Journal of Gerontological Nursing

Guest Editorial Free

Considerations When Disseminating American-Developed, Evidence-Based Health Promotion Programs in China

Minhui Liu, BSN, BS, RN; Basia Belza , PhD, RN, FAAN; Xi Zhang , MSN, RN

The authors have disclosed no potential conflicts of interest, financial or otherwise. Mr. Liu is partially funded by the China Scholarship Council and the University of Washington Retirement Association Scholarship in Aging. The authors thank Siyuan Tang and Jonika Hash for providing feedback on an earlier draft.

Similar to other countries, the older adult population in China is experiencing a shift from having infectious diseases to chronic diseases. This shift is coupled with the need for older adults to better manage their health. Older adults in China have traditionally participated in activities, such as square dancing (Huang, Lin, & Sun, 2011) and walking. However, the evidence demonstrating health outcomes for these and other similar community-based activities that are appealing to older adults in China is scant, and the work of examining and testing their effects can be costly and time consuming. Given that evidence-based programs are still in the development phase in China, adopting American well-designed, evidence-based programs might be a viable option. A number of issues should be taken into consideration. An American-developed, evidence-based health promotion program—Enhance®Fitness—will be used to explore potential issues with disseminating such programs in China. EnhanceFitness is a low-cost, group exercise program taught in community settings by certified EnhanceFitness instructors. Offered 3 times per week, classes are 60 minutes long and include cardiovascular, strength, flexibility, and balance exercises (Belza, Snyder, Thompson, & LoGerfo, 2010). Exercises are tailored to meet various levels of physical ability.

Familiarity with Evidence-Based Practice

Chinese older adults have little knowledge about and exposure to evidence-based programs. Evidence-based medicine has less than a 20-year history in China (Li, Sun, & Wang, 2008). Currently, most evidence-based research focuses on pharmaceutical trials as opposed to health promotion programs (Wang, 2010). In addition, some health professionals in rural areas base their practice on experience rather than evidence (Wang, 2010). The benefits of evidence-based programs have not been wholeheartedly embraced or valued by many professionals or the public in China.

Limited Funding for Dissemination

Research funding opportunities for health promotion programs are limited. The largest funding agency in China, the National Natural Science Foundation of China, established the first funding for evidence-based medicine in 2005 (Li et al., 2008). However, the majority of funds have been awarded to study mechanisms of diseases. Although some non-profit organizations fund evidence-based programs, resources are limited. Furthermore, differences in health systems between the East and West complicate the dissemination efforts. For example, many of the EnhanceFitness classes are offered in community centers, senior centers, or churches in the United States (Belza et al., 2006). EnhanceFitness is covered by some insurance plans, and community-based agencies cover participation fees. However, in China, it would be a challenge to find community-based sites to offer and cover the costs of the EnhanceFitness program.


EnhanceFitness was developed in partnership with Senior Services, University of Washington Health Promotion Research Center, and Group Health Cooperative. This type of collaborative model among an academic partner, non-profit agency, and managed care organization is only beginning to be developed in China. For EnhanceFitness to be disseminated in China, it would be advantageous to seek and secure university support. A university partner could help identify cultural discrepancies to ensure a Western-based program could be adapted to Chinese culture. The training manual would need to be translated and culturally sensitive marketing materials would need to be developed; the name EnhanceFitness might need to be changed to better resonate with locals (Tomioka, Sugihara, & Braun, 2012); and music played during the class would likely need to be adapted. The academic partner could also provide oversight to the program to assure program fidelity.

Recruiting and Training Instructors

Trained EnhanceFitness instructors need to be able to implement the program per the EnhanceFitness protocol. Identifying appropriate instructors may be a challenge. Unlike the United States, China has few physical therapists and fitness trainers who could be trained as instructors. Older adults with certain skill sets who are retired may be potential candidates for instructors. However, the current cohort of older adults has a low education level; therefore, it may be difficult for them to be adequately trained as instructors. Retirees who previously worked as health care professionals or physical education teachers might be appropriate instructors for the EnhanceFitness program. These individuals have a higher education level, are more knowledgeable about physical activities, and are committed to fitness. China could consider having an academic partner train EnhanceFitness instructors.

Nurses in China, although too busy to be trained as instructors, can play a vital role in helping adopt and adapt EnhanceFitness. They can become directly involved as part-time program managers, overseeing implementation and determining program success among older adults. Nurse researchers can also provide insight in the adoption and adaptation of EnhanceFitness.

Teaching the Value of Physical Activity

Strategies need to be developed to improve the public awareness of the value of health promotion programs. Health care professionals, whose opinions are highly valued, could refer their patients to evidence-based health promotion programs. In addition, nurses could develop and offer health education sessions to teach the community about evidence-based health promotion programs and why they should choose them and who will benefit. For older adults residing in rural areas, traditional health beliefs may impede their involvement in health promotion programs. They believe that being disease-free is a health status and, traditionally, they do not seek further information to enhance their fitness.


Currently, China is lacking evidence-based health promotion programs for older adults. Disseminating Western-developed health promotion programs, such as EnhanceFitness, is a viable option, but a number of issues need to be taken into consideration. Given the popularity, beneficial outcomes, and cost-effectiveness of EnhanceFitness in the United States, it would be worthwhile to explore disseminating this program in China. These endeavors should be coupled with improving the public and health care professional awareness of evidence-based programs, identifying cultural discrepancies, and building partnerships to ensure the American-developed EnhanceFitness would be readily adapted for older adults in China.

Minhui Liu, BSN, BS, RN

PhD Student in Nursing Science

School of Nursing

University of Washington

Seattle, Washington

Basia Belza, PhD, RN, FAAN

The Aljoya Endowed Professor in Aging

School of Nursing

University of Washington

Seattle, Washington

Xi Zhang, MSN, RN

Clinical Nurse

Henan Provincial People’s Hospital

Zhengzhou, China


  • Belza, B., Shumway-Cook, A., Phelan, E.A., Williams, B., Snyder, S.J. & LoGerfo, J.P. (2006). The effects of a community-based exercise program on function and health in older adults: The EnhanceFitness program. Journal of Applied Gerontology, 25, 291–306. doi:10.1177/0733464806290934 [CrossRef]
  • Belza, B., Snyder, S., Thompson, M. & LoGerfo, J. (2010). From research to practice: EnhanceFitness, an innovative community-based senior exercise program. Topics in Geriatric Rehabilitation, 26, 299–309. doi:10.1097/TGR.0b013e3181fee69e [CrossRef]
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  • Li, Y., Sun, X. & Wang, L. (2008). Evidence-based medicine in China. Value in Health, 11(Suppl. 1), S156–S158. doi:10.1111/j.1524-4733.2008.00379.x [CrossRef]
  • Tomioka, M., Sugihara, N. & Braun, K.L. (2012). Replicating the EnhanceFitness physical activity program in Hawaii’s multicultural population, 2007–2010. Preventing Chronic Disease, 9, E74.
  • Wang, J. (2010). Evidence-based medicine in China. Lancet, 375, 532–533. doi:10.1016/S0140-6736(09)62131-0 [CrossRef]


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