Abstract
Purpose: This study sought to advance the state of knowledge regarding physical activity and aging by identifying areas of agreement among experts regarding topics that are well understood versus those that are in urgent need of continued research efforts. Design and methods: We used a web-based survey with snowball sampling to identify 348 experts who were invited to complete a brief web-based survey. Responses were received from 38% of invited respondents. Results: Respondents reported that the efficacy and effectiveness of several types of physical activity were well understood but the dose–response relationship required for a health benefit was not. In general, more research is needed examining the effectiveness of programs on cognitive health outcomes and the impact of multiple risk factor programs. With respect to translation, more research is needed on how to maintain older adults in evidence-based programs and how to adapt programs for special populations. Researchers agreed that racial/ethnic minorities; persons with low socioeconomic status; and those with physical, intellectual, or mental health disability were substantially understudied. Finally, research on maintenance, implementation, and reach with respect to these populations was judged to be more urgently needed than research on efficacy and effectiveness. Implications: A substantial amount of consensus was found across a national group of experts. These findings should be instrumental in forging a new research agenda in the area of aging and physical activity.
Keywords: Older adults, Exercise, Research needed, Expert survey
The past decade has seen a rapid increase in research examining the impact of physical activity on older adults. To date, research has shown benefits of physical activity on strength, mobility, aerobic capacity, energy, anxiety, and depression in both general and disease-specific populations of older adults (Cress, Moore, Johnson, & Quinn, 2003; Hughes et al., 2004, 2006; Liu-Ambrose et al., 2010; Pahor et al., 2006; Penninx et al., 2002; Wallace et al., 1998; Wilcox et al., 2008). The U.S. Department of Health and Human Services (2008) published Physical Activity Guidelines for Americans. These guidelines stated that in order to derive substantial health benefits, older adults should participate, to the extent possible, in 150 min of moderate-intensity aerobic activity or 75 min of vigorous-intensity aerobic activity per week in sessions of at least 10 min, with at least 2 days of strengthening and 3 days of balance exercises. The guidelines also suggested that additional health benefits could be gained through greater amounts of physical activity and that the guidelines should be viewed as the minimum amount of activity required to achieve a health benefit. Currently, the number of older adults who engage in regular physical activity falls far short of meeting the Activity Guidelines. For example, a Healthy People 2010 objective was to increase the proportion of older adults who perform physical activities that enhance and maintain muscular strength and endurance by 30% (U.S. Department of Health and Human Services, Office of Disease Prevention and Health Promotion, 2010). In 2001, only 12% of persons 65–74 years and 10% of persons 75 and older met the strength-training objective. This gap is particularly pronounced among ethnic minority older adults (Kruger et al., 2009).
The Centers for Disease Control and Prevention established the Healthy Aging Research Network (CDC-HAN) in 2001 to assist with the development and implementation of a national research and dissemination agenda related to the public health aspects of healthy aging. The network currently encompasses CDC researchers and investigators at eight Schools of Public Health in the United States who have strong interest and expertise in health promotion for older adults. In 2006, the CDC-HAN established a Physical Activity Interest Group (PAIG), which is an interdisciplinary group of physical activity and aging research experts at funded CDC-HAN sites, as well as researchers with expertise in physical activity and aging at other universities and institutions (including the American Association of Retired Persons, National Council on Aging (NCOA), International Council on Active Aging, and others). The PAIG was charged with conducting an inventory of members to assess the current state of knowledge regarding physical activity and aging and frontiers for basic and applied translational research on this topic. One of the first steps the PAIG undertook was the review of a prior paper developed by an earlier group of CDC-HAN members and colleagues in 2005. This review paper by Prohaska and colleagues (2005) summarized the state of knowledge at the time regarding the following four critical issues: (a) types and levels of physical activity engaged in by diverse older populations, (b) health benefits of physical activity, (c) factors that influence exercise participation, and (d) our capacity to develop successful interventions and policies to promote physical activity along with criteria to evaluate their success. Based on their review, the authors concluded that progress had been made in documenting the benefits of physical activity but that more research was needed on the effects on ethnic/racial minority participants, on translational research, and on environmental and policy barriers to and facilitators of physical activity.
