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Original Investigation

The ENJOY Project: Usage and Factors to Support Adherence and Physical Activity Participation

Levinger, Pazit1,2,3; Dunn, Jeremy1; Panisset, Maya1; Haines, Terry4; Dow, Briony1,5,6; Batchelor, Frances1,6,7; Biddle, Stuart J.H.8; Duque, Gustavo9; Hill, Keith D.3

Author Information
Translational Journal of the ACSM: Summer 2021 - Volume 6 - Issue 3 - p 1-6
doi: 10.1249/TJX.0000000000000163
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Abstract

INTRODUCTION

The growing prevalence of physical inactivity among older people is an important public health problem in light of the rapidly growing aging population globally (1). Physical activity is recognized as one of the most important behaviors for reducing the overall burden of disease and increasing healthy lifespan (2). Despite the many health benefits of physical activity, more than a quarter (1.4 billion) of the world’s adult population do not get enough physical activity to maintain their health (3). Specifically, fewer than half of older adults in most countries are sufficiently active to achieve most of these health benefits (4).

Although there are many studies examining physical activity intervention strategies, only few evaluate long-term participation with effective implementation to increase population level physical activity. Despite the proven effectiveness of physical activity interventions, knowledge translation has been limited (5), as few interventions have been effectively implemented, evaluated, and scaled up in the community (6). In fact, Australia ranks second internationally in terms of physical activity research productivity and output (7), but implementation of research into practice to increase physical activity levels in the population is limited. Another key challenging aspect of participation in physical activity is adherence. Long-term engagement and participation in physical activity by older adults in the general population is poor (8), which prevents long-term health benefits and can further lead to deterioration of physical function. Community-based group exercise interventions have been suggested to foster social connections among program participants and thereby support long-term exercise adherence (9). Social interaction, fun, and enjoyment have been identified as important motivators for older people to be physically active (10) to the extent that social interaction is identified as a benefit by group exercise participants twice as frequently as they mention other health benefits (11). Consequently, group settings might offer an important social support platform for older people to improve exercise adherence behaviors.

The Exercise interveNtion outdoor proJect in the cOmmunitY for older people (the ENJOY project) is a community-based research project that evaluated the effects of sustained engagement in physical activity on mental, social, and physical health outcomes through the use of an outdoor Seniors Exercise Park physical activity program for older people. The Seniors Exercise Park (12) comprises outdoor exercise equipment that has been installed in three locations in Melbourne, offering the advantage of being available free of charge for the public. Previously reported results from the ENJOY project demonstrated that inactive older people who underwent a 12-wk outdoor physical and social activity program increased their physical activity level as well as reported other physical and mental health benefits (13). After 9 months, exercise uptake was maintained, with participants meeting the recommended levels of physical activity of 150 min·wk−1 of moderate intensity (13).

The aim of the present study was to explore participants’ perceptions about barriers and facilitators to ongoing participation during the 12-wk structured program and during the maintenance phase. We also report the usage pattern of the Seniors Exercise Park during the maintenance phase to inform the future implementation of this initiative in the community. Given the low level of physical activity reported for older people, understanding the barriers and facilitators can assist in better design of outdoor physical activity programs and to better support long-term engagement. This in turn can further assist to generate suitable strategies around the built environment to promote increased physical activity among older people.

METHODS

This study was a multisite prospective study with a preintervention and postintervention design with 9-month follow-up. Participants underwent a 12-wk structured, supervised physical activity program using an outdoor Seniors Exercise Park followed by a 6-month unstructured physical activity program, including ongoing supervised and unsupervised access (independent access) to the exercise park (maintenance phase). Each exercise session during the supervised sessions (both in the 12-wk and 6-month maintenance phase) was followed by a social gathering with morning/afternoon tea. The full description of the study’s methods, design, and procedure can be found in the trial protocol (14). Participants were asked to complete two surveys: one at the end of the 12-wk structured, supervised program and the second one at the end of the 6-month maintenance phase. Access to the Seniors Exercise Park was electronically monitored during the 6-month maintenance phase.

