Journal of Gerontological Nursing

Feature Article 

Using Targeted Messaging to Increase Physical Activity in Older Adults: A Review

Rachel E. Ostrander, MN, RN; Hilaire J. Thompson, PhD, RN, CNRN, ACNP-BC, FAAN; George Demiris, PhD, FACMI

Abstract

Physical activity has many benefits for older adults; however, motivating older adults to engage in and maintain optimal levels of physical activity can be challenging for health care providers. A comprehensive literature review was performed to determine whether any evidence-based methods of delivery or particular content for targeted messaging exist that result in actual improvements in physical activity of older adults. Findings of the review demonstrate that messaging directed toward older adults to be physically active resulted in improvements in physical activity up to 1 year. Across studies many different modes of message delivery were shown to be effective. Message content, whether tailored or not, resulted in significant increases in physical activity. There is evidence to support the use of environmentally mediated messaging (i.e., local walking paths) for stronger results. Targeting the client’s stage of change, having an activity partner if preferred, and scheduling physical activity also contribute to improved effects. [Journal of Gerontological Nursing, 40(9), 36–48.]

Ms. Ostrander is graduate, Adult/Gerontology Nurse Practitioner Track, and Dr. Thompson is Associate Professor, Biobehavioral Nursing and Health Systems, University of Washington; and Dr. Demiris is Alumni Endowed Professor, Biobehavioral Nursing and Health Systems, and Professor, Biomedical Informatics and Medical Education, University of Washington, Seattle, Washington.

Ms. Ostrander was supported, in part, by the Division of Nursing, Bureau of Health Professions, Health Resources and Services Administration, Department of Health and Human Services (grant D62HP24194). The remaining authors have disclosed no potential conflicts of interest, financial or otherwise.

Address correspondence to Hilaire J. Thompson, PhD, RN, CNRN, ACNP-BC, FAAN, Associate Professor, Biobehavioral Nursing and Health Systems, University of Washington, UW SON, BNHS Box 357266, Seattle, WA 98195-7266; e-mail: hilairet@uw.edu.

Received: July 26, 2013
Accepted: February 07, 2014
Posted Online: March 31, 2014

Abstract

Physical activity has many benefits for older adults; however, motivating older adults to engage in and maintain optimal levels of physical activity can be challenging for health care providers. A comprehensive literature review was performed to determine whether any evidence-based methods of delivery or particular content for targeted messaging exist that result in actual improvements in physical activity of older adults. Findings of the review demonstrate that messaging directed toward older adults to be physically active resulted in improvements in physical activity up to 1 year. Across studies many different modes of message delivery were shown to be effective. Message content, whether tailored or not, resulted in significant increases in physical activity. There is evidence to support the use of environmentally mediated messaging (i.e., local walking paths) for stronger results. Targeting the client’s stage of change, having an activity partner if preferred, and scheduling physical activity also contribute to improved effects. [Journal of Gerontological Nursing, 40(9), 36–48.]

Ms. Ostrander is graduate, Adult/Gerontology Nurse Practitioner Track, and Dr. Thompson is Associate Professor, Biobehavioral Nursing and Health Systems, University of Washington; and Dr. Demiris is Alumni Endowed Professor, Biobehavioral Nursing and Health Systems, and Professor, Biomedical Informatics and Medical Education, University of Washington, Seattle, Washington.

Ms. Ostrander was supported, in part, by the Division of Nursing, Bureau of Health Professions, Health Resources and Services Administration, Department of Health and Human Services (grant D62HP24194). The remaining authors have disclosed no potential conflicts of interest, financial or otherwise.

Address correspondence to Hilaire J. Thompson, PhD, RN, CNRN, ACNP-BC, FAAN, Associate Professor, Biobehavioral Nursing and Health Systems, University of Washington, UW SON, BNHS Box 357266, Seattle, WA 98195-7266; e-mail: hilairet@uw.edu.

