Effectiveness of physical activity interventions for older adults - A review

Centre for Quality of Care Research, University Medical Centre St Radboud, Nijmegen, The Netherlands.
American Journal of Preventive Medicine (Impact Factor: 4.53). 02/2002; 22(2):120-33. DOI: 10.1016/S0749-3797(01)00413-5
Source: PubMed
ABSTRACT
This review evaluates the effectiveness of physical activity interventions among older adults.
Computerized searches were performed to identify randomized controlled trials. Studies were included if: (1) the study population consisted of older adults (average sample population age of > or =50 years and minimum age of 40 years); (2) the intervention consisted of an exercise program or was aimed at promoting physical activity; and (3) reported on participation (i.e., adherence/compliance) or changes in level of physical activity (e.g., pre-post test measures and group comparisons).
The 38 studies included 57 physical activity interventions. Three types of interventions were identified: home-based, group-based, and educational. In the short-term, both home-based interventions and group-based interventions achieved high rates of participation (means of 90% and 84%, respectively). Participation declined the longer the duration of the intervention. Participation in education interventions varied widely (range of 35% to 96%). Both group-based interventions and education interventions were effective in increasing physical activity levels in the short-term. Information on long-term effectiveness was either absent or showed no difference of physical activity level between the study groups.
Home-based, group-based, and educational physical activity interventions can result in increased physical activity, but changes are small and short-lived. Participation rates of home-based and group-based interventions were comparable, and both seemed to be unrelated to type or frequency of physical activity. The beneficial effect of behavioral reinforcement strategies was not evident. Comparative studies evaluating the effectiveness of diverse interventions are needed to identify the interventions most likely to succeed in the initiation and maintenance of physical activity.

Full-text

Available from: Miranda GH Laurant, Oct 29, 2015
Review and Special Articles
Effectiveness of Physical Activity
Interventions for Older Adults
A Review
Akke K. van der Bij, MSc, Miranda G.H. Laurant, MSc, Michel Wensing, PhD
Objective: This review evaluates the effectiveness of physical activity interventions among older adults.
Methods: Computerized searches were performed to identify randomized controlled trials. Studies
were included if: (1) the study population consisted of older adults (average sample
population age of 50 years and minimum age of 40 years); (2) the intervention consisted
of an exercise program or was aimed at promoting physical activity; and (3) reported on
participation (i.e., adherence/compliance) or changes in level of physical activity (e.g.,
pre–post test measures and group comparisons).
Results: The 38 studies included 57 physical activity interventions. Three types of interventions were
identified: home-based, group-based, and educational. In the short-term, both home-based
interventions and group-based interventions achieved high rates of participation (means of
90% and 84%, respectively). Participation declined the longer the duration of the
intervention. Participation in education interventions varied widely (range of 35% to 96%).
Both group-based interventions and education interventions were effective in increasing
physical activity levels in the short-term. Information on long-term effectiveness was either
absent or showed no difference of physical activity level between the study groups.
Conclusions: Home-based, group-based, and educational physical activity interventions can result in
increased physical activity, but changes are small and short-lived. Participation rates of
home-based and group-based interventions were comparable, and both seemed to be
unrelated to type or frequency of physical activity. The beneficial effect of behavioral
reinforcement strategies was not evident. Comparative studies evaluating the effectiveness
of diverse interventions are needed to identify the interventions most likely to succeed in
the initiation and maintenance of physical activity.
Medical Subject Headings (MeSH): aged, exercise, health promotion, intervention studies,
physical fitness, review literature (Am J Prev Med 2002;22(2):120 –133) © 2002 American
Journal of Preventive Medicine
Introduction
A
verage life expectancy has improved in the last
century. Currently about 7% of the world pop-
ulation is aged 65 years. In developed coun-
tries, this percentage is even higher (15%) and still
growing.
1
In the United States, 60% of the elderly are
not regularly involved in physical activity.
2–5
In other
developed countries, 30% to 80% of the elderly are
physically inactive.
6–8
Physical inactivity is an important
modifiable risk factor for many chronic health prob-
lems, such as cardiovascular diseases, hypertension,
obesity, osteoporosis, diabetes mellitus, and mental
health conditions.
5,9–12
Furthermore, physical activity
has proven to be favorable for muscle strength, aerobic
capacity, reduction of fracture risk, and general well-
being in the elderly.
5,9,13–17
Therefore, the initiation
and maintenance of regular exercise are important
objectives of health promotion and crucial in delaying
the onset, or reducing the incidence and severity, of
many chronic diseases.
Many interventions have been set up to enhance
physical activity among older adults and to improve
their health status and functional performance. How-
ever, despite the proven benefits of successfully imple-
mented interventions, persuading older adults to be-
come physically active and to maintain activity is a
difficult task. Many physical activity interventions do
not reach the people who would benefit most from
them. Furthermore, people who participate in an exer-
From the Centre for Quality of Care Research, University Medical
Centre St Radboud, Nijmegen, The Netherlands
Address correspondence and reprint requests to: Miranda G.H.
Laurant, Centre for Quality of Care Research, WOK 229, University
Medical Centre St Radboud, P.O. Box 9101, 6500 HB Nijmegen, The
Netherlands. E-mail: M.Laurant@hsv.kun.nl.
The full text of this article is available via AJPM Online at
www.elsevier.com/locate/ajpmonline.
120 Am J Prev Med 2002;22(2) 0749-3797/02/$–see front matter
© 2002 American Journal of Preventive Medicine Published by Elsevier Science Inc. PII S0749-3797(01)00413-5
Page 1
cise program often fall back into their old inactive
habits after a program ends.
18,19
Therefore, critical
issues such as getting people to initiate and maintain
physical activity need to be addressed, as these issues
have received little attention in the evaluation of the
effectiveness of physical activity interventions. Observa-
tional research suggests that the success of an interven-
tion is inuenced by individual factors such as motiva-
tion, social support, health, beliefs, and education, as
well as organizational factors such as the percentage of
older adults reached, resources, accessibility, and type
of physical activity.
