Collaborative evaluation of the healthy habits program: An effective community intervention to improve mobility and cognition of Chinese older adults living in the U.S.

Abstract

Objectives

There is a growing demand to reduce ethnic health disparities. The Healthy Habits Program (HHP) was implemented to provide a community-based physical activity and education intervention for Chinese older adults living in Boston, Massachusetts. This study evaluated the HHP by assessing outcomes that are critical for maintaining independence of older persons.

Design, setting & participants

Quantitative evaluation was performed on 50 Chinese older adults enrolled in the HHP. The community members were trained in data collection and management.

Measurements

Cognition (Mini Mental State Examination (MMSE), Trail Making Test & Complex Walking Task), mobility (Short Physical Performance Battery (SPPB) & maximal gait speed), depressive symptoms (Patient Health Questionnaire-9), perceived disability (World Health Organization Disability Assessment 2.0), nutritional status (Mini Nutrition Assessment®), and strength (grip and leg strength) were assessed at baseline and at 6 months. All tests were translated into Chinese.

Results

Of the 50 participants (mean age 68.4 years; 68% female), 78% achieved the goal of performing exercise ≥3 times/week. After 6 months, clinically meaningful improvements were observed in mobility (mean SPPB score changed from 10.3 to 11.1 points; p=0.01) and cognition (mean MMSE score changed from 26.0 to 27.8 points; p=0.001). There were also statistically significant improvements in executive function, depressive symptoms and perceived disability (p<0.05).

Conclusion

Culturally sensitive community interventions, such as the HHP, are effective for improving mobility and cognition of Chinese older adults. This reveals the potential of promoting successful aging in minority populations through community settings, and should be advocated to reduce ethnic health disparities in the U.S.

Introduction

Advancing age is associated with progressive loss of functional capacity (1, 2, 3, 4, 5, 6), which increases the risk for morbidity, hospitalization, institutionalization (7, 8), and ultimately results in a negative impact on the overall health of older adults (9, 10). As the U.S. population continues to age, with increasing numbers of older ethnic minorities (11, 12), the need to strategically mitigate or reverse agerelated functional decline is of high priority for public health (13). Engaging in regular physical activity has consistently been shown to improve function and health, and is widely recommended for the aging population (14, 15). However, despite the foreseeable benefits, many older adults in the U.S. do not meet the National Physical Activity Guidelines (14, 16). Physical inactivity may be more prominent in older minority populations, due to the combination of low socioeconomic status and limited access to recreational resources (17).

Interventions designed to promote physical activity are an effective means of improving functional capacity among older adults (18), and should be translated into community practice. Public locations, such as senior centers and local recreation facilities, present a great opportunity to promote physical activity in community-dwelling older adults. Additionally, developing a culturally appropriate intervention offers a unique platform to reach the underserved older minority populations.

In response to the potential of promoting successful aging in minority populations through community settings, the Healthy Habits Program (HHP) was implemented near Boston's Chinatown neighborhood for Chinese older adults who may experience language barriers, low socioeconomic status, and social isolation (19). Evaluation of the HHP was performed previously, and revealed its positive effects on body weight, body mass index, blood pressure, chair standing time, one-leg stand time, depressive symptoms, and emotional well-being (20). However, functional measures relevant to predicting injuries and institutionalization rates among older adults (i.e. gait speed and cognitive function) had not yet been examined (20). Therefore, this study was performed to further evaluate the HHP, with the goal of supporting the community to promote successful aging. Distinct from the previous evaluation (20), this study built community capacity to quantify changes in outcomes that are critical for maintaining independence of older persons. This study also examined the effectiveness of the HHP on executive function, nutritional status and strength. Furthermore, we investigated whether the potential effects of the intervention varied by gender. We hypothesized that participation in the HHP would have positive effects on important health outcomes, including mobility and cognitive function. Additionally, the present study results will be used to reflect on potential areas of improvement, and provide evidence-based suggestions to advance the HHP.

