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Walk Across Arizona, Community-based Walking Program: Promoting and Sustaining Physical Activity in Older Adults

 

Nobuko Hongu, PhD, RD,
Assistant Professor and Nutrition Extension Specialist
The University of Arizona

Linda M. Block, MS,
Associate Agent, Family & Consumer Health Sciences
The University of Arizona Cooperative Extension

Stephanie A. Sanchez, MPH,
Research Specialist
The University of Arizona

Sharon Hoelscher Day, MA, CFCS
Area Agent, Family & Consumer Health Sciences
The University of Arizona Cooperative Extension

Robin B. Harris, PhD, M.P.H.,
Associate Professor
The University of Arizona

Abstract

Most older Americans aged 65 years and older are not sufficiently active (have at least 150 minutes of physical activity a week). The Walk Across Arizona program started as a pilot project in one retirement community as a part of outreach from Cooperative Extension and the College of Public Health. The purposes of the program were promoting a healthy lifestyle and reducing social isolation among residents. Between 2005 and 2008, 675 participants completed pre and post event surveys and reported weekly miles walked through our Web site. Participants reported walking an average of 16 miles per week and maintained or increased activity over the 16-week program period.The Walk Across Arizona programis an excellent feasible model that Cooperative Extension can utilize to develop a long-term relationship within a community as a resource for healthy lifestyle program. It promotes physical activity using social network (sense of the community) and team concepts.

Key words: Physical Activity, Walking Program, Older Adults, Community Program Sustainability

Introduction

Between 2000 and 2005, the population aged 55 and older in the United States increased 13 percent, to 67.1 million. The rate of growth was more than four times the rate for the population under age 55 (3 percent). About one third of these older adults live alone, potentially making it difficult for them to continue to be active or begin a new activity regime (US National Center for Health Statistics, Vital Statistics of the United States 2007). Older adults are looking for ways to maintain their health and to stay physically and mentally active. Several studies have documented that social support provided by friends, acquaintances, and community members can influence daily physical activity (PA), well-being and health (Hawley and Klauber 1988; Mowen et al. 2007; Steptoe et al. 1997). Regular PA provides a health benefit to older adults, including improvements in blood pressure and lipid profile, while reducing the risk of diabetes, osteoarthritis and osteoporosis (Taylor et al. 2004; Tüzün et al. 2010). Regular PA is also associated with decreased mortality and age-related morbidity in older adults (Blair et al. 1989; Gando et al, 2010). More importantly, regular PA promotes overall successful aging by helping older adults maintain independent lifestyles and higher quality of life (Meisner et al. 2010). Despite these well-documented connections, only 25 percent of older adults are “sufficiently active” (have 150 minutes of moderate PA/week) to achieve the health benefits associated with PA (American College of Sports Medicine 2009; Physical Activity Guidelines Advisory Committee 2008; US Dept of Health and Human Services 2000). Clearly, there is a need to improve the effectiveness of community fitness programs targeting older adults and to expand the research literature on the effectiveness of PA interventions and community program sustainability. This study introduces a feasible model to address both these needs which involves Cooperative Extension.

Program description

In 2000, the Health and Human Services Committee of the Green Valley Community Coordinating Council formulated a set of goals to promote a healthy community based upon a 1998 needs assessment. Green Valley is a booming state retirement community in Southern Arizona that was planned explicitly to promote active adult life-style options. One specific goal for the community was to “Promote a Healthy Lifestyle” among residents. In 2001, a task force was formed of community members and University researchers with expertise in community program development, nutrition, and PA with the local county extension agent as the chair. The partnership between the retirement community and the College of Public Health, College of Agriculture and Life Sciences, and Cooperative Extension was formed as part of the activities of the Community Health Advancement Partnership (CHAPS) initiative (Houtkooper et al. 2001). The primary activity initiated by the community task force was the development and implementation of a community-wide walking program (Walk Across Arizona) designed to increase PA of residents and increase their sense of community. Since this initial pilot year (2001), the community-wide walking program has been implemented every year, including participants from Green Valley and various other communities (University, wellness programs from churches and industries) surrounding the initial retirement community. The original Green Valley Task Force remained active with organizing the event each year. Furthermore, the program expanded into statewide outreach program (10 out of all 15 counties in Arizona participated in the program at least once). From 2001 to 2010, the Walk Across Arizona Program included10,426 participants from 1,207 teams representing all age groups (including older adults, greater than 65 years old) who reported walking over 2 million miles. Formats for the walking program and materials used by the different communities were similar to PA/walking promotion programs used in Texas, (Walk Across Texas!), Michigan, (Walk Michigan!), and Kansas (Walk Kansas).

