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Correspondence: Address correspondence to Susan L. Hughes, DSW, Center for Research on Health and Aging, University of Illinois at Chicago, 1747 W. Roosevelt Road, Room 558, M/C 275, Chicago, IL 60608. E-mail: shughes{at}uic.edu
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Abstract |
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Key Words: Exercise • Needs and demand • Providers • Facilities
Despite these documented benefits, estimates suggest that 33% of men and 50% of women over the age of 75 engage in no physical activity (CDC, 2004). The prevalence of inactivity varies by racial and ethnic group and by gender, from 47% in White women aged 75 and older to 59% in older Black men and 61% in older Black women (Rejeski, Brawley, McAuley, & Rapp, 2000). Healthy People 2010 national health objectives recommend an increase in the proportion of adults who engage in regular, moderate physical activity for 30 min or more per day or vigorous physical activity 3 or more days per week for 20 min or more per occasion (U.S. Department of Health and Human Services, 2000). Current estimates suggest that, of older adults who engage in any physical activity, only 25% aged 65 to 74 and 15% aged 75 and older meet these recommendations for vigorous or moderate physical activity (CDC, 2002). A Robert Wood Johnson Foundation (2001) report identified the removal of barriers to increased physical activity among older adults as a major current national public health need. However, a potential key barrier to engaging in physical activity—the available supply of affordable physical activity programs for older adults—has not been studied to date.
In this article we address this important issue by presenting findings from a multisite survey of physical activity programs for older adults in seven diverse geographic locations across the United States. Members of the Healthy Aging Research Network (HAN) conducted the survey between January and July 2003 with support from a CDC program—the Prevention Research Centers (PRCs). The goal of the PRC program is to support the development of academic and community partnerships to conduct prevention research, and each PRC conducts research and demonstration projects to address the most pertinent public health problems (Doll & Kreuter, 2001).
The HAN survey built on the methods and findings of an earlier survey conducted by the Senior Health Alliance Promoting Exercise (SHAPE) in Cook County, IL, which compared the existing supply of physical activity programs to potential demand among older adults. The survey found that approximately 4% of the potential demand, defined as persons older than 65 in Cook County, based on the 2000 Census, could be met by the current supply (Hughes & Molina, 2002). The purposes of the current survey were to (a) obtain new information regarding the types of facilities that provide programs for older adults and the types of activities provided; (b) undertake an initial effort to estimate the supply of these programs in a variety of geographic areas across the nation; and (c) compare capacity data for the specific geographic areas studied to estimate the potential demand for programming by using U.S. census data. To our knowledge, this is the first study of the extent of physical activity programming for older adults at multiple sites across the United States.
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Methods |
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In addition to collecting data on existing physical activity programs for older adults, the survey collected information about reasons that some organizations do not provide programs. The first survey questions asked respondents if they provided programming specifically for older adults or if older adults participated in any of their programs (e.g., 1. Do you provide physical activity programs designed specifically for older adults? 2. Do you have physical activity programs that younger as well as older adults attend?). If respondents answered "no" to both questions, they were asked why they did not provide programming for seniors. If respondents answered "yes" to either question, the instructions asked respondents to complete the entire questionnaire.
Several survey items addressed program capacity. They included questions on the maximum capacity of older adults (aged 65+) per week, the actual number of older-adult participants per week, whether there were waiting lists for activities, and the estimated unduplicated number of older-adult participants in the past year.
Organizations that provide physical activity programs for older adults pilot tested the survey twice. The National Council on the Aging conducted the first pilot test in 14 senior centers across the country. HAN members at the University of North Carolina conducted the second pilot test at 10 community sites. Survey items were revised and clarified based on the pilot findings.
