June 2008

Grant Results

SUMMARY

From 2002 to 2006, the national program office of Faith in Action® implemented a home-based exercise program designed to improve strength, function and balance in frail older adults at 10 Faith in Action sites.

Faith in Action is a national program of the Robert Wood Johnson Foundation (RWJF) that brings together volunteers from different faiths to work together to care for their neighbors who have long-term health needs. For more information, see Grant Results on the program.

Key Results

  • Coordinators at the 10 pilot sites recruited and trained 103 volunteers and enrolled 106 frail older adult participants for the 12-month, home-based exercise program.
  • Seven of the 10 sites continued to implement exercise programs after the first 12 months, recruiting an additional 34 volunteers and 133 participants.
  • Based on these seven sites' continued enthusiasm, the national program office gave them leftover funds from this grant, which enabled them to recruit an additional 76 volunteers and 463 participants and offer home-based and group exercise programs.

Key Findings
Evaluators at the University of Illinois at Chicago reported the following findings in a 2006 article in the Gerontologist:

  • Participants and volunteers expressed satisfaction with the exercise program after four months. At four months, all 63 volunteers still participating in the exercise program and 69 out of 70 older adults still participating felt "excellent," "very good" or "good" about their participation.
  • Some 83 participants turned in an exercise calendar. They reported engaging in exercise an average of 2.2 times per week; 44 of those participants (53 percent) reported exercising 2 to 4 times per week.
  • Participants had significant improvements in social functioning after four months. The evaluators measured social functioning by the degree to which an individual's emotional or physical problems disrupt his/her normal social activities.
  • The evaluators found no changes in participants' physical functioning, role functioning (the degree to which an individual's emotional problems interfere with his/her work or other daily activities), mental health, health perceptions and pain. There were no serious injuries or illnesses reported.

Funding
RWJF supported the project with a grant of $602,600 between August 2002 and August 2006.

 See Grant Detail & Contact Information
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THE PROBLEM

Most people lose 20 to 40 percent of their muscle tissue as they get older, according to a publication of NASA and the National Institute on Aging. This loss of strength can diminish people's capacity over time to conduct such basic daily activities as climbing stairs, getting up from a chair or even walking.

Strength training in the form of muscle-building exercises can improve strength in most older adults. While strength training benefits frail older adults, when this grant began, such training had not been widely disseminated to those who were homebound because this population was difficult to reach and serve.

A Tested Exercise Program

Strong for Life is a home-based strength-training program designed for frail older adults who have limitations in their daily activities.

The exercise program uses a 35-minute videotape consisting of a warm up, 11 strengthening exercises using Therabands (color-coded bands that provide positive and negative force on the muscles and range from light to heavy resistance) and a cool down. Each participant's goal is to exercise three times a week at a resistance level specified by a trainer.

Researchers at the Boston University Roybal Center for Enhancement of Late-Life Function (now called the Health & Disability Research Institute) and the MGH Institute of Health Professions developed and then tested the program in two randomized, controlled trials with disabled and nondisabled older adults.

Participants in the trial gained muscle strength and more stable gaits, among other improvements. Results were published in two journal articles:

  • Krebs DE, Jette AM and Assmann SF. "Moderate Exercise Improves Gait Stability in Disabled Elders." Archives of Physical and Medical Rehabilitation, 79: 1489–1495, 1998.
  • Jette AM, Harris BA, Sleeper L, Lachman ME, Heislen D. Giorgetti M and Levenson C. "A Home-based Exercise Program for Nondisabled Older Adults." Journal of the American Geriatric Society, 44: 644–649, 1996.

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RWJF STRATEGY

At the time of this grant RWJF was funding physical activity projects across the age span. In 2003, it confined its focus to physical activity to address the epidemic of childhood obesity, including communitywide approaches. Projects for older adults included:

  • Developing a national blueprint to help increase physical activity among adults age 50 and over. See Grant Results for more information.
  • Creating an assessment tool for older adults called the Exercise/Physical Activity Assessment and Screening for You (EASY). See Grant Results for more information.
  • A study of the factors that encourage older adults to use local parks and recreational services and what policy changes might be made to promote park use among older adults to increase their physical activity. For more information see Grant Results.
  • A social marketing project by the AARP from 2002 to 2004 to promote increased physical activity by older adults in Richmond, Va., and Madison, Wis. See Grant Results for more information.
  • Support for task forces that promoted and provided strength-training, balance and mobility classes to older adults in the 28 California counties with the highest levels of nonfatal injuries from falls among individuals age 50 and older. See Grant Results for more information.
  • A study that examined communication between health care practitioners and their older adult patients on physical activity, which found that physician empathy is more important than physician behavior. See Grant Results for more information.