Since that time, the field of physical activity and aging has continued to grow with multiple studies resulting in new evidence-based programs (EBPs), more emphasis on translating effective programs into practice, and new guidelines for levels and types of older adult participation. We now have compelling evidence that physical activity is associated with improved functional status (Morey et al., 2008), delays the onset and prevents the progression of frailty (Peterson et al., 2009), and reduces risk of mortality among older adults (Manini et al., 2006). We also have made some progress examining successful ways of translating EBPs into practice. Specifically, Glasgow’s RE-AIM model has been adopted by many researchers and government agencies seeking to evaluate the impact of translation efforts in a systematic way. The RE-AIM framework is a conceptual approach developed to translate research into practice and to help implement evidence-based interventions with fidelity and improve their chances of success in “real-world” settings (Glasgow, McKay, Piette, & Reynolds, 2001; Glasgow, Vogt, & Boles, 1999). RE-AIM is an acronym for reach, effectiveness, adoption, implementation, and maintenance—five steps or stages of program implementation and dissemination—which, if followed, ensure that essential program elements are retained during the implementation process, resulting in greater external validity and thereby in more widely transferable more sustainable evidence-based interventions.
Recently, the NCOA, the Administration on Aging (AoA), and the CDC-HAN have collaborated in applying the RE-AIM framework to the evaluation of the AoA Evidence-Based Disease Prevention Program and have held numerous joint workshops with providers during which the framework has been explained and demonstrated (Administration on Aging, 2011). Given the rapid development of literature and practice in this field over the past 5 years, the PAIG agreed that a need existed to systematically assess current research needs in the field based on expert assessments, leading to the development of the survey used in this study.
Customarily, consensus statements about future research needs are based on face-to-face meetings that are followed by rounds of reviews. An earlier investigation by researchers in the CDC Physical Activity Policy Research Network of physical activity research priorities for the entire U.S. population used web-based concept mapping among researchers and practitioners that was followed by a face-to-face meeting (Brownson et al., 2008). Given current economic constraints and the availability of web-based survey technology, we used a brief web-based survey to examine the perceptions of experts in the area of physical activity for older adults about the state of research in this field. Our intent was to examine the extent to which consensus exists/does not exist for specific research topics, to explore research priorities in the new field of translation and diffusion research, and to discover areas that are emerging as the next frontier of research in the field.
Design and Methods
This study sought to survey a sample of persons with expertise in research on aging and physical activity and used a snowball sampling technique to refine that sample. Once the sample was identified, we designed and implemented a survey to elicit expert views about the state of the art of completed research on physical activity and aging, as well as the views of experts in the field about emerging issues for which research is lacking and urgently needed.
Expert Sample
The identification of experts is a major point for consideration in expert surveys. This study identified expert panelists using a method similar to the “reputation approach” (Sanders, 1966). Specifically, panelists were chosen because they were believed to be experts in the field of aging and physical activity and invested in the advancement of those fields, and thus, likely to find the survey results of interest.
The experts who were invited to respond to Wave 1 of the survey were identified based upon recommendation from members of the broader CDC-HAN and the PAIG. The Wave 2 experts were identified based upon recommendations from Wave 1 respondents. The expert panel of respondents included faculty, researchers, clinicians, policy makers, and other key experts selected from the following: (a) CDC-HAN’s national research-to-practice conference, “Effective Community-Based Physical Activity Programs for Older Adults,” held in Seattle in February 2007; (b) a CDC-HAN Semi-Annual Meeting, held in Atlanta in March 2009; (c) a list of graduates of the National Physical Activity and Public Health course, taught in various locations between 1995 and 2008 and funded by the CDC and University of South Carolina; (d) PAIG membership; and (e) individual nominations from CDC-HAN members. These experts represented a variety of organizations nationally, including universities, public agencies, national foundations, and health and medical centers from across the country. Potential respondents received an e-mail invitation to complete the survey.
