Independent living (IL) communities were developed to meet the residential needs of the ever-increasing older adult population (Assisted Living Federation of America, 2004). Although an important goal of these communities is to sustain and promote independence, an objective that is consistent with the known effects of physical activity (8), older adults in IL environments are typically sedentary. Recent studies evaluating physical activity programming in these communities reveal that rates of attendance are low (14,17). Because our own research shows that it is difficult to get older adults in IL settings to attend programs on physical activity (14), the goal of this investigation was to test the efficacy of a brief intervention that was designed to increase the likelihood that older adults would attend an introductory physical activity session.
Motivating older adults in IL settings to consider adopting positive health behaviors such as physical activity has been challenging (6,14), with difficulty in motivating older residents identified as a primary barrier in the IL setting (7,15). For example, in the Mihalko and Wickley study (14), directors were only moderately confident that residents would be interested in physical activity participation. Resnick (16) recently demonstrated the challenge of stimulating initial interest in physical activity when conducting a study with the IL residents of a continuing care retirement community. Using a convenience sample consisting of 212 IL residents, an invitation was extended for an educational session on exercise. A small number of the residents actually attended the educational session (N = 48), and only 38 went on to engage in a walking or exercise program. Although lack of interest in physical activity is a clear barrier to participation, there is a paucity of data in the literature to evaluate what strategies may trigger older adults living in IL to attend programs designed to promote physical activity.
To address this challenge, our team collaborated with IL communities to test the efficacy of a brief cognitive-behavioral intervention to increase attendance to an informational session on the topic of physical activity and the prevention of physical disability. The intervention was based on social cognitive theory (2,3) and recent research on risk perception (4). In short, the objective of the intervention was to increase older adults' perception that they were at risk of physical disablement and that physical activity provided a potential protection against this risk (3,7).
Older adults living in three different communities were randomly selected for participation in the study. The three facilities were selected from a prior descriptive study (15) to ensure the communities were similar in that they all provided independent living environments for residents who wanted some assistance with their daily living, but could live and function on their own. Once it was verified that participants met the inclusion criteria, they were randomized to one of two treatment conditions: an informational flyer-only arm or one that included the informational flyer plus a brief cognitive-behavioral intervention.
Activity/wellness directors identified all residents who met the following inclusion criteria: 1) no clear cognitive deficits (i.e., Alzheimer's disease), 2) ability to ambulate with a cane or walker, and 3) reside in the IL tier of the facility. To protect resident privacy, the directors assigned a number to each eligible resident, and a random list of numbers was generated to identify participants for the study. These randomly chosen identification numbers were then given back to the directors along with a script to follow when asking each resident about his or her willingness to participate. If the resident agreed to participate, eligibility was verified by the study coordinator (15) and the resident was randomly assigned to either the cognitive-behavioral intervention or the flyer-only group, with 30, 28, and 21 participants from each facility, respectively. The average participation rate was 60%, which is comparable to rates reported in the literature using similar selection processes (9). Collectively, 41 residents were randomized into the informational flyer-only arm and 38 were randomized into the cognitive-behavioral treatment.
The primary outcome measure was participant attendance at an introductory educational physical activity session. In addition, measures of health history and demographic information, self-reported physical activity participation, and lower extremity physical function were obtained from all participants, with the exception of the physical function measure, which was assessed for all those in the cognitive-behavioral treatment and for only those in the information-only group who attended the activity session.
The Physical Activity Readiness Questionnaire (5) was used to briefly assess the participant's health history and contraindications to exercise. The self-reported physical activity questionnaire developed by Godin and Shephard (10) asks participants to consider a typical week to indicate how often they engage in regular physical activity long enough to build up a sweat, with ordinal responses indicating never/rarely, sometimes, or often. The Short Physical Performance Battery (SPPB) is a scale developed by Guralnik (12) to assess lower extremity function among older adults. This scale has been validated in large cohorts of older adults living in the community as well as in long-term care environments (11,12). The SPPB battery consists of three categories including assessments of balance, walking speed, and ability to rise from a chair (chair stand). A complete description of each task has been previously described in the literature (12). The scores for each category range from 0 to 4, and a total performance score is calculated by adding the individual scores for each of the three categories. The total lower extremity physical performance score ranges from 0 to 12, with higher numbers indicating better physical function and less risk of disability.
The protocol was approved by the local institutional review board and each participant gave written consent before participating. Initially, the directors at the three facilities were contacted via telephone and a meeting was scheduled to discuss the purpose and procedures of the study. Once participants were recruited into the study (see Participants section), they were randomized to either the informational flyer-only group or the cognitive-behavioral intervention group. A description of each condition, as well as of the introductory physical activity session, follows.
Informational flyer-only group.
Participants in the informational flyer-only group received an initial phone call in order to screen for eligibility. Each participant was then told that the researchers would contact them within a month to further discuss a research project related to health in older adults. With no explicit link to the previously described phone call, the information-only group participants received a flyer in the mail advertising the physical activity session. The use of promotional flyers is a standard protocol used by retirement communities to recruit residents for therapeutic and recreational programming.
Cognitive-behavioral intervention group.