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THE PROJECT

This project tested whether the Strong for Life exercise program would also achieve positive results in community settings. If the results were promising, RWJF staff was interested in developing a larger initiative to disseminate the program more widely, according to the RWJF Robin E. Mockenhaupt, Ph.D., the RWJF program officer.

RWJF staff proposed to implement the exercise program in an existing, well-established RWJF national program—Faith in Action—to reach homebound frail older adults. Faith in Action brings together volunteers from different faiths to work together to care for their neighbors who have long-term health needs.

The national program office of Faith in Action, located at Wake Forest University in Winston-Salem, N.C., carried out the project.

Under the project, national program staff selected 12 Faith in Action projects around the country and invited them to apply to participate. From those 12 projects, staff chose 10 that:

  • Had an interest in offering the exercise program for 12 months.
  • Were well established in the community (that is, they were more than three years old).
  • Had strong staff capacity to administer the exercise program and would commit approximately 10 hours a week to it.
  • Could recruit approximately 10 volunteers able to implement the exercise program for the full 12 months with approximately 10 frail older adults.
  • Had adequate insurance to cover volunteers and participants.
  • Had the ability to collect data and report on the implementation of the program.

The project sites were located in eight states: California, Florida, Massachusetts, New Jersey, Oregon, Texas (two sites), West Virginia and Wisconsin (two sites).

The sites represented urban, suburban and rural locations. Some stood alone and some were part of umbrella organizations, including two hospitals, a university and a YMCA. The sites were:

  • Partners in Caring, Stanford, Calif.
  • Upper Pinellas Interfaith Volunteer Caregivers, Dunedin, Fla.
  • MATCH-UP Interfaith Volunteers, Boston, Mass.
  • Interfaith Network of Care, Milltown, N.J.
  • Interfaith Volunteer Caregivers, Newberg, Ore.
  • YMCA of Greater El Paso, El Paso, Texas
  • Southwest Texas State University, San Marcos, Texas
  • Beaver Dam Area Interfaith Volunteer Caregivers, Beaver Dam, Wis.
  • Interfaith Volunteer Caregivers of Clark County, Neillsville, Wis.
  • Ohio Valley Interfaith Volunteer Caregivers, Wheeling, W.Va.

Each site initially received $25,000. These funds primarily provided salary support for a site coordinator who recruited volunteers and facilitated their training, identified frail older adult participants and oversaw the start-up and implementation of the 12-month exercise program.

Participants needed a physician's approval. Volunteers went to the homes of the approved participants once a week to do a half-hour exercise session on videotape with the frail elders. Volunteers asked participants to do the exercise program twice more a week on their own.

The volunteers and the site coordinator also had to fill out forms about the implementation and progress of the project for the evaluators.

Faith in Action subcontracted with Boston University Roybal Center on Aging to assist in training the volunteers. Staff at the center also revised the training manual they had developed for their initial trial to make it applicable to community settings.

The national program office hired a coordinator, Marsha Berry in Forest, Ind., to oversee the project. Berry had worked as a mentor to several Faith in Action projects as part of the larger national program.

Under a subcontract, Thomas Prohaska, Ph.D., and Caryn Etkin, M.P.H., at the University of Illinois at Chicago carried out an evaluation to assess volunteer and participant satisfaction with the program as well as changes in functioning in participants.

Activities

  • Between March and August 2003, a team of three physical therapists from Boston University trained coordinators and volunteers at each site. Over two days, the trainees learned the program methodology by practicing the exercises, playing roles and discussing how to respond to challenging situations such as dealing with a participant with memory loss or adapting the exercise routine to a participant who needed to remain seated.
  • The Faith in Action national program office produced a monthly e-newsletter for sites to share lessons learned and strategies for success. The office also developed and maintained an interactive Web site (no longer active) with tools and tips for using the Strong for Life program. The project coordinator held monthly conference calls with the site coordinators and compiled the evaluation data from the sites to send on to the evaluators.
  • Site coordinators, the project coordinator, national program office staff, program developers at Boston University and the evaluators met twice, at Faith in Action meetings, on May 2, 2003, in Indianapolis and April 29, 2004, in Winston-Salem, N.C., to discuss project progress and challenges.
  • In August 2004, when most sites had completed their 12-month exercise program, the project staff offered a "refresher" workshop through a Webinar (seminar on the Web). The purpose of the Webinar was to provide the sites with ideas and strategies for how to sustain the exercise program within the local Faith in Action project. Included in the seminar were tips for recruiting new volunteers and identifying participants as well as for motivating participants.