19
Randomized trials are needed to
determine what interventions are most successful in
promoting physical activity. Information on actual par-
ticipation and changes in physical activity levels by
older adults can help in the design of more effective
physical activity interventions.
20
Therefore, we reviewed
randomized controlled trials to determine what inter-
ventions are most effective with respect to (1) partici-
pation (i.e., adherence/compliance) and changes in
physical activity by older adults, and (2) maintenance of
participation and changes in physical activity when
comparing short- and long-term physical activity inter-
ventions. We also explored what features of interven-
tions were associated with achieving high participation
and maintenance of physical activity levels.
Methods
We focused on recent literaturestudies published from
1985 through August 2000aimed at physical activity inter-
ventions for older adults. Systematic searches were carried out
using the following electronic databases: MEDLINE, Current
Contents, Cinahl, Eric, Psychlit, Social Sciences, and the
Cochrane Library. Keywords used included combinations of
exercise, physical activity, elderly, older adults, middle aged,
randomized controlled trial, intervention, adherence, com-
pliance, participation, and effectiveness. Abstracts were
screened for information on participation or changes in
physical activity levels. Other relevant studies were identied
from the reference list of selected studies and from existing
reviews on physical activity and older adults. Only studies
published in English or Dutch were considered for inclusion.
Multiple publications based on the same study were treated as
a single study. Multiple interventions described in a single
publication were treated as separate interventions.
Studies were reviewed if they met the following inclusion
criteria: randomized controlled design; average sample pop-
ulation age of 50 years and minimum age of 40 years;
intervention consisting of an exercise program or aimed at
promoting physical activity otherwise (e.g., information and
counseling); and information on participation or physical
activity levels. Studies were excluded if the intervention was
aimed at older adults with a diagnosed disease (e.g., rehabil-
itation programs for cardiac or pulmonary patients) or if the
intervention group consisted of 10 participants.
For this review, two outcomes were documented: (1) par-
ticipation in the intervention; and (2) changes in physical
activity levels over time. In addition, two independent review-
ers evaluated the following factors in each study: characteris-
tics of the participants; number of participants; recruitment
procedure; randomization procedure; setting of the interven-
tion; type of intervention; intensity of the intervention; dura-
tion of the intervention; use of behavior modication strate-
gies; and follow-up period.
Our results provide a descriptive overview of the studies
categorized according to the length of the intervention. We
dened two categories: short-term interventions (1 year),
and long-term interventions (1 year).
Results
Study Characteristics
Thirty-eight studies, comprising 57 physical activity
interventions, were included. Most studies were based
in the United States (55%) and Europe (23%). A slight
majority of the studies (53%) were published between
1995 and 2000. The randomization procedure was
described thoroughly in only one fth of the studies. In
other studies, information on the randomization pro-
cedure was insufcient or absent. Thirty-six studies
reported participation or change in physical activity as
well as other outcomes; in fact, primary outcomes in
most studies were measures of functional parameters as
aerobic capacity, muscle strength, bone density, and
fracture risk. Fourteen studies identied barriers to
participation or increased physical activity.
Most studies focused on healthy, inactive older adults
who were recruited by strategies such as advertisements
in local newspapers, radio, and community senior
centers. Four studies focused on older adults living in a
residential or nursing home and ve studies focused on
older adults using primary healthcare facilities. Most
studies (71%) contained at least 60 participants (medi-
an101). The mean age ranged from 51 to 88 years
(mean68, SD10 years). Eleven studies were focused
on women only, and three on men only. Men were the
minority in most study populations (mean29%,
SD29%). In 16 of the 17 studies that reported partic-
ipants ethnicity, a large majority were white. Fifteen
studies reported on participants education level and 10
studies reported on income levels; most subjects were
relatively well educated and had moderate to high
incomes.
The following three types of physical activity inter-
ventions were identied: (1) home-based physical activ-
ity interventions (n9), in which an explicit exercise
prescription was given and where the participants had
to exercise at home according to this prescription;
(2) group-based physical activity interventions (n38),
in which subjects engaged in a supervised group-based
exercise program; and (3) educational physical activity
interventions (n10), in which information was given
on exercise and health and participants were encour-
aged to engage in regular physical activity. A structured
Am J Prev Med 2002;22(2) 121
Page 2
Table 1. Home-based physical activity interventions (7 studies, 9 interventions)
First author,
year, N
Age: mean (SD)
Gender: % men
Physical activity
targeted
Frequency
(days/week)
Behavioral
strategies
Duration of
intervention
(months)
Participation
(%)
Effect on
physical
activity
c
Follow-up
Short-term interventions (<1 year)
DeBusk, 1990
21
I-1: 52 (6) Jogging 5 Telephone contact 2 93
a
NA NA
40 100%
I-2: 52 (6) Jogging 5 Telephone contact 2 93
a
NA NA
100% (times/day)
Gillet, 1996
22,23
64 (0) Aerobic exercise 3 Feedback 4 86
a
Mean of 3.6
days/week vs
3.8,
b
After 18 months,
mean exercise
2.8 days/week
182 0%
Jette, 1999
24
75 (7) Strength training 3 Behavioral
contract,
telephone contact,
rewards, goal
setting
689
a
NA NA
215 22%
Long-term interventions (>1 year)
Campbell, 1997
25,26
84 (3) Walking, strength and
balance exercises
3 (walking) Telephone
contact,
contacting
physiotherapist in
case of problems
24 44
c
Mean change in
PASE: I, 4.6 vs
C 11 after 12
months
NA
233 0% 3 (exercises)
King, 1991
2729
I-1: 57 (4) Walking, jogging 3 Telephone contact 24 68
a
NA NA
357 55%
I-2: 57 (4) Walking, jogging 5 Telephone contact 24 49
a
NA NA
55%
Preisinger, 1995
30,31
60 (7) Walking; jogging;
strength, mobility, and
exibility exercises
3 Supervised
sessions twice/year
90 36
c
NA NA
246 0%
Preisinger, 1996
32
61 (7) Strength, mobility,
and exibility
exercises
3 Supervised
sessions twice/year
48 44
c
NA NA
92 0%
a
Mean percentage of sessions attended by participants.
b
Prepost test difference not statistically signicant.
c
Percentage of participants who exercised at least 3 times per week.
d
Intervention and control group difference signicant (p0.05).
