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Feasibility of Implementing the Strong for Life Program in Community Settings

Correspondence: Address correspondence to Thomas R. Prohaska, PhD, Center for Research on Health and Aging, 1747 W. Roosevelt Rd. (M/C 275), Chicago, IL 60608. E-mail: prohaska{at}uic.edu

	Abstract

TOP Abstract Methods Community Implementation Training Procedures Data Sources and Measures Results Discussion References

 
Purpose: We describe the results of the dissemination of an efficacious, home-based exercise program called Strong for Life as it was implemented in a nationwide, volunteer caregiving program called Faith in Action, including training of volunteers who implemented the program, recruitment of older adult participants, exercise adherence, and attitudes and perceptions of program staff and participants. Design and Methods: Frail, homebound older adults (N = 105) were recruited from 10 Faith in Action sites to participate in the Strong for Life exercise program. Volunteer trainers (n = 103) were trained by physical therapists to assist the older adults with the program. Surveys were conducted with older adults, volunteer trainers, and Faith in Action sites at baseline and after the older adults had been engaged in the program for 4 months. Results: Satisfaction with program components was very high: At follow-up, 100% of volunteers and 98.6% of older adults rated the program positively. Participants reported engaging in exercise on average 2.2 times per week, with 53% of the participants exercising at least 2 to 4 times per week. Participants also had significant improvements in the Short Form-20 social functioning scale. There were no serious adverse events reported. Implications: Dissemination of the Strong for Life program in a community setting using trained lay volunteers was feasible, acceptable, and safe. Existing volunteer caregiving organizations such as Faith in Action offer a feasible and safe means of disseminating late-life exercise programs to the frail older population.

Key Words: Physical activity • Homebound older adults • Dissemination • Strong for Life • Faith in Action • Exercise

Considerable literature from randomized controlled trials demonstrates the efficacy and effectiveness of physical activity programs for older adults and frail older adults (Cress et al., 1999; Judge, 2003; King, 2001; Mangione et al., 1999; Messier et al., 2000; Moore & Blumenthal, 1998; Seguin & Nelson, 2003; Yan, 1999). Physical activity in frail adults maintains or improves their physical functioning and muscle strength (Binder et al., 2002; Chandler, Duncan, Kochersberger, & Studenski, 1998; Fiatarone et al., 1994; Lord et al., 2003). It also improves their gait velocity, stair-climbing power (Fiatarone et al.), chair-to-stand time, ability to perform activities of daily living, and self-ratings of depression (McMurdo & Rennie, 1993). The benefits of strength training in the general older adult population are well documented (Brill, Macera, Davis, Blair, & Gordon, 2000; Brown, Sinacore, & Host, 1995; Hurley, 1995; Hurley & Hagberg, 1998; Singh, 2002). Singh reports that strength training may attenuate age-related loss of strength, muscle mass, and bone, and it has the potential to improve morale, depressive symptoms, and self-efficacy.

Given the prevalence of sedentary behavior among older adults, it is becoming increasingly important that successful programs reach a wider audience than those traditionally delivered through group-based programs led by exercise experts. There is evidence that older adults prefer home-based exercise programs (King, 2001). These programs are able to reach older adults who are unable or unwilling to participate in community-based physical activity programs or in individual walking programs. What makes home-based physical activity programs less appealing to health care professionals is the potential cost associated with individual one-on-one involvement with an exercise leader. Thus, a desirable program would be a cost-effective home-based physical activity program implemented in an existing community service system that is coordinated by a professional such as a case manager.

Even with demonstrated efficacy and effectiveness, most physical activity programs designed specifically for older adults are not widely disseminated in communities. The few that have made it to a wider community setting include Active for Life, Active Living Every Day (Blair, Dunn, Marcus, Carpenter & Jaret, 2001) and Strong for Life (Jette, Lachman, et al., 1999). In this article we examine the application of Strong for Life as disseminated in 10 locations nationally by partnering with the Robert Wood Johnson Foundation (RWJF) Faith in Action volunteer caregiving initiative.

We use the RE-AIM model (Glasgow, Vogt & Boles, 1999) as a conceptual framework for evaluating the success of Strong for Life dissemination. RE-AIM addresses the following: reach (proportion of the target populations that participated in the intervention); efficacy (success rate if implemented as in guidelines; defined as positive outcomes minus negative outcomes); adoption (proportion of settings, practices, and plans that adopt this intervention); implementation (extent to which the intervention is implemented as intended in the real world); and maintenance (extent to which a program is sustained over time). Our research focuses on the adoption and implementation portions of the model. Specifically, we examine dissemination of Strong for Life in a community-based intervention provided in a faith-based volunteer service program and address the degree to which the intervention was delivered as intended. Our overall goal was to determine if Strong for Life could safely and effectively be disseminated to frail, homebound older adults by using volunteer caregivers trained by experienced physical therapists. We sought to measure the perceived usefulness of Strong for Life by the site coordinators, volunteer caregivers, and participants.