Methods

Participants

The HHP has been implemented at the Wang branch of the Young Men's Christian Association (Wang YMCA) since February 2006 (20). The Wang YMCA is located in the Chinatown neighborhood of Boston, MA. Every 6 months, cohorts of 50 Chinese older adults aged ≥60 years are enrolled. The HHP aims to improve overall health of the older Chinese participants, through a 6-month physical activity and education intervention designed to promote healthy lifestyles.

In this study, Chinese older adults who enrolled in the HHP between July and December 2013 were invited to participate. During the 6-month period, participants were asked to perform physical activity for a minimum of 3 times per week, utilizing available facilities, equipment, and exercise classes offered at the Wang YMCA (20). The 43,000 square-foot facility consists of a gymnasium, indoor and outdoor walking track, a 25-yard swimming pool, a two-story fitness center fully equipped with aerobic machines, free weights and resistance training equipment, and an aerobic studio with a variety of stability balls, yoga mats, elastic bands, and step platforms. To facilitate the delivery of culturally sensitive intervention, participants were permitted to engage their preference of physical activity mode and intensity. Participants were free to exercise individually or partner with other Wang YMCA gym member(s). In addition, the Wang YMCA provides a selection of supervised group fitness classes that are specifically designed for older members, including Tai Chi, Zumba®, conditioning workouts, and water aerobics, all of which were available to the study participants.

Furthermore, participants were asked to attend a 1-hour weekly group counseling session to discuss topics related to healthy lifestyles, which included healthy diet, regular physical activity and disease management. In order to bridge communication barriers, the counseling sessions were culturally tailored (i.e. the nutrition curriculum was designed to incorporate cultural festivals and traditional Chinese cuisine), and executed using the most common Chinese languages (Mandarin and Cantonese).

Community Engagement Evaluation Procedures

The study was conducted in partnership between the Wang YMCA and the Nutrition, Exercise Physiology, and Sarcopenia (NEPS) Laboratory in the Jean Mayer U.S. Department of Agriculture (USDA) Human Nutrition Research Center on Aging (HNRCA) at Tufts University. The Wang YMCA is dedicated to providing social services to improve the health of individuals and families of its community, and one mission of the NEPS laboratory is to evaluate and understand the effects of physical activity on changes in the functioning and mobility of older individuals. The Tufts University Health Science Campus Institutional Review Board approved this study.

A community engagement approach was employed in which the Wang YMCA staff members were actively involved in the research process (Figure 1). To ensure voluntary participation and culturally appropriate communication, the consenting process and assessments were conducted in the preferred language of the respondent (English, Mandarin, Cantonese, or Taishanese). The scripts, instructions, and questions for all assessments were translated into Chinese. The Wang YMCA staff members were trained and certified in all data collection procedures by an experienced research technician in the NEPS Laboratory. The certification process involved reviewing standard operating procedures and practicing data collection techniques while observed by the trained technician. Distinct from the previous evaluation (20), a customized electronic data management system was developed for the HHP, and the Wang YMCA staff members were also trained in data entry and management by an experienced research technician in the NEPS Laboratory. All Wang YMCA staff members who were involved with the collection and management of data were unaware of the training mode and intensity performed by the participants.

Figure 1.

Community engagement research study procedures

Adherence measures

The site coordinator at the Wang YMCA was responsible for monitoring program attendance. Adherence to the physical activity component was considered the number of times per week each participant exercised at the Wang YMCA. Adherence to the education component was calculated as the percentage of scheduled classes attended by the study participants.

Outcomes

Four important outcomes were identified to quantify the changes in overall function and health. All outcome measures listed below are standardized instruments that have been widely used in studies of older adults, and were assessed at baseline and repeated after 6-months.

Physical Function and Muscle Strength

The Short Physical Performance Battery (SPPB) was performed to assess lower-extremity function. It is an objective measure of standing balance (ability to maintain a side-by-side, semi-tandem, and tandem stand position for up to 10 seconds), habitual gait speed (timed 4-meter (m) walk at a usual pace) and lower-extremity strength (timed 5-repeated chair rises). Each subtask is rated with a score from 0-4, which provides a summary score ranging from 0-12. The SPPB summary score is used to indicate the level of mobility limitation and has been shown to be highly predictive of mortality and nursing home admission rate (8). In this study, the changes in habitual gait speed and timed 5-repeated chair rises were further examined to provide a comprehensive evaluation of lower-extremity function.