C, control group; I, intervention group; PASE, Physical Activity Scale for the Elderly; NA, not applicable; N, total sample size; SD, standard deviation.
122 American Journal of Preventive Medicine, Volume 22, Number 2
Page 3
exercise program was rarely included in this third type
of intervention.
Participation was usually dened as the participation
rate (number of exercise sessions or counseling ses-
sions attended divided by the number of sessions
prescribed). In 10 studies, participation was dened
differently as the number of participants exercising
regularly or maintaining a minimum level of physical
activity. In order to make comparison possible, mean
participation was only calculated for studies that used
the percentage of sessions attended (i.e., participation
rate) as participation outcome (n28). Means were
calculated as unweighted.
Home-Based Physical Activity Interventions
The home-based interventions are described in Table
1.
2132
In only one of the nine interventions, partici-
pants were provided with information on benets of
exercise to health.
22
All interventions used behavioral
strategies for reinforcement such as telephone calls,
rewards, or feedback. The duration of the interventions
ranged from 2 months to 90 months. Two interventions
were ongoing programs.
30,32
In all interventions, par-
ticipants were instructed to exercise at least 3 times per
week. Seven interventions provided information on the
intensity of the exercise sessions; most were of moder-
ate intensity (60% to 75% of the maximum heart
rate).
21,22,25,27,32
Participation varied with the length of
the intervention. Four interventions were short-term
(1 year) and had participation rates ranging between
86% and 93% (mean90%).
21,22,24
Short-term partici-
pation seemed to be independent of the frequency or
type of prescribed physical activity, gender, or age of
the participants.
Participation in the long-term interventions (1
year) was lower than in the short-term interventions.
The participation rate ranged between 49% and 68%,
and the participation varied between 36% and 44%
based on the number of participants complying with
the prescribed physical activity.
2528,3032
King et al.
27,28
reported a signicant difference in participation at 1
year and 2 years after the start of interventions. Partic-
ipation at 1 year compared to participation at 2 years
dropped from 79% to 68% and from 75% to 49%,
respectively, for the intervention group that exercised 3
times a week and the intervention group that exercised
5 times per week The decline in participation appeared
to be related to the number of exercise sessions per
week.
Only two studies published results on changes in
physical activity. Both studies reported a decline in
physical activity level after the interventions ended. In
one study,
26
older adults in both the intervention group
and control group became less active after the 1-year
intervention, measured via the Physical Activity Scale
for the Elderly. However, the decline in physical activity
was signicantly larger in the control group. In the
other study,
23
a general decline in exercise frequency
was apparent 18 months after the intervention ended
(3.6 days per week vs 2.8 days per week).
23
Group-Based Physical Activity Interventions
Six of the 38 group-based interventions also instructed
participants to exercise individually at home (Table
2).
22,23,2729,3338,42,4463
Four interventions were situ-
ated in a residential or nursing home.
34,36,50,54
Only four
interventions provided participants with information on
the benets of exercise to health.
22,45,53
A minority of the
interventions used strategies such as postal or telephone
reminders, feedback, rewards, or nancial incentives for
reinforcement.
22,33,34,42,45,46,53,5962
The duration of
the interventions varied among 1, 5, and 24 months. In
most interventions, participants exercised 3 times a
week at moderate or high intensity.
Twenty-eight group-based interventions were of
short-term duration.
22,3338,42,4446,4856
These short-
term interventions reported participation rates ranging
between 55% and 100% (mean84%). Participation
seemed to be unrelated to the type or frequency of the
physical activity. It is worthwhile noting that most
short-term interventions retained high participation
rates without using special reinforcement strategies.
For instance, McAuley et al.
45
used behavioral strategies
consisting of videotapes, letters of encouragement,
meetings, progress reports, and the formation of buddy
groups to maintain high participation in one interven-
tion group (I-1). This study reported lower participa-
tion compared to other short-term interventions. How-
ever, when I-1 was compared to a second intervention
group (I-2) that received the same exercise interven-
tion and met biweekly with an investigator to discuss
nonexercise-related topics such as diet or smoking,
participation was consistently higher in I-1 (67% vs
55%, p0.05). Estabrooks and Carron
33
used a team-
building strategy based on group-dynamic principles to
increase participation (I-1). This strategy resulted in
higher participation when compared to two other
intervention groups: I-2 received the same exercise
program and no team-building (91% vs 70%, p0.05),
and I-3 received a different exercise program and no
team-building (91% vs 65%, p0.05). Remarkably, in-
terventions in nursing or residential homes or among
older age groups (80 years) also achieved high par-
ticipation (mean87%).
34,36,48,50,54
In long-term interventions (1 year), the participa-
tion rate ranged between 63% and 84% (mean75%)
for the interventions that lasted 1 year.
27,5762
Only two
long-term interventions
27,62
reported results on partic-
ipation after 2 years of intervention. In one interven-
tion,
27
only 36% of the sessions were attended. In the
other intervention,
62
61% of the participants still main-
tained an average seven miles of walking per week.
