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Enhancing Support for Physical Activity in Older Adults: A Public Health Call to Action

Dondzila, Christopher, J., PhD; Perry, Cynthia, K., PhD, NFP-BC; Bornstein, Daniel, B., PhD

Journal of Public Health Management and Practice: January/February 2018 - Volume 24 - Issue 1 - p e26–e29
doi: 10.1097/PHH.0000000000000559
Commentary

Department of Movement Science, Grand Valley State University, Allendale, Michigan (Dr Dondzila); School of Nursing, Portland Campus, Oregon Health and Science University, Portland, Oregon (Dr Perry); and Department of Health, Exercise, and Sport Science, School of Science and Mathematics, The Citadel, Charleston, South Carolina (Dr Bornstein).

Correspondence: Christopher J. Dondzila, PhD, Department of Movement Science, Grand Valley State University, 1 Campus Dr, Kindschi Hall of Science Room 4403, Allendale, MI 49401 (dondzich@gvsu.edu).

The authors thank Rahma Ajja, Nancy Bruning, Morgan Clennin, and Amy Eyler.

The authors declare no conflicts of interest.

Physical activity (PA) is an effective form of primary, secondary, and tertiary prevention against a myriad of noncommunicable diseases, including cardiovascular disease, diabetes, and certain cancers.1 Almost 90% of older adults (65+ years) have 1 chronic disease and 65% have 2 or more chronic diseases,2 which create a vicious downward spiral of lower PA engagement and further incidence of disease.3 This carries significant economic costs, given that older adults who are active 1 to 3 days per week have 8% to 20% lower health care costs and those who are active at least 4 days per week realize an additional 8% to 11% reduction in health care costs,4 compared with sedentary counterparts. Despite public health interventions aimed specifically at promoting PA in older adults,5–7 they have been ineffective to thwart steadily declining PA levels and proliferating chronic diseases. This is influenced by a myriad of variables, including rapid expansion and diversification of older adults,8 a wide-ranging list of mediating variables to PA adoption and maintenance,9 and a public health workforce ill-prepared in the field of active aging.10 Accordingly, such complexities represent immense opportunities to realize the public health and concomitant economic benefits associated with increasing PA levels among older adults.

While acting as president of the Association of State and Territorial Health Officials, Jewel Mullen10 discussed the importance of collaborative efforts for improving the health of older adults. The purpose of this commentary, which expands upon Mullen's recommendations, is to provide tangible, evidence-based action steps for increasing PA in older adults, with consideration to individual-, social-, and environmental-level mediating barriers to behavior change. Supplementary strategies to accomplishing action steps are provided in an effort to bolster translational impact. Adopting these steps will ultimately result in minimizing the individual and public health impacts of chronic disease among older adults while minimizing health disparities across socioeconomic status, environmental, gender, and ethnic subgroups of older adults.

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Culminating Mediating Variables

Factors influencing the adoption and maintenance of PA behavior are multifaceted, spanning individual, social, and environmental variables that collectively pose complex barriers for older adults. For example, the presence of chronic disease can initiate a trajectory in which disease symptoms lead to further inactivity, which, in turn, exacerbates the disease process.11 Additional influential variables to intervene upon include older adults' beliefs about and motivation for PA.7 Such individual-level factors are modifiable, and interventions targeting these factors have demonstrated modest success.12 However, as has been well established through social-ecological models of health behavior, intervening beyond the individual level is required for minimizing population-level disparities in PA and health.13

The observed disparities in PA among older adults are similar to those found in the adult population overall; namely, PA levels among Hispanic Americans and non-Hispanic blacks being lower than non-Hispanic whites.9 In addition, income-level differences among older adults impact PA behavior, with a lower socioeconomic status related to a lack of access to PA resources (eg, facilities, equipment, transportation), which negatively impacts their participation.14 Taken together with the range of facilitators/barriers to PA from different cultures,15 a diverse older adult population represents unique challenges for future programming to consider.