Received: July 26, 2013
Accepted: February 07, 2014
Posted Online: March 31, 2014

Regular aerobic physical activity in older adults is important for overall health and the reduction of chronic disease burden. It is known to reduce the incidence of obesity, cardiovascular disease, hypertension, diabetes mellitus, colon cancer, and premature death (Centers for Disease Control and Prevention [CDC], 2011b; Yap & Davis, 2008). Physical activity also improves mood and reduces depression and anxiety (Yap & Davis, 2008). It has been demonstrated that greater physical activity results in reduced use of psychoactive medications and fewer hospital days over 1 year in community-dwelling frail older adults (Leveille et al., 1998). However, even with so many known benefits of physical activity, less than 50% of adults older than 50 meet recommended levels (Dearden & Sheahan, 2002; Yap & Davis, 2008) of 2 hours and 30 minutes of moderate intensity aerobic activity or 1 hour and 15 minutes of vigorous intensity aerobic activity per week (CDC, 2011a). Despite targeting physical activity goals in the United States in the Healthy People 2020 initiatives (U.S. Department of Health and Human Services, 2010), few gains have been made in this area on a national level.

Considering all of the benefits of physical activity, one of the challenges facing health care providers is determining how to engage older adults in behavior change to motivate them to become or remain physically active. Sending individualized messages to older adults promoting physical activity may be a cost-effective and convenient way to encourage them to increase their activity levels and improve health literacy over the long term. For purposes of this article, messaging was defined as sending a brief communication (either oral or written) to older adults. Recent evidence supports the idea that increased engagement and activation improve confidence and build skills to promote healthy behaviors, which includes being physically active (Hibbard & Greene, 2013). Improved health literacy is particularly important as it has been shown to be a greater predictor of health status than age, income, employment, or education (Allen, Zoellner, Motley, & Estabrooks, 2011). Sending a targeted message to older adults is one way to increase engagement and improve health literacy related to physical activity, both of which may result in improved health overall (Bickmore et al., 2010). There is evidence that the use of periodic messaging may result in positive behavior change, including increased physical activity (Fry & Neff, 2009). To determine whether evidence-based methods of delivery or particular content for targeted messaging exist that result in actual improvements in physical activity of older adults, a comprehensive literature review was performed. The clinical question of interest was: How can gerontology/geriatric clinicians most successfully and time-efficiently deliver a message to older adults to be physically active?

Method

A comprehensive literature review was completed in PubMed and CI-NAHL databases for the years 2002–2012. Keywords used in the search included: health promotion message, exercise, communication, text message, and blogging. The search results were limited to articles written in the English language and focusing on adult populations. Additional articles were found by mining reference lists of articles retrieved in the initial search. In the initial search, a total of 530 articles were found; 13 duplicates were removed, resulting in 517 abstracts that were reviewed for relevancy. Eighty-one full-text articles were retrieved and analyzed against inclusion criteria: (a) the mean age of the study sample must be older than 55, and (b) physical activity must have been actually measured. After reviewing the full text of the 81 articles, seven articles met inclusion criteria and were included in this review (Table).

Summary of Studies Included in the Literature ReviewSummary of Studies Included in the Literature ReviewSummary of Studies Included in the Literature Review

Table:

Summary of Studies Included in the Literature Review

Results

The studies included in this review all have a specific focus regarding motivating older adults to exercise through messaging. The number of participants in the different studies ranged from 18 to 1,971. The study populations were balanced in terms of gender, income level, education, partnership status, and body mass index. The race of participants in the studies examined, when reported, was primarily White; two studies only reported nationality, with 100% of participants being Dutch (De Greef et al., 2011; van Stralen, de Vries, Mudde, Bolman, & Lechner, 2011).

In each of the six studies that examined physical activity over a period of time, physical activity significantly increased with the messaging intervention when compared to control over the course of the study period (David et al., 2012; De Greef et al., 2011; Holland et al., 2005; King et al., 2008; Strath et al., 2011; van Stralen et al., 2011). The sole quasi-experimental study examined the response of physical activity in older adults to specific instructions given on a single day (Fitzsimons et al., 2005).

Mode of Message Delivery

Messages were delivered to participants in a variety of modes, including the phone (by a live person or interactive voice recorder [IVR]), print, in-person consultations, hand-held computerized devices (e.g., personal digital assistants [PDAs]), e-mail, websites, or group classes or activities (Table). Regardless of the method used to deliver the message, physical activity of participants increased over the time course of each study. Print messaging was used most frequently (n = 5). The format ranged from printed instructions given one time only (Fitzsimons et al., 2005), to standardized (Holland et al., 2005; Strath et al., 2011) and individualized newsletters relating to physical activity (Strath et al., 2011; van Stralen et al., 2011), and weekly feedback (David et al., 2012). Four of the seven studies used phone interactions; one used an IVR (David et al., 2012), whereas the remaining three used the phone for one-on-one consultations (De Greef et al., 2011; Holland et al., 2005; Strath et al., 2011). Generally, e-mail and website use were cited as supplemental supports to printed materials for promoting physical activity in studies (David et al., 2012; Holland et al., 2005; van Stralen et al., 2008, 2011), as were group classes or activities (Holland et al., 2005; van Stralen et al., 2008, 2011).