Study Population

Inclusion Criteria

Older people were included in the study if they 1) were 60 yr and older living in the community (e.g., not living in an institution, such as a nursing home); 2) had one or more falls in the previous 12 months or were concerned about having a fall; 3) were generally independent around the house (able to take care of themselves) and in the community (e.g., able to walk away from home to visit local stores, friends, and other local venues), and who were able to attend the outdoor exercise park; 4) were able to walk outdoors and use the exercise equipment with no more gait aid support than a single-point stick; and 5) did not have cognitive impairment (Abbreviated Mental Test Score >7/10) (15)

Exclusion Criteria

Older adults were excluded from this study if they 1) had neurological or musculoskeletal conditions limiting the person to walking less than one block; 2) had a history of stroke, Parkinson’s disease, or other neurological disorder impacting on mobility; 3) were unable to understand conversational English; 4) were taking part in a structured resistance training and or an organized balance training program more than once a week; 5) met the Australian physical activity recommendations of 150 min of physical activity per week (16); and 6) had any documented medical condition or physical impairment that was deemed by their medical practitioner to contraindicate their inclusion.

Recruitment

Older people were recruited from the general community in the suburbs close to the Seniors Exercise Parks locations in Melbourne, Australia. Advertisements in local newspapers, council newsletters, posters displayed on notice boards, and flyers distributed to senior groups were used for recruitment. Information was also placed online on the councils’ and participating partners’ websites as well as associated social media platforms (e.g., Facebook and Twitter).

Procedure

Participants underwent a 12-wk supervised exercise intervention program twice a week using the Seniors Exercise Park delivered by a qualified exercise instructor (accredited exercise physiologist or physiotherapist). Participants were assessed at baseline, after intervention, and at 9-month follow-up time points (14).

Exercise Uptake and Physical Activity Maintenance

Exercise Participation After Completion of the Structured Supervised Program: 12 wk to 9 Months

After completion of the 12-wk program, participants were familiar with the equipment, the exercises, and their physical abilities and therefore were encouraged to exercise independently and safely if they chose to do so. At the completion of the structured 12-wk exercise program, participants were given two options to choose from to continue their physical activity. Option 1 refers to independent unsupervised access and usage of the exercise park in participants’ own preferred time, and option 2 refers to access to twice-weekly exercise sessions at the exercise park under supervision, but with no formal structured group activity. The days for option 2 were kept similar to the days where the 12-wk structure program was run.

During this 6-month follow-up period, participants were informed of twice-weekly times when the exercise instructors were available at the Seniors Exercise Park. Participants could then attend their preferred time/sessions. At these sessions, the exercise instructors supervised participants and provided advice regarding exercise progression to fit individual’s progression needs.

Monitoring Exercise Uptake After the 12-wk Exercise Program for 6 Months: Fob Access System

Adherence and exercise uptake for the 6-month maintenance phase (between 12 wk and 9 months) was monitored using a fob access system (CityWatch Security, Victoria, Australia; www.citywatchsecurity.com.au/). The fob access system included a scanner/card reader (Asperio RF card reader) installed at each site (mounted on a bollard), a control panel (Integriti Control Panel) within a secure cabinet installed at a location (external wall) nearby to the card reader (receives signals from the RF card reader to the control panel), and specialized software (Integriti Professional Software) installed in the head office (National Ageing Research Institute researchers’ office). Participants were assigned an individual identification key (fob: a small security hardware device with built-in authentication), which they were able to tap at the card reader each time they accessed the Seniors Exercise Park. Their access was then recorded and monitored electronically, including details of date, time of the day, and start and finish exercise times (exercise duration).

Participants’ Feedback and Satisfaction Surveys (12 wk and 9 Months)

Survey 1

At the completion of the 12-wk exercise program, participants were asked to fill an evaluation form that collected feedback about the exercise program (duration, frequency, difficulty of the exercises), usability of the exercise park (in terms of location, safety), facilities/amenities available (water, benches, toilet etc.), and any suggestions for further improvement of the site. The survey included questions using a 5-point Likert scale (from strongly disagree to strongly agree) as well as open-ended questions for additional comments/suggestions (optional).