	Methods

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Strong for Life Program
Strong for Life, a home-based program designed for frail and functionally limited elders, was developed and tested by researchers at Boston University Roybal Center for Enhancement of Late-Life Function and the MGH Institute of Health Professions. In randomized trials, Strong for Life achieved positive improvements in muscle strength, gait stability, and functional ability, with high adherence and participation rates. The program was safe with no adverse events (Jette et al., 1996; Jette, Lachman, et al., 1999).

The Strong for Life program uses a 35-min videotape consisting of a warm-up, 11 strengthening exercises using Thera-Bands (color-coded bands that provide positive and negative force on the muscles from light to heavy resistance), and a cool down. As a way to increase adherence and motivation, cognitive behavioral strategies are built into the program, including a motivational video, Exercise: It's Never Too Late, positive reinforcement by the exercise trainer, and behavioral incentives. Each participant's goal is to exercise 3 times a week at the resistance level specified by the trainer.

	Community Implementation

TOP Abstract Methods Community Implementation Training Procedures Data Sources and Measures Results Discussion References

 
Overview
Community dissemination of Strong for Life was attempted with an RWJF-sponsored collaboration between staff and volunteer caregivers from the national Faith in Action program and Strong for Life developers. Faith in Action is a national caregiving initiative of RWJF that comprises over 1,000 coalitions of all faiths, and social service, health, and civic organizations that train volunteers to provide care and companionship to individuals with long-term health needs. The Faith in Action network was seen as an ideal setting for implementing Strong for Life with trained volunteers who seek to help older persons maintain health and function in the community.

We developed a model of training volunteer caregivers in all elements of Strong for Life to be delivered to older adults in their homes through Faith in Action programs. This enabled researchers to design a train-the-trainer program to educate lay volunteers to teach the exercise program to participants. Grant funds supported the development of a detailed training manual and user's manual, travel support for three physical therapists to conduct training sessions at each Faith in Action site, costs of a site coordinator, training materials, VCRs, and videotapes for 10 trainers and 10 participants at each selected site. A process evaluation was done independently.

Recruitment of Sites
We recruited 10 Faith in Action sites to participate in this pilot project. Sites represented varying regions with urban and rural locations, and racial and ethnic diversity. We also selected sites on the basis of their affiliation with a hospital or university, their alliance with an existing network, or whether or not they were independent. The locations were as follows: Faith in Action of Upper Pinellas in Dunedin, Florida; Ohio Valley Interfaith Volunteer Caregivers in Wheeling, West Virginia; Interfaith Volunteer Caregivers in Newberg, Oregon; Partners in Caring at Stanford Hospital, California; Interfaith Network of Care in Milltown, New Jersey; Interfaith Volunteer Caregivers of Clark County, Wisconsin; Texas State University in San Marcos; Interfaith Volunteer Caregivers in Beaver Dam, Wisconsin; MATCH-UP Interfaith Volunteers in Boston; and the YMCA of Greater El Paso, Texas. Sites received all training materials, VCRs, and videotapes for the participants.

Recruitment of Volunteers
We selected 10 lay volunteer trainers at each site to train participants in Strong for Life. We selected volunteers on the basis of their interest, ability to attend the 2-day training session, availability to participate for 1 year, and perceived ability to motivate participants. There were no other specified inclusion criteria. We recruited volunteers from word of mouth or references from existing Faith in Action volunteers. Texas State University volunteers were graduate students in physical therapy who provided an opportunity to compare a different subset of trainers with community volunteers.

Recruitment of Participants
Site coordinators identified 10 participants, aged 60 and older, who they thought would be interested in and appropriate for Strong for Life. Other than perceptions that an older adult was frail and able to participate and benefit from Strong for Life, there were no specified inclusion criteria. To recruit participants, site coordinators made announcements to local congregations, senior centers, and retirement communities. Site coordinators also identified participants from physician referrals or existing Faith in Action volunteers. A physician's consent was required before participants could begin.