Instrument
An online survey was developed for use in this study. During the initial phase of survey development, the PAIG compiled a list of topic areas and crosscutting questions designed to identify the gaps in knowledge with respect to the impact of physical activity among older adults on health/functional outcomes. Over a period of 6 months, and through a series of conference calls, PAIG members developed a paper-and-pencil version of the survey that addressed four content areas: (a) professional background of respondents, including self-assessed research focus and areas of expertise; (b) rating of the strength of available evidence to support both the impact of different types of physical activity on health benefits for older adults and the dose–response relationship required to achieve health benefits; (c) ranking the priority of a number of research areas related to aging and physical activity including efficacy and effectiveness, translation and diffusion of evidence-based interventions, and understudied populations; and (d) identifying topic areas for which research is most urgently needed. Questions in sections (b) and (c) were structured on a 5-point Likert scale, ranging from 1 (Very Low Strength/Importance) to 5 (Very High Strength/Importance) and 9 (Don’t Know). Questions in section (d) were open-ended.
The paper-and-pencil version of the survey was transferred to a secure web-based survey mark-up tool. The final online version consisted of 60 items that could be completed in more than one session, with an anticipated completion time of less than 30 min. Prior to its full distribution, the survey was pilot tested in March 2009 with 15 members of the CDC-HAN who completed the online survey and provided feedback regarding challenges and/or problems. The survey was revised based on this feedback, mainly to improve the clarity of the items and their formatting. Study researchers obtained approval for the study and the use of the online survey from the institutional review boards at their respective academic institutions (University of Illinois at Chicago, West Virginia University, University of South Carolina, and University of Washington).
Data Collection
Data collection using the online survey began in late summer 2009. Selected experts were sent an e-mail invitation that explained the purpose of the study and its voluntary nature, time frame for completion, and provided both a link to the survey that was uniquely tied to each respondent’s e-mail address as well as an opt-out link for persons who did not wish to participate. Access to the survey was kept open for 3 weeks after the initial invitation was issued. Respondents received reminder e-mails 1 and 2 weeks after the initial invitation, respectively.
Data collection took place in two waves. For Wave 1, an initial list of 459 potential respondents was compiled. Duplicate entries were removed, and entries with invalid, incomplete, or missing contact information were updated where possible. The final Wave 1 invitee list contained names and contact information for 315 experts in the fields of aging and physical activity. Data collection with this first set of preselected expert panelists occurred between August 3 and 24, 2009. Wave 2 data collection was then conducted with 83 expert panelists who were either nonresponders from Wave 1 (n = 21) or who had been suggested as additional contacts by Wave 1 respondents (n = 62). Wave 2 data collection occurred between August 31 and September 21, 2009.
Data Analyses
The quantitative data were analyzed using simple descriptive techniques available in SPSS. Text analysis and coding of open-ended survey responses were performed independently by three members of the research team. The team members then conferred with each other to share commonalities and to reconcile differences in their coding. Based on these discussions, five broad thematic areas were identified in the data.
Results
Response Rates
As shown in Figure 1, 315 invitations were issued for Wave 1 data collection, of which 305 reached their intended recipients. Of those, 29 sent a return e-mail indicating that they deemed themselves unqualified to provide expert feedback in the field of aging or physical activity. Of the 276 appropriate invitations, 101 partially or fully completed the survey, 12 declined participation via the opt-out link, and 163 did not respond.
Figure 1.
Flow Diagram
For Wave 2 data collection, an additional 83 invitations were e-mailed. Of those, 76 reached their intended recipients, 4 of whom were inappropriate respondents. Of the 72 appropriately made invitations, 30 respondents partially or fully completed the survey. Therefore, the combined Wave 1 and Wave 2 response rate was 38%; responses were received from 131 of the 348 appropriate respondents in the sample.
Data comparing characteristics of responders with nonresponders (Table 1) demonstrate very little difference by respondent type with respect to gender, survey administration wave, or the individual’s institutional affiliation. The majority of persons in both groups were female and affiliated with an academic institution.
Table 1.