Frequency of Message Delivery

The frequency of messages ranged greatly across studies. The time periods of the interventional period included in this review ranged from 1 day only up to 1 year (Table). On the 1-day-only encounter, participants received four different instructions that day. In the remaining studies, participants were contacted anywhere from three times per day to approximately once every 40 days. The frequency was not consistent across studies, with participants receiving messages at regular intervals, varied intervals, or a combination of the two. The most frequent regular contact was with the use of a study-provided PDA. Whether older adults were prompted to think about physical activity three times per day (King et al., 2008) or once per month (van Stralen et al., 2011), the results across studies examined in this review were similar—a significant increase in physical activity behavior was noted over the course of the intervention.

Of note, the design of several studies’ timing of messaging allowed feedback to be provided to the individual. For example, participants were prompted to enter their physical activity twice per day in the PDA and then received daily feedback based on their previous entries (King et al., 2008). Participants in this study also received weekly graphic and text feedback via the PDA related to their overall progress toward physical activity goals (King et al., 2008). Holland et al. (2005) provided a combination of regular and varied messaging: Print newsletters specific to local environmental supports for physical activity were sent monthly for 1 year; one-on-one consultations were conducted at the beginning and at 6 months; and participants had the option of attending group classes, sessions with social workers, and/or individual counseling, or accessing a website for support based on their own preferences and needs for support.

Individualization of Messaging

Two studies delivered the same messages to each of the participants over the time course of the study (David et al., 2012; Fitzsimons et al., 2005). The remaining five studies individualized the message regarding physical activity (De Greef et al., 2011; Holland et al., 2005; King et al., 2008; Strath et al., 2011; van Stralen et al., 2011). Individualization ranged from one-on-one phone calls to reach individualized goals (De Greef et al., 2011; Holland et al., 2005) to individualized printed letters based on answers to questionnaires (Strath et al., 2011; van Stralen et al., 2011) to motivational PDA messages based on participant-entered data (King et al., 2008). In all five studies, the intervention groups significantly increased physical activity compared to control groups (De Greef et al., 2011; Holland et al., 2005; King et al., 2008; Strath et al., 2011; van Stralen et al., 2011). Interestingly, in the nonindividualized study (David et al., 2012), a significant increase was also noted in physical activity.

Two studies specifically compared standard motivational and individualized motivational printed materials (Strath et al., 2011; van Stralen et al., 2011). Strath et al. (2011) divided participants into four groups: (a) control, (b) generic feedback, (c) individualized printed motivational feedback, and (d) individualized printed feedback plus phone calls with the goal to increase steps walked per day over a 12-week time period. The control and generic feedback groups did not significantly increase their steps per day; however, both individualized groups significantly increased steps per day (p < 0.001) (Strath et al., 2011). van Stralen et al. (2011) used a print delivery mode with three groups: (a) no intervention (control) (n = 586), (b) participants who received individualized letters based on psychosocial mediators (n = 652), and (c) participants who received individualized letters by psychosocial and environmental mediators (n = 733). Both intervention groups were found to have significantly increased the total days per week of physical activity over 12 months (p < 0.01). However, only the group receiving individualized letters with environmental mediators significantly increased total minutes per week of physical activity at 2 months (p < 0.05) (van Stralen et al., 2011). It would appear based on the evidence that individualization of messages promoting physical activity has more beneficial effects when these messages are focused on environmental mediators for participants.

