Feasibility and outcomes of a multilevel place-based walking intervention for seniors: A pilot study
Introduction
Physical activity can prevent or reduce many common health problems among older adults, a population with very low activity levels (Agency for Healthcare Research and Quality and the Centers for Disease Control, June 2002; Lee and Park, 2006). In 2001–2002, only 21% of adults over the age of 65 years were regularly physically active (Federal Interagency Forum on Aging-Related Statistics, 2004). New data with objective measurement of physical activity indicate that the prevalence of meeting public health recommendations may be as low as 2.5% among adults over age 60 (Troiano et al., 2008). Walking is a prime target for interventions in this population because it is well accepted, inexpensive, can serve as a form of transportation, and is gentle on the body (Belza et al., 2004; Cunningham and Michael, 2004; US Department of Transportation, 2004; Wong et al., 2003). Even small amounts of walking can protect against loss of mobility (Simonsick et al., 2005). Frail and chronically ill older adults can particularly benefit from exercise via improved muscle mass, bone density and cardiovascular fitness, which can enhance mobility, functional independence, and reduce the risk of common complications of aging (Heath and Stuart, 2002).
Reviews of physical activity interventions for older adults suggest that some older adults prefer to exercise alone and some prefer groups, simple activity changes are easier to maintain than more complex ones, and lifestyle activities are just as effective as structured activity to improve health outcomes (Brawley et al., 2003; King, 2001; van der Bij et al., 2002). Walking is a type of activity that is consistent with all of the review's conclusions. However, it is important to consider the places where older adults reside and walk, because their characteristics can promote or deter walking and other activities (Owen et al., 2004).
Continuing care retirement communities (CCRCs; Harris-Kojetin et al., 2005) that provide both congregate-independent living and assisted living promote continued independence for the older adult population and offer a dwelling place that is more independent than skilled nursing settings (Joseph and Zimring, 2007; Mihalko and Wickley, 2003; Pruchno and Rose, 2000). While there was a 22% increase in skilled nursing facilities between 1991 and 1999, there was a 50% increase in assisted-living facilities (Mihalko and Wickley, 2003), and the population projected to live in these settings will likely grow. Thus, CCRCs will become an increasingly important setting for interventions to improve the health of seniors. Individuals living in such facilities are thought to be relatively inactive and more frail than community-dwelling older adults (Mihalko and Wickley, 2003). Some of these facilities may offer physical activity programs, but they are often understaffed and lack exercise equipment and supervised walking programs (Mihalko and Wickley, 2003). Moreover, the campus and facilities generally have not been designed to promote walking and are not always located in neighborhoods that provide safe and accessible walking opportunities.
To guide health interventions in specific settings, ecological models are needed. Ecological models emphasize the interaction among biological, psychological, behavioral, social, and environmental factors for individuals, social networks, families, neighborhoods, and communities (Sallis and Owen, 2002; Satariano and McAuley, 2003). Such models propose that interventions are most effective when they change influences at multiple levels. A unique contribution of ecological models is their focus on environmental factors in health behavior change, as many other models only focus on psychological and social factors (Sallis and Owen, 2002). Environments can shape behavior directly (e.g., an individual cannot walk to a store because there are no stores within walking distance from home) or indirectly via perceptions of the environment (e.g., a neighborhood may be safe relative to other neighborhoods but individuals may believe their area is unsafe and choose not to walk). The nesting of individually targeted behavior change models, such as social cognitive theory (Bandura, 2004), within ecological models can lead to the development of multilevel interventions that are tailored to specific individuals and populations in specific places.
Consistent with ecological models, researchers have increasingly examined the importance of the built environment for promoting regular physical activity in older adults (Cunningham and Michael, 2004). Safe footpaths for walking, access to local facilities and services, presence of hills, absence of unattended dogs, enjoyable scenery, heavy traffic, and availability of sidewalks have been associated with physical activity in at least some groups of seniors (Cunningham and Michael, 2004; Li et al., 2005; Patterson and Chapman, 2004). The environment has also been related to the disablement process and depression among older populations (Clarke and George, 2005). For example, older adults with declining physical functioning were less able to perform daily instrumental activities when living in neighborhoods with limited land use mix (which refers to having a variety of uses in an area such as shops and residences; Clarke and George, 2005). In another study, older men living in more walkable neighborhoods had fewer depressive symptoms (Berke et al., 2007).
Researchers have called for better integration of individual and environment factors in physical activity interventions (Mihalko and Wickley, 2003; Satariano and McAuley, 2003; van der Bij et al., 2002) as well as better translation of research findings about environmental correlates into policy changes (Michael et al., 2006). While changes to the built environment can be expensive and take time to produce, such changes are permanent and affect the entire population. An alternative and less expensive interim strategy is to educate seniors about how to effectively overcome barriers and use available environmental resources that support physical activity.
Older adults’ motivation and walking behavior may be influenced by actual access to and perceptions of safe walking routes (Giles-Corti and Donovan, 2002; Reed et al., 2004) Self-monitoring using pedometers can increase older adults’ walking, and some studies have used motivational goals for accumulating steps such as ‘walk across America’ (Ogilvie et al., 2007), based on a social cognitive model of behavior change (Brawley et al., 2003). However, to our knowledge, there are no published studies of interventions to promote physical activity in CCRCs that simultaneously address individual, social, and environmental factors using a combination of principles from ecological models and social cognitive theory. This approach is supported by ecological models that predict multilevel interventions will be most effective in improving health behaviors, including physical activity (Satariano and McAuley, 2003). The purpose of this pilot study was to explore the feasibility and acceptability of such a novel place-based intervention. We hypothesized that older adults living in a CCRC would improve their amount of daily walking if they had better knowledge of places they could walk and individualized counseling sessions to teach specific physical activity self-management strategies.
Section snippets
Participants and setting
Adults over the age of 65 years were recruited from a CCRC for military veterans located near San Diego, CA. The facility has 400 beds and offers three levels of care—independent, assisted, and skilled nursing. Participants in this study were recruited from independent and assisted-living residences. Inclusion criteria were: not regularly physically active (less than 30 min three times per week), able to speak and write in English, score of less than 14 s on the Timed Up and Go Test (Shumway-Cook
Analysis
Descriptive statistics were computed. Pre–post changes were analyzed using paired samples t-tests. The alpha was set at .05, two tailed; however, because of the small sample and exploratory nature of this study, non-significant trends were examined.
Main outcomes
A total of 12 individuals were recruited from fliers and completed each measurement point in the 3-week intervention study. Ten additional individuals who were initially recruited did not complete the study due to a variety of reasons, including health problems (n=1), failure to attend study meetings (n=2), time conflicts (n=2), because they felt the program was not right for them (n=1) or for unknown reasons (n=4). Non-completers had lower baseline daily step counts (M=1736, SD=1701) than
Discussion
The results of this pilot study indicated that a brief multilevel place-based walking intervention is a promising method for promoting walking among seniors who live in CCRCs. Combining site-tailored maps and materials with brief weekly individualized goal setting led to a 41% increase in average daily steps after 2 weeks. Evidence from the physical activity and aging literature indicates that movement from a sedentary lifestyle to doing some activity, even if below recommendations, can improve
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