After the initial 12-month exercise program, seven of the 10 sites continued the program with their own funds, recruiting new volunteers and matching them with new participants. In light of these sites' sustained commitment to the exercise program, in November 2005 Faith in Action staff awarded each of these seven sites an additional $9,000 of unexpended funds from grant ID# 046090 that funded Strong for Life to support continued activities.

Sites mostly used this funding for salary support for the coordinators. The coordinators continued to recruit new volunteers and enroll new participants. The coordinators trained the new volunteers; the trainers at Boston University remained available for conference calls and individual telephone consultations.

All seven sites began offering both home-based and group exercise. They hoped group exercise sessions would help motivate participants to adhere to the goal of exercising three times a week. Offering group exercise also helped overcome the shortage of volunteers relative to the number of frail older adults wanting to participate. With the advent of group classes, numbers of participants in the exercise program increased sharply.

Two sites among the original group did not continue the exercise program:

  • The board members of one site in Wisconsin decided that liability for the exercise program was too great.
  • The second Wisconsin Faith in Action project merged with a neighboring Faith in Action project not part of this demonstration.

The tenth site, in Texas, did not return phone calls, or respond to letters or complete other paperwork that the national program office requested so the status of their exercise program is unknown.

Evaluation Methodology

The evaluators surveyed site coordinators after each site's training session and four months after the exercise program began. The evaluators also interviewed the site coordinators by telephone after 12 months.

The coordinators, in turn, surveyed volunteers and participants when the program began and four months later. Coordinators asked participants to keep track of their exercise and any problems in a calendar. See the Appendix for more details on evaluation methodology.

Challenges

The implementation and evaluation of Strong for Life faced a number of challenges:

  • About half of the pilot sites did not meet the project timeline for recruiting and matching volunteers with older adults. It took longer than expected to get started with the exercise program. Some sites had delays in identifying and hiring a site coordinator.
  • It was difficult for the evaluators to collect the data they needed. The site coordinators were responsible for completing baseline and follow-up surveys for volunteers and participants and gathering the monthly calendars and injury reports. Project staff at the Faith in Action national program office reported that that the paperwork was too burdensome for some of the project sites given the site coordinator position was most often part time.
  • Some site coordinators reported difficulties maintaining volunteer and participant motivation after volunteers and participants had worked seven to eight months with the same, now stale, video. Some of the volunteers and participants opted to go for a walk or participate together in some other physical activity instead of following the video. Others followed the video with the sound muted and substituted music for variety.
  • It was sometimes difficult to identify appropriate people to participate in the exercise program. Sharon Hendrickson participated as a volunteer with the Interfaith Volunteer Caregivers of Clark County in Neillsville, Wis. She said she ended up with two people in their late 80s or early 90s who had Alzheimer's disease and could not participate fully in the program. They didn't remember what the program was about from week to week and were not interested in exercising, she said. What's more, the participants either did not have a VCR or did not have a television. The Faith in Action project supplied the equipment.

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RESULTS

  • Coordinators at the 10 pilot sites recruited and trained 103 volunteers and enrolled 106 frail older adult participants for the 12-month, home-based exercise program.
  • Coordinators in the seven sites that continued to implement exercise programs without RWJF grant support after the first 12-month Strong for Life program ended in August 2004 recruited an additional 34 volunteers and 133 participants.
  • The November 2005 infusion of unexpended RWJF grant funds to the seven continuing sites enabled them to recruit an additional 76 volunteers and 463 participants for both home-based and group exercise program (but mainly for group exercise program) by August 2006. Several of the site coordinators also used the additional grant support to strengthen the foundation of the program, for example, by establishing relationships with local hospitals, community health centers, physical therapy schools and universities to encourage older adult referrals and identify potential volunteers.

    Some sites began receiving support from local funders; at one site, the family of a participant's spouse gave money towards the exercise program.

Stanford (Calif.) Faith in Action Home-Based Exercise Program Transitions to Group Exercise

One of the biggest benefits of the exercise program was the social aspect, said Candace Mandigo, a registered nurse and director of the Faith in Action project Partners in Caring in Stanford, Calif. The project is part of Stanford Hospital.

"Everyone just loved having the volunteer come," she said. "They just felt better and more positive about their health…The social connection was huge."

Once the pilot project ended, however, Mandigo decided to continue it as a group exercise program at four different senior centers because of difficulties of finding enough volunteers.