Comparison of Responders and Nonresponders
| Variable | Type of participation, n (%) |
|
| Responders | Nonresponders | |
| Gender | ||
| Male | 42 (33.9) | 60 (34.3) |
| Female | 84 (66.1) | 115 (65.7) |
| Wave of administration | ||
| Wave 1 | 101 (77.1) | 159 (80.7) |
| Wave 2 | 30 (22.9) | 38 (19.3) |
| Institutional affiliation | ||
| Academic institution | 86 (75.5) | 119 (73.0) |
| Governmental agency | 16 (14.0) | 15 (9.2) |
| Private, not-for-profit agency | 12 (10.5) | 29 (17.8) |
Quantitative Findings—Content Areas 1 Through 3
Self-assessment of Research Expertise.—
Respondents reported having worked in the physical activity field for an average of 15.6 years (SD = 8.9, median = 13.0). Respondents primarily conducted intervention research (69.5%) and specialized in experimental/quasi-experimental (64.1%) or in observational studies (50.4%; Table 1). Roughly comparable proportions of respondents reported focusing on White, Black, and Latino populations; however, a clear majority (72.8%) had focused their work on relatively healthy study participants, with few respondents reporting prior work with older adults with mental illnesses (5.3%; Table 2).
Table 2.
Respondent Self-assessment of Research Expertise
| Areas of research expertise | n (%)a |
| Research topics | |
| Intervention | 91 (69.5) |
| Behavior change motivation | 62 (47.3) |
| Translation | 35 (26.7) |
| Environment | 34 (26.0) |
| Effectiveness | 31 (23.7) |
| Efficacy | 30 (22.9) |
| Other | 27 (20.6) |
| Policy | 21 (16.0) |
| Recruitment and retention | 19 (14.5) |
| Marketing | 11 (8.4) |
| Cost-effectiveness | 7 (5.3) |
| Research methods | |
| Experimental/quasi-experimental studies | 84 (64.1) |
| Observational studies | 64 (50.4) |
| Measurement | 35 (26.7) |
| Outcomes/health services research | 27 (20.6) |
| Qualitative studies | 25 (19.1) |
| Meta-analyses | 14 (10.7) |
| Research populations | |
| By race/ethnicity | |
| White | 34 (29.8) |
| Black/African American | 28 (24.6) |
| Latino/Hispanic | 26 (22.8) |
| Asian | 11 (9.6) |
| By health status | |
| Healthy | 83 (72.8) |
| Specific health problems | 48 (42.1) |
| Disabilities and/or functional limitations | 32 (28.1) |
| Frail | 20 (17.5) |
| Mental health problems | 6 (5.3) |
| By socioeconomic status | |
| Low income | 29 (25.4) |
Percents do not sum to 100; respondents could select more than one response.
Strength Rating of Research Evidence.—
When asked to rate the body of available evidence supporting the known health benefits of specific types of physical activity, a large proportion of respondents rated the evidence for aerobic exercise and walking programs as strong, 81.7% and 73.3%, respectively (Table 3). Almost one half of the respondents rated the evidence for the benefits of anaerobic/resistance exercise as strong (49%), followed by 27.2% for balance, and 15.5% for flexibility.
Table 3.
