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  See discussions, stats, and author profiles for this publication at: Participation levels of physical activity programs for community-dwellingolder adults: A systematic review  Article   in  BMC Public Health · December 2014 DOI: 10.1186/1471-2458-14-1301 · Source: PubMed CITATIONS 6 READS 1,031 4 authors , including: Some of the authors of this publication are also working on these related projects: Reducing stress and smoking among lower income groups in Rotterdam (in The Netherlands)   View projectMINDMAP - Promoting mental well-being and healthy ageing in cities   View projectAstrid Schop-EtmanErasmus University Rotterdam 14   PUBLICATIONS   205   CITATIONS   SEE PROFILE Carlijn KamphuisUtrecht University 86   PUBLICATIONS   1,886   CITATIONS   SEE PROFILE Frank van LentheErasmus MC 284   PUBLICATIONS   10,940   CITATIONS   SEE PROFILE All content following this page was uploaded by Astrid Schop-Etman on 07 January 2015. The user has requested enhancement of the downloaded file.  RESEARCH ARTICLE Open Access Participation levels of physical activity programsfor community-dwelling older adults: a systematicreview Marielle van der Deijl, Astrid Etman * , Carlijn B M Kamphuis and Frank J van Lenthe Abstract Background:  Although many physical activity (PA) programs have been implemented and tested for effectiveness,high participation levels are needed in order to achieve public health impact. This study aimed to determineparticipation levels of PA programs aimed to improve PA among community-dwelling older adults. Methods:  We searched five databases up until March 2013 (PubMed, PubMed publisher, Cochrane Library, EMBASE,and Web of Science) to identify English-written studies investigating the effect of PA programs on at least onecomponent of PA (e.g. frequency, duration) among community-dwelling populations (i.e. not in a primary caresetting and/or assisted living or nursing home) of persons aged 55 years and older. Proportions of participantsstarting and completing the PA programs (initial and sustained participation, respectively) were determined. Results:  The search strategy yielded 11,994 records of which 16 studies were included reporting on 17 PAprograms. The number of participants enrolled in the PA programs ranged between 24 and 582 persons. For 12PA programs it was not possible to calculate initial participation because the number of older adults invited toparticipate was unknown due to convenience sampling. Of the five remaining programs, mean initial participationlevel was 9.2% (±5.7%). Mean sustained participation level of all 17 programs was 79.8% (±13.2%). Conclusions:  Understanding how to optimize initial participation of older adults in PA programs deserves moreattention in order to improve the population impact of PA programs for community-dwelling older adults. Keywords:  Elderly, Participation level, Exercise, Intervention Background The worldwide population is ageing rapidly. Between2000 and 2050, the world ’ s population over 60 years willdouble from about 11% to 22% [1], and healthcare costswill rise substantially [2]. Participating in regular phys-ical activity (PA) is important for older adults, since ithas positive effects on muscle strength, flexibility, bal-ance, falls risk, and occurrence of chronic diseases [3],and may prevent or delay loss of independent living[4]. Preventive measures aimed at increasing PA levelsshould focus on those aged 55 years and older since they have been found to be at increased risk of adverse out-comes such as frailty and disability [5,6]. High initial and sustained participation in PA pro-grams is important for achieving public health impact[7]. However, although many PA programs have beenimplemented and tested for effectiveness [8], strikingly little is known about the participation levels of theseprograms [9,10]. For example, low-intensity programs with a small effect and high participation rates may havea higher overall impact as compared to high-intensity programs with large effects and low participation rates[11-13]. As such, the identification of PA programs with high levels of participation is important for the develop-ment of future PA programs. Therefore, a systematic re- view was conducted to determine participation levels of PA programs aimed to improve PA among community-dwelling older adults aged 55 years and older. Further-more, it was investigated what program characteristicsand characteristics of participants distinct PA programs * Correspondence: a.etman@erasmusmc.nlDepartment of Public Health Erasmus MC, P.O. Box 2040, 3000, CA,Rotterdam, Netherlands © 2014 van der Deijl et al.; licensee BioMed Central. This is an Open Access article distributed under the terms of the CreativeCommons Attribution License (, which permits unrestricted use, distribution, andreproduction in any medium, provided the srcinal work is properly credited. The Creative Commons Public DomainDedication waiver ( ) applies to the data made available in this article,unless otherwise stated. van der Deijl  et al. BMC Public Health  2014,  14 :1301  with higher participation levels from PA programs withlower participation levels. Methods Search strategy Specified search strategies were developed for five biblio-graphic databases up until March 2013: PubMed, PubMedpublisher, Cochrane Library, EMBASE, and Web of Sci-ence. The full electronic search strategy for Pubmed was:((aged NOT (boy* OR girl* OR child*OR month* ORmiddle)) OR elder* OR senior* OR (old* AND (adult*OR people*))) AND (((communit* OR home) AND (liv-ing OR dwell* OR residen* OR based OR population*))OR (residential* NOT (care OR home OR facilit*)) ORin home OR at home OR domestic*))) AND (exerci* ORsports OR physical OR activity OR activities OR walkingOR swimming OR cycling OR strength OR enduranceOR power OR pedometer OR accelerometer) AND(program* OR intervention* OR experiment* OR (groupAND lesson*) OR government*) AND (effectiv* ORevaluat* OR outcome* OR benefit*)The search strategies for the other databases can befound in the Additional file 1. Study selection Studies were included when they were: 1) written inEnglish; 2) conducted among community-dwelling popu-lations (i.e. not in a primary care setting and/or assistedliving or nursing home); 3) among persons aged 55 yearsand older; 4) described programs targeting at least onecomponent of PA (e.g. walking