Copyright 1997 by
The Cerontological Society of America
The Cerontologist
Vol. 37, No. 2, 208-215
The effects of a physical activity intervention on strength, balance, motor coordination, and
mobility were tested in a quasi-experiment at rural congregate nutrition sites. Twice-weekly
sessions of low intensity movements were conducted for one year. Logistic regression results
showed significant differences between intervention (n = 61) and comparison (n = 49)
groups on several performance-based measures. Intervention subjects perceived significantly
greater improvements in physical functioning over the previous year than did comparison
subjects. A qualitative evaluation revealed perceived program benefits of pain reduction,
increased flexibility, muscle strengthening, increased walking speed,
and improved mental outlook.
Key Words: Physical activity, Older adults, Rural
Effects of a One-Year Physical Activity
Intervention for Older Adults
at Congregate Nutrition Sites1
Patricia A. Sharpe,2 Kirby L. Jackson,2 Carolyn White, 2 Victoria L. Vaca/
Tom Hickey,3 Jakook Gu,2 and Conrad Otterness'
Declines in functional mobility contribute to a loss
of independence in activities of daily living (ADLs)
and an increased risk for falls (Tinetti, Speechley, &
Cinter, 1988). Performing ADLs depends on the ability to reach, maneuver, and maintain balance (Tinetti
& Cinter, 1988). The association of mobility impairment to difficulties in ADLs and the risk of falls
underscores the importance of developing effective
community-based interventions to preserve and enhance mobility. Mounting evidence indicates that
physical activity is a key factor in preserving physical
ability in old age; that a sedentary life hastens decline
in physical functioning and predicts excess mortality
risk; and that even low intensity activity imparts benefits among previously sedentary people (Badenhop,
Cleary, Schaal, Fox, & Bartles, 1983; Blair, Kohl, Cordon, & Paffenbarger, 1992; Foster, Hume, Byrnes,
Dickinson, & Chatfield, 1989; Gossard et al., 1986;
Harkcom, Lampman, Barnwell, & Castor, 1985;
Hickey, Wolf, Robins, Wagner, & Harik, 1995; Mor et
1
This research was supported by Grant Number U48/CCU409664-01 from
the Centers for Disease Control and Prevention through the University of
South Carolina Prevention Center. The contents of this report are solely the
responsibility of the authors and do not necessarily represent the official
views of the Centers for Disease Control and Prevention. The assistance of
the Council on Aging and Prevention Center staff and graduate students
and the cooperation of the participants are gratefully acknowledged. Dr.
Harriet Williams' measurement consultation and Dr. Robert McKeown's
comments on an earlier draft of the manuscript are appreciated.
2
School of Public Health, The University of South Carolina, Columbia,
SC. Address correspondence to Patricia A. Sharpe, PhD, MPH, Department
of Health Promotion and Education, School of Public Health, University of
South Carolina, Health Sciences Building, Columbia, SC 29208.
3
School of Public Health, The University of Michigan, Ann Arbor, M l .
4
Carolina Medical Review, Columbia, SC.
208
al., 1989; Rakowski & Mor, 1992; Wagner, LaCroix,
Buchner, & Larson, 1992).
Despite the great potential for physical activity to
preserve mobility in old age, activity levels decline
with age and are particularly low for female, lowincome, and undereducated people (Duelberg,
1992; Fitzgerald, Singleton, Neale, Prasad, & Hess,
1994; Folsom et al., 1991; Ford et al., 1991; O'Brien &
Vertinsky, 1991), who are also especially vulnerable
to impairment in old age. There is surprisingly little
research on the effectiveness and appeal of
community-based physical activity interventions
with functionally impaired or "at risk" older adults or
minority elders (Stewart & King, 1991), and existing
studies tend to be of limited time spans. Little is
known about the development of health promotion
programs for low income, rural, or minority elders,
and most health promotion programs for older
adults have attracted relatively healthy, well educated, and white participants (Buchner & Pearson,
1989; Carter, Elward, Malmgren, Martin, & Larson,
1991).
This pilot study examined the effects of a one-year
intervention of low intensity physical activity based
at congregate meal centers in rural southeastern
communities. The project was designed to encourage peer leadership among the participants to insure
program sustainability. Dependence in mobility and
personal care is more prevalent among both African
American and White older adults living in the southern U.S. than in other regions of the country (Fulton,
Katz, Jack, & Hendershot, 1989; Gibson & Jackson,
1987); thus, the public health importance of developing and evaluating interventions to preserve physical
functioning in the rural south is great.