Body of Research Evidence Supporting the Known Health Benefits, by Program Type
| Strength of evidence |
||||
| Known health benefits | n (%) | Dose–response relationship | n (%) | |
| Type of program | Strong evidence | |||
| Aerobic exercise | 85 (81.7) | Aerobic exercise | 34 (32.7) | |
| Walking | 77 (73.3) | Walking | 31 (29.8) | |
| Anaerobic/resistance exercise | 51 (49.0) | Anaerobic/resistance exercise | 15 (14.6) | |
| Balance exercise | 28 (27.2) | Balance exercise | 7 (6.8) | |
| Multicomponent exercise programs | 20 (19.2) | Multicomponent exercise programs | 6 (5.8) | |
| Flexibility exercise | 16 (15.5) | Behavior change programs | 6 (5.9) | |
| Behavior change programs | 16 (15.4) | Flexibility exercise | 5 (4.9) | |
| Moderate evidence | ||||
| Behavior change programs | 56 (53.8) | Walking | 45 (43.3) | |
| Balance exercise | 52 (50.5) | Aerobic exercise | 40 (38.5) | |
| Multicomponent exercise programs | 48 (46.2) | Anaerobic/resistance exercise | 32 (31.1) | |
| Flexibility exercise | 44 (42.7) | Balance exercise | 29 (28.2) | |
| Anaerobic/resistance exercise | 42 (40.4) | Flexibility exercise | 21 (20.4) | |
| Walking | 25 (23.8) | Multicomponent exercise programs | 21 (20.4) | |
| Aerobic exercise | 16 (15.4) | Behavior change programs | 20 (19.6) | |
| Low evidence | ||||
| Flexibility exercise | 37 (35.9) | Behavior change programs | 52 (51.0) | |
| Multicomponent exercise programs | 26 (25.0) | Flexibility exercise | 49 (47.6) | |
| Behavior change programs | 17 (16.3) | Multicomponent exercise programs | 49 (47.6) | |
| Balance exercise | 16 (15.5) | Anaerobic resistance exercise | 47 (45.6) | |
| Anaerobic/resistance exercise | 9 (8.7) | Balance exercise | 43 (41.7) | |
| Aerobic exercise | 2 (1.9) | Aerobic exercise | 26 (25.0) | |
| Walking | 2 (1.9) | Walking | 26 (25.0) | |
The body of evidence supporting the dose–response relationship for each type of physical activity was rated to be considerably weaker (Table 3). For instance, only 32.7% of respondents agreed that the dose–response evidence for aerobic exercise was strong. Ratings on dose–response for all other forms of physical activity received even weaker evidence ratings, ranging from 29.8% (walking) to 4.9% (flexibility). Notably, the types of activity for which the dose–response was judged to be the least well understood included flexibility, balance, multicomponent programs, and behavior change programs.
Priority Ranking of Research Evidence.—
Respondents were also asked about the need to conduct more research on the topics of efficacy and effectiveness (e.g., recruitment and retention, cost-effectiveness, and outcomes), translation and diffusion (e.g., reach, adoption, implementation, and maintenance), supply and demand, and environmental issues (Table 4). For efficacy and effectiveness, a majority of respondents assigned a rating of high or very high importance to each of the subtopics with the exception of best methods for effective recruitment. Percentages ranged from 82.9% for research on the impact of physical activity on cognitive health outcomes to 65.1% for effects on physical health outcomes. The need for effectiveness research on the impact of physical activity interventions that use a multiple risk factor approach and the need to assess the comparative cost-effectiveness of specific programs were also ranked by substantial proportions of respondents as being high or very high (77.2% and 74.8%, respectively).
Table 4.
Priority Rankings of Topics Requiring Further Research
| Research topic | Very high/high, n (%) |
| A. Efficacy and effectiveness | |
| PA impact on cognitive health outcomes | 87 (82.9) |
| Impact of PA interventions that use a multiple risk factor approach | 78 (77.2) |
| Comparative cost-effectiveness of specific programs | 77 (74.8) |
| PA impact on mental health outcomes | 74 (71.2) |
| Best methods for effective retention | 68 (64.8) |
| PA impact on physical health outcomes | 69 (65.1) |
| Best methods for effective recruitment | 46 (43.8) |
| B. Translation and diffusion | |
| Elements needed to sustain engagement of older adults in EB PA programs | 82 (84.3) |
| Adapting EB PA programs for populations with different needs | 68 (70.1) |
| Facilitators of EB program adoption at organizational level | 66 (68.0) |
| Extent to which program components are maintained | 60 (64.5) |
| Identifying and engaging stakeholders for program maintenance | 85 (60.4) |
| Role of formal partnership/collaboration on EB programs | 57 (58.8) |
| Identifying critical components of EB PA programs for adopters | 56 (58.3) |
| Type/level of monitoring needed to maintain fidelity | 56 (57.7) |
| Enrolling representative populations of older adults in EB programs | 54 (55.7) |
| Enrolling large numbers of older adults in EB programs | 52 (53.6) |
| Type/level of training needed to implement specific EB PA programs | 47 (48.5) |
| Impact of multiple vs. single delivery channels | 42 (44.7) |
| C. Supply and demand | |
| Correspondence between demand and programs offered | 35 (38.9) |
| Adequacy of number of PA program supply | 20 (21.1) |
| D. Environmental issues | |
| Impact of policies to promote PA | 73 (76.8) |
| Impact of physical/built environment on PA | 68 (71.6) |
Note: EB = evidence-based; PA = physical activity.
