Study design
This pilot implementation study involved a pre-post experimental research design. The 20-week study took place in August 2017 and was based on the ecofit efficacy trial, protocol published elsewhere (8). The ecofit program was adapted and implemented by health officers employed by the Upper Hunter Shire Council, New South Wales (NSW), Australia. The Upper Hunter Shire Council is a local government area which consists of four rural communities with an estimated population of 10,507 of which, 4,698 (44.7%) are 45-years of age or older (9). Assessments were conducted at baseline, 6-weeks and 20-weeks post-baseline.
Participants
Participants were recruited by the Upper Hunter Shire Council using a variety of strategies (e.g., local radio stations, flyers, newspaper advertisements and local seniors’ clubs). Inclusion criteria included: (i) ≥45 years of age, and (ii) not meeting current physical activity guidelines. Participants were excluded if they had a medical condition that might preclude participation in physical activity. All participants provided written informed consent prior to enrollment.
Intervention components
The face-to-face sessions were adopted from the ecofit efficacy trial (8) and were composed of two parts; cognitive mentoring (30-minutes) followed by an outdoor exercise session (60-minutes). The cognitive mentoring sessions were developed to provide participants with skills and strategies to overcome barriers, increase motivation and set goals. The supervised outdoor training sessions were developed to provide participants with the confidence, skills and knowledge to perform aerobic and resistance activities using the outdoor built environment (e.g., stairs, railings, benches). Sessions were composed of approximately 50% aerobic and 50% resistance training with a moderate-to-vigorous intensity equal to (or greater) than three metabolic equivalents. The aerobic workout included approximately three kilometers of moderate-to-vigorous intensity aerobic activity (i.e., walking or jogging) and the resistance workout included six exercises (i.e., abdominal strengthening, external rotations, knee lifts, pulls-ups, push-ups, and squats). Participants were also provided with the ecofit smartphone app for the duration of the study. The app had been adapted from the ecofit efficacy trial (8) and included tailored workouts designed specifically for four locations in the Upper Hunter Shire, a rural area of NSW.
Intervention overview
The intervention consisted of two phases; Phase 1 (1-6 weeks) and Phase 2 (7-20 weeks). During Phase 1, participants attended the face-to-face session once per week. Phase 2 consisted of three parts. In the first part (weeks 7-10) participants received no face-to-face sessions but were encouraged to meet with other participants to continue their workouts. Participants were then provided with weekly face-to-face sessions for a further 4-weeks (weeks 11-14), this was followed by six weeks of no sessions (weeks 15-20). For the duration of the project, participants had access to the purpose-built ecofit smartphone application.
A training day was held at the University of Newcastle for the two Council representatives (qualified health professionals) who would conduct the assessments and deliver the intervention. During an eight-hour workshop, the Council representatives were trained by the original ecofit research team on how to deliver the program. The content of the program was adopted from the original study (7, 8). This training included instructions and guidance on how to conduct the face-to-face components (i.e., the outdoor exercise and cognitive mentoring sessions) and protocols for data collection and participant outcomes. Some of the materials (i.e., face-to-face session and in the app) were adopted to reflect this older population. For example, a greater focus was provided on physical activity barriers such as joint pain, balance issues, and lack of company as opposed to a of lack of time or work fatigue. The Council representatives were also provided a training manual which included written material and slides for the face-to-face session and a standardized assessment manual for data collection.
Outcomes
Assessments were conducted at baseline, 6-weeks (primary time-point) and at 20-weeks (follow-up). Baseline assessments were conducted prior to commencing in the ecofit implementation program. Participants were measured using most (but not all) measures from the ecofit efficacy trial (8). In addition, the present study used the 6-Minute Walk Test (10) instead of the Single Stage Treadmill Walking test to measure aerobic fitness (11). All assessments were administered by the trained Upper Hunter Shire Council representatives. Upon completion of assessments, data log sheets were returned to the researchers at the University of Newcastle for analysis.
Health-related outcomes
Aerobic fitness. Aerobic fitness was measured using the 6-Minute Walk Test (12). The 6-Minute Walk Test has been extensively used in both clinical and research contexts to measure cardiorespiratory fitness (10). In preparations for the test, a 30-meter straight track was set up by the assessors. During the test, participants were instructed to complete as many laps (one lap constituted walking back and forth along the track) as possible for six minutes.
Functional mobility. Functional mobility was assessed using the Timed Up and Go Test (13). The Timed Up and Go Test assess an individual’s mobility, and static and dynamic balance. During the test, participants starts from a seated position, and on command stands up from the chair and walks to a point three meters from the chair. Once the participant has reached the three-meter mark, they turn around and walk back to the chair and sits down. Timing starts when participants stand up from the chair and ends when they return to the chair.
Upper body muscular fitness. Upper body muscular fitness was assessed with the Arm Curl Test (14). During the Arm Curl Test, participants were instructed to while seated perform as many arm curls as possible in 30 seconds.
Lower body muscular fitness. Lower body muscular fitness was assessed using the chair stand test (14). The testing procedures includes participants starting from a seated position on a chair and standing up and sitting down (one repetition) as many times as possible within 30 seconds. The participant’s score is the number of repetitions completed within 30 seconds (15).
Blood pressure. Systolic and diastolic blood pressure were measured using a standard digital automatic blood pressure monitor.
Waist circumference. Waist circumference was measured between the top of the iliac crest and the lowest floating rib using a non-extensile steal tape. Measures were recorded to the nearest 0.1 centimeter.
Retention
Retention rates were calculated by the number of participants completing the assessments at each assessment time-point (6-weeks and 20-weeks) compared to baseline.
Program satisfaction
A process evaluation survey was provided to all participants who attended their final follow-up assessment. The survey was divided up in two parts (i.e., Part 1 and Part 2). Part 1 included close-ended questions regarding the cognitive mentoring sessions, outdoor personal training sessions, outdoor fixed fitness equipment and the smartphone app. Response options for all close-ended questions ranged from 1 (strongly disagree) to 5 (strongly agree), or 1 (poor) to 5 (excellent). In Part 2 of the survey, participants were asked to comment (i.e., likes and dislikes) on each of the abovementioned components.
Statistical methods
Statistical analysis of the study outcomes was conducted using IBM SPSS Statistics, Version 22.0. Results are reported as means (M) and standard deviations (SD). Effect sizes were calculated for all health-related outcomes at 6-weeks and 20-weeks using Cohen’s d. Two paired-sample t-tests were conducted to compare health-related outcomes between baseline and 6-weeks, and between baseline and 20-weeks. Descriptive statistics were used to summarize participants’ demographics.