National physical activity recommendations for older Australians: Discussion Document

5.3 Structural influences

The National Ageing Research Institute was commissioned by The Department of Health and Ageing to review the evidence and develop physical activity recommendations for older people.

Page last updated: 01 February 2011

In this section, means of delivering the physical activity health promotion message and the options for providing physical activity programs for older people are considered. The influences of social planning and the built environment are then discussed.

Delivery media: from written materials to use of the Internet

Many strategies have been used to disseminate the physical activity health promotion message. The evidence base indicates that individually tailored advice is likely to be preferable to the use of generic materials. Increasingly, the advice is tailored according to the tenets of an underlying theoretical model, such as those referred to in Section 5.1. King and colleagues’ review of the options concluded that greater success was attained where interventions used behavioural and/or cognitive strategies rather than health education or instruction alone (King, Rijeski et al. 1998).

In recent times, advice has been provided via telephone and Internet. Reger and colleagues (2002) used media advertisements, public relations campaigns and workplace programs to promote daily walking amongst older Americans. They also sought to build community capacity via the involvement of the community in a local advisory committee that advised the project. The authors reported a 20% increase in walking and a significant increase in the proportion of participants doing 30 minutes of activity per day in the intervention area, compared to the control area. Marshall et al. (2005) explored using the Internet and email as a means of disseminating physical activity information. Their sample of Internet users reflected previous findings that GP advice and group activity were the most popular sources of support. However a third listed Internet and email as desirable sources: 8% of these respondents were 65 years or over. With increasing access to the Web, electronic resources may be an additional option for some.

Options for providing physical activity programs for older people

There is no clear evidence for any preferred delivery mode (King, Rijeski et al. 1998). Hillsdon et al’s Cochrane review suggests that more consistent effect estimates emerge from interventions that include professional guidance and self-direction, along with continued professional support (Hillsdon, Foster et al. 2005). Cyarto and colleagues’ review suggested that the best outcomes for older people were obtained by interventions featuring greater levels of contact plus multiple reinforcement of the physical activity advice and messages (Cyarto, Moorhead et al. 2004). The US-based Activity Counselling Trial (ACT) reported that whilst women showed improved outcomes with more intensive support, this was not so for men (Simons-Morton, Blair et al. 2001). It is likely that a range of options, tailored to the individual, will be needed to assist the maintenance of physical activity behaviour. For example, the US CHAMPS study produced programs that accommodated for older peoples’ health, activity preferences and local environment (Stewart, Mills et al. 2001). In addition to minimising injury risk, the programs sought to optimise motivation by reducing barriers to activity. The researchers used face-to face behavioural counselling and cognitive techniques to encourage older people to use local exercise venues or to develop their own physical activity programs. Participants attended information meetings, planning sessions and monthly workshops. Participants were strongly encouraged to attend at least the initial two workshops, where a walking clinic was offered. To maintain their involvement they received activity diaries, telephone calls, newsletters and physical function assessments. A range of similar models is currently being field tested in the USA as part of the National Blueprint program.

Settings for physical activity programs: home and facility based

A range of settings have been used for physical activity promotion. For ease of categorisation, these can be described as home based versus facility based. The content may be either structured or unstructured in format (Dunn, Marcus et al. 1999). Home based activity encompasses not only physical activity in the home, but also independent walking. Facility based programs include group programs in the community and specialist in-patient and outpatient rehabilitation programs. Both home and externally based programs have been shown to be effective in achieving health benefits (Hillsdon, Foster et al. 2005). A recent review found that home-based, group-based and educational interventions can all increase physical activity, but the changes were modest and short-lived (van der Bij, Laurent et al. 2002). Home based programs have been beneficial not only for healthy older people, but also those with chronic conditions such as chronic obstructive pulmonary disease (COPD) and arthritis and those undergoing rehabilitation following a myocardial infarction or coronary artery bypass graft (Atienza 2001). In a Cochrane systematic review, home based programs for older people were considered preferable to facility based programs for promoting adherence, particularly in the longer-term (Ashworth, Chad et al. 2005). One trial reported greater adherence to a home based than to a group based program (75-79% versus 53% respectively) (King, Haskell et al. 1991). In another physical activity study involving older people, King and colleagues noted that there was greater adherence to the home based than to the class based formats (King 2000). Whilst group programs may afford social interaction benefits as well as physiological gains, not all older people will need or desire this aspect of physical activity. There may be practical reasons why some older people prefer home -based programs (Dishman 1994; Tai and Iliffe 2000; Atienza 2001). Home based programs have the potential to provide cheaper physical activity programs, but for older people with comorbidities they will often need to be preceded by training by a health practitioner or exercise facilitator, to ensure that the program is conducted safely and correctly.
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Counselling in primary care

Individuals have commonly been assisted to exercise using written materials and advice from health professionals. General practitioners (GPs) in particular are seen as trusted sources of information about health behaviours. Since older people regularly visit a GP, physical activity promotion in the general practice setting has the potential to reach a large proportion of this population group. Many GPs also provide medical care to people in residential aged care accommodation. The majority of general practice based interventions have focused on advice, in some instances supported by telephone follow-up or referral to a facilitator or program (Goldstein, Pinto et al. 1999; Elley, Kerse et al. 2003).

