Evaluation and enhancement of the Walk with Ease program to support older adult physical activity

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Lamoureux, Nicholas
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Welk, Greg
Phillips, Alison
Meyer, Jacob
Franke, Warren
Margrett, Jennifer
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The growth of the older adult population segment creates a need for evidence-based lifestyle programs to support healthy aging. With strong links to both chronic disease prevention and the promotion of independence and quality of life, physical activity is a key public health strategy for supporting older adults. Effective community-based programs are an important opportunity to promote physical activity due to the ability to be disseminated on statewide or national levels. One potentially advantageous program is Walk with Ease, an evidence-based program for the self-management of arthritis pain and symptoms that emphasizes the value of regular, self-paced walking, which may also be beneficial for a number of other outcomes relevant to the promotion of healthy aging. The simple nature of the program has led to the implementation of both group and self-directed formats in a variety of community and worksite applications. However, this increased interest in the program creates a need to better understand how and why the program works so that it can be tailored to better fit the delivery context, and how it can be enhanced to improve participant outcomes. Therefore, the purpose of this dissertation was to utilize implementation science methods to evaluate the feasibility and utility of enhancements designed to improve the Walk with Ease program. The research emphasized the use of hybrid effectiveness-implementation designs to enable simultaneous evaluation of participant outcomes as well as the delivery of the enhancements. This research approachprovides a better understanding of the factors that influence outcomes and is encouraged to accelerate the dissemination process. Well-designed feasibility studies also allow for iterative refinement and engagement with community partners, increasing the likelihood of institutionalization into standard practice. Thus, the series of studies were conducted in partnership with a statewide community-based organization to both evaluate the widespread delivery through a centralized organization, as well as provide insight into the typical “real-world” effects of programming. The feasibility and pilot studies that make up this dissertation are an important step towards widespread dissemination as they validate the resources necessary for clinical trials. The first study examined the effectiveness of the group version of Walk with Ease when implemented in a naturalized community-context. The results showed promise for enhancing physical activity, but minimal changes were observed in physical function and fall risk. However, it was noted that individuals at an elevated risk for falls at baseline consistently had larger positive effects for all function and fall-risk outcomes, suggesting that the program may be particularly beneficial for individuals already at risk for falling. The second study evaluated the feasibility of supplementing the online (self-directed) version of Walk with Ease with personalized health coaching. The results documented that telephonic motivational interviewing was highly acceptable to older adults. Feedback revealed common trends of coaches assisting with setting and accomplishing relevant goals throughout the program, as well as acting as an ongoing source of accountability. At post-program evaluations, participants experienced large beneficial effects to autonomous motivation (i.e., identified, integrated, and intrinsic regulation) which is associated with long-term activity participation, supporting further evaluations focused on behavioral outcomes. The third study was a pilot trial designed to evaluate the effectiveness of enhancements to Walk with Ease when delivered through a centralized statewide hub. At the completion of the program participants in Walk with Ease increased their self-reported weekly walking, however, motivational interviewing provided no additional benefit. Secondary psychological outcomes documented that motivational interviewing led to large increases in autonomous motivation and stronger walking related habits than standard practice, which may be beneficial for long-term activity maintenance. Collectively, this dissertation documents the feasibility of delivering evidence-based programming in partnership with a centralized hub organization and adds to the evidence-base for both the group-based Walk with Ease program and the use of telephonic motivational interviewing to supplement virtual program formats. The use of hybrid effectiveness-implementation research methods provides insights into both the real-world outcomes and generalizable strategies for future implementation of telephonic motivational interviewing. Additional research is needed to further understand the sources of variability among program outcomes, document long-term effects, and improve delivery of self-guided online behavior change content.
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