Promoting older peoples' participation in activity, whose responsibility? A case study of the response of health, local government and voluntary organizations

Interventions to Promote Physical Activity and Healthy Ageing: An Editorial

The Healthy Ageing Challenge aims for people to enjoy at least five extra healthy, independent years of life by 2035, while narrowing the gap between the experiences of the richest and poorest [...].

Changes in anthropometric parameters and physical fitness in older adults after participating in a 16-week physical activity program

Introduction: Physical activity is important for achieving healthy aging. Objective: To analyze changes in anthropometric parameters and physical fitness among Chilean older adults after participating in a 16-week physical activity program and to evaluate whether there were differences in relation to their baseline nutritional status or not. Materials and methods: Pre-experimental quantitative study. The study population consisted of 176 older adults (155 women and 21 men) distributed in three groups: normal weight (n=56), overweight (n=67) and obese (n=53). The following variables were evaluated: body mass index (BMI), waist circumference (WC), waist-to-height ratio (WHR) and physical fitness. Results: Significant decreases between pre- and post-measurements were found for WC (p<0.001), BMI (p=0.015), and WHR (p<0.001). Improvements were observed in the following tests: chair stand (p<0.001), arm curl (p<0.001), 2-min step (p<0.001), chair sit-&-reach (p=0.018) and back scratch (p=0.014). Regarding BMI, significant changes were observed between normal weight vs. overweight participants (p=0.001) and between normal weight vs. obese participants (p=0.001). Conclusion: Older adult participants that regularly attended the physical activity program were able to reduce their WC, BMI and WHR, and also improved their physical-functional performance on the chair stand, arm curl, 2-min step, chair sit-&-reach and back scratch tests. In addition, anthropometric parameters and physical fitness also improved regardless of their baseline nutritional status.  

A pedometer-based walking intervention in 45- to 75-year-olds, with and without practice nurse support: the PACE-UP three-arm cluster RCT

BACKGROUND

Guidelines recommend walking to increase moderate to vigorous physical activity (MVPA) for health benefits.

OBJECTIVES

To assess the effectiveness, cost-effectiveness and acceptability of a pedometer-based walking intervention in inactive adults, delivered postally or through dedicated practice nurse physical activity (PA) consultations.

DESIGN

Parallel three-arm trial, cluster randomised by household.

SETTING

Seven London-based general practices.

PARTICIPANTS

A total of 11,015 people without PA contraindications, aged 45-75 years, randomly selected from practices, were invited. A total of 6399 people were non-responders, and 548 people self-reporting achieving PA guidelines were excluded. A total of 1023 people from 922 households were randomised to usual care (n = 338), postal intervention (n = 339) or nurse support (n = 346). The recruitment rate was 10% (1023/10,467). A total of 956 participants (93%) provided outcome data.

INTERVENTIONS

Intervention groups received pedometers, 12-week walking programmes advising participants to gradually add '3000 steps in 30 minutes' most days weekly and PA diaries. The nurse group was offered three dedicated PA consultations.

MAIN OUTCOME MEASURES

The primary and main secondary outcomes were changes from baseline to 12 months in average daily step counts and time in MVPA (in ≥ 10-minute bouts), respectively, from 7-day accelerometry. Individual resource-use data informed the within-trial economic evaluation and the Markov model for simulating long-term cost-effectiveness. Qualitative evaluations assessed nurse and participant views. A 3-year follow-up was conducted.

RESULTS

Baseline average daily step count was 7479 [standard deviation (SD) 2671], average minutes per week in MVPA bouts was 94 minutes (SD 102 minutes) for those randomised. PA increased significantly at 12 months in both intervention groups compared with the control group, with no difference between interventions; additional steps per day were 642 steps [95% confidence interval (CI) 329 to 955 steps] for the postal group and 677 steps (95% CI 365 to 989 steps) for nurse support, and additional MVPA in bouts (minutes per week) was 33 minutes per week (95% CI 17 to 49 minutes per week) for the postal group and 35 minutes per week (95% CI 19 to 51 minutes per week) for nurse support. Intervention groups showed no increase in adverse events. Incremental cost per step was 19p and £3.61 per minute in a ≥ 10-minute MVPA bout for nurse support, whereas the postal group took more steps and cost less than the control group. The postal group had a 50% chance of being cost-effective at a £20,000 per quality-adjusted life-year (QALY) threshold within 1 year and had both lower costs [-£11M (95% CI -£12M to -£10M) per 100,000 population] and more QALYs [759 QALYs gained (95% CI 400 to 1247 QALYs)] than the nurse support and control groups in the long term. Participants and nurses found the interventions acceptable and enjoyable. Three-year follow-up data showed persistent intervention effects (nurse support plus postal vs. control) on steps per day [648 steps (95% CI 272 to 1024 steps)] and MVPA bouts [26 minutes per week (95% CI 8 to 44 minutes per week)].