62
Am J Prev Med 2002;22(2) 123
Page 4
Table 2. Group-based physical activity interventions (27 studies, 38 interventions)
First author,
year, N
Age: mean
(SD)
Gender:
% men
Physical activity
targeted
Frequency
(days/week) Behavioral strategies
Duration of
intervention
(months)
Participation
(%)
Effect on
physical
activity Follow-up
Short-term interventions (<1 year)
Estabrooks, 1999
33
33
I-1: 75
9%
Aerobic exercise,
strength training
2 Team building
intervention, juice and
biscuits at end of
session
1.5 91
a
NA NA
I-2: 75
9%
Aerobic exercise,
strength training
2 Juice and biscuits at
end of session
1.5 70
a
NA NA
I-3: 75
9%
Basic tness
program
2 Juice and biscuits at
end of session
1.5 65
a
NA NA
Schnelle, 1996
34
97
84
16%
Strength,
mobility, and
exibility
exercises
3 Verbal reminders of
safe practice of
exercises
292
a
NA NA
Emery, 1990
35
48
72 (6)
17%
Walking, dance,
strength training
3NA 3 6194
a
NA NA
Gillies, 1999
36
20
88 (5)
5%
Every day
functional tasks
2NA 3 92
a
NA NA
Rubenstein, 2000
37
59
75 (5)
100%
Walking, cycling,
strength and
balance exercises
3NA 3 84
a
NA NA
Blumenthal, 1989
3841
101
I-1: 67 (5)
50%
Walking,
jogging, cycling
3NA 4 96
a
NA After 26 months, 94%
reported some form of
physical activity
I-2: 67 (5)
50%
Yoga 2 NA 4 100
a
NA NA
Dustman, 1984
42,43
32
I-1: 61 (4)
63%
Walking, jogging 3 Paid a modest sum at
end of intervention
477
a
NA At 48 months, 64%
continued to exercise
in large-muscle aerobic
activities at least 3
times/week
I-2: 61 (4)
63%
Strength,
mobility, and
exibility
exercises
3 Paid a modest sum at
end of intervention
484
a
NA At 48 months, 64%
continued to exercise
in large-muscle aerobic
activities at least 3
times/week
Gillet, 1996
22,23
182
64 (3)
0%
Dance 3 Feedback 4 86
a
Mean of 3.6
days vs 3.8
days/week vs
3.8
b
After 18 months, mean
exercise of 2.8 days/
week
(Continued)
124 American Journal of Preventive Medicine, Volume 22, Number 2
Page 5
Table 2. Continued
First author,
year, N
Age: mean
(SD)
Gender:
% men
Physical activity
targeted
Frequency
(days/week) Behavioral strategies
Duration of
intervention
(months)
Participation
(%)
Effect on
physical
activity Follow-up
Thompson, 1988
44
35
73 (5)
23%
Strength
exercises, dance
3NA 4 87
a
NA NA
McAuley, 1994
45
114
I-1: 55 (6)
49%
Walking 3 Videotapes, booster
letters, meetings,
progress reports,
formation of buddy
groups
567
a
Minutes
walked
per week at
E: 193 vs I-2,
132
c
I-2: 55 (6)
49%
Walking 3 Videotapes, handouts,
and meetings
555
a
NA
Hamdorf, 1992
46,47
80
64 (3)
0%
Walking 2 NA 6 91
a
Maximum
current activity
scores at B and
E, IB, 77; E,
80 CB, 75;E,
75
d
Maximum current
activity scores at 12
months: I, 79; C, 75
e
Hamdorf, 1999
48
49
82
0%
Walking 2 NA 6 90
a
Maximum
current activity
scores at B and
at E, ;IB, 68;
E, 72 CB,
65; E, 61
d
McAuley, 1999
49
174
I-1: 67 (5)
28%
Strength
exercises
3NA 6 88
a
NA NA
I-2: 67 (5) Walking 3 NA 6 88
a
NA NA
McMurdo, 1994
50
65
83 (8)
17%
Strength,
mobility, and
exibility
exercises;
exercise to music
2NA 6 72
a
NA NA
Nichols, 1993
51
36
67 (2)
0%
Strength training 3 NA 6 87
a
NA NA
Pollock, 1991
52
57
I-1: 72 (3)
44%
Walking, jogging 3 NA 6 99
a
NA NA
I-2: 72 (3) Strength training 3 NA 6 98
a
NA NA
(Continued)
Am J Prev Med 2002;22(2) 125
Page 6
Table 2. Continued
First author,
year, N
Age: mean
(SD)
Gender:
% men
Physical activity
targeted
Frequency
(days/week) Behavioral strategies
Duration of
intervention
(months)
Participation
(%)
Effect on
physical
activity Follow-up
Wallace, 1998
53
100
72
27%
Walking,
strength,
balance,
mobility, and
exibility
exercises
3 Feedback, telephone
reminders
690
a
After 6
months, 50%
of C and 50%
of I continued
to attend the
exercise
classes
e
NA
McMurdo, 1993
54
40
81 (6)
20%
Strength,
mobility, and
exibility
exercises;
exercise to music
2NA 7 91
a
NA NA
McMurdo, 1992
55
87
65 (4)
43%
Strength
training, exercise
to music
3NA 8 83
a
NA NA
Rooks, 1997
56
131
I-1: 73 (5)
36%
Strength training 3 NA 10 85
a
NA NA
I-2: 73 (5)
36%
Walking 3 NA 10 82
a
NA NA
Long-term interventions (>1 year)
Bassey, 1995
57
63
I-1: 55 (3)
0%
Heel-drop
exercises,
exercise to music
1 group 7
home
NA 12 84
a
NA NA
I-2: 55 (3)
0%
Mobility and
exibility
exercises
1 group NA 12 82
a
NA NA
Chow, 1987
58
58
I-1: 56
0%
Walking,
jogging, dance
3NA 12 70
a
NA NA
I-2: 56
0%
Walking,
jogging, dance,
strength
exercises
3NA 12 70
a
NA NA
(Continued)
126 American Journal of Preventive Medicine, Volume 22, Number 2
Page 7
Table 2. Continued
First author,
year, N
Age: mean
(SD)
Gender:
% men
Physical activity
targeted
Frequency
(days/week) Behavioral strategies
Duration of
intervention
(months)
Participation
(%)
Effect on
physical
activity Follow-up
Cunningham, 1987
59
224
63
100%
Walking, jogging 3 group
1 home
NA 12 63
a
High intensity
leisure
activities in
minutes/day at
B and E: IB,
65; E, 138
d
CB, 47; E,
84
b
NA
King, 2000
60
103
I-1: 70 (4)
35%
Walking,
strength,
exercises
2 group, 2
home
Telephone contact 12 79
a
NA NA
I-2: 60 (4)
35%
Mobility and
exibility
exercises
2 group, 2
home
Telephone contact 12 80
a
NA NA
Lord, 1995
61
197
72 (5)
0%
Aerobic exercise;
strength,
balance,
mobility, and
exibility
exercises
2 Major emphasis on
social interaction and
enjoyment
12 73
a
NA NA
King, 1991
2729
57 (4) Walking, jogging 3 NA 24 36
a
NA NA
357 55%
Kriska 1986
62,63
229
58 (4)
0%
Walking 2 group, 1
home
f
Postal reminder cards
and newsletters,
telephone contact,
home visits, meetings,
rewards
24 61
g
Miles per week
at B and E;
IB, 3.4; E, 7
d
CB, 3.5;
E, 4.4
b
Miles per week after 10
years: I10.5; C, 3.2
h
a
Mean percentage of sessions attended by participants.