The group exercise program started with about 10 people in 2004. In December 2007, there were 130 people participating in the exercise classes, she said. The Faith in Action project has also tapped into a new group of volunteers to conduct the group exercise sessions that they might not have otherwise found and attracted new donations, she said.

But it has been difficult to bring homebound Faith in Action participants to the group exercise class. Mandigo began asking volunteer drivers to bring homebound elders to the classes. As of December 2007, the project was transporting two older people to the group exercise class.

Boston Faith in Action Project Continues its Exercise Program With Home-Based and Group Exercise

The MATCH-UP Interfaith Volunteer program in Boston, which started in 1984, was looking to diversify the services they offered and the idea of an exercise program to help people stay in their home appealed to project staff, according to director Janet Seckel-Cerrotti.

"Our mission is to decrease social isolation and increase the quality of life. That has a lot to do with physical activity," Seckel-Cerrotti said.

The biggest challenge in the project was getting referrals from health clinics, hospitals and home care agencies for older adults who would be appropriate for the program, she said. Referring agencies were not accustomed to making referrals for exercise programs and potential participants were not used to thinking about trying an exercise program.

Seckel-Cerrotti said some participants saw physical changes and several appreciated the interaction with the volunteers. She said that the required paperwork was cumbersome and, like other pilot sites, the volunteers and participants grew tired of the exercise program.

She added that most of the participants were white and middle class. She said that it was hard to find low-income people and people of color to participate. She speculated that the difficulty might be because that population was struggling with basic issues like paying bills, making exercise a lower priority.

"I think we had decent results—not over-the-top fabulous," she said. "It was nice because it opened up a diversification of volunteers and diversified the work we were doing."

The site used its additional $9,000 to continue the exercise program and the site coordinator, a woman in her 20s, used the Internet to tap into a new volunteer group for Faith in Action — people in their 20s who were interested in exercise and liked working with older people.

In December 2007, the project was providing group exercise and home-based exercise to participants. It had five participants receiving the exercise program at home and three groups with a total of about 40 participants.

MATCH-UP has sustained the exercise program with funding from other foundations.

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EVALUATION FINDINGS

The evaluators assessed the first four months of the exercise program only. They reported findings in a 2006 article in the Gerontologist:

  • Almost 60 percent of the 86 participants who began the program (out of the 106 originally enrolled) reported having three or more chronic conditions. More than half of the participants had osteoarthritis and 45 percent had hypertension. Seventy-four participants (86 percent) were white, nine were Hispanic, one was African American, one was Asian or Pacific Islander and one was Native American.
  • Participants and volunteers expressed satisfaction with the exercise program. At four months, all 63 volunteers still participating in the exercise program and 69 out of 70 older adults still participating felt "excellent," "very good" or "good" about their participation.
  • Site coordinators were also positive after four months: five rated the program as excellent, four as very good and one as good.
  • Eighty-three participants had turned in an exercise calendar after four months. They reported engaging in exercise an average of 2.2 times per week; 44 of those participants (53 percent) reported exercising 2 to 4 times per week.
  • Participants had significant improvements in social functioning after four months. The evaluators measured social functioning by the degree to which an individual's emotional or physical problems disrupt his/her normal social activities.
  • The evaluators found no changes in participants' physical functioning, role functioning, mental health, health perceptions and pain. The evaluators measured role functioning by the degree to which an individual's emotional problems interfere with his/her work or other daily activities. There were no serious injuries or illness reported.

    "It's not like it made a gangbusters difference but the fact that the frail homebound elderly didn't have significant declines was significant," said Caryn Etkin, one of the evaluators. "They didn't get worse and that's really important when you talk about this population."

At 12 months, when the evaluators followed up by telephone with the site coordinators, 55 of the 86 participants who began the exercise program were still in the program, a 34 percent attrition rate. The evaluators wrote that this rate was in line with other exercise programs for frail older adults. The main reason participants dropped out was failing health. (Many volunteers left when their match left.)

Conclusions

  • 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, the evaluators concluded. Success also depends on the appropriate matching of volunteers with participants in a timely manner.

Limitations

The researchers reported the following limitations of their evaluation:

  • The short time for follow-up (four months after the program began) and the limited ethnic diversity of the participants make it hard to generalize the evaluation results to broader populations over longer periods.
  • The lack of specific criteria about which participants to include meant that site coordinators may have selected some people too ill to participate.
  • There were no standard recruitment procedures from site to site, and sites did not keep complete information about volunteer and participant attrition.
  • Volunteers and participants were inconsistent in collecting and reporting exercise progression.
  • Volunteers and site coordinators helped many participants complete the surveys. This introduced bias into the evaluation.