Sampling Frame
All seven participating HAN academic centers agreed to participate in the study, but each site chose its own geographic target area to study. The Seattle site, for example, wanted to do an in-depth assessment of programming availability within a precisely defined, underserved minority community. In contrast, the Chicago site had previously surveyed Cook County, had already developed an initial sampling frame, and wanted to update its findings on the same population of respondents. As previously noted, the size of the geographic target area included in the surveys varied across sites from 26 square miles (67.34 km2) in southwest Seattle to 8,194 square miles (21,222.46 km2) in San Luis Valley. Despite this variation in size, each participating site attempted to assemble as exhaustive a list of potential physical activity providers as possible within its geographic area, given available resources. To err on the side of inclusiveness, each site initially included a broad spectrum of community organizations thought to provide physical activity programs for older adults. Thus, the initial sampling frames included a wide array of potential providers, including senior centers, community centers, YMCAs or YWCAs, commercial gyms, county and city parks and recreation facilities, churches, schools, hospitals, private or public housing for seniors, and residential facilities for able-bodied older adults (e.g., independent-living facilities). These sampling frames included most of the organizations that might have had contracts with Area Agencies on Aging and all known senior centers. Information gathered during the survey process led to refinement of the sampling frames and elimination of initially suggested facilities or programs that no longer existed, had moved from the area, or did not provide physical activity programming for persons of any age.
Survey Administration
Each HAN site acquired approval for the study protocol from its human subject research institutional review board. All HAN sites began survey administration at the same time and followed similar protocols. Five sites conducted surveys initially by mail and followed up by telephone or in person. The remaining two sites administered the survey primarily by telephone. One of the seven sites also made the survey accessible on the Internet. In most cases, sites used a combination of methods to maximize response. Initial contact by an introductory letter or phone call gave recipients information about the HAN, the survey's history and purpose, benefits of the survey to the organization (specifically, future publication of directories of available programs and facilities), HAN site-specific contact information, and expected survey timing. This introduction also requested confirmation of the appropriate contact person in the facility or organization to receive the survey. Most HAN sites waited 2 weeks after the introduction letter or call to mail the survey. For the HAN site that conducted the survey by telephone, the initial call also served as the first attempt to complete the survey. If the first mailing or phone calls did not generate responses, all sites made follow-up calls or on-site visits to nonrespondents. The follow-up process spanned several months. During follow-up, sites offered organizations the choice of responding to the survey by telephone or in person, and having the survey re-sent or faxed. Some sites with a comparatively small number of providers in their target areas were able to achieve very high response rates by calling repeatedly until they achieved a response. Others with larger numbers of providers in their target areas had lower response rates, but still used multiple call backs to all potential respondents. The use of a combination of administration methods yielded higher response rates than any single method and offered the opportunity to clarify respondents' questions about the survey.
Each HAN site recorded survey activities on an Excel tracking sheet that was separate from data received from programs and facilities. This tracking sheet listed the organization name or identification number, contact information, date of initial mailing, follow-up activity, response dates, and any specific data-collection issues that arose. The University of Washington HAN site's Health Promotion Research Center (UWHPRC) served as the central data-collection site. UWHPRC created a universal Microsoft Access database and provided each HAN site with detailed instructions for data entry. Submitted data excluded all personal identifiers (institutional or individual). UWHPRC conducted a database reliability check 1 month after each HAN site began using the database. HAN sites sent all survey data to UWHPRC for analysis when data collection and entry were completed.
Table 2 provides sampling frame sizes for each HAN site (adjusted for initially incorrect or incomplete information as described earlier), response rates, and the number of facilities in each sample that offered programs. Respondents included organizations that offered physical activity programs for older adults and completed the entire survey, organizations that did not offer physical activity programs for older adults and completed the abbreviated version of the survey, and organizations that responded orally that they did not offer physical activity programs for older adults and did not complete any version of the survey.
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Results |
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Of 326 facilities that stated they did not offer programs and provided a reason for lack of programs, 161 (50%) identified the most common reason as a perceived lack of interest from older adults, followed by lack of funding (46%), lack of staff interest (44%), lack of staff knowledge regarding frail adults (34%), staff shortage (34%), lack of staff training regarding older adults (24%), and concerns about liability (23%). Respondents could give multiple reasons for not offering programs.
Of 675 facilities that provided programming designed for or used by older adults, 652 (97%) provided information regarding the specific types of programs offered (Table 3). Overall, aerobic programs were offered most frequently (73%), in contrast to flexibility (47%) and strength training (26%), and 31% of facilities offered multicomponent programs. Among facility types, senior centers most frequently offered aerobic programs, and hospitals and clinics most frequently offered strength-training and flexibility programs.