	Training Procedures

TOP Abstract Methods Community Implementation Training Procedures Data Sources and Measures Results Discussion References

 
Volunteer trainers attended a 2-day workshop at their local Faith in Action site that was taught by a team of three physical therapists. Two of the therapists conducted all workshops; a graduate-level physical therapy student was rotated into each site. Training was based on the concepts of Elements of Successful Dissemination (Farkas, Jette, Tennstedt, Haley, & Quinn, 2003; see Tables 1 and 2). For "exposure," volunteers received an instructional manual and participated in lectures and discussions to increase knowledge. To gain "experience," volunteers watched a motivational video, a Strong for Life video, and followed viewings with a discussion. Volunteers developed "expertise" in teaching Strong for Life by practicing the program, role playing, and problem solving in challenging situations through case scenarios. We wrote case scenarios to test volunteers in their abilities, which gave the physical therapists an opportunity to observe how competent volunteers were in implementing Strong for Life.

Site coordinators completed the "embedding" component by maintaining contact with volunteers and physical therapists. Site coordinators conducted monthly meetings with volunteers and maintained contact with physical therapists through an interactive Web site and hotline in which they could present concerns about Strong for Life, participants, or both. Finally, site coordinators remained in contact with each other through regular phone calls from a Faith in Action liaison and a monthly newsletter produced by the Faith in Action national office.

Matching of Older Adult Participants and Volunteer Trainers
Upon completion of the training, site coordinators matched participants and volunteers for implementation of Strong for Life. Although no specific criteria were provided, coordinators paired volunteers and participants by geographical proximity, an issue of utmost importance at the rural sites. Site coordinators also matched pairs on the basis of what they deemed to be compatible personalities.

	Data Sources and Measures

TOP Abstract Methods Community Implementation Training Procedures Data Sources and Measures Results Discussion References

 
Evaluation procedures focused on participants, volunteers, and sites. We give a summary of the process evaluation content in Table 3. Because previous randomized controlled trials of Strong for Life found positive health outcomes for participants (Jette et al., 1996; Jette, Lachman, et al., 1999), we primarily focused on questions related to dissemination of the intervention through the Faith in Action volunteers. We administered survey instruments to volunteers and Faith in Action site coordinators immediately after their introductory training. Either the volunteer or site coordinator administered survey instruments to participants when they began Strong for Life.

Site Evaluation
At baseline, we asked the site coordinator, in a series of open-ended questions, to describe the composition of his or her site, and the criteria and methods used to select volunteers and participants. We also asked site coordinators about their plans for program monitoring. At follow-up, we asked site coordinators to rate whether or not Strong for Life was a benefit to their programs; their satisfaction with Strong for Life; experiences with recruitment; whether or not they would like to continue with Strong for Life; and whether or not they would recommend Strong for Life to other Faith in Action programs.

Volunteer Trainer Evaluation
The volunteer evaluation utilized a series of measures to assess their attitudes and prior experiences engaging in and instructing exercise and physical activity; to rate the training; and to rate their self-efficacy to learn and implement the program. The follow-up survey asked them to evaluate their satisfaction with Strong for Life and skills in delivering it. Volunteers also were asked if they or their participant had difficulties with the program, and whether or not they would recommend Strong for Life to others.

Older Adult Participant Evaluation
Participant baseline surveys asked respondents for demographic information and contained open-ended questions about reasons for becoming involved in the program and expected benefits. The baseline survey utilized standard measures of self-efficacy for exercise (Lorig et al., 1996), decisional balance (Marcus, Rakowski, & Rossi, 1992; Nigg, Rossi, Norman, & Benisovich, 1998), and the Short Form-20 Health Survey (SF-20; Stewart, Hays, & Ware, 1988). Follow-up questions included participants' rating of the program, and they were asked to describe any problems with Strong for Life; self-efficacy, decisional balance, and the SF-20 also were repeated at follow-up.

Site coordinators instructed volunteers that participants were to complete and turn in adherence calendars biweekly, including dates of exercise and which color Thera-Band they had used at the time of exercising. An additional question on the calendar asked if the participant had any injuries or health problems as a result of Strong for Life. During their weekly visits with their participant, volunteers collected and reviewed calendars. The volunteer site coordinators and the program developers closely monitored adverse events.

	Results

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Sites
Demographic descriptions of participants, volunteers, and sites can be found in Table 4. The Faith in Action sites represented considerable diversity and were located in urban, rural, and suburban locations serving a wide range of populations.

In terms of the recruitment process of volunteer trainers, the response was mixed. Only 1 of the 10 sites reported that recruitment was difficult.