Maximal gait speed was also assessed, where participants were instructed to walk over a 7-meter walk course as quickly as possible (21, 22). Time needed to complete the walk was recorded, and was further reported as gait speed (m/s).

Grip strength was measured using an adjustable, hydraulic dynamometer (JAMAR® 5030JI, Sammons Preston, Bolingbrook, IL, USA). Participants were asked to squeeze the dynamometer twice, as hard as possible, with a 10-second rest period separating each attempt. The peak force was recorded to the nearest 0.1 kg. Isometric knee extensor strength was evaluated by a belt-resisted, hand-held dynamometer (Model WB-2C, Neuroscience Research Australia, Randwick, NSW 2031, AU) (23). Participants were instructed to sit comfortably in an armless chair, with both feet on the ground and knees flexed at 90 degrees. To stabilize the pelvis, a nylon belt was placed around the lower frontal part of the leg just proximal to the lateral malleoli. The input arm of the dynamometer was positioned posteriorly on the distal shank. Participants were asked to extend their legs as hard as possible. The test was performed three times on both right and left sides. The peak force was reported to the nearest 0.1 kg.

Cognition and Executive Function

The Folstein Mini-Mental State Examination (MMSE) was used to measure global cognitive function. It provides a summary score ranging from 0 to 30, which can be used to estimate the severity of cognitive impairment (24).

Performance of executive function was added as another cognitive outcome. Assessment of executive function has become increasingly popular in geriatric research, because of the potential to resemble situations often encountered in everyday life (6). In this study, the Trail Making Test (TMT) and Complex Walking Task (CWT) were used. The TMT is a neuropsychological test that involves skills of visual attention and task switching (25). It consists of two parts: Part A—numeric sequence and Part B—alternating numeric & alphabetic sequence. Participants were asked to complete the tests as quickly as possible, and the time required to finish was recorded to the nearest 0.01 second. For the CWT, a modified version of the 7-meter walk and talk test was adapted to minimize potential problems related to language barriers (21). Participants were asked to perform mental calculation while walking on a 7-meter course at their usual pace. Participants were instructed to subtract 3 from 50, and keep subtracting 3 from each answer provided until the walk was completed. The time used to finish the CWT was recorded to the nearest 0.1 second.

Nutritional Status

The Mini Nutrition Assessment (MNA) was used to determine participant's nutritional status (MNA®, Nestlé Nutrition, Vevey, Switzerland). The MNA is validated (26) and has been largely used to screen for risk of malnutrition in the elderly (27).

Depressive Symptoms and Disability

Depressive symptoms and perceived disability were evaluated using the Patient Health Questionnaire-9 (PHQ-9) and 32-item World Health Organization Disability Assessment Schedule 2.0 (WHODAS-II), respectively. The PHQ-9 provides a summary score ranged from 0 - 27, and can be used to assess the presence and severity of depressive disorder (28). The summary score of the WHODAS-II was computed following the guidelines provided by the World Health Organization (29).

Statistical Analysis

All statistical analyses were performed using SPSS version 22.0 for Windows (SPSS Inc., Chicago, IL, USA). Results with a p-value of <0.05 were considered statistically significant. T-tests were used to compare baseline characteristics between men and women. The overall mean change in all outcome measures were examined using paired T-tests. The effects of the intervention for all outcome measures were evaluated as change from baseline to 6-months using repeated measure analysis. A dichotomous dummy variable was created to indicate baseline and 6-month measures, and used as an independent variable. Linear mixed models were employed to assess the changes on all available data utilizing an unconstructed covariance matrix. An individual model was generated for each outcome measure. Potential confounders such as age, gender, weight, and average exercise adherence (defined as the average number of exercise sessions performed per week over a 6-month interval) were adjusted. To explore whether the intervention effects differed between men and women, a subgroup analysis was performed to examine the interaction between gender and changes in outcomes.

