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Developing Effective Physical Activity Programs
by Lynda B. Ransdell, Mary K. Dinger, Jennifer Huberty and Kim H. Miller
Series: Physical Activity Intervention
216 Pages, 7
Developing Effective Physical Activity Programs emphasizes the move away from a one-size-fits-all approach to physical activity interventions by providing evidence-based recommendations for designing, implementing, and evaluating more effective and appropriate physical activity interventions for diverse populations. Part of Human Kinetics' Physical Activity Intervention series, the book provides research, methods, techniques, and support to health professionals seeking ways to promote physical activity programs that meet the specific needs of women, overweight and obese populations, older adults, and ethnically diverse populations—those shown as most likely to be sedentary and in need of the benefits of physical activity interventions.
Developing Effective Physical Activity Programs offers background information to guide the planning process:
-Physical activity recommendations for adults from various federal agencies and professional organizations, including the Centers for Disease Control and Prevention, the U.S. Department Health and Human Services, and the American College of Sports Medicine
-An overview of scientific literature, which serves as a foundation for the physical activity recommendations
-Detailed information regarding the four cornerstones of physical activity promotion: needs assessment, program planning, program implementation, and program evaluation
-Descriptions of various physical activity measurement techniques and factors to consider when choosing one of these techniques
The authors explain how careful consideration of the needs of specific populations can increase the success of physical activity interventions. They present evidence-based recommendations for working with various populations. Key considerations are discussed for each population, including the elements that make up the most successful interventions, unique barriers, and techniques for overcoming those barriers. Helpful tables summarize the barriers and solutions for each group, providing quick reference for designing programs.
The final section of the text examines how the built environment, setting, and technology can influence intervention planning. You'll look at the ways in which neighborhood and community design can affect a person's physical activity levels. You'll also consider the various settings in which a program can be held, including homes, churches, and worksites, and how those settings will affect your program. This section also shows you how technology, such as Web- and phone-based interventions and podcasts, can be used to expand the reach of your program and positively influence the physical activity levels of participants.
Throughout the book are summaries of current research studies examining physical activity interventions in various populations and settings along with descriptions and examples of successful programs and explanations for their success. In addition, each chapter concludes with helpful checklists that provide recommendations for developing and implementing physical activity interventions in various populations and settings.
Unique in its comprehensive coverage of special populations, Developing Effective Physical Activity Programs shows practitioners how to answer the physical activity needs of each client or client group, address issues relevant to sedentary populations, and offer viable physical activity programs to improve the lives of the unique individuals they serve.
Developing Effective Physical Activity Programs is part of the Physical Activity Intervention series. This timely series provides educational resources for professionals interested in promoting and implementing physical activity programs to a diverse and often resistant population.
Part I: Thinking About the Foundations of Physical Activity
Chapter 1: Promoting and Maintaining Health Through Physical Activity Recommendations
Chapter 2: Planning and Evaluating Physical Activity Programs
Chapter 3: Measuring Physical Activity
Part II: Working With Specific Populations
Chapter 4: Interventions for Women
Chapter 5: Interventions for Obese and Overweight Individuals
Chapter 6: Interventions for Older Adults
Chapter 7: Interventions for Ethnically Diverse Populations
Part III: Considering the Variables
Chapter 8: Increasing Physical Activity Through Environmental Approaches
Chapter 9: Increasing Physical Activity by Considering the Setting
Chapter 10: Effectively Using Mediated Programming
Lynda B. Ransdell, PhD, is a professor in the department of kinesiology at Boise State University.
Ransdell has dedicated her career and research to helping sedentary people increase their levels of physical activity. Ransdell has designed, implemented, and evaluated numerous physical activity interventions and has worked as a consultant to help others develop interventions in community settings.
Known for her research of physical activity patterns of women, Ransdell has conducted two well-respected studies, Daughters and Mothers Exercising Together (DAMET) and Generations Exercising Together to Improve Fitness (GET FIT), which detail some of the only family-based interventions known to be successful in increasing physical activity in typically inactive women.
Ransdell has published over 60 peer-reviewed articles and 14 book chapters, mostly related to increasing physical activity in sedentary individuals. She is also the author of Ensuring the Health of Active and Athletic Girls and Women, a popular text for courses examining the physiological and psychological implications of sport and physical activity participation for girls and women.
She is a fellow of the American College of Sports Medicine (ACSM) and the Research Consortium of the American Alliance for Health, Physical Education, Recreation and Dance. Ransdell has also served as president of the National Association for Girls and Women in Sport, editor of the Women in Sport and Physical Activity Journal, and coeditor of Physical Activity Today. She is the recipient of the ACSM Visiting Scholar award from University of South Carolina (1998) and Outstanding Alumni awards from Arizona State University and Eastern Kentucky University.
Ransdell resides in Boise, Idaho, where she enjoys participating in ice hockey, cross-country skiing, running, and mountain biking.
Mary K. Dinger, PhD, is a professor in the department of health and exercise science at the University of Oklahoma at Norman, where her teaching and research focus on promoting physical activity.
Working in a research, consulting, or community service capacity, Dinger has designed, implemented, and evaluated several physical activity interventions. She has published her research in more than 50 articles in peer-reviewed journals.
Dinger is a fellow of both the American College of Sports Medicine (ACSM) and the Research Consortium of the American Alliance for Health, Physical Education, Recreation and Dance (AAHPERD). She currently serves as epidemiology section editor for Research Quarterly for Exercise and Sport and on the editorial board of the American Journal of Health Behavior. She was previously an editorial board member of the American Journal of Health Education and an executive board member of the American Academy of Health Behavior and the Research Consortium of AAHPERD.
Dinger resides in Norman, Oklahoma. She enjoys staying physically active by playing with her daughter, biking, and hiking.
Jennifer Huberty, PhD, is an assistant professor in the department of health, physical education, and recreation at the University of Nebraska at Omaha, where she manages the graduate curriculum for physical activity in health promotion.
Huberty has designed, implemented, and evaluated numerous research- and community-based physical activity interventions. She is the creator of Women Bound to Be Active, a physical activity book club aimed at increasing the number of women who maintain healthy physical activity behaviors. This nine-month intervention provides women with the skills and tools for initiating and maintaining a physically active lifestyle. The rationale for this program and details on its feasibility have been published in Research Quarterly and Women and Health.
Based on research gathered in Women Bound to Be Active, Huberty also created a locally implemented weight management program, Fit for Life, which provides a no-cost opportunity for underserved people to learn healthy behaviors and be active within their communities. Huberty directs the physical activity component for Club Possible, a physical activity and nutrition education afterschool program focusing on prevention of childhood obesity. The program has been implemented in 18 afterschool agencies, including CampFire USA, YMCA, Boys and Girls Club, and Girl Scouts.
Huberty is a member of the Society of Behavioral Medicine and the American Alliance for Health, Physical Education, Recreation and Dance. For outstanding research and community service, Huberty was awarded the Varner Professorship for 2007. In 1999, she received a graduate student research award from the Southern Academy for Women in Physical Activity, Sport, and Health.
Huberty resides in LaVista, Nebraska, with her husband, Rodger. She enjoys Spinning, running, weight training, and scrapbooking in her free time.
Kim H. Miller, PhD, is an associate professor of health promotion in the department of kinesiology and health promotion at the University of Kentucky at Lexington, where she works with undergraduate and graduate students to design and implement health promotion interventions.
Miller received her doctorate in health education from Southern Illinois University in 2000. For over eight years, she has conducted research in the area of health and physical activity, publishing numerous research papers and presenting her findings at international conferences. Miller has also served as a consultant in designing physical activity and health promotion interventions for employee wellness programs in a variety of settings. She is a member of the American Academy of Health Behavior and the American Association for Health Education.
In her free time, she enjoys running, hiking, reading, and cooking. Miller resides in Lexington, Kentucky.
Confidence and positive attitude help older adults stick with exercise
To develop effective older adult physical activity interventions, it is important to understand factors that predict participation and adherence.
Because the majority of older adults clearly can engage in physical activity safely, a growing body of research has been conducted to identify effective programs for increasing physical activity in this population (Brawley, Rejeski, & King, 2003; Taylor et al., 2004; U.S. Department of Health and Human Services, 1996). However, increasing older adult physical activity participation presents unique challenges. Although some programs have been effective in the short term, the effectiveness of long-term physical activity programs has been limited (Brawley, Rejeski, & King, 2003; Taylor et al., 2004).
Factors Related to Successful Physical Activity Interventions
To develop effective older adult physical activity interventions, it is important to understand factors that predict participation and adherence. Numerous research studies have investigated correlates of older adult physical activity participation (Benjamin, Edwards, & Baharti, 2005; Brassington, Atienza, Perczek, DiLorenzo, & King 2002; Hays & Clark, 1999; Lee & Lafferty, 2006; Stuart, Marret, Kelly, & Nelson, 2002). Although many factors influence the participation rates of older adults, we will examine the following, which demonstrate the greatest potential for increasing physical activity:
- Psychological factors of self-efficacy, self-regulation, positive attitudes toward physical activity, and social support
- Health care provider referral
- Physical activity intensity
- Group- and home-based interventions
- Disease management
Psychological Factors
As with other populations, self-efficacy, or the confidence a person has to perform an activity, is one of the strongest determinants of physical activity for older adults (Brassington et al., 2002; Resnick, Orwig, Magaziner, & Wynne, 2002; Schutzer & Graves, 2004). Interventions should help older adults build their confidence through mastery of the physical activity. This can be achieved by beginning the intervention at a low intensity and gradually increasing the intensity over time. This gradual increase is especially important for frail older adults. Improvements in fitness and or health that result from physical activity will also enhance self-efficacy.
To promote long-term adherence to physical activity, interventions need to be designed so older adults move from a supervised, or center-based, setting to the home, where they can use self-regulation skills to make physical activity part of their lifestyle (Rejeski & Brawley, 2006). Behavioral counseling is one method that can be used to help older adults transition from center-based to home-based activity. Through counseling, older adults can develop a plan of action for making physical activity a part of their daily routine.
Having a positive attitude toward physical activity is another factor influencing older adult participation (Stuart et al., 2002). If the activity is positive and enjoyable, older adults will be more likely to continue to exercise. Past participation is also a predictor of future participation (Benjamin et al., 2005). For those who have had a negative attitude toward physical activity, strategies such as providing positive images depicting the activity with role models who may have similar limitations can be used to entice older adults to participate.
Receiving positive reinforcement or social support from friends and family is also one of the predictors of physical activity involvement in the older adult population (Booth, Owen, Bauman, Clavisi, & Leslie 2002; McAuley, Jerome, Elavvsky, Marquez, & Ramsey, 2003; Resnick et al., 2002). Litt, Kepplinger, and Judge (2002) found that social support is a strong determinant of physical activity particularly for older women. In addition, positive comments help strengthen people's self-efficacy and can enhance exercise adherence. Programs need to be carefully designed to create a positive environment. In residential care facilities, older adults may have limited contact with family members; thus, support from friends may be more important.
Health Care Provider Referrals
Receiving a recommendation from a physician to exercise is another important positive predictor of physical activity in the older adult population (Benjamin et al., 2005; Navarro, Sanz, del Castillo, Izquierdo, & Rodriguez, 2007; Stuart et al., 2002). Having a health care provider "prescribe" exercise helps older adults overcome their fear of being injured during the physical activity. This type of prescription may be especially important for physically frail older adults (Benjamin et al., 2005). More research needs to be conducted in this area to determine the most effective type of physician advice and the amount of contact needed with the older adult to improve physical activity levels.
Physical Activity Intensity
Older adults are more likely to participate in low- to moderate-intensity physical activity (Brawley et al., 2003; Taylor et al., 2004) such as light housework, chair exercises, and walking. Lower-intensity activity is less likely to cause injuries and is often perceived as less threatening, especially to older adults who have functional disabilities or limitations. Although interventions should to be tailored to the ability level of the participant, planners must also recognize that low-intensity exercises conducted in a chair may have few functional benefits for the older adult. Specificity of the exercise is the issue. If the goal is to improve mobility and balance, exercises should be conducted while participants are standing and walking. Physical activity interventions that begin at lower intensities should progress over time to moderate intensities.
Group- and Home-Based Interventions
Physical activity interventions can be designed to be group based, home based, or a combination of both. Group-based interventions require participants to go to a facility or center where the activity program is usually supervised. For typical home-based interventions, the physical activity occurs at the older adult's home, and contact with the practitioner is minimal. Combination designs usually begin with a few weeks of group-based instruction followed by a period of home-based activity. Table 6.1 lists some of the positive and negative aspects of group- and home-based interventions.
Research has demonstrated that both home-based and group-based physical activity interventions can be successful with the older adult population (Campbell, Robertson, Gardner, Norton, & Buchner, 1999; King, Haskell, Taylor, Kraemer, & Debusk, 1991; King, Haskell, Young, Oka, & Stefanic, 1995; McMurdo & Rennie, 1993; van der Bij, Laurant, & Wensing, 2002). One study found similar participation rates in both home- and group-based environments for short-term programs; however, adherence rates tended to decrease as the length of the study increased (King et al., 1995; van der Bij et al., 2002). The use of behavioral strategies including phone calls and various incentives may help improve long-term participation rates. More research should be conducted using a combination of group- and home-based environments to determine which programs work best for which population.
Disease Management
Disease management, in the context of this chapter, is using physical activity as a strategy to prevent disease and maintain favorable health status. Studies have found that mobile older adults who have few or no limitations view physical activity as a way to maintain their health (Cohen-Mansfield, Marx, & Guralnick, 2003; Rasinaho, Herninalo, Leinonen, Linutenen, & Rantinen, 2006). Older adults with higher self-efficacy and a motivation to improve their health are more likely to be physically active than those with lower self-efficacy and little motivation to improve their health (Lee & Lafferty, 2006). Increased self-efficacy may help older adults overcome barriers that prevent them from engaging in physical activity. Physical activity can help all adults, both the young and the old, avoid chronic diseases.
When planning physical activity interventions for older adults, planners should consider factors that will improve participation and adherence. This section highlighted just a few of the factors that typically result in success. Intervention specialists are encouraged to use these strategies to overcome barriers to physical activity in older adults.
Sample Successful Interventions
Home-Based Progressive Strength Training
Osteoarthritis is a common ailment that causes pain, reduces functional abilities, and limits physical activity for many older adults. Baker and colleagues (2001) investigated the effectiveness of home-based strength training for improving symptoms of knee osteoarthritis in a group of 46 adults over the age of 55. Participants were randomized into a nutritional education control group or home-based strength training group. The home-based strength group trained for 4 months. Intervention participants received in-home visits twice a week for 3 weeks, one in the 4th week and every other week thereafter. Compared to the control group, the home-based training group significantly improved in strength, pain reduction, physical function, and quality of life. These important gains highlight the need for home-based programs designed to reduce pain and other osteoarthritis symptoms and improve older adult physical function.
Walk; Address Pain, Fear, Fatigue During Exercise; Learn About Exercise; Cue by Self-Modeling (WALC)
WALC was designed to address some of the common barriers older adults have relative to physical activity (Resnick, 2002). Twenty sedentary participants were divided into treatment or control groups. The treatment group followed the four phases of the WALC program. They were asked to walk in groups or individually for 20 minutes three times per week for 6 months. The intervention group received regular visits from a practitioner who addressed unpleasant reactions associated with exercise (i.e., addressed pain, fear, fatigue during exercise). This part of the intervention included pain management techniques, relaxation methods, and scheduling of rest and exercise. Those in the treatment groups were given a book about exercise benefits and barriers and received assistance developing short- and long-term goals, planning exercise sessions, and logging their results (i.e., learned about exercise).
When compared to the controls, the treatment group demonstrated significant improvement in exercise behavior, physical activity levels, and self-efficacy expectations. Although the number of participants used in this study was small, the results indicate that physical activity levels can be increased with the sedentary older adult population by using techniques to improve self-efficacy, which can mediate common exercise barriers.
Learn more about Developing Effective Physical Activity Programs.
Effective use of mediated programming in physical activity interventions
As the influence of technology continues to increase, those interested in promoting physical activity should consider developing physical activity programs that effectively use technology.
Using technology or intervention techniques that are not delivered face-to-face is known as mediated program delivery (Marshall, Owen, & Bauman, 2004). Because of the ability to reach large numbers of people with relatively low cost, mediated programs in our field have increased dramatically. Wantland, Portillo, Holzemer, Slaughter, and McGhee (2004) reported that during a 7-year period (1996-2003), there was a 12-fold increase in MEDLINE citations for "Web-based therapies". Some examples of mediated program delivery include using email to contact program participants, using the Internet to track activity or seek social support or program feedback from group leaders, or offering podcasts or Web-streamed videos to provide access to important program information.
Factors Related to Successful Mediated Physical Activity Interventions
Factors related to successful mediated physical activity interventions fall into two categories: (a) general and relevant for all types of mediated interventions and (b) specific and relevant to only certain types of mediated interventions. Both are addressed in this section. Designers of interventions should consider both general and specific aspects when planning mediated programs.
General Factors Related to Success in All Mediated Interventions
The following six factors are related to success with any type of mediated intervention, regardless of medium:
- Increasing dose-response
- Designing memorable campaign slogans and information
- Using market segmentation and message personalization strategies
- Targeting multiple media outlets
- Ensuring theoretical fidelity
- Paying attention to quality control
• Dose-response issues. Dose-response, in this context, means that more media exposure typically results in increased physical activity behavior, increased satisfaction with program components, or both. Mediated interventions, if used correctly, can reach large numbers of people in a cost-effective manner. Exposure to media is measured in weekly gross rating points (GRP). One GRP means that 1% of the target audience viewed the advertisement once. Obviously, higher GRPs are more likely to result in a successful campaign (i.e., reach large numbers of people).
• Memorable campaign slogans. A second key to developing a successful mediated campaign is to develop and use memorable and reproducible images. Most people interested in physical activity will remember Nike's most memorable ad campaigns: "Just Do It," "If you let me play . . .," and the recent ads in conjunction with the women's World Cup soccer tournament ("The greatest team you've never heard of"). The average American is exposed to 3,000 ads per day (Peterson, Abraham, & Waterfield, 2005); therefore, media must be memorable to make an impact.
• Market segmentation. Market segmentation refers to designing marketing strategies for a specific segment of the population. Designing campaigns so they will reach various age or ethnic groups or men or women is an important strategy because what works for one segment of the population may be offensive or nonmeaningful to another (Peterson, Abraham, & Waterfield, 2005). To ensure memorable messages and accurate market segmentation, program promoters should pilot test campaign slogans and designs with the target audience. In addition to pilot testing, it is important to continually seek feedback, preferably from a local advisory committee, to refine and improve a media message as necessary. When possible, booster campaigns should be administered to sustain a promotional effort beyond the life of the initial campaign (Reger et al., 2002).
• Personalization strategies. Similar to market segmentation (or personalizing a message to reach a target audience), Marcus and colleagues (1998) suggested that one of the most important factors contributing to a successful mediated program is identifying and including relevant attributes of role models. For example, if a message is designed to reach young African Americans in a community, then characteristics and attributes of young African Americans and representative role models should be included in that message. To ascertain what these characteristics are and what information might be meaningful to that group, members of the relevant group should be surveyed and included
in a pilot testing process. The bottom line is that if people can personalize a message, they are more likely to internalize and act on it. Additional factors that can help facilitate program success are (a) tailoring information to a specific stage of change (such as the contemplation stage in the transtheoretical model), (b) updating the stage of change regularly; and (c) using reinforcement letters, phone calls, or e-mails regularly (e.g., biweekly) (Marshall et al., 2003).
• Targeting multiple areas of the media. Numerous media outlets are available for health and fitness-related messages (e.g., billboards, buses, signs, television, radio, Internet, and newspaper) (Peterson et al., 2005). A good example of creative media blitzing is using point-of-decision prompts. Point-of-decision prompts are reminders in the form of signs, bulletin boards, billboards, or bus signs that encourage people to take advantage of physical activity opportunities when they arise (Marcus et al., 1998). Some examples of point-of-decision prompts that work include Use the Stairs and Park and Walk (Marcus et al., 1998).
• Theoretical fidelity. Theoretical fidelity refers to the precision with which theory-based recommendations are used. Rovniak and colleagues (2005) tested the effectiveness of high- and low-fidelity e-mail-based walking interventions in 65 sedentary adults, mostly women. One 12-week intervention, which demonstrated high fidelity to the social cognitive theory (SCT), used targeted skills, specific and hierarchical goals, and precise self-monitoring and feedback. The other intervention, which demonstrated low fidelity to the SCT, provided information (rather than modeling) to teach skills and did not provide ongoing self-monitoring and feedback. Several outcomes were monitored before and after the intervention, including a 1-mile (1.6 km) walk test of physical fitness, a log of walking behavior, and several measures of social cognitive theory (e.g., exercise self-efficacy, benefits and enjoyment of physical activity, goal setting, exercise planning, and social support). Compared to those in the low-fidelity group, those in the high-fidelity group completed more of their prescribed walking sessions and walked faster at posttest. Those in the high-fidelity group also reported greater program satisfaction and increased their goal setting and positive outcome expectations for walking more than twice as much as those in the low-fidelity group. Clearly, efforts to ensure theoretical fidelity are important for improving the success of mediated interventions.