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LESSONS LEARNED

  1. Homebound older adults benefit from social interaction as well as physical activity. The volunteers recommended that participants do the exercise program twice a week on their own, but some sites reported that this schedule was difficult for participants to sustain. The program's benefits to the participants, however, went beyond exercise—they looked forward each week to a social interaction with a volunteer who cared about them. (Grantee/Partners in Caring, Stanford, Calif.)
  2. Find ways to add new elements and interest to a video or other exercise routine; otherwise it can get boring over time. Several sites reported that the video grew stale for participants over time. Some volunteers addressed this problem by going for walks instead with their participant, putting the video on mute and playing different music or adding new exercises. One site enhanced the project by also providing participants with health information and recipes. (Grantee/Partners in Caring, Stanford, Calif.; Evaluator).
  3. Make sure that older adults are appropriate for an exercise program and have family support if possible. While the exercise program was designed for frail older people, it may not be appropriate for people who have advanced senility or who are extremely frail. Having family support helps participants keep up with the exercises even when a volunteer is not there. (Grantee/Partners in Caring, Stanford, Calif., and Interfaith Volunteer Caregivers of Clark County, Neillsville, Wis.)

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AFTER THE GRANT

According to Tom Brown, the director of Faith in Action and Strong for Life, about half of the original pilot sites were still providing exercise programs as of December 2007. RWJF's priorities changed during the course of the project so it did not provide further funding.

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GRANT DETAILS & CONTACT INFORMATION

Project

Adding a Strong for Life Physical Activity Component to Faith in Action Projects

Grantee

Wake Forest University Health Sciences (Winston-Salem,  NC)

  • Amount: $ 602,600
    Dates: August 2002 to August 2006
    ID#:  046090

Contact

Tom Brown
(336) 716-0101
tcbrown@wfubmc.edu

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APPENDICES


Appendix 1

Evaluation Methodology

The researchers at the University of Illinois at Chicago described the methodology for their evaluation of the Strong for Life project in a 2006 article published in the Gerontologist:

The evaluators 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.

Four months after the participant was matched with a volunteer and began the Strong for life program, the site coordinator administered the follow-up survey to the participant and the volunteer. Site coordinators also measured participation and attrition for participants and volunteers.

The surveys measured satisfaction with the Strong for Life program, experiences with recruitment and working with older adults and participants' reports on physical, social and mental functioning.

Participants were also asked to complete and turn in exercise adherence calendars every other week, including dates of exercise and which color Theraband they had used at the time of exercising. An additional question on the calendar asked if the participants had any injuries or health problems as a result of participating in Strong for Life.

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BIBLIOGRAPHY

(Current as of date of this report; as provided by grantee organization; not verified by RWJF; items not available from RWJF.)

Articles

Etkin CD, Prohaska TR, Harris BA, Latham N and Jette A. "Feasibility of Implementing the Strong for Life Program in Community Settings." Gerontologist, 40(2): 284–292, 2006. Abstract available online.

Audio-Visuals and Computer Software

Faith in Action Strong for Life meeting. Approximately 25-minute video in which Faith in Action Strong for Life site coordinators share stories of success from the pilot initiative. Winston-Salem, NC: Wake Forest University Health Sciences, 2004.

Survey Instruments

"Baseline Surveys for Faith in Action Sites," University of Illinois, Chicago, March–June 2003.

"Baseline Surveys for Older Adult Participants," University of Illinois, Chicago, March–June 2003.

"Baseline Surveys for Volunteer Trainers," University of Illinois, Chicago, March–June 2003.

"Follow-Up Surveys for Faith in Action Sites," University of Illinois, Chicago, July–October 2003.

"Follow-Up Surveys for Older Adult Participants," University of Illinois, Chicago, July–October 2003.

"Follow-Up Surveys for Volunteer Trainers," University of Illinois, Chicago, July–October 2003.

"Adherence Calendar with Injury Report," University of Illinois, Chicago, March 2003–April 2004.

World Wide Web Sites

www.fianationalnetwork.org/extranet/authenticate.cfv. Web site created specifically for the pilot sites and collaborating organizations to facilitate access to tools and materials to implement the Strong for Life exercise program. Winston-Salem, NC: Wake Forest University Health Sciences.

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Report prepared by: Susan G. Parker
Reviewed by: Janet Heroux
Reviewed by: Molly McKaughan
Program Officer: Robin E. Mockenhaupt

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