Chapter 1: Introduction

Overview

This chapter provides an overview of the Staying Healthy Through Education and Prevention (STEP) Implementation Guide and a summary of the STEP study results and the STEP physical activity program.

Objectives

After reading this chapter, you will:

• Understand the purpose of the STEP Implementation Guide.
• Have general knowledge of the STEP program.
• Understand the STEP study and its main findings.

Terms

Implementation guide: An online resource used to set up the STEP program in a continuing care retirement community or other congregate living environment.

Continuing care retirement community (CCRC): A community that often consists of independent apartments, assisted living apartments, and a skilled nursing facility.

STEP program: A structured program consisting of behavioral coaching, lower extremity strength training, and walking.

STEP study: A 12-month research study that compared the effects on physical function of a structured physical activity program and a wellness program that focused on lectures and social events. STEP was conducted in congregate senior housing.

Short Physical Performance Battery: A set of functional tests that constitutes the outcome of the STEP study.

Key Points

• This guide is meant as a tool to be used by CCRC wellness and activities staff to implement the STEP physical activity program.
• The STEP program is a physical activity program that focuses on walking and strength training for seniors.
• The STEP study showed that increased time spent in physical activity—particularly aerobic physical activity such as walking—resulted in better physical function among seniors in CCRCs.

Purpose of Implementation Guide

The purpose of this guide is to provide the information, tools, curricular material, and other resources that are needed to implement the STEP program in CCRCs. The STEP program is an exercise program that is consistent with the Surgeon General's recommendations for exercise in older adults-at least 30 minutes of moderate exercise on most days of the week. The STEP program involves walking as its primary mode of exercise, supplemented by lower extremity strength training that takes place in a group setting. The intended audience for this guide includes activities coordinators, wellness coordinators, and other staff responsible for organizing and implementing programming for seniors in congregate living settings.

Overview of STEP Study

Much of the material in this guide is based on the STEP study, which enrolled 317 seniors into a structured research study to test the effectiveness of the STEP exercise program compared to a wellness program that focused on lectures and social events. STEP was conducted in 10 congregate senior housing properties operated by a single nonprofit provider of services to older adults. This implementation guide is targeted at staff in similar congregate living settings.

The STEP exercise program and materials were adopted from a university-based research study called the LIFE-P study, which showed that a structured physical activity program consisting of walking and strength training resulted in more favorable scores on a battery of functional tests. That battery of tests is called the Short Physical Performance Battery (SPPB). The SPPB results constitute the main outcome of the STEP study.

The STEP study divided 317 seniors into two groups, with one group doing the STEP physical activity program and the other group meeting twice a month for educational lectures and social programs. The SPPB was done at the beginning of the study, at 6 months, and again at 12 months. In addition, over the 12 months, staff contacted participants every other month for a brief interview in which they were asked about falls, hospitalizations, and other health events. At the end of the study, SPPB and other data were compared between the group that did the STEP exercise program and the group that met monthly for education and social events.

Study Findings

Both the physical activity and wellness groups increased their SPPB scores between the beginning of the study and at 6 months. Overall, between the beginning of the study and when it finished 12 months later, there were no overall differences in SPPB scores between the groups. However, in both groups, a greater degree of adherence with the interventions resulted in better SPPB scores. The remainder of this chapter focuses on findings related to the physical activity group.

As detailed in subsequent chapters of this guide, the STEP physical activity program consisted primarily of lower extremity strength training in a class setting using ankle weights and aerobic activity, mostly walking, done independently. Both of these types of activity were to be done at a moderate level of intensity, with a target of 150 minutes of exercise per week. Over the course of 1 year, STEP participants reported attending STEP strength classes 64 percent of the time and engaging in 150 minutes or more of walking or aerobic exercise 76 percent of the time.

Study results showed that seniors who increased the weight used for the lower extremity strength training exercises had more favorable SPPB scores at the end of the study compared to people who did not. In addition, as the number of minutes of total exercise increased, so too did participants' SPPB scores. The data showed that compared to people who did not follow the physical activity protocol at all, people who followed it 100 percent would increase their SPPB score by 2.25 points, a significant difference. Previous research has shown that among seniors, as SPPB scores go up, the risk of falls and nursing home admission goes down.