• Quality control. Quality control, or attention to clarity, accuracy, and timeliness, is important. Information must be of high quality to earn respect, reach the critical mass, and facilitate changes in physical activity behavior (Marcus et al., 1998). Although obesity prevention and physical activity promotion are multimillion-dollar industries, it is not right to promise something that cannot be delivered. Failure to deliver programs based on factual information may result in an ineffective and disrespected program.
Factors Related to Success in Specific Mass Media Programs
The mass media has the potential to reach large numbers of people in a short period of time for a relatively low cost. To maximize this opportunity and ensure that mass media programs are successful, Cavill and Bauman (2004) recommend the following strategies:
- The mass media should target multiple media outlets in a systematic and sustained fashion.
- Campaigns should maximize contact or message exposure, because doing so typically results in greater behavior change.
- Other supportive community activities should be organized around mass media messages (e.g., self-help groups, counseling, screening and education, community events, and walking trails).
- The message coming from the mass media should be singular and simple-so it will be memorable.
- Mass media campaigns should target a specific audience or audiences based on demographics, attitudes, and preferred media usage; this will ensure that the message is heard by those for whom it is designed.
Print-Based Programs Those designing physical activity programs are probably most familiar with print-based handouts. Print handouts have been around longer than other means of media, and they are probably still the most common method of promoting increased physical activity. Distributors of print media should use some of the suggestions provided earlier for all mediated interventions, while also considering specific recommendations for this medium. Following are some suggestions for designing a successful print-based program (Napolitano & Marcus, 2002):
- Follow up with participants quickly after distributing print material.
- Provide opportunities for participants to find interactions with others because social support is a desirable feature of many physical activity programs.
- Make sure the information is concise, accurate, and specifically directed to the targeted population.
- Pilot test materials with members of the targeted population.
- Write materials to a level appropriate for the targeted population.
Phone-Based Programs Phone-based programs are delivered as phone calls or text messages. The following recommendations can help ensure that a phone-based program is successful:
- Consider the purpose of the contact (e.g., touching base, structured, or automated with prompts); studies have demonstrated that phone calls designed to touch base were just as effective as contacts that were highly structured (Lombard, Lombard, & Winett, 1995, as cited in Marcus et al., 1998).
- Consider the frequency with which phone calls or text messages are delivered. Schultz (1993) concluded that adherence and frequency of phone contacts are positively correlated, although there is probably a point at which a high frequency of phone contacts becomes a nuisance.
- Be as specific as possible with feedback (e.g., overcoming barriers, the benefits of exercise that are motivating to that participant, the type of activity the participant enjoyed) to facilitate maximal change (Hurling et al., 2007).
Although phone-based interventions have been around for a while, the use of text messaging to prompt physical activity is a relatively new means of communicating using mediated technology. Given the increase in text messaging in this country, this technology offers significant potential for reaching many people.
Web-Based Programs Web-based programs demand a significant time investment prior to implementation. To ensure that Web-based programs are designed successfully, Ferney and Marshall (2006) recommended considering four factors that are important to Web site users in the field of physical activity promotion: Web design (structure), interactivity, environmental context, and content.
- Web design. To be maximally useful, Web sites should be easy to navigate and download time should be minimal (Ferney & Marshall, 2006). Users should be able to navigate a Web site easily, and links should be intuitive and downloadable in no more than 10 seconds. Making Web sites password protected facilitates tracking people's use around the site. Web site designers should conduct pilot and usability tests with proposed and developing Web sites and correct any problems found.
- Interactivity. A Web site that facilitates information exchange between a participant and an intervention specialist is interactive. Following are some examples of interactive activities on a PA Web site (Ferney & Marshall, 2006; Hurling et al., 2006):
• Logging on to a Web site to report activity or set goals
• Receiving specific feedback about one's performance compared to others or a previous best effort
• Accessing social support and expert advice
• Calculating target heart rate
• Accessing information about local community events
• Identifying barriers and receiving feedback about ways to overcome them
According to experts (Bull, Kreuter, & Scharff, 1999; Ferney & Marshall, 2006; Fogg, 2003; Hurling et al., 2006; Tate, Wing, & Winett, 2001; Wantland et al., 2004), interactive Web sites are more effective than non-interactive sites because they
• are more enjoyable to use,
• are less impersonal,
• facilitate better user retention and longer Web sessions,
• create higher expectations for exercise,
• facilitate higher levels of motivation and improved self-perception of fitness,
• are more likely to be saved and revisited in the future,
• are more likely to be discussed with others, and
• result in real behavior change with regular visitations.
- Environmental context. Providing information such as an updated community calendar of events; maps of physical activity opportunities in the community; and a physical activity database with information about times, costs, deadlines, and facilities (Ferney & Marshall, 2006) are examples of considering the environmental context. This information should be updated regularly to facilitate the desire to visit the Web site.
- Content. Information presented on the Web as audio, video, or text is known as content. It is important to update Web site content as often as possible. Those who use the Web frequently do not like to read volumes of text or wade through repetitive information, and they do not like to visit Web sites and see the same information over and over.
Podcasting Research is sparse on the factors related to success with podcasting-especially as it relates to increasing physical activity. However, until more research is conducted, the following basic strategies can help ensure that podcasts are successful (Eads, 2007; Hartman & Jackson, 2007):
- Be aware that those in the iPod generation are typically young and technologically savvy.
- When possible, provide the means for interaction with others.
- Pilot test podcasts with members of the target population.
- Make sure podcasts are simple and easy to download with a computer.
Sample Successful Program
Active Living (Web and Print)
Active Living is an 8-week Web-based program that evolved from a print-based program (Marshall et al., 2003). This program assessed stage of change (according to the transtheoretical model) and featured personalized Web links to sites on goal setting, activity planning, and determining target heart rate. People who participated in this project were regularly reassessed to ensure that their Web information was tailored to their specific stage of change. The Web information was supplemented with personalized and stage-based reinforcement e-mails sent every 2 weeks. These e-mails contained hyperlinks to relevant areas of the Active Living Web site. The print information for this intervention was identical to the information found in the Web-based program except that people receiving the print materials received supplemental letters with stage-matched information every 2 weeks.
The impact of the intervention was assessed by comparing baseline and postintervention physical activity data: (a) MET-minutes per week and minutes in specific categories of activity (e.g., vigorous, moderate, and seated activities), collected with the International PA Questionnaire (IPAQ), (b) meeting or not meeting the public health recommendation (i.e., 30 minutes of at least moderate physical activity most days of the week), and (c) stage of change in the transtheoretical model. Results of the study indicate that Web interven tion participants reported a decrease in the amount of time spent sitting, and print-based intervention participants increased their total minutes of physical activity. About 26% of the participants in both groups progressed forward at least one stage of change in the transtheoretical model, indicating that they should be likely to continue being physically active in the future. It is interesting to note that both print- and Web-based programs facilitated increases in physical activity, although people in the print group reported larger increases in activity and they were better able to recognize intervention materials after the program was completed.
Learn more about Developing Effective Physical Activity Programs.
Confidence and positive attitude help older adults stick with exercise
To develop effective older adult physical activity interventions, it is important to understand factors that predict participation and adherence.
Because the majority of older adults clearly can engage in physical activity safely, a growing body of research has been conducted to identify effective programs for increasing physical activity in this population (Brawley, Rejeski, & King, 2003; Taylor et al., 2004; U.S. Department of Health and Human Services, 1996). However, increasing older adult physical activity participation presents unique challenges. Although some programs have been effective in the short term, the effectiveness of long-term physical activity programs has been limited (Brawley, Rejeski, & King, 2003; Taylor et al., 2004).
Factors Related to Successful Physical Activity Interventions
To develop effective older adult physical activity interventions, it is important to understand factors that predict participation and adherence. Numerous research studies have investigated correlates of older adult physical activity participation (Benjamin, Edwards, & Baharti, 2005; Brassington, Atienza, Perczek, DiLorenzo, & King 2002; Hays & Clark, 1999; Lee & Lafferty, 2006; Stuart, Marret, Kelly, & Nelson, 2002). Although many factors influence the participation rates of older adults, we will examine the following, which demonstrate the greatest potential for increasing physical activity:
- Psychological factors of self-efficacy, self-regulation, positive attitudes toward physical activity, and social support
- Health care provider referral
- Physical activity intensity
- Group- and home-based interventions
- Disease management
Psychological Factors
As with other populations, self-efficacy, or the confidence a person has to perform an activity, is one of the strongest determinants of physical activity for older adults (Brassington et al., 2002; Resnick, Orwig, Magaziner, & Wynne, 2002; Schutzer & Graves, 2004). Interventions should help older adults build their confidence through mastery of the physical activity. This can be achieved by beginning the intervention at a low intensity and gradually increasing the intensity over time. This gradual increase is especially important for frail older adults. Improvements in fitness and or health that result from physical activity will also enhance self-efficacy.
To promote long-term adherence to physical activity, interventions need to be designed so older adults move from a supervised, or center-based, setting to the home, where they can use self-regulation skills to make physical activity part of their lifestyle (Rejeski & Brawley, 2006). Behavioral counseling is one method that can be used to help older adults transition from center-based to home-based activity. Through counseling, older adults can develop a plan of action for making physical activity a part of their daily routine.
Having a positive attitude toward physical activity is another factor influencing older adult participation (Stuart et al., 2002). If the activity is positive and enjoyable, older adults will be more likely to continue to exercise. Past participation is also a predictor of future participation (Benjamin et al., 2005). For those who have had a negative attitude toward physical activity, strategies such as providing positive images depicting the activity with role models who may have similar limitations can be used to entice older adults to participate.
Receiving positive reinforcement or social support from friends and family is also one of the predictors of physical activity involvement in the older adult population (Booth, Owen, Bauman, Clavisi, & Leslie 2002; McAuley, Jerome, Elavvsky, Marquez, & Ramsey, 2003; Resnick et al., 2002). Litt, Kepplinger, and Judge (2002) found that social support is a strong determinant of physical activity particularly for older women. In addition, positive comments help strengthen people's self-efficacy and can enhance exercise adherence. Programs need to be carefully designed to create a positive environment. In residential care facilities, older adults may have limited contact with family members; thus, support from friends may be more important.
Health Care Provider Referrals
Receiving a recommendation from a physician to exercise is another important positive predictor of physical activity in the older adult population (Benjamin et al., 2005; Navarro, Sanz, del Castillo, Izquierdo, & Rodriguez, 2007; Stuart et al., 2002). Having a health care provider "prescribe" exercise helps older adults overcome their fear of being injured during the physical activity. This type of prescription may be especially important for physically frail older adults (Benjamin et al., 2005). More research needs to be conducted in this area to determine the most effective type of physician advice and the amount of contact needed with the older adult to improve physical activity levels.
Physical Activity Intensity
Older adults are more likely to participate in low- to moderate-intensity physical activity (Brawley et al., 2003; Taylor et al., 2004) such as light housework, chair exercises, and walking. Lower-intensity activity is less likely to cause injuries and is often perceived as less threatening, especially to older adults who have functional disabilities or limitations. Although interventions should to be tailored to the ability level of the participant, planners must also recognize that low-intensity exercises conducted in a chair may have few functional benefits for the older adult. Specificity of the exercise is the issue. If the goal is to improve mobility and balance, exercises should be conducted while participants are standing and walking. Physical activity interventions that begin at lower intensities should progress over time to moderate intensities.
Group- and Home-Based Interventions
Physical activity interventions can be designed to be group based, home based, or a combination of both. Group-based interventions require participants to go to a facility or center where the activity program is usually supervised. For typical home-based interventions, the physical activity occurs at the older adult's home, and contact with the practitioner is minimal. Combination designs usually begin with a few weeks of group-based instruction followed by a period of home-based activity. Table 6.1 lists some of the positive and negative aspects of group- and home-based interventions.
Research has demonstrated that both home-based and group-based physical activity interventions can be successful with the older adult population (Campbell, Robertson, Gardner, Norton, & Buchner, 1999; King, Haskell, Taylor, Kraemer, & Debusk, 1991; King, Haskell, Young, Oka, & Stefanic, 1995; McMurdo & Rennie, 1993; van der Bij, Laurant, & Wensing, 2002). One study found similar participation rates in both home- and group-based environments for short-term programs; however, adherence rates tended to decrease as the length of the study increased (King et al., 1995; van der Bij et al., 2002). The use of behavioral strategies including phone calls and various incentives may help improve long-term participation rates. More research should be conducted using a combination of group- and home-based environments to determine which programs work best for which population.
Disease Management
Disease management, in the context of this chapter, is using physical activity as a strategy to prevent disease and maintain favorable health status. Studies have found that mobile older adults who have few or no limitations view physical activity as a way to maintain their health (Cohen-Mansfield, Marx, & Guralnick, 2003; Rasinaho, Herninalo, Leinonen, Linutenen, & Rantinen, 2006). Older adults with higher self-efficacy and a motivation to improve their health are more likely to be physically active than those with lower self-efficacy and little motivation to improve their health (Lee & Lafferty, 2006). Increased self-efficacy may help older adults overcome barriers that prevent them from engaging in physical activity. Physical activity can help all adults, both the young and the old, avoid chronic diseases.
When planning physical activity interventions for older adults, planners should consider factors that will improve participation and adherence. This section highlighted just a few of the factors that typically result in success. Intervention specialists are encouraged to use these strategies to overcome barriers to physical activity in older adults.
Sample Successful Interventions
Home-Based Progressive Strength Training
Osteoarthritis is a common ailment that causes pain, reduces functional abilities, and limits physical activity for many older adults. Baker and colleagues (2001) investigated the effectiveness of home-based strength training for improving symptoms of knee osteoarthritis in a group of 46 adults over the age of 55. Participants were randomized into a nutritional education control group or home-based strength training group. The home-based strength group trained for 4 months. Intervention participants received in-home visits twice a week for 3 weeks, one in the 4th week and every other week thereafter. Compared to the control group, the home-based training group significantly improved in strength, pain reduction, physical function, and quality of life. These important gains highlight the need for home-based programs designed to reduce pain and other osteoarthritis symptoms and improve older adult physical function.
Walk; Address Pain, Fear, Fatigue During Exercise; Learn About Exercise; Cue by Self-Modeling (WALC)
WALC was designed to address some of the common barriers older adults have relative to physical activity (Resnick, 2002). Twenty sedentary participants were divided into treatment or control groups. The treatment group followed the four phases of the WALC program. They were asked to walk in groups or individually for 20 minutes three times per week for 6 months. The intervention group received regular visits from a practitioner who addressed unpleasant reactions associated with exercise (i.e., addressed pain, fear, fatigue during exercise). This part of the intervention included pain management techniques, relaxation methods, and scheduling of rest and exercise. Those in the treatment groups were given a book about exercise benefits and barriers and received assistance developing short- and long-term goals, planning exercise sessions, and logging their results (i.e., learned about exercise).
When compared to the controls, the treatment group demonstrated significant improvement in exercise behavior, physical activity levels, and self-efficacy expectations. Although the number of participants used in this study was small, the results indicate that physical activity levels can be increased with the sedentary older adult population by using techniques to improve self-efficacy, which can mediate common exercise barriers.
Learn more about Developing Effective Physical Activity Programs.
Effective use of mediated programming in physical activity interventions
As the influence of technology continues to increase, those interested in promoting physical activity should consider developing physical activity programs that effectively use technology.
Using technology or intervention techniques that are not delivered face-to-face is known as mediated program delivery (Marshall, Owen, & Bauman, 2004). Because of the ability to reach large numbers of people with relatively low cost, mediated programs in our field have increased dramatically. Wantland, Portillo, Holzemer, Slaughter, and McGhee (2004) reported that during a 7-year period (1996-2003), there was a 12-fold increase in MEDLINE citations for "Web-based therapies". Some examples of mediated program delivery include using email to contact program participants, using the Internet to track activity or seek social support or program feedback from group leaders, or offering podcasts or Web-streamed videos to provide access to important program information.
Factors Related to Successful Mediated Physical Activity Interventions
Factors related to successful mediated physical activity interventions fall into two categories: (a) general and relevant for all types of mediated interventions and (b) specific and relevant to only certain types of mediated interventions. Both are addressed in this section. Designers of interventions should consider both general and specific aspects when planning mediated programs.
General Factors Related to Success in All Mediated Interventions
The following six factors are related to success with any type of mediated intervention, regardless of medium:
- Increasing dose-response
- Designing memorable campaign slogans and information
- Using market segmentation and message personalization strategies
- Targeting multiple media outlets
- Ensuring theoretical fidelity
- Paying attention to quality control
• Dose-response issues. Dose-response, in this context, means that more media exposure typically results in increased physical activity behavior, increased satisfaction with program components, or both. Mediated interventions, if used correctly, can reach large numbers of people in a cost-effective manner. Exposure to media is measured in weekly gross rating points (GRP). One GRP means that 1% of the target audience viewed the advertisement once. Obviously, higher GRPs are more likely to result in a successful campaign (i.e., reach large numbers of people).
• Memorable campaign slogans. A second key to developing a successful mediated campaign is to develop and use memorable and reproducible images. Most people interested in physical activity will remember Nike's most memorable ad campaigns: "Just Do It," "If you let me play . . .," and the recent ads in conjunction with the women's World Cup soccer tournament ("The greatest team you've never heard of"). The average American is exposed to 3,000 ads per day (Peterson, Abraham, & Waterfield, 2005); therefore, media must be memorable to make an impact.
• Market segmentation. Market segmentation refers to designing marketing strategies for a specific segment of the population. Designing campaigns so they will reach various age or ethnic groups or men or women is an important strategy because what works for one segment of the population may be offensive or nonmeaningful to another (Peterson, Abraham, & Waterfield, 2005). To ensure memorable messages and accurate market segmentation, program promoters should pilot test campaign slogans and designs with the target audience. In addition to pilot testing, it is important to continually seek feedback, preferably from a local advisory committee, to refine and improve a media message as necessary. When possible, booster campaigns should be administered to sustain a promotional effort beyond the life of the initial campaign (Reger et al., 2002).
• Personalization strategies. Similar to market segmentation (or personalizing a message to reach a target audience), Marcus and colleagues (1998) suggested that one of the most important factors contributing to a successful mediated program is identifying and including relevant attributes of role models. For example, if a message is designed to reach young African Americans in a community, then characteristics and attributes of young African Americans and representative role models should be included in that message. To ascertain what these characteristics are and what information might be meaningful to that group, members of the relevant group should be surveyed and included
in a pilot testing process. The bottom line is that if people can personalize a message, they are more likely to internalize and act on it. Additional factors that can help facilitate program success are (a) tailoring information to a specific stage of change (such as the contemplation stage in the transtheoretical model), (b) updating the stage of change regularly; and (c) using reinforcement letters, phone calls, or e-mails regularly (e.g., biweekly) (Marshall et al., 2003).
• Targeting multiple areas of the media. Numerous media outlets are available for health and fitness-related messages (e.g., billboards, buses, signs, television, radio, Internet, and newspaper) (Peterson et al., 2005). A good example of creative media blitzing is using point-of-decision prompts. Point-of-decision prompts are reminders in the form of signs, bulletin boards, billboards, or bus signs that encourage people to take advantage of physical activity opportunities when they arise (Marcus et al., 1998). Some examples of point-of-decision prompts that work include Use the Stairs and Park and Walk (Marcus et al., 1998).
• Theoretical fidelity. Theoretical fidelity refers to the precision with which theory-based recommendations are used. Rovniak and colleagues (2005) tested the effectiveness of high- and low-fidelity e-mail-based walking interventions in 65 sedentary adults, mostly women. One 12-week intervention, which demonstrated high fidelity to the social cognitive theory (SCT), used targeted skills, specific and hierarchical goals, and precise self-monitoring and feedback. The other intervention, which demonstrated low fidelity to the SCT, provided information (rather than modeling) to teach skills and did not provide ongoing self-monitoring and feedback. Several outcomes were monitored before and after the intervention, including a 1-mile (1.6 km) walk test of physical fitness, a log of walking behavior, and several measures of social cognitive theory (e.g., exercise self-efficacy, benefits and enjoyment of physical activity, goal setting, exercise planning, and social support). Compared to those in the low-fidelity group, those in the high-fidelity group completed more of their prescribed walking sessions and walked faster at posttest. Those in the high-fidelity group also reported greater program satisfaction and increased their goal setting and positive outcome expectations for walking more than twice as much as those in the low-fidelity group. Clearly, efforts to ensure theoretical fidelity are important for improving the success of mediated interventions.
• Quality control. Quality control, or attention to clarity, accuracy, and timeliness, is important. Information must be of high quality to earn respect, reach the critical mass, and facilitate changes in physical activity behavior (Marcus et al., 1998). Although obesity prevention and physical activity promotion are multimillion-dollar industries, it is not right to promise something that cannot be delivered. Failure to deliver programs based on factual information may result in an ineffective and disrespected program.
Factors Related to Success in Specific Mass Media Programs
The mass media has the potential to reach large numbers of people in a short period of time for a relatively low cost. To maximize this opportunity and ensure that mass media programs are successful, Cavill and Bauman (2004) recommend the following strategies:
- The mass media should target multiple media outlets in a systematic and sustained fashion.
- Campaigns should maximize contact or message exposure, because doing so typically results in greater behavior change.
- Other supportive community activities should be organized around mass media messages (e.g., self-help groups, counseling, screening and education, community events, and walking trails).
- The message coming from the mass media should be singular and simple-so it will be memorable.
- Mass media campaigns should target a specific audience or audiences based on demographics, attitudes, and preferred media usage; this will ensure that the message is heard by those for whom it is designed.