Factors within the social and built environments further contribute to PA behavior among older adults. In urban settings, factors such as fear of crime, poorly maintained sidewalks and streets, few walking paths close to home, poor street connectivity, concerns about heavy vehicle traffic, and lack of accessible transportation are all barriers to PA.7 Older adults residing in rural settings report similar concerns to those in urban settings, such as lack of transportation to recreational facilities, absence of sidewalks and lighting, and safety concerns.16 However, those in rural settings report isolation, lack of safe places to be physically active, and climate and terrain as barriers to PA.16 Thus, while differences in race/ethnicity, socioeconomic status, gender, and setting (urban vs rural) pose unique challenges, they also represent opportunities for intervention. Acknowledging such differences, coupled with a properly trained public health workforce, will appropriately inform targeted interventions to ameliorate the public health burden of low PA levels among older adults.

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Moving Forward: A Public Health Call to Action

While both the Community Guide17 and the American Geriatrics Society18 recommend focusing on individual-level behavior change programs, there are gaps in evidence regarding which strategies are most effective in older people. As previously stated, such individual-level interventions in the absence of supportive environments have been shown to have limited effectiveness.7 , 17 , 19 Extensive research supports the importance of policies and environments in older adults' PA,19–21 including infrastructure,22 transportation,6 and green spaces/recreational resources.23 Such evidence, however, does not always translate to meaningful impacts in the community. This is highlighted by Rodriguez and colleagues,24 whose data showed that local health department assurance of health promoting services had no benefits on PA and falls in seniors. The limited adoption of the aforementioned policies may be the result of a public health workforce not sufficiently trained in design, implementation, and evaluation of PA interventions for older adults and ineffective policy advocacy for older adult active living strategies.

As recognized in the US National Physical Activity Plan and by the American Public Health Association, an important strategy to pursue is development of a robust public health workforce in the area of active aging.25 , 26 Empirical evidence suggests the need for proper training of public health practitioners in active aging both to intervene on social and intra-individual obstacles and to advocate for and plan and implement these multidisciplinary interventions. In their seminal article, Beard and colleagues6 provide a blueprint for addressing keenly identified areas for healthy aging including aligning health systems, developing long-term care solutions, establishing age-friendly environments, and making better use of data to inform practices. Inherent in realizing the Beard and colleagues blueprint is a properly trained public health workforce that is essential to framing and messaging PA, as well as designing, implementing, and evaluating evidence-based PA programs that effectively address the diverse nature of the older adult population.26 In addition, the workforce must be trained in the nuances of effective PA policy advocacy, the challenges of quantifying PA at the population levels, and measuring the relative strength or weakness of environmental correlates of PA.26 , 27

Based upon overwhelming evidence on the importance of PA for the prevention and treatment of chronic disease, the rapidly growing older adult segment of the US population, and the well-documented need for a public health workforce with expertise in active aging, we recommend the following evidence-based strategies (Table).

TABLE

TABLE

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Effectively Translating Action Steps

