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National Reach and Dissemination of EnhanceFitness
Abstract
Objectives: This study examines the national dissemination of EnhanceFitness, a senior group-based exercise program, and describes lessons learned about participant and delivery site recruitment and retention. Methods: Program data for EnhanceFitness in 10 states were
analyzed. Quantitative findings were augmented with state-specific cases pertaining to infrastructure development, recruitment, and retention. Results: Between 2006 and 2009, 5719 unique participants were enrolled in EnhanceFitness. Nearly 50% of participants were from racial/ethnic
minority backgrounds and were more complex patients with multiple pre-existing conditions at the time of enrollment. Case studies illustrate the importance of broad-based technical assistance, infrastructure development, creative funding, and recruitment and retention strategies salient to
local communities. Conclusions: Growing and sustaining evidence-based programming require policies that allow for flexibility when applying resources and tailoring recruitment and retention strategies.
... Earlier studies have investigated the impact of Enhance ® Fitness on physical performance [15][16][17][18][19][20]. For example, Belza and colleagues examined 2,889 Enhance ® Fitness participants who participated in outcomes testing and found improvements at 4 and 8 months on performance tests [15]. ...
... Each class enrolls up to 25 participants, depending on the space of the site. e classes are offered in a variety of community settings, such as residential and retirement communities, senior housing facilities, adult day care centers, YMCAs, private gyms, churches, and multipurpose centers [15][16][17][18][19][20][21]. ...
... Improvements in physical performance were also found in multiple previous Enhance ® Fitness studies, as shown in the scoping review of qualitative and quantitative studies conducted by Petrescu-Prahova and colleagues [20]. Other studies show its effectiveness with minority populations [15,17,18] and at a variety of Enhance ® Fitness sites [16]. ...
Introduction:
Enhance®Fitness is a low-cost group exercise program designed specifically for older adults (60+ years) to improve physical performance. The Hawai'i Healthy Aging Partnership, a statewide health promotion initiative, has continuously offered Enhance®Fitness to Hawai'i's multicultural population since 2007. This study examined 12-month participation in and impact of Enhance®Fitness on physical performance among older adults in Hawai'i.
Method:
Linear mixed-effects models were applied to analyze the physical performance measures (chair-stands, arm curls, and the up-and-go test) collected at baseline (month 0) and at 4, 8, and 12 months. We also compared the characteristics of participants who participated in the program for 12 months with those who dropped out in order to gain insights on participant retention.
Results:
Of 1,202 older adults with baseline data, 427 (35.5%) were continuously enrolled in Enhance®Fitness for 12 months and participated in follow-up data collection. On average, participants attended 63.7% of thrice-weekly classes each month. Participants' physical performance measures improved after 4 months, continued to improve until 8 months, and were maintained thereafter. Besides continuous attendance, performance-measure improvements were associated with younger age, male gender, living with others (vs. alone), and fewer chronic conditions. Compared to those who completed 12 months of the program, the 775 who left the program over the course of the year were more likely to be younger, to be Caucasian (vs. Asian or Pacific Islander), to self-report depression as a chronic condition, and to have lower levels of fitness at baseline. Common reasons for dropping out were illness, relocation, time conflicts, lost interest, and transportation issues.
Conclusions:
Long-term participants in Enhance®Fitness initially improved and then maintained physical performance. Future research is needed to identify strategies to maintain enrollment of older adults in the exercise programs over time.
... In concert with public health officials and policy makers' interests to identify effective ways to lessen the impact of chronic disease and other complications among the aging population [e.g., Healthy People 2020 (15)], evidence-based programs (EBP) for older adults have emerged and proliferated in the US (16)(17)(18)(19)(20). In recent years, multiple EBP have been disseminated through the US aging services network to address different healthcare concerns www.frontiersin.org ...
... While it is assumed that distinct EBP attract specific types of participants (17,18) and certain types of participants are more likely to attend EBP at particular types of delivery sites (16), the extent to which EBP attract and retain potentially vulnerable older adults is not fully understood. Older adults deemed vulnerable can include those with comorbid conditions (22), in advanced age, and of racial/ethnic minority status (23)(24)(25). ...
... We note that an overwhelming number of women participated in these programs, which, in part, seems to reflect the larger proportion of women representing the American older adult population. However, this is frequently reported in other national studies of EBP for older adults (16)(17)(18)20). The lower reach to males and ethnic minorities raises questions as to whether the programs lack saliency to specific subpopulations or whether the providers are finding it difficult to find the right strategies to recruit such subpopulations. ...