Topics of Messaging

Message topics varied by the theory used in designing the intervention and the outcomes targeted by the researchers. Six studies specifically cited a theory or model used in the development of messaging (David et al., 2012; De Greef et al., 2011; Holland et al., 2005; King et al., 2008; Strath et al., 2011; van Stralen et al., 2011). The most frequently cited theories used for design of messaging for the promotion of physical activity in older adults were the transtheoretical model and social cognitive theory (David et al., 2012; King et al., 2008; Strath et al., 2011; van Stralen et al., 2011). Other theories and models used to individualize and focus messaging included goal-setting theory and problem-solving theory (David et al., 2012), motivational interviewing (De Greef et al., 2011), and the health action process approach, precaution adoption process model, self-regulation theory, and self-determination theory (van Stralen et al., 2011). The most common themes of messaging addressed across studies included: increased knowledge and awareness of physical activity; increased self-monitoring of physical activity; awareness of barriers to being physically active; and improvement of goal setting. Other common themes that were addressed included awareness of motivators for being physically active (De Greef et al., 2011; Holland et al., 2005; King et al., 2008; van Stralen et al., 2011), improving self-efficacy related to being physically active (De Greef et al., 2011; Strath et al., 2011; van Stralen et al., 2011), problem solving (David et al., 2012; Strath et al., 2011; van Stralen et al., 2011), and time management and relapse prevention (De Greef et al., 2011; van Stralen et al., 2011). Regardless of the theory chosen to support the message being delivered, significant changes occurred in physical activity in all intervention groups over the time course of the studies.

Discussion

Of 530 studies originally identified in search, seven (1.3%) had a relevant focus on older adults and messaging related to physical activity. Even with only this limited number of studies to analyze, there are several promising themes available to answer the initial question of interest as well as certain areas that could be expanded in future research.

Message Content

Message content may have resulted in different results over time. Certain studies analyzed the differences between standard and tailored messages and found that the type of tailoring might make a difference. In particular, focusing on environmental mediators (i.e., local walking trails) resulted in a significant increase in physical activity over 1 year compared to psychosocial mediators alone (van Stralen et al., 2011). The importance of environmental mediators for long-term gains in physical activity has also been supported in a 26-week, web-intervention study focused on middle-aged adults (mean age = 52) (Ferney, Marshall, Eakin, & Owen, 2009).

As a gerontological provider who is trying to promote older adults to engage in physical activity, it may be important to tailor the message to fit the older adult’s local environment and access for physical activity. Environmental suggestions may include information or maps of local walking or cycling routes, exercises that could be done at home, or information about neighborhood exercise clubs or gyms that match the participant’s interests (van Stralen et al., 2008). These may help keep older adults engaged in regular physical activity. A rurally based intervention with middle-aged women that used face-to-face contact but also emphasized local opportunities for physical activity resulted in a significant increase in steps per day, further supporting the importance of environmentally mediated messages (Warren, Maley, Sugarwala, Wells, & Devine, 2010). In the study by Strath et al. (2011), tailoring of content was examined on multiple levels—a standard versus tailored print letter and the addition of one-on-one phone consultations. Tailoring was based on the older adult’s individual stage of change from the transtheoretical model. Both tailored intervention groups had a significant increase in physical activity over the control and standard-print materials groups, but the phone call was not additive (Strath et al., 2011). Thus, it may not be necessary to have direct contact when tailoring the messaging to improve physical activity in older adults.

Further knowledge related to the content of targeted messaging has been gained by using focus groups to determine what older adults would find to be motivational for increasing physical activity (Price et al., 2011). Participants specifically suggested emphasizing walking because of its ease of accessibility. They also mentioned it would be motivational to use a positive approach and to mention the effect activity may have on reducing the risk of dementia (Price et al., 2011). The use of a positive approach or gain-framed messaging has been examined in multiple studies, with a literature review suggesting that positive framing did not significantly affect the persuasiveness of the message related to physical activity (Berry & Carson, 2010).

It also may be important to focus on the personal readiness of older adults to start exercising. Older adults may be at the stage of contemplating the pros and cons related to regular exercise or may already be exercising, but are losing interest and motivation. Older adults’ current relationships with physical activity will ideally change the type of message that is delivered by a health care provider. Practice guidelines related to counseling middle-aged women about physical activity specifically cite using the client’s stage of change, based on the transtheoretical model, to structure the message (Dearden & Sheahan, 2002). For example, if a client is preparing to start exercising it would be helpful to emphasize the pros and cons of regular physical activity, assist with goal setting, or create a behavioral contract (Dearden & Sheahan, 2002). Sending a message, tailored or not, may result in increased physical activity among older adults. However, tailoring by environmental mediators, personal readiness, type of local activity, and use of a positive approach may result in even more significant increases. Of note, in the studies with control groups who received no messaging, physical activity levels were unchanged in two studies (Strath et al., 2011; van Stralen et al., 2011) and decreased in three others (De Greef et al., 2011; Holland et al., 2005; King et al., 2008), thus there does not appear to be a Hawthorne effect.

