Participation, adherence, and associated facilitators and barriers for Otago-based exercise programs in two continuing care retirement communities

By Meta Katherine Carter, SPT

Background:

I had the great opportunity to volunteer at two local continue care retirement communities (CCRCs) through course assignments as part of the UNC DPT curriculum. I was inspired to focus my Capstone on this topic after helping with balance testing for older adults and working on Dr. Vicki Mercer’s Community Health and Mobility Partnership (CHAMP) research which utilized the Otago Exercise Program to help prevent falls. These opportunities gave me insight and real-life experience as to how testing and evidence-based interventions function with an older adult population in current practice, with the goal of preventing falls and injuries from falls, and prolonging independence in this population group. As part of my research experience elective, I helped collect and review participant information regarding adherence to exercise recommendations made as part of the falls prevention program. This exposure prompted me to consider the facilitators and barriers to ongoing exercise and physical activity in this population, and to want to better understand the experience of the individuals that had participated in the program, and what modifications might be made to improve adherence.

To accomplish this, I endeavored to create a pilot study which would include conducting telephonic interviews with participants of two different exercise programs, a home-based Otago exercise program offered at one CCRC and a group Otago exercise class offered in a different CCRC. Semi-structured interviews would be used to collect and analyze data regarding participant participation, adherence, and associated facilitators and barriers in these two exercise programs.

 

Statement of Need:

Falls are well recognized as a major health problem given that they are responsible for the second highest number of accidental or unintentional injury-related deaths across the global population.¹ For older adults, falls are the main cause of emergency department visits.² Furthermore, evidence indicates 13-33.3% of those individuals will become repeat fallers within 6 months, and 46-52% will fall again within 12 months of their emergency department visit.² Some studies report that for individuals age 65 and older, approximately one third of this group will experience a fall each year, with an increasing incidence of falls as they continue to age.³

Many studies have been conducted that examine facilitators and barriers to sustained exercise and physical activity in older adults as a means of falls prevention; however, few examine the Otago program specifically. The Otago Exercise Program is a strength and balance exercise program which has been shown to be effective in reducing falls and injuries associated with falls in high risk older adults, and has been recommended by the Centers for Disease Control as an effective program to prevent falls.^4,5 However, despite evidence that this program is effective, uptake and maintenance of this type of program remains challenging.⁶

This project is needed because no studies that examine the experience of individuals living in CCRS who participate in Otago exercise have been identified. CCRCs are a growing industry offering residential opportunities for the expanding older adult population along the continuum of health care needs. There are approximately 2,000 CCRCs nationwide providing services to 700,000 residents, up from 700 CCRCs in 1986.^7,8 Given that a growing percentage of the older adult population is residing in CCRCs, it is important to know more about how individuals living in these facilities, who may be more limited physically or cognitively, respond to exercise-based interventions and what tools can be used to improve their ongoing participation in exercise-based falls prevention programs, like the Otago program.

 

Purpose:

The purpose of this project was to gain a better understanding of facilitators and barriers to ongoing physical activity and exercise in older adults, specifically those that participated in Otago-based exercise programs offered at two local CCRCs. One program provided individualized home-based exercises that were performed in conjunction with a walking program, and the other offered regularly scheduled group exercise classes based on the Otago Exercise Program. I decided to examine both a home-based and group-based program utilizing the Otago exercises in order to develop a better understanding of how exercise setting and social interactions impact the experience of an exercise intervention and adherence over time. My ultimate goal is that the information gleaned by examining these two programs will help the administrators of these programs, as well as other health care professionals involved with similar programs, to increase adherence and participation, promote long-term exercise behaviors in older adults, and reduce the incidence of falls in this population.

 

Products:

One product of this project was completing the Institutional Review Board (IRB) application that was required in order to get approval to interview participants of these two programs. Having had little to no experience in research prior to beginning the UNC Doctor of Physical Therapy program, this was a new and challenging process for me. Completing the process required multiple revisions and working with my project advisor, Dr. Vicki Mercer, PT, PhD, to create a clear and complete representation of the project we are proposing. A copy of the application is included below. At the time of publishing this webpage, our application was under review by the Institutional Review Board.

IRB Application

Part of the IRB application included writing a “background” section indicating why the project proposed is needed. I was able to use some of the resources I found when working on my literature review to complete this part of the application.

IRB Background

Another product of this project was a literature review. I performed a database search that resulted in nearly 60 qualitative research studies that were relevant to my research topic. The titles and abstracts of these studies were reviewed to isolate those that demonstrated the most overlap with my chosen intervention and patient population. Nine of the most appropriate articles were selected and examined in my literature review.

