While the need to address disparities in care is well known, few strategies for reducing disparities have been studied systematically.
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.
Evaluators at the University of Illinois at Chicago reported the following findings in a 2006 article in the Gerontologist:
RWJF supported the project with a grant of $602,600 between August 2002 and August 2006.
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.
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:
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:
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:
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:
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.
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 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.
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.
The implementation and evaluation of Strong for Life faced a number of challenges:
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.
The evaluators assessed the first four months of the exercise program only. They reported findings in a 2006 article in the Gerontologist:
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.)
The researchers reported the following limitations of their evaluation:
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.
Adding a Strong for Life Physical Activity Component to Faith in Action Projects
Wake Forest University Health Sciences (Winston-Salem, NC)
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.
(Current as of date of this report; as provided by grantee organization; not verified by RWJF; items not available from RWJF.)
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): 284292, 2006. Abstract available online.
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.
"Baseline Surveys for Faith in Action Sites," University of Illinois, Chicago, MarchJune 2003.
"Baseline Surveys for Older Adult Participants," University of Illinois, Chicago, MarchJune 2003.
"Baseline Surveys for Volunteer Trainers," University of Illinois, Chicago, MarchJune 2003.
"Follow-Up Surveys for Faith in Action Sites," University of Illinois, Chicago, JulyOctober 2003.
"Follow-Up Surveys for Older Adult Participants," University of Illinois, Chicago, JulyOctober 2003.
"Follow-Up Surveys for Volunteer Trainers," University of Illinois, Chicago, JulyOctober 2003.
"Adherence Calendar with Injury Report," University of Illinois, Chicago, March 2003April 2004.
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.
Report prepared by: Susan G. Parker
Reviewed by: Janet Heroux
Reviewed by: Molly McKaughan
Program Officer: Robin E. Mockenhaupt
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