Mode of Delivery

The mode of message delivery that might be optimal or preferred for older adults is important to examine. The current review includes modes of message delivery that range from in-person to print to phone to web-based. All of these methods, whether used alone or in some combination, resulted in a statistically significant increase in physical activity among older adults. It seems clear that the mode of delivery is not as important as actually delivering a message to older adults about being physically active. Unfortunately, none of the studies included in this review specifically examined the cost-effectiveness of one intervention compared to another. In other populations (e.g., middle-aged adults), it has been found that print-based interventions were more successful in increasing physical activity and were also more cost-effective compared to phone interventions (Sevick et al., 2007). Similar studies in older adults should be replicated.

Focus groups conducted in South Carolina asked older adults how they would prefer to receive a message; they stated a preference for print, television (TV), and word-of-mouth (Price et al., 2011). Using print modes to deliver a message were shown to be significantly effective in three studies in this review (Holland et al., 2005; Strath et al., 2011; van Stralen et al., 2011). None of the studies included in this review specifically examined the effects of TV or word-of-mouth interventions.

A review related to the use of mass media for health promotion and education found that in some interventions there are short-term gains in physical activity and knowledge related to the mass media programs, which included TV as an intervention (Finlay & Faulkner, 2005). There is also evidence from other studies suggesting that face-to-face message delivery by a clinician is a highly effective method for communication, particularly among older adults (Bickmore et al., 2010). The cost-effectiveness and ongoing sustainability of a mass media intervention and face-to-face communication diminish significantly over time.

For sustainability, it is important to find a mode of delivery that is both easy and efficient for older adults to use as well as cost-effective for ongoing use. None of the adults in the South Carolina focus groups identified a preference for using computer-based applications (e.g., Internet, PDA) to receive information about physical activity. However, as noted in this review, interventions using these modes of delivery have been successful when used with older adults. Specifically, King et al. (2008) trained PDA-naïve older adults to use the devices, and over the course of 8 weeks, the participants significantly increased the number of minutes per week they engaged in moderate to vigorous physical activity. Ferney et al. (2009) delivered an intervention via websites only for physical activity, resulting in significant increases in physical activity over 26 weeks. Lastly, older adults with Parkinson’s disease were trained to use a pedometer and tablet computer to interact with a virtual exercise coach, resulting in improved physical activity measured over 1 month (Ellis et al., 2013).

Mobile devices, such as PDAs or cell phones with short message service (SMS) capability, have been shown to be successful and cost-effective in other populations for improving physical activity, such as women experiencing postpartum depression (Fjeldsoe, Miller, & Marshall, 2010) and middle-aged adults (Hurling et al., 2007). A systematic review suggests that SMS via mobile phone may be an effective method for clinicians to deliver messages related to disease management and health education (Krishna, Boren, & Balas, 2009). With increasing use of cell phones and other mobile devices (e.g., tablet computers, e-readers) among older populations (Zickuhr & Madden, 2012), this may make them an increasingly useful and sustainable platform for motivational messaging in the future.

Message Verbiage

Only one of the seven studies included for analysis specifically examined the actual words contained in the message related to physical activity in older adults. The focus of the study was on examining how physical activity varied based on the words used to deliver a message to young versus old participants. All participants received the same four instructions for walking and their walking response to those instructions was measured by speed and percentage of VO2 max utilized. Fitzsimons et al. (2005) asked younger and older women to walk a set distance at what they considered a speed equivalent to the following terms: slow, fast, brisk, and comfortable. The results of the study illustrated that older women, while walking an actual slower speed compared to younger women, used much more energy for each given term, especially for the term brisk (Fitzsimons et al., 2005). Asking an older woman to walk briskly resulted in 67% VO2 max being used, whereas a younger woman only used 45% VO2 max (Fitzsimons et al., 2005). The terms slow, comfortable, and fast did not result in significant differences in VO2 max between older and younger volunteers, illustrating the importance of thinking about what words are being used to describe walking speed (Fitzsimons et al., 2005). This raises the point that the actual words used in a message will be important for eliciting the desired response. As a provider, it will be important to explain what type of walking or physical activity older adults could be doing and providing them a way to monitor their efforts. This is particularly important when considering individual patient functional status and overall health. The CDC (2011b) suggests the use of a 10-point scale for rating one’s own exertion, with 0 being sitting and 10 being equivalent to working as hard as one can. The CDC (2011a) recommends moderate aerobic activity be scored 5 to 6 and vigorous aerobic activity be scored 7 to 8. When educating older adults about exercise, this could be a helpful tool for clinicians to communicate how to measure exertion to ensure optimal effects.