Print-Based Programs Those designing physical activity programs are probably most familiar with print-based handouts. Print handouts have been around longer than other means of media, and they are probably still the most common method of promoting increased physical activity. Distributors of print media should use some of the suggestions provided earlier for all mediated interventions, while also considering specific recommendations for this medium. Following are some suggestions for designing a successful print-based program (Napolitano & Marcus, 2002):
- Follow up with participants quickly after distributing print material.
- Provide opportunities for participants to find interactions with others because social support is a desirable feature of many physical activity programs.
- Make sure the information is concise, accurate, and specifically directed to the targeted population.
- Pilot test materials with members of the targeted population.
- Write materials to a level appropriate for the targeted population.
Phone-Based Programs Phone-based programs are delivered as phone calls or text messages. The following recommendations can help ensure that a phone-based program is successful:
- Consider the purpose of the contact (e.g., touching base, structured, or automated with prompts); studies have demonstrated that phone calls designed to touch base were just as effective as contacts that were highly structured (Lombard, Lombard, & Winett, 1995, as cited in Marcus et al., 1998).
- Consider the frequency with which phone calls or text messages are delivered. Schultz (1993) concluded that adherence and frequency of phone contacts are positively correlated, although there is probably a point at which a high frequency of phone contacts becomes a nuisance.
- Be as specific as possible with feedback (e.g., overcoming barriers, the benefits of exercise that are motivating to that participant, the type of activity the participant enjoyed) to facilitate maximal change (Hurling et al., 2007).
Although phone-based interventions have been around for a while, the use of text messaging to prompt physical activity is a relatively new means of communicating using mediated technology. Given the increase in text messaging in this country, this technology offers significant potential for reaching many people.
Web-Based Programs Web-based programs demand a significant time investment prior to implementation. To ensure that Web-based programs are designed successfully, Ferney and Marshall (2006) recommended considering four factors that are important to Web site users in the field of physical activity promotion: Web design (structure), interactivity, environmental context, and content.
- Web design. To be maximally useful, Web sites should be easy to navigate and download time should be minimal (Ferney & Marshall, 2006). Users should be able to navigate a Web site easily, and links should be intuitive and downloadable in no more than 10 seconds. Making Web sites password protected facilitates tracking people's use around the site. Web site designers should conduct pilot and usability tests with proposed and developing Web sites and correct any problems found.
- Interactivity. A Web site that facilitates information exchange between a participant and an intervention specialist is interactive. Following are some examples of interactive activities on a PA Web site (Ferney & Marshall, 2006; Hurling et al., 2006):
• Logging on to a Web site to report activity or set goals
• Receiving specific feedback about one's performance compared to others or a previous best effort
• Accessing social support and expert advice
• Calculating target heart rate
• Accessing information about local community events
• Identifying barriers and receiving feedback about ways to overcome them
According to experts (Bull, Kreuter, & Scharff, 1999; Ferney & Marshall, 2006; Fogg, 2003; Hurling et al., 2006; Tate, Wing, & Winett, 2001; Wantland et al., 2004), interactive Web sites are more effective than non-interactive sites because they
• are more enjoyable to use,
• are less impersonal,
• facilitate better user retention and longer Web sessions,
• create higher expectations for exercise,
• facilitate higher levels of motivation and improved self-perception of fitness,
• are more likely to be saved and revisited in the future,
• are more likely to be discussed with others, and
• result in real behavior change with regular visitations.
- Environmental context. Providing information such as an updated community calendar of events; maps of physical activity opportunities in the community; and a physical activity database with information about times, costs, deadlines, and facilities (Ferney & Marshall, 2006) are examples of considering the environmental context. This information should be updated regularly to facilitate the desire to visit the Web site.
- Content. Information presented on the Web as audio, video, or text is known as content. It is important to update Web site content as often as possible. Those who use the Web frequently do not like to read volumes of text or wade through repetitive information, and they do not like to visit Web sites and see the same information over and over.
Podcasting Research is sparse on the factors related to success with podcasting-especially as it relates to increasing physical activity. However, until more research is conducted, the following basic strategies can help ensure that podcasts are successful (Eads, 2007; Hartman & Jackson, 2007):
- Be aware that those in the iPod generation are typically young and technologically savvy.
- When possible, provide the means for interaction with others.
- Pilot test podcasts with members of the target population.
- Make sure podcasts are simple and easy to download with a computer.
Sample Successful Program
Active Living (Web and Print)
Active Living is an 8-week Web-based program that evolved from a print-based program (Marshall et al., 2003). This program assessed stage of change (according to the transtheoretical model) and featured personalized Web links to sites on goal setting, activity planning, and determining target heart rate. People who participated in this project were regularly reassessed to ensure that their Web information was tailored to their specific stage of change. The Web information was supplemented with personalized and stage-based reinforcement e-mails sent every 2 weeks. These e-mails contained hyperlinks to relevant areas of the Active Living Web site. The print information for this intervention was identical to the information found in the Web-based program except that people receiving the print materials received supplemental letters with stage-matched information every 2 weeks.
The impact of the intervention was assessed by comparing baseline and postintervention physical activity data: (a) MET-minutes per week and minutes in specific categories of activity (e.g., vigorous, moderate, and seated activities), collected with the International PA Questionnaire (IPAQ), (b) meeting or not meeting the public health recommendation (i.e., 30 minutes of at least moderate physical activity most days of the week), and (c) stage of change in the transtheoretical model. Results of the study indicate that Web interven tion participants reported a decrease in the amount of time spent sitting, and print-based intervention participants increased their total minutes of physical activity. About 26% of the participants in both groups progressed forward at least one stage of change in the transtheoretical model, indicating that they should be likely to continue being physically active in the future. It is interesting to note that both print- and Web-based programs facilitated increases in physical activity, although people in the print group reported larger increases in activity and they were better able to recognize intervention materials after the program was completed.
Learn more about Developing Effective Physical Activity Programs.
Confidence and positive attitude help older adults stick with exercise
To develop effective older adult physical activity interventions, it is important to understand factors that predict participation and adherence.
Because the majority of older adults clearly can engage in physical activity safely, a growing body of research has been conducted to identify effective programs for increasing physical activity in this population (Brawley, Rejeski, & King, 2003; Taylor et al., 2004; U.S. Department of Health and Human Services, 1996). However, increasing older adult physical activity participation presents unique challenges. Although some programs have been effective in the short term, the effectiveness of long-term physical activity programs has been limited (Brawley, Rejeski, & King, 2003; Taylor et al., 2004).
Factors Related to Successful Physical Activity Interventions
To develop effective older adult physical activity interventions, it is important to understand factors that predict participation and adherence. Numerous research studies have investigated correlates of older adult physical activity participation (Benjamin, Edwards, & Baharti, 2005; Brassington, Atienza, Perczek, DiLorenzo, & King 2002; Hays & Clark, 1999; Lee & Lafferty, 2006; Stuart, Marret, Kelly, & Nelson, 2002). Although many factors influence the participation rates of older adults, we will examine the following, which demonstrate the greatest potential for increasing physical activity:
- Psychological factors of self-efficacy, self-regulation, positive attitudes toward physical activity, and social support
- Health care provider referral
- Physical activity intensity
- Group- and home-based interventions
- Disease management
Psychological Factors
As with other populations, self-efficacy, or the confidence a person has to perform an activity, is one of the strongest determinants of physical activity for older adults (Brassington et al., 2002; Resnick, Orwig, Magaziner, & Wynne, 2002; Schutzer & Graves, 2004). Interventions should help older adults build their confidence through mastery of the physical activity. This can be achieved by beginning the intervention at a low intensity and gradually increasing the intensity over time. This gradual increase is especially important for frail older adults. Improvements in fitness and or health that result from physical activity will also enhance self-efficacy.
To promote long-term adherence to physical activity, interventions need to be designed so older adults move from a supervised, or center-based, setting to the home, where they can use self-regulation skills to make physical activity part of their lifestyle (Rejeski & Brawley, 2006). Behavioral counseling is one method that can be used to help older adults transition from center-based to home-based activity. Through counseling, older adults can develop a plan of action for making physical activity a part of their daily routine.
Having a positive attitude toward physical activity is another factor influencing older adult participation (Stuart et al., 2002). If the activity is positive and enjoyable, older adults will be more likely to continue to exercise. Past participation is also a predictor of future participation (Benjamin et al., 2005). For those who have had a negative attitude toward physical activity, strategies such as providing positive images depicting the activity with role models who may have similar limitations can be used to entice older adults to participate.
Receiving positive reinforcement or social support from friends and family is also one of the predictors of physical activity involvement in the older adult population (Booth, Owen, Bauman, Clavisi, & Leslie 2002; McAuley, Jerome, Elavvsky, Marquez, & Ramsey, 2003; Resnick et al., 2002). Litt, Kepplinger, and Judge (2002) found that social support is a strong determinant of physical activity particularly for older women. In addition, positive comments help strengthen people's self-efficacy and can enhance exercise adherence. Programs need to be carefully designed to create a positive environment. In residential care facilities, older adults may have limited contact with family members; thus, support from friends may be more important.
Health Care Provider Referrals
Receiving a recommendation from a physician to exercise is another important positive predictor of physical activity in the older adult population (Benjamin et al., 2005; Navarro, Sanz, del Castillo, Izquierdo, & Rodriguez, 2007; Stuart et al., 2002). Having a health care provider "prescribe" exercise helps older adults overcome their fear of being injured during the physical activity. This type of prescription may be especially important for physically frail older adults (Benjamin et al., 2005). More research needs to be conducted in this area to determine the most effective type of physician advice and the amount of contact needed with the older adult to improve physical activity levels.
Physical Activity Intensity
Older adults are more likely to participate in low- to moderate-intensity physical activity (Brawley et al., 2003; Taylor et al., 2004) such as light housework, chair exercises, and walking. Lower-intensity activity is less likely to cause injuries and is often perceived as less threatening, especially to older adults who have functional disabilities or limitations. Although interventions should to be tailored to the ability level of the participant, planners must also recognize that low-intensity exercises conducted in a chair may have few functional benefits for the older adult. Specificity of the exercise is the issue. If the goal is to improve mobility and balance, exercises should be conducted while participants are standing and walking. Physical activity interventions that begin at lower intensities should progress over time to moderate intensities.
Group- and Home-Based Interventions
Physical activity interventions can be designed to be group based, home based, or a combination of both. Group-based interventions require participants to go to a facility or center where the activity program is usually supervised. For typical home-based interventions, the physical activity occurs at the older adult's home, and contact with the practitioner is minimal. Combination designs usually begin with a few weeks of group-based instruction followed by a period of home-based activity. Table 6.1 lists some of the positive and negative aspects of group- and home-based interventions.
Research has demonstrated that both home-based and group-based physical activity interventions can be successful with the older adult population (Campbell, Robertson, Gardner, Norton, & Buchner, 1999; King, Haskell, Taylor, Kraemer, & Debusk, 1991; King, Haskell, Young, Oka, & Stefanic, 1995; McMurdo & Rennie, 1993; van der Bij, Laurant, & Wensing, 2002). One study found similar participation rates in both home- and group-based environments for short-term programs; however, adherence rates tended to decrease as the length of the study increased (King et al., 1995; van der Bij et al., 2002). The use of behavioral strategies including phone calls and various incentives may help improve long-term participation rates. More research should be conducted using a combination of group- and home-based environments to determine which programs work best for which population.
Disease Management
Disease management, in the context of this chapter, is using physical activity as a strategy to prevent disease and maintain favorable health status. Studies have found that mobile older adults who have few or no limitations view physical activity as a way to maintain their health (Cohen-Mansfield, Marx, & Guralnick, 2003; Rasinaho, Herninalo, Leinonen, Linutenen, & Rantinen, 2006). Older adults with higher self-efficacy and a motivation to improve their health are more likely to be physically active than those with lower self-efficacy and little motivation to improve their health (Lee & Lafferty, 2006). Increased self-efficacy may help older adults overcome barriers that prevent them from engaging in physical activity. Physical activity can help all adults, both the young and the old, avoid chronic diseases.
When planning physical activity interventions for older adults, planners should consider factors that will improve participation and adherence. This section highlighted just a few of the factors that typically result in success. Intervention specialists are encouraged to use these strategies to overcome barriers to physical activity in older adults.
Sample Successful Interventions
Home-Based Progressive Strength Training
Osteoarthritis is a common ailment that causes pain, reduces functional abilities, and limits physical activity for many older adults. Baker and colleagues (2001) investigated the effectiveness of home-based strength training for improving symptoms of knee osteoarthritis in a group of 46 adults over the age of 55. Participants were randomized into a nutritional education control group or home-based strength training group. The home-based strength group trained for 4 months. Intervention participants received in-home visits twice a week for 3 weeks, one in the 4th week and every other week thereafter. Compared to the control group, the home-based training group significantly improved in strength, pain reduction, physical function, and quality of life. These important gains highlight the need for home-based programs designed to reduce pain and other osteoarthritis symptoms and improve older adult physical function.
Walk; Address Pain, Fear, Fatigue During Exercise; Learn About Exercise; Cue by Self-Modeling (WALC)
WALC was designed to address some of the common barriers older adults have relative to physical activity (Resnick, 2002). Twenty sedentary participants were divided into treatment or control groups. The treatment group followed the four phases of the WALC program. They were asked to walk in groups or individually for 20 minutes three times per week for 6 months. The intervention group received regular visits from a practitioner who addressed unpleasant reactions associated with exercise (i.e., addressed pain, fear, fatigue during exercise). This part of the intervention included pain management techniques, relaxation methods, and scheduling of rest and exercise. Those in the treatment groups were given a book about exercise benefits and barriers and received assistance developing short- and long-term goals, planning exercise sessions, and logging their results (i.e., learned about exercise).
When compared to the controls, the treatment group demonstrated significant improvement in exercise behavior, physical activity levels, and self-efficacy expectations. Although the number of participants used in this study was small, the results indicate that physical activity levels can be increased with the sedentary older adult population by using techniques to improve self-efficacy, which can mediate common exercise barriers.
Learn more about Developing Effective Physical Activity Programs.
Effective use of mediated programming in physical activity interventions
As the influence of technology continues to increase, those interested in promoting physical activity should consider developing physical activity programs that effectively use technology.
Using technology or intervention techniques that are not delivered face-to-face is known as mediated program delivery (Marshall, Owen, & Bauman, 2004). Because of the ability to reach large numbers of people with relatively low cost, mediated programs in our field have increased dramatically. Wantland, Portillo, Holzemer, Slaughter, and McGhee (2004) reported that during a 7-year period (1996-2003), there was a 12-fold increase in MEDLINE citations for "Web-based therapies". Some examples of mediated program delivery include using email to contact program participants, using the Internet to track activity or seek social support or program feedback from group leaders, or offering podcasts or Web-streamed videos to provide access to important program information.
Factors Related to Successful Mediated Physical Activity Interventions
Factors related to successful mediated physical activity interventions fall into two categories: (a) general and relevant for all types of mediated interventions and (b) specific and relevant to only certain types of mediated interventions. Both are addressed in this section. Designers of interventions should consider both general and specific aspects when planning mediated programs.
General Factors Related to Success in All Mediated Interventions
The following six factors are related to success with any type of mediated intervention, regardless of medium:
- Increasing dose-response
- Designing memorable campaign slogans and information
- Using market segmentation and message personalization strategies
- Targeting multiple media outlets
- Ensuring theoretical fidelity
- Paying attention to quality control
• Dose-response issues. Dose-response, in this context, means that more media exposure typically results in increased physical activity behavior, increased satisfaction with program components, or both. Mediated interventions, if used correctly, can reach large numbers of people in a cost-effective manner. Exposure to media is measured in weekly gross rating points (GRP). One GRP means that 1% of the target audience viewed the advertisement once. Obviously, higher GRPs are more likely to result in a successful campaign (i.e., reach large numbers of people).
• Memorable campaign slogans. A second key to developing a successful mediated campaign is to develop and use memorable and reproducible images. Most people interested in physical activity will remember Nike's most memorable ad campaigns: "Just Do It," "If you let me play . . .," and the recent ads in conjunction with the women's World Cup soccer tournament ("The greatest team you've never heard of"). The average American is exposed to 3,000 ads per day (Peterson, Abraham, & Waterfield, 2005); therefore, media must be memorable to make an impact.
• Market segmentation. Market segmentation refers to designing marketing strategies for a specific segment of the population. Designing campaigns so they will reach various age or ethnic groups or men or women is an important strategy because what works for one segment of the population may be offensive or nonmeaningful to another (Peterson, Abraham, & Waterfield, 2005). To ensure memorable messages and accurate market segmentation, program promoters should pilot test campaign slogans and designs with the target audience. In addition to pilot testing, it is important to continually seek feedback, preferably from a local advisory committee, to refine and improve a media message as necessary. When possible, booster campaigns should be administered to sustain a promotional effort beyond the life of the initial campaign (Reger et al., 2002).
• Personalization strategies. Similar to market segmentation (or personalizing a message to reach a target audience), Marcus and colleagues (1998) suggested that one of the most important factors contributing to a successful mediated program is identifying and including relevant attributes of role models. For example, if a message is designed to reach young African Americans in a community, then characteristics and attributes of young African Americans and representative role models should be included in that message. To ascertain what these characteristics are and what information might be meaningful to that group, members of the relevant group should be surveyed and included
in a pilot testing process. The bottom line is that if people can personalize a message, they are more likely to internalize and act on it. Additional factors that can help facilitate program success are (a) tailoring information to a specific stage of change (such as the contemplation stage in the transtheoretical model), (b) updating the stage of change regularly; and (c) using reinforcement letters, phone calls, or e-mails regularly (e.g., biweekly) (Marshall et al., 2003).
• Targeting multiple areas of the media. Numerous media outlets are available for health and fitness-related messages (e.g., billboards, buses, signs, television, radio, Internet, and newspaper) (Peterson et al., 2005). A good example of creative media blitzing is using point-of-decision prompts. Point-of-decision prompts are reminders in the form of signs, bulletin boards, billboards, or bus signs that encourage people to take advantage of physical activity opportunities when they arise (Marcus et al., 1998). Some examples of point-of-decision prompts that work include Use the Stairs and Park and Walk (Marcus et al., 1998).
• Theoretical fidelity. Theoretical fidelity refers to the precision with which theory-based recommendations are used. Rovniak and colleagues (2005) tested the effectiveness of high- and low-fidelity e-mail-based walking interventions in 65 sedentary adults, mostly women. One 12-week intervention, which demonstrated high fidelity to the social cognitive theory (SCT), used targeted skills, specific and hierarchical goals, and precise self-monitoring and feedback. The other intervention, which demonstrated low fidelity to the SCT, provided information (rather than modeling) to teach skills and did not provide ongoing self-monitoring and feedback. Several outcomes were monitored before and after the intervention, including a 1-mile (1.6 km) walk test of physical fitness, a log of walking behavior, and several measures of social cognitive theory (e.g., exercise self-efficacy, benefits and enjoyment of physical activity, goal setting, exercise planning, and social support). Compared to those in the low-fidelity group, those in the high-fidelity group completed more of their prescribed walking sessions and walked faster at posttest. Those in the high-fidelity group also reported greater program satisfaction and increased their goal setting and positive outcome expectations for walking more than twice as much as those in the low-fidelity group. Clearly, efforts to ensure theoretical fidelity are important for improving the success of mediated interventions.
• Quality control. Quality control, or attention to clarity, accuracy, and timeliness, is important. Information must be of high quality to earn respect, reach the critical mass, and facilitate changes in physical activity behavior (Marcus et al., 1998). Although obesity prevention and physical activity promotion are multimillion-dollar industries, it is not right to promise something that cannot be delivered. Failure to deliver programs based on factual information may result in an ineffective and disrespected program.
Factors Related to Success in Specific Mass Media Programs
The mass media has the potential to reach large numbers of people in a short period of time for a relatively low cost. To maximize this opportunity and ensure that mass media programs are successful, Cavill and Bauman (2004) recommend the following strategies:
- The mass media should target multiple media outlets in a systematic and sustained fashion.
- Campaigns should maximize contact or message exposure, because doing so typically results in greater behavior change.
- Other supportive community activities should be organized around mass media messages (e.g., self-help groups, counseling, screening and education, community events, and walking trails).
- The message coming from the mass media should be singular and simple-so it will be memorable.
- Mass media campaigns should target a specific audience or audiences based on demographics, attitudes, and preferred media usage; this will ensure that the message is heard by those for whom it is designed.
Print-Based Programs Those designing physical activity programs are probably most familiar with print-based handouts. Print handouts have been around longer than other means of media, and they are probably still the most common method of promoting increased physical activity. Distributors of print media should use some of the suggestions provided earlier for all mediated interventions, while also considering specific recommendations for this medium. Following are some suggestions for designing a successful print-based program (Napolitano & Marcus, 2002):
- Follow up with participants quickly after distributing print material.
- Provide opportunities for participants to find interactions with others because social support is a desirable feature of many physical activity programs.
- Make sure the information is concise, accurate, and specifically directed to the targeted population.
- Pilot test materials with members of the targeted population.
- Write materials to a level appropriate for the targeted population.
Phone-Based Programs Phone-based programs are delivered as phone calls or text messages. The following recommendations can help ensure that a phone-based program is successful:
- Consider the purpose of the contact (e.g., touching base, structured, or automated with prompts); studies have demonstrated that phone calls designed to touch base were just as effective as contacts that were highly structured (Lombard, Lombard, & Winett, 1995, as cited in Marcus et al., 1998).