The data suggested that seniors who dropped out of the STEP program and those who did not follow the protocol closely tended to be less healthy at the beginning of the study. Although these individuals may have realized limited benefit in terms of SPPB scores, staff reported that a general sense of belonging and purpose was evident among seniors who enrolled in the program regardless of their baseline physical abilities. An ongoing, positive group dynamic cemented by regular classroom-based strength training and behavioral modification coaching by staff who were familiar with participants helped encourage residents to define and safely work toward long-term physical activity goals.

Ongoing feedback from STEP program coordinators indicated that personal relationships between participants and staff were very important in maintaining interest in the program. Since realizing the benefits of physical activity requires readiness to make long-term behavior changes, existing relationships between staff and seniors are an excellent springboard to implementing this program in congregate housing. After the STEP study ended, interviews with program coordinators in all communities that participated in the physical activity program revealed that the program would be continued.

In all cases, the decision to continue the STEP program was made before the reporting of study results. This finding strongly suggests that program personnel focus not only on quantitative information regarding the efficacy of new programs, but also on the impressions they gather locally from residents and other staff. For example, one program coordinator shared an anecdote in which a resident said that the STEP program was a "miracle" because she could now use a public restroom without assistance due to her increased leg strength. The resident's ability to use a public restroom allowed her to engage more fully in activities outside the community and contributed substantially to her quality of life. The same resident added that she felt "less tired" because of the increased time spent walking.

Many participants shared similar observations. Although not all seniors in the physical activity arm experienced improvement (some were frail at the beginning of the study and could not follow the STEP protocol to its fullest), STEP coordinators expressed universal agreement that the program was popular with residents and would be continued.

In poststudy interviews, STEP coordinators provided feedback and suggestions to improve the program. These included:

• Identify ways to make walking fun. One example is crafting a walking program in which residents meet walking goals as they "walk around the world" or "walk across town." Participants are each given a map (local, national, international) and track their walking distances. As destinations are reached, participants mark their progress on their personal walking maps. In this way, seniors could experience short-term successes while working toward long-term goals. In general, coordinators felt that to meet the walking goal of 150 minutes per week, this goal should be accompanied by a fun element that helped seniors see their incremental progress.
• Motivate residents who are not currently involved in community programming. Several STEP coordinators observed that the most successful STEP participants were residents who were already known to staff because of their high degree of involvement in community activities. Coordinators said that additional outreach to less engaged residents—via personal contact—was needed to secure participation by these individuals. Since disengaged, sedentary residents are likely to realize substantial benefit from physical activity, identifying effective approaches to engaging these individuals is needed.
• Engage residents as program ambassadors. In many congregate housing communities, residents who are recognized by their peers as community leaders can be leveraged as programmatic ambassadors, both to recruit peers into the program and to encourage ongoing participation. A number of STEP coordinators shared their experiences with these "program ambassadors" who enrolled early in the program and subsequently played an important role in motivating peers to join.
• Enroll new participants in the program on a quarterly basis. In the STEP study, a fixed group of participants was enrolled and followed for a year. STEP coordinators suggested that for real world implementation, new participants be enrolled in the program every 3 months, at which time the behavioral coaching sessions would begin anew. New participants would attend the behavioral coaching sessions, and "veteran" participants could be invited to refresh their knowledge and skills by repeating these sessions if desired. In this way, the behavioral coaching elements of the program could be reinforced on a regular basis to existing participants as new participants are welcomed into the program.
• Understand the importance of incentives. One theme that emerged from many STEP coordinators was the importance of the link between goal setting and incentives. Incentives do not have to be costly. Indeed, incentives can take the form of certificates when physical activity benchmarks are reached (printed on a personal computer) or public recognition at congregate meals or events.
• Celebrate achievements often. STEP coordinators indicated that recognizing seniors' physical activity achievements—even small ones—was an important factor in retaining people in the program and for success of the program overall. Coordinators emphasized that seniors will enter the program at varying levels of fitness, and acknowledging achievements in a manner that is tailored to the baseline fitness level of participants never goes unnoticed. This is particularly true among participants who are less active when they enter the program and for whom behavioral modifications favoring increased activity represent substantial lifestyle changes.

The remainder of this guide will focus on how to set up the physical activity program that was conducted in the STEP study.

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