Responses regarding specific components of translation and diffusion research were more varied. The topics that were rated high by the greatest number of respondents concerned research on elements needed to sustain the engagement of older adults in EBPs (84.3%), research on adapting EBPs for populations with different needs (70.1%), and the identification of facilitators of program adoption at the organizational level (68%). In contrast, research on the type/level of training needed to implement specific EBPs (48.5%) and the impact of multiple versus single delivery channels was ranked lower (44.7%).
Neither item listed under the topic of supply and demand was ranked as high or very high by a majority of respondents. In contrast, both topics listed under environmental issues were ranked highly indicating that the majority of respondents believed that the level of importance of further research on the impact of policies to promote physical activity (76.8%) and the impact of the physical/built environment on physical activity (71.6%) was very high or high.
Types of Understudied Populations.—
Respondents were asked if they considered specific populations to be understudied in terms of physical activity and aging research. A substantial majority of respondents agreed that understudied populations included those of low socioeconomic status (85.9%) and ethnic/racial minorities (79.8%), followed by persons with physical disabilities (73.4%), persons with intellectual disabilities (68.4%), and persons with mental illness (67.4%). Importantly, more than two thirds of respondents agreed that each of these groups was understudied, indicating substantial agreement across respondents about the need for further research on the impact of physical activity for all of these special populations.
Importance of Additional Translation and Diffusion Research.—
Finally, respondents were asked to rate the importance of research focusing on specific components of translation and diffusion based on the RE-AIM model (Glasgow, Vogt, & Boles, 1999) as they applied to specific understudied populations (see Table 5). Although the majority of respondents identified all issues as requiring additional research for all populations listed (proportions ranging from 96.3% to 67.1%), the need for more research with respect to maintenance, closely followed by implementation and engagement/recruitment, was clearly seen across all target populations. Interestingly, the smallest proportion of respondents agreed that it was important to conduct more efficacy research with people of low socioeconomic status or racial and ethnic minorities compared with other populations listed.
Table 5.
Importance of Additional Translation and Diffusion Research by RE-AIM Dimension and by Target Population
| Dimension, by target population | n (%) |
| A. People of low socioeconomic status | |
| Maintenance | 79 (96.3) |
| Engagement and recruitment | 79 (95.2) |
| Implementation | 75 (92.6) |
| Effectiveness | 68 (82.9) |
| Efficacy | 55 (67.1) |
| B. Racial/ethnic minorities | |
| Maintenance | 74 (97.4) |
| Implementation | 76 (96.1) |
| Effectiveness | 70 (93.9) |
| Engagement and recruitment | 70 (92.1) |
| Efficacy | 58 (77.3) |
| C. People with physical disabilities | |
| Maintenance | 65 (94.3) |
| Engagement and recruitment | 66 (93.0) |
| Implementation | 65 (91.5) |
| Effectiveness | 63 (88.7) |
| Efficacy | 61 (85.1) |
| D. People with intellectual disabilities | |
| Implementation | 62 (93.9) |
| Maintenance | 62 (93.9) |
| Effectiveness | 59 (89.4) |
| Engagement and recruitment | 59 (89.4) |
| Efficacy | 56 (84.8) |
| E. People with mental illness | |
| Maintenance | 59 (95.2) |
| Implementation | 55 (88.7) |
| Effectiveness | 55 (87.3) |
| Efficacy | 54 (85.7) |
| Engagement and recruitment | 54 (85.7) |
Note: RE-AIM = reach, effectiveness, adoption, implementation, and maintenance.
Qualitative Findings
Five broad thematic areas requiring further research were identified from the open-ended survey responses and are presented subsequently along with illustrative quotes from respondents.