Results

Baseline Characteristics

Baseline characteristics are shown in Table 1. All 50 Chinese older adults signed the informed consent form and completed the baseline assessment. There were 34 (68%) females and 16 (32%) males. A significant gender difference was found in height and weight, but not in body mass index and any baseline outcome measures (p>0.05). As indicated by the mean SPPB and MMSE scores, the participants were categorized as mildly mobility-limited (8) and cognitively impaired (24). Based on the self-reported medical history, a 28% of the participants were diagnosed with diabetes and 50% with hypertension.

Table 1.

Baseline Characteristics (N=50)

	Mean (SD)	Range
Demographics
Age	68.4 (6.2)	60 – 85
Height, cm	156.4 (8.3)	124.5 – 171.5
Weight, kg	61.1 (11.1)	41.4 – 89.5
BMI, kg/m2	24.9 (3.1)	18.4 – 31.4
Blood Pressure
SBP, mm Hg	125.0 (9.9)	104 – 146
DBP, mm Hg	78.3 (3.9)	72 – 88
Physical and mental function
4-meter gait, m/s	1.1 (0.3)	0.7 – 2.1
SPPB, score	10.4 (2.3)	2 – 12
MMSE, score	26.1 (3.0)	17 – 30

Adherence

Overall, the participants exercised an average of 3.1 times/week. Of the 50 participants, 78% achieved the goal of exercising ≥3 times/week, with 19 exceeding the goal and performing exercise >3 times/week. Adherence to the weekly counseling sessions was approximately 76%. In total, 4 participants withdrew from the HHP prior to completing the 6-month follow-up assessment (2 males and 2 females; mean age 68.5 years). These withdrawals were due to reported time constraints and lost interest in the study, which are common in physical activity programs for older adults (30).

Outcome Measures

Table 2 shows the changes in outcomes after 6 months of the HHP. After adjusting for age, gender, weight, and average exercise adherence, statistically significant improvements were found in SPPB (p=0.01;Figure 2), habitual gait speed (p<0.001), 5-repeated chair rises (p=0.007), maximal gait speed (p<0.001), MMSE (p=0.001; Figure 3), TMT-Part A (p<0.001), CWT (p=0.03), and PHQ-9 (p=0.03) at 6 months. There was no statistically significant interaction between gender and changes in the outcomes listed above (p≥0.05).

Table 2.

Six-month changes in the selected outcome measures (n=50)

	Baseline Mean (SD)	6-month Mean (SD)	Change*(95% CI)	P+
Physical Function
SPPB, score	10.3 (2.4)	11.1 (1.5)	0.8 (0.2, 1.5)	0.01
Habitual gait speed #, m/s	0.94 (0.2)	1.07 (0.2)	0.1 (0.1, 0.2)	<0.001
5-repeated chair rises #, s	9.5 (2.5)	8.4 (2.2)	-1.1 (-1.8, -0.3)	0.007
Maximal gait speed, m/s	1.4 (0.4)	1.6 (0.3)	0.2 (0.1, 0.3)	<0.001
Cognitive function
MMSE-I, score	26.0 (3.0)	27.8 (2.0)	1.8 (0.8, 2.8)	0.001
Trail making part A, sec	55.8 (22.3)	48.1 (20.0)	-7.8 (-11.9, -3.6)	<0.001
Trail making part B, sec	152.3 (54.2)	153.2 (110.6)	-0.9 (-33.2, 31.4)	0.12
Complex walking task, sec	10.8 (4.7)	9.1 (5.4)	-1.7 (-3.1, -0.3)	0.03
Muscle Strength
Grip Strength, kg	22.3 (8.9)	21.8 (7.4)	-0.4 (-2.0, 1.2)	0.37
Isometric right knee strength, kg	18.7 (8.7)	20.3 (8.3)	1.5 (-0.5, 3.3)	0.17
Isometric left knee strength, kg	17.5 (9.2)	19.0 (8.5)	1.5 (-0.3, 3.2)	0.14
Depressive Symptoms
PHQ-9, score	2.8 (3.9)	1.8 (3.7)	-1.1 (-0.2, -0.1)	0.03
Perceived Disability
WHODAS-II**, score	9.0 (12.3)	6.7 (11.3)	-2.3 (-4.4, 0.01)	0.003
Nutritional Status
MNA, score	25.1 (2.2)	25.7 (2.3)	0.6 (-0.2, 1.3)	0.13

^*Mean Change (6-month less baseline)

^#Derived from the Short Physical Performance Battery (SPPB)

⁺Linear mixed model on all available data adjusted for age, gender, weight, and exercised adherence

^**Further adjusted interaction between gender and change in outcome.