A review of strategies for use in the primary care setting to promote physical activity (Eakin 2001) identified 15 studies. Interventions targeting people aged 50 and over were less effective in the short -term when compared to those targeting younger adults. The authors concluded that for short term gains, physical activity-only interventions were more effective than multiple risk factor interventions, but better results were obtained for multifaceted interventions in the longer term. Written material appeared helpful. Short term benefits were reported independent of the type of person delivering the intervention. Brief counselling (3-10 minutes) was as effective as longer counselling (>15 minutes). They found no unequivocal additional benefit to using theory based interventions or incorporating participant follow-up, although tailoring advice according to readiness to change behaviour was effective in shorter interventions. Since this review, other trials have been conducted in the primary care setting. An educational intervention for Victorian GPs improved physical activity behaviour and health outcomes in their older patients compared to a control group (Kerse, Flicker et al. 1999). In addition to brief advice giving by GPs, more extensive advice has been provided by exercise facilitators (Halbert, Silagy et al. 2000; Stewart, Mills et al. 2001) or practice nurses (Sims, Smith et al. 1999; Steptoe, Doherty et al. 1999). The STEPS physical activity intervention assessed the effect of different levels of follow-up support on walking behaviour in older people (Dubbert, Cooper et al. 2002). All participants received brief physical activity advice from a nurse. Participants in the intervention arms either had 20 follow-up telephone calls or 10 calls from the nurse and 10 automated motivational calls. Both groups increased walking over the subsequent 12 months. Automated motivational calls in addition to nurse calls produced positive self-reported physical activity outcomes compared to the control group. No other significant between group differences in health related variables or fitness were found.

The New Zealand Green Prescription scheme allows referral to an exercise specialist employed by the Regional Sports Trusts as part of a Sports and Recreation New Zealand initiative. The program has been thoroughly evaluated and found to have acceptable cost effectiveness and cost utility (Elley, Kerse et al. 2004; Dalziel, Segal et al. 2006). A cluster randomised trial of the New Zealand Green Prescription scheme in 42 general practices reported improvements in physical activity behaviour and health amongst adult participants (Elley, Kerse et al. 2003). The GPs gave brief advice, which took about 7 minutes, then referred the patient to a trained exercise specialist who provided telephone support over a three month period. In a sub-group analyses of those 65 years and over, a distinct increase in physical activity (average 40 minutes per week more than the control group) was reported at one year post intervention (Kerse, Elley et al. 2005). Improved vitality and general health was also reported (based on the SF-36), plus a decrease in hospitalisations. No increases in falls or injuries resulted from the intervention. Australian GPs now have the option of using Lifestyle scripts for their patients.

Exercise referral schemes have been popular in the UK for some time. Although there are national guidelines for their evaluation (UK Department of Health 2001), the amount of evidence for their effectiveness has been restricted by the lack of systematically occurring evaluation and the limited scope of most evaluations’ methodologies. In a critical commentary, Dugdill and colleagues recommended using a participatory action research approach to provide a more comprehensive evaluation of these schemes, incorporating biopsychosocial data, rather than simply demographic and clinical data (Dugdill, Graham et al. 2005). The authors reported on two urban schemes involving several thousand adults. Adherence ranged from 30-45% over a typical 12-week program. They noted that amongst adherers, physical activity did increase on average over a three -month period and was partially maintained to one year, but failed to reach levels sufficient to obtain health benefit. Interestingly, older people (those 60 + years old) were more likely to attend initial assessment and to adhere. There was no assessment of whether this trend was age related, or linked to the reported increased likelihood amongst those with pre-existing chronic conditions.

Since January 2006, Australian GPs have been able to refer patients with chronic and complex conditions to a physiotherapist or an exercise physiologist for physical activity advice, with costs covered by the Enhanced Primary Care Program. Lessons learned from the overseas evaluations will be helpful in shaping the evaluation of this initiative.
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The built environment

The importance of a supportive environment is acknowledged. In reviewing environmental and policy interventions, Kahn et al. (2002) found that enabling access to sites for physical activity, accompanied by informational outreach, was successful. Other approaches they reviewed had insufficient evidence to be properly assessed. The focus of the interventions reviewed was upon providing supportive environments and strengthening community action at a structural level. None of the studies specifically evaluated the impact upon the older population, but the increased numbers of people reporting being physically active included older people, thus such models are to be promoted. In Australia, support from the wider community, via media campaigns such as Victoria’s ‘Go For Your Life’ initiative, accompanied by policy and structural changes to facilitate physical activity appear promising, but the evidence base remains limited. Developing the infrastructure to support physical activity programs designed to change individual behaviour is critical. Alongside the reorientation of services, the wider environment in which they are delivered needs consideration. The environment in which older people live plays an important role in determining their physical activity patterns.

