- Email: [email protected]
Older women and physical activity: Using the telephone to walk
Older Women and Physical Activity: Using the Telephone to Walk Karla L. Jarvis, MPH Robert H. Friedman, MD Timothy Heeren, PhD Paula M. Cullinane, MD Medical Information Systems Unit Section of General Internal Medicine Evans Department of Medicine Boston Medical Center Boston, Massachusetts
egular physical activity has been shown to have beneficial effects on both physical and mental health.i4 The Centers for Disease Control and the American College of Sports Medicine have suggested that adults should accumulate at least 30 minutes of moderate physical activity during the course of most days.* In the elderly population, moderate physical activity, such as walking, is associated with improved health outcomes.*5 Nevertheless, the majority of older people are sedentary. Results from the 1985 National Health Interview Survey show that two-thirds of those ages 65 and over do not exercise regularly.‘j The benefits of physical activity for elderly women include decreased risk of osteoporosis, decreased incidence of depression, and increased functional status.‘~7W’0 Despite these findings, the Behavioral Risk Factor Surveillance System reported that in 1990, 86.7% of women surveyed ages 65 and over were sedentary.i’ Yet, little is known about the determinants of exercise behavior in this population. Interventions to increase physical activity in the elderly include public education campaigns, formal education, and training programs.‘2-‘4 These efforts have been unsuccessful at maintaining the adoption of this behavior.‘2-‘4 Dishman et all3 report that 50% of those who participate in organized exercise programs such as aerobics classes will drop out during the first 3-6 months. An individual’s knowledge, attitude, and demographics are some factors that researchers have found to influence exercise habits.13 Among elderly women, physical and health problems, time constraints, personal issues such as inclement weather, lack of companionship, safety concerns, and lack of motivation interfere with regular exercise.15 Our objective was to use telecommunications technology to underpin an intervention that would be effective, easy to use, convenient, and inexpensive, require little time commitment; and be capable of widespread distribution. Additionally, we sought to personalize the intervention to increase its acceptability and motivate users.
R
24
WOMEN’S
HEALTH
ISSUES
VOL.
7, NO.
1 JANUARY/FEBRUARY
1997
0 1997 by The Jacobs of Women’s Health Published by Elsevier
Institute Science
1049~3867,97,s17,00
PI1 SlO49-3867(96)00050-3
Inc.
METHODS The Intervention The Telephone-Linked Communication (TLC) System is an interactive computer-based telecommunication system that converses with patients in their homes over their telephone to motivate and improve health-related behaviors. TLC “speaks” to users over the telephone using computer-controlled speech generation. Users communicate with TLC by using their telephone touch-tone keypad. TLC functions as a monitor or “counselor” that provides positive feedback to reinforce or change the individual’s health behavior. TLC stores the user’s response in a database. The information provided by the person controls the direction of the conservation. This information is also forwarded to the person’s physician on a report, similar to a laboratory report, in which medical problems are highlighted.* Telephone-Linked Communication for Activity Counseling and Tracking (TLC-ACT) is a TLC application designed to encourage sedentary elders to engage in regular exercise such as walking. The contents of TLC-ACT conversation is based on the Transtheoretical Model of behavior change developed by Prochaska and DiClemente.r6 The Transtheoretical Model combines the individual’s current behavioral status with his or her intention to change such behavior.r6 Marcus et a1.r7 have applied this model to physical activity. The model identifies five stages of change that are common in changing health-related behaviors. Applied to activity, they are precontemplation, contemplation, preparation, action, and maintenance. Precontemplators do not engage in physical activity and do not intend to start. Contemplators do not participate in physical activity but intend to start in the near future. Those in preparation participate in some physical activity but not regularly. Those in the action stage regularly participate in some form of physical activity for at least 6 months. Finally, those in maintenance participate in regular physical activity longer than 6 months. Regular physical activity is defined as exercising five or more times a week for at least 30 minutes.2 TLC-ACT dialogues employ the five stages of change to determine the individual’s current physical activity pattern and her intention to change. During the TLC-ACT conversation, the person’s amount of activity and stage of change is determined by asking her to report the number of walks taken in the past week and the total number of minutes walked. Using this information, subjects are engaged in dialogues specific to their stage. For example, a subject determined to be in contemplation will be informed of the benefits of walking and the risks of inactivity. TLC-ACT will then determine the subject’s interest in starting to walk. If interested, TLC-ACT will negotiate a start date and a goal for walking (frequency and duration of each walk).