Figure 2.

Change in SPPB after 6 months of the Healthy Habits Program

Figure 3.

Change in MMSE after 6 months of the Healthy Habits Program

There was also a positive change in WHODAS-II (p=0.05). A statistically significant interaction was found between gender and changes in WHODAS-II score (p=0.01). The mean WHODAS-II score decreased significantly among female participants (9.0 points versus 5.0 points; p=0.004), but not in male participants (9.1 points versus 11.0 points; p=0.40). As shown in Table 2, the intervention effect on WHODAS-II was considered as statistically significant when further accounting for the gender effect (p=0.003).

There were no statistically significant changes in grip strength (p=0.37), isometric knee extensor strength (p=0.17 at right side; p=0.14 at left side) and MNA (p=0.15). Furthermore, only 28 participants were able to complete Part B of the TMT. The time required to complete the test varied widely among participants, with a mean change of -0.9 seconds (95% CI: -33.2, 31.4), and no significant change was observed after 6 months (p=0.12).

Discussion

The present study is the first to demonstrate statistically significant and clinically important improvements in mobility and cognition following completion of the HHP among older Chinese participants. The overall mean SPPB score had increased by 0.8 points after 6 months (Figure 2), a magnitude of improvement that is considered clinically meaningful (31, 32) and has been shown to be associated with lower mortality and nursing home admission rate (8). The overall MMSE score improved from 26.0 at baseline to 27.8 at 6-month (Figure 3), which suggests a decreased risk of developing dementia (33). These primary findings reveal the potential of communitybased interventions in the promotion of successful aging among older minority populations, and should be used as a potent strategy to reduce ethnic health disparities, considering the dramatic demographic transition in the U.S. (34).

This study has several unique findings worth mentioning. As derived from the SPPB, the improvement observed in habitual gait speed (from 0.9 m/s at baseline to 1.0 m/s at 6-month) also has a substantial implication for older adults. Based on previous research, a 0.1 m/s increment in gait speed is determined as a substantial improvement (31, 32), and older adults with gait speed of ≥1.0 m/s have consistently reported to have better lower-extremity function and survival rate compared to those with gait speed <1.0 m/s (35, 36).

This study examined changes in outcomes that have not been examined in previous evaluation of the HHP (20), and found significant improvement in executive function when measured by CWT. Executive functioning requires higher level of motor coordination skills, and independent older adults with normal gait speed may still demonstrate limitations when walking under complex conditions (6, 37). Additionally, there was a significant improvement in performance on the TMT-Part A. Older adults with poor performance on the TMT have been shown to have higher mortality rates when compared to those with high performance (38). Nevertheless, a significant change was not observed with the TMT-Part B, causing the effect of the HHP on visual attention and task switching to remain undetermined. It should be noted, however, that the lack of improvement on TMT-Part B was likely to be influenced by the low English proficiency among the studied population.

This study also explored whether the potential effects of the intervention varied by gender. In contrast with the conclusion drawn from the previous evaluation (20), a significant positive change was observed in perceived disability among the older Chinese female participants.

The remarkably high exercise adherence rate (78% the participants achieved the goal of exercising ≥3 times per week) observed in the present study suggests that community-based intervention is an effective means to promote physical activity among community-dwelling older adults (18). A recent multicenter study was performed to examine the long-term effect of physical activity at older age (The Lifestyle Intervention and Independence for Elders (LIFE) Study), and found that engaging in regular physical activity can reduce the risk of developing major mobility disability by 18% in the first year and 21% after 2 years (15).