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We also report findings regarding two measures of demand. The first measure estimates demand as a function of the existence of waiting lists to gauge demand for physical activity programming in each geographic area (Table 6). Only 4% of programs reported that they had waiting lists—a consistent finding across all sites. The second measure compares the U.S. census population at each site with reported participation in programs. Of 1,123,401 total older adults that the 2000 Census enumerated across the seven sites combined, the facilities identified 69,634 individuals as current weekly program participants. This number of participants equals 6% of the total older-adult population across the sites. The participation percentage varied from 3% in Pittsburgh to 28% in Colorado and was generally higher in areas with the fewest numbers of programs. It is important to note that these percentages, although low, may overestimate participation because they likely include individuals who participated in more than one activity.
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Finally, responses to several survey items indicate the presence of program-management issues. First, nonresponses and follow-up calls to a number of facilities regarding the aforementioned capacity items revealed that several respondents had difficulty documenting the number of persons served per year or the number of persons attending programs during a given year and had a particularly difficult time estimating the number of persons who could be served by equipment as opposed to classes.
Other responses concerning program-management issues show that, for the 675 facilities offering programs, 49% conducted program evaluations, 74% tracked attendance, 47% tracked participant progress, and 56% trained instructors. Senior centers and hospitals, more than other facilities, performed program evaluations (62% and 70%, respectively) and tracked attendance (83% and 89%, respectively), whereas churches were least likely to conduct program evaluations (38%) or track attendance (64%). Hospitals also were most likely to train instructors (81%). Forty-one percent of organizations indicated an interest in obtaining assistance with programming for older adults.
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Discussion |
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The HAN physical activity program capacity survey provides new information regarding the types of organizations that provide programs to older adults and the types of activities provided. The data also yield an estimate of the supply of these programs in a variety of settings across the nation, and they provide crude estimates of the existing supply compared with the potential demand for programming based on U.S. census data for the specific geographic areas studied.
With respect to those facilities that do not provide programs, the most commonly reported reason cited was a perceived lack of interest from older adults (50%), followed by lack of funding, lack of staff interest, and lack of staff knowledge regarding frail older adults. This finding indicates that substantial effort has to be invested in educating older adults about the benefits of physical activity, in increasing funding for programs, and conducting staff training regarding the exercise needs and capacities of older adults.
The overall low percentage of total population served (6% across study sites) is another noteworthy finding of the survey. The fact that study sites with the highest response rates reported greater attendance on average tempers our confidence in this finding. Improved response rates could result in an upward adjustment of attendance. In contrast, the data may overestimate participation because some individuals participate in more than one physical activity program in a given week. For example, they may attend an aerobics class and also participate in a senior golf league. Despite these cautionary notes, this indicator of program participation causes concern regarding the engagement of older adults in physical activity. Even if we take into account individuals in institutions and the portion of the older adult population that prefers individual physical activity to structured programs, a significant gap remains to be filled.
For example, consider Cook County, which, according to data from the 2000 Census, has 630,265 persons aged 65 and older (U.S. Census Bureau, 2000). CDC (2003) data indicate that nationally about 4% of the elderly population resides permanently in nursing homes, reducing the size of the relevant Cook County population to roughly 600,000. If we further estimate, using national averages on participation in leisure-time physical activity, that 33% of the population is currently sedentary, that reduces the number of persons in Cook County needing programs to 198,000 (CDC, 2001). If we further assume, on the basis of prior reports in the literature, that 28% of the remaining population prefer group as opposed to individual or home-based exercise, then we estimate that 55,440 persons not currently involved in facility-based programming in Cook County might participate in and benefit from programming if it were available (Mills, Stewart, Sepsis, & King, 1997). Because the findings presented in this article indicate that 31,171 older adults already participate in programs, program capacity in Cook County would have to increase by 78% to meet the needs of this group, assuming that we can motivate them to become involved.
Findings regarding attendance per facility type are also of interest. A majority of participants (57%) attend programs that are not geared specifically to older adults, and 43% attend programs tailored for older adults. Across all programs offered, 55% are not geared to older adults, and 45% of programs target only older adults. These data underscore the important role of general physical activity programs in addressing the needs of both older and younger adults. Not all older adults need specialized or senior-only programs. These data demonstrate the key contribution that private-sector organizations make to physical activity programming. Accordingly, as we move to build capacity, we must look both to the private sector and to traditional senior-service organizations for growth in size and program scope.
