenced by the fact that they got to know each other more.

Discussion
The present study identified benefits of involvement in the development and evaluation of HPP, in line with aim of the study, from the perspective of the participants. As indicated by the main theme, this involvement added value and new experience to life, beyond taking part in the HPP. The focus groups were added as a mean for user involvement in the research process. However, the analysis revealed that the participants experienced the focus groups as a vital part of the HPP, even if this was not the initial intention.
From the very beginning, participants were rather quiet in the focus group, making the discussions somewhat challenging to moderate (Lewes & Hulatt, 2005). However, similar to previous studies (Lewes & Hulatt, 2005), this changed over time, and the participants took more and more part in the discussions. The focus group discussions were experienced by the participants as an opportunity to reflect upon personal experiences, and compare them to other person's experiences also deepening the understanding of the current session content. This was an unexpected result, influencing the transferability of results to other contexts, but gave us the idea that focus groups could add value to the actual HPP. Further and larger studies are needed to confirm these results in other contexts.
Our study intended to involve the participants beyond being subjects of the research, as previously suggested (Fudge et al., 2007). However, our results show the complexity of their involvement. The older adults clearly appreciated being invited to participate, said to feel "special" from being asked for, and seemed to feel empowered from this involvement. But, since they had no previous experiences from similar situations they seemed to find it somewhat difficult to contribute, at least in the beginning. Obviously, user involvement in research can take different forms, and various measures (e.g. participant training or workshops) are likely to be needed in order to enable involvement for different target groups (Lewes & Hulatt, 2005).
In the present study, we aimed for the higher steps of Arnstein´s (1969) ladder, that is steps above tokenism as reported in Nolan, Hanson and Magnusson (2011), including partnership, delegated power and citizens' control respectively. The study was initiated in partnership with a representative of the senior organisation. However, several participants considered themselves rather "voluntold" to go to the first HPP session, i.e., they agreed to go since they were encouraged to, rather than attended based on own interest. This had an impact on their involvement, at least to begin with. Over time they developed an involvement close to partnership. In fact, previous research (Clough, Green, & Hawkes et al., 2006;Warren & Cook, 2005) question if, for example older adults, want to use control on the highest level or if partnership is enough.
For an even higher degree of user involvement, it would have been relevant to include the participants when planning the programme. On the one hand, given the experiences described above that would have required another kind of recruitment and measures (Lewes & Hulatt, 2005) to enable at least partnership as defined in Arnstein´s (1969) ladder, reported in (Nolan et al., 2011). On the other hand, is it quite rare to hold focus groups after each session in a HPP. Most previous studies (to our knowledge) include evaluation together with users upon completion of the whole programme. Importantly, several contributions to the development of the HPP were given, that probable not would have been captured without the involvement of the older adults in these regular focus group discussions.
Previous research in this area has shown that older adults sometimes perceive barriers and refuse to participate in HPP (Wright & Hyner, 2011). On the contrary, our results show that this group of older adults gladly participated since they were involved in the process. Over time, the participants clearly developed a health-promoting sense of belonging (Wilcock & Hocking, 2015) within their new group, a benefit previously noted from user involvement (Lewes & Hulatt, 2005). Because of living in a smaller town, they were familiar with each other, however, did not really know each other, from the start. They acknowledged that making these new relationships was something quite unique at their age, and that it would not have happened outside this programme. Actually, gaining a sense of belonging from doing something together with others (Wilcock & Hocking, 2015) may be the most important health-promoting effect from participating in the HPP.
Not only the relationship among participants was acknowledged, but also the relation to group leaders, lectures and researchers were acknowledged by participants to be important. For example, participants pointed to the importance of having leaders with a gerontological competence, since many of the participants faced age-related health disorders. They thought a leader with this competence could provide health promoting advices that would be more applicable to their unique and individual life situation.
Although appreciating the lectures expertise, the participants sometimes said they took the knowledge presented "with a pinch of salt". For example, they questioned advices on diet, the amount of physical activity and medication. This may be due to the fact, that they are likely to have heard a lot of different health advices during their lifetime, since for example diet recommendations have changed somewhat over time. Thus, the older adults lived experience of changing health recommendations may contribute to their current attitude. Consequently, HPP leaders must pay respect to these previous experiences of shifting advices, and also adapt the content in a person-centred manner (Ekman et al., 2011).
Moreover, participants found it stressful to follow the physical activity recommendations. For example, the recommended amount of time in physical activity per day, gave them a bad conscience. Their reflections in this area seemed quite rational, pointing to the need of adapting health advice to individuals in different situations and with limited physical ability, something that is supported by previous research (Physical Activity and Public Health, 2007). There is a risk of giving participants a bad conscience if lifestyle matters are discussed, without gerontological knowledge or life course perspectives in mind. Again, HPP leaders must pay respect to these previous experiences of shifting advices, and also adapt the content in a person-centred manner (Ekman et al., 2011). This is vital, also from the point that older adults' are a heterogeneous group, as described by, for example (Bäckman, Small, & Wahlin, 2000). Similarly, participants also questioned some of their own drug treatments, based on the common standpoint that older persons take too many medications (National Board of Health and Welfare, 2010). However, joint decisions including medical staff and the older persons (rather than laymen decisions) seem vital in this area, in line with person-centered care (Ekman et al., 2011).
Interestingly, much of the focus group discussions focused on these advices, most likely since the participants found some of them annoying. The group sessions, with their focus on activities and how to use the information from the lectures in their daily life, received less attention from the participants during the focus groups. We cannot say for certain why this was the case. Maybe the group session discussions were experienced as less controversial by the participants. Or, perhaps the group leaders, with gerontological knowledge as well as occupational therapy backgrounds, were more successful in adapting the content to the participants, including their life situation and everyday life.
Previous research shows variations in older persons' reasoning about taking responsibility for their own health (Kjellström & Ross, 2011). HPP needs to acknowledge these variations in reasoning, including the participants' different pre-conditions and circumstances potentially affecting their possibility in taking responsibility for their own health (Kjellström & Ross, 2011). Our results suggest that health care staff and other experts should include older persons in the discussions and reflections on health advice, rather than just informing them as end-users. Discussions during the sessions and in the subsequent focus groups provided opportunities for clarification. Again, such parts of the HPP can be important to avoid the risk of misinterpretation of the message that could jeopardize the older adult's health.
The leaders, together with the focus group moderators, were considered to be an overall important part of the HPP. Generally, for being enablers but also for playing an important role for the social interaction in the group. The participants pointed out that, as long as the leader was part of the HPP, they experienced the meeting as meaningful, and they would like to continue to meet. However, they claimed they would not continue meeting after the HPP without a leader.
Unexpectedly, a willingness to integrate existential topics including palliative care and death as a natural part of an HPP was expressed. To address such existential aspects (Melder, 2011), would be clearly in line with a holistic health promotion perspective (Moll, Gewurtz, Krupa, & Law, 2013). Since, the HPP, clearly had an emphasis on doing (Wilcock & Hocking, 2015), the wish from our participants to add content that reflects and supports being as well as becoming (Wilcock & Hocking, 2015), are interesting and relevant. In fact, few current HPPs seems to address these areas.