- Consider the frequency with which phone calls or text messages are delivered. Schultz (1993) concluded that adherence and frequency of phone contacts are positively correlated, although there is probably a point at which a high frequency of phone contacts becomes a nuisance.
- Be as specific as possible with feedback (e.g., overcoming barriers, the benefits of exercise that are motivating to that participant, the type of activity the participant enjoyed) to facilitate maximal change (Hurling et al., 2007).
Although phone-based interventions have been around for a while, the use of text messaging to prompt physical activity is a relatively new means of communicating using mediated technology. Given the increase in text messaging in this country, this technology offers significant potential for reaching many people.
Web-Based Programs Web-based programs demand a significant time investment prior to implementation. To ensure that Web-based programs are designed successfully, Ferney and Marshall (2006) recommended considering four factors that are important to Web site users in the field of physical activity promotion: Web design (structure), interactivity, environmental context, and content.
- Web design. To be maximally useful, Web sites should be easy to navigate and download time should be minimal (Ferney & Marshall, 2006). Users should be able to navigate a Web site easily, and links should be intuitive and downloadable in no more than 10 seconds. Making Web sites password protected facilitates tracking people's use around the site. Web site designers should conduct pilot and usability tests with proposed and developing Web sites and correct any problems found.
- Interactivity. A Web site that facilitates information exchange between a participant and an intervention specialist is interactive. Following are some examples of interactive activities on a PA Web site (Ferney & Marshall, 2006; Hurling et al., 2006):
• Logging on to a Web site to report activity or set goals
• Receiving specific feedback about one's performance compared to others or a previous best effort
• Accessing social support and expert advice
• Calculating target heart rate
• Accessing information about local community events
• Identifying barriers and receiving feedback about ways to overcome them
According to experts (Bull, Kreuter, & Scharff, 1999; Ferney & Marshall, 2006; Fogg, 2003; Hurling et al., 2006; Tate, Wing, & Winett, 2001; Wantland et al., 2004), interactive Web sites are more effective than non-interactive sites because they
• are more enjoyable to use,
• are less impersonal,
• facilitate better user retention and longer Web sessions,
• create higher expectations for exercise,
• facilitate higher levels of motivation and improved self-perception of fitness,
• are more likely to be saved and revisited in the future,
• are more likely to be discussed with others, and
• result in real behavior change with regular visitations.
- Environmental context. Providing information such as an updated community calendar of events; maps of physical activity opportunities in the community; and a physical activity database with information about times, costs, deadlines, and facilities (Ferney & Marshall, 2006) are examples of considering the environmental context. This information should be updated regularly to facilitate the desire to visit the Web site.
- Content. Information presented on the Web as audio, video, or text is known as content. It is important to update Web site content as often as possible. Those who use the Web frequently do not like to read volumes of text or wade through repetitive information, and they do not like to visit Web sites and see the same information over and over.
Podcasting Research is sparse on the factors related to success with podcasting-especially as it relates to increasing physical activity. However, until more research is conducted, the following basic strategies can help ensure that podcasts are successful (Eads, 2007; Hartman & Jackson, 2007):
- Be aware that those in the iPod generation are typically young and technologically savvy.
- When possible, provide the means for interaction with others.
- Pilot test podcasts with members of the target population.
- Make sure podcasts are simple and easy to download with a computer.
Sample Successful Program
Active Living (Web and Print)
Active Living is an 8-week Web-based program that evolved from a print-based program (Marshall et al., 2003). This program assessed stage of change (according to the transtheoretical model) and featured personalized Web links to sites on goal setting, activity planning, and determining target heart rate. People who participated in this project were regularly reassessed to ensure that their Web information was tailored to their specific stage of change. The Web information was supplemented with personalized and stage-based reinforcement e-mails sent every 2 weeks. These e-mails contained hyperlinks to relevant areas of the Active Living Web site. The print information for this intervention was identical to the information found in the Web-based program except that people receiving the print materials received supplemental letters with stage-matched information every 2 weeks.
The impact of the intervention was assessed by comparing baseline and postintervention physical activity data: (a) MET-minutes per week and minutes in specific categories of activity (e.g., vigorous, moderate, and seated activities), collected with the International PA Questionnaire (IPAQ), (b) meeting or not meeting the public health recommendation (i.e., 30 minutes of at least moderate physical activity most days of the week), and (c) stage of change in the transtheoretical model. Results of the study indicate that Web interven tion participants reported a decrease in the amount of time spent sitting, and print-based intervention participants increased their total minutes of physical activity. About 26% of the participants in both groups progressed forward at least one stage of change in the transtheoretical model, indicating that they should be likely to continue being physically active in the future. It is interesting to note that both print- and Web-based programs facilitated increases in physical activity, although people in the print group reported larger increases in activity and they were better able to recognize intervention materials after the program was completed.
Learn more about Developing Effective Physical Activity Programs.
Confidence and positive attitude help older adults stick with exercise
To develop effective older adult physical activity interventions, it is important to understand factors that predict participation and adherence.
Because the majority of older adults clearly can engage in physical activity safely, a growing body of research has been conducted to identify effective programs for increasing physical activity in this population (Brawley, Rejeski, & King, 2003; Taylor et al., 2004; U.S. Department of Health and Human Services, 1996). However, increasing older adult physical activity participation presents unique challenges. Although some programs have been effective in the short term, the effectiveness of long-term physical activity programs has been limited (Brawley, Rejeski, & King, 2003; Taylor et al., 2004).
Factors Related to Successful Physical Activity Interventions
To develop effective older adult physical activity interventions, it is important to understand factors that predict participation and adherence. Numerous research studies have investigated correlates of older adult physical activity participation (Benjamin, Edwards, & Baharti, 2005; Brassington, Atienza, Perczek, DiLorenzo, & King 2002; Hays & Clark, 1999; Lee & Lafferty, 2006; Stuart, Marret, Kelly, & Nelson, 2002). Although many factors influence the participation rates of older adults, we will examine the following, which demonstrate the greatest potential for increasing physical activity:
- Psychological factors of self-efficacy, self-regulation, positive attitudes toward physical activity, and social support
- Health care provider referral
- Physical activity intensity
- Group- and home-based interventions
- Disease management
Psychological Factors
As with other populations, self-efficacy, or the confidence a person has to perform an activity, is one of the strongest determinants of physical activity for older adults (Brassington et al., 2002; Resnick, Orwig, Magaziner, & Wynne, 2002; Schutzer & Graves, 2004). Interventions should help older adults build their confidence through mastery of the physical activity. This can be achieved by beginning the intervention at a low intensity and gradually increasing the intensity over time. This gradual increase is especially important for frail older adults. Improvements in fitness and or health that result from physical activity will also enhance self-efficacy.
To promote long-term adherence to physical activity, interventions need to be designed so older adults move from a supervised, or center-based, setting to the home, where they can use self-regulation skills to make physical activity part of their lifestyle (Rejeski & Brawley, 2006). Behavioral counseling is one method that can be used to help older adults transition from center-based to home-based activity. Through counseling, older adults can develop a plan of action for making physical activity a part of their daily routine.
Having a positive attitude toward physical activity is another factor influencing older adult participation (Stuart et al., 2002). If the activity is positive and enjoyable, older adults will be more likely to continue to exercise. Past participation is also a predictor of future participation (Benjamin et al., 2005). For those who have had a negative attitude toward physical activity, strategies such as providing positive images depicting the activity with role models who may have similar limitations can be used to entice older adults to participate.
Receiving positive reinforcement or social support from friends and family is also one of the predictors of physical activity involvement in the older adult population (Booth, Owen, Bauman, Clavisi, & Leslie 2002; McAuley, Jerome, Elavvsky, Marquez, & Ramsey, 2003; Resnick et al., 2002). Litt, Kepplinger, and Judge (2002) found that social support is a strong determinant of physical activity particularly for older women. In addition, positive comments help strengthen people's self-efficacy and can enhance exercise adherence. Programs need to be carefully designed to create a positive environment. In residential care facilities, older adults may have limited contact with family members; thus, support from friends may be more important.
Health Care Provider Referrals
Receiving a recommendation from a physician to exercise is another important positive predictor of physical activity in the older adult population (Benjamin et al., 2005; Navarro, Sanz, del Castillo, Izquierdo, & Rodriguez, 2007; Stuart et al., 2002). Having a health care provider "prescribe" exercise helps older adults overcome their fear of being injured during the physical activity. This type of prescription may be especially important for physically frail older adults (Benjamin et al., 2005). More research needs to be conducted in this area to determine the most effective type of physician advice and the amount of contact needed with the older adult to improve physical activity levels.
Physical Activity Intensity
Older adults are more likely to participate in low- to moderate-intensity physical activity (Brawley et al., 2003; Taylor et al., 2004) such as light housework, chair exercises, and walking. Lower-intensity activity is less likely to cause injuries and is often perceived as less threatening, especially to older adults who have functional disabilities or limitations. Although interventions should to be tailored to the ability level of the participant, planners must also recognize that low-intensity exercises conducted in a chair may have few functional benefits for the older adult. Specificity of the exercise is the issue. If the goal is to improve mobility and balance, exercises should be conducted while participants are standing and walking. Physical activity interventions that begin at lower intensities should progress over time to moderate intensities.
Group- and Home-Based Interventions
Physical activity interventions can be designed to be group based, home based, or a combination of both. Group-based interventions require participants to go to a facility or center where the activity program is usually supervised. For typical home-based interventions, the physical activity occurs at the older adult's home, and contact with the practitioner is minimal. Combination designs usually begin with a few weeks of group-based instruction followed by a period of home-based activity. Table 6.1 lists some of the positive and negative aspects of group- and home-based interventions.
Research has demonstrated that both home-based and group-based physical activity interventions can be successful with the older adult population (Campbell, Robertson, Gardner, Norton, & Buchner, 1999; King, Haskell, Taylor, Kraemer, & Debusk, 1991; King, Haskell, Young, Oka, & Stefanic, 1995; McMurdo & Rennie, 1993; van der Bij, Laurant, & Wensing, 2002). One study found similar participation rates in both home- and group-based environments for short-term programs; however, adherence rates tended to decrease as the length of the study increased (King et al., 1995; van der Bij et al., 2002). The use of behavioral strategies including phone calls and various incentives may help improve long-term participation rates. More research should be conducted using a combination of group- and home-based environments to determine which programs work best for which population.
Disease Management
Disease management, in the context of this chapter, is using physical activity as a strategy to prevent disease and maintain favorable health status. Studies have found that mobile older adults who have few or no limitations view physical activity as a way to maintain their health (Cohen-Mansfield, Marx, & Guralnick, 2003; Rasinaho, Herninalo, Leinonen, Linutenen, & Rantinen, 2006). Older adults with higher self-efficacy and a motivation to improve their health are more likely to be physically active than those with lower self-efficacy and little motivation to improve their health (Lee & Lafferty, 2006). Increased self-efficacy may help older adults overcome barriers that prevent them from engaging in physical activity. Physical activity can help all adults, both the young and the old, avoid chronic diseases.
When planning physical activity interventions for older adults, planners should consider factors that will improve participation and adherence. This section highlighted just a few of the factors that typically result in success. Intervention specialists are encouraged to use these strategies to overcome barriers to physical activity in older adults.
Sample Successful Interventions
Home-Based Progressive Strength Training
Osteoarthritis is a common ailment that causes pain, reduces functional abilities, and limits physical activity for many older adults. Baker and colleagues (2001) investigated the effectiveness of home-based strength training for improving symptoms of knee osteoarthritis in a group of 46 adults over the age of 55. Participants were randomized into a nutritional education control group or home-based strength training group. The home-based strength group trained for 4 months. Intervention participants received in-home visits twice a week for 3 weeks, one in the 4th week and every other week thereafter. Compared to the control group, the home-based training group significantly improved in strength, pain reduction, physical function, and quality of life. These important gains highlight the need for home-based programs designed to reduce pain and other osteoarthritis symptoms and improve older adult physical function.
Walk; Address Pain, Fear, Fatigue During Exercise; Learn About Exercise; Cue by Self-Modeling (WALC)
WALC was designed to address some of the common barriers older adults have relative to physical activity (Resnick, 2002). Twenty sedentary participants were divided into treatment or control groups. The treatment group followed the four phases of the WALC program. They were asked to walk in groups or individually for 20 minutes three times per week for 6 months. The intervention group received regular visits from a practitioner who addressed unpleasant reactions associated with exercise (i.e., addressed pain, fear, fatigue during exercise). This part of the intervention included pain management techniques, relaxation methods, and scheduling of rest and exercise. Those in the treatment groups were given a book about exercise benefits and barriers and received assistance developing short- and long-term goals, planning exercise sessions, and logging their results (i.e., learned about exercise).
When compared to the controls, the treatment group demonstrated significant improvement in exercise behavior, physical activity levels, and self-efficacy expectations. Although the number of participants used in this study was small, the results indicate that physical activity levels can be increased with the sedentary older adult population by using techniques to improve self-efficacy, which can mediate common exercise barriers.
Learn more about Developing Effective Physical Activity Programs.
Effective use of mediated programming in physical activity interventions
As the influence of technology continues to increase, those interested in promoting physical activity should consider developing physical activity programs that effectively use technology.
Using technology or intervention techniques that are not delivered face-to-face is known as mediated program delivery (Marshall, Owen, & Bauman, 2004). Because of the ability to reach large numbers of people with relatively low cost, mediated programs in our field have increased dramatically. Wantland, Portillo, Holzemer, Slaughter, and McGhee (2004) reported that during a 7-year period (1996-2003), there was a 12-fold increase in MEDLINE citations for "Web-based therapies". Some examples of mediated program delivery include using email to contact program participants, using the Internet to track activity or seek social support or program feedback from group leaders, or offering podcasts or Web-streamed videos to provide access to important program information.
Factors Related to Successful Mediated Physical Activity Interventions
Factors related to successful mediated physical activity interventions fall into two categories: (a) general and relevant for all types of mediated interventions and (b) specific and relevant to only certain types of mediated interventions. Both are addressed in this section. Designers of interventions should consider both general and specific aspects when planning mediated programs.
General Factors Related to Success in All Mediated Interventions
The following six factors are related to success with any type of mediated intervention, regardless of medium:
- Increasing dose-response
- Designing memorable campaign slogans and information
- Using market segmentation and message personalization strategies
- Targeting multiple media outlets
- Ensuring theoretical fidelity
- Paying attention to quality control
• Dose-response issues. Dose-response, in this context, means that more media exposure typically results in increased physical activity behavior, increased satisfaction with program components, or both. Mediated interventions, if used correctly, can reach large numbers of people in a cost-effective manner. Exposure to media is measured in weekly gross rating points (GRP). One GRP means that 1% of the target audience viewed the advertisement once. Obviously, higher GRPs are more likely to result in a successful campaign (i.e., reach large numbers of people).
• Memorable campaign slogans. A second key to developing a successful mediated campaign is to develop and use memorable and reproducible images. Most people interested in physical activity will remember Nike's most memorable ad campaigns: "Just Do It," "If you let me play . . .," and the recent ads in conjunction with the women's World Cup soccer tournament ("The greatest team you've never heard of"). The average American is exposed to 3,000 ads per day (Peterson, Abraham, & Waterfield, 2005); therefore, media must be memorable to make an impact.
• Market segmentation. Market segmentation refers to designing marketing strategies for a specific segment of the population. Designing campaigns so they will reach various age or ethnic groups or men or women is an important strategy because what works for one segment of the population may be offensive or nonmeaningful to another (Peterson, Abraham, & Waterfield, 2005). To ensure memorable messages and accurate market segmentation, program promoters should pilot test campaign slogans and designs with the target audience. In addition to pilot testing, it is important to continually seek feedback, preferably from a local advisory committee, to refine and improve a media message as necessary. When possible, booster campaigns should be administered to sustain a promotional effort beyond the life of the initial campaign (Reger et al., 2002).
• Personalization strategies. Similar to market segmentation (or personalizing a message to reach a target audience), Marcus and colleagues (1998) suggested that one of the most important factors contributing to a successful mediated program is identifying and including relevant attributes of role models. For example, if a message is designed to reach young African Americans in a community, then characteristics and attributes of young African Americans and representative role models should be included in that message. To ascertain what these characteristics are and what information might be meaningful to that group, members of the relevant group should be surveyed and included
in a pilot testing process. The bottom line is that if people can personalize a message, they are more likely to internalize and act on it. Additional factors that can help facilitate program success are (a) tailoring information to a specific stage of change (such as the contemplation stage in the transtheoretical model), (b) updating the stage of change regularly; and (c) using reinforcement letters, phone calls, or e-mails regularly (e.g., biweekly) (Marshall et al., 2003).
• Targeting multiple areas of the media. Numerous media outlets are available for health and fitness-related messages (e.g., billboards, buses, signs, television, radio, Internet, and newspaper) (Peterson et al., 2005). A good example of creative media blitzing is using point-of-decision prompts. Point-of-decision prompts are reminders in the form of signs, bulletin boards, billboards, or bus signs that encourage people to take advantage of physical activity opportunities when they arise (Marcus et al., 1998). Some examples of point-of-decision prompts that work include Use the Stairs and Park and Walk (Marcus et al., 1998).
• Theoretical fidelity. Theoretical fidelity refers to the precision with which theory-based recommendations are used. Rovniak and colleagues (2005) tested the effectiveness of high- and low-fidelity e-mail-based walking interventions in 65 sedentary adults, mostly women. One 12-week intervention, which demonstrated high fidelity to the social cognitive theory (SCT), used targeted skills, specific and hierarchical goals, and precise self-monitoring and feedback. The other intervention, which demonstrated low fidelity to the SCT, provided information (rather than modeling) to teach skills and did not provide ongoing self-monitoring and feedback. Several outcomes were monitored before and after the intervention, including a 1-mile (1.6 km) walk test of physical fitness, a log of walking behavior, and several measures of social cognitive theory (e.g., exercise self-efficacy, benefits and enjoyment of physical activity, goal setting, exercise planning, and social support). Compared to those in the low-fidelity group, those in the high-fidelity group completed more of their prescribed walking sessions and walked faster at posttest. Those in the high-fidelity group also reported greater program satisfaction and increased their goal setting and positive outcome expectations for walking more than twice as much as those in the low-fidelity group. Clearly, efforts to ensure theoretical fidelity are important for improving the success of mediated interventions.
• Quality control. Quality control, or attention to clarity, accuracy, and timeliness, is important. Information must be of high quality to earn respect, reach the critical mass, and facilitate changes in physical activity behavior (Marcus et al., 1998). Although obesity prevention and physical activity promotion are multimillion-dollar industries, it is not right to promise something that cannot be delivered. Failure to deliver programs based on factual information may result in an ineffective and disrespected program.
Factors Related to Success in Specific Mass Media Programs
The mass media has the potential to reach large numbers of people in a short period of time for a relatively low cost. To maximize this opportunity and ensure that mass media programs are successful, Cavill and Bauman (2004) recommend the following strategies:
- The mass media should target multiple media outlets in a systematic and sustained fashion.
- Campaigns should maximize contact or message exposure, because doing so typically results in greater behavior change.
- Other supportive community activities should be organized around mass media messages (e.g., self-help groups, counseling, screening and education, community events, and walking trails).
- The message coming from the mass media should be singular and simple-so it will be memorable.
- Mass media campaigns should target a specific audience or audiences based on demographics, attitudes, and preferred media usage; this will ensure that the message is heard by those for whom it is designed.
Print-Based Programs Those designing physical activity programs are probably most familiar with print-based handouts. Print handouts have been around longer than other means of media, and they are probably still the most common method of promoting increased physical activity. Distributors of print media should use some of the suggestions provided earlier for all mediated interventions, while also considering specific recommendations for this medium. Following are some suggestions for designing a successful print-based program (Napolitano & Marcus, 2002):
- Follow up with participants quickly after distributing print material.
- Provide opportunities for participants to find interactions with others because social support is a desirable feature of many physical activity programs.
- Make sure the information is concise, accurate, and specifically directed to the targeted population.
- Pilot test materials with members of the targeted population.
- Write materials to a level appropriate for the targeted population.
Phone-Based Programs Phone-based programs are delivered as phone calls or text messages. The following recommendations can help ensure that a phone-based program is successful:
- Consider the purpose of the contact (e.g., touching base, structured, or automated with prompts); studies have demonstrated that phone calls designed to touch base were just as effective as contacts that were highly structured (Lombard, Lombard, & Winett, 1995, as cited in Marcus et al., 1998).
- Consider the frequency with which phone calls or text messages are delivered. Schultz (1993) concluded that adherence and frequency of phone contacts are positively correlated, although there is probably a point at which a high frequency of phone contacts becomes a nuisance.
- Be as specific as possible with feedback (e.g., overcoming barriers, the benefits of exercise that are motivating to that participant, the type of activity the participant enjoyed) to facilitate maximal change (Hurling et al., 2007).
Although phone-based interventions have been around for a while, the use of text messaging to prompt physical activity is a relatively new means of communicating using mediated technology. Given the increase in text messaging in this country, this technology offers significant potential for reaching many people.
Web-Based Programs Web-based programs demand a significant time investment prior to implementation. To ensure that Web-based programs are designed successfully, Ferney and Marshall (2006) recommended considering four factors that are important to Web site users in the field of physical activity promotion: Web design (structure), interactivity, environmental context, and content.