Theme 1: Dose–Response.—
The experts identified a need for more studies on the following: (a) the varying levels of dose–response across diverse populations, medical conditions, and risk factors; (b) establishing minimum and maximum thresholds for activity; and (c) measuring low-intensity physical activity.
“We know people need to move more to remain healthy and independent. What is not clear is how, how often, how hard, and how much”
“If we can get positive outcomes from smaller amounts of exercise, it may be easier to get more people active.”
“An issue that needs further study is the effect of different intensities of physical activity on body composition and other health markers, for a given total energy expenditure. For example, assuming that the energy expenditure related to 60 minutes of slow walking is equal to 20 minutes of fast walking, which of these activities will have more health benefits?”
Theme 2: Adoption, Implementation, and Sustainability of Physical Activity Programs.—
Issues related to the adoption, implementation, and sustainability of physical activity programs in older adults was a key theme identified by the respondents. In particular, there is a need to conduct more research on how to make physical activity programs more effective with respect to outcomes and cost. In addition, more studies should focus on diverse subpopulations.
“How does one design effective programs, policies, and environmental changes to promote physical activity in diverse populations in a wide variety of settings, and assure fidelity to those elements that made it effective in the first place?”
“It is important to learn and then translate what works and does not work for each group. A one size fits all approach certainly does not.”
Theme 3: Reach and Maintenance.—
With respect to reach and maintenance, the experts felt that more research was needed in the areas of social support, barriers and facilitators of adherence, and messaging and marketing strategies.
“Only 10–30% of participants in community-based programs are men— where are they? What do they prefer? How can we reach them?”
“If the message isn’t getting out, who will do it?”
“Getting people to sustain behavior is still the biggest challenge.”
“Once a person does have the opportunity and the desire to become more active, what are the resources available to make this happen?”
Theme 4: Physical Environment.—
Another key topic area that emerged from the survey was the need for more research related to the physical environment. The experts felt that more research was needed in the areas of safety and design, transportation to and from physical activity programs, access to programs, and alternative environments such as in-home or self-directed programs.
“Are environments that support active living in adults the same for older adults?”
“How does the physical environment of your average health and wellness facility need to be adjusted to meet the needs of an aging population?”
Theme 5: Policy.—
There was consensus that further research was needed to evaluate the impact of changes in fiscal, environmental, and health policies on physical activity promotion. Specifically, understudied areas included systems change strategies; creative reimbursement options; architectural, safety, and accessibility policies; and the role of physical activity providers in dissemination.
“Policy research is a neglected research priority but essential for high-impact high-reach to promote physical activity.”
“ … policies that apply to the infrastructure (e.g., street connectivity), pricing of facilities (e.g., discounts for seniors), the availability of a variety of low impact (e.g., senior friendly classes) in addition to high impact classes … ”
“This area may have the most potential to directly influence physical activity in older adults, as integrating physical activity into benefits received in older adulthood may well be the best motivating factor we have (particularly at this time, and the current economy).”
Discussion
To our knowledge, this study is the first to use expert opinion to examine the state of the science of physical activity research with older adult populations, with a particular emphasis on the growing field of translational research. Our literature search of expert surveys on physical activity found that a single prior national expert survey was conducted in Germany in 2008 with a relatively small number of expert respondents (Rutten, Abu-Omar, Gelius, & Freiberger, 2008). However, the German survey did not explicitly examine the status of translation research in this field. Responses obtained from 131 experts in the field of physical activity and aging found a substantial degree of consensus regarding areas that are well understood as well as those that need considerably more research effort. Experts agreed that the research evidence documenting the health benefits of specific types of physical activity was strong with the notable exception of flexibility. In contrast, the evidence supporting the activity dose required to affect specific health outcomes was considerably weaker, especially with respect to flexibility, balance, and multiple component programs. The lack of evidence related to dose–response relationships was noted in both our quantitative and qualitative results. Understanding dose–response relationships regarding physical activity is important because it will help us to justify and refine physical activity guidelines for older adults in the future. Prior literature, for example, suggests that moderate levels of physical activity may suffice to provide protection for certain chronic diseases (DiPietro, 2001). As we learn more about the precise amounts of physical activity needed for specific benefits, we can adapt current eEBPs and National Guidelines to reflect these new standards.