The theoretical basis for the Walk Across Arizona program was to use social support networks to increase PA levels within the community by developing and maintaining walking clubs. This strategy was expected to be effective for both promotion of PA and the sense of community (both goals of the original Green Valley task force). The program was designed to be of 16 weeks duration, with individual participants registering as part of teams. Teams could be formed as part of a social group, neighborhood, housing unit, or work site. Community kick-off, mid-course (8-week), and end-of-program events were established to increase awareness of the walking program and to boost confidence of the participants. The duration of the program was determined to be 16 weeks from the authors’ examination of successful theory-based behavior change programs in increasing PA (King, Rejeski & Buchner, 1998). Studies have indicated that this time period is sufficient time to elicit a long-term behavior change (Reed et al. 1997; Wilcox et al, 2009). County coordinators managed the various community programs in the participating counties, setting their own “start date”, incentives, and registration fees for the Walk Across Arizona program.

In this paper, we describe how the Walk Across Arizona program was implemented and how older adults (aged 65 and older) participated in the program over a three year period from late 2005 to early 2008. We also explored the strengths (i.e., increasing numbers of older adult participants and sustainability of the program) and challenges (i.e., specific determinants of physical activity, limitations of the program) in creating community-based programs that have the potential to lead to improvements in PA among older adults.

Methods

Recruitment and format of walking program

Potential Walk Across Arizona participants were recruited by program fliers, community newspapers, and through postings in community buildings and offices. Word of mouth was also a great resource to recruit walkers. Beginning in 2005, participants registered or enrolled in the program via the Internet completing an on-line registration form that included a brief survey to collect information about demographic characteristics of the participants, their usual PA behaviors and community involvement history. Participants without Internet access enrolled in the program by completing printed registration and survey forms. Later, their team captains or the County Coordinator for the team’s county entered their registration and survey information on-line. Following completion of the 16-week program, participants were asked to complete an on-line (or printed) “wrap-up” form. In addition to questions about PA behaviors and community involvement, participants were asked to evaluate potential benefits of the Walk Across Arizona program, including stress and energy levels. Teams of up to 10 individuals then engaged in a county-wide friendly competition over total miles walked. During the program, the miles logged by each participant were recorded weekly and subsequently entered into an on-line database by team captains. The total miles walked by the teams were posted by county on the home page of Walk Across Arizona Web site, so all participants could see their own progress and that of other teams. Over three program years (2005/2006, 2006/2007, 2007/2008), the Walk Across Arizona program involved ten of our state’s fifteen counties; each county had a corresponding page on the Walk Across Arizona program Web site. The University of Arizona Institutional Review Board approved the program and its materials on an annual basis. A disclaimer waiver was included on the Web site and registrants were asked to indicate that they had read the information before registration.

Data analysis

The three years of the Walk Across Arizona program data were analyzed cross-sectionally and longitudinally using Stata 9.2 (Stata Corp 2007). Returning participants during the three years were identified by matching registration files by age, gender, name and county. Participants were classified as “returning” participants if they participated in a prior Walk Across Arizona program from 2004 to 2007, and as “new” participants if they had not. Based on the PA recommendations by the American College of Sports Medicine and the American Heart Association (Nelson, et al. 2007), which states “Do moderately intense cardio 30 minutes a day, five days a week,” participants were classified as regularly active at entry if they responded “I currently participate in PA regularly (5 or more days a week)” or insufficiently active otherwise (Table 1). The Fischer’s exact test was used to detect differences in participant characteristics between the three program years. The ages of participants reported at registration were compared across the three program years using one-way analysis of variance.

To determine the effectiveness and sustainability of the Walk Across Arizona program, we examined the reported miles walked by participants during each of three 16-week program periods. Average miles were calculated at each week of the three program years. Mixed-effect linear models were used to investigate differences in miles walked across the three program years, and examined across the 16-week program for a mileage slope, which represents the sustainability of walking over the duration of the program. Differences in miles walked by PA status at baseline and returning participant status were adjusted in the final model. Within subjects across the study period, the model fitted a participant level random intercept and random slope to adjust for the serial correlation. Statistical significance was considered at the 0.05 level.