- Web design. To be maximally useful, Web sites should be easy to navigate and download time should be minimal (Ferney & Marshall, 2006). Users should be able to navigate a Web site easily, and links should be intuitive and downloadable in no more than 10 seconds. Making Web sites password protected facilitates tracking people's use around the site. Web site designers should conduct pilot and usability tests with proposed and developing Web sites and correct any problems found.
- Interactivity. A Web site that facilitates information exchange between a participant and an intervention specialist is interactive. Following are some examples of interactive activities on a PA Web site (Ferney & Marshall, 2006; Hurling et al., 2006):
• Logging on to a Web site to report activity or set goals
• Receiving specific feedback about one's performance compared to others or a previous best effort
• Accessing social support and expert advice
• Calculating target heart rate
• Accessing information about local community events
• Identifying barriers and receiving feedback about ways to overcome them
According to experts (Bull, Kreuter, & Scharff, 1999; Ferney & Marshall, 2006; Fogg, 2003; Hurling et al., 2006; Tate, Wing, & Winett, 2001; Wantland et al., 2004), interactive Web sites are more effective than non-interactive sites because they
• are more enjoyable to use,
• are less impersonal,
• facilitate better user retention and longer Web sessions,
• create higher expectations for exercise,
• facilitate higher levels of motivation and improved self-perception of fitness,
• are more likely to be saved and revisited in the future,
• are more likely to be discussed with others, and
• result in real behavior change with regular visitations.
- Environmental context. Providing information such as an updated community calendar of events; maps of physical activity opportunities in the community; and a physical activity database with information about times, costs, deadlines, and facilities (Ferney & Marshall, 2006) are examples of considering the environmental context. This information should be updated regularly to facilitate the desire to visit the Web site.
- Content. Information presented on the Web as audio, video, or text is known as content. It is important to update Web site content as often as possible. Those who use the Web frequently do not like to read volumes of text or wade through repetitive information, and they do not like to visit Web sites and see the same information over and over.
Podcasting Research is sparse on the factors related to success with podcasting-especially as it relates to increasing physical activity. However, until more research is conducted, the following basic strategies can help ensure that podcasts are successful (Eads, 2007; Hartman & Jackson, 2007):
- Be aware that those in the iPod generation are typically young and technologically savvy.
- When possible, provide the means for interaction with others.
- Pilot test podcasts with members of the target population.
- Make sure podcasts are simple and easy to download with a computer.
Sample Successful Program
Active Living (Web and Print)
Active Living is an 8-week Web-based program that evolved from a print-based program (Marshall et al., 2003). This program assessed stage of change (according to the transtheoretical model) and featured personalized Web links to sites on goal setting, activity planning, and determining target heart rate. People who participated in this project were regularly reassessed to ensure that their Web information was tailored to their specific stage of change. The Web information was supplemented with personalized and stage-based reinforcement e-mails sent every 2 weeks. These e-mails contained hyperlinks to relevant areas of the Active Living Web site. The print information for this intervention was identical to the information found in the Web-based program except that people receiving the print materials received supplemental letters with stage-matched information every 2 weeks.
The impact of the intervention was assessed by comparing baseline and postintervention physical activity data: (a) MET-minutes per week and minutes in specific categories of activity (e.g., vigorous, moderate, and seated activities), collected with the International PA Questionnaire (IPAQ), (b) meeting or not meeting the public health recommendation (i.e., 30 minutes of at least moderate physical activity most days of the week), and (c) stage of change in the transtheoretical model. Results of the study indicate that Web interven tion participants reported a decrease in the amount of time spent sitting, and print-based intervention participants increased their total minutes of physical activity. About 26% of the participants in both groups progressed forward at least one stage of change in the transtheoretical model, indicating that they should be likely to continue being physically active in the future. It is interesting to note that both print- and Web-based programs facilitated increases in physical activity, although people in the print group reported larger increases in activity and they were better able to recognize intervention materials after the program was completed.
Learn more about Developing Effective Physical Activity Programs.
Confidence and positive attitude help older adults stick with exercise
To develop effective older adult physical activity interventions, it is important to understand factors that predict participation and adherence.
Because the majority of older adults clearly can engage in physical activity safely, a growing body of research has been conducted to identify effective programs for increasing physical activity in this population (Brawley, Rejeski, & King, 2003; Taylor et al., 2004; U.S. Department of Health and Human Services, 1996). However, increasing older adult physical activity participation presents unique challenges. Although some programs have been effective in the short term, the effectiveness of long-term physical activity programs has been limited (Brawley, Rejeski, & King, 2003; Taylor et al., 2004).
Factors Related to Successful Physical Activity Interventions
To develop effective older adult physical activity interventions, it is important to understand factors that predict participation and adherence. Numerous research studies have investigated correlates of older adult physical activity participation (Benjamin, Edwards, & Baharti, 2005; Brassington, Atienza, Perczek, DiLorenzo, & King 2002; Hays & Clark, 1999; Lee & Lafferty, 2006; Stuart, Marret, Kelly, & Nelson, 2002). Although many factors influence the participation rates of older adults, we will examine the following, which demonstrate the greatest potential for increasing physical activity:
- Psychological factors of self-efficacy, self-regulation, positive attitudes toward physical activity, and social support
- Health care provider referral
- Physical activity intensity
- Group- and home-based interventions
- Disease management
Psychological Factors
As with other populations, self-efficacy, or the confidence a person has to perform an activity, is one of the strongest determinants of physical activity for older adults (Brassington et al., 2002; Resnick, Orwig, Magaziner, & Wynne, 2002; Schutzer & Graves, 2004). Interventions should help older adults build their confidence through mastery of the physical activity. This can be achieved by beginning the intervention at a low intensity and gradually increasing the intensity over time. This gradual increase is especially important for frail older adults. Improvements in fitness and or health that result from physical activity will also enhance self-efficacy.
To promote long-term adherence to physical activity, interventions need to be designed so older adults move from a supervised, or center-based, setting to the home, where they can use self-regulation skills to make physical activity part of their lifestyle (Rejeski & Brawley, 2006). Behavioral counseling is one method that can be used to help older adults transition from center-based to home-based activity. Through counseling, older adults can develop a plan of action for making physical activity a part of their daily routine.
Having a positive attitude toward physical activity is another factor influencing older adult participation (Stuart et al., 2002). If the activity is positive and enjoyable, older adults will be more likely to continue to exercise. Past participation is also a predictor of future participation (Benjamin et al., 2005). For those who have had a negative attitude toward physical activity, strategies such as providing positive images depicting the activity with role models who may have similar limitations can be used to entice older adults to participate.
Receiving positive reinforcement or social support from friends and family is also one of the predictors of physical activity involvement in the older adult population (Booth, Owen, Bauman, Clavisi, & Leslie 2002; McAuley, Jerome, Elavvsky, Marquez, & Ramsey, 2003; Resnick et al., 2002). Litt, Kepplinger, and Judge (2002) found that social support is a strong determinant of physical activity particularly for older women. In addition, positive comments help strengthen people's self-efficacy and can enhance exercise adherence. Programs need to be carefully designed to create a positive environment. In residential care facilities, older adults may have limited contact with family members; thus, support from friends may be more important.
Health Care Provider Referrals
Receiving a recommendation from a physician to exercise is another important positive predictor of physical activity in the older adult population (Benjamin et al., 2005; Navarro, Sanz, del Castillo, Izquierdo, & Rodriguez, 2007; Stuart et al., 2002). Having a health care provider "prescribe" exercise helps older adults overcome their fear of being injured during the physical activity. This type of prescription may be especially important for physically frail older adults (Benjamin et al., 2005). More research needs to be conducted in this area to determine the most effective type of physician advice and the amount of contact needed with the older adult to improve physical activity levels.
Physical Activity Intensity
Older adults are more likely to participate in low- to moderate-intensity physical activity (Brawley et al., 2003; Taylor et al., 2004) such as light housework, chair exercises, and walking. Lower-intensity activity is less likely to cause injuries and is often perceived as less threatening, especially to older adults who have functional disabilities or limitations. Although interventions should to be tailored to the ability level of the participant, planners must also recognize that low-intensity exercises conducted in a chair may have few functional benefits for the older adult. Specificity of the exercise is the issue. If the goal is to improve mobility and balance, exercises should be conducted while participants are standing and walking. Physical activity interventions that begin at lower intensities should progress over time to moderate intensities.
Group- and Home-Based Interventions
Physical activity interventions can be designed to be group based, home based, or a combination of both. Group-based interventions require participants to go to a facility or center where the activity program is usually supervised. For typical home-based interventions, the physical activity occurs at the older adult's home, and contact with the practitioner is minimal. Combination designs usually begin with a few weeks of group-based instruction followed by a period of home-based activity. Table 6.1 lists some of the positive and negative aspects of group- and home-based interventions.
Research has demonstrated that both home-based and group-based physical activity interventions can be successful with the older adult population (Campbell, Robertson, Gardner, Norton, & Buchner, 1999; King, Haskell, Taylor, Kraemer, & Debusk, 1991; King, Haskell, Young, Oka, & Stefanic, 1995; McMurdo & Rennie, 1993; van der Bij, Laurant, & Wensing, 2002). One study found similar participation rates in both home- and group-based environments for short-term programs; however, adherence rates tended to decrease as the length of the study increased (King et al., 1995; van der Bij et al., 2002). The use of behavioral strategies including phone calls and various incentives may help improve long-term participation rates. More research should be conducted using a combination of group- and home-based environments to determine which programs work best for which population.
Disease Management
Disease management, in the context of this chapter, is using physical activity as a strategy to prevent disease and maintain favorable health status. Studies have found that mobile older adults who have few or no limitations view physical activity as a way to maintain their health (Cohen-Mansfield, Marx, & Guralnick, 2003; Rasinaho, Herninalo, Leinonen, Linutenen, & Rantinen, 2006). Older adults with higher self-efficacy and a motivation to improve their health are more likely to be physically active than those with lower self-efficacy and little motivation to improve their health (Lee & Lafferty, 2006). Increased self-efficacy may help older adults overcome barriers that prevent them from engaging in physical activity. Physical activity can help all adults, both the young and the old, avoid chronic diseases.
When planning physical activity interventions for older adults, planners should consider factors that will improve participation and adherence. This section highlighted just a few of the factors that typically result in success. Intervention specialists are encouraged to use these strategies to overcome barriers to physical activity in older adults.
Sample Successful Interventions
Home-Based Progressive Strength Training
Osteoarthritis is a common ailment that causes pain, reduces functional abilities, and limits physical activity for many older adults. Baker and colleagues (2001) investigated the effectiveness of home-based strength training for improving symptoms of knee osteoarthritis in a group of 46 adults over the age of 55. Participants were randomized into a nutritional education control group or home-based strength training group. The home-based strength group trained for 4 months. Intervention participants received in-home visits twice a week for 3 weeks, one in the 4th week and every other week thereafter. Compared to the control group, the home-based training group significantly improved in strength, pain reduction, physical function, and quality of life. These important gains highlight the need for home-based programs designed to reduce pain and other osteoarthritis symptoms and improve older adult physical function.
Walk; Address Pain, Fear, Fatigue During Exercise; Learn About Exercise; Cue by Self-Modeling (WALC)
WALC was designed to address some of the common barriers older adults have relative to physical activity (Resnick, 2002). Twenty sedentary participants were divided into treatment or control groups. The treatment group followed the four phases of the WALC program. They were asked to walk in groups or individually for 20 minutes three times per week for 6 months. The intervention group received regular visits from a practitioner who addressed unpleasant reactions associated with exercise (i.e., addressed pain, fear, fatigue during exercise). This part of the intervention included pain management techniques, relaxation methods, and scheduling of rest and exercise. Those in the treatment groups were given a book about exercise benefits and barriers and received assistance developing short- and long-term goals, planning exercise sessions, and logging their results (i.e., learned about exercise).
When compared to the controls, the treatment group demonstrated significant improvement in exercise behavior, physical activity levels, and self-efficacy expectations. Although the number of participants used in this study was small, the results indicate that physical activity levels can be increased with the sedentary older adult population by using techniques to improve self-efficacy, which can mediate common exercise barriers.
Learn more about Developing Effective Physical Activity Programs.
Effective use of mediated programming in physical activity interventions
As the influence of technology continues to increase, those interested in promoting physical activity should consider developing physical activity programs that effectively use technology.
Using technology or intervention techniques that are not delivered face-to-face is known as mediated program delivery (Marshall, Owen, & Bauman, 2004). Because of the ability to reach large numbers of people with relatively low cost, mediated programs in our field have increased dramatically. Wantland, Portillo, Holzemer, Slaughter, and McGhee (2004) reported that during a 7-year period (1996-2003), there was a 12-fold increase in MEDLINE citations for "Web-based therapies". Some examples of mediated program delivery include using email to contact program participants, using the Internet to track activity or seek social support or program feedback from group leaders, or offering podcasts or Web-streamed videos to provide access to important program information.
Factors Related to Successful Mediated Physical Activity Interventions
Factors related to successful mediated physical activity interventions fall into two categories: (a) general and relevant for all types of mediated interventions and (b) specific and relevant to only certain types of mediated interventions. Both are addressed in this section. Designers of interventions should consider both general and specific aspects when planning mediated programs.
General Factors Related to Success in All Mediated Interventions
The following six factors are related to success with any type of mediated intervention, regardless of medium:
- Increasing dose-response
- Designing memorable campaign slogans and information
- Using market segmentation and message personalization strategies
- Targeting multiple media outlets
- Ensuring theoretical fidelity
- Paying attention to quality control
• Dose-response issues. Dose-response, in this context, means that more media exposure typically results in increased physical activity behavior, increased satisfaction with program components, or both. Mediated interventions, if used correctly, can reach large numbers of people in a cost-effective manner. Exposure to media is measured in weekly gross rating points (GRP). One GRP means that 1% of the target audience viewed the advertisement once. Obviously, higher GRPs are more likely to result in a successful campaign (i.e., reach large numbers of people).
• Memorable campaign slogans. A second key to developing a successful mediated campaign is to develop and use memorable and reproducible images. Most people interested in physical activity will remember Nike's most memorable ad campaigns: "Just Do It," "If you let me play . . .," and the recent ads in conjunction with the women's World Cup soccer tournament ("The greatest team you've never heard of"). The average American is exposed to 3,000 ads per day (Peterson, Abraham, & Waterfield, 2005); therefore, media must be memorable to make an impact.
• Market segmentation. Market segmentation refers to designing marketing strategies for a specific segment of the population. Designing campaigns so they will reach various age or ethnic groups or men or women is an important strategy because what works for one segment of the population may be offensive or nonmeaningful to another (Peterson, Abraham, & Waterfield, 2005). To ensure memorable messages and accurate market segmentation, program promoters should pilot test campaign slogans and designs with the target audience. In addition to pilot testing, it is important to continually seek feedback, preferably from a local advisory committee, to refine and improve a media message as necessary. When possible, booster campaigns should be administered to sustain a promotional effort beyond the life of the initial campaign (Reger et al., 2002).
• Personalization strategies. Similar to market segmentation (or personalizing a message to reach a target audience), Marcus and colleagues (1998) suggested that one of the most important factors contributing to a successful mediated program is identifying and including relevant attributes of role models. For example, if a message is designed to reach young African Americans in a community, then characteristics and attributes of young African Americans and representative role models should be included in that message. To ascertain what these characteristics are and what information might be meaningful to that group, members of the relevant group should be surveyed and included
in a pilot testing process. The bottom line is that if people can personalize a message, they are more likely to internalize and act on it. Additional factors that can help facilitate program success are (a) tailoring information to a specific stage of change (such as the contemplation stage in the transtheoretical model), (b) updating the stage of change regularly; and (c) using reinforcement letters, phone calls, or e-mails regularly (e.g., biweekly) (Marshall et al., 2003).
• Targeting multiple areas of the media. Numerous media outlets are available for health and fitness-related messages (e.g., billboards, buses, signs, television, radio, Internet, and newspaper) (Peterson et al., 2005). A good example of creative media blitzing is using point-of-decision prompts. Point-of-decision prompts are reminders in the form of signs, bulletin boards, billboards, or bus signs that encourage people to take advantage of physical activity opportunities when they arise (Marcus et al., 1998). Some examples of point-of-decision prompts that work include Use the Stairs and Park and Walk (Marcus et al., 1998).
• Theoretical fidelity. Theoretical fidelity refers to the precision with which theory-based recommendations are used. Rovniak and colleagues (2005) tested the effectiveness of high- and low-fidelity e-mail-based walking interventions in 65 sedentary adults, mostly women. One 12-week intervention, which demonstrated high fidelity to the social cognitive theory (SCT), used targeted skills, specific and hierarchical goals, and precise self-monitoring and feedback. The other intervention, which demonstrated low fidelity to the SCT, provided information (rather than modeling) to teach skills and did not provide ongoing self-monitoring and feedback. Several outcomes were monitored before and after the intervention, including a 1-mile (1.6 km) walk test of physical fitness, a log of walking behavior, and several measures of social cognitive theory (e.g., exercise self-efficacy, benefits and enjoyment of physical activity, goal setting, exercise planning, and social support). Compared to those in the low-fidelity group, those in the high-fidelity group completed more of their prescribed walking sessions and walked faster at posttest. Those in the high-fidelity group also reported greater program satisfaction and increased their goal setting and positive outcome expectations for walking more than twice as much as those in the low-fidelity group. Clearly, efforts to ensure theoretical fidelity are important for improving the success of mediated interventions.
• Quality control. Quality control, or attention to clarity, accuracy, and timeliness, is important. Information must be of high quality to earn respect, reach the critical mass, and facilitate changes in physical activity behavior (Marcus et al., 1998). Although obesity prevention and physical activity promotion are multimillion-dollar industries, it is not right to promise something that cannot be delivered. Failure to deliver programs based on factual information may result in an ineffective and disrespected program.
Factors Related to Success in Specific Mass Media Programs
The mass media has the potential to reach large numbers of people in a short period of time for a relatively low cost. To maximize this opportunity and ensure that mass media programs are successful, Cavill and Bauman (2004) recommend the following strategies:
- The mass media should target multiple media outlets in a systematic and sustained fashion.
- Campaigns should maximize contact or message exposure, because doing so typically results in greater behavior change.
- Other supportive community activities should be organized around mass media messages (e.g., self-help groups, counseling, screening and education, community events, and walking trails).
- The message coming from the mass media should be singular and simple-so it will be memorable.
- Mass media campaigns should target a specific audience or audiences based on demographics, attitudes, and preferred media usage; this will ensure that the message is heard by those for whom it is designed.
Print-Based Programs Those designing physical activity programs are probably most familiar with print-based handouts. Print handouts have been around longer than other means of media, and they are probably still the most common method of promoting increased physical activity. Distributors of print media should use some of the suggestions provided earlier for all mediated interventions, while also considering specific recommendations for this medium. Following are some suggestions for designing a successful print-based program (Napolitano & Marcus, 2002):
- Follow up with participants quickly after distributing print material.
- Provide opportunities for participants to find interactions with others because social support is a desirable feature of many physical activity programs.
- Make sure the information is concise, accurate, and specifically directed to the targeted population.
- Pilot test materials with members of the targeted population.
- Write materials to a level appropriate for the targeted population.
Phone-Based Programs Phone-based programs are delivered as phone calls or text messages. The following recommendations can help ensure that a phone-based program is successful:
- Consider the purpose of the contact (e.g., touching base, structured, or automated with prompts); studies have demonstrated that phone calls designed to touch base were just as effective as contacts that were highly structured (Lombard, Lombard, & Winett, 1995, as cited in Marcus et al., 1998).
- Consider the frequency with which phone calls or text messages are delivered. Schultz (1993) concluded that adherence and frequency of phone contacts are positively correlated, although there is probably a point at which a high frequency of phone contacts becomes a nuisance.
- Be as specific as possible with feedback (e.g., overcoming barriers, the benefits of exercise that are motivating to that participant, the type of activity the participant enjoyed) to facilitate maximal change (Hurling et al., 2007).
Although phone-based interventions have been around for a while, the use of text messaging to prompt physical activity is a relatively new means of communicating using mediated technology. Given the increase in text messaging in this country, this technology offers significant potential for reaching many people.
Web-Based Programs Web-based programs demand a significant time investment prior to implementation. To ensure that Web-based programs are designed successfully, Ferney and Marshall (2006) recommended considering four factors that are important to Web site users in the field of physical activity promotion: Web design (structure), interactivity, environmental context, and content.
- Web design. To be maximally useful, Web sites should be easy to navigate and download time should be minimal (Ferney & Marshall, 2006). Users should be able to navigate a Web site easily, and links should be intuitive and downloadable in no more than 10 seconds. Making Web sites password protected facilitates tracking people's use around the site. Web site designers should conduct pilot and usability tests with proposed and developing Web sites and correct any problems found.
- Interactivity. A Web site that facilitates information exchange between a participant and an intervention specialist is interactive. Following are some examples of interactive activities on a PA Web site (Ferney & Marshall, 2006; Hurling et al., 2006):
• Logging on to a Web site to report activity or set goals
• Receiving specific feedback about one's performance compared to others or a previous best effort
• Accessing social support and expert advice
• Calculating target heart rate
• Accessing information about local community events
• Identifying barriers and receiving feedback about ways to overcome them
According to experts (Bull, Kreuter, & Scharff, 1999; Ferney & Marshall, 2006; Fogg, 2003; Hurling et al., 2006; Tate, Wing, & Winett, 2001; Wantland et al., 2004), interactive Web sites are more effective than non-interactive sites because they
• are more enjoyable to use,
• are less impersonal,
• facilitate better user retention and longer Web sessions,
• create higher expectations for exercise,
• facilitate higher levels of motivation and improved self-perception of fitness,
• are more likely to be saved and revisited in the future,
• are more likely to be discussed with others, and
• result in real behavior change with regular visitations.
