This final Chapter provides an overview of issues that need to be considered in order to contextualise the findings from the evidence base and to optimise the implementation of the recommendations by older people and key stakeholders alike.
The ‘Be Active Australia: A Health Sector Framework for Action 2005-2010’ (National Public Health Partnership 2003) document noted that a focus on ‘strategic management and coordination’, ‘community education’, ‘a coordinated health sector approach to testing community interventions’ and ‘research, monitoring and evaluation’ would facilitate the translation of physical activity evidence into daily practice. In the United States, National Blueprint partner organizations analysed the barriers in the initial Blueprint and identified a range of feasible, short-term priority strategies that could be implemented in the areas of home and community, marketing, medical systems, research, and public policy (National Blueprint: Increasing Physical Activity Among Adults Age 50 and Older). These strategies, which are currently being implemented and evaluated in a range of American communities, are listed in Appendix 8. Whilst a number of these strategies have been employed in Australia, they have not been systematically planned, implemented or evaluated at a national level. In this Chapter we highlight some of the key strategies that will enable the older Australians physical activity recommendations to be comprehensively implemented. The aim is to enable an optimal context for the adoption and maintenance of physical activity in older people.
Cross-sectoral strategiesMany agencies, organisations and all levels of government have a key role in supporting older people to become more physically active. Cross-sectoral coordination and collaboration will be needed at local, regional, state and national level.
Policy and planningPublic policy and advocacy strategies are needed at local, state, and national levels. The development of a cohesive regulatory agenda and the development of a consensus statement on the benefits of physically active lifestyles is recommended. Physical activity is a key feature of many of the National Health priority areas. However, whilst we have national physical activity recommendations, we do not have targets set. That is, unlike immunisation, there is no target for proportions to become physically active by a set time. Nor are there nationwide health service targets for physical activity assessment nor the development of training programs for providers. There is scope to encompass such target setting into the evaluation of the recently introduced MBS item for physical activity assistance and the Lifestyle Prescription program.
Governments at all levels should work with relevant agencies to influence organizational, structural and environmental changes to support active transport and incidental physical activity. One policy initiative that could be advanced is the promotion of active transport. In order to promote alternatives to driving, strategies to improve public transport, walking and cycling tracks are needed. Another challenge is to consider the provision of a more comprehensive community transport system to enable older people with disabilities to access community based programs.
There are a range of barriers which increase the difficulty for older people to participate in physical activity, including environmental barriers. Environments (for example, parks, footpaths and shopping centres) should be designed and built to be supportive of physical activity participation by older people. Important considerations include access, safety, lighting, seating availability, and walkway surfaces. Ensuring physical activity friendly environments for older people will improve the likelihood of participation.
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Services: comprehensive, coordinated and sustainableStructural support is needed from State and Commonwealth governments for service providers. It is telling that, despite the existence of a national quality framework for exercise referral schemes in the UK (UK Department of Health 2001), Taylor et al. comment ‘collaboration between health services and community physical activity programs is patchy, without any milestones and clear directives’ (Taylor, Cable et al. 2004) p719.
Local governments, community health services and the fitness industry should work to provide more physical activity classes suitable for older people, facilitated by appropriately trained staff. Where possible, a range of opportunities for different types of physical activity should be available from organisations involved in providing physical activity opportunities for older people. Different types of physical activity will achieve different types of improved abilities and outcomes for older people. Therefore, participating in programs that include components of the three main types of physical activity (fitness, strength, and balance/mobility), or undertaking separate programs which incorporate each of these individually will provide the greatest health benefit.
Physical activity can occur in a home based or an external group based program. For frail older people, or those with multiple medical problems commencing a physical activity program, supervision by a trained professional such as a physiotherapist may be useful to ensure the appropriate amount and type of physical activity is introduced. Once a person is competent in the physical activity program, there is scope for it to continue unsupervised. Educating older people about the actual risks of physical activity and assisting them to self-monitor their exercise intensity levels as part of a program will help to overcome concerns about safety.
The needs of frail older people, and those with disabilities need to be considered to maximise the opportunity to participate in physical activity options. For example, the design of residential aged care facilities should enable safe incidental physical activity to occur within the facility. Residential aged care facilities should seek to incorporate physical activity into their resident’s programs.