Survey 2

At 9 months after the baseline assessment, participants were asked to complete another evaluation form that gathered information about their exercise habits (if they continued using the exercise park, exercise frequency, and duration). The survey included questions using a 5-point Likert scale, multiple-choice questions, and open-ended questions for additional comments/suggestions.

Statistical Approach

The results from the surveys (5-point Likert scale questions) were grouped based on percentage of responders for each category and were plotted in graphs. For the open questions, the frequency of the items identified/cited was reported as percentage of responders.

Analysis of usage (frequency and duration) of the Seniors Exercise Park was conducted using the data extracted from the fob access software system. Descriptive data of frequency of usage per week for the 6-month period, duration of sessions, and overall adherence were reported. For the 6-month period, participants were expected to exercise twice per week, similar to frequency of the delivery of the exercise program in the structured 12-wk program. Therefore, a total of 48 times/visits during the 6-month follow-up period was considered as optimal adherence (100%). In circumstances where a participant was not able to attend the exercise park because of medical conditions, illness, or being away (travel), the total number of visits was adjusted to reflect the overall time a participant was able to attend the site (number of available visits was considered as 100%). This method represents a realistic approach, where an individual’s attendance has been affected by ill health or vacation, but they were still committed to returning to the class (17,18). Average weekly visits and duration were calculated. The frequency of their visits was then compared with the expected frequency over 6 months and reported as percentage of adherence.

RESULTS

Of the 95 older people living in the community who enrolled for the program, 80 completed the 12-wk exercise program (mean age, 72.8 ± 7.5 yr; 81.3% females). For those who completed the 12 wk, the majority of participants (93.7%) had at least one medical condition, with the most common conditions reported being arthritis (68%), hypertension (60%), and hypercholesterolemia (55%; Table 1).

TABLE 1 - Participant Demographic Characteristics and Fob Access Data.
Participant characteristics (n = 80)
 Age, mean (SD), yr 72.8 (7.5)
 Female, n (%) 65 (81.3)
 Height, mean (SD), m 1.6 (0.9)
 Weight, mean (SD), kg 76.6 (15.2)
Medical conditions and musculoskeletal conditions, n (%)
 Hypertension 48 (60)
 Arthritis (osteoarthritis/rheumatoid arthritis) 55 (68)
 Hypercholesterolemia 44 (55)
 Hearing impairments 31 (38.7)
 Incontinence 20 (25)
 Other metabolic conditions (kidney/thyroid disorder) 20 (25)
 Osteoporosis 19 (23.8)
 Cardiovascular conditions 19 (23.8)
 Respiratory conditions 18 (22.5)
 Diabetes mellitus 15 (18.8)
Fob access data (n = 74)
 Did not use the park, n (%) 29 (39.1)
 Regular/active users, n (%) 45 (60.8)
 Regular users, reported use outside supervised sessions, n (%) 9 (20)
 Average adherence, % 50.9
 Frequency of weekly visits, mean (SD) 1.3 (0.2)
 Duration of weekly visits, mean (SD), min 57.0 (16.8)

Interruption to data collection occurred during the last several months of follow-up for some participants because of the COVID-19 pandemic, with physical distancing and lockdown restrictions subsequently preventing access to the Seniors Exercise Park. Participants were in various stages of their 6-month maintenance phase: from several weeks to near completion of the follow-up. This meant that partial data were available for the 9 months after survey: n = 19 were not available because of COVID-19, and 3 participants were lost to follow-up; therefore, 9-month data were available for 58 participants for analysis. However, for the fob access data analysis (usage of the Seniors Exercise Park during the maintenance phase), data that had been collected until the lockdown could still be used. To minimize data loss, participants who had been exposed to at least 4 wk of the maintenance phase (until the time where restrictions were imposed) have been included in the analysis for the Exercise Park usage. Their adherence calculation (in percent) was adjusted such that the total number of available visits was based on the relative available exposure to the exercise park, before the lockdown restrictions. Data from six participants were excluded because of less than the minimum 4-wk exposure during the pandemic. Overall, data from 74 participants were used to examine fob access user patterns. Those who used the Exercise Park for at least 4 wk were considered regular users (45 people; 60.8%). Most visits occurred during the supervised sessions of the 6-month maintenance phase (87.2%). Further details are provided in Table 1.