- Environmental context. Providing information such as an updated community calendar of events; maps of physical activity opportunities in the community; and a physical activity database with information about times, costs, deadlines, and facilities (Ferney & Marshall, 2006) are examples of considering the environmental context. This information should be updated regularly to facilitate the desire to visit the Web site.
- Content. Information presented on the Web as audio, video, or text is known as content. It is important to update Web site content as often as possible. Those who use the Web frequently do not like to read volumes of text or wade through repetitive information, and they do not like to visit Web sites and see the same information over and over.
Podcasting Research is sparse on the factors related to success with podcasting-especially as it relates to increasing physical activity. However, until more research is conducted, the following basic strategies can help ensure that podcasts are successful (Eads, 2007; Hartman & Jackson, 2007):
- Be aware that those in the iPod generation are typically young and technologically savvy.
- When possible, provide the means for interaction with others.
- Pilot test podcasts with members of the target population.
- Make sure podcasts are simple and easy to download with a computer.
Sample Successful Program
Active Living (Web and Print)
Active Living is an 8-week Web-based program that evolved from a print-based program (Marshall et al., 2003). This program assessed stage of change (according to the transtheoretical model) and featured personalized Web links to sites on goal setting, activity planning, and determining target heart rate. People who participated in this project were regularly reassessed to ensure that their Web information was tailored to their specific stage of change. The Web information was supplemented with personalized and stage-based reinforcement e-mails sent every 2 weeks. These e-mails contained hyperlinks to relevant areas of the Active Living Web site. The print information for this intervention was identical to the information found in the Web-based program except that people receiving the print materials received supplemental letters with stage-matched information every 2 weeks.
The impact of the intervention was assessed by comparing baseline and postintervention physical activity data: (a) MET-minutes per week and minutes in specific categories of activity (e.g., vigorous, moderate, and seated activities), collected with the International PA Questionnaire (IPAQ), (b) meeting or not meeting the public health recommendation (i.e., 30 minutes of at least moderate physical activity most days of the week), and (c) stage of change in the transtheoretical model. Results of the study indicate that Web interven tion participants reported a decrease in the amount of time spent sitting, and print-based intervention participants increased their total minutes of physical activity. About 26% of the participants in both groups progressed forward at least one stage of change in the transtheoretical model, indicating that they should be likely to continue being physically active in the future. It is interesting to note that both print- and Web-based programs facilitated increases in physical activity, although people in the print group reported larger increases in activity and they were better able to recognize intervention materials after the program was completed.
Learn more about Developing Effective Physical Activity Programs.
Confidence and positive attitude help older adults stick with exercise
To develop effective older adult physical activity interventions, it is important to understand factors that predict participation and adherence.
Because the majority of older adults clearly can engage in physical activity safely, a growing body of research has been conducted to identify effective programs for increasing physical activity in this population (Brawley, Rejeski, & King, 2003; Taylor et al., 2004; U.S. Department of Health and Human Services, 1996). However, increasing older adult physical activity participation presents unique challenges. Although some programs have been effective in the short term, the effectiveness of long-term physical activity programs has been limited (Brawley, Rejeski, & King, 2003; Taylor et al., 2004).
Factors Related to Successful Physical Activity Interventions
To develop effective older adult physical activity interventions, it is important to understand factors that predict participation and adherence. Numerous research studies have investigated correlates of older adult physical activity participation (Benjamin, Edwards, & Baharti, 2005; Brassington, Atienza, Perczek, DiLorenzo, & King 2002; Hays & Clark, 1999; Lee & Lafferty, 2006; Stuart, Marret, Kelly, & Nelson, 2002). Although many factors influence the participation rates of older adults, we will examine the following, which demonstrate the greatest potential for increasing physical activity:
- Psychological factors of self-efficacy, self-regulation, positive attitudes toward physical activity, and social support
- Health care provider referral
- Physical activity intensity
- Group- and home-based interventions
- Disease management
Psychological Factors
As with other populations, self-efficacy, or the confidence a person has to perform an activity, is one of the strongest determinants of physical activity for older adults (Brassington et al., 2002; Resnick, Orwig, Magaziner, & Wynne, 2002; Schutzer & Graves, 2004). Interventions should help older adults build their confidence through mastery of the physical activity. This can be achieved by beginning the intervention at a low intensity and gradually increasing the intensity over time. This gradual increase is especially important for frail older adults. Improvements in fitness and or health that result from physical activity will also enhance self-efficacy.
To promote long-term adherence to physical activity, interventions need to be designed so older adults move from a supervised, or center-based, setting to the home, where they can use self-regulation skills to make physical activity part of their lifestyle (Rejeski & Brawley, 2006). Behavioral counseling is one method that can be used to help older adults transition from center-based to home-based activity. Through counseling, older adults can develop a plan of action for making physical activity a part of their daily routine.
Having a positive attitude toward physical activity is another factor influencing older adult participation (Stuart et al., 2002). If the activity is positive and enjoyable, older adults will be more likely to continue to exercise. Past participation is also a predictor of future participation (Benjamin et al., 2005). For those who have had a negative attitude toward physical activity, strategies such as providing positive images depicting the activity with role models who may have similar limitations can be used to entice older adults to participate.
Receiving positive reinforcement or social support from friends and family is also one of the predictors of physical activity involvement in the older adult population (Booth, Owen, Bauman, Clavisi, & Leslie 2002; McAuley, Jerome, Elavvsky, Marquez, & Ramsey, 2003; Resnick et al., 2002). Litt, Kepplinger, and Judge (2002) found that social support is a strong determinant of physical activity particularly for older women. In addition, positive comments help strengthen people's self-efficacy and can enhance exercise adherence. Programs need to be carefully designed to create a positive environment. In residential care facilities, older adults may have limited contact with family members; thus, support from friends may be more important.
Health Care Provider Referrals
Receiving a recommendation from a physician to exercise is another important positive predictor of physical activity in the older adult population (Benjamin et al., 2005; Navarro, Sanz, del Castillo, Izquierdo, & Rodriguez, 2007; Stuart et al., 2002). Having a health care provider "prescribe" exercise helps older adults overcome their fear of being injured during the physical activity. This type of prescription may be especially important for physically frail older adults (Benjamin et al., 2005). More research needs to be conducted in this area to determine the most effective type of physician advice and the amount of contact needed with the older adult to improve physical activity levels.
Physical Activity Intensity
Older adults are more likely to participate in low- to moderate-intensity physical activity (Brawley et al., 2003; Taylor et al., 2004) such as light housework, chair exercises, and walking. Lower-intensity activity is less likely to cause injuries and is often perceived as less threatening, especially to older adults who have functional disabilities or limitations. Although interventions should to be tailored to the ability level of the participant, planners must also recognize that low-intensity exercises conducted in a chair may have few functional benefits for the older adult. Specificity of the exercise is the issue. If the goal is to improve mobility and balance, exercises should be conducted while participants are standing and walking. Physical activity interventions that begin at lower intensities should progress over time to moderate intensities.
Group- and Home-Based Interventions
Physical activity interventions can be designed to be group based, home based, or a combination of both. Group-based interventions require participants to go to a facility or center where the activity program is usually supervised. For typical home-based interventions, the physical activity occurs at the older adult's home, and contact with the practitioner is minimal. Combination designs usually begin with a few weeks of group-based instruction followed by a period of home-based activity. Table 6.1 lists some of the positive and negative aspects of group- and home-based interventions.
Research has demonstrated that both home-based and group-based physical activity interventions can be successful with the older adult population (Campbell, Robertson, Gardner, Norton, & Buchner, 1999; King, Haskell, Taylor, Kraemer, & Debusk, 1991; King, Haskell, Young, Oka, & Stefanic, 1995; McMurdo & Rennie, 1993; van der Bij, Laurant, & Wensing, 2002). One study found similar participation rates in both home- and group-based environments for short-term programs; however, adherence rates tended to decrease as the length of the study increased (King et al., 1995; van der Bij et al., 2002). The use of behavioral strategies including phone calls and various incentives may help improve long-term participation rates. More research should be conducted using a combination of group- and home-based environments to determine which programs work best for which population.
Disease Management
Disease management, in the context of this chapter, is using physical activity as a strategy to prevent disease and maintain favorable health status. Studies have found that mobile older adults who have few or no limitations view physical activity as a way to maintain their health (Cohen-Mansfield, Marx, & Guralnick, 2003; Rasinaho, Herninalo, Leinonen, Linutenen, & Rantinen, 2006). Older adults with higher self-efficacy and a motivation to improve their health are more likely to be physically active than those with lower self-efficacy and little motivation to improve their health (Lee & Lafferty, 2006). Increased self-efficacy may help older adults overcome barriers that prevent them from engaging in physical activity. Physical activity can help all adults, both the young and the old, avoid chronic diseases.
When planning physical activity interventions for older adults, planners should consider factors that will improve participation and adherence. This section highlighted just a few of the factors that typically result in success. Intervention specialists are encouraged to use these strategies to overcome barriers to physical activity in older adults.
Sample Successful Interventions
Home-Based Progressive Strength Training
Osteoarthritis is a common ailment that causes pain, reduces functional abilities, and limits physical activity for many older adults. Baker and colleagues (2001) investigated the effectiveness of home-based strength training for improving symptoms of knee osteoarthritis in a group of 46 adults over the age of 55. Participants were randomized into a nutritional education control group or home-based strength training group. The home-based strength group trained for 4 months. Intervention participants received in-home visits twice a week for 3 weeks, one in the 4th week and every other week thereafter. Compared to the control group, the home-based training group significantly improved in strength, pain reduction, physical function, and quality of life. These important gains highlight the need for home-based programs designed to reduce pain and other osteoarthritis symptoms and improve older adult physical function.
Walk; Address Pain, Fear, Fatigue During Exercise; Learn About Exercise; Cue by Self-Modeling (WALC)
WALC was designed to address some of the common barriers older adults have relative to physical activity (Resnick, 2002). Twenty sedentary participants were divided into treatment or control groups. The treatment group followed the four phases of the WALC program. They were asked to walk in groups or individually for 20 minutes three times per week for 6 months. The intervention group received regular visits from a practitioner who addressed unpleasant reactions associated with exercise (i.e., addressed pain, fear, fatigue during exercise). This part of the intervention included pain management techniques, relaxation methods, and scheduling of rest and exercise. Those in the treatment groups were given a book about exercise benefits and barriers and received assistance developing short- and long-term goals, planning exercise sessions, and logging their results (i.e., learned about exercise).
When compared to the controls, the treatment group demonstrated significant improvement in exercise behavior, physical activity levels, and self-efficacy expectations. Although the number of participants used in this study was small, the results indicate that physical activity levels can be increased with the sedentary older adult population by using techniques to improve self-efficacy, which can mediate common exercise barriers.
Learn more about Developing Effective Physical Activity Programs.
Effective use of mediated programming in physical activity interventions
As the influence of technology continues to increase, those interested in promoting physical activity should consider developing physical activity programs that effectively use technology.
Using technology or intervention techniques that are not delivered face-to-face is known as mediated program delivery (Marshall, Owen, & Bauman, 2004). Because of the ability to reach large numbers of people with relatively low cost, mediated programs in our field have increased dramatically. Wantland, Portillo, Holzemer, Slaughter, and McGhee (2004) reported that during a 7-year period (1996-2003), there was a 12-fold increase in MEDLINE citations for "Web-based therapies". Some examples of mediated program delivery include using email to contact program participants, using the Internet to track activity or seek social support or program feedback from group leaders, or offering podcasts or Web-streamed videos to provide access to important program information.
Factors Related to Successful Mediated Physical Activity Interventions
Factors related to successful mediated physical activity interventions fall into two categories: (a) general and relevant for all types of mediated interventions and (b) specific and relevant to only certain types of mediated interventions. Both are addressed in this section. Designers of interventions should consider both general and specific aspects when planning mediated programs.
General Factors Related to Success in All Mediated Interventions
The following six factors are related to success with any type of mediated intervention, regardless of medium:
- Increasing dose-response
- Designing memorable campaign slogans and information
- Using market segmentation and message personalization strategies
- Targeting multiple media outlets
- Ensuring theoretical fidelity
- Paying attention to quality control
• Dose-response issues. Dose-response, in this context, means that more media exposure typically results in increased physical activity behavior, increased satisfaction with program components, or both. Mediated interventions, if used correctly, can reach large numbers of people in a cost-effective manner. Exposure to media is measured in weekly gross rating points (GRP). One GRP means that 1% of the target audience viewed the advertisement once. Obviously, higher GRPs are more likely to result in a successful campaign (i.e., reach large numbers of people).
• Memorable campaign slogans. A second key to developing a successful mediated campaign is to develop and use memorable and reproducible images. Most people interested in physical activity will remember Nike's most memorable ad campaigns: "Just Do It," "If you let me play . . .," and the recent ads in conjunction with the women's World Cup soccer tournament ("The greatest team you've never heard of"). The average American is exposed to 3,000 ads per day (Peterson, Abraham, & Waterfield, 2005); therefore, media must be memorable to make an impact.
• Market segmentation. Market segmentation refers to designing marketing strategies for a specific segment of the population. Designing campaigns so they will reach various age or ethnic groups or men or women is an important strategy because what works for one segment of the population may be offensive or nonmeaningful to another (Peterson, Abraham, & Waterfield, 2005). To ensure memorable messages and accurate market segmentation, program promoters should pilot test campaign slogans and designs with the target audience. In addition to pilot testing, it is important to continually seek feedback, preferably from a local advisory committee, to refine and improve a media message as necessary. When possible, booster campaigns should be administered to sustain a promotional effort beyond the life of the initial campaign (Reger et al., 2002).
• Personalization strategies. Similar to market segmentation (or personalizing a message to reach a target audience), Marcus and colleagues (1998) suggested that one of the most important factors contributing to a successful mediated program is identifying and including relevant attributes of role models. For example, if a message is designed to reach young African Americans in a community, then characteristics and attributes of young African Americans and representative role models should be included in that message. To ascertain what these characteristics are and what information might be meaningful to that group, members of the relevant group should be surveyed and included
in a pilot testing process. The bottom line is that if people can personalize a message, they are more likely to internalize and act on it. Additional factors that can help facilitate program success are (a) tailoring information to a specific stage of change (such as the contemplation stage in the transtheoretical model), (b) updating the stage of change regularly; and (c) using reinforcement letters, phone calls, or e-mails regularly (e.g., biweekly) (Marshall et al., 2003).
• Targeting multiple areas of the media. Numerous media outlets are available for health and fitness-related messages (e.g., billboards, buses, signs, television, radio, Internet, and newspaper) (Peterson et al., 2005). A good example of creative media blitzing is using point-of-decision prompts. Point-of-decision prompts are reminders in the form of signs, bulletin boards, billboards, or bus signs that encourage people to take advantage of physical activity opportunities when they arise (Marcus et al., 1998). Some examples of point-of-decision prompts that work include Use the Stairs and Park and Walk (Marcus et al., 1998).
• Theoretical fidelity. Theoretical fidelity refers to the precision with which theory-based recommendations are used. Rovniak and colleagues (2005) tested the effectiveness of high- and low-fidelity e-mail-based walking interventions in 65 sedentary adults, mostly women. One 12-week intervention, which demonstrated high fidelity to the social cognitive theory (SCT), used targeted skills, specific and hierarchical goals, and precise self-monitoring and feedback. The other intervention, which demonstrated low fidelity to the SCT, provided information (rather than modeling) to teach skills and did not provide ongoing self-monitoring and feedback. Several outcomes were monitored before and after the intervention, including a 1-mile (1.6 km) walk test of physical fitness, a log of walking behavior, and several measures of social cognitive theory (e.g., exercise self-efficacy, benefits and enjoyment of physical activity, goal setting, exercise planning, and social support). Compared to those in the low-fidelity group, those in the high-fidelity group completed more of their prescribed walking sessions and walked faster at posttest. Those in the high-fidelity group also reported greater program satisfaction and increased their goal setting and positive outcome expectations for walking more than twice as much as those in the low-fidelity group. Clearly, efforts to ensure theoretical fidelity are important for improving the success of mediated interventions.
• Quality control. Quality control, or attention to clarity, accuracy, and timeliness, is important. Information must be of high quality to earn respect, reach the critical mass, and facilitate changes in physical activity behavior (Marcus et al., 1998). Although obesity prevention and physical activity promotion are multimillion-dollar industries, it is not right to promise something that cannot be delivered. Failure to deliver programs based on factual information may result in an ineffective and disrespected program.
Factors Related to Success in Specific Mass Media Programs
The mass media has the potential to reach large numbers of people in a short period of time for a relatively low cost. To maximize this opportunity and ensure that mass media programs are successful, Cavill and Bauman (2004) recommend the following strategies:
- The mass media should target multiple media outlets in a systematic and sustained fashion.
- Campaigns should maximize contact or message exposure, because doing so typically results in greater behavior change.
- Other supportive community activities should be organized around mass media messages (e.g., self-help groups, counseling, screening and education, community events, and walking trails).
- The message coming from the mass media should be singular and simple-so it will be memorable.
- Mass media campaigns should target a specific audience or audiences based on demographics, attitudes, and preferred media usage; this will ensure that the message is heard by those for whom it is designed.
Print-Based Programs Those designing physical activity programs are probably most familiar with print-based handouts. Print handouts have been around longer than other means of media, and they are probably still the most common method of promoting increased physical activity. Distributors of print media should use some of the suggestions provided earlier for all mediated interventions, while also considering specific recommendations for this medium. Following are some suggestions for designing a successful print-based program (Napolitano & Marcus, 2002):
- Follow up with participants quickly after distributing print material.
- Provide opportunities for participants to find interactions with others because social support is a desirable feature of many physical activity programs.
- Make sure the information is concise, accurate, and specifically directed to the targeted population.
- Pilot test materials with members of the targeted population.
- Write materials to a level appropriate for the targeted population.
Phone-Based Programs Phone-based programs are delivered as phone calls or text messages. The following recommendations can help ensure that a phone-based program is successful:
- Consider the purpose of the contact (e.g., touching base, structured, or automated with prompts); studies have demonstrated that phone calls designed to touch base were just as effective as contacts that were highly structured (Lombard, Lombard, & Winett, 1995, as cited in Marcus et al., 1998).
- Consider the frequency with which phone calls or text messages are delivered. Schultz (1993) concluded that adherence and frequency of phone contacts are positively correlated, although there is probably a point at which a high frequency of phone contacts becomes a nuisance.
- Be as specific as possible with feedback (e.g., overcoming barriers, the benefits of exercise that are motivating to that participant, the type of activity the participant enjoyed) to facilitate maximal change (Hurling et al., 2007).
Although phone-based interventions have been around for a while, the use of text messaging to prompt physical activity is a relatively new means of communicating using mediated technology. Given the increase in text messaging in this country, this technology offers significant potential for reaching many people.
Web-Based Programs Web-based programs demand a significant time investment prior to implementation. To ensure that Web-based programs are designed successfully, Ferney and Marshall (2006) recommended considering four factors that are important to Web site users in the field of physical activity promotion: Web design (structure), interactivity, environmental context, and content.
- Web design. To be maximally useful, Web sites should be easy to navigate and download time should be minimal (Ferney & Marshall, 2006). Users should be able to navigate a Web site easily, and links should be intuitive and downloadable in no more than 10 seconds. Making Web sites password protected facilitates tracking people's use around the site. Web site designers should conduct pilot and usability tests with proposed and developing Web sites and correct any problems found.
- Interactivity. A Web site that facilitates information exchange between a participant and an intervention specialist is interactive. Following are some examples of interactive activities on a PA Web site (Ferney & Marshall, 2006; Hurling et al., 2006):
• Logging on to a Web site to report activity or set goals
• Receiving specific feedback about one's performance compared to others or a previous best effort
• Accessing social support and expert advice
• Calculating target heart rate
• Accessing information about local community events
• Identifying barriers and receiving feedback about ways to overcome them
According to experts (Bull, Kreuter, & Scharff, 1999; Ferney & Marshall, 2006; Fogg, 2003; Hurling et al., 2006; Tate, Wing, & Winett, 2001; Wantland et al., 2004), interactive Web sites are more effective than non-interactive sites because they
• are more enjoyable to use,
• are less impersonal,
• facilitate better user retention and longer Web sessions,
• create higher expectations for exercise,
• facilitate higher levels of motivation and improved self-perception of fitness,
• are more likely to be saved and revisited in the future,
• are more likely to be discussed with others, and
• result in real behavior change with regular visitations.
- Environmental context. Providing information such as an updated community calendar of events; maps of physical activity opportunities in the community; and a physical activity database with information about times, costs, deadlines, and facilities (Ferney & Marshall, 2006) are examples of considering the environmental context. This information should be updated regularly to facilitate the desire to visit the Web site.
- Content. Information presented on the Web as audio, video, or text is known as content. It is important to update Web site content as often as possible. Those who use the Web frequently do not like to read volumes of text or wade through repetitive information, and they do not like to visit Web sites and see the same information over and over.