Results

Characteristics of participants at registration

Between 2005 and 2008, a total of 675 adults aged 65 and older participated in the Walk Across Arizona program. Table 1 shows participant characteristics at registration for the three program years (2005/2006, 2006/2007, and 2007/2008). Participants were predominately female (72 percent, n=482) and non-Hispanic white (93 percent, n=449). Participant numbers increased during the three year period with three times the number of older adult registrants in 2007/2008 relative to 2005/2006. With this increase in numbers there have also been an increasing number of participants repeating the program. In 2005/2006, there were 51 returning participants while 61 participants returned in 2006/2007 (increased 19 percent compared to the year 2005/2006), and 80 participants returned in 2007/2008 (increased 21 percent compared to the year 2006/2007). The 2007/2008 program had a significant increase in new, younger, and insufficiently active participants. Even though all participants were over age 65, the average age was significantly lower in 2007/2008 than in 2005/2006 (75.6 years in 2005 compared to 72.8 years in 2007). In 2005/2006, 24 percent of respondents reported insufficient PA at entry, compared to 29 percent of respondents in 2007/2008. Additionally, there has been a significant increase in participants registered from primarily urban county in Arizona with the percentage of participants increasing from 2% in 2005/2006 to 51% in 2007/2008 (Table 1).

Reported walking miles during the program periods

The average weekly mileage reported for all time periods was 16 miles per week, with participants reporting the range of 202-210 total miles per program during the 16-week periods (Figure 1). As shown in the figure, participants from primarily rural counties maintained a rather constant walking level throughout the 16-week program period for all program years at approximately 15 miles per week. Note that Figure 1 only included the last two program years (2006/2007 and 2007/2008). In year 1, only three of the participants were from urban area, and their reported miles did not show any walking pattern. Thus, we did not include program year 1 (2005/2006) in the Figure 1. In program year 2 (2006/2007) the number of participants from urban counties increased from three to 31, and participants from rural area increased from 123 to 140 participants. Participants from the urban county increased their walking (miles per week) over the 16-week periods, resulting in an overall higher average miles walked by participants in the program year 3 (2007/2008). Miles reported were shown to significantly increase by 0.18 miles per week (p<0.001) only during the program year 3 (2007/2008), but not other program years. A multi-level mixed effect linear regression model adjusting for participant age, PA status at baseline, and returning participation status indicated that there was a statistically significant difference in reported miles by age, PA status at baseline, and returning participation status. Younger, insufficiently active, new participants reported higher weekly mileage compared to older, regularly active, repeating participants (Table 2). Gender and ethnicity groups were not significantly different in miles reported, and adjustment for county did not fully account for the significant difference in miles walked during the program year 3 (2007/2008).

Table 1. Characteristics of Older-Adult Participants in the Walk Across Arizona Program, 2006-2008

Characteristics of Older-Adult Participants in the Statewide Walking Program, 2006-2008

[Table 1 Characteristics of Older-Adult Participants in the Walk Across Arizona Program, 2006-2008: Characteristics of Older-Adult Participants for Table 1 goes here]

Table 2. Adjusted Walking Miles from Linear Mixed-Effect Regression Model

Program Year

Reported Miles Walked*

Week 1

Week 16

P-value

Mean

95% CI

Mean

95% CI

WAAZ 2005/2006

16.93

(16.87,

16.99)

16.57

(15.60,

17.54)

0.433

WAAZ 2006/2007

17.04

(16.96,

17.12)

17.29

(15.99,

18.59)

0.682

WAAZ 2007/2008

17.14

(17.06,

17.22)

19.72

(18.46,

20.98)

<0.001

*Adjusted for age, activity status at baseline, and returning participant status.

**Significant difference, p<0,001

Figure 1. Average miles reported by participants during two years of the Walk AcrossArizona program, stratified by county

Average miles reported by participants during two years of the ‘Statewide Walking’ program, stratified by county

[Alt tag content for Figure 1: Reported average miles during two years stratified by county goes here.]

Discussion

From 2005 to 2008, the Walk Across Arizona program tripled in numbers of participation (Table 1). The adaptation of the Walk Across Arizona program in the community was successful as demonstrated by 1) the maintenance of the original community task force, 2) the increase in participation every year in both new participants and returning participants, and 3) the increased number of other communities and counties participating in the program. The strength of this community-based walking program for older adults might be the team approach which allowed participants to join a group of community members, family and friends, then set their own goals, and communicate via the Internet or interact face-to-face for continuous social support. The effectiveness of the Walk Across Arizona program in increasing PA was demonstrated through the increase in reported walking miles, particularly during 2007-2008. This increase is especially meaningful since half of these participants did not meet PA recommendations at registration, based on the survey results on PA status (Table 1). It is interesting to note that in the first two program years (2005/2006 and 2006/2007) we did not see an increase in reported miles; even though the majority (71-75percent) of participants reported they were active (reported PA for 5 or more days per week). It is difficult to know why the first two program years with more active participants did not show an increase in walking miles, while there was such an increase among the less active participants in the 2007-2008 program year. While some of these changes can be explained by an increase in workplace teams from the urban county, this may not be the whole story. Did “active” participants feel satisfied just by joining the Walk Across Arizona program without actually increasing PA? Did the group-based social support create a norm of “maintaining PA” rather than “increasing PA”? The participants in this study who self-reported as “active” may not meet the current recommendation of 150 minutes a week of moderate-intensity PA. This issue could be addressed by expanding our efforts to make older adults with no limiting chronic conditions aware that the current PA recommendation are essentially the same as those proposed for younger adults (USDHHS 2008). The challenge may also be related to program flexibility to account for special needs of older adults. Practitioners may need to strive to facilitate the special requests of older adults who may be participating in a group-based program (Orsega-Smith et al 2008).