Strategies should be undertaken to encourage older people to trial new opportunities for physical activity, and to support long term participation. If an older person is able to sustain participation in a new physical activity program for at least a month, there is increased likelihood that they will continue with the activity in the long term. Maximal benefits from physical activity programs are likely if participation is sustained for longer periods. A person is more likely to continue to be active if the physical activity program is tailored to their needs and interests. Encouraging older people to set their own short and long term goals for a physical activity program will also enhance their self-efficacy. Social support and the involvement of family and friends can improve long term participation. Strategies such as intermittent monitoring of certain health related outcomes (for example, blood pressure, balance, strength) and regular positive reinforcement can improve motivation for older people participating in physical activity programs.
Continuity of physical activity support is important. Intersectoral collaboration should occur to create, promote and sustain physical activity opportunities in a cost effective manner. Partnerships between medical professionals and local community resources are needed to help refer patients to local physical activity opportunities. For example, the benefits of hospital based rehabilitation programs need to be maintained by ensuring the provision and monitoring of home and community based programs to sustain physical activity behaviour.
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Education and TrainingMarketing that promotes physical activity by disseminating targeted messages about best practices and benefits is needed. Information about the health benefits of physical activity for older people, including those with existing health problems, should be widely available across a variety of media, and targeting key sub-groups. Private/public sector partnerships could be formed to develop marketing messages targeted at specific segments of the older population. Although an increasing proportion of older Australians are aware of the health benefits of physical activity, there remain key areas where improved knowledge will increase likelihood of participation in different levels and types of physical activity. Examples include understanding that physical activity is still possible, and achieves positive health outcomes, even in the presence of moderate health problems such as arthritis or stroke. Culturally appropriate key messages also need to be disseminated widely among people from culturally and linguistically diverse backgrounds, and Aboriginal and Torres Strait Islanders. These are key groups with low levels of physical activity and high prevalence of health problems associated with low levels of physical activity, such as cardiovascular disease and diabetes.
Medical clearance for the older person to begin physical activity may not be necessary so long as their health conditions are stable, and that a progressive program is introduced that commences at a manageable level. For example, unless contraindicated, all people with peripheral vascular disease (PVD), diabetes or stroke survivors with sufficient residual function should progress over time to the recommended dose of physical activity.
Overall, there has been an increase in the number of physical activity programs available for older people. Alongside this growth, there has been an increase in the number of personnel trained to facilitate physical activity delivery and uptake amongst older people. People providing physical activity facilitation for older people need appropriate training, particularly for dealing with those with a range of comorbidities. The table below illustrates the numbers of people registered with Fitness Australia to work with older people.
Table 10.1 Registered fitness professionals in Australia
1 The Older Adults/Specific Populations figure is a combination of two registration categories. Until December 2005, Older Adults Trainers were registered in the same category as those trained for Specific Populations. In 2005 the training package changed and therefore so too did the registration categories. As of December 2005 ‘Older Adults Trainer’ became a separate category. Due to the lag time between the change and the identification of those registered as Specific Populations and qualified as Older Adults trainers, the figure cited can only be viewed as an approximation since it includes all those registered in either category. However, it is not possible to be registered in both categories at the same time so there is no double counting of the same registration. In Victoria, personnel can also register independently with Kinect Australia, so the state figures may not be a true estimate of capacity in Victoria.
Source: Fitness Australia
Physical activity programs and opportunities for older people should be conducted by people with appropriate experience and training. With all formal physical activity programs, there is a need for appropriate training of those providing the programs to ensure safety and appropriateness of the programs. There are international curriculum guidelines for the training of physical activity instructors to work with older people (Cress, Buchner et al. 2004). Similar needs exist for those involved in providing informal physical activity opportunities for older people, such as aged care staff. Those involved need to be aware of the specific needs, precautions, and benefits of physical activity as they apply to older people.