Older adults, who are racial/ethnic minorities, report multiple chronic conditions, reside in medically underserved rural areas, or have low incomes carry a high burden of chronic illness but traditionally lack access to disease prevention programs. The Chronic Disease Self-Management Program (CDSMP), A Matter of Balance/Volunteer Lay Leader (AMOB/VLL), and EnhanceFitness (EF) are widely disseminated evidence-based programs (EBP), but the extent to which they are simultaneously delivered in communities to reach vulnerable populations has not been documented. We conducted cross-sectional analyses of three EBP disseminated within 27 states throughout the United States (US) (2006–2009) as part of the Administration on Aging (AoA) Evidence-Based Disease and Disability Prevention Initiative, which received co-funding from the Atlantic Philanthropies. This study measures the extent to which CDSMP, AMOB/VLL, and EF reached vulnerable older adults. It also examines characteristics of communities offering one of these programs relative to those simultaneously offering two or all three programs. Minority/ethnic participants represented 38% for CDSMP, 26% for AMOB/VLL, and 43% for EF. Rural participation was 18% for CDSMP, 17% for AMOB/VLL, and 25% for EF. Those with comorbidities included 63.2% for CDSMP, 58.7% for AMOB/VLL, and 63.6% for EF while approximately one-quarter of participants had incomes under $15,000 for all programs. Rural areas and health professional shortage areas (HPSA) tended to deliver fewer EBP relative to urban areas and non-HPSA. These EBP attract diverse older adult participants. Findings highlight the capability of communities to serve potentially vulnerable older adults by offering multiple EBP. Because each program addresses unique issues facing this older population, further research is needed to better understand how communities can introduce, embed, and sustain multiple EBP to ensure widespread access and utilization, especially to traditionally underserved subgroups.
... The program is offered by many community organizations: senior and community centers, YMCAs, residential settings, and others. 5,6 Since 1999, EF has reached 59,065 participants in 889 community sites in 41 states (P Denison, Sound Generations, personal communication, 2016). ...
... 16 Adoption, Implementation, and Organizational-Level Maintenance State-level increases in EF adoption and implementation were facilitated by broad-based technical assistance, infrastructure development, creative funding, and recruitment and retention strategies salient to local communities. 6 No study reported the proportion and representativeness of organizations adopting or maintaining the program. ...
Introduction:
Physical activity has many benefits for older adult physical and mental health. Enhance®Fitness (EF) is an evidence-based group exercise program delivered by community-based organizations. The purpose of this study was to review recent evidence on the dissemination and implementation of EF.
Methods:
A scoping review of qualitative and quantitative studies with EF as main focus was conducted. CINAHL, PubMed, PubMed Central, SCOPUS, Web of Science, PsycINFO, and Google Scholar were searched between October and November 2015 for data-based studies on EF published in 2010-2015. Two team members abstracted each paper independently using a data abstraction tool. Results were summarized using the Reach, Effectiveness, Adoption, Implementation, and Maintenance (RE-AIM) framework.
Results:
Seventeen publications met inclusion criteria. EF has reached and is effective across a broad population base, including individuals with low SES and diverse ethnic/racial backgrounds. EF participation may be associated with reduced risk for falls requiring medical care, and is associated with fewer hospital admissions. Analyses of medical cost savings from EF participation and program implementation costs suggest economic benefits of EF implementation for communities. Organization-level maintenance is facilitated by program-specific and organizational factors, such as instructor training and funding. Individual-level maintenance is facilitated by program structure, absence of pain, and increased quality of life.
Conclusions:
More-rigorous evidence is needed about the association between participation in EF and conditions such as falls. Evaluation of program fidelity, adaptations, and sustainability is limited; more-systematic examination across population groups and types of organizations would help ensure older adults continue to benefit from EF participation.
... Exceeding programmatic goals of having 50,000 participants complete CDSME program workshops (12), over 100,000 participants were reached more quickly than in previous efforts (16). Further, with the exception of a predominant female participant population typically served with health promotion programs (16)(17)(18), participants were representative of the U.S. population and not just easy-to-reach subgroups. The ability of this initiative to quickly reach 100,000 participants can be attributed to many factors. ...