The novelty of the action steps (Table) is that there is a dire need for a holistic approach to PA promotion in older adults. Ecological research about the determinants of PA often provides a framework from which to prioritize factors influencing behavior at various levels (eg, individual, social, environmental). Using an ecological approach can be helpful in distinguishing unique challenges, guiding identification of appropriate interventions that address these challenges in older adults, and recognizing specific settings such as low-resourced rural areas.28 , 29 Acknowledging there is not a “one-size-fits-all” approach to PA programming, Yousefian et al30 elaborated on the ecological model to identify themes influencing inactivity, albeit only in rural youth. Thus, the future public health workers, if they are to have a meaningful impact on healthy aging, necessitate education, training, and leadership in a myriad of PA determinants across the ecological domains. This spectrum of expertise is outlined in the proposed action steps, which address environmental, socioeconomic, and ethnicity-related mediators to PA, as well as expertise to utilize in varying employment outlets. The rationale for these action steps is substantiated by existing examples of public health officials' cross-sector collaborations, suggesting that optimal results in healthy aging will be achieved through partnering with federal government and national organizations.10 Developing cross-sector collaborations, however, is challenging and time consuming to create and maintain. Some steps that can enhance the success of these cross-sector collaborations include identifying a lead agency and a champion with strong leadership skills within that agency to lead collaboration; leveraging existing networks and connections; reaching out to broad-spectrum community members to include in collaboration using a participatory action approach; developing clear governance structure for the collaboration articulated in memorandums of understanding that delineate resource contribution and/or allocation, roles and responsibilities of paid agency staff and unpaid volunteers, committee structure, and agreed-upon vision and mission for the collaboration; and ongoing evaluation of the functioning of the collaboration.31 , 32 To maximize the benefits from the proposed action steps, the future public health workforce is reliant on appropriate training and education. Professional schools within public health, nursing, and medical workforces adopting holistic admission review processes and providing resources for student success (eg, social support groups, academic support) are strategies integral to increasing a workforce of diverse professionals.33 Presenting the proposed action steps, in accordance with rationale and evidence for their impact, is an important first step in augmenting healthy aging through PA in older adults.