Study Design We conducted a randomized clinical trial to assess the effects of TLC-ACT. The study was conducted in a general internal medicine (primary care) practice at a teaching hospital in Boston. Screening requirements specified that the subjects had to be at least 60 years old, English-speaking, with no medical conditions that would prevent them from walking or for which regular walking exercise was contraindicated. A letter of introduction was sent to all those whose physician indicated that they met the screening requirements. Potential participants were contacted by telephone. The study was described to the subject, and eligibility was assessed. In addition to the screening criteria, a person had to be sedentary (defined as participating in less than 60 minutes of physical activity per week,
JARVIS
*A detailed description of the Telephone-Linked communications (TLC) System, including the TLC-ACT dialogue and report layout is available from the National Auxillary Publications Service.
ET AL: TELEPHONE-LINKED
COMMUNICATION
25
with a minimum of 20 minutes of exercise per time and a minimum of three times per week), and also needed to have touch-tone telephone service. The person could be in either contemplation or preparation stage (ie, not precontemplation). An office visit was arranged for those eligible subjects who agreed to participate. Informed consent and a baseline questionnaire were completed at the office visit. Then subjects were randomized to use TLC-ACT, or to a usual medical care control group. Research staff and subjects were blinded to the study assignment until the baseline questionnaire was completed. Subjects randomly assigned to TLC-ACT received a password and training on how to use TLC. TLC-ACT subjects selected a day and time to call the system weekly. If they failed to call on their scheduled day, they received up to three telephone calls to remind them to call TLC. All subjects received printed information on the benefits of walking and how to begin a walking program. At the end of the 3-month study period, each subject returned for an office visit to complete a follow-up questionnaire. If a subject could not come to this visit, a questionnaire was mailed, along with a self-addressed stamped envelope. Those who failed to return the questionnaire within 3 weeks completed it over the telephone with a study staff person. Upon completion of the followup questionnaire, individuals in the control group were invited to use TLCACT.
Study
Instruments
The study instruments included (1) the State of Adoption of Physical Activity instrument, a four-item scale to determine the stage of readiness of a person to engage in regular physical activity,” (2) the subjects’ self-report of numbers of minutes walked on each of the 4 preceding days, and (3) a study-specific baseline sociodemographic and health/quality-of-life questionnaire. These were completed both at baseline and at 3 months. TLC-ACT users completed a questionnaire that captured their attitudes toward TLC-ACT at the end of the study. A total of 600 potential study participants received letters of introduction. There were 22 letters returned for incorrect addresses, and 578 persons were contacted by telephone. Except for 46 potential study participants who had unpublished telephone numbers, all potential participants were contacted. Of those contacted (5321, 296 (56%) were found to be ineligible for the following reasons: language barriers (61, no touch-tone telephone service (161, medical disability (1071, too active (167). Of the 236 eligible participants, 85 (36%) were recruited into the study: 41 subjects were randomized to the intervention TLC, and 44 to the control group. Sixty-eight subjects (80%) completed the study: 29 in the TLC-ACT group and 39 in the control group. The drop out rate for the intervention group was 29% (12/41), whereas that of the control group was 11% (5/44). Analysis of the reasons for drop out revealed that a majority of subjects dropped out for newly documented major medical reasons such as need for surgery.
Statistical
Methods
The analysis was performed on the 68 subjects who completed the study. Seventy-six percent (n = 52) were women, of whom 30% were AfricanAmerican, with a mean age of 66.6 years. As a check for differential TLC effects by gender, we ran a multiple regression model including terms for gender and interaction between gender and treatment. To evaluate the impact of TLC-ACT on stage of change, the percentage of women who showed an increase in stage (for those at the highest stage of 26
WOMEN’S
HEALTH
ISSUES
VOL.
7, NO.