Literature Review

Lastly, I created an interview script that will be used to guide the telephonic interviews with participants from these two programs once the IRB has approved the project application. To create the interview script, I reviewed prior studies that performed similar interviews examining adherence, participation, facilitators, and barriers. The studies that included a copy of their interview script were isolated and two of these were used as the foundation for the script that I developed with the help of Dr. Mercer.

Interview Script

 

Self-Evaluation and Reflection:

Under the best of circumstances, this was always going to be a difficult semester. While neither the world nor local/personal events that have come to pass over the past three to four months could be categorized as “the best of circumstances,” I have learned a lot from this time and from working on this project. While I am proud of the effort that has gone into the products detailed above, I was hoping to make more progress with this project, including being able to begin the interview process and review some of the data collected. The original draft of the IRB application was changed over the course of the project when social distancing, mandated by the COVID-19 pandemic, ruled out the option for in-person interviews.

Despite this, I believe I could have made more progress with this project if I had utilized my committee members more frequently during the process. In trying to balance being respectful of their time with making the best use of my resources, there were times where I could have contacted my advisor to address a question rather than spending much more unproductive time trying to come up with the answer on my own. While struggling through some of these decisions helped me grow by learning more about the research process, there were instances when it would have been beneficial to reach out for assistance sooner.

I feel that my literature review is a strong part of my project and provides a helpful synthesis of multiple qualitative analyses regarding facilitators and barriers to exercise adherence in older adults. As addressed above in the Statement of Need, promoting maintenance of falls prevention exercises in this population is a worldwide health concern, and this resource may bring to light certain facilitators or barriers that some clinicians may not have considered. I also believe that the interview script has been carefully developed to elicit useful information during the interviews.

My committee advisors were very encouraging and generous with their time, and provided me with extremely helpful feedback that was incorporated into the final draft of the project products. I also worked to remain aware of health literacy while creating these products, and did my best to make sure that when appropriate, the language used was not excessively academic and could be read at approximately a high school reading level.

 

Acknowledgements:

First, I would like to thank Dr. Vicki Mercer who provided me with the opportunity to work on her research, and helped me develop this project idea and create and improve the products attached above. She helped give me direction when I felt lost, and to make sense out of chaos.

Thank you to Ann Chamberlin, PT at Carol Woods Retirement Community and Kayla McBane, Assistant Wellness Director at Pennybyrn Retirement Community, for agreeing to be on my advisory board, and helping me develop and improve this project through your knowledge and expertise. I appreciate your efforts, time, and contributions in helping to facilitate and improve this undertaking and all of the elements of this project.

Thank you also to Erin Fines-Crawford, Fitness Facilitator at Carol Woods, for the opportunity to work with the residents at your facility and observe your wonderful group exercise class. Your assistance and contributions have also been invaluable.

Thank you to my family and friends for their support during this semester, this program, and everything that came before.

 

References:

1. Sandlund M, Pohl P, Ahlgren C, et al. Gender perspective on older people’s exercise preferences and motivators in the context of falls prevention: A qualitative study. Biomed Res Int. 2018;2018:6865156. doi:10.1155/2018/6865156.
2. Morris RL, Hill KD, Ackerman IN, et al. A mixed methods process evaluation of a person-centred falls prevention program. BMC Health Serv Res. 2019;19(1):906. doi:10.1186/s12913-019-4614-z.
3. Sandlund M, Skelton DA, Pohl P, Ahlgren C, Melander-Wikman A, Lundin-Olsson L. Gender perspectives on views and preferences of older people on exercise to prevent falls: a systematic mixed studies review. BMC Geriatr. 2017;17(1):58. doi:10.1186/s12877-017-0451-2.
4. Robertson MC, Campbell AJ, Gardner MM, Devlin N. Preventing injuries in older people by preventing falls: a meta-analysis of individual-level data. J Am Geriatr Soc. 2002;50(5):905-911. doi:10.1046/j.1532-5415.2002.50218.x.
5. Stevens JA, Burns E. A CDC compendium of effective fall interventions: what works for community-dwelling older adults. Center for Disease Control and Prevention. https://www.cdc.gov/homeandrecreationalsafety/pdf/falls/CDC_Falls_Compendium-2015-a.pdf. 2015. Accessed April 9, 2020.
6. Finnegan S, Bruce J, Seers K. What enables older people to continue with their falls prevention exercises? A qualitative systematic review. BMJ Open. 2019;9(4):e026074. doi:10.1136/bmjopen-2018-026074.
7. James S. Boomers create surge in luxury care communities. New York Times website. https://www.nytimes.com/2018/12/04/business/retirement/continuing-care-retirement-communities-baby-boomers.html. December 4, 2018. Accessed April 9, 2020.
8. Hermann D, Brod K, Giradi J. Ziegler national CCRC listing and profile. Chicago, IL: Ziegel Capital Markets-Senior Leaving Research. 2009.