Site coordinators utilized a variety of criteria to recruit participants. Some site coordinators sought participants who were able to walk independently or who appeared to be able to follow through with the program. Others sought out participants based on level of frailty or those with impairments. Two site coordinators reported participant recruitment to be difficult; the remainder reported recruitment to be easy or neither difficult nor easy.

At follow-up, all sites rated the program positively (5 excellent, 4 very good, and 1 good). However, only half of the site coordinators adhered to their projected timeline, as they found that starting the program took longer than expected. Indeed, recruitment and matching of participants with volunteers presented a problem for five sites. Coordinators for seven sites reported that they faced barriers in the implementation of the program, including difficulties with volunteer trainers (hard to get enough volunteers, volunteers dropped out) and difficulties with older adult participants (participants were too frail or had too many health issues).

Volunteer Trainers
The coordinators from 10 sites enrolled 103 volunteer trainers, all of whom completed baseline surveys. Twenty-one of 103 volunteer trainers never began the program. Of those, 9 persons were not matched with a participant as a result of the deteriorating health or well-being of the participant; 2 did not start because of personal matters, 3 were unable to be placed with an appropriate participant, and 7 simply never started (e.g., participants did not want to be involved, died prior to starting, or moved to long-term-care facility). We found no significant demographic differences between volunteers who did and did not begin the program.

The volunteer trainers who began the program (n = 82) were primarily Caucasian (86.6%) and female (86%; Table 4), with a mean age of 53.2 years (range = 16–90 years; SD = 18.7). Seventy-nine volunteers (96.3%) rated the training program favorably (excellent or good) and 78 (95.1%) felt well skilled with the exercises after the training. Self-efficacy was high among volunteer trainers. Specifically, on a scale from 0 to 100 where 100 is maximal self-efficacy, self-efficacy to implement the components of the exercise program had a mean of 83.9; self-efficacy to keep older adults engaged in the program rated 78.3; and self-efficacy to motivate participant to maintain activity rated 80.0.

A total of 40 volunteer trainers were lost to attrition by the 4-month follow-up, including the 21 persons who never began the program and 19 who discontinued after they were matched with a participant. Seventeen dropped out as a result of participant issues (e.g., no match was made, participant moved to a nursing home), 9 never started the program, 3 moved away, 3 had school-related reasons for leaving (Texas State students); and 3 had competing employment issues. The remaining 5 had a variety of reasons for dropping out. Again, on measures of demographic characteristics and baseline training measures, we found no significant differences between dropouts and those completing the program.

Sixty-three follow-up surveys were completed by volunteer trainers. Those remaining in the program were surveyed at 4 months and expressed strong positive feelings about their participation. In response to the question, "Overall, how do you feel about your participation in the Faith in Action Strong for Life exercise program?" all volunteer trainers felt excellent, very good, or good. In addition, 62 of the volunteer trainers would recommend the program to others.

Older Adult Participants
Of the 108 participants enrolled, 22 never began the program. Of those, 18 were unable to begin because they had deteriorating mental or physical health, and 4 did not start because the site did not have enough volunteers. At baseline, those 86 persons who began the program had a mean age of 78.2 years (range = 59–95; SD = 8.4); 74 of them (86%) were female. Seventy-four (86%) participants were Caucasian, 9 were Hispanic, 1 was African American, 1 was Asian or Pacific Islander, and 1 was Native American. We report specific demographics at each site in Table 4. We found no significant demographic differences between participants who did and did not begin the program. Chronic conditions were prevalent in this sample at baseline; 50 participants (58.2%) reported three or more chronic conditions. Over half of the participants (54.7%, or n = 47) had osteoarthritis, and 39 of the participants (45.3%) had hypertension.

A total of 38 participants had been lost to attrition by the 4-month follow-up, including the 22 persons who never began the program and 16 who discontinued after they were matched with a volunteer trainer. Of the 16 who discontinued, 10 dropped out as a result of health-related issues and 6 lost interest.

Similar to the volunteer trainers, at follow-up, participants were very satisfied with the Strong for Life program. In response to the question, "Overall, how would you rate the Faith in Action Strong for Life exercise program?," 69 participants (98.6%) rated the program as excellent, very good, or good and 66 (94.3%) said that they would recommend Strong for Life to others.

Some problems were noted for program components, as 14 persons reported problems with operation of the Strong for Life video, 19 had troubles with their Thera-Band, 11 reported problems with the program routine, and 8 persons had concerns with the adherence calendar.