Podcasting Research is sparse on the factors related to success with podcasting-especially as it relates to increasing physical activity. However, until more research is conducted, the following basic strategies can help ensure that podcasts are successful (Eads, 2007; Hartman & Jackson, 2007):
- Be aware that those in the iPod generation are typically young and technologically savvy.
- When possible, provide the means for interaction with others.
- Pilot test podcasts with members of the target population.
- Make sure podcasts are simple and easy to download with a computer.
Sample Successful Program
Active Living (Web and Print)
Active Living is an 8-week Web-based program that evolved from a print-based program (Marshall et al., 2003). This program assessed stage of change (according to the transtheoretical model) and featured personalized Web links to sites on goal setting, activity planning, and determining target heart rate. People who participated in this project were regularly reassessed to ensure that their Web information was tailored to their specific stage of change. The Web information was supplemented with personalized and stage-based reinforcement e-mails sent every 2 weeks. These e-mails contained hyperlinks to relevant areas of the Active Living Web site. The print information for this intervention was identical to the information found in the Web-based program except that people receiving the print materials received supplemental letters with stage-matched information every 2 weeks.
The impact of the intervention was assessed by comparing baseline and postintervention physical activity data: (a) MET-minutes per week and minutes in specific categories of activity (e.g., vigorous, moderate, and seated activities), collected with the International PA Questionnaire (IPAQ), (b) meeting or not meeting the public health recommendation (i.e., 30 minutes of at least moderate physical activity most days of the week), and (c) stage of change in the transtheoretical model. Results of the study indicate that Web interven tion participants reported a decrease in the amount of time spent sitting, and print-based intervention participants increased their total minutes of physical activity. About 26% of the participants in both groups progressed forward at least one stage of change in the transtheoretical model, indicating that they should be likely to continue being physically active in the future. It is interesting to note that both print- and Web-based programs facilitated increases in physical activity, although people in the print group reported larger increases in activity and they were better able to recognize intervention materials after the program was completed.
Learn more about Developing Effective Physical Activity Programs.
Confidence and positive attitude help older adults stick with exercise
To develop effective older adult physical activity interventions, it is important to understand factors that predict participation and adherence.
Because the majority of older adults clearly can engage in physical activity safely, a growing body of research has been conducted to identify effective programs for increasing physical activity in this population (Brawley, Rejeski, & King, 2003; Taylor et al., 2004; U.S. Department of Health and Human Services, 1996). However, increasing older adult physical activity participation presents unique challenges. Although some programs have been effective in the short term, the effectiveness of long-term physical activity programs has been limited (Brawley, Rejeski, & King, 2003; Taylor et al., 2004).
Factors Related to Successful Physical Activity Interventions
To develop effective older adult physical activity interventions, it is important to understand factors that predict participation and adherence. Numerous research studies have investigated correlates of older adult physical activity participation (Benjamin, Edwards, & Baharti, 2005; Brassington, Atienza, Perczek, DiLorenzo, & King 2002; Hays & Clark, 1999; Lee & Lafferty, 2006; Stuart, Marret, Kelly, & Nelson, 2002). Although many factors influence the participation rates of older adults, we will examine the following, which demonstrate the greatest potential for increasing physical activity:
- Psychological factors of self-efficacy, self-regulation, positive attitudes toward physical activity, and social support
- Health care provider referral
- Physical activity intensity
- Group- and home-based interventions
- Disease management
Psychological Factors
As with other populations, self-efficacy, or the confidence a person has to perform an activity, is one of the strongest determinants of physical activity for older adults (Brassington et al., 2002; Resnick, Orwig, Magaziner, & Wynne, 2002; Schutzer & Graves, 2004). Interventions should help older adults build their confidence through mastery of the physical activity. This can be achieved by beginning the intervention at a low intensity and gradually increasing the intensity over time. This gradual increase is especially important for frail older adults. Improvements in fitness and or health that result from physical activity will also enhance self-efficacy.
To promote long-term adherence to physical activity, interventions need to be designed so older adults move from a supervised, or center-based, setting to the home, where they can use self-regulation skills to make physical activity part of their lifestyle (Rejeski & Brawley, 2006). Behavioral counseling is one method that can be used to help older adults transition from center-based to home-based activity. Through counseling, older adults can develop a plan of action for making physical activity a part of their daily routine.
Having a positive attitude toward physical activity is another factor influencing older adult participation (Stuart et al., 2002). If the activity is positive and enjoyable, older adults will be more likely to continue to exercise. Past participation is also a predictor of future participation (Benjamin et al., 2005). For those who have had a negative attitude toward physical activity, strategies such as providing positive images depicting the activity with role models who may have similar limitations can be used to entice older adults to participate.
Receiving positive reinforcement or social support from friends and family is also one of the predictors of physical activity involvement in the older adult population (Booth, Owen, Bauman, Clavisi, & Leslie 2002; McAuley, Jerome, Elavvsky, Marquez, & Ramsey, 2003; Resnick et al., 2002). Litt, Kepplinger, and Judge (2002) found that social support is a strong determinant of physical activity particularly for older women. In addition, positive comments help strengthen people's self-efficacy and can enhance exercise adherence. Programs need to be carefully designed to create a positive environment. In residential care facilities, older adults may have limited contact with family members; thus, support from friends may be more important.
Health Care Provider Referrals
Receiving a recommendation from a physician to exercise is another important positive predictor of physical activity in the older adult population (Benjamin et al., 2005; Navarro, Sanz, del Castillo, Izquierdo, & Rodriguez, 2007; Stuart et al., 2002). Having a health care provider "prescribe" exercise helps older adults overcome their fear of being injured during the physical activity. This type of prescription may be especially important for physically frail older adults (Benjamin et al., 2005). More research needs to be conducted in this area to determine the most effective type of physician advice and the amount of contact needed with the older adult to improve physical activity levels.
Physical Activity Intensity
Older adults are more likely to participate in low- to moderate-intensity physical activity (Brawley et al., 2003; Taylor et al., 2004) such as light housework, chair exercises, and walking. Lower-intensity activity is less likely to cause injuries and is often perceived as less threatening, especially to older adults who have functional disabilities or limitations. Although interventions should to be tailored to the ability level of the participant, planners must also recognize that low-intensity exercises conducted in a chair may have few functional benefits for the older adult. Specificity of the exercise is the issue. If the goal is to improve mobility and balance, exercises should be conducted while participants are standing and walking. Physical activity interventions that begin at lower intensities should progress over time to moderate intensities.
Group- and Home-Based Interventions
Physical activity interventions can be designed to be group based, home based, or a combination of both. Group-based interventions require participants to go to a facility or center where the activity program is usually supervised. For typical home-based interventions, the physical activity occurs at the older adult's home, and contact with the practitioner is minimal. Combination designs usually begin with a few weeks of group-based instruction followed by a period of home-based activity. Table 6.1 lists some of the positive and negative aspects of group- and home-based interventions.
Research has demonstrated that both home-based and group-based physical activity interventions can be successful with the older adult population (Campbell, Robertson, Gardner, Norton, & Buchner, 1999; King, Haskell, Taylor, Kraemer, & Debusk, 1991; King, Haskell, Young, Oka, & Stefanic, 1995; McMurdo & Rennie, 1993; van der Bij, Laurant, & Wensing, 2002). One study found similar participation rates in both home- and group-based environments for short-term programs; however, adherence rates tended to decrease as the length of the study increased (King et al., 1995; van der Bij et al., 2002). The use of behavioral strategies including phone calls and various incentives may help improve long-term participation rates. More research should be conducted using a combination of group- and home-based environments to determine which programs work best for which population.
Disease Management
Disease management, in the context of this chapter, is using physical activity as a strategy to prevent disease and maintain favorable health status. Studies have found that mobile older adults who have few or no limitations view physical activity as a way to maintain their health (Cohen-Mansfield, Marx, & Guralnick, 2003; Rasinaho, Herninalo, Leinonen, Linutenen, & Rantinen, 2006). Older adults with higher self-efficacy and a motivation to improve their health are more likely to be physically active than those with lower self-efficacy and little motivation to improve their health (Lee & Lafferty, 2006). Increased self-efficacy may help older adults overcome barriers that prevent them from engaging in physical activity. Physical activity can help all adults, both the young and the old, avoid chronic diseases.
When planning physical activity interventions for older adults, planners should consider factors that will improve participation and adherence. This section highlighted just a few of the factors that typically result in success. Intervention specialists are encouraged to use these strategies to overcome barriers to physical activity in older adults.
Sample Successful Interventions
Home-Based Progressive Strength Training
Osteoarthritis is a common ailment that causes pain, reduces functional abilities, and limits physical activity for many older adults. Baker and colleagues (2001) investigated the effectiveness of home-based strength training for improving symptoms of knee osteoarthritis in a group of 46 adults over the age of 55. Participants were randomized into a nutritional education control group or home-based strength training group. The home-based strength group trained for 4 months. Intervention participants received in-home visits twice a week for 3 weeks, one in the 4th week and every other week thereafter. Compared to the control group, the home-based training group significantly improved in strength, pain reduction, physical function, and quality of life. These important gains highlight the need for home-based programs designed to reduce pain and other osteoarthritis symptoms and improve older adult physical function.
Walk; Address Pain, Fear, Fatigue During Exercise; Learn About Exercise; Cue by Self-Modeling (WALC)
WALC was designed to address some of the common barriers older adults have relative to physical activity (Resnick, 2002). Twenty sedentary participants were divided into treatment or control groups. The treatment group followed the four phases of the WALC program. They were asked to walk in groups or individually for 20 minutes three times per week for 6 months. The intervention group received regular visits from a practitioner who addressed unpleasant reactions associated with exercise (i.e., addressed pain, fear, fatigue during exercise). This part of the intervention included pain management techniques, relaxation methods, and scheduling of rest and exercise. Those in the treatment groups were given a book about exercise benefits and barriers and received assistance developing short- and long-term goals, planning exercise sessions, and logging their results (i.e., learned about exercise).
When compared to the controls, the treatment group demonstrated significant improvement in exercise behavior, physical activity levels, and self-efficacy expectations. Although the number of participants used in this study was small, the results indicate that physical activity levels can be increased with the sedentary older adult population by using techniques to improve self-efficacy, which can mediate common exercise barriers.
Learn more about Developing Effective Physical Activity Programs.
Effective use of mediated programming in physical activity interventions
As the influence of technology continues to increase, those interested in promoting physical activity should consider developing physical activity programs that effectively use technology.
Using technology or intervention techniques that are not delivered face-to-face is known as mediated program delivery (Marshall, Owen, & Bauman, 2004). Because of the ability to reach large numbers of people with relatively low cost, mediated programs in our field have increased dramatically. Wantland, Portillo, Holzemer, Slaughter, and McGhee (2004) reported that during a 7-year period (1996-2003), there was a 12-fold increase in MEDLINE citations for "Web-based therapies". Some examples of mediated program delivery include using email to contact program participants, using the Internet to track activity or seek social support or program feedback from group leaders, or offering podcasts or Web-streamed videos to provide access to important program information.
Factors Related to Successful Mediated Physical Activity Interventions
Factors related to successful mediated physical activity interventions fall into two categories: (a) general and relevant for all types of mediated interventions and (b) specific and relevant to only certain types of mediated interventions. Both are addressed in this section. Designers of interventions should consider both general and specific aspects when planning mediated programs.
General Factors Related to Success in All Mediated Interventions
The following six factors are related to success with any type of mediated intervention, regardless of medium:
- Increasing dose-response
- Designing memorable campaign slogans and information
- Using market segmentation and message personalization strategies
- Targeting multiple media outlets
- Ensuring theoretical fidelity
- Paying attention to quality control
• Dose-response issues. Dose-response, in this context, means that more media exposure typically results in increased physical activity behavior, increased satisfaction with program components, or both. Mediated interventions, if used correctly, can reach large numbers of people in a cost-effective manner. Exposure to media is measured in weekly gross rating points (GRP). One GRP means that 1% of the target audience viewed the advertisement once. Obviously, higher GRPs are more likely to result in a successful campaign (i.e., reach large numbers of people).
• Memorable campaign slogans. A second key to developing a successful mediated campaign is to develop and use memorable and reproducible images. Most people interested in physical activity will remember Nike's most memorable ad campaigns: "Just Do It," "If you let me play . . .," and the recent ads in conjunction with the women's World Cup soccer tournament ("The greatest team you've never heard of"). The average American is exposed to 3,000 ads per day (Peterson, Abraham, & Waterfield, 2005); therefore, media must be memorable to make an impact.
• Market segmentation. Market segmentation refers to designing marketing strategies for a specific segment of the population. Designing campaigns so they will reach various age or ethnic groups or men or women is an important strategy because what works for one segment of the population may be offensive or nonmeaningful to another (Peterson, Abraham, & Waterfield, 2005). To ensure memorable messages and accurate market segmentation, program promoters should pilot test campaign slogans and designs with the target audience. In addition to pilot testing, it is important to continually seek feedback, preferably from a local advisory committee, to refine and improve a media message as necessary. When possible, booster campaigns should be administered to sustain a promotional effort beyond the life of the initial campaign (Reger et al., 2002).
• Personalization strategies. Similar to market segmentation (or personalizing a message to reach a target audience), Marcus and colleagues (1998) suggested that one of the most important factors contributing to a successful mediated program is identifying and including relevant attributes of role models. For example, if a message is designed to reach young African Americans in a community, then characteristics and attributes of young African Americans and representative role models should be included in that message. To ascertain what these characteristics are and what information might be meaningful to that group, members of the relevant group should be surveyed and included
in a pilot testing process. The bottom line is that if people can personalize a message, they are more likely to internalize and act on it. Additional factors that can help facilitate program success are (a) tailoring information to a specific stage of change (such as the contemplation stage in the transtheoretical model), (b) updating the stage of change regularly; and (c) using reinforcement letters, phone calls, or e-mails regularly (e.g., biweekly) (Marshall et al., 2003).
• Targeting multiple areas of the media. Numerous media outlets are available for health and fitness-related messages (e.g., billboards, buses, signs, television, radio, Internet, and newspaper) (Peterson et al., 2005). A good example of creative media blitzing is using point-of-decision prompts. Point-of-decision prompts are reminders in the form of signs, bulletin boards, billboards, or bus signs that encourage people to take advantage of physical activity opportunities when they arise (Marcus et al., 1998). Some examples of point-of-decision prompts that work include Use the Stairs and Park and Walk (Marcus et al., 1998).
• Theoretical fidelity. Theoretical fidelity refers to the precision with which theory-based recommendations are used. Rovniak and colleagues (2005) tested the effectiveness of high- and low-fidelity e-mail-based walking interventions in 65 sedentary adults, mostly women. One 12-week intervention, which demonstrated high fidelity to the social cognitive theory (SCT), used targeted skills, specific and hierarchical goals, and precise self-monitoring and feedback. The other intervention, which demonstrated low fidelity to the SCT, provided information (rather than modeling) to teach skills and did not provide ongoing self-monitoring and feedback. Several outcomes were monitored before and after the intervention, including a 1-mile (1.6 km) walk test of physical fitness, a log of walking behavior, and several measures of social cognitive theory (e.g., exercise self-efficacy, benefits and enjoyment of physical activity, goal setting, exercise planning, and social support). Compared to those in the low-fidelity group, those in the high-fidelity group completed more of their prescribed walking sessions and walked faster at posttest. Those in the high-fidelity group also reported greater program satisfaction and increased their goal setting and positive outcome expectations for walking more than twice as much as those in the low-fidelity group. Clearly, efforts to ensure theoretical fidelity are important for improving the success of mediated interventions.
• Quality control. Quality control, or attention to clarity, accuracy, and timeliness, is important. Information must be of high quality to earn respect, reach the critical mass, and facilitate changes in physical activity behavior (Marcus et al., 1998). Although obesity prevention and physical activity promotion are multimillion-dollar industries, it is not right to promise something that cannot be delivered. Failure to deliver programs based on factual information may result in an ineffective and disrespected program.
Factors Related to Success in Specific Mass Media Programs
The mass media has the potential to reach large numbers of people in a short period of time for a relatively low cost. To maximize this opportunity and ensure that mass media programs are successful, Cavill and Bauman (2004) recommend the following strategies:
- The mass media should target multiple media outlets in a systematic and sustained fashion.
- Campaigns should maximize contact or message exposure, because doing so typically results in greater behavior change.
- Other supportive community activities should be organized around mass media messages (e.g., self-help groups, counseling, screening and education, community events, and walking trails).
- The message coming from the mass media should be singular and simple-so it will be memorable.
- Mass media campaigns should target a specific audience or audiences based on demographics, attitudes, and preferred media usage; this will ensure that the message is heard by those for whom it is designed.
Print-Based Programs Those designing physical activity programs are probably most familiar with print-based handouts. Print handouts have been around longer than other means of media, and they are probably still the most common method of promoting increased physical activity. Distributors of print media should use some of the suggestions provided earlier for all mediated interventions, while also considering specific recommendations for this medium. Following are some suggestions for designing a successful print-based program (Napolitano & Marcus, 2002):
- Follow up with participants quickly after distributing print material.
- Provide opportunities for participants to find interactions with others because social support is a desirable feature of many physical activity programs.
- Make sure the information is concise, accurate, and specifically directed to the targeted population.
- Pilot test materials with members of the targeted population.
- Write materials to a level appropriate for the targeted population.
Phone-Based Programs Phone-based programs are delivered as phone calls or text messages. The following recommendations can help ensure that a phone-based program is successful:
- Consider the purpose of the contact (e.g., touching base, structured, or automated with prompts); studies have demonstrated that phone calls designed to touch base were just as effective as contacts that were highly structured (Lombard, Lombard, & Winett, 1995, as cited in Marcus et al., 1998).
- Consider the frequency with which phone calls or text messages are delivered. Schultz (1993) concluded that adherence and frequency of phone contacts are positively correlated, although there is probably a point at which a high frequency of phone contacts becomes a nuisance.
- Be as specific as possible with feedback (e.g., overcoming barriers, the benefits of exercise that are motivating to that participant, the type of activity the participant enjoyed) to facilitate maximal change (Hurling et al., 2007).
Although phone-based interventions have been around for a while, the use of text messaging to prompt physical activity is a relatively new means of communicating using mediated technology. Given the increase in text messaging in this country, this technology offers significant potential for reaching many people.
Web-Based Programs Web-based programs demand a significant time investment prior to implementation. To ensure that Web-based programs are designed successfully, Ferney and Marshall (2006) recommended considering four factors that are important to Web site users in the field of physical activity promotion: Web design (structure), interactivity, environmental context, and content.
- Web design. To be maximally useful, Web sites should be easy to navigate and download time should be minimal (Ferney & Marshall, 2006). Users should be able to navigate a Web site easily, and links should be intuitive and downloadable in no more than 10 seconds. Making Web sites password protected facilitates tracking people's use around the site. Web site designers should conduct pilot and usability tests with proposed and developing Web sites and correct any problems found.
- Interactivity. A Web site that facilitates information exchange between a participant and an intervention specialist is interactive. Following are some examples of interactive activities on a PA Web site (Ferney & Marshall, 2006; Hurling et al., 2006):
• Logging on to a Web site to report activity or set goals
• Receiving specific feedback about one's performance compared to others or a previous best effort
• Accessing social support and expert advice
• Calculating target heart rate
• Accessing information about local community events
• Identifying barriers and receiving feedback about ways to overcome them
According to experts (Bull, Kreuter, & Scharff, 1999; Ferney & Marshall, 2006; Fogg, 2003; Hurling et al., 2006; Tate, Wing, & Winett, 2001; Wantland et al., 2004), interactive Web sites are more effective than non-interactive sites because they
• are more enjoyable to use,
• are less impersonal,
• facilitate better user retention and longer Web sessions,
• create higher expectations for exercise,
• facilitate higher levels of motivation and improved self-perception of fitness,
• are more likely to be saved and revisited in the future,
• are more likely to be discussed with others, and
• result in real behavior change with regular visitations.
- Environmental context. Providing information such as an updated community calendar of events; maps of physical activity opportunities in the community; and a physical activity database with information about times, costs, deadlines, and facilities (Ferney & Marshall, 2006) are examples of considering the environmental context. This information should be updated regularly to facilitate the desire to visit the Web site.
- Content. Information presented on the Web as audio, video, or text is known as content. It is important to update Web site content as often as possible. Those who use the Web frequently do not like to read volumes of text or wade through repetitive information, and they do not like to visit Web sites and see the same information over and over.
Podcasting Research is sparse on the factors related to success with podcasting-especially as it relates to increasing physical activity. However, until more research is conducted, the following basic strategies can help ensure that podcasts are successful (Eads, 2007; Hartman & Jackson, 2007):
- Be aware that those in the iPod generation are typically young and technologically savvy.
- When possible, provide the means for interaction with others.
- Pilot test podcasts with members of the target population.
- Make sure podcasts are simple and easy to download with a computer.
Sample Successful Program
Active Living (Web and Print)
Active Living is an 8-week Web-based program that evolved from a print-based program (Marshall et al., 2003). This program assessed stage of change (according to the transtheoretical model) and featured personalized Web links to sites on goal setting, activity planning, and determining target heart rate. People who participated in this project were regularly reassessed to ensure that their Web information was tailored to their specific stage of change. The Web information was supplemented with personalized and stage-based reinforcement e-mails sent every 2 weeks. These e-mails contained hyperlinks to relevant areas of the Active Living Web site. The print information for this intervention was identical to the information found in the Web-based program except that people receiving the print materials received supplemental letters with stage-matched information every 2 weeks.