The Gerontologist
Table 1. Characteristics by Group
Method
Setting
Intervention sites were two congregate meal centers in a central South Carolina county that includes a
metropolitan center (County A); however, the small
outlying towns where these centers are located are
quite rural and distinct from the city. For example,
many of the congregate meals participants live on
unpaved rural roads on farmland. While the whole
county's population is 42% African American, 93% of
the citizens in one of the small towns are African
American. In the census divisions containing the two
intervention centers (which are 10 miles apart), 56%
and 40% of residents age 65 and over are limited in
mobility or self-care; 38% and 26% of elders aged 65
and older live below the poverty level, compared to
15% for elders in the county as a whole (Carullo,
1993; U.S. Department of Commerce, 1992).
Comparison sites were three congregate meal centers located in a rural county in southwestern South
Carolina (County B). More than 50% of this rural
county's residents are African American, 52% of its
residents over age 65 are limited in mobility or selfcare, and 35% of residents 65 and over live below the
poverty level (Carullo, 1993; U.S. Department of
Commerce, 1992).
Sample
Participants at two sites in County A were the intervention subjects (n = 75) and participants at three
sites in County B were the comparison subjects (n =
64). Intervention and comparison sites were approximately 100 miles apart. The entire census of participants attending the sites during the T, data collection
period (November 1993 through January 1994) was
included in the study. Attrition during the one-year
program period resulted in 49 comparison subjects
(C) and 61 intervention subjects (I). Reasons for attrition were: death (n = 3 C; n = 2 I), moved/lost
contact (n = 2 C; n = 0 I), entered a nursing home (n
= 2 C; n = 21), hospitalized/ill at home (n = 3 C ; n =
4 I), and refused/not interested (n = 5 C; n = 6 I).
Chi-squared analyses and Student's t tests revealed
no significant differences at T, between treatment and
comparison groups on self-rated health, body mass
index, having fallen during the previous year (Yes/No),
self-reported medication for diabetes or cardiovascular disease (Yes/No), experience of select symptoms
(Yes/No to dizziness, fainting, weakness, swelling,
shortness of breath, chest pain), gender, education, or
any of the functional outcome measures. The groups
were significantly different in age and race; however,
both groups consisted largely of African American
women (59% C and 89% I). The comparability of the
intervention and comparison groups remained constant whether the analyses were conducted by group
(intervention versus comparison) or by site (five sites)
and remained constant after attrition. Thus, the comparison and intervention groups were quite similar at
baseline on health and functional status. Table 1
shows participant characteristics.
Vol. 37, No. 2,1997
209
Characteristic/Group
n
M
(SD)
Range
Age (years)*
Intervention
Comparison
61
49
73.7
77.9
(6.5)
(7.8)
(60 to 88)
(62 to 91)
Self-rated health
(excellent = 1,good = 2,
fair = 3, poor = 4)
Intervention
Comparison
61
49
2.6
2.7
(.8)
(.8)
Education (years)
Intervention
Comparison
60
48
7.9
7.4
(2.8)
(3.7)
Characteristic/
Group
Race**
Black
White
Gender
Male
Female
Intervention
n
Comparison
(%)
n
(%)
61
(100)
35
(71)
0
(0)
14
(29)
6
54
(11)
(89)
8
41
(16)
(84)
*f-test,p < .01; **chi-squared test,p < .001.
Procedure
A qualitative needs assessment conducted at the
intervention and comparison sites through interviews with 20 participants and the two center directors revealed an interest in exercise, generally positive beliefs about the health benefits of exercise, and
positive but very limited experience with exercise at
the centers. None of the centers had formal, ongoing
exercise programs (Sharpe, 1994).
During the one-year program period, a low intensity exercise class was conducted twice a week at the
two intervention sites. The intervention employed in
this research was modeled after the SMILE program
(So Much Improvement with a Little Exercise), a lowintensity exercise demonstration project designed
for a chronically impaired population of older adults
who were at risk of institutionalization. The SMILE
program was initially developed with 90 older adults
drawn from over 500 clients of a midwestern nonprofit agency serving older people in urban highrise
housing. After six weeks of the SMILE program, participants (n = 77) improved in mobility, flexibility,
blood pressure, and three measures of psychological
well-being. Those participants who continued the
program (n = 32) for 12 weeks maintained their gains
(Hickey, Wolf, Robins, Wagner, & Harik, 1995). The
theoretical framework for the SMILE program has
been described elsewhere (Hickey et al., 1996).
The low-intensity program consisted of movements that are performed sitting and standing, and
all standing movements may be adapted for participants who cannot or prefer not to stand. We
adapted the SMILE program by adding optional
hand-held weights of one half pound to one pound
for strengthening, handheld bean bags for flexibility
and coordination, and standing dance movements of
about 10 minutes' duration. Participants performed 4
to 16 repetitions of the movements for three weeks,
increased to 6 to 20 repetitions for 12 weeks, and
finally maintained 12 to 20 repetitions for the remainder of the year. Weights were added after week six,
and dance movements were added after week 16 and
maintained for the remainder of the year. All participants received a manual with pictures and instructions (Hickey et al., 1992) to guide them in performing the 41 SMILE movements at home. The class
instructors assisted each participant in achieving
proper execution of the movements and in making
adaptations as necessary to accommodate existing
limitations (e.g., prostheses). T-shirts with the SMILE
logo were given as incentives for attendance.