LIMITATIONS

The 10% recruitment level, with lower levels in Asian and socioeconomically deprived participants, limits the generalisability of the findings. Assessors were unmasked to the group.

CONCLUSIONS

A primary care pedometer-based walking intervention in 45- to 75-year-olds increased 12-month step counts by around one-tenth, and time in MVPA bouts by around one-third, with similar effects for the nurse support and postal groups, and persistent 3-year effects. The postal intervention provides cost-effective, long-term quality-of-life benefits. A primary care pedometer intervention delivered by post could help address the public health physical inactivity challenge.

FUTURE WORK

Exploring different recruitment strategies to increase uptake. Integrating the Pedometer And Consultation Evaluation-UP (PACE-UP) trial with evolving PA monitoring technologies.

TRIAL REGISTRATION

Current Controlled Trials ISRCTN98538934.

FUNDING

This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 22, No. 37. See the NIHR Journals Library website for further project information.

Effects of Physical Activity Governmental Programs on Health Status in Independent Older Adults: A Systematic Review

This systematic review analyzes the evidence of the effects of physical activity governmental programs oriented toward the health of independent older adults. Medline, Web of Science, PsycINFO, and Psychology & Behavioral Sciences Collection databases were used for data mining, and the Preferred Reporting Items for Systematic Review and Meta-Analysis Protocols recommendations were followed. Five studies (n = 2,545 participants) fulfilled the established inclusion criteria. The physical activity programs had beneficial effects on the older adults' quality of life, fall risk, activities of daily living, physical activity levels, nutritional risk, body mass index, arterial pressure, resting heart rate, blood glucose, triglycerides, and/or cholesterol, but did not significantly alter their body fat mass percentage. Programs involving diverse physical capacities seem to be more effective for healthy aging. It is recommended that governments start to disseminate the outcomes of these programs within society and the scientific community.

PACE-UP (Pedometer and consultation evaluation--UP)--a pedometer-based walking intervention with and without practice nurse support in primary care patients aged 45-75 years: study protocol for a randomised controlled trial

BACKGROUND

Most adults do not achieve the 150 minutes weekly of at least moderate intensity activity recommended for health. Adults' most common physical activity (PA) is walking, light intensity if strolling, moderate if brisker. Pedometers can increase walking; however, most trials have been short-term, have combined pedometer and support effects, and have not reported PA intensity. This trial will investigate whether pedometers, with or without nurse support, can help less active 45-75 year olds to increase their PA over 12 months.

METHODS/DESIGN

DESIGN

Primary care-based 3-arm randomized controlled trial with 12-month follow-up and health economic and qualitative evaluations.

PARTICIPANTS

Less active 45-75 year olds (n = 993) will be recruited by post from six South West London general practices, maximum of two per household and households randomised into three groups. Step-count and time spent at different PA intensities will be assessed for 7 days at baseline, 3 and 12 months by accelerometer. Questionnaires and anthropometric assessments will be completed.

INTERVENTION

The pedometer-alone group will be posted a pedometer (Yamax Digi-Walker SW-200), handbook and diary detailing a 12-week pedometer-based walking programme, using targets from their baseline assessment. The pedometer-plus-support group will additionally receive three practice nurse PA consultations. The handbook, diary and consultations include behaviour change techniques (e.g., self-monitoring, goal-setting, relapse prevention planning). The control group will receive usual care.

OUTCOMES

Changes in average daily step-count (primary outcome), time spent sedentary and in at least moderate intensity PA weekly at 12 months, measured by accelerometry. Other outcomes include change in body mass index, body fat, self-reported PA, quality of life, mood and adverse events. Cost-effectiveness will be assessed by the incremental cost of the intervention to the National Health Service and incremental cost per change in step-count and per quality adjusted life year. Qualitative evaluations will explore reasons for trial non-participation and the interventions' acceptability.