... Underserved populations (e.g., African Americans) were overrepresented in this study because of the focus of the larger initiative to serve this subgroup of Americans. However, males were underrepresented in this study, as they traditionally are in evidence-based programs delivered through the aging services network (16)(17)(18). Despite these limitations inherent when using administrative records, we nevertheless believe this study represents a unique examination about how a national evidencebased dissemination rolls out over time, what infrastructure facilitates this type of grand-scale roll out, and what types of participants are reached. ...
With a near 20-year developmental history as an evidence-based program, the suite of Chronic Disease Self-Management Education (CDSME) programs were selected in 2010 for grand-scale dissemination in a federally supported initiative to improve the health of older Americans. The primary charge of this national effort was to establish a sustainable program delivery system for empowering American adults with one or more chronic conditions to better manage their health. The current study focused on a series of dissemination and implementation science research questions to: (1) examine the geographic distribution of participation in this initiative across the Unites States; (2) describe workshop characteristics engaged to reach program participants in various settings; and (3) describe personal characteristics of the first 100,000 participants. Each subsequent entering cohort was descriptively examined to indicate whether there was constancy or change in delivery sites and populations reached over time. Findings show a strengthening of the workshop delivery infrastructure in that it took 9.4 months to reach the first 25,000 participants in 853 counties compared to 5.4 months to reach the last 25,000 participants in 1,109 counties. The workshop delivery characteristics and participant characteristics remained relatively consistent across increments of 25,000 participants reached, although general trends were observed for some variables. For example, after reaching the first 25,000 participants, subsequent groups of 25,000 participants were reached more quickly. Additionally, workshops were increasingly delivered in ZIP Codes with higher percentages of families residing below the federal poverty line. As more participants were reached, more participants with chronic conditions were enrolled. This national translational study illustrates the rapid expansion of CDSME programs throughout the United States and capability to reach diverse populations in a variety of settings.
... We report here the outcomes of the Physical Therapists-Recommending Enhance®Fitness to Expand Reach (PT-REFER) trial, testing a capacity-building intervention with Young Men's Christian Association (YMCA) Associations (hereafter referred to as Associations) to form CCLs with physical-therapy clinics, thereby increasing PT referrals to Enhance®Fitness (EF). EF is an evidence-based PA program designed for older adults and delivered by Associations and other community organizations across the country [13][14][15]. We hypothesized that implementing the intervention would lead to increased older adult enrollment in EF compared to usual delivery of EF. ...
Background
Most older adults do not meet recommended guidelines for physical activity. Referrals from physical therapists (PTs) to community- and evidence-based physical-activity programs like Enhance®Fitness have potential to address this gap. We tested an intervention intended to increase referrals of older adults to Enhance®Fitness programs offered at YMCAs.
Materials and methods
We developed a capacity-building intervention that included a structured toolkit and technical-assistance calls. From April 2016 to September 2018, using stratified randomization, we conducted a trial with 20 YMCA Associations randomized into intervention and control arms. The primary outcome was the number of new Enhance®Fitness enrollees during the trial period. Using both quantitative and qualitative methods, we also conducted process and intermediate-outcome evaluations to assess intervention implementation and Association outreach activities, barriers, and facilitators.
Results
The intervention was implemented as intended, but PT outreach was similar for both intervention and control YMCA Associations. The intervention arm had similar enrollment (1695 new enrollees) to the control arm (1326 new enrollees; 95% confidence interval, −47%–199%, P = 0.61). Interviews revealed that barriers, including lack of staff and time for outreach, limited capacity for Enhance®Fitness program growth, and competing priorities, outweighed facilitators, including existing partnerships, presence of an outreach team, senior leadership support, and infrastructure for referrals.
Conclusions
YMCA Associations in the intervention arm were unable to increase their outreach to PTs and enrollment in Enhance®Fitness. Our evaluation findings indicate that community organizations that prioritize program growth, have support at all organizational levels, and allocate staff and time for outreach and partnership development may be more successful in creating sustainable linkages with clinical partners and increasing evidence-based-program reach.
... In this study, the highest utilized resource was senior centers, primarily among community-dwelling and service-poor residents. Senior centers are community hubs for community-based services, especially in their offering of evidence-based programs that address health topics including chronic disease, fall prevention, and physical activity [63][64][65][66][67]. However, senior centers use and locale may limit utilization. ...