Consistent with principles of behavior change,
participants were asked during the second week of
classes to set personal goals they would like to
achieve as a result of their exercise participation.
These goals were recorded, and participants were
asked to assess their progress toward their goals at
the end of six months. At the end of one year, peer
leaders at each intervention site attended a threehour training session on exercise safety and on leading the exercise class using the program on videotape after the research project period ended. After all
data collection was completed, the comparison site
staff and participants were assisted in implementing
the program.
At T, and T2, before and after the year-long program, performance-based and self-report measures
were collected. Blood pressure was assessed as a
safety check, and participants with elevated readings
were referred to their physician or assisted with
transportation to the rural primary care clinic for
evaluation. Because of the low intensity of the intervention, no participant had to be eliminated from the
study. At T, data collection, all participants received
information sheets about their blood pressure, safe
use and storage of medications, and prevention of
fall hazards in the home. The comparison group
received no other intervention during the year.
A qualitative evaluation was conducted at the intervention sites after all data collection was completed.
The two site directors and their assistants were interviewed, and a focus group discussion was conducted
at each intervention site. The focus group participants
were selected by one of the two exercise instructors;
however, a staff person previously unknown to the
participants facilitated the discussions to minimize
social desirability bias that may have occurred in responding to the more popular instructors.
Measures
Trained graduate students in public health were
the observers and interviewers for the performancebased and self-report measures. A pretest to determine inter-rater reliability was conducted with 18
subjects at a retirement community. The intraclass
correlation coefficient for two raters was computed.
Values between .4 and .74 indicate fair to good inter210
rater reliability, and values greater than or equal to
.75 indicate excellent inter-rater reliability (Rosner,
1995).
Mobility (balance and gait) was assessed using the
short form of the Performance Oriented Mobility
Assessment (POMA; Tinetti, 1986). The measure was
developed to reflect position changes and gait maneuvers common to normal daily activities and has
been predictive of falls in community studies
(Tinetti, 1986). The short form includes seven maneuvers, rated by trained observers on a three-point
ordinal scale (0,1,2): stand to sit, nudge on sternum,
turn 360 degrees, path deviation, trunk sway, one-leg
balance, pick up the (walking) pace. The possible
range of summed scores on this index was 0 to 14.
Inter-rater reliability for the summed score was .74.
Grip strength was measured using a hand dynamometer (Lafayette Instrument Co., model no.
78010). Subjects raised the dynamometer overhead
using the preferred hand (preferred hand was recorded at TT for consistency at T2), squeezed to exert
maximal force, and maintained maximal force while
lowering the arm. A practice trial was allowed, and
the next three trials were recorded (Potvin & Syndulko, 1980). Grip score in kilograms exerted was the
mean of three trials. Inter-rater reliability was .99.
Bilateral motor coordination was measured using
the Pegs-over test (Frey, 1979). Using both hands in a
lead-assist manner, the subject picked up a wooden
peg with one hand and used the other hand to turn
the peg over and place it into a round slot in a
pegboard (Lafayette Instrument Co., model no.
32023). Practice with six pegs was allowed. Subject's
score was the mean of three timed trials to place 20
pegs, in seconds. Inter-rater reliability was .97.
Tandem balance was timed starting when the subject assumed the correct position with the heel of the
preferred foot in front, touching the toe of the foot in
back (preferred foot was recorded at Tn for consistency at T2). Raters stopped timing when the subject
lost balance or exceeded a maximum of 30 seconds.
A practice trial was allowed. Subject's score was the
mean of three trials. Inter-rater reliability was .68.
One-leg balance was timed as well as being rated
as part of the POMA (Tinetti, 1986). Subjects were
allowed one practice trial. Standing with hands at
side, the subject stood on the preferred foot while
lifting the opposite foot (the preferred foot was recorded at T, for consistency at T2). Timing started
when the foot cleared the floor and stopped when
the foot touched the floor or when the subject struggled to maintain balance or exceeded a maximum of
30 seconds. Inter-rater reliability was .99.
Timed walk (normal speed) and timed walk (maximum speed) are used to determine the subject's
ability to pick up the pace as one of the POMA tasks.
In addition to the ordinal POMA rating, the subject's
time to walk a 10-foot-long, 2-foot-wide flat course
was recorded at normal speed and maximum speed
(Williams & Greene, 1994). Inter-rater reliability for
the timed walk at normal speed was .84 and for timed
walk at maximum speed, .52.
Demographic variables, including self-reported
The Gerontologist
age at last birthday, highest grade completed, race,
and gender were recorded.