The impact of the intervention was assessed by comparing baseline and postintervention physical activity data: (a) MET-minutes per week and minutes in specific categories of activity (e.g., vigorous, moderate, and seated activities), collected with the International PA Questionnaire (IPAQ), (b) meeting or not meeting the public health recommendation (i.e., 30 minutes of at least moderate physical activity most days of the week), and (c) stage of change in the transtheoretical model. Results of the study indicate that Web interven tion participants reported a decrease in the amount of time spent sitting, and print-based intervention participants increased their total minutes of physical activity. About 26% of the participants in both groups progressed forward at least one stage of change in the transtheoretical model, indicating that they should be likely to continue being physically active in the future. It is interesting to note that both print- and Web-based programs facilitated increases in physical activity, although people in the print group reported larger increases in activity and they were better able to recognize intervention materials after the program was completed.
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Confidence and positive attitude help older adults stick with exercise
To develop effective older adult physical activity interventions, it is important to understand factors that predict participation and adherence.
Because the majority of older adults clearly can engage in physical activity safely, a growing body of research has been conducted to identify effective programs for increasing physical activity in this population (Brawley, Rejeski, & King, 2003; Taylor et al., 2004; U.S. Department of Health and Human Services, 1996). However, increasing older adult physical activity participation presents unique challenges. Although some programs have been effective in the short term, the effectiveness of long-term physical activity programs has been limited (Brawley, Rejeski, & King, 2003; Taylor et al., 2004).
Factors Related to Successful Physical Activity Interventions
To develop effective older adult physical activity interventions, it is important to understand factors that predict participation and adherence. Numerous research studies have investigated correlates of older adult physical activity participation (Benjamin, Edwards, & Baharti, 2005; Brassington, Atienza, Perczek, DiLorenzo, & King 2002; Hays & Clark, 1999; Lee & Lafferty, 2006; Stuart, Marret, Kelly, & Nelson, 2002). Although many factors influence the participation rates of older adults, we will examine the following, which demonstrate the greatest potential for increasing physical activity:
- Psychological factors of self-efficacy, self-regulation, positive attitudes toward physical activity, and social support
- Health care provider referral
- Physical activity intensity
- Group- and home-based interventions
- Disease management
Psychological Factors
As with other populations, self-efficacy, or the confidence a person has to perform an activity, is one of the strongest determinants of physical activity for older adults (Brassington et al., 2002; Resnick, Orwig, Magaziner, & Wynne, 2002; Schutzer & Graves, 2004). Interventions should help older adults build their confidence through mastery of the physical activity. This can be achieved by beginning the intervention at a low intensity and gradually increasing the intensity over time. This gradual increase is especially important for frail older adults. Improvements in fitness and or health that result from physical activity will also enhance self-efficacy.
To promote long-term adherence to physical activity, interventions need to be designed so older adults move from a supervised, or center-based, setting to the home, where they can use self-regulation skills to make physical activity part of their lifestyle (Rejeski & Brawley, 2006). Behavioral counseling is one method that can be used to help older adults transition from center-based to home-based activity. Through counseling, older adults can develop a plan of action for making physical activity a part of their daily routine.
Having a positive attitude toward physical activity is another factor influencing older adult participation (Stuart et al., 2002). If the activity is positive and enjoyable, older adults will be more likely to continue to exercise. Past participation is also a predictor of future participation (Benjamin et al., 2005). For those who have had a negative attitude toward physical activity, strategies such as providing positive images depicting the activity with role models who may have similar limitations can be used to entice older adults to participate.
Receiving positive reinforcement or social support from friends and family is also one of the predictors of physical activity involvement in the older adult population (Booth, Owen, Bauman, Clavisi, & Leslie 2002; McAuley, Jerome, Elavvsky, Marquez, & Ramsey, 2003; Resnick et al., 2002). Litt, Kepplinger, and Judge (2002) found that social support is a strong determinant of physical activity particularly for older women. In addition, positive comments help strengthen people's self-efficacy and can enhance exercise adherence. Programs need to be carefully designed to create a positive environment. In residential care facilities, older adults may have limited contact with family members; thus, support from friends may be more important.
Health Care Provider Referrals
Receiving a recommendation from a physician to exercise is another important positive predictor of physical activity in the older adult population (Benjamin et al., 2005; Navarro, Sanz, del Castillo, Izquierdo, & Rodriguez, 2007; Stuart et al., 2002). Having a health care provider "prescribe" exercise helps older adults overcome their fear of being injured during the physical activity. This type of prescription may be especially important for physically frail older adults (Benjamin et al., 2005). More research needs to be conducted in this area to determine the most effective type of physician advice and the amount of contact needed with the older adult to improve physical activity levels.
Physical Activity Intensity
Older adults are more likely to participate in low- to moderate-intensity physical activity (Brawley et al., 2003; Taylor et al., 2004) such as light housework, chair exercises, and walking. Lower-intensity activity is less likely to cause injuries and is often perceived as less threatening, especially to older adults who have functional disabilities or limitations. Although interventions should to be tailored to the ability level of the participant, planners must also recognize that low-intensity exercises conducted in a chair may have few functional benefits for the older adult. Specificity of the exercise is the issue. If the goal is to improve mobility and balance, exercises should be conducted while participants are standing and walking. Physical activity interventions that begin at lower intensities should progress over time to moderate intensities.
Group- and Home-Based Interventions
Physical activity interventions can be designed to be group based, home based, or a combination of both. Group-based interventions require participants to go to a facility or center where the activity program is usually supervised. For typical home-based interventions, the physical activity occurs at the older adult's home, and contact with the practitioner is minimal. Combination designs usually begin with a few weeks of group-based instruction followed by a period of home-based activity. Table 6.1 lists some of the positive and negative aspects of group- and home-based interventions.
Research has demonstrated that both home-based and group-based physical activity interventions can be successful with the older adult population (Campbell, Robertson, Gardner, Norton, & Buchner, 1999; King, Haskell, Taylor, Kraemer, & Debusk, 1991; King, Haskell, Young, Oka, & Stefanic, 1995; McMurdo & Rennie, 1993; van der Bij, Laurant, & Wensing, 2002). One study found similar participation rates in both home- and group-based environments for short-term programs; however, adherence rates tended to decrease as the length of the study increased (King et al., 1995; van der Bij et al., 2002). The use of behavioral strategies including phone calls and various incentives may help improve long-term participation rates. More research should be conducted using a combination of group- and home-based environments to determine which programs work best for which population.
Disease Management
Disease management, in the context of this chapter, is using physical activity as a strategy to prevent disease and maintain favorable health status. Studies have found that mobile older adults who have few or no limitations view physical activity as a way to maintain their health (Cohen-Mansfield, Marx, & Guralnick, 2003; Rasinaho, Herninalo, Leinonen, Linutenen, & Rantinen, 2006). Older adults with higher self-efficacy and a motivation to improve their health are more likely to be physically active than those with lower self-efficacy and little motivation to improve their health (Lee & Lafferty, 2006). Increased self-efficacy may help older adults overcome barriers that prevent them from engaging in physical activity. Physical activity can help all adults, both the young and the old, avoid chronic diseases.
When planning physical activity interventions for older adults, planners should consider factors that will improve participation and adherence. This section highlighted just a few of the factors that typically result in success. Intervention specialists are encouraged to use these strategies to overcome barriers to physical activity in older adults.
Sample Successful Interventions
Home-Based Progressive Strength Training
Osteoarthritis is a common ailment that causes pain, reduces functional abilities, and limits physical activity for many older adults. Baker and colleagues (2001) investigated the effectiveness of home-based strength training for improving symptoms of knee osteoarthritis in a group of 46 adults over the age of 55. Participants were randomized into a nutritional education control group or home-based strength training group. The home-based strength group trained for 4 months. Intervention participants received in-home visits twice a week for 3 weeks, one in the 4th week and every other week thereafter. Compared to the control group, the home-based training group significantly improved in strength, pain reduction, physical function, and quality of life. These important gains highlight the need for home-based programs designed to reduce pain and other osteoarthritis symptoms and improve older adult physical function.
Walk; Address Pain, Fear, Fatigue During Exercise; Learn About Exercise; Cue by Self-Modeling (WALC)
WALC was designed to address some of the common barriers older adults have relative to physical activity (Resnick, 2002). Twenty sedentary participants were divided into treatment or control groups. The treatment group followed the four phases of the WALC program. They were asked to walk in groups or individually for 20 minutes three times per week for 6 months. The intervention group received regular visits from a practitioner who addressed unpleasant reactions associated with exercise (i.e., addressed pain, fear, fatigue during exercise). This part of the intervention included pain management techniques, relaxation methods, and scheduling of rest and exercise. Those in the treatment groups were given a book about exercise benefits and barriers and received assistance developing short- and long-term goals, planning exercise sessions, and logging their results (i.e., learned about exercise).
When compared to the controls, the treatment group demonstrated significant improvement in exercise behavior, physical activity levels, and self-efficacy expectations. Although the number of participants used in this study was small, the results indicate that physical activity levels can be increased with the sedentary older adult population by using techniques to improve self-efficacy, which can mediate common exercise barriers.
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Effective use of mediated programming in physical activity interventions
As the influence of technology continues to increase, those interested in promoting physical activity should consider developing physical activity programs that effectively use technology.
Using technology or intervention techniques that are not delivered face-to-face is known as mediated program delivery (Marshall, Owen, & Bauman, 2004). Because of the ability to reach large numbers of people with relatively low cost, mediated programs in our field have increased dramatically. Wantland, Portillo, Holzemer, Slaughter, and McGhee (2004) reported that during a 7-year period (1996-2003), there was a 12-fold increase in MEDLINE citations for "Web-based therapies". Some examples of mediated program delivery include using email to contact program participants, using the Internet to track activity or seek social support or program feedback from group leaders, or offering podcasts or Web-streamed videos to provide access to important program information.
Factors Related to Successful Mediated Physical Activity Interventions
Factors related to successful mediated physical activity interventions fall into two categories: (a) general and relevant for all types of mediated interventions and (b) specific and relevant to only certain types of mediated interventions. Both are addressed in this section. Designers of interventions should consider both general and specific aspects when planning mediated programs.
General Factors Related to Success in All Mediated Interventions
The following six factors are related to success with any type of mediated intervention, regardless of medium:
- Increasing dose-response
- Designing memorable campaign slogans and information
- Using market segmentation and message personalization strategies
- Targeting multiple media outlets
- Ensuring theoretical fidelity
- Paying attention to quality control
• Dose-response issues. Dose-response, in this context, means that more media exposure typically results in increased physical activity behavior, increased satisfaction with program components, or both. Mediated interventions, if used correctly, can reach large numbers of people in a cost-effective manner. Exposure to media is measured in weekly gross rating points (GRP). One GRP means that 1% of the target audience viewed the advertisement once. Obviously, higher GRPs are more likely to result in a successful campaign (i.e., reach large numbers of people).
• Memorable campaign slogans. A second key to developing a successful mediated campaign is to develop and use memorable and reproducible images. Most people interested in physical activity will remember Nike's most memorable ad campaigns: "Just Do It," "If you let me play . . .," and the recent ads in conjunction with the women's World Cup soccer tournament ("The greatest team you've never heard of"). The average American is exposed to 3,000 ads per day (Peterson, Abraham, & Waterfield, 2005); therefore, media must be memorable to make an impact.
• Market segmentation. Market segmentation refers to designing marketing strategies for a specific segment of the population. Designing campaigns so they will reach various age or ethnic groups or men or women is an important strategy because what works for one segment of the population may be offensive or nonmeaningful to another (Peterson, Abraham, & Waterfield, 2005). To ensure memorable messages and accurate market segmentation, program promoters should pilot test campaign slogans and designs with the target audience. In addition to pilot testing, it is important to continually seek feedback, preferably from a local advisory committee, to refine and improve a media message as necessary. When possible, booster campaigns should be administered to sustain a promotional effort beyond the life of the initial campaign (Reger et al., 2002).
• Personalization strategies. Similar to market segmentation (or personalizing a message to reach a target audience), Marcus and colleagues (1998) suggested that one of the most important factors contributing to a successful mediated program is identifying and including relevant attributes of role models. For example, if a message is designed to reach young African Americans in a community, then characteristics and attributes of young African Americans and representative role models should be included in that message. To ascertain what these characteristics are and what information might be meaningful to that group, members of the relevant group should be surveyed and included
in a pilot testing process. The bottom line is that if people can personalize a message, they are more likely to internalize and act on it. Additional factors that can help facilitate program success are (a) tailoring information to a specific stage of change (such as the contemplation stage in the transtheoretical model), (b) updating the stage of change regularly; and (c) using reinforcement letters, phone calls, or e-mails regularly (e.g., biweekly) (Marshall et al., 2003).
• Targeting multiple areas of the media. Numerous media outlets are available for health and fitness-related messages (e.g., billboards, buses, signs, television, radio, Internet, and newspaper) (Peterson et al., 2005). A good example of creative media blitzing is using point-of-decision prompts. Point-of-decision prompts are reminders in the form of signs, bulletin boards, billboards, or bus signs that encourage people to take advantage of physical activity opportunities when they arise (Marcus et al., 1998). Some examples of point-of-decision prompts that work include Use the Stairs and Park and Walk (Marcus et al., 1998).
• Theoretical fidelity. Theoretical fidelity refers to the precision with which theory-based recommendations are used. Rovniak and colleagues (2005) tested the effectiveness of high- and low-fidelity e-mail-based walking interventions in 65 sedentary adults, mostly women. One 12-week intervention, which demonstrated high fidelity to the social cognitive theory (SCT), used targeted skills, specific and hierarchical goals, and precise self-monitoring and feedback. The other intervention, which demonstrated low fidelity to the SCT, provided information (rather than modeling) to teach skills and did not provide ongoing self-monitoring and feedback. Several outcomes were monitored before and after the intervention, including a 1-mile (1.6 km) walk test of physical fitness, a log of walking behavior, and several measures of social cognitive theory (e.g., exercise self-efficacy, benefits and enjoyment of physical activity, goal setting, exercise planning, and social support). Compared to those in the low-fidelity group, those in the high-fidelity group completed more of their prescribed walking sessions and walked faster at posttest. Those in the high-fidelity group also reported greater program satisfaction and increased their goal setting and positive outcome expectations for walking more than twice as much as those in the low-fidelity group. Clearly, efforts to ensure theoretical fidelity are important for improving the success of mediated interventions.
• Quality control. Quality control, or attention to clarity, accuracy, and timeliness, is important. Information must be of high quality to earn respect, reach the critical mass, and facilitate changes in physical activity behavior (Marcus et al., 1998). Although obesity prevention and physical activity promotion are multimillion-dollar industries, it is not right to promise something that cannot be delivered. Failure to deliver programs based on factual information may result in an ineffective and disrespected program.
Factors Related to Success in Specific Mass Media Programs
The mass media has the potential to reach large numbers of people in a short period of time for a relatively low cost. To maximize this opportunity and ensure that mass media programs are successful, Cavill and Bauman (2004) recommend the following strategies:
- The mass media should target multiple media outlets in a systematic and sustained fashion.
- Campaigns should maximize contact or message exposure, because doing so typically results in greater behavior change.
- Other supportive community activities should be organized around mass media messages (e.g., self-help groups, counseling, screening and education, community events, and walking trails).
- The message coming from the mass media should be singular and simple-so it will be memorable.
- Mass media campaigns should target a specific audience or audiences based on demographics, attitudes, and preferred media usage; this will ensure that the message is heard by those for whom it is designed.
Print-Based Programs Those designing physical activity programs are probably most familiar with print-based handouts. Print handouts have been around longer than other means of media, and they are probably still the most common method of promoting increased physical activity. Distributors of print media should use some of the suggestions provided earlier for all mediated interventions, while also considering specific recommendations for this medium. Following are some suggestions for designing a successful print-based program (Napolitano & Marcus, 2002):
- Follow up with participants quickly after distributing print material.
- Provide opportunities for participants to find interactions with others because social support is a desirable feature of many physical activity programs.
- Make sure the information is concise, accurate, and specifically directed to the targeted population.
- Pilot test materials with members of the targeted population.
- Write materials to a level appropriate for the targeted population.
Phone-Based Programs Phone-based programs are delivered as phone calls or text messages. The following recommendations can help ensure that a phone-based program is successful:
- Consider the purpose of the contact (e.g., touching base, structured, or automated with prompts); studies have demonstrated that phone calls designed to touch base were just as effective as contacts that were highly structured (Lombard, Lombard, & Winett, 1995, as cited in Marcus et al., 1998).
- Consider the frequency with which phone calls or text messages are delivered. Schultz (1993) concluded that adherence and frequency of phone contacts are positively correlated, although there is probably a point at which a high frequency of phone contacts becomes a nuisance.
- Be as specific as possible with feedback (e.g., overcoming barriers, the benefits of exercise that are motivating to that participant, the type of activity the participant enjoyed) to facilitate maximal change (Hurling et al., 2007).
Although phone-based interventions have been around for a while, the use of text messaging to prompt physical activity is a relatively new means of communicating using mediated technology. Given the increase in text messaging in this country, this technology offers significant potential for reaching many people.
Web-Based Programs Web-based programs demand a significant time investment prior to implementation. To ensure that Web-based programs are designed successfully, Ferney and Marshall (2006) recommended considering four factors that are important to Web site users in the field of physical activity promotion: Web design (structure), interactivity, environmental context, and content.
- Web design. To be maximally useful, Web sites should be easy to navigate and download time should be minimal (Ferney & Marshall, 2006). Users should be able to navigate a Web site easily, and links should be intuitive and downloadable in no more than 10 seconds. Making Web sites password protected facilitates tracking people's use around the site. Web site designers should conduct pilot and usability tests with proposed and developing Web sites and correct any problems found.
- Interactivity. A Web site that facilitates information exchange between a participant and an intervention specialist is interactive. Following are some examples of interactive activities on a PA Web site (Ferney & Marshall, 2006; Hurling et al., 2006):
• Logging on to a Web site to report activity or set goals
• Receiving specific feedback about one's performance compared to others or a previous best effort
• Accessing social support and expert advice
• Calculating target heart rate
• Accessing information about local community events
• Identifying barriers and receiving feedback about ways to overcome them
According to experts (Bull, Kreuter, & Scharff, 1999; Ferney & Marshall, 2006; Fogg, 2003; Hurling et al., 2006; Tate, Wing, & Winett, 2001; Wantland et al., 2004), interactive Web sites are more effective than non-interactive sites because they
• are more enjoyable to use,
• are less impersonal,
• facilitate better user retention and longer Web sessions,
• create higher expectations for exercise,
• facilitate higher levels of motivation and improved self-perception of fitness,
• are more likely to be saved and revisited in the future,
• are more likely to be discussed with others, and
• result in real behavior change with regular visitations.
- Environmental context. Providing information such as an updated community calendar of events; maps of physical activity opportunities in the community; and a physical activity database with information about times, costs, deadlines, and facilities (Ferney & Marshall, 2006) are examples of considering the environmental context. This information should be updated regularly to facilitate the desire to visit the Web site.
- Content. Information presented on the Web as audio, video, or text is known as content. It is important to update Web site content as often as possible. Those who use the Web frequently do not like to read volumes of text or wade through repetitive information, and they do not like to visit Web sites and see the same information over and over.
Podcasting Research is sparse on the factors related to success with podcasting-especially as it relates to increasing physical activity. However, until more research is conducted, the following basic strategies can help ensure that podcasts are successful (Eads, 2007; Hartman & Jackson, 2007):
- Be aware that those in the iPod generation are typically young and technologically savvy.
- When possible, provide the means for interaction with others.
- Pilot test podcasts with members of the target population.
- Make sure podcasts are simple and easy to download with a computer.
Sample Successful Program
Active Living (Web and Print)
Active Living is an 8-week Web-based program that evolved from a print-based program (Marshall et al., 2003). This program assessed stage of change (according to the transtheoretical model) and featured personalized Web links to sites on goal setting, activity planning, and determining target heart rate. People who participated in this project were regularly reassessed to ensure that their Web information was tailored to their specific stage of change. The Web information was supplemented with personalized and stage-based reinforcement e-mails sent every 2 weeks. These e-mails contained hyperlinks to relevant areas of the Active Living Web site. The print information for this intervention was identical to the information found in the Web-based program except that people receiving the print materials received supplemental letters with stage-matched information every 2 weeks.
The impact of the intervention was assessed by comparing baseline and postintervention physical activity data: (a) MET-minutes per week and minutes in specific categories of activity (e.g., vigorous, moderate, and seated activities), collected with the International PA Questionnaire (IPAQ), (b) meeting or not meeting the public health recommendation (i.e., 30 minutes of at least moderate physical activity most days of the week), and (c) stage of change in the transtheoretical model. Results of the study indicate that Web interven tion participants reported a decrease in the amount of time spent sitting, and print-based intervention participants increased their total minutes of physical activity. About 26% of the participants in both groups progressed forward at least one stage of change in the transtheoretical model, indicating that they should be likely to continue being physically active in the future. It is interesting to note that both print- and Web-based programs facilitated increases in physical activity, although people in the print group reported larger increases in activity and they were better able to recognize intervention materials after the program was completed.
Learn more about Developing Effective Physical Activity Programs.
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