b
Prepost test difference not statistically signicant.
c
Difference between two intervention groups signicant (p0.05).
d
Prepost test difference for intervention group and intervention and control group difference signicant (p0.05).
e
Intervention and control group difference not signicant.
f
After 8 weeks, participants opted to exercise in a group or alone.
g
Percentage of participants who maintained a minimum of walking 7 miles per week.
h
Intervention and control group difference signicant (p0.05).
B, baseline; C, control group; E, end of intervention; I, intervention group; N, total sample size; NA, not applicable; SD, standard deviation.
Am J Prev Med 2002;22(2) 127
Page 8
The latter intervention used various strategies to rein-
force physical activity, such as meetings, rewards, birth-
day and get-well cards, and newsletters.
A minority of the long-term studies published results
on changes in physical activity levels or performed
control group comparisons.
22,38,42,45,46,48,5962
Four
studies
46,48,59,62
compared baseline and intervention-
end physical activity levels in the intervention group.
All four interventions reported outcome levels that
were signicantly higher than baseline levels. Five stud-
ies performed control group comparisons, and all ve
found physical activity levels in the intervention groups
to be signicantly higher than those reported in con-
trol groups.
45,46,48,59,62
The control groups in four of
these studies received no intervention.
46,48,59,62
In the
remaining study,
45
the control group received a physi-
cal activity intervention and should be viewed as the
placebo group. Three studies compared levels of activ-
ity at the end of the intervention with levels after
follow-ups of 12, 18, or 120 months.
23,47,63
Only one
intervention group sustained signicantly higher activ-
ity levels compared to a control group, which received
no intervention, even after a 10-year follow-up.
63
The
latter intervention differed from the other two inter-
ventions with respect to the use of behavioral reinforce-
ment strategies, such as birthday or get-well cards,
newsletters, telephone reminders, meetings, and
rewards.
Education Interventions
Eight of 10 education interventions were aimed at older
adults in the primary healthcare setting (Table 3).
64
69,7173
These interventions usually consisted of preven-
tive examinations or health risk appraisal and physical
activity counseling by a general practitioner, public
health student, exercise specialist, or health visitor. Two
interventions consisted of an individualized, serially
reinforced, health promotion intervention, including
risk appraisal, feedback, recommendation letters, and
self-management material delivered by mail.
71
All inter-
ventions educated the participant on the benets of
physical activity for health. Most interventions used the
results of the health risk appraisal to inform the partic-
ipant on his or her risks and provided brief advice and
counseling to promote physical activity. All studies used
behavioral strategies such as follow-up visits, telephone
support, goal setting, feedback, behavioral contract, or
vouchers for free aerobic activities. The duration of the
interventions ranged from 2.5 to 24 months.
Participation in education interventions was usually
dened as the percentage of participants attending at
least one counseling session. Participation ranged be-
tween 35% and 96%. There was a large variation in
participation between studies because of a different
approach to subject recruitment. Studies
65,66,72
in
which participants were randomized after they were
approached and agreed to participate had higher par-
ticipation than those studies
64,67,71
in which partici-
pants were randomized before they were approached
for participation. However, studies in which patients
volunteered to participate prior to randomization re-
ported high nonresponse rates (range of 68% and
88%). Studies inviting participants for more than one
session showed that with more sessions scheduled fewer
participants usually attended.
64,65,67,72
For instance, in
the study conducted by Harland et al.,
65
between 77%
and 87% of participants attended one motivational
interview, but only an average of 4% (in two interven-
tion groups) attended all six interviews, with a median
of three interviews attended by participants. Only 27%
and 44% of participants, respectively, in two of this
studys intervention groups used one or more vouchers
for free aerobic activity sessions, which suggests that
more strategies are needed in addition to offering free
activities.
All studies reported on changes in physical activity
levels. All six interventions reporting short-term results
(1 year) showed a signicant increase in physical
activity compared to a control group.
6466
Among the
studies reporting long-term results (1 year), only
three of the nine interventions showed a positive effect
on physical activity levels.
6567,71,72
The number of visits
or interviews or offering vouchers for free aerobic
activities did not have any impact on physical activity
levels.