Tinetti's falls self-efficacy scale (Tinetti, Richman, &
Powell, 1990) was administered at T v Subjects rated
their confidence to perform ten tasks without falling
(e.g., getting in and out of bed, doing light housekeeping) on a 10-point response scale. Although we
modified Tinetti's 10-point scale to a 5-point scale for
ease of comprehension, 56 of 139 subjects (40%) were
unable to understand and respond to these items;
therefore, this measure was dropped from the study.
Perceived change in physical functioning was assessed at T2 by asking subjects if they could perform
"better," "the same," or "worse," in nine areas, than
they could a year ago. The nine areas of functioning
were "getting around," "getting up out of a chair,"
"getting in and out of a car or van," "keeping your
balance," "walking around inside your house,"
"reaching up into cabinets for things," "doing your
housework or chores," having "flexibility in your
hands," and having "strength in your legs." "The
possible range of scores was 9 to 27, with higher
scores indicating decline. Principal axis factor analysis (n = 107) extracted one factor with all loadings
above .40, which accounted for 56% of the variance.
Internal consistency reliability was high (Cronbach's
alpha = .92).
A total participation score was computed for the
intervention group participants. Class instructors recorded a zero (absent, or present but did not participate), a one (fully participated), or a .5 (participated
in some but not all movements). The total participation score was the sum of the class participation
scores divided by the number of classes provided,
with a possible range of 0 to 1. At T2, participants
were asked "Do you ever do any of the exercises
from the class at home? (Yes/No)."
A qualitative evaluation was conducted through
interviews with the center directors and assistants
and through focus groups of participants at each of
the intervention sites after all quantitative T2 data
correction was complete. Open-ended questions addressed overall impressions of the classes, perceived
appropriateness and level of difficulty of the movements, perceived program benefits and barriers, logistical considerations, feasibility of program continuation with peer leaders, and quality of the
instructors and the videotape. To minimize social
desirability bias as much as possible, research assistants previously unknown to the participants and center staff conducted the interviews and focus groups.
Data Analysis
To make full use of the data, two types of analyses
were conducted. Repeated measures analysis of variance with age and race (ANOVA) as covariates were
conducted with each of the performance-based measures, which employed interval or ordinal data. Included in these analyses were subjects for whom
data could be collected at both T, and T2. The effect of
group, time, and group x time interaction were
examined, adjusting for age and race. In these analyVol. 37, No. 2,1997
ses, the group x time interaction measured the
effect of the intervention; if the intervention had an
effect, a different change over time between the
intervention and comparison groups would be expected. As reported above, the comparison and intervention groups did not differ at T, on any of the
performance-based measures, even after attrition.
By necessity, the ANOVAs did not include subjects
who were completely unable to perform a given task
and received a score at T, or T2 (the exception to this
is the ordinal POMA index, for which a score on each
of the seven tasks was recorded even if a subject was
unable to perform the task). Thus, not only were
disabled subjects (e.g., blind, unable to understand
instructions due to cognitive deficits, amputees)
omitted from certain analyses, but subjects whose
functional level changed beyond the parameters of
the scoring were also omitted. If a person was unable
to perform a given task at T, and thus had no recorded score, but was able to perform that task at T2
(or vice versa), then there was clearly important information conveyed which could not be analyzed in
an ANOVA framework. In order to examine these
data further, we performed nonparametric test (twosample median test) by assigning values beyond the
range of possible scores on a task to subjects with
missing scores at one time point or the other. These
analyses were based on the assumption that changing from "unable" to "able" to perform a task, or
vice versa, over the project year was a larger change
in mobility (in either a desirable or undesirable direction) than was a straightforward increase or decrease
in recordable scores from T, to T2. These analyses
considered ranks of observations; therefore, the actual values of scores were not important as long as
the rank orders were set appropriately. In the twosample median test, subjects were classified as having "greater than or equal t o " and "less than" median change.
Although these analyses allowed for use of all of
the data and showed significant differences between
the intervention and comparison groups on some
tasks, these nonparametric tests did not allow the
inclusion of covariates. Therefore, to extend the twosample median test, logistic regression was used to
examine age, race, and group as independent variables to predict the odds of change being equal/above
or below the median (without covariates, this logistic
model produced essentially the same results as the
two-sample median test). For the categorical variable
group, the logistic model gave the odds of being
equal to or above the median in terms of change (in
the desirable direction) for the intervention group
relative to the comparison group, adjusted for age
and race. The logistic regression results, which adjust for the covariates, rather than the preliminary
nonparametric tests, are reported here. For ease in
practical interpretation, the logistic regression analysis was also conducted with the dependent variable
defined as change "greater than or equal to zero"
(i.e., improvement/maintenance of performance for
a task) versus change "less than zero" (i.e., decline
of performance for a task).