Survey Feedback: Survey 1

Feedback about the 12-wk exercise program showed that the majority of participants (agree and strongly agree combined) enjoyed participating in the program (98.6%) and exercising outdoors (93.5%). The majority also enjoyed the social aspect of the program (94.7%), appreciated the supervision (97.4%), and felt safe while exercising (98.7%; Fig. 1). The frequency and duration of the exercise program were also received well (Fig. 1). The weather did affect some participants, but the majority (66.1%) indicated it did not interrupt participation (Fig. 1). The majority also agreed that the surrounding areas were attractive and welcoming (96%) and identified that the proximity to the community center was important (69.7%; Fig. 1).

F1
Figure 1:
Feedback provided (in percent responders) at the completion of the 12-wk supervised programs.

The survey findings (open questions) indicate that most participants accessed the site by car (84.6%). In terms of improvements, the majority requested a cover over the Exercise Park Equipment to provide more protection from weather and would like to see the equipment close to their residence (74.3%; Table 2). During the 12-wk structured physical activity program, the most cited factors that helped participants keep attending the exercise park program were the social aspect (60%), followed by the health benefits/improvement (41.5%) and the supervision (36.9%). Barriers to attending the program included other commitments (29.2%), pain/illness (preexisting medical problems; 26.8%), and the weather (26.8%).

TABLE 2 - Participants’ Feedback from the 12-wk Survey (Survey 1).
Survey 1: Open Questions, 12 wk % Responders
How did you get to the exercise park?
 Car 84.6
 Foot/walk 10.3
 Public transport 2.6
 Community bus 2.3
What else would you like to have included in the park and surrounding area?
 Cover/shade 74.3
 Bins 15.3
 Water fountain 10.2
Would you like to see this type of equipment elsewhere?
 Yes 74.3
What factors helped you keep attending the exercise park program?
 Social (group, other participants) 60
 Health benefits/improvement 41.5
 Supervisors 36.9
 Commitment 20
 Enjoyment 13.8
What factors made it more difficult or less likely for you to keep participating in the exercise park program?
 Other commitments 29.2
 Pain/illness (preexisting medical problems) 26.8
 Weather 26.8
 Distance/travel distance 12.1
 Lack of shade/cover 9.7
 Others 7.3

Survey Feedback: Survey 2

At the 9-month follow up, regular users reported the main motivators to attend the exercise park were the company and socialization (40.7%), followed by the supervision (37%) and the exercises themselves (37%; Table 3). Regular users also reported they enjoyed exercising outdoors (96%) and planned to continue using the Seniors Exercise Park (92%; Fig. 2). Participants who stopped using the exercise park reported it to be due to medical issues/illness (35.7%), other commitments (26.0%), and engagement in other physical activity (27.3%). Main barriers to continued use of the Seniors Exercise Park for both regular users and nonusers (stopped using the Seniors Exercise Park) included other commitments (71.4%), the weather (60.7%), and medical/health problems (42.8%; Table 3).

TABLE 3 - Participants’ Feedback from the 9-Month Survey (Survey 2).
Survey 2: Open Questions, 9 months % Responders
Regular/active users
 What did you consider to be the most important part of the supervised exercise sessions?
  The company and socialization (other participants) 40.7
  The supervision 37.0
  The exercises themselves 37.0
  Being outdoors 25.9
  I feel safe 14.8
 What factors helped you keep attending the exercise park program over the past 6 months?
  Socialization 53.5
  Health benefits 24.13
  The exercises 14.2
  Supervision/structure 10.7
  Location/facilities 7.1
  Enjoyment 14.2
  Being outdoors 7.1
  No cost 3.5
Nonusers at 9 months
 Reason for stopping using the Seniors Exercise Park
  Medical issues/illness 35.7
  Other commitments 26.0
  Doing other physical activity 27.3
  Lack of motivation 14
  Weather 13
  Poor location/lack of transport 8.6
  Others (fatigue from the exercises, exercises not challenging enough) 8.6
Both users/nonusers
 What factors made it more difficult or less likely for you to keep participating in the exercise park program over the past 6 months?
  Other commitments 71.4
  Weather (cold, hot, wet) 60.7
  Health/medical problem/illness 42.8
  Location (too far, traffic) 17.8
  Lack of transport 14.2
  Lack of motivation 10.7
  Exercise (not challenging) 10.7
  Other physical activities 10.7
  Miss the structure of group exercise 7.1
  Lack of cover 3.5