With respect to the need for more research on efficacy and effectiveness, the need for more research on cognitive health outcomes received high marks, as did studies testing multiple risk factor interventions. This finding from the expert survey is consistent with a recent systematic literature review by Snowden and colleagues, which found limited experimental evidence that physical activity or exercise improved cognition in community-dwelling older adults. Recommendations were made in that review to strengthen the methodology of future studies to fully understand the impact of exercise on cognitive outcomes (Snowden et al., 2011). With respect to translation and diffusion, the need for more research on successful methods to sustain participants in EBPs was rated highly along with methods of adapting EBPs for populations with special needs.
The paper by Prohaska and colleagues (2005) concluded that more physical activity research was needed with older ethnic/racial minority participants on translational research and on environmental and policy barriers to and facilitators of physical activity. Interestingly, expert respondents to our survey rated the need for new research on the impact of policies to promote physical activity and the impact of the built environment as high or very high in priority, consistent with prior articles in the literature calling for the merging of interventions undertaken at the person or interpersonal level with environmental and policy strategies (King, 2001). Moreover, we found near-universal agreement that special populations have been understudied to date with high proportions of experts agreeing that more work needed to be done with persons of low socioeconomic status and racial/ethnic minorities. Clearly, not enough progress has been made in these areas, and our study highlights the urgent need for continued research in these areas.
While more investigators are becoming familiar with the elements of translational research and with the RE-AIM model, our findings indicate consensus regarding specific components of the model in need of targeted research. More than 90% of experts agreed that, across understudied populations, more research was needed on maintenance followed by implementation and engagement and recruitment. Across the RE-AIM components, the need for research on maintenance, implementation, and reach (engagement/recruitment) was more highly ranked than research on efficacy and effectiveness.
Despite this study’s strengths, it also suffered from certain limitations. The study achieved a response rate of 38%, which is lower than the average response rate of 48% cited in a review of web-based surveys (Archer, 2007). This response rate is lower than would be expected despite the fact that the survey was conducted with an “educated population with access to computers” (Greenlaw & Brown-Welty, 2009). Also, because we used this methodology, we have limited information about individuals who did not respond and how their lack of response affects the interpretation of the study findings. A possible explanation for the response rate is the time of the year (summer and early fall when many respondents may have been traveling or preparing for fall teaching) that the survey was administered. However, our comparison of respondents with nonrespondents found no significant differences by group with respect to gender, wave of administration, or institutional affiliation. Furthermore, among individuals who responded, the mean number of years of experience in the field was 15.6, indicating that they were well versed in the survey topic and were well qualified to be described as experts and to answer the survey questions knowledgeably.
Our survey also found that experts felt that considerable work had been achieved documenting the benefits of physical activity and clearly highlights the need for more research on the dose of specific types of activities that is required to achieve a health benefit. We also call attention to the need for targeted research on the effects of physical activity on low-income, ethnic/racial minority, and special populations and have identified specific topics that require more research within components of translation and diffusion research. The 2008 National Physical Activity Guidelines established the amount and types of physical activity that older adults need to perform to obtain and maintain health benefits. The accomplishment of the research agenda outlined by this paper can substantially advance the validity of these guidelines and/or the need for their revision based on empirical evidence. The accomplishment of the agenda should also increase the ability of all older adult populations, including those of minority or low socioeconomic status, in the United States to adhere to future guidelines, with very important implications for their improved health and functioning.
Funding
CDC-HAN is a Prevention Research Centers Program funded by the CDC Healthy Aging Program. Efforts were supported in part by cooperative agreements from CDC's Prevention Research Centers Program: U48-DP-001911, 001908, 01921, 001924, 001936, 001938, and 001944.
Acknowledgments
CDC-HAN Statement—This publication is the result of research conducted by the CDC-HAN. The contents of this document are solely the responsibility of the authors and do not necessarily represent the official views of the CDC.
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