211
Performance-Based Outcomes
Results
Table 2 shows unadjusted means by group and
time. As stated above, no statistically significant differences between the groups was found at T v Table 3
shows the mean change (T2 minus TJ by group, adjusted for age and race, and p values for the group by
time interaction, group main effects, time main effects, age, and race for the repeated measures
ANOVA. The interaction term, group x time, was
statistically significant only for the 10-foot walk at
normal speed. Age was a significant predictor in all
seven models.
Table 4 shows the results of the logistic regression
analysis with the dependent variable categorized as
"change equal to or above the median" versus
"change below the median." The odds ratios indicate that for five of the seven measures, the odds of
the intervention group having pretest to post-test
change equal to or above the median change was at
least twice the odds of the comparison group. These
odds ratios were statistically significant atp < .05 for
grip strength, tandem balance, and 10-foot walk at
fast pace.
Table 5 shows the results of the logistic regression
analysis with the dependent variable categorized as
"change greater than or equal to zero" versus
"change less than z e r o " (i.e., improvement/
maintenance versus decline from Tn to T2). Again, five
Participation
During the intervention period, 92% of scheduled
classes were actually conducted at the two intervention sites. Maintenance problems with the physical
plant or with the centers' vans were the primary
causes of canceled classes. The mean participation
score for the 61 intervention subjects was .36 {SD =
.24), and the median score was .34. Six subjects had
attendance scores s= .7, and nine subjects had attendance scores =s .1. Seventy-two percent of the intervention subjects (n = 44) reported that they had
been doing the exercises from the class at home.
Neither age nor self-rated health were significantly
associated with participation or with self-reported
performance of the exercises at home.
Perceived Changes in Physical Functioning
At T2, comparison subjects had an unadjusted
mean score of 19.1, and intervention subjects had an
unadjusted mean score of 17.3 on the "perceived
change in physical functioning" scale. Adjusting for
age and race in a regression model, being in the
intervention group was significantly associated with
more positive perceptions of changes in functioning
over the past year (6 = -2.44, p = .02).
Table 2. Unadjusted Means and Standard Deviations by Group at T, and T2
Time
T,
Variable/
Group
n
M
(SD)
M
(SD)
Grip strength (kilos)
Intervention
Comparison
60
47
18.38
16.74
(6.99)
(8.30)
18.41
15.56
(6.78)
(8.58)
Bilateral motdr coordination 6 (sec.)
Intervention
Comparison
55
41
35.93
40.99
(11.02)
(12.07)
33.72
36.19
(12.16)
(11.99)
Tandem balance"0 (sec.)
Intervention
Comparison
35
27
12.36
16.00
(8.92)
(9.68)
13.08
11.58
(8.78)
(9.75)
One leg balance'0 (sec.)
Intervention
Comparison
54
40
3.53
4.42
(4.44)
(5.81)
4.02
4.36
(4.74)
(5.24)
Walk (normal 6 ; sec.)
Intervention
Comparison
60
48
3.98
4.46
(1.19)
(2.64)
4.03
5.03
(1.30)
(2.75)
Walk (fast6; sec.)
Intervention
Comparison
60
48
2.99
3.25
(0.87)
(1.61)
2.97
3.64
(1.12)
(1.82)
POMA' (0 to 14 index)
Intervention
Comparison
59
48
9.81
9.58
(1.80)
(2.23)
9.85
8.77
(2.47)
(3.23)
4
Note: Subjects who were completely unable to perform a given task at T, or T2 were excluded from analysis since no score could be
recorded.
'Higher scores indicate better performance.
b
Lower scores indicate better performance.
c
Maximum score allowed = 30 seconds.
212
The Gerontologist
Table 3. Repeated Measures ANOVA Results for Performance-Based Outcomes, Adjusted for Age and Race
Group
n
Adjusted
Mean Change
(Tr-T,)
Crip strength 3
(kilos)
Intervention
Comparison
60
47
-0.06
-1.08
.22
.64
.26
.01
.59
Bilateral motor
coordination 6 (sec.)
Intervention
Comparison
55
41
-1.19
-5.29
.07
.09
.32
.01
.01
Tandem balance"-0
(sec.)
Intervention
Comparison
35
27
0.26
-3.83
.16
.29
.89
.02
.78
One leg balance"
(sec.)
Intervention
Comparison
54
40
.75
-0.38
.31
.14
.50
.01
.64
Walk (normal)"
(sec.)
Intervention
Comparison
60
48
0.00
0.63
.05
.13
.95
.01
.11
Walk (fast)"
(sec.)
Intervention
Comparison
60
48
0.00
0.36
.06
.06
.03
.01
.02
Intervention
Comparison
59
48
0.14
-0.67
.10
.60
.38
.00
.40
Variable
a
POMA
(0 to 14 index)
p Values
TimexGroup
Group
Time
Aged
Racee
Note: Subjects who were completely unable to perform a given task at T, orT 2 were excluded since no score could be recorded.