Additional need for programming documented by survey results is also of interest. First, findings indicate that only 31% of 163 facilities that serve non-English-speaking populations tailor programs for non-English-speaking participants. This finding demonstrates a need for additional focus on non-English-speaking populations. Second, given that attendance largely parallels program offerings and that 73% of facilities offer some form of aerobic activity, it is not surprising that aerobic programs are best attended. However, this finding also raises the question of whether facilities provide what consumers request or whether consumers use what is available. Another consideration relates to consumer and organization perceptions about what constitutes appropriate and safe activity for older adults. For example, flexibility programs are widely believed to be safe and low risk, whereas strength training is less familiar to older adults, and both older adults and organizations that serve them may perceive it as a more risky undertaking.
Given the strong evidence concerning the benefits of strength-training activity for older adults (CDC, 2004), these data point clearly to the need to develop more strength-training programs and to engage a higher percentage of older adults in these programs. A need to create demand for such programs through public education also may be indicated. It is likely that strength training requires technical assistance for providers to support sound program development.
This study has limitations that merit discussion. The communities surveyed have diverse ethnic and geographic characteristics but constitute a convenience sample and do not represent the nation as a whole. Although the actual data collected were consistent across sites, administration methods varied (e.g., telephone, mail, and in-person interviews). For example, South Carolina used a telephone survey as the primary administration method because the site believed it would be better received, particularly at churches in its sampling frame. This variability can affect response rates. Moreover, some sampling-frame differences existed across sites. For example, in some areas, churches generally did not offer programs; in other communities, faith-based organizations represented a key provider type. In those cases, sites chose to include or exclude specific types of organizations. Other types of organizations like Federally Qualified Health Centers also were not included.
In some instances, responses indicated possible problems among responding organizations relative to the estimation of capacity. For example, some organizations could not provide data pertaining to the number of persons served over the course of a year or the number of persons in attendance during a week. Organizations had a particularly difficult time estimating the number of persons who could be served by using equipment as opposed to attending classes. Similarly, organizations serving both older and younger adults had to estimate participants' ages (older or younger than age 65), and they found estimating use by older adults to be challenging. Other program-management issues noted by survey respondents included limited attention to evaluating programs, tracking participant progress, and training instructors. These management issues also may be appropriate foci for technical assistance, especially because 41% of the surveyed organizations indicated an interest in obtaining assistance with their programming for older adults.
Despite these limitations, findings from this survey suggest that the current supply of physical activity programs designed for older adults in the target communities does not adequately meet potential demand for programs by older adults. More energy should be focused on increasing demand by raising awareness of the importance of physical activity among older adults and reducing barriers to exercise. The barriers perceived by providers indicate a substantial need for health-promotion campaigns for users and providers, as well as increased funding for programs. Future research should examine ways to refine the survey sampling methodology, streamline the survey instrument, and replicate this survey in other communities. These efforts are vital if we are to obtain valid data on the existing supply of physical activity programs and be empowered to make valid assessments of the fit between supply and demand in the future.
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Footnotes |
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We acknowledge the following people for their contributions to survey development, data collection, or manuscript review: Melissa Kealey, University of California, Berkeley; Jennifer I. McLean, University of Colorado; Thomas Prohaska, Ella Fermin, Megan Renehan, University of Illinois at Chicago; members of the Cook County Senior Health Alliance Promoting Exercise; Christen Sible, Cindy Schrauder, Michael Randall, Carol Giuliani, Franzi Zabolitizki, Victor Marshall, Mary Altpeter, and Tiffany Small, University of North Carolina; Jane Schall, University of Pittsburgh; Harriet Williams, Sara Wilcox, Bridget Kane, Larissa Oberrecht, Jill Maxwell, and Joey Vrazel, University of South Carolina; Gwen Moni and James LoGerfo, University of Washington; and Nancy Whitelaw at the National Council on the Aging.
1 Center for Research on Health and Aging, University of Illinois at Chicago.
2 Health Promotion Research Center, University of Washington, Seattle.
3 Center for Healthy Aging, University of Pittsburgh, PA.
4 Division of Health Care Policy and Research, University of Colorado Health Sciences Center, Denver, CO.
5 Chapel Hill School of Medicine Program on Aging, University of North Carolina.
6 Berkeley School of Public Health, University of California.
7 Department of Health Promotion, Education, and Behavior, University of South Carolina, Columbia.
Decision Editor: Linda S. Noelker, PhD
Received for publication August 23, 2004. Accepted for publication February 8, 2005.
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65 years—United States, 2001. Morbidity and Mortality Weekly Report, 53, 25-26.
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