Introduction

Low levels of physical activity contribute to some of the most serious health challenges facing older adults today. For example, the leading cause of injurious death among older adults is falls.(1) Despite evidence that falls can be reduced with the regular practice of exercises and movements recommended in evidence-based physical activity guidelines, less than 12% of older adults perform these on a regular basis (2) and fall rates have continued to increase.(1) One reason for this knowledge-translation gap is that although the types and doses of physical activity to recommend are well known, less is known about the behavior change strategies that might motivate older adults to perform them.(3-5) Although several behavior change strategies are promising, research examining their effects is scarce and inconclusive. In this paper, we describe a factorial experiment testing the relative effects of two empirically and theoretically informed sets of behavior change strategies—interpersonal and intrapersonal-that have the potential to motivate older adults to engage in physical activity as recommended by evidence-based guidelines.

Age related decreases in leg strength and balance are the most common causes of falls,(6) but these can be mitigated with the regular practice of leg-strengthening and balance challenging exercises, augmented with walking and flexibility movement.(7) In fact, these four types of exercises and movements, encompassed in evidence-based physical activity guidelines for older adults, (8,9) have been integrated into physical activity protocols such as Otago Exercise Program(10) and Senior Fitness and Prevention. (11) Such protocols have been proven to be safe, relatively simple, and the most effective type of fall prevention intervention for older adults, including those with multiple chronic conditions and frailty.(7) However, their broad dissemination has not made an impact on older adults’ physical activity behavior or health (e.g., fall rates).

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Important content may be missing from existing evidence-based physical activity protocols and guidelines for older adults, which limits their impact. Although protocols specify the biomechanical aspects of exercises and movements, they do not provide guidance in how older adults might be motivated to integrate physical activity into their everyday lives.(12) In the field of fall prevention, factors that ensure “uptake” of and “adherence” to activities within interventions tested, such as behavior change strategies, have not been examined.(7) In the broader field of physical activity in older adults, meta-analyses of prior research results indicate that certain behavior change strategies such as “barrier identification” and “problem-solving” are associated with greater effects on physical activity than other strategies such as “goal setting”. (3-5) Although these results are intriguing, the individual studies upon which they are based were designed to evaluate, on average, 7-10 strategies bundled together with other intervention components. This treatment package approach to evaluation limits our ability to delineate unique and joint effects of behavior change strategies, or sets thereof, used within interventions.

Prior research in this area is also limited by the fact that studies have primarily focused on the assessment of fall risk or occurrence, have relied on self-report measures when measuring physical activity, and have not captured follow-up data. Intervention research in the field of fall prevention has primarily focused on the distal outcomes of fall risk and occurrence, not the proximal outcome of physical activity.(12) Assessing physical activity is warranted in this line of research because the ability of interventions to make an impact on distal health outcomes (e.g., falls) is dependent on their ability to increase physical activity. Thus, fundamental questions remain regarding if and how physical activity can be increased among older adults; questions that can serve as a starting point for also understanding how to increase specific exercises and movements encompassed within existing guidelines and protocols. These types of questions warrant assessing parameters that reflect the quantity of physical activity over time (e.g, duration), which historically have been assessed using self-report measures.(13) However, self-report measures are associated with recall bias, which limits their precision. (14,15) Objective measurements from physical activity monitors overcome these limitations and are now the preferred source of data for clinical research addressing questions related to the quantity of physical activity.(13,16) Finally, assessing physical activity over time warrants measurements captured at several time points. Intervention research in the field of physical activity in older adults has primarily focused on pre and post intervention measurements; less on longer term follow-up measurements after intervention completion.(17) Such follow-up measures are critical for understanding if changes in physical activity are independently maintained, or if they decay over time in the absence of a structured program. (18)

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The current study represents a key step in the process of developing an intervention that combines key behavior change strategies with an evidence-based physical activity protocol for older adults, Otago. (19) The first iteration of the intervention, piloted in prior research, (20) was comprised of 10 behavior change strategies linked to wellness motivation theory (WMT) (21) plus the Otago protocol and a physical activity monitor. In preparation for this study, the behavior change strategies were separated into two sets; interpersonal (e.g., social comparison) and intrapersonal (e. g., goal development), based on empirical evidence and theory that suggest both sets have the potential to elicit increased physical activity among older adults, but in different ways.(5,22,23) Consistent with the multiphase optimization strategy (MOST),(24) separating these strategies into two sets enabled testing, through experimentation, their individual and joint effects.(25) The primary focus of this study is the effect of the intervention strategies on the quantity of physical activity as a primary outcome, assessed through objective and self-report measures, immediately and six months after the intervention. Functional strength and balance is also assessed as a secondary outcome to confirm that participants engage in the types of exercises and movements within Otago that targets fall risk.

In sum, the overall purpose of this study was to assess the unique and joint effects of two sets of behavior change strategies; interpersonal and intrapersonal on older adults’ physical activity, when combined with the core content of an evidence-based physical activity protocol and a physical activity monitor (Figure 1). Our primary and secondary hypotheses were that community-dwelling older adults who receive each set of behavior change strategies, compared to those not receiving them, would (a) increase the quantity of their physical activity, and (b) improve their functional strength and balance, immediately post-intervention and six months’ post-intervention. This research will yield valuable data to help guide the integration of effective behavior change strategies into evidence-based physical activity protocols for older adults.

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