"Higher scores indicate better performance; therefore, positive change scores indicate improvement.
"Lower scores indicate better performance; therefore, negative change scores indicate improvement.
c
Maximum score allowed = 30 seconds.
'Time x Age interaction significant for fast walk, p < .05.
e
Time x Race interaction significant for bilateral motor coordination, p < .05.
Table 4. Odds Ratios for Change Greater Than or Equal to the Median Change
From Logistic Regression Analysis, Adjusted for Age and Race1
Variable
Grip strength (kilos)
Bilateral motor coordination (sec.)
Tandem balance (sec.)
One leg balance (sec.)
Walk (normal; sec.)
Walk (fast; sec.)
POMA (0 to 14)
Intervention
Group n
Comparison
Group n
Odds Ratio
p Value
60
57
46
59
61
61
59
49
45
35
47
48
48
48
2.61
.53
3.81
2.08
2.01
3.85
1.45
.04
.20
.02
.12
.13
.01
.42
'Ratio of the odds of achieving change greater than or equal to the median change in the desired direction (intervention group relative
to comparison group).
of the seven odds ratios were greater than 2.0; the
odds ratios for timed walk at both normal and fast
paces were statistically significant at p < .05. For
these two measures, the odds of the intervention
group subjects improving or maintaining their walking time was nearly four times the odds of the comparison group improving or maintaining their time.
Qualitative Evaluation
During the second week of classes, 47 subjects in
the intervention group set personal goals that covered a variety of outcomes, including improved flexibility, decreased pain, increased energy level, improved walking ability, improved ability to reach,
and maintenance of strength and mobility levels. A
midyear assessment of perceived progress toward
personal goals (n = 43) revealed that 79% of participants who had set a goal believed that they had made
progress toward their goal, and 5% of participants
believed they had completely achieved their goal.
Vol. 37, No. 2,1997
Two focus groups of six and seven participants
held at the two intervention sites after the intervention and data collection were completed revealed
very positive impressions of the program. Perceived
benefits that were mentioned during the focus group
discussions included arthritis pain reduction, muscle
strengthening, increased walking speed, increased
flexibility, and improved mental outlook. That the
program was provided free of charge and that the
instructors were well liked were seen as special
strengths of the program. The movements' intensity
level was viewed as generally appropriate, although
the participants felt that some people could have
benefited from heavier handheld weights. The focus
group participants observed that even people with
disabilities that limited their full participation were
able to benefit from the classes. Participants were
unanimously optimistic about the program's continuation by the peer leaders and videotape. During the
weeks since the instructors turned the classes over to
213
Table 5. Odds Ratios for Change Greater Than or Equal to Zero
From Logistic Regression Analysis, Adjusted for Age and Race4
Variable
Grip strength (kilos)
Bilateral motor coordination (sec.)
Tandem balance (sec.)
One leg balance (sec.)
Walk (normal; sec.)
Walk (fast; sec.)
POMA (0 to 14)
Intervention
Group n
Comparison
Group n
Odds Ratio
p Value
60
57
46
59
61
61
59
49
45
35
47
48
48
48
2.17
.52
2.76
2.11
3.54
3.80
1.45
.10
.20
.07
.11
.02
.01
.42
•Ratio of the odds of achieving change greater than or equal to zero (i.e., improved/maintained performance) in the desired direction
(intervention group relative to comparison group).
the peer leaders, exercise class frequency had increased from two to five days a week. Since the
project's completion, one peer leader had been recruited to lead classes at a senior center not involved
in the project.
The center directors and assistants noted improvements in physical functioning and mental outlook that
they attributed to the program. They noted that several older adults had begun to decline offers of transportation to the local store, preferring to walk there.
They also commented on the leadership abilities that
were evident since the responsibility for the classes
was transferred to the participants. The class remained popular several months after the investigators
withdrew, and some participants came to the center
for exercise exclusively, even when they did not stay
for the meal. The center directors were particularly
positive concerning the opportunity to develop a relationship with the university, as they perceived that
centers in rural areas are often overlooked in favor of
conveniently located urban centers.
Discussion
In this study, intervention subjects maintained or
improved their performance significantly on several
measures of strength, balance, and mobility compared to subjects not receiving the twice-weekly
classes. These findings are particularly notable for
several reasons. This study represents a rather conservative test of the physical activity program's efficacy because of the relatively small number of subjects in each group (and therefore, lowered power to
detect effects). Additionally, a wide range of participation scores in the intervention group represents a
weakened average dose of the intervention compared to what might be considered optimum participation. Subjects received full credit for participation
only if they attempted the majority of the movements; therefore, the score reflected a more accurate measure of exposure to the intervention than
simple attendance. While nearly three quarters of
the intervention subjects reported performing the
movements at home, it was not feasible to monitor
home activity or validate these self-reports, and they
may be inflated. Finally, the project period of a year is
relatively long compared to previously published
studies of physical activity among older adults and
214
offers a realistic picture of attrition, retention, and
participation in a rural community at a congregate
nutrition site. Despite these various factors which
would lower the likelihood of detecting program
effects, significant results were obtained on some of
the performance-based measures. These findings,
therefore, attest to the positive impact of physical
activity on maintaining physical performance in old
age, even when the activity is of a relatively small
dose on average, of low intensity, and executed
under less than optimum conditions.