Distinct from the previous evaluation (20), this was the first study to include the Wang YMCA members in the formulation of research questions and the evaluation plan (Figure 1). Community engagement research, also termed community-based participatory research, has been increasingly recognized by public health officials and governmental officers to empower local communities (39, 40). In our experience, this collaborative research design allowed the present study procedures to be formulated in a way that would strengthen community capacity to conduct a meaningful program evaluation. We believe that the standardized tools and procedures introduced during this study are highly pragmatic, and can potentially be replicated in future program evaluations. In addition, the collaborative review of the research findings may potentially foster the development of the program by addressing shortcomings uncovered in this study. For example, it was suggested to incorporate a structured resistance training session (41, 42) into the HHP, in order to address the lack of improvement seen in upper- and lower-extremity strength.

This study has several limitations. First, there was no control group to compare the magnitude of change among individuals who participated in the HHP. Second, the exercise adherence reported in this study was subject to self-report bias and there were no data available to corroborate the type, duration and intensity of exercise performed by the participants. Third, limited demographic characteristics were collected during the course of study and therefore, crucial information including education level, employment status, number of years living in the U.S., and number of diagnoses were not available. Lastly, the alphabetic sequencing aspect of the TMT might not have been ideal for this population, and should be reconsidered for future evaluation. Though these limitations were recognized and discussed prior to the start of the study, it was believed that gradual introduction of standardized tools and procedures should be prioritized for building a trusting relationship with community stakeholders. Moreover, other outcomes, such as dietary intake and cost-effectiveness, were not evaluated this study, as such efforts were beyond the scope of the present investigation.

Regardless of the limitations, the outcome of this study is highly positive and has strong implications for public health. Community-based programs, designed to promote successful aging in a culturally sensitive manner, can improve functional capacity of Chinese older adults living in the U.S.. This reveals the potential of promoting successful aging in minority populations through community settings, and should be advocated to reduce ethnic health disparities in the U.S. Program evaluation performed with an underlying goal of enhancing community engagement is practical for capacity building, and therefore, should be utilized to empower other community members and advance future community-based programs.

Funding sources: The Healthy Habits Program was funded by the Asian Health Initiative at Tufts Medical Center. This study was supported and conducted by the Wang Branch of the Young Men's Christian Association (YMCA), the U.S. Department of Agriculture, under agreement No. 58-1950-4-003, and the Nutrition, Exercise Physiology, and Sarcopenia (NEPS) laboratory in the Jean Mayer USDA Human Nutrition Research Center on Aging (HNRCA) at Tufts University. Any opinions, findings, conclusions, or recommendations expressed in this publication are those of the author(s) and do not necessarily reflect the view of the U.S. Department of Agriculture.

Contributors: K. F. Reid, R. J. Chin, and T. J. Botto conceptualized and formulated the research design and evaluation plan. C. Hau was responsible for the implementation of the research study, trained and certified community members in data collection and management, performed all statistical analyses, drafted and edited the manuscript. K. F. Wong assisted in collecting data and managing datasets for this study. K. F. Reid and R. A. Fielding provided substantial input to analysis and writing, and approved the final article. O. I. Bermudez and M. Eliasziw provided advice on analysis.

Acknowledgement: The authors would like to thank Kit Wong for coordinating the HHP and assessments for this program evaluation. The abstract of this study was nominated for the National Delta Omega Poster Competition, won and selected to be presented at the 2014 American Public Health Association Meeting and Exposition; November 15-19; New Orleans, LA.

Conflicts of interest: There are no financial or personal conflicts of interest associated with this study. There have been no financial benefits to the authors that could have influenced its outcome.

Disclosure of corporate sponsorship: Dr. Reid has been a consultant for Bay Cove Human Services and Eli Lily & Co in the past. Dr. Fielding serves on the boards of Ammonett, Cytokinetics, Pronutria, and Myosyntax. He is also a consultant for Eli Lilly, Pfizer, Merck, Regeneron, Astellas, and ICON.

Ethical standards: This study was in accordance with the Declaration of Helsinki for human studies. The informed consent process and study procedures were conducted in the preferred language of the respondent. This study was reviewed and approved by the Tufts University Health Sciences Campus Institutional Review Board under protocol number 10907.