Background: The majority of older adults prefer to remain in their homes, or to “age-in-place.” To accomplish this goal, many older adults will rely upon home- and community-based services (HCBS) for support. However, the availability and accessibility of HCBS may differ based on whether the older adult lives in the community or in a senior housing apartment facility. Methods: This paper reports findings from the Pathways to Life Quality study of residential change and stability among seniors in upstate New York. Data were analyzed from 663 older adults living in one of three housing types: service-rich facilities, service-poor facilities, and community-dwelling in single-family homes. A multinomial logistic regression model was used to examine factors associated with residence type. A linear regression model was fitted to examine factors associated with HCBS utilization. Results: When compared to community-dwelling older adults, those residing in service-rich and service-poor facilities were more likely to be older, report more activity limitations, and provide less instrumental assistance to others. Those in service-poor facilities were more likely to have poorer mental health and lower perceived purpose in life. The three leading HCBS utilized were senior centers (20%), homemaker services (19%), and transportation services (18%). More HCBS utilization was associated with participants who resided in service-poor housing, were older, were female, and had more activity limitations. More HCBS utilization was also associated with those who received instrumental support, had higher perceived purpose in life, and poorer mental health. Conclusions: Findings suggest that older adults’ residential environment is associated with their health status and HCBS utilization. Building upon the Person–Environment Fit theories, dedicated efforts are needed to introduce and expand upon existing HCBS available to facility residents to address physical and mental health needs as well as facilitate aging-in-place.
... The majority of participants in our study (75%), continued to participate in EF classes. The high percentage of women in the study was expected, as 84.2% of all EF participants that enrolled between 2006 and 2009 were women 42 . The demographic data we collected from former and current participants in this study were comparable and is shown to have no significant impact on the rate of dropout from EF. ...
Physical activity has many benefits for older adults, but adherence is often low. The purposes of this study were to (1) identify motivators and barriers for participation in EnhanceFitness (EF), a group-based exercise program; and (2) quantitatively examine the association between motivators, barriers and individual characteristics, and ongoing participation in the program.
This was a prospective, cross-sectional study. We mailed a pilot, investigator-developed survey to assess motivators and barriers to exercising to 340 adults who started a new EF class, regardless of their attendance rate. We precoded surveys on the basis of class attendance, with former participants defined as having no attendance a month or more before a 4-month fitness check.
Of the 241 respondents (71% response rate), 61 (25%) were precoded as former participants and 180 (75%) as current participants. The mean age of respondents was 71 years and they were predominately female (89%). More than half of respondents were whites (58%), and almost half were married (46%). Former participants reported lower total motivation scores than current participants (P < .01) and had a significantly higher mean total barrier score (P < .001). The effects of 5 barriers ("Class was too hard," "Class was too easy," "I don't like to exercise," "Personal illness," and "Exercise caused pain") and 2 motivators ("I want to exercise" and "I plan exercise as part of my day") were significantly different between current and former participants. Discrete event history models show that dropout was related positively to ethnicity (whites were more likely to drop out) and health-related barriers.
In newly formed EF classes, participants who drop out report more program, psychosocial, and health barriers, and fewer program and psychosocial motivators. Total barrier score and health barriers significantly predict a participant's dropping out, and white ethnicity is associated with a higher likelihood of dropping out.
Employing strategies that address health barriers to participation could improve attendance rates for group-based exercise programs.
Background and Objectives
This study evaluated the effectiveness of the evidence-based, Enhance®Fitness (EF) physical activity (PA) intervention in improving arthritis symptoms, physical and mental function, and PA in adults with arthritis.
Research Design and Methods
This was a community-based, randomized, controlled effectiveness trial that switched to a non-randomized controlled trial. Participants were sedentary/low-active adults, aged ≥ 18 years, with self-reported physician-diagnosed arthritis, who were assigned to an immediate (IG) or delayed group (DG) (12-week, wait-list control group). Classes were held thrice weekly for 12 weeks at 17 community sites in four urban and five rural West Virginia counties. Data were collected at baseline, 12 weeks, and 24 weeks. The RE-AIM Framework evaluated EF’s: 1) reach (enrollment); 2) effectiveness (outcomes); 3) adoption (proportion of sites/instructors that delivered EF); 4) implementation (attendance, fidelity, adverse events, satisfaction); and 5) maintenance (EF continuation). Outcomes were analyzed using linear mixed-effects regression.