The issues of a) practical significance versus statistical significance of program effects; b) the sensitivity of measures to detect change; and c) the selection
of valid measures of program effects are topics of
ongoing discussion in intervention research. Categorical or ordinal measures, e.g., the POMA, may be
too gross to capture small but important changes;
however, continuous measures may fail to capture
functional status beyond the range of possible
scores, such as the case in this study when a person
cannot perform a task at all, yet zero is not a legitimate value because a low score may represent good
(fast) performance. In a similar vein, the validity of
timing performance may be questioned, because
being able to perform a task, no matter how slowly,
may represent an improvement of practical significance; speed may be irrelevant or unimportant for
some activities of daily living. In this study, we used
both ordinal and continuous measures. The POMA
analyses showed no significant results. For the continuous measures, actual values of pretest to posttest changes were small, and some subjects could
not perform at all at either time point, and thus had
to be excluded from those analyses. We addressed
the issue by creating dichotomous dependent variables and comparing the groups in terms of
maintenance/improvement versus decline. We contend that the maintenance of performance over a
year's time is an important outcome for an exercise
intervention. From this perspective, even small improvement or no change is superior to decline.
The qualitative findings, presented briefly in this
report, indicated that participants' and center staffs'
perceptions of improvement were perhaps stronger
than the improvements that the quantitative data
indicate. These perceptions may be influenced by
social desirability bias, and they are not generalizThe Gerontologist
able to the entire intervention group. Among the
subset of focus group participants, however, they
may reflect accurate assessments of improvements
that the quantitative measures did not capture. To
the extent that the qualitative impressions are valid,
they suggest that high levels of satisfaction and enjoyment, along with perceptions of personal goal
attainment, may contribute to quality of life in their
own right. They are essential to program longevity
and create an atmosphere of enthusiasm for additional health promotion activities.
This pilot study adds to the growing body of evidence showing the importance of physical activity in
old age and demonstrates the feasibility of implementing programs in rural areas among low-income
elders. The potential for community-based physical
activity programs to preserve functional independence, prevent or delay institutionalization, reduce
caregiving costs, and enhance quality of life merits
investigation through large scale community-based
intervention trials.
References
Badenhop, D. T., Cleary, P. A., Schaal, S. F., Fox, E. L , & Battles, R. L. (1983).
Physiologic adjustments to higher or lower intensity exercise in elders.
Medicine and Science in Sports and Exercise, 15, 496-502.
Blair, S. N., Kohl, H. W., Cordon, N. F., & Paffenbarger, R. S. (1992). How
much physical activity is good for health? Annual Review of Public
Health, 13, 99-126.
Buchner, D. M., & Pearson, D. C. (1989). Factors associated with participation in a community senior health promotion program: A pilot study.
American Journal of Public Health, 79, 775-777.
Carullo, J. J. (Ed.). (1993). S.C. Statistical Abstracts, 1990. Columbia, SC: SC
State Budget and Control Board, Division of Research and Statistical
Services.
Carter, W. B., Elward, K., Malmgren, J., Martin, M. L , & Larson, E. (1991).
Participation of older adults in health programs and research: A critical
review of the literature. The Cerontologist, 21, 584-592.
Ouelberg, S. I. (1992). Preventive health behavior among black and white
women in urban and rural areas. Social Science and Medicine, 34,
191-198.
Fitzgerald, J. T., Singleton, S. P., Neale, A. V., Prasad, A. S., & Hess, J. W.
(1994). Activity levels, fitness status, exercise knowledge, and exercise
beliefs among healthy, older African American and White women.
Journal of Aging and Health, 6, 296-313.
Folsom, A. R., Cook, T. C , Sprafka, J. M., Burke, G. L , Noested, S. W., &
Jacobs, D. R. (1991). Differences in leisure-time physical activity levels
between blacks and whites in population-based samples: The Minnesota Heart Survey. Journal of Behavioral Medicine, 74(1), 1-9.
Ford, E. S., Merritt, R. K., Heath, C. W., Powell, K. E., Washburn, R. A.,
Kriska, A., & Haile, C. (1991). Physical activity behaviors in lower and
higher socioeconomic status populations. American Journal of Epidemiology, 133,1246-1256.
Foster, V. L , Hume, C. J. E., Byrnes, W. C , Dickinson, A. L. &, Chatfield, S.