Discussion
Effect of Physical Activity Interventions
This review shows that high participation rates can be
achieved with short-term physical activity interventions
(1 year). However, these high participation rates were
not found for long-term interventions (1 year). Thus,
the participation rate declines the longer the interven-
tion duration, but this relationship appears to be less
strong in group-based interventions compared to
home-based interventions. Participation in education
interventions was much lower: Only a minority of
participants attended all planned counseling sessions.
Possible explanations for the inverse relationship be-
tween the participation rate and length of intervention
are lack of interest, motivation, enjoyment, time, or
perceived benets.
18,19
It is difcult to draw unambiguous conclusions about
changes in physical activity levels, as only a minority of
the studies evaluated these changes. It appears that
group-based interventions and education interventions
were effective in increasing physical activity in the
short-term. Long-term education interventions proved
to be ineffective. Insufcient data were available regard-
ing long-term effectiveness of group-based interven-
tions. Failure of long-term studies to maintain high
128 American Journal of Preventive Medicine, Volume 22, Number 2
Page 9
Table 3. Education interventions (6 studies, 10 interventions)
First author,
year, N
Age: Mean
(SD)
Gender:
% men Intervention Frequency
Behavioral
strategies
Duration of
intervention
(months)
Participation
(%)
Effect on
physical
activity level Follow-up
Short-term interventions (<1 year)
Stevens, 1998
64
714
59
42%
Counseling from
exercise
specialist
2 session No pre-set goals,
follow-up visits to
discuss progress
2.5 35
a
,25
b
NA Mean number of
occasions of physical
activity in 4 weeks
before follow-up at 8
months: I: 6, C: 4.4
e
Harland, 1999
65
520
I-1: 51
41%
Motivational
interview
1 Feedback 3 77
d
Moving up one or more
levels on activity score at E:
I, 36%; C, 16%
c
Moving up one or more
levels on activity score
at 12 months: I, 23%;
C, 23%
e
I-2: 51
41%
Motivational
interview
1 Feedback, vouchers
for free aerobic
activities
386
d
,27
f
Moving up one or more
levels on activity score at E:
I, 28%; C, 16%
c
Moving up one or more
levels on the activity
score at 12 months:
I, 26%; C, 23%
e
I-3: 51
41%
Motivational
interview
6 Feedback 3 77
d
,5
g
Moving up one or more
levels on activity score at E:
I, 35%; C, 16%
c
Moving up one or more
levels on the activity
score at 12 months:
I, 31%, C, 23%
e
I-4: 51
41%
Motivational
interview
6 Feedback, vouchers
for free aerobic
activities
387
d
,44
f
,3
g
Moving up one or more
levels on activity score at E;
I, 42%; C, 16%
c
Moving up one or more
levels on the activity
score at 12 months:
I, 27%; C, 23%
e
Halbert, 2000
66
299
68 (6)
46%
Counseling from
exercise
specialist
1 Follow-up visits to
discuss progress,
setting of modest
targets
6 NA Mean number of walking
sessions per week at B and
E:
IB,0E,3
h
CB,
0; E, 2
c,h
Mean number of
walking at 12 months:
I, 3; C: 2
c
Mean number of vigorous
exercise sessions per week at
B and E; IB, 0; E, 2
h
CB, 0; E, 0
c,h
Mean number of
vigorous exercise
sessions per week at 12
months, I, 2; C, 0
c
Long-term interventions (>1 year)
Burton, 1995
6770
4195
74
37%
Preventive
examination,
health
promotion
counseling
1 per year Follow-up
counseling sessions
if deemed
necessary
24 63
a
,33
b
No difference found
between C and I
No change in sedentary
habits after 2 years
(Continued)
Am J Prev Med 2002;22(2) 129
Page 10
Table 3. (Continued)
First author,
year, N
Age: Mean
(SD)
Gender:
% men Intervention Frequency
Behavioral
strategies
Duration of
intervention
(months)
Participation
(%)
Effect on physical
activity level Follow-up
Fries, 1993
71
4712
I-1: 68
47%
Self-management
material
delivered by mail
NA Feedback, health
risk appraisal
24 47
i
Change from B in exercise
(minutes/week) at 12
months: I,6%; C, 9%
e,j
At 24 months: I, 14%
h
NA
I-2: 68
47%
Self-management
material
delivered by mail
NA Feedback, health
risk appraisal
12 47
i
Control group during rst
year of I-1. Change from B
in exercise (minutes/week)
at 12 months: I, 15%
h
NA
Mayer, 1994
72,73
1800
73 (5)
44%
Preventive
examination,
health
promotion
counseling,
health
promotion
sessions
2
preventive
sessions
and 8
health
promotion
sessions
Health risk
appraisal, feedback,
telephone
counseling,
behavioral contract
24 96
a
,87
k
,59
l
Metabolic rate at B and E:
IB, 355; E, 507 CB, 375;
E, 423
c
Metabolic rate at 48
months: I, 432; C, 388
c
a
Attended one session.
b
Attended two sessions.
c
Difference between intervention and control group signicant (p0.05).
d
Attended one motivational interview.
e
Intervention and control group difference not signicant.
f
Issued one or more vouchers.
g
Attended all six interviews.
h
Prepost test difference signicant (p0.05).
i
Completed questionnaires.
j
Prepost test difference not signicant.
k
Attended one health promotion session.
l
Attended six health promotion sessions.
B, baseline; C, control group; E, end of intervention; I, intervention group; N, total sample size; NA, not applicable; SD, standard deviation.
130 American Journal of Preventive Medicine, Volume 22, Number 2
Page 11
participation rates and to change physical activity levels
suggests that more effective approaches for maintain-
ing exercise participation, especially in the long-term,
are necessary.
Participation rates of home-based interventions and
group-based interventions appeared to be comparable.
Group-based interventions, however, seemed to achieve
higher participation rates in the long-term compared to
home-based interventions. Previous studies and reviews
found that home-based interventions may promote
equal or enhanced participation compared to more
conventional, supervised, group-based physical activity
interventions. Gillet et al.