DISCUSSION

The PACE-UP trial will determine the effectiveness and cost-effectiveness of a pedometer-based walking intervention delivered by post or practice nurse to less active primary care patients aged 45-75 years old. Approaches to minimise bias and challenges anticipated in delivery will be discussed.

TRIAL REGISTRATION

ISRCTN98538934.

The effectiveness of inter-professional working for older people living in the community: a systematic review

Health and social care policy in the UK advocates inter-professional working (IPW) to support older people with complex and multiple needs. Whilst there is a growing understanding of what supports IPW, there is a lack of evidence linking IPW to explicit outcomes for older people living in the community. This review aimed to identify the models of IPW that provide the strongest evidence base for practice with community dwelling older people. We searched electronic databases from 1 January 1990-31 March 2008. In December 2010 we updated the findings from relevant systematic reviews identified since 2008. We selected papers describing interventions that involved IPW for community dwelling older people and randomised controlled trials (RCT) reporting user-relevant outcomes. Included studies were classified by IPW models (Case Management, Collaboration and Integrated Team) and assessed for risk of bias. We conducted a narrative synthesis of the evidence according to the type of care (interventions delivering acute, chronic, palliative and preventive care) identified within each model of IPW. We retrieved 3211 records and included 37 RCTs which were mapped onto the IPW models: Overall, there is weak evidence of effectiveness and cost-effectiveness for IPW, although well-integrated and shared care models improved processes of care and have the potential to reduce hospital or nursing/care home use. Study quality varied considerably and high quality evaluations as well as observational studies are needed to identify the key components of effective IPW in relation to user-defined outcomes. Differences in local contexts raise questions about the applicability of the findings and their implications for practice. We need more information on the outcomes of the process of IPW and evaluations of the effectiveness of different configurations of health and social care professionals for the care of community dwelling older people.

Randomised controlled trial of a complex intervention by primary care nurses to increase walking in patients aged 60-74 years: protocol of the PACE-Lift (Pedometer Accelerometer Consultation Evaluation - Lift) trial

BACKGROUND

Physical activity is essential for older peoples' physical and mental health and for maintaining independence. Guidelines recommend at least 150 minutes weekly, of at least moderate intensity physical activity, with activity on most days. Older people's most common physical activity is walking, light intensity if strolling, moderate if brisker. Less than 20% of United Kingdom 65-74 year olds report achieving the guidelines, despite most being able to. Effective behaviour change techniques include strategies such as goal setting, self-monitoring, building self-efficacy and relapse prevention. Primary care physical activity consultations allow individual tailoring of advice. Pedometers measure step-counts and accelerometers measure physical activity intensity. This protocol describes an innovative intervention to increase walking in older people, incorporating pedometer and accelerometer feedback within a primary care nurse physical activity consultation, using behaviour change techniques.

METHODS/DESIGN

DESIGN

Randomised controlled trial with intervention and control (usual care) arms plus process and qualitative evaluations.

PARTICIPANTS

300 people aged 60-74 years registered with 3 general practices within Oxfordshire and Berkshire West primary care trusts, able to walk outside and with no restrictions to increasing their physical activity.

INTERVENTION

3 month pedometer and accelerometer based intervention supported by practice nurse physical activity consultations. Four consultations based on behaviour change techniques, physical activity diary, pedometer average daily steps and accelerometer feedback on physical activity intensity. Individual physical activity plans based on increasing walking and other existing physical activity will be produced.

OUTCOMES

Change in average daily steps (primary outcome) and average time spent in at least moderate intensity physical activity weekly (secondary outcome) at 3 months and 12 months, assessed by accelerometry. Other outcomes include quality of life, mood, exercise self-efficacy, injuries. Qualitative evaluations will explore reasons for trial non-participation, the intervention's acceptability to patients and nurses and factors enhancing or acting as barriers for older people in increasing their physical activity levels.

DISCUSSION

The PACE-Lift trial will determine the feasibility and efficacy of an intervention for increasing physical activity among older primary care patients. Steps taken to minimise bias and the challenges anticipated will be discussed. Word count 341.

TRIAL REGISTRATION NUMBER

ISRCTN42122561.

A tale of two trails: exploring different paths to success

BACKGROUND

This comparative case study investigates 2 successful community trail initiatives, using the Active Living By Design (ALBD) Community Action Model as an analytical framework. The model includes 5 strategies: preparation, promotion, programs, policy, and physical projects.