Facilitators of Physical Activity

Although not a specific end-point of the research studies included in the current review, factors that facilitated physical activity in older adults were frequently assessed qualitatively. Walking was the most popular activity for older adults, and walking on sidewalks, roads, and walking paths were the most popular locations (King et al., 2008). Two thirds of older adults walked alone, whereas approximately one quarter walked with a partner (King et al., 2008). van Stralen et al. (2011) found that having an activity partner was an independent mediator for increasing total days of physical activity per week at 3 months. Good weather and location, enjoyable scenery, and prescheduling the activity were all noted as facilitators of regular physical activity by older adults (King et al., 2008). Strategic planning related to physical activity was a key mediator at 6 and 12 months for increasing regular physical activity among older adults (van Stralen et al., 2011). Common barriers cited by older adults were lack of time, feeling tired, and family obligations (King et al., 2008).

A combination of locally focused suggestions, finding an exercise partner for those who prefer not to walk alone, and prescheduling or planning for the activity may all help facilitate ongoing exercise in older adults, and these factors should be reinforced by gerontological nurses or other health care providers when talking with their clients. Reminding older adults to be physically active is one thing, reminding them to schedule it and find someone to do it with is another, which may result in long-term positive effects. Further, given the preference for walking seen across studies as well as the positive effects of walkable environments on activity, nurses should work together with city planners and policy makers to encourage accessible walkways for older adults.

Limitations

This review was limited to articles written in English and indexed in PubMed or CINAHL, therefore, other relevant published studies may have been omitted. Also, it may have been subject to interpretive bias due to the manual screening and review processes used in the review.

Overall, regarding the state of the science, there are additional limitations to note, including the relatively small number of published studies, the lack of consistency of measurements among studies, and the overall lack of diversity of participant populations. Further, none of the identified studies measured either baseline health literacy or education level, which is important to elaborate in future studies. Also, there was no discussion of cultural or ethnic background consideration within the messaging design or delivery context to make it more person-centered, and thus more likely to have a positive effect. Lastly, the ages of study participants in this review are somewhat young compared to the general older adult population, which may limit generalizability to all older adults. Additional research targeted to examine differences in categories of older adults (young, middle, and oldest old) and the possible benefit of individualized messaging is warranted.

Implications for Practice

The take-home message for both gerontological nurses and adult/gerontology nurse practitioners for health promotion with older adults is to find a way to make the message relevant to the location in which the older adult lives and to the goal the older adult is trying to achieve. In this context, it is also important to (a) keep the message short and simple; (b) encourage the older adult to schedule and find partners to exercise with, if appropriate to improve engagement; (c) provide options for where to walk in the local environment, such as walking paths or trails, information for a local gym, or a calendar of upcoming events; (d) reinforce the message on a regular basis, anywhere from weekly to monthly, depending on the mode of delivery (i.e., e-mail, phone, print); and finally, (e) adjust the message if it is goal-related as the goals are achieved to move patients forward in their health promoting activities. The evidence in this review indicates that when given a message to be physically active, older adults are able to change their behaviors and successfully maintain improvement in physical activity behavior up to 1 year.

Conclusion

From a practical standpoint, it can be seen that at the simplest level, reminding older adults to be physically active is effective for increasing physical activity over a 12-month period of time. The mode of delivery may range from print to phone to PDA to Internet; all have been demonstrated to be effective with older adults. There is evidence for improved effects with frequency of contact ranging from three times per day to once every 40 days. From a clinical standpoint, three times per day is unlikely to be feasible unless an application with automatic delivery is being used (e.g., PDA, e-mail). Any time from once per week to once per month may be an equally effective message dose for older adults. Individualization has been demonstrated to improve results in relation to specific steps-per-day goals and should include environmental mediators.