F2
Figure 2:
Feedback provider (in percent responders) from regular users after the maintenance phase (9 months).

DISCUSSION

The ENJOY Seniors Exercise Park program is a physical and social activity program, integrating multiple exercise stations that specifically target balance, function, and strength. The overall results suggest that this type of physical and social activity program is positively perceived by older people in the community as a suitable program to improve their physical health and socialization. Positive feedback was reported for the 12-wk structured, supervised program, highlighting satisfaction with the length, frequency, safety, and structure of the program. Approximately 60% of participants (regular users) continued utilizing the Exercise Park beyond the 12-wk structured program, emphasizing the potential positive effect of the outdoor equipment to promote sustainable engagement in physical activity for older people.

Attendance and adherence to exercise programs in older people are important predictors of health status and well-being. Adherence to falls prevention group exercise programs is reported to be around 74%, with several program-related factors that adversely affect adherence, such as the inclusion of flexibility-based exercise, longer duration of 20 wk or more, or two or fewer sessions per week (19). In the present study, a high adherence (86%) was reported for the 12-wk structure exercise program (13) with a lower adherence during the maintenance phase for regular users (~50%). However, given that participants reported to remain physically active at the 9-month follow-up, it is likely that participants were engaged in other physical activity types in addition to the usage of the Seniors Exercise Park (13). Although predictors of adherence in fall prevention programs are not fully understood (20), addressing some of the barriers identified in the present study may improve long-term usage of the Seniors Exercise Park for sustained health and well-being benefits.

The key aspects that were identified as common contributing factors for participation during both the 12-wk program (survey 1) and the maintenance phase (survey 2) were the social aspect, the perceived health benefits/improvement, and the supervision. Indeed, socialization has been frequently acknowledged as an important facilitator for ongoing participation in physical activity programs (9–11). Group-based physical activity programs (involving older people of similar age) that also offer social gatherings can improve adherence to positively influence older adults’ physical activity behavior (21). Initial motivation factors for joining physical activity program previously reported include improvement in health and fitness, but the provision of opportunities for social interaction seems to be a key program element in promoting long-term participation (22). This highlights the importance of incorporating social elements to provide opportunities to meet and spend time with others to build, strengthen, and maintain social networks that support behavior change (23).

The presence of professional exercise instructors (e.g., physiotherapists and accredited exercise physiologists) during the supervised session was identified as a contributing factor for participation. In the ENJOY study, allied health professionals (physiotherapists, accredited exercise physiologists) run the exercise sessions. Allied health professionals are qualified to work closely with older people with various complex medical issues and hence play an important role in older peoples’ safe participation and adherence to exercise, as they can act as external motivators (24,25). The exercise program was designed to enable older people to continue independent participation if they chose to do so. The equipment comprises stations that mimic daily movements with the exercises being gradually progressed, providing sufficient duration (12 wk) for participants to feel comfortable using it by themselves. Despite this, it was noted that most participants continued attending the same days and times when the supervised (unstructured) sessions were offered. Providing supervision and instructional sessions by qualified exercise instructors can positively engage older adults in usage of outdoor exercise equipment (26,27), as well as provide reassurance and another avenue to socialize.