1 JANUARY/FEBRUARY
1997
maintenance at baseline, the percentage who remained in maintenance) was calculated for the TLC and control groups. The number of stages increased was analyzed through the Wilcoxon rank sum test. Minutes walked over 4 days showed a highly skewed distribution both at baseline and follow-up with a few women reporting several hours of walking. To normalize the data for statistical analysis, data were scaled to reflect minutes walked per week and transformed by taking the natural log of minutes walked. Because the log transform requires all data to be greater than zero, 5 minutes were added to minutes walked to account for those reporting no walking. The TLC and control groups were compared on minutes walked at follow-up through an analysis of covariance with interaction model, with minutes walked at baseline as the covariate. The interaction term in this model examined whether the effect of TLC differs according to minutes walked at baseline. These differences were described by contrasting predicted means from the model for the TLC and control groups to different levels of minutes walked at baseline. Results of the analysis were transformed back to the original scale of minutes walked for presentation. For stage of change, study groups were compared through x2 analysis on the percentage of subjects who increased their stage from baseline to 3 month or remained in the highest stage at both baseline and 3 months. Also, groups were compared on change in stage through the Wilcoxon rank sum test. The two-tailed P < .05 was taken for significance.
RESULTS There were no significant differences between the groups based on age, number of co-morbidities, Stage of Adoption of Physical Activity, and minutes walked over the 4 recall days at baseline (Table 1). In a multivariate model controlling for minutes walked at baseline and treatment group, sex was not significantly related to minutes walked at followup (P = .879), nor did the effect of TLC differ for males and females (P = .374). This analysis had low power of showing a gender effect, however, given the small numbers of males in the sample. Overall, there was no significant difference in the proportion of women Table 1. DESCRIPTION AT BASELINE
OF THE TLC-ACT
AND
CONTROL
TLC-ACT
Age (mean f sd) Number of co-morbidities Stage of adoption (%) Contemplation Preparation Action Maintenance Minutes per week walked at baseline (%) O-30 31-60 61-120 121+ TLC-ACT,
Telephone-Linked
Communication-Activity
Counseling
GROUPS Control
(n = 20)
(n = 32)
66.3 + 4.4 3.4 + 2.4
67.4 + 5.8 2.8 + 1.8
40 40 20 0
66 22 3 9
30 20 15 35
22 6 19 53
P
.481 .280 ,192
.345
and
Tracking;
SD, standard
deviation.
JARVIS
ET AL:
TELEPHONE-LINKED
COMMUNICATION
27
who increased their stage of change (60% for TLC, and 69% of control women). For women in the contemplation stage (the earliest stage represented by our sample), however, TLC was seen to have an effect. Of the women in TLC-ACT, 88% (7/S) showed an increase in stage, compared with 62% (13/21) of those in the control group (P < .05 by the Wilcoxon rank sum test). Similar results were observed for minutes walked at followup. The significant interaction in the analysis of covariance model (P = .036) indicates that although TLC has an effect on minutes walked, the effect varies depending on minutes walked at baseline. Examination of the adjusted mean walk times shows that TLC has greatest impact for those reporting little walking at baseline. For women reporting no walking at baseline, TLC-ACT users had increased walk time at 3 months of 50 minutes (P < .02). For women who reported walking 60 minutes or more at baseline, there was no statistically significant difference between baseline and followup comparing the two groups (Table 2). TLC-ACT users were very satisfied with the system. Analysis of user’s satisfaction data shows a high TLC-ACT user satisfaction score with the mean of 8.6 (where 1 = very dissatisfied and 10 = very satisfied); 74% of the women rated their satisfaction with TLC-ACT as 10 of 10. TLC users’ perceived benefit score was 7.5 of 10; 63% of the women rated the benefit of TLC as 10 of 10.
DISCUSSION Reducing physical inactivity in the elderly population is one of the Year 2000 objectives.” Although numerous studies have documented the health benefits of regular exercise,‘-4,7-‘0,20 the majority of the elderly women remain sedentary, and little remains known about the effective means to stimulate exercise behavior in this population. We sought to develop an intervention that encourages elders to engage in moderate physical activity that could be used at home and which cost the same as making a local telephone call. Our goal was to encourage sedentary elders to walk for 60 minutes over the course of a week. We were able to demonstrate, in the most sedentary women, a significant effect of TLC-ACT on walking for exercise. The women also found TLC-ACT to be beneficial to their health and enjoyed using the system. The study was conducted with a relatively small number of individuals followed for a 3-month period. This limiting factor did not allow us to substantiate the long-term effects of the intervention. Given these results, using a Table 2. AVERAGE
MINUTES
WALKED
Minutes
AT 3 MONTHS*
Walked per Weekat Follow-up
TLC-ACT
Control
(n = 20)
(n = 32)
Minutes Walked per Week at Baseline
Pt
0 15 30 60 120 *Analysis tP value
28
WOMEN’S
124 139 146 156 168
of covariance adjusted for minutes walked based on contrast of predicted means from
HEALTH
ISSUES
VOL.
