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.
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.
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).
Evidenced-Based Action Steps for Developing a Public Health Workforce With Expertise in Active Aging
Leadership in state and local health departments should create a physical activity and health unit that is part of a chronic disease prevention unit. These units should be staffed with physical activity practitioners who are specialists in physical activity and public health among diverse populations, particularly older adults.
Leadership in public parks and recreational departments should prioritize and appropriate required resources for building and maintaining amenities (ie, walking trails, shaded areas, and benches) that support the health and well-being of older adults, particularly in rural and other low-resourced neighborhoods and communities.
Leadership in health care systems should prioritize physical activity assessment and promotion, develop reimbursement mechanisms for physical activity assessment and counseling, and develop comprehensive approaches to physical activity promotion in older adult populations.
Leadership in public health departments and health care organizations (eg, clinics, hospitals) should implement training for a workforce skilled in CLAS standards, and they should institute polices directed toward CLAS standards and provide needed financial and organizational support to achieve CLAS standards.
Faculty in public health schools should include required curriculum training on physical activity promotion and strategies specific to the older adult population. Special training in healthy aging and active living strategies that are culturally relevant should be emphasized.
Leadership in schools of nursing, medical, and public health should expand recruitment, outreach, and training efforts (eg, through scholarship programs sponsored by professional societies) to increase numbers of ethnic minority students, students with disabilities, and students representing groups at particular risk of physical inactivity, thereby increasing diversity of nursing, medical, and public health workforce.
Practitioners/workers in public health departments should develop collaborative relationships with other government sector workers (eg, planning and design, transportation) to plan, design, and implement activity-friendly communities to support older adults being active (such as improved street lighting, open spaces, sidewalks, and sidewalk buffer zones).
Practitioners/workers in public health and transportation departments should collaborate on designing and implementing enhancement of local transportation systems to better support the needs of older adults in active transport, including but not limited to providing accessible and safe transit services as well as extended walk times at pedestrian crosswalks, particularly in rural and other low-resourced neighborhoods and communities.
Public parks and recreation departments and private recreation facilities should offer culturally, racially, and linguistically appropriate programming to meet the needs of diverse older adults (eg, level of physical ability, language, racial and ethnic groups, female-only offerings).
Leadership in public health departments should develop, maintain, and leverage partnerships and coalitions with agencies and organizations with a vested interest in healthy aging (eg, Senior Services, American Association of Retired People) to better implement effective strategies to promote physical activity among older adults.
Abbreviation: CLAS, culturally and linguistically appropriate services.
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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