Methodological considerations
The use of focus-group interviews (Krueger & Casey, 2015) analysed by qualitative content analysis (Elo & Kyngäs, 2007) was designed according to the aim of study, namely to collect a broad range of older persons' reflections on participation in an HPP.
It is vital to consider whether the recruitment of the study group in some way risked causing bias in the results. The older persons were "voluntold" to join the programme by another member of their senior association. This implies that some of them did not attend the programme out of their own interest, but felt they were expected to do so. This may cause a risk that they participated to avoid being excluded by other members in the association. On the other hand, this entailed that the participant group consisted of a broad spectrum of persons with both positive and negative attitudes towards participating in the programme. Another problem was the role conflict it may have caused for them both to participate in the programme and to reflect upon the content and structure of the programme in the focus group discussions. However, the information they shared for the study points in rather the opposite direction.
The participants comprised older Swedish men and women of different ages. Our ambition was also to recruit a group of persons with immigrant backgrounds to the programme, but this failed, mostly because of our lack of contacts within the area where they were situated. This means there is a limitation of transferability (Creswell, 2013) to a broader group of older persons in society. Similar studies are needed to explore issues in line with the aim of this study in other groups and contexts.
To strengthen the dependability of results, several of the authors have analysed parts of the material together to obtain a consensus of the meaning. To further strengthen the confirmability, the results were presented to the participants on one occasion where they had the opportunity to discuss and reflect upon the interpretations. These discussions confirmed the present results.

Conclusion and significance for occupational therapy
Results of the present study show that the participants' contribution was useful for programme development. Having a leader with a gerontological competence was mentioned as important, as well as to integrate existential topics including palliative care and death as a natural part of an HPP. Social inclusion together with the possibility to influence the HPP had a positive effect on the participants and provided a sense of belonging. Results in the present study will be useful to further develop evidence-based HHP within occupational therapy, building on research and competence from occupational science and gerontology. Importantly, several other contributions to the development of the HPP was given, that would not have been captured without the involvement of the older adults. However, more and larger studies are needed to capture additional perspectives from other groups or confirm our results. More and larger studies are also needed to develop strategies that will enable older adult's involvement in the development of HHP.