7, NO.
37 65 84 113 156 at baseline. the analysis
1 JANUARY/FEBRUARY
of covariance.
1997
.019 ,031 ,062 .225 ,797
telecommunication system like the TLC seems to be a viable option care delivery organizations. It is reasonable to suggest, therefore, should be studied with a larger number of users for longer periods
for health that TLC of time.
REFERENCES 1. Larson E. Benefits of exercise for older adults: a review of existing evidence and current recommendation for the general population. Clin Geriatr Med 1992;8:35-50. 2. Pate RR. Physical activity and public health: a recommendation from the Centers for Disease Control and Prevention and the American College of Sports Medicine. JAMA 1995;273:402-7. 3. Stevenson JS, Topp R. Effects of moderate and low intensity long-term exercise by older adults. Res Nurs Health 1990;13:209-18. 4. Posner JD, Gorman KM, Gitlin LN, Sands LP, Kleban M, Windsor L, et al. Effects of exercise training in the elderly on the occurrence and time to onset of cardiovascular diagnoses. J Am Geriatr Sot 1989;38:205-10. 5. Morey MC, Cowper PA, Feussner JP, DiPasquale RC, Crowley GM, Kitzman DW, et al. Evaluation of a supervised exercise program in a geriatric population. J Am Geriatr Sot 1989;37:348-54. 6. Thomberry OT, Wilson RW, Golden PM. The 1985 Health Promotion and Disease Prevention Survey. Public Health Rep 1986;101:566-610. 7. Young D, Haskel W, Jatulis D, et al. Association between changes in physical activity and risk factors for coronary heart disease in a community-based sample of men and women: the Stanford Five-City Project. Am J Epidemiol 1993;138:205-16. 8. Blair SN, Kohn HW III, Paffenbarger RE Jr, et al. Physical fitness and all-cause mortality: a prospective study of healthy men and women. JAMA 1989;262:23952401. 9. Duncan JJ. Women walking for health and fitness: how much is enough? JAMA 1991;266:3295-99. 10. Dalsky GE’, Stocke KS, Ehsani AA, Slatopolsky E, Lee WC, Birge SJ. Weight-bearing and fracture risk in a free-living elderly cohort. J Gerontol 1987;43:M134-9. 11. Caspersen CJ, Merritt RK. Physical activity trends among 26 states, 1986-1990. 12. King AC, Blair SN, Bild DE, Dishman RK, Dubbert PM, Marcus BH, et al. Determinants of physical exercise. Med Sci Sports Exert 1992;24(Suppl):S221-32. 13. Dishman RK, Sallis JF, Orenstein DR. The determinants of physical activity and exercise. Public Health Rep 1985;100:158-71. 14. Dishman RK. Compliance/adherence in health-related exercise. Health Psycho1 1982;1:23747. 15. COM VS, Libbus MK, Thompson SE, Kelley MF. Older women and heart disease: Beliefs about preventive behaviors. Womens Health Issues 1994;4:162-9. 16. Prochaska JO, DiClemente CC. Stage and processes of self-change in smoking: towards an integrative model of change. J Consult Clin Psycho1 1983;51:390-5. 17. Marcus BH, Selby VC, Niaura RS, Rossi JS. Self-efficacy and the stages of exercise behavior change. Res Q Exert Sport 1992;11:386-95. 18. Washburn RA, Smith KW, Jette AM, Janney CA. The physical activity scale for the elderly (PASE): development and evaluation. J Clin Epidemiol 1993;48:153-62. 19. Institute of Medicine. Healthy people 2000. National Health and Promotion and Disease Prevention Objective. DHHS Publication No. (PHS) 91-50212. Public Health Service Published Government Printing Office. Washington (DC): National Academy Press, 1990. 20. King AC, Haskell WL, Taylor CB, Kramer HC, DeBusk RF. Group vs home based exercise training in healthy older men and women. JAMA 1991;226:1535-42.