Another measure of program effectiveness was seen in the assessment of the participants. In the “wrap-up” form, participants were asked to evaluate potential benefits of the Walk Across Arizona program. There were a total of nine possible answers and participants could select all that apply. Across all three program years, participants answered that the benefits of participating in the Walk Across Arizona program were that it: 1) increased exercise I was already doing (40 percent of total responses), 2) increased my energy (32 percent), 3) helped me feel less stressed (27 percent), 4) kept me motivated when I felt like quitting (24 percent), and 5) helped me find a group to walk with (17 percent). Although these are impressive results, the study does have limitations. For this study specifically, we are not able to make judgments regarding why the Walk Across Arizona program participants walked and continue coming back to participate in the program every year. It will be important for future research to examine those key elements of program success further.

Conclusions and recommendations

The development of the community-based walking program (Walk Across Arizona) for older adults is an example of how Cooperative Extension can help to develop a long-term relationship within a specific community to serve as a resource for healthy lifestyle program development. As described, the CHAPS initially set out to develop a long-term partnership with the retirement community by establishing professional liaisons between the University and the community through various activities, including community involvement and board membership, seeking additional grant funding to benefit the community, and serving as evaluators on needs assessment. Cooperative Extension provided leadership to various community projects, including non-formal education with community displays, presentations and media contracts, health fairs and other community outreach programs, such as state aging network, healthy lifestyle initiatives, and financial managements. As part of developing this relationship, local residents became active members of the task force and contributed their ideas on how the program should be implemented resulting in the opportunity to develop an innovative community-based health promotion program.

The task force members were actively involved in recruiting Walk Across Arizona participants from neighborhood associations and partnering agencies and assisted in the formation of teams and the recruitment of team captains who could motivate participants in the community. The direct contact and personal invitation from task force members of the community might be main reasons the participants came back each year to continue their involvement. Results from the “wrap-up” survey on community involvement suggested that it may be the case among the Walk Across Arizona participants. On the questionnaire the participants were asked, “How much do you feel you are a part of your community?” There were three possible answers: a lot, somewhat, and not at all. In the first program year (2005/2006), 53% participants answered a lot (40%) or somewhat (13%) and for the next 2 program years (2006/2007 and 2007/2008) 90% of participants answered a lot (36-37%) or somewhat (54%) to the question. We are not able to answer the reasons of this increase, but we were promoting social support and a sense of belonging among participants in a community through the Walk Across Arizona program, as one of main goals of the program.

Results of this study suggest that the walking program addresses a perceived need, as indicated by an anecdotal response from one participant who said, “I love to exercise, but it isn’t to try to live to be 100. I just want good quality of life.” The social interaction a community program can provide is equally important to sustained participation, as noted by another respondent who commented, “I enjoy being part of a team because it keeps me accountable.” The anecdotal evidence from our participants is similar to findings using qualitative content analysis from other community-based programs (Nies et al. 2003; Wellman et al. 2007). In the study of the Eat Better & Move More program, the researchers assessed outcomes of an integrated nutrition and exercise program designed for the Older Americans Act Nutrition Program (frequently called, “meals on wheels”). They concluded that the intervention significantly improved nutrition and PA behaviors in participants (n=620). The researchers noted that the volunteer nature of the study (much like the Walk Across Arizona program) may have influenced participants’ readiness to make changes (Wellman et al. 2007). This relates to the Walk Across Arizona program in that participants adhered to the community-based walking program goals and kept walking or increased walking, because they readily volunteered to be a part of the program. Cooperative Extension facilitates both participation and the social interaction by linking researchers, practitioners and community members through extension professionals to insure options like the Walk Across Arizona program are not only available but effective at encouraging and sustaining PA in older adults. Extension professionals, health educators, and community practitioners in public health interested in developing a walking program such as the Walk Across Arizona program may want to visit our Web site http://cals.arizona.edu/waaz/.

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Cited walking promotion program websites:

Acknowledgement

We thank the Senior Support Systems Analyst of Arizona Cooperative Extension, Robert Armstrong, for his invaluable assistance and support of our Web site; and older adults of the Walk Across Arizona program for their participation in the study.

http://ncsu.edu/ffci/publications/2010/v15-n2-2010-summer/index-v15-n2-August-2010.php

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