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Summary of Studies Included in the Literature Review

Study Study Aims Mean Age (Range) (Years) N Type of Messaging Delivery Method Time Perioda Messages Delivered (Total Contacts Made [N]) Frequency of Contact Individualized Messages Method of Individualization Study Findings
David et al. (2012) To assess the feasibility of increasing steps per day (goal = 10,000 steps per day) over 12 weeks using IVR and messaging via mobile phones in post-menopausal women 57 (<75) 71 Daily 15- to 30-second phone message based on changing weekly theme. IVR contact two times per day: 1 – (a) Did you walk or are you planning to?, (b) Rate self-efficacy to achieve the daily goal, (c) Good or bad day?; 2 – Enter number of steps walked for the day. Receive e-mail or mail each week with summary of steps per week and reinforcement of phone messages. Mobile phone message (15 to 30 seconds) Mobile phone IVR E-mail or mail for feedback Coach versus no-coach division 12 weeks 84 daily messages (84) Once per day Yes - weekly feedback No - daily message Participant data entry of steps per day and self-efficacy rating Use of IVR and a pedometer resulted in significant reduction in the time to walk 1 mile from baseline over 12 weeks (p < 0.001). Significant decrease in self-efficacy of achieving goal of 10,000 steps per day. No difference between coach versus no-coach groups.
De Greef et al. (2011) To assess effectiveness of an in-person and phone behavior modification program on physical activity at 24 weeks and 1 year in patients with type 2 diabetes mellitus 62 (35 to 75) 92 In-person session to set goals at the start of the intervention (based on CBT). Individual phone calls (N = 7) with a counselor using a flexible script based on motivational interviewing and CBT. Phone calls (20 minutes each) 24-week intervention, 1-year follow-up assessment One in-person session, 7 phone calls (every 2 weeks for the first 4 weeks, then every 4 weeks for the next 20 weeks) (8) Once every 24 days Yes - phone calls Phone counseling sessions based on participant’s pedometer diary and baseline physical activity levels versus end-goal number of steps per day. In-person session to set activity goals. Goals updated twice more during the intervention. A behavior modification program with one in-person session, phone calls, and use of a pedometer resulted in a significant increase in steps per day and minutes of physical activity per day compared to a control group (p < 0.001). Results remained significant at 1-year follow up (p < 0.001).
Fitzsimons et al. (2005) To examine effects of age on descriptive walking instructions by measuring speed and oxygen consumption in younger and older volunteers 21.1 (20 to 23) 78.2 (75 to 83) 18 Participants were given four different walking instructions to read and were asked to walk 150 m on a track according to their interpretation of the instructions. Read instructions on 1 day. 1 day Four different instructions to walk One day only No N/A Words used to describe walking resulted in significantly different responses between young and old volunteers. In brisk walking, older volunteers use significantly greater max compared to VO2 younger volunteers (p < 0.005). At baseline, younger volunteers walk 20% faster than older volunteers (p < 0.001). At baseline, older volunteers have greater variability in walking speed compared to younger volunteers.
Holland et al. (2005) To assess effectiveness of health matters (includes in-person, print, phone, web-based, and class supports) on aerobic activity and stretching in participants 73.1 (>65) 504 In-person screening interview and meeting with nurse health coach (NHC) to develop a plan related to goals at the start of the intervention and at 6 months. Monthly newsletter (N = 12) with standardized and community-related health information. Optional social work consultation and counseling, community education, and exercise classes, access to NHC via phone. In-person screening and coaching. Print newsletters (monthly). Optional phone, e-mail, and group class support. 12 months Two in-person sessions, 12 monthly newsletters, 11 hours (estimated) of NHC contact via phone, e-mail, or in-person. Optional social work (14) Once every 26 days Yes - in-person sessions and coached time No - newsletters Initial and follow-up goal setting and action plan with NHC. Ongoing optional support from NHC via phone, e-mail, or group classes. Optional social work support. Intervention significantly increased minutes per week of aerobic activity and stretching compared to control group (p < 0.01). The greatest impact was noted in participants who were already moderate-to-high exercisers or had a higher education level. Over 1 year, a trend toward less inpatient stays, less hospital days, less health distress, and decreased BMI was noted among participants compared to controls.