IARVIS
ET AL: TELEPHONE-LINKED
COMMUNICATION
29
egular physical activity has been shown to have beneficial effects on both physical and mental health.i4 The Centers for Disease Control and the American College of Sports Medicine have suggested that adults should accumulate at least 30 minutes of moderate physical activity during the course of most days.* In the elderly population, moderate physical activity, such as walking, is associated with improved health outcomes.*5 Nevertheless, the majority of older people are sedentary. Results from the 1985 National Health Interview Survey show that two-thirds of those ages 65 and over do not exercise regularly.‘j The benefits of physical activity for elderly women include decreased risk of osteoporosis, decreased incidence of depression, and increased functional status.‘~7W’0 Despite these findings, the Behavioral Risk Factor Surveillance System reported that in 1990, 86.7% of women surveyed ages 65 and over were sedentary.i’ Yet, little is known about the determinants of exercise behavior in this population. Interventions to increase physical activity in the elderly include public education campaigns, formal education, and training programs.‘2-‘4 These efforts have been unsuccessful at maintaining the adoption of this behavior.‘2-‘4 Dishman et all3 report that 50% of those who participate in organized exercise programs such as aerobics classes will drop out during the first 3-6 months. An individual’s knowledge, attitude, and demographics are some factors that researchers have found to influence exercise habits.13 Among elderly women, physical and health problems, time constraints, personal issues such as inclement weather, lack of companionship, safety concerns, and lack of motivation interfere with regular exercise.15 Our objective was to use telecommunications technology to underpin an intervention that would be effective, easy to use, convenient, and inexpensive, require little time commitment; and be capable of widespread distribution. Additionally, we sought to personalize the intervention to increase its acceptability and motivate users.
R
24
WOMEN’S
HEALTH
ISSUES
VOL.
7, NO.
1 JANUARY/FEBRUARY
1997
0 1997 by The Jacobs of Women’s Health Published by Elsevier
Institute Science
1049~3867,97,s17,00
PI1 SlO49-3867(96)00050-3
Inc.
METHODS The Intervention The Telephone-Linked Communication (TLC) System is an interactive computer-based telecommunication system that converses with patients in their homes over their telephone to motivate and improve health-related behaviors. TLC “speaks” to users over the telephone using computer-controlled speech generation. Users communicate with TLC by using their telephone touch-tone keypad. TLC functions as a monitor or “counselor” that provides positive feedback to reinforce or change the individual’s health behavior. TLC stores the user’s response in a database. The information provided by the person controls the direction of the conservation. This information is also forwarded to the person’s physician on a report, similar to a laboratory report, in which medical problems are highlighted.* Telephone-Linked Communication for Activity Counseling and Tracking (TLC-ACT) is a TLC application designed to encourage sedentary elders to engage in regular exercise such as walking. The contents of TLC-ACT conversation is based on the Transtheoretical Model of behavior change developed by Prochaska and DiClemente.r6 The Transtheoretical Model combines the individual’s current behavioral status with his or her intention to change such behavior.r6 Marcus et a1.r7 have applied this model to physical activity. The model identifies five stages of change that are common in changing health-related behaviors. Applied to activity, they are precontemplation, contemplation, preparation, action, and maintenance. Precontemplators do not engage in physical activity and do not intend to start. Contemplators do not participate in physical activity but intend to start in the near future. Those in preparation participate in some physical activity but not regularly. Those in the action stage regularly participate in some form of physical activity for at least 6 months. Finally, those in maintenance participate in regular physical activity longer than 6 months. Regular physical activity is defined as exercising five or more times a week for at least 30 minutes.2 TLC-ACT dialogues employ the five stages of change to determine the individual’s current physical activity pattern and her intention to change. During the TLC-ACT conversation, the person’s amount of activity and stage of change is determined by asking her to report the number of walks taken in the past week and the total number of minutes walked. Using this information, subjects are engaged in dialogues specific to their stage. For example, a subject determined to be in contemplation will be informed of the benefits of walking and the risks of inactivity. TLC-ACT will then determine the subject’s interest in starting to walk. If interested, TLC-ACT will negotiate a start date and a goal for walking (frequency and duration of each walk).