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Role of health professionalsHealth professionals should promote physical activity to all their older clients to increase the prevalence of physical activity amongst older Australians. Health professionals should work together across the primary, secondary and tertiary care sectors in promoting physical activity to prevent the development of chronic conditions and to optimise their management as part of a seamless care program. Schofield and colleagues have recently confirmed the trust that older Australians have in advice received from health professionals, particularly general practitioners (GPs) (Schofield, Croteau et al. 2005), yet A US Centers of Disease Control and Prevention report stated that less than half of all patients were asked about physical activity by their healthcare providers (Centers for Disease Control and Prevention 2002). Health professionals spend very little time providing physical activity advice to clients, particularly older people [e.g. (Melillo, Houde et al. 2000)].
Another challenge is extending the reach of advice giving across GPs and other healthcare providers, so that a greater proportion of the population are exposed to physical activity information and support. A population health approach, raising physical activity levels in all older people would be most beneficial. Where advice is given, it tends to be targeted at high-risk individuals. The primary care based Lifestyle Prescriptions and the New Zealand Green Prescription schemes both have a population health approach. Evidence from the Victorian Active Script and Green Prescription initiatives’ evaluation indicates that implementation has not been as broad as intended. Rather, doctors have tended to provide scripts to specific groups, particularly the high risk overweight people, rather than older people. A GP exercise referral pilot study in NSW (Smith, Cook et al. 2004) found that uptake of this process amongst GPs was limited. Although the intent was to target those with cardiovascular risk factors, the people being referred were predominantly those who were overweight. Opportunities for those with other risk factors were being missed. The reasons for this were not explored, but could be related to a reticence amongst GPs to consider management of chronic conditions using non-drug interventions. A broader population health, prevention approach to the use of the Lifestyle Prescriptions scheme and the exercise item in the older person’s health check (MBS item), and during routine health checks for chronic conditions needs to be encouraged amongst health practitioners.
General practitioner engagement in association with the Rockhampton 10,000 Steps campaign has been more promising (Eakin, Brown et al. 2004). Practices displayed posters, used brochures and loaned pedometers as well as providing direct advice during consultations. As part of the evaluation, telephone surveys of patients found that significantly more of the Rockhampton community recalled receiving advice on physical activity from their GP in contrast to the comparison community (31% increase in likelihood, 95% CI 1.11-1.54, vs. 16% decrease, 95% CI 0.68-1.04).
Whilst health professionals can be effective in providing advice to their clients, many will benefit from the availability of user-friendly clinical guidelines. Several such documents exist [e.g. (Christmas and Andersen 2000)] and a selection of resources is provided in Appendix 7.
Translation of evidence into practiceWe note that for the translation of evidence into practice to occur, there is a need to reflect upon the feasibility of transferring interventions found to be successful in effectiveness studies into routine daily life/situations. Feasibility will be determined by factors such as the availability of behavioural facilitators, both health professionals and exercise instructors. The cost effectiveness of formal programs also requires consideration.
Whilst there is a large literature on physical activity interventions and their impact on health outcomes, the degree to which the findings are generalisable to older Australians is less clear. Firstly, many studies have used screening processes that have excluded those with pre-existing medical conditions, resulting in more healthy samples. For example, in the CHAMPS study, participants had high baseline levels of physical activity, limiting the generalisability of the findings (Stewart, Mills et al. 2001). Secondly, the intensive screening may have deterred some from participating, making for a highly motivated group undergoing the actual intervention. Thirdly, as noted by Hillsdon and colleagues (Hillsdon, Foster et al. 2005), the complexity of many interventions would limit the extent to which they could be routinely delivered in Australian health and community settings.
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SurveillanceIn order to track the impact of the physical activity recommendations on older Australians’ physical activity behaviour we need to conduct surveillance and monitoring. As we have seen, the older population is a particularly heterogeneous group, with varying capacity to engage in physical activity. The national physical activity surveys to date have included older people, but the data has largely been reported in aggregate fashion. Even an age band such as ‘75 years and over’ can contain more than one generation of older person. A more detailed breakdown of the older population would be helpful, to see which groups may need further targeting. There is scope to distinguish between community dwelling older people and those living in residential care.