22
also found no difference in
exercise participation in an intervention group where
participants were instructed to exercise individually at
home compared to an intervention group that received
a group-based exercise program.
Age also seemed to inuence participation. People
aged 60 years have lower participation rates com-
pared to those aged 60 years. Nevertheless, even the
very old (80 years) can be motivated to increase
physical activity.
25,34,36,48,50,54
Gender does not inu-
ence participation, but in general more women partic-
ipate in physical activity interventions than men. Other
possible factors, such as frequency, type, and intensity
of the physical activity were not related to participation.
Randomized controlled trials that compared outcomes
of different behavioral strategies suggest that the use of
certain strategies has a positive effect on participa-
tion.
33,45
However, our review does not support these
results. There is no clear evidence for the effectiveness
of behavioral reinforcement strategies (e.g., reminder
telephone calls, social support, formation of buddy
groups, or other incentives) on the initiation and
maintenance of physical activity.
Study Limitations
All included studies were randomized controlled trials
with a sufcient number of participants. Most studies
(82%), however, did not describe the concealment of
the randomization procedure. For pragmatic reasons,
only studies with a measure of participation or changes
in physical activity levels in abstracts were included.
Another issue was the limited generalizability of the
study populations, as most of the older adults were
white, of relatively high social class status, and healthy,
although the majority of the population aged 45 years
have signicant chronic conditions or disabilities.
75
In
addition, most studies had large nonresponse rates (the
percentage of subjects who never participated in the
intervention). Nonresponse rates in our review ranged
from 21% to 90%. Participation in and levels of physical
activity may be lower among the older people not
included in these studies, but it is unclear how the
conclusions of this review are affected.
Some studies did not employ an intention-to-treat
principle. It was sometimes unclear whether dropouts
were included in the calculation of participation rates.
Excluding dropouts can lead to ination of the partic-
ipation rate. Only a few studies performed control
group comparisons to evaluate the effect of the inter-
vention on physical activity levels. All other studies only
reported participation rates or performed prepost
testing. In addition, the denition and measurement of
participation was inconsistent. Finally, there were few
long-term studies and follow-up results.
In closing, the wide variation in methodology and
study subjects made it impossible to conduct a formal
meta-analysis.
Implications for Public Policy
Physical activity is an important goal for public health
and public policy, as regular physical activity improves
well-being and contributes to the prevention or delay of
disease.
76
Unfortunately, effective physical activity in-
terventions are not always successful in promoting
health, as older adults often do not comply with the
planned exercise and do not continue increased phys-
ical activity in the long-term. In order to assist in the
maintenance of physically active lifestyles, it is essential
that interventions are tailored to individuals ideas and
preferences and that a variety of physical activity op-
tions is made available.
76
Alternatives to traditional
group-based interventions, such as helping older adults
to exercise at home, during leisure time, and in com-
petition-oriented activities, are necessary to eventually
affect the overall health of this population. It is essen-
tial that relapse behavior (i.e., adherence/compliance
problems) be recognized. More intense long-term strat-
egies are needed, and multi-level interventions or be-
havioral strategies (e.g., safe community design, com-
munity-level resources, workplace promotion efforts,
counseling in healthcare delivery systems, and educa-
tion) are necessary to promote long-term changes in
lifestyle.
Education interventions in primary healthcare set-
tings could be highly effective, as many older adults use
healthcare services regularly and physicians represent
key social inuences.
77
Many of the contacts between
the older adult and the physician offer opportunities
for primary prevention, such as the promotion of an
active lifestyle.
7779
Changes in healthcare delivery sys-
tems and physicians attitudes toward the delivery of
preventive services may be necessary so that older
adults receive appropriate information and counseling
related to physical activity. The effectiveness of this
counseling may be similar to advice provided to smok-
ers (i.e., for every patient who stops smoking, many
more have been advised to stop but have not yet done
so).
Am J Prev Med 2002;22(2) 131
Page 12
Implications for Research
The positive effects of interventions on health benets
and functional outcomes have been demonstrated ex-
tensively.
5,917
Therefore, future research should focus
on comparative studies evaluating the effectiveness of
diverse interventions to identify the ones most likely to
be successful in the initiation and maintenance of
physical activity among older adults. Such studies will
support the development of effective exercise interven-
tions for the older population. More intensive interven-
tions that reach large segments of the older adult
population and that can be sustained over time should
be developed. Furthermore, appropriate, valid, and
reliable measures of physical activity should be identi-
ed and used in future research. These efforts would
increase comparability among studies of diverse
interventions.
Conclusions
Physical activity interventions included were often con-
ducted over a brief period of time and had little or no
follow-up. This review of physical activity interventions
for older adults provides limited evidence for long-term
effectiveness. However, it can be concluded that home-
based, group-based, and education interventions result
in increased physical activity, although changes were
small and short-lived. Maintenance of increased physi-
cal activity levels needs to be improved, as ongoing
participation is necessary to sustain health benets.
More attention should be given to the development
and implementation of more intense and tailored
interventions that include policy, environmental, and
behavioral support.
This study was supported by a grant (3550,000,3) from the
Health Research and Development Council of the
Netherlands.