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References

1. Lee IM, Shiroma EJ, Lobelo F, et al Effect of physical inactivity on major non-communicable diseases worldwide: an analysis of burden of disease and life expectancy. Lancet. 2012;380(9838):219–229.
2. Centers for Disease Control and Prevention. Adult participation in aerobic and muscle-strengthening physical activities—United States, 2011. MMWR Morb Mortal Wkly Rep. 2013;62(17):326–330.
3. US Department of Health and Human Services. Physical Activity Guidelines for Americans. Washington, DC: US Department of Health and Human Services; 2008.
4. Wang F, McDonald T, Reffitt B, Edington DW. BMI, physical activity, and health care utilization/costs among Medicare retirees. Obes Res. 2005;13(8):1450–1457.
5. Frank JC. A missing piece in the infrastructure to promote healthy aging programs: education and work force development. Front Public Health. 2014;2:287.
6. Beard JR, Officer A, de Carvalho IA, et al The World report on ageing and health: a policy framework for healthy ageing. Lancet. 2016;387(10033):2145–2154.
7. King A, King D. Physical activity for an aging population. Public Health Rev. 2010;32(2):401–426.
8. Federal Interagency Forum on Aging-Related Statistics. Older Americans 2012: Key Indicators of Well-Being. Washington, DC: US Government Printing Office; 2012.
9. Troiano RP, Berrigan D, Dodd KW, Masse LC, Tilert T, McDowell M. Physical activity in the United States measured by accelerometer. Med Sci Sports Exerc. 2008;40(1):181–188.
10. Mullen J. Living longer better: a call to action to promote the health of older adults and their communities. J Public Health Manag Pract. 2015;21(4):410–412.
11. Durstine JL, Gordon B, Wang Z, Luo X. Chronic disease and the link to physical activity. J Sport Health Sci. 2013;2:3–11.
12. Frank L, Kavage S. A national plan for physical activity: the enabling role of the built environment. J Phys Act Health. 2009;6(suppl 2):S186–S195.
13. Golden SD, Earp JA. Social ecological approaches to individuals and their contexts: twenty years of health education & behavior health promotion interventions. Health Educ Behav. 2012;39(3):364–372.
14. Bauman AE, Reis RS, Sallis JF, Wells JC, Loos RJ, Martin BW; Lancet Physical Activity Series Working Group. Correlates of physical activity: why are some people physically active and others not? Lancet. 2012;380(9838):258–271.
15. Belza B, Walwick J, Shiu-Thornton S, Schwartz S, Taylor M, LoGerfo J. Older adult perspectives on physical activity and exercise: voices from multiple cultures. Pre Chronic Dis. 2004;1(4):1–12.
16. Yousefian Hansen A, Hartley D. Promotion Activity Living in Rural Communities. San Diego, CA: Active Living Research; 2015. http://www.activelivingresearch.org. Accessed December 16, 2016.
17. US Preventive Services Task Force. The guide to community preventive services. The Community Guide. http://http://www.thecommunityguide.org. Published 2015. Accessed February 2, 2015.
18. The American Geriatrics Society. Multidisciplinary competencies in the care of older adults at the completion of the entry-level health professional degree. http://http://www.americangeriatrics.org/about_us/partnership_for_health_in_aging/multidisciplinary_competencies/multidisciplinary_competencies778926. Published 2016. Accessed December 1, 2016.
19. Kestens Y, Chaix B, Gerber P, et al Understanding the role of contrasting urban contexts in healthy aging: an international cohort study using wearable sensor devices (the CURHA study protocol). BMC Geriatr. 2016;16:96.
20. Levasseur M, Généreux M, Bruneau JF, et al Importance of proximity to resources, social support, transportation and neighborhood security for mobility and social participation in older adults: results from a scoping study. BMC Public Health. 2015;15:503.
21. Strath SJ, Greenwald MJ, Isaacs R, et al Measured and perceived environmental characteristics are related to accelerometer defined physical activity in older adults. Int J Behav Nutr Phys Act. 2012;9:40.
22. Sallis JF, Spoon C, Cavill N, et al Co-benefits of designing communities for active living: an exploration of literature. Int J Behav Nutr Phys Act. 2015;12:30.
23. Astell-Burt T, Feng X, Kolt G. Green space is associated with walking and moderate-to-vigorous physical activity (MVPA) in middle-to-older aged adults: findings from 203 883 Australians in the 45 and Up Study. Br J Sports Med. 2014;48:404–406.
24. Rodriguez HP, Herrera AP, Wang Y, Jacobson DM. Local health department assurance of services and the health of California's seniors. J Public Health Manag Pract. 2013;19(6):550–561.
25. National Physical Activity Plan Alliance. National Physical Activity Plan. http://physicalactivityplan.org/index.html#. Accessed November 21, 2016.
26. American Public Health Association. Policy statement 201514: building environments and a public health workforce to support physical activity among older adults. http://http://www.apha.org/policies-and-advocacy/public-health-policy-statements/policy-database/2016/01/26/14/18/building-environments-and-a-public-health-workforce-to-support-physical-activity-among-older-adults. Accessed November 21, 2016.
27. Koh HK, Gracia JN, Alvarez ME. Culturally and linguistically appropriate services-advancing health with CLAS. N Engl J Med. 2014;371(3):198–201.
28. Thornton CM, Kerr J, Conway TL, et al Physical activity in older adults: an ecological approach [published online ahead of print September 28, 2016]. Ann Behav Med. doi:10.1007/s12160-016-9837-1.
29. Umstattd Meyer M, Moore JB, Abildso C, Edwards MB, Gamble A, Baskin ML. Rural active living: a call to action. J Public Health Manag Pract. 2016;22(5):E11–E20.
30. Yousefian A, Ziller E, Swartz J, Hartley D. Active living for rural youth: addressing physical inactivity in rural communities. J Public Health Manag Pract. 2009;15(3):223–231.
31. Baker EA, Wilkerson R, Brennan LK. Identifying the role of community partnerships in creating change to support active living. Am J Prev Med. 2012;43(5)(suppl 4):S290–S299.
32. Barnidge EK, Baker EA, Estlund A, Motton F, Hipp PR, Brownson RC. A participatory regional partnership approach to promote nutrition and physical activity through environmental and policy change in rural Missouri. Prev Chronic Dis. 2015;12:E92.
33. Scott LD, Zerwic J. Holistic review in admissions: a strategy to diversify the nursing workforce. Nurs Outlook. 2015;63(4):488–495.
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