One example of such work is the National Heart Foundation’s Supportive Environments for Physical Activity (SEPA) Initiative. The SEPA initiative addresses factors that either inhibit or encourage people to lead healthy, socially engaged and physically active lives. The Initiative aims to enable an environment to be created that will encourage all Australians to use their local and regional areas for physical activity pursuits. The Initiative is working towards changing public policy and the planning and design processes that contribute to providing safe and healthy environments for active living. This entails promotion of community development and engagement via the development of urban areas that allow culturally appropriate options for active living. Intergovernmental and intersectoral collaboration to further the development of urban environments are endorsed by SEPA. Partnerships are important: cross-sectoral connections, beyond the health and leisure sectors, are necessary. The following example highlights the importance of incorporating a structural perspective in physical activity promotion initiatives. Schofield and colleagues engaged local councils in promoting dog-walking as part of the Rockhampton 10,000 steps physical activity promotion campaign (Schofield, Steele et al. 2004). Aside from the modest impact of this scheme amongst residents, the authors noted the challenges of involving the councils in this community education strategy. Physical activity was not seen as a council goal. Discussions led to common ground for communicating with the community, within the context of promoting registration and sensible dog-ownership.
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Over the past few decades urban planning has been designed with a focus on automotive transport to connect people with destinations. This has led to housing development that is reliant upon car usage. The current generation of older people includes some who didn’t learn to drive and an increasing number who are unable to drive for health reasons. This has major implications for access to services and social connectivity. There is growing awareness that adult pedestrian journeys have an optimal range of around 400m. Ideally, a whole range of services should be available to the resident within this range. Planners are encouraged to develop housing and service centres using a mixed land-use policy, to minimise distances between homes and services. Older people need facilities such as medical centres and post offices to be available in their neighbourhood to assist pedestrian access.

The promotion of ‘active transport’, that is walking, cycling or using public transport rather than driving to a destination is commendable, but may not be an option for some older people, particularly those living in regional and rural Australia where this infrastructure doesn’t exist, and for those with multiple comorbidities. Older people need to feel safe when walking the streets: this is not possible if the council does not properly maintain the environment. Older people need to be able to cross the road safely, yet consumer focus groups often note that the time that lights remain green is insufficient for many older people to cross the road (Wright, MacDouglas et al. 1996). There is a role for local governments in enabling older people’s access around their neighbourhood. For example, strategies to minimise uneven pavements and active maintenance programs can be implemented. Access for older people with a range of disabilities can be assisted by providing curbs with ramps or sloping curbs. A Swedish study (Sthl, Carlsson et al. 2006) used a three stage needs assessment process with a range of stakeholders including older residents in one municipality. Based on the findings, environmental measures such as lowering of curbs, widening of pavements and placing benches along pedestrian routes, were decided upon and implemented by the local municipality. The evaluation of this intervention has just been completed. It will provide some guidance on the feasibility of making environmental changes and their impact on walking behaviour in older people.

Research on the links between the built environment and health, including physical activity promotion, is limited (Handy, Boarnet et al. 2002; Saelens, Sallis et al. 2003). Emerging evidence confirms that access to aesthetically pleasing public open spaces in conducive to higher rates of walking, implying that health gains can be achieved by providing access to such environments (Giles-Corti, Broomhall et al. 2005) (Pikora, Giles-Corti et al. 2006). There remains huge potential for land-use and design policies to improve opportunities for walking and cycling, along with creating more aesthetically pleasing environments in which to do so. The existing evidence base tends to focus on purposeful travel patterns, i.e. to a destination, such as workplace or shops. Data on travel for leisure and physical activity purposes is scarce. Some examples are the United States’ Behavioural Risk Factor Surveillance System (BRFSS), the US National Health Interview Survey (NIS) and the US National Health and Nutrition Examination Survey (NHANES), which report a range of leisure time activities (albeit with limited information about older age groups). Although several researchers are documenting physical activity patterns using geographic information systems (GIS) methodologies, further research on travel trends is needed. Data can be collected from existing sources, such as census data, real estate records, public health statistics, and public safety data. Such ecological level information ideally needs to be interpreted alongside individual level data, both from self-report measures and objective measures such as pedometers and accelerometers.

In Australia, consideration of environmental factors extends beyond the built environment to the geographical challenges of rural and remote living. Many rural and remote communities lack the community infrastructure to support sport and leisure activities. This issue is particularly salient for Aboriginal and Torres Strait Islander communities. Survey data from remote Indigenous communities highlight that the people view recreational facilities as a priority need. Indeed, one Western Australian survey ranked the need for recreational facilities second, behind road access to and from communities (Environmental Health Needs Coordinating Committee 1998). The national Indigenous Sports Program has begun to address some access issues, but its focus is not directly relevant to older people.
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