J. (1989). Endurance training for elderly women: Moderate vs. low
intensity. Journal of Gerontology, 44, M184-M188.
Frey, C. J. (1979). Development of alternative fine motor manipulation tasks.
Unpublished master's thesis. Toledo, Ohio: University of Toledo.
Vol. 37, No. 2,1997
215
Fulton, J. P., Katz, S., Jack, S. S., & Hendershot, C. E. (1989). Physical
functioning of the aged, U.S., 1984. (National Center for Health Statistics, Vital and Health Statistics 10[167]). Hyattsville, M D : U.S. Government Printing Office.
Gibson, R. C , & Jackson, J. S. (1987). The health, physical functioning and
informal supports of the black elderly. The Milbank Quarterly, 65,
(Suppl. 2), 421-453.
Gossard, D., Haskell, W. L , Taylor, C. B., Mueller, J. K., Rogers, F., Chandler,
M., Ahn, D. K., Miller, N. H., & DeBusk, R. F. (1986). Effects of low and
high intensity home-based exercise training on functional capacity in
healthy middle-aged men. American Journal of Cardiology, 57, 446-449.
Harkcom, T. M., Lampman, R. M., Barnwell, B. F., & Castor, C. W. (1985).
Therapeutic value of graded aerobic exercise in rheumatoid arthritis.
Arthritis and Rheumatism, 28, 32-39.
Hickey,T., Sharpe, P. A., Wolf, F. M., Robins, L. S., Wagner, M. B., & Harik,
W. (19%). Exercise participation in a frail elderly population. Journal of
Health Care for the Poor and Underserved, 7(3), 219-231.
Hickey, T., Wolf, F. M., Robins, L. S., Wagner, M. B., & Harik, W. (1995).
Physical activity training for functional mobility in older persons. Journal of Applied Gerontology, 14, 357-371.
Hickey, T., Wolf, F. M., Robins, L. S., Wagner, M. B., Harik, W., Orgain, L.
S., Garrity, C. R., Gurgard, W. C , Hornyak, S., & Wyman, S. E. (1992).
The SMILE program: A low-intensity physical activity program for older
adults [participant's instructional manual]. Ann Arbor, M l : The University of Michigan.
Mor, V., Murphy, J., Masterston-Allen, S., Willey, C , Razmpour, A., Jackson, M. E., Greer, D., & Katz, S. C. (1989). Risk of functional decline
among well elders. Journal of Clinical Epidemiology, 42, 895-904.
O'Brien, S. J., & Vertinsky, P. A. (1991). Unfit survivors: Exercise as a
resource for aging women. The Gerontologist, 31, 347-357.
Potvin, A., & Syndulko, K. (1980). Human neurologic function and the aging
process. Journal of the American Geriatrics Society, 38(1), 1-9.
Rakowski, W., & Mor, V. (1992). The association of physical activity with
mortality among older adults in the Longitudinal Study of Aging (19841988). Journal of Gerontology: Medical Sciences, 47, M122-M129.
Rosner, B. (1995). Fundamentals of Biostatistics (4th ed.). New York:
Wadsworth Publishing.
Sharpe, P. A. (1994). Qualitative needs assessment in the development of a
physical activity intervention for rural elderly. The Gerontologist, 34
(Special Issue), 178.
Stewart, A. L., & King, A. C. (1991). Evaluating the efficacy of physical activity
for influencing quality-of-life outcomes in older adults. Annals of Behavioral Medicine, 12, 108-116.
Tinetti, M. E. (1986). Performance-oriented assessment of mobility problems in elderly patients. Journal of the American Geriatrics Society, 34,
119-126.
Tinetti, M. E., & Ginter, S. F. (1988). Identifying mobility dysfunctions in
elderly patients: Standard neuromuscular examination or direct assessment? Journal of the Medical Association, 259, 1190-1193.
Tinetti, M. E., Richman, D., & Powell, L. (1990). Falls efficacy as a measure of
fear of falling. Journal of Gerontology: Psychological Sciences, 45,
P239-P243.
Tinetti, M. E., Speechley, M., & Ginter, S. F. (1988). Risk factors for falls
among elderly persons living in the community. Journal of the American
Medical Association, 319, 1701-1707.
U.S. Department of Commerce. (1992). 7990 Census of Population and
Housing. Summary of social, economic, and housing characteristics.
Washington, DC: SC Bureau of the Census.
Wagner, E. H., LaCroix, A. Z., Buchner, D. M., & Larson, E. B. (1992). Effects
of physical activity on health status of older adults I: Observational
Studies. Annual Review of Public Health, 13, 451-468.
Williams, H. G., & Greene, L. S. (1994). The Williams-Greene test of
physical/motor function. Columbia, SC: University of South Carolina
Motor Development/Motor Control Laboratory.
Received February 13, 1996
Accepted August 18, 1996