Results
There were 323 adults with a mean age of 68.3 years (range 27-95). Reach was 74%; site and instructor adoption rates were 100% and 55%, respectively; attendance (1.8 sessions per week) and fidelity were good; injury rate was low (3.8%); participants were highly satisfied and experienced improvements in arthritis symptoms and physical function; and 27% of instructors and 18% of sites continued EF.
Discussion and Implications
Enhance®Fitness was safe and effective in improving arthritis symptoms and physical function in sedentary/low-active adults with arthritis, across the adult age spectrum, under real-world conditions, in both urban and rural communities.
Despite evidence of the benefits of regular physical activity, many older adults are not physically active. Health professionals are challenged to replicate evidence-based programs to address low levels of physical activity among members of their communities.
EnhanceFitness is an evidence-based group exercise program developed in Seattle to increase the strength, flexibility, and balance of older adults. Hawai`i's Healthy Aging Partnership supported the rural island of Kaua`i to select, adapt, implement, and evaluate EnhanceFitness to increase physical activity among older adult residents (75% Asian/Pacific Islander [API]).
Evaluation measures of the replication of EnhanceFitness included fidelity of EnhanceFitness delivery and participants' attendance, satisfaction with the program, confidence to exercise regularly, and pre-post fitness check measures of physical performance (chair stands, arm curls, and the up-and-go test).
Between July 2007 and December 2010, 223 Kaua`i residents enrolled in EnhanceFitness; 178 (80%) participated at least 4 months and completed the 4-month fitness checks. EnhanceFitness classes were offered with a high degree of fidelity, and both API and white participants significantly improved their physical performance (chair stands, t = -11.06, P < .001; arm curls, t = -6.66, P < .001; and up-and-go test, t = 6.56, P < .001). Participants reported high satisfaction with the program and instructors and high confidence to continue to exercise regularly.
EnhanceFitness is replicable in Hawai`i and increased physical performance among API and white older adults. This case study outlines a replication process that other communities can follow.
The elderly consume a disproportionate amount of health care resources, and the recent trend in obesity will only escalate costs. EnhanceFitness® (EF) is an exercise program designed to increase the strength, flexibility, and balance of older adults. A comprehensive controlled study in Washington state of an elderly population has shown that participants who attend at least one EF class per week reduce healthcare costs by 20% per year. The present study reports the costs and potential benefits of replicating EF on Kaua'i. For Kaua'i the annual cost of an EF pilot program for 132 clients would be 344,256 per year. The expected investment to return ratio, I-R ratio, for EF on Kaua'i is about 1-1.8. On economic grounds, a case can be made to support and expand these types of programs. In these times of budget cuts, cost-benefit analysis provides a common economic "language" to prioritize among different programs.
Fifteen to twenty years is how long it takes for the billions of dollars of university-based research to translate into evidence-based policies and programs suitable for public use. Over the past decade, an exciting science has emerged that seeks to narrow the gap between the discovery of new knowledge and its application in public health, mental health, and health care settings. Dissemination and implementation (D&I) research seeks to understand how to best apply scientific advances in the real world, by focusing on pushing the evidence-based knowledge base out into routine use. To help propel this crucial field forward, this book aims to address a number of key issues, including: how to evaluate the evidence base on effective interventions; which strategies will produce the greatest impact; how to design an appropriate study; and how to track a set of essential outcomes. D&I studies must also take into account the barriers to uptake of evidence-based interventions in the communities where people live their lives and the social service agencies, hospitals, and clinics where they receive care. The challenges of moving research to practice and policy are universal, and future progress calls for collaborative partnerships and cross-country research. The fundamental tenet of D&I research-taking what we know about improving health and putting it into practice-must be the highest priority.
This study examined the effectiveness of participation in EnhanceFitness (EF) (formerly the Lifetime Fitness Program), an established community-based group exercise program for older adults. EF incorporated performance and health status measure testing in year 2000. Initial performance was compared to age and gender-based norms to classify participants as within or at or above normal limits (WNL) or below (BNL). In 2,889 participants who participated in outcomes testing, improvements were observed at 4 and 8 months on performance tests for both subgroups. Participants’ self-rating of health improved at 8 months. All participants improved on performance tests. Implementation of performance-based measures in community studies is possible. Challenges included selecting measures, staff training, collecting performance measures, and deciding on time points for data collection. Older adults can maintain and/or improve physical function through participation in EnhanceFitness.