group, exercise class);and 5) evaluating the effect of at least one component of PA (e.g. frequency, duration). Studies were excludedwhen these: exclusively targeted older adults with a spe-cific medical condition (e.g. dementia, depression), fo-cused on cost-effectiveness; and/or reported on study protocols only.One reviewer (MvdD) performed the initial selectionof titles and abstracts in the literature search. A secondreviewer (AE) was consulted to screen a random sub-set,and in case of doubt to discuss until agreement wasreached. All corresponding authors of included studieswere contacted and reference lists of previously pub-lished systematic reviews were checked to make sure allrelevant articles were captured. This extra search did notresult in extra studies eligible for inclusion. Data extraction A data extraction form was used to collect informationon participation levels (dependent variable) and charac-teristics of participants and program characteristics(independent variables). Characteristics of participantsincluded sex distribution (% females) and mean age of the participants. The program characteristics included:sampling method (probability sampling vs. convenience);method of recruitment; location (home-based vs. group-based); content (e.g. walking group); duration (months);number of contacts; supervision (yes vs. no); and (max-imal) group size. Probability sampling is a method of sampling that utilizes some form of random selection,whereas convenience sampling is a technique where sub- jects are selected because of their convenient accessibil-ity and proximity to the researcher (e.g. inviting throughadvertisements). One reviewer (MvdD) performed thedata extraction and a second reviewer (AE) verified allextracted data. In case of doubt, data were discusseduntil agreement was reached. Participation levels In order to calculate participation levels the followingmeasures were used, numbers of persons that: 1) wereinvited to participate (i.e. available sample); 2) startedthe PA program; and 3) completed the PA program. By using these measures initial and sustained participationlevels were calculated. Initial participation was definedas the number of participants that enrolled in the pro-gram divided by the number of persons invited to par-ticipate. Sustained participation was defined as thenumber of participants who completed the program di- vided by the number of participants that started the pro-gram [7]. Risk of bias Studies reporting significant effects of PA programs onPA outcomes are more likely to be published as com-pared to studies in which no significant results werefound. However, it is unlikely that this publication biaswould affect our results since we focused on participa-tion level as the main outcome, and no differences inparticipation level are to be expected between effectiveand non-effective PA programs. Statistical analysis Descriptive statistics (e.g. means, standard deviations,ranges) were used to summarize the results. Mean sus-tained participation level was calculated for all PA pro-grams as well as for  effective  PA programs only. An effective  PA program was defined as a program for whicha significant effect on at least one PA outcome was re-ported. Pearson correlations were calculated in order toinvestigate the correlation between participation levelsand: gender distribution of the participants; mean age of the participants; program duration; and group size. Results Literature search The search strategy yielded 11,994 records. After removingduplicates, 6,759 records remained which were screened van der Deijl  et al. BMC Public Health  2014,  14 :1301 Page 2 of 8  based on title and abstract. Sixteen studies reporting on 17PA programs, were included which were published between2002 and 2013 since no studies prior to this time met theinclusion criteria (Figure 1). Characteristics of participants and programs The mean age of the participants ranged between 66 to84 years (overall mean 73.8±6.6 years). In three programsonly females participated [14-16]. Of the remaining 14 PA programs, on average 70.2% (±13.3%) of the participantswere females (range 47-89%).Program characteristics that showed the most vari-ation were the location at which the program took placeand the content of the program. Six programs werehome-based [14,15,17-20], five programs were group- based [16,21-24], and six were both home- and group- based [25-29]. Three programs involved group-walking [14,16,18], seven programs involved multifaceted activ- ities such as a combination of education and a trainingprogram [15,17,20,22,25,27], and seven programs involved  various PA such as a pedometer intervention or differentexercise programs [19,21,23,24,26,28,29] (Table 1). PA out- comes that were evaluated were: general PA level (n=9);walking (n=6); and household and sports activities (n=1). Initial and sustained participation The number of participants enrolled in the PA programsranged between 24 and 582, with a mean of 174 (±165).It was not possible to calculate initial participation levelsfor 12 PA programs, because their applied samplingmethods (e.g. convenience sampling) made it unclearhow many older adults were invited to participate. Themean initial participation level of the five remaining PAprograms was 9.2% (±5.7%), with a range between 1%[27] and 16% [17]. It was not possible to calculate corre- lations of characteristics of participants and programswith initial participation levels because of the low num-ber of studies reporting initial participation levels. PRISMA 2009 Flow Diagram Records identified throughdatabase searching(n = 11,994)       S     c     r     e     e     n      i     n     g      I     n     c      l     u      d     e      d       E      l      i     g      i      b      i      l      i      t     y       I      d     e     n      t      i      f      i     c     a      t      i     o     n Additional records identifiedthrough other sources(n = 0)Records after duplicates removed(n = 6,759)Records screened(n = 6,759)Records excluded(n = 6,730)for eligibility(n = 29)Fulltext articles assessed Fulltext articles excluded,with reasons(n = 13)Studies included inqualitative synthesis(n = 16)Studies included inquantitative synthesis(metaanalysis)(n = 0) Figure 1  PRISMA 2009 Flow Diagram. van der Deijl  et al. BMC Public Health  2014,  14 :1301 Page 3 of 8
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