Several barriers to ongoing participation (6-month maintenance phase) included illness and medical problems and other commitments. Lack of motivation was also noted, although to a lesser degree than the other main barriers. Older people are likely to suffer from a wide range of health issues and comorbidities (28). Indeed, the majority of the participants suffered from at least one medical condition (93.7%; Table 1). The presence of medical issues can lead to absence from exercise sessions as well as to interruption of continuous participation on a regular basis. Poor health was also reported as a main reason for withdrawal in a long-term strength and balance exercise intervention trial (29). Maintaining regular physical activity despite the existence of complex medical problems can be challenging, but it is important that older people learn to manage these so they can continue with exercise and maintain their physical health. Similarly, other commitments (e.g., caring for others and other appointments/events) often take precedence over participation in physical activity. Adherence may require the ability to self-regulate certain behaviors by overriding a well-established/predicted response (other commitment/activity) and replacing it with a less common but desirable response (being physically active) (30). Educating and teaching participants self-control strategies and offering an array of coping strategies from which to choose, as a solution to inhibiting habitual poor health behaviors (e.g., exercising at other times and reducing activity on “bad/painful” days) may be utilized as an approach to both manage chronic conditions and other commitments. It is also of interest to note that the second most common reason for ceasing participation in the Seniors Exercise Park in the 6-month maintenance phase was “doing other physical activity” (27% of nonusers at 9 months), which suggests that the program may have been an avenue to commence or recommence physical activity participation, that has been continued, although in another form of physical activity. This may be considered another positive outcome.

Exercising outdoors offers many health benefits but can equally present barriers due to weather elements (31). The weather in Melbourne is a temperate oceanic climate (e.g., moderate rainfall spread across the year or portion of the year with sporadic drought, mild to warm summers, and cool to cold winters) and is well known for its changeable weather conditions (sudden temperature drops). The weather was acknowledged by the participants as a contributing factor that was both a positive and a negative influence on attending sessions. Moreover, over 70% of participants suggested the addition of a shade cover as part of the park. In the ENJOY project, the two public sites had no cover at the beginning of the project, whereas the third site (aged care site) had cover installed before commencement of recruitment at that site. Midway through the project, a sail shade was installed by Wyndham City Council followed by a late installation (after completion of the project) by Whittlesea City Council. The addition of a shade cover played a major role in enabling exercise sessions to take place during wet days and hot days. Older people’s bodies are less able to tolerate stress posed by the environment (extreme hot/cold weather), which makes them vulnerable to extreme weather (32,33); therefore, the installation of a shade cover over outdoor exercise equipment should be included in any open plan outdoor design.

There were several physical environmental differences between the three sites that might have affected the experience and the responses. The Seniors Exercise Parks at the two public sites were freely available for all public to access and were situated in a residential area near a community center. Toilets and water were available at the community centers, as well as parking. The third site included various aged care and retirement living arrangements for older people with limited available parking. The Seniors Exercise Park was installed adjacent to the aged care facility in the village and was fenced with a locked gate. Although participants outside the village could access it, restrictions around accessibility without supervision existed. The distance and the travel required to attend sites were also different, and this may affect ongoing adherence.

In conclusion, the Seniors Exercise Park is a safe and enjoyable outdoor equipment that can be utilized to promote sustainable engagement in physical activity for older people. The social aspect, the perceived health benefits/improvement, and supervision were highlighted as important facilitators for ongoing participation for older people. The presence of medical problems, illness, and other commitments seem to negatively affect participation. Factors associated with the physical/environmental features such as lack of shade cover and distance to the site were also identified as barriers. Future installation of the Seniors Exercise Park outdoor equipment and associated implementation strategies to promote physical and social activity programs for older people should take this information into consideration.

The authors would like to acknowledge Whittlesea City Council, Wyndham City Council, and the Old Colonists’ Association of Victoria for their collaboration and partnership in this project. Moreover, the authors would like to thank Lark Industries for the Seniors Exercise Park equipment installation and associated advice and support.

The authors declare no conflict of interest.

The views expressed in this article do not constitute endorsement by the American College of Sports Medicine.

This study was funded by Gandel Philanthropy. This funding source had no role in the design of the study, its execution, analyses, interpretation of the data, and writing the manuscript for publication.

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