The Active Australia survey helps in making intergenerational comparisons. For specific monitoring of the older population, it will be necessary to use instruments shown to be valid and reliable with this population sector. A discussion of measurement considerations is provided in Appendix 4.
Economic evaluationAlthough there is a wealth of evidence to support the uptake of physical activity, at a societal level we need to consider the costs associated with providing programs. In line with the rationing of health care, economic analyses of physical activity interventions is needed. Here, the evidence is scarce. Take for example a recent Netherlands trial of a high intensity exercise program for people with rheumatoid arthritis (van den Hout, de Jong et al. 2005). The clinical outcomes, measures of functional status, demonstrated that the program was significantly superior to usual care, namely individual therapy from a physiotherapist. When cost utility analyses were conducted, the utility measures failed to replicate the benefit in financial terms. Based on a ‘societal willingness to pay’ criterion, usual care had better cost utility. Any reductions in medical costs from health improvement were not wholly offset by costs associated with the program. The authors note that although more than half continued the program at their own expense, as a cost effective model it failed. Nicholl and colleagues have estimated that in Britain, participation in physical activity by older people leads to an annual healthcare cost benefit of over £20 per person (Nicholl, Coleman et al. 1994). Stevens et al. (1998) estimated that it would cost £2,500 to move an adult to the recommended physical activity levels and £600 to move them from sedentary behaviour. Huang et al. (2004) estimated that the amounts saved by the Active Script program, where Victorian general practitioners provided brief advice and an exercise prescription, were $138 per patient to become sufficiently active to gain health benefits and $3,647 per DALY saved. There is solid economic evidence for the use of physical activity counselling in general practice (Elley, Kerse et al. 2004; Dalziel, Segal et al. 2006): this type of analyses is needed for other physical activity interventions.
Although the costs of providing physical activity programs for older people may be higher, given the level of training and supervision required to ensure safe practice, the potential gains may be greater, given the older person’s greater absolute risk for a range of health conditions. The existing economic data for practical reasons relates to a limited number of health measures, whilst epidemiological evidence indicates that health and societal benefits can be multiple.
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Research gapsFurther research should be supported to address key gaps in the evidence base about effective physical activity options for older people. Although there has been substantial growth in the research evidence supporting physical activity benefits for older people in recent years, there remain a number of areas where further research is required. A key area for future research is to evaluate innovative strategies to achieve effective translation of the research evidence into widespread practice, including for specific sub-groups, for example older people with complex health problems, those from culturally and linguistically diverse backgrounds, and Aboriginal and Torres Strait Islanders.
Improved understanding of ways to maximise uptake and sustained engagement of older people in physical activity is also required. Individual behaviour change occurs within the context of one’s social and physical environment. Future research needs to evaluate the relative impact of societal and structural changes upon individual physical activity behaviour and health outcomes.
From a biopsychosocial perspective, some key research questions to be addressed are:
- What is the minimum amount of physical activity needed to promote health benefits in older people, and what are the relative changes in outcomes achieved for different dosage of physical activity?
- What are the best strategies for sustaining engagement in physical activity behaviour over periods longer than a year?
- What are the gender and cultural differences in responding to physical activity programs that need to be considered in the development of tailored options?
Methodological weaknesses in the existing evidence base also need to be addressed. These include:
- Small sample sizes.
- Limited sociodemographic characteristics of study participants.
- Lack of follow-up, particularly longer term.
- Inappropriate outcome measurement tools for older people.
- Mismatch between intervention focus and outcome measures used e.g. resistance training is less likely to influence measures of cardiorespiratory fitness.
- Aggregation of findings about older people into broad chronological age groups rather than relating to baseline functional status.
SummaryThere is a wealth of evidence that supports the efficacy of a range of physical activity forms in promoting health and wellbeing. We have less evidence about how societal and structural factors impact on physical activity behaviour. We need more evidence for how effective interventions are when they are transferred into routine care settings in the home, community, primary care, and residential care settings. We also need to pay attention to participants receiving a dose of physical activity sufficient to attain health benefits: this will require greater focus upon adherence strategies.
It is hoped that the current document and draft recommendations can assist in guiding best practice for the promotion, uptake and sustainability of physical activity for older Australians.
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