Successful health promotion and disease prevention efforts require not only the development of evidence-based programs but also the broad dissemination of those programs. In this article, we trace the development and dissemination of an evidence-based exercise program for older adults, EnhanceFitness (EF). We summarize its effectiveness, describe its adoption by partners, and highlight best practices related to program maintenance. We organize the article around a program planning and evaluation framework called RE-AIM. The EF enterprise remains robust because of its scientific evidence (it works), easy replicability, low-cost, strong advocates, timely technical assistance, and affiliation with an academic partner.
To determine whether participation in a physical activity benefit by Medicare managed care enrollees is associated with lower healthcare utilization and costs.
Retrospective cohort study.
Medicare managed care.
A cohort of 1,188 older adult health maintenance organization enrollees who participated at least once in the EnhanceFitness (EF) physical activity benefit and a matched group of enrollees who never used the program.
Healthcare costs and utilization were estimated. Ordinary least squares regression was used, adjusting for demographics, comorbidity, indicators of preventive service use, and baseline utilization or cost. Robustness of findings was tested in sensitivity analyses involving continuous propensity score adjustment and generalized linear models with nonconstant variance assumptions.
EF participants had similar total healthcare costs during Year 1 of the program, but during Year 2, adjusted total costs were 3,384; P=.02), which did not result from high-cost outliers. Enrollees who attended EF an average of one visit or more per week had lower adjusted total healthcare costs in Year 1 (-1,784; P<.001) than nonusers.
Health plan coverage of a preventive physical activity benefit for seniors is a promising strategy to avoid significant healthcare costs in the short term.
Regular exercise is associated with many health benefits. Community-based exercise programs may increase exercise participation, but little is known about cost implications.
A retrospective, matched cohort study was conducted to determine if changes in healthcare costs for Medicare-eligible adults who choose to participate in a community-based exercise program were different from similar individuals who did not participate. Exercise program participants included 1114 adults aged > or = 65 years, who were continuously enrolled in Group Health Cooperative of Puget Sound (GHC) between October 1, 1997 and December 31, 2000 and who participated in the Lifetime Fitness (exercise) Program Copyright (LFP) at least once; three GHC enrollees who never attended LFP were randomly selected as controls for each participant by matching on age and gender. Cost and utilization estimates from GHC administrative data for the time from LFP enrollment to December 31, 2000 were compared using multivariable regression models.
The average increase in annual total healthcare costs was less in participants compared to controls (+642 dollars vs +1175 dollars; p=0.05). After adjusting for differences in age, gender, enrollment date, comorbidity index, and pre-exposure cost and utilization levels, total healthcare costs for participants were 94.1% (95% confidence interval [CI], 85.6%-103.5%) of control costs. However, for participants who attended the exercise program at an average rate of > or = 1 visit weekly, total adjusted follow-up costs were 79.3% (95% CI, 71.3%-88.2%) of controls.
Including a community exercise program as a health insurance benefit shows promise as a strategy for helping some Medicare-eligible adults to improve their health through exercise.
Because preventing functional decline in older adults is a national priority and senior centers have been identified as potentially important venues for health-promotion activities, a trial of a multicomponent disability prevention program was conducted at a senior center.
One hundred older adults were recruited for a 6-month randomized clinical trial. All members of the experimental group received an exercise intervention, nutrition counseling, and a home safety assessment. Smoking and alcohol interventions were delivered to at-risk subjects. Outcome variables included the Medical Outcomes Study Short Form (SF-36) health survey, the CES-Depression scale, bed days, and restricted-activity days.
A single study announcement resulted in a response sufficient to recruit 100 subjects. The exercise program was well received: 85% of intervention subjects completed the 6-month program and adherence was excellent, with over 90% attendance at exercise classes. After 6 months the intervention group had significantly better scores on 7 of 8 SF-36 subscales and fewer depressive symptoms than controls.
Senior centers may be excellent sites for community-based health promotion interventions: participation and adherence rates may be acceptable, interventions can be designed that are feasible in this setting, and these interventions appear to affect health status positively. The study program improved physical and psychosocial functioning and is a promising model for preventing functional decline through activities based at senior centers.
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Creating a business plan for evidence-based health promotion programs
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