Similar to the information-only group, participants in the cognitive-behavioral group received an initial phone call to screen for eligibility. At that point, however, they were scheduled to meet individually for approximately 30 min with members of the research team in a common area of the IL community. The goals of this session were to have participants engage in the SPPB and to then provide feedback on their current level of physical function and concomitant risk for disability. Standardized feedback scripts were generated and used for three different levels of risk based on the participants' SPPB scores. The three levels included high risk (0–4), moderate risk (5–8), and low risk (9–12). For example, if a participant was at a high risk, he or she was told the following: “Your score was 3; this means that you are at a high risk of disability. Research has shown that a low score not only predicts risk for disability, but also one's mortality and one's risk of entering a nursing home. So, your current low level of physical functioning puts you at a greater risk of losing your independence.” Whereas if a participant was at a low risk, with a score of 10, he or she was told “You are at a level where you are still living independently and have little or no trouble performing normal everyday activities. Even though you still function at an optimal level and remain independent…physical activity could prevent the early onset of disability and keep you at a low risk level.” The following areas were highlighted in each session: 1) identifying the participant's function level; 2) comparing their level of function with other participants their age; 3) discussing their risk of chronic disease, nursing home admission, and death as associated with disability; 4) recommending physical activities that were tailored to the individuals interests and ability level; and 5) highlighting the group informational physical activity session. Participants in this group received the same promotional flyer as the informational flyer-only condition to announce the introductory physical activity session.
Introductory physical activity session.
The introductory physical activity session was held in a common room within the facility, lasted approximately 45 min, and consisted of information regarding physical activity, risk for disability, ways in which physical activity can enhance function, and a demonstration of how to use dynabands to increase muscular strength. Those participants who attended the session were asked to confirm their name on the attendance sheet. If the participant was in the feedback intervention group, he or she was asked to find a seat and wait for the session to begin. If a participant was in the information-only group, an informed consent to participate in the study was signed and the self-reported measures were collected. Two research associates led the session and briefly summarized the purpose of the study. At the end of the session, participants who were part of the information-only group were then offered the opportunity to participate in the cognitive-behavioral intervention. Participants who did not attend the information session were called and asked questions regarding the reason for their absence.
As shown in Table 1, the total sample was predominantly female (63%) and white (97%), with a mean age of 82 yr. The majority of participants (68%) had some college education or higher and 32% of the sample was currently married. Approximately one half of the sample reported that they never or rarely engaged in regular physical activity, with the other half reporting regular activity participation sometimes (29%) or often (17%). There were no significant differences between treatment groups on any of the participant characteristics, including physical activity levels.
Attendance at session.
To compare attendance at the introductory physical activity session between the cognitive-behavioral group and the information-only group, a χ2 analysis was conducted. Twenty of the 38 participants randomized to the intervention group, as compared with only 5 of the 41 participants randomized to the control group, attended the introductory session (Table 2). This difference was significant, χ2 (1, N = 79) = 24.31, P < 0.001, indicating that significantly more participants in the cognitive-behavioral intervention group attended the introductory physical activity session than did participants in the information flyer–only group.
Age, function, and physical activity effects on attendance.
Independent t-tests were conducted to determine if SPPB scores, age, or level of participation in physical activity may have accounted for differences observed in rates of attendance to the introductory physical activity session. These analyses were conducted within the cognitive-behavioral intervention group only, simply because there were so few participants (N = 5) from the control group who attended the introductory physical activity session. Results revealed that those in the cognitive-behavioral intervention group who attended the physical activity session did not have total SPPB scores (mean = 7.75, SD = 2.31) that differed from those who did not attend the session (mean = 7.83, SD = 2.48). There were also no differences in age or levels of physical activity (P > 0.05). To further examine potential explanations for attendance, phone calls were used to follow-up with those participants who did not attend the activity session (N = 54). The top three reasons cited for failure to attend were as follows: 1) conflict or other plans (22.2%), 2) lack of interest (20.4%), or 3) simply forgot the meeting (18.5%).
The current findings support the efficacy of using a brief multicomponent cognitive-behavioral intervention to generate interest in physical activity for older adults residing in IL communities. That is, participants who received tailored feedback regarding their function and risk of disability were more likely to attend the introductory physical activity session than those participants randomized to the information flyer–only group. At least in the cognitive-behavioral treatment group, this behavior appears to have been independent of age, level of participation in physical activity, or level of functioning as assessed by the SPPB. Based on social cognitive theory and research in risk perception (3,4), the feedback was specifically tailored to emphasize outcomes that are potentially meaningful and valued by older adults residing in an IL setting. In this manner, the intervention was designed to address the documented barriers to physical activity participation by educating residents about the decline in physical function with aging and providing feedback on their related risk of disability.
Past research has demonstrated that tailored messages can increase one's confidence for making decisions under conditions of uncertainty (1,13). In the present context, the implication is that when older adults believe that they are at risk of losing a valued outcome (i.e., functional independence), the likelihood of their participation in a positive health behavior such as physical activity is greater. However, it is important to point out that the brief cognitive-behavioral intervention involved multiple components. Thus, it is not clear what feature(s) of the treatment actually led to the observed group differences in behavior. For example, it is possible that simple contact between the interventionists and the participants was responsible for the differential levels of between-group attendance to the physical activity session. A contact-only comparison condition would have allowed us to rule out this possibility, and we would recommend that future research tease out the specific dose and structure of treatment that are required to produce the desired effect. Furthermore, in the current study design, it would have been illustrative to ask those participants who attended the introductory session their reasons for attending in an attempt to more fully understand what generated participant interest.
Despite its limitations, this is the first study to evaluate the use of a tailored feedback intervention grounded in risk perception and social cognitive frameworks to promote interest in physical activity participation among older adults residing in an IL environment. The transition to IL from the community can be stressful for residents as well as for their family members. Older adults often move to an IL community due to a decrease in their physical functioning. A loss in function, when accompanied by a change in one's social environment, may decrease quality of life and confidence in the ability to engage in regular physical activity. This presents an opportune time for generating interest in physical activity participation through functional assessment and tailored feedback, while providing the resident with the knowledge and understanding that further loss in function can be reduced through performing regular physical activity.
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