King et al. (2008) To evaluate effectiveness of using a hand-held device for enhancing moderate-to-vigorous physical activity in adults over 8 weeks 60.7 (>50) 37 Intervention group: Initial questionnaire on PDA to determine behavioral and motivational factors. Two PDA alerts per day to enter physical activity and revisit goal setting; weekly cumulative graphic and textual feedback via PDA. Control group: standardized, printed health education information. In-person training on PDA. PDA alerts for data entry and feedback. 8 weeks 112 PDA alerts to enter daily activity and assess goals; 56 PDA daily feedback reports on activity; eight PDA weekly goal and feedback reports with graphics; one in-person session to train on PDA (177) Three times per day Yes - daily and weekly feedback on activity Participant’s data entry of steps per day into PDA. Initial questionnaire on PDA related to physical activity and goals. A PDA-delivered physical activity intervention resulted in a significant increase in minutes per week of moderate physical activity compared to the control group (p < 0.05).
Strath et al. (2011) To assess the effectiveness of four different interventions (including a combination of standardized and individualized print, and/or phone support) on physical activity in older adults over 12 weeks 63.8 (55 to 80) 81 Group 1: standardized, printed physical activity literature (six letters). Group 2: same as Group 1 + pedometer and weekly log for tracking steps walked per day. Group 3: individualized, printed motivational literature specific to physical activity (six letters) + pedometer and weekly log. Group 4: same as Group 3 + scripted phone calls on alternate weeks from mailings (six calls). Printed literature (standardized or individualized, every 2 weeks), phone calls 12 weeks Six mailed letters to each group, six phone calls (Group 4 only) (6 or 12) Once every 14 days (Groups 1, 2, and 3) Once every 7 days (Group 4) No - letters to Groups 1 and 2 Yes - letters to Groups 3 and 4 Yes - phone calls to Group 4 Individualized letters with motivational literature related to participant’s stage of change, goals, and previous steps per day. Phone calls for support. Individualized letters related to participant’s stage of change (Groups 3 and 4) resulted in significant increases in steps per day compared to a control group and non-individualized group (p < 0.001). No significant difference in steps per day was noted between the control group and nonindividualized letter group (Groups 1 and 2). No significant difference in steps per day in group receiving the additional support of phone calls (Group 4).
van Stralen et al. (2011) To examine the efficacy of computer-tailored print interventions (targeting psychosocial versus environmental mediators) on physical activity in older adults over 1 year 64 (>50) 1,971 Intervention group: three individualized letters based on psychosocial mediators of physical activity mailed at 2 weeks and 2 months; third letter mailed after feedback received at 3 months. Intervention-plus group: three individualized letters on the same schedule as the intervention group, but based on additional environmental mediators of physical activity; optional access to a website and e-buddy system. Control group: no intervention. Printed letters (N = 3). Website and e-buddy support (for intervention-plus group only) 4-month intervention, 1-year follow-up assessment Three letters (3) Once every 40 days Yes - letters Participant questionnaires regarding psychosocial and/or environmental mediators of physical activity. Completed at the start of the intervention and again at 3 months. Individualized letters resulted in significant increases in days per week for both groups of mediators compared to controls (p < 0.01). Letters related to environmental mediators resulted in a significant increase in minutes per week of physical activity compared to controls and the letters based on psychosocial mediators only (p < 0.05). Changes in the total minutes per week of physical activity were mediated by self-efficacy and strategic planning.

Keypoints

Ostrander, R.E., Thompson, H.J. & Demiris, G. (2014). Using Targeted Messaging to Increase Physical Activity in Older Adults: A Review. Journal of Gerontological Nursing, 40(9), 36–48.

  1. Even with many known benefits, less than 50% of older adults meet recommended levels for physical activity.

  2. A literature review was conducted to evaluate whether sending individualized messages to older adults promoting physical activity may be a way to help them increase activity.

  3. When given a message to be physically active, older adults are able to change their behaviors and successfully maintain that improvement in physical activity behavior up to 1 year.

  4. Improved effects may be seen if the message targets an individual’s stage of change, prompts the scheduling of physical activity, and includes environmental cues, such as local walking paths.

10.3928/00989134-20140324-03

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