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    • "There is therefore potential for PA interventions to address widening health inequalities in older age. A number of previous reviews have examined PA interventions in populations of older adults (over 50 s, over 60 s, over 65 s, 55–75 year olds or older adults generally), or associations between life changes and PA5678910111213141516. Three previous reviews have specifically considered retirement [1, 16, 17]. "
    [Show abstract] [Hide abstract] ABSTRACT: It has been argued that transition points in life, such as the approach towards, and early years of retirement present key opportunities for interventions to improve the health of the population. Research has also highlighted inequalities in health status in the retired population and in response to interventions which should be addressed. We aimed to conduct a systematic review to synthesise international evidence on the types and effectiveness of interventions to increase physical activity among people around the time of retirement. A systematic review of literature was carried out between February 2014 and April 2015. Searches were not limited by language or location, but were restricted by date to studies published from 1990 onwards. Methods for identification of relevant studies included electronic database searching, reference list checking, and citation searching. Systematic search of the literature identified 104 papers which described study populations as being older adults. However, we found only one paper which specifically referred to their participants as being around the time of retirement. The intervention approaches for older adults encompassed: training of health care professionals; counselling and advice giving; group sessions; individual training sessions; in-home exercise programmes; in-home computer-delivered programmes; in-home telephone support; in-home diet and exercise programmes; and community-wide initiatives. The majority of papers reported some intervention effect, with evidence of positive outcomes for all types of programmes. A wide range of different measures were used to evaluate effectiveness, many were self-reported and few studies included evaluation of sedentary time. While the retirement transition is considered a significant point of life change, little research has been conducted to assess whether physical activity interventions at this time may be effective in promoting or maintaining activity, or reducing health inequalities. We were unable to find any evidence that the transition to retirement period was, or was not a significant point for intervention. Studies in older adults more generally indicated that a range of interventions might be effective for people around retirement age.
    Full-text · Article · Dec 2016 · International Journal of Behavioral Nutrition and Physical Activity
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    • "The superiority of center-versus home-based approach was discussed in three reviews; two found that the effects of home-based interventions were similar to that of centerbased interventions (Chase, 2015; van der Bij et al., 2002), whereas Conn and colleagues (2002) indicated that centerbased interventions had greater effects compared with home-based interventions (ESs 0.47 vs 0.24), but without controlling for intervention duration. The majority of interventions reviewed were short term (<6 months), and the differences between these two approaches were small, yet in " real world " settings, there is a substantial decline in attendance at center-based classes for seniors (Ecclestone, Myers, & Paterson, 1998; van der Bij et al., 2002). Overall, there were some methodological issues overlooked in these reviews. "
    [Show abstract] [Hide abstract] ABSTRACT: Purpose of the study: There is a global imperative to increase awareness of the emerging evidence on physical activity (PA) among older adults. "Healthy aging" has traditionally focused on preventing chronic disease, but greater efforts are required to reduce frailty and dependency and to maintain independent physical and cognitive function and mental health and well-being. Design and methods: This integrated review updates the epidemiological data on PA, summarizes the existing evidence-based PA guidelines, describes the global magnitude of inactivity, and finally describes the rationale for action. The first section updates the epidemiological evidence for reduced cardiometabolic risk, reduced risks of falls, the burgeoning new evidence on improved cognitive function and functional capacity, and reduced risk of depression, anxiety, and dementia. This is followed by a summary of population prevalence studies among older adults. Finally, we present a "review of reviews" of PA interventions delivered from community or population settings, followed by a consideration of interventions among the "oldest-old," where efforts are needed to increase resistance (strength) training and balance. Results: This review identifies the global importance of considering "active aging" beyond the established benefits attributed to noncommunicable disease prevention alone. Implications: Innovative population-level efforts are required to address physical inactivity, prevent loss of muscle strength, and maintain balance in older adults. Specific investment in healthy aging requires global policy support from the World Health Organization and is implemented at the national and regional levels, in order to reduce the burden of disease and disability among older adults.
    Full-text · Article · Apr 2016 · The Gerontologist
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    • "It is recommended that children participate daily in at least 60 minutes of moderate-intensity physical activity to reduce the risk of developing coronary heart disease, diabetes, asthma, as well as promoting musculoskeletal health, aerobic capacity, healthier adipose levels (van der Bij, Laurant, & Wensing, 2002; Cleland, Tully, Kee, & Cupples, 2012; Cunningham & Michael, 2004; Hillsdon, Foster, & Thorogood, 2005; Janssen, 2007; Physical Activity Guidelines Advisory Committee, 2008; Strong et al., 2005 ) and enhance psychological benefits of academic achievement, self-esteem, and general well-being (van der Bij et al., 2002; Centers for Disease Control and Prevention, 2010; Saxena, Van Ommeren, Tang, & Armstrong, 2005; Strong et al., 2005;). Unfortunately, physical inactivity is on the rise (Caspersen, Pereira, & Curran, 2000; Observatory, G. H., n.d.) as physical activity is being replaced by non-active forms of commuting (e.g. less bicycling or walking to school) and increases in electronic media usage (Terzian & Moore, 2009; Vitalsigns, 2012). "
    [Show abstract] [Hide abstract] ABSTRACT: Objective: Research on bicycle safety education (BSE) programmes has examined limited factors beyond bicycle safety knowledge. Additionally, evaluations of BSE have not been theoretically grounded. The purpose of this study was to apply expectancy-value theory to examine changes in perceptions of biking competence, bicycling enjoyment, and value of bicycling as broader outcomes of BSE beyond bicycle safety knowledge. Design: Pre–post programme survey. Setting: Fifth-grade students participating in a one-week BSE programme. Method: Participants (N = 130) completed assessments of programme outcomes (bicycle safety knowledge, perceived bicycling competence, enjoyment, and value) and predictors of outcomes (perceived support). Results: Knowledge of bicycle safety, perceived bicycling competence, bicycling enjoyment, and value of bicycling increased significantly (p < .05). Perceptions of support for bicycling predicted increases in the perceptions of competence, enjoyment, and value of bicycling (p < .05), but no study variables predicted increases in knowledge. Conclusion: The BSE programme not only increased general bicycle safety knowledge but also other key theoretical outcomes relevant to physical activity. Autonomy support predicted positive outcomes, highlighting a key factor to be incorporated in future education programmes. Perceived parental support predicted student perceptions of competence, enjoyment, and value of bicycling, highlighting the potential of also involving parents in school-based programmes to leverage their influential role in shaping motivational outcomes.
    Full-text · Article · Aug 2015 · International Journal of Sport and Exercise Psychology
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