Using paired t tests for the 56 participants who completed the SF-20 questions at baseline and follow-up, in Table 5 we demonstrate a statistically significant improvement in their SF-20 social functioning scale scores following their participation in Strong for Life (p =.003). We found no significant differences in the other scale scores of physical functioning, role functioning, mental health, health perceptions, or pain.

Results from a 12-month telephone follow-up with site coordinators demonstrated that 29 of the 86 participants who began Strong for Life dropped out of the program (66% adherence at 1 year). Seventeen persons dropped out because of deteriorating health, 5 did not want to continue or lost interest, 2 reported being too busy to continue the program, 2 moved away, 2 were told by their physicians to do another activity, and 1 person died. There were no significant differences between those persons who remained in Strong for Life and those who did not.

	Discussion

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Our results indicate that, with the use of trained volunteers, Strong for Life could safely and successfully be disseminated to a wider community group of frail older persons. Although some consequences of Strong for Life were reported, we found no serious adverse events, and the dissemination strategy of integrating Strong for Life within the Faith in Action volunteer caregiving program was feasible. It was successful in recruiting both participants and volunteers. The volunteer training successfully prepared volunteers to teach Strong for Life to frail older adults. Volunteers and participants also rated Strong for Life positively after 4 months of participation.

The participants and volunteers were primarily female. Although very few older adults refused to participate, additional strategies to recruit males are warranted. In addition, with the exception of Hispanic volunteers and participants, we were not able to obtain the ethnic and racial diversity that we had hoped to obtain. We do not know how acceptable Strong for Life would be for diverse older populations.

Although many of the participants dropped out of the program over time, a 1-year adherence rate of 66% is compatible with similar exercise programs with older adults (Gill et al., 2003). The program attrition of 34% was understandable given the frail health of the target population. Thus, volunteer trainers and participants did not drop out because of program-related issues, but because of other factors, mainly the failing health of the participants.

The resulting exercise frequency of 2.2 times per week that participants averaged was lower than the recommended level of 3 or more times a week. Although we do not know what the frequency of exercise was for those who did not provide adherence calendars, it is possible that it may be lower than the frequency of exercise for those who did. However, Strong for Life is effective at getting frail older adults to exercise at least 3 times per week, as 17% of the participants reached the recommended level.

Though there were difficulties in getting participants to use the adverse events reporting form, it appears that injuries were minimal. Of the 16 persons reporting adverse events, none withdrew from the program.

Although this was an evaluation of an evidence-based program of exercise with proven efficacy and effectiveness, we did examine before–after changes in health outcomes. Only the participants' scores on the SF-20 social functioning scale showed significant improvement from before the program to after it. However, other measures showed stability over the 4-month period. Given the level of frailty of the population, stability might be considered a successful outcome. In addition, our use of a generic measure of health status possibly decreased our ability to detect change in this frail population.

There are several limitations worth noting. First, the short time period for follow-up and the limited ethnic diversity of the participants limit external generalization to White females and program success over a short duration. Second, the lack of specified inclusion criteria for participants meant that site coordinators selected persons who may have been too ill to participate successfully. Third, there was a lack of standardization and detail on recruitment procedures and recruitment attrition. Fourth, site coordinators and participants were inconsistent in collecting and reporting exercise progression as measured by change in Thera-Band color. Finally, there was potential bias in the implementation of the evaluation as a result of the lack of blind assessment by volunteers and site coordinators who assisted many participants in their completion of the surveys. Nevertheless, the findings for exercise participation at 1 year were promising.

In terms of lessons learned, findings suggest that the Strong for Life program can be successfully implemented into community settings by using lay volunteers to execute the program. These volunteers can be successfully trained to implement Strong for Life safely. However, success also depends on the appropriate matching of volunteers with participants in a timely manner. These findings clearly provide evidence for the Adoption and Implementation components of the RE-AIM model (Glasgow et al., 1999). This demonstration project suggests that Strong for Life may be a useful supplement to incorporate into aging service programs that involve regular home visits of older adults.

	Footnotes

 
The study on which this article is based was funded by the Robert Wood Johnson Foundation (to Thomas R. Prohaska, Principal Investigator). We thank the Faith in Action National Office, as well as the 10 Faith in Action sites that participated in this project.

¹ Center for Research on Health and Aging, University of Illinois at Chicago.

² MGH Institute of Health Professions, Boston, MA.

³ Health and Disability Research Institute, Boston University, MA.

Decision Editor: Nancy Morrow-Howell, PhD

Received for publication April 22, 2005. Accepted for publication October 6, 2005.

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