METHODS

Key stakeholders at 2 sites participated in in-depth interviews (N=14). Data were analyzed for content using Atlas Ti and grouped according to the 5 strategies.

RESULTS

PREPARATION: Securing trail resources was challenging, but shared responsibilities facilitated trail development. PROMOTIONS: The initiatives demonstrated minimal physical activity encouragement strategies.

PROGRAMS

Community stakeholders did not coordinate programmatic opportunities for routine physical activity. POLICY: Trails' inclusion in regional greenway master plans contributed to trail funding and development. Policies that were formally institutionalized and enforced led to more consistent trail construction and safer conditions for users. PHYSICAL PROJECTS: Consistent standards for wayfinding signage and design safety features enhanced trail usability and safety.

CONCLUSIONS

Communities with different levels of government support contributed unique lessons to inform best practices of trail initiatives. This study revealed a disparity between trail development and use-encouragement strategies, which may limit trails' impact on physical activity. The ALBD Community Action Model provided a viable framework to structure cross-disciplinary community trail initiatives.

Barriers to participation in a hospital-based falls assessment clinic programme: an interview study with older people

AIMS

To gain new knowledge about barriers to participation in hospital-based falls assessment.

METHODS

Semi-structured interviews with 20 older people referred to falls assessment at a hospital-based clinic were conducted. A convenience sample of 10 refusers and 10 accepters was collected. Those who refused referral were recruited in relation to a systematic falls screening programme performed by preventive home visitors. Accepters were selected among 72 participants successively completing the falls assessment clinic programme. The time between the interviews was 12 months; different levels of knowledge were expected, owing to accepters' participation in the programme. Interview transcriptions were thematically analysed. The analysis was directed towards identification of barriers to falls assessment.

RESULTS

Barriers to participation were categorized as being either within or outside the falls clinic, and included administration, time, communication, attitudes to fall prevention, and expected future costs. Accepters completing the programme expressed a feeling of being ''met'' in the system and maintaining authority over their own life, while the refusers expressed concern about the healthcare system taking over their life.

CONCLUSIONS

This study indicates that older at-risk patients acknowledge their falls problem, but refuse to participate in hospital-based assessment programmes because they expect to lose their authority and to be caught up in the healthcare system. In order to transform the findings of this study to a public health message, we have to consider moving the focus of falls prevention strategies from disease control to the domain of health promotion in order to engage older adults in preventive healthcare.

Establishing a new falls clinic--conflicting attitudes and inter-sectoral competition affecting the outcome

Falls clinics are a newer model for falls management among the elderly. Few studies have addressed the impact of the strategy on falls prevention in the healthcare system. The aim of the present study was to describe the social processes that affect the implementation of new strategies in falls management. A newly established falls clinic was chosen as an instrumental case to describe the systematic and comprehensive approach to falls prevention among the elderly. The investigation had a qualitative case study research design with triangulation of sources and methods, including interviews, participant observation and analysis of documents. The study was conducted from January 2006 to June 2007 at a newly established falls clinic at a Danish hospital. Data were analysed qualitatively according to four main themes: The concept of falls, success/failure, competition and expertise. The study showed that the falls clinic was embedded in a context where interests varied at different levels of the organizational hierarchy. In contrast to the political agenda for falls prevention, patients and professionals did not associate falls with chronological age. The biomedical structure of the falls clinic and the hegemonic mode of handling falls prevention may have facilitated falls prevention services and patient trajectories across sectors, but if falls are associated with chronic disease secondary to an unhealthy lifestyle, the individual patient becomes responsible for the falls problem. This may subsequently prevent the patients from seeking timely help from the healthcare system, or patients may drop out of the existing programmes. Future research needs to look at sustainability and dropping out in relation to falls prevention programmes.

Participation in community exercise classes: barriers to access

Falls prevention is an important part of national health policy and while there are many causes of falls, there is increasing evidence that advocates the use of targeted balance and stability exercise training to address the risk factor of postural instability. The introduction of these exercise programmes in primary care raise questions about the most effective implementation methods that are accessible and acceptable to older people and support maximum adherence. An understanding of factors that support adherence of older people to exercise programmes is of value to community nurses to enable them to deliver health promotion advice appropriately. The purpose of this paper is to discuss the findings from interviews with older people to explore their experiences in relation to access and acceptability of local community based postural stability exercise classes.