Study Design We conducted a randomized clinical trial to assess the effects of TLC-ACT. The study was conducted in a general internal medicine (primary care) practice at a teaching hospital in Boston. Screening requirements specified that the subjects had to be at least 60 years old, English-speaking, with no medical conditions that would prevent them from walking or for which regular walking exercise was contraindicated. A letter of introduction was sent to all those whose physician indicated that they met the screening requirements. Potential participants were contacted by telephone. The study was described to the subject, and eligibility was assessed. In addition to the screening criteria, a person had to be sedentary (defined as participating in less than 60 minutes of physical activity per week,
JARVIS
*A detailed description of the Telephone-Linked communications (TLC) System, including the TLC-ACT dialogue and report layout is available from the National Auxillary Publications Service.
ET AL: TELEPHONE-LINKED
COMMUNICATION
25
with a minimum of 20 minutes of exercise per time and a minimum of three times per week), and also needed to have touch-tone telephone service. The person could be in either contemplation or preparation stage (ie, not precontemplation). An office visit was arranged for those eligible subjects who agreed to participate. Informed consent and a baseline questionnaire were completed at the office visit. Then subjects were randomized to use TLC-ACT, or to a usual medical care control group. Research staff and subjects were blinded to the study assignment until the baseline questionnaire was completed. Subjects randomly assigned to TLC-ACT received a password and training on how to use TLC. TLC-ACT subjects selected a day and time to call the system weekly. If they failed to call on their scheduled day, they received up to three telephone calls to remind them to call TLC. All subjects received printed information on the benefits of walking and how to begin a walking program. At the end of the 3-month study period, each subject returned for an office visit to complete a follow-up questionnaire. If a subject could not come to this visit, a questionnaire was mailed, along with a self-addressed stamped envelope. Those who failed to return the questionnaire within 3 weeks completed it over the telephone with a study staff person. Upon completion of the followup questionnaire, individuals in the control group were invited to use TLCACT.
Study
Instruments
The study instruments included (1) the State of Adoption of Physical Activity instrument, a four-item scale to determine the stage of readiness of a person to engage in regular physical activity,” (2) the subjects’ self-report of numbers of minutes walked on each of the 4 preceding days, and (3) a study-specific baseline sociodemographic and health/quality-of-life questionnaire. These were completed both at baseline and at 3 months. TLC-ACT users completed a questionnaire that captured their attitudes toward TLC-ACT at the end of the study. A total of 600 potential study participants received letters of introduction. There were 22 letters returned for incorrect addresses, and 578 persons were contacted by telephone. Except for 46 potential study participants who had unpublished telephone numbers, all potential participants were contacted. Of those contacted (5321, 296 (56%) were found to be ineligible for the following reasons: language barriers (61, no touch-tone telephone service (161, medical disability (1071, too active (167). Of the 236 eligible participants, 85 (36%) were recruited into the study: 41 subjects were randomized to the intervention TLC, and 44 to the control group. Sixty-eight subjects (80%) completed the study: 29 in the TLC-ACT group and 39 in the control group. The drop out rate for the intervention group was 29% (12/41), whereas that of the control group was 11% (5/44). Analysis of the reasons for drop out revealed that a majority of subjects dropped out for newly documented major medical reasons such as need for surgery.
Statistical
Methods
The analysis was performed on the 68 subjects who completed the study. Seventy-six percent (n = 52) were women, of whom 30% were AfricanAmerican, with a mean age of 66.6 years. As a check for differential TLC effects by gender, we ran a multiple regression model including terms for gender and interaction between gender and treatment. To evaluate the impact of TLC-ACT on stage of change, the percentage of women who showed an increase in stage (for those at the highest stage of 26
WOMEN’S
HEALTH
ISSUES
VOL.
7, NO.
1 JANUARY/FEBRUARY
1997
maintenance at baseline, the percentage who remained in maintenance) was calculated for the TLC and control groups. The number of stages increased was analyzed through the Wilcoxon rank sum test. Minutes walked over 4 days showed a highly skewed distribution both at baseline and follow-up with a few women reporting several hours of walking. To normalize the data for statistical analysis, data were scaled to reflect minutes walked per week and transformed by taking the natural log of minutes walked. Because the log transform requires all data to be greater than zero, 5 minutes were added to minutes walked to account for those reporting no walking. The TLC and control groups were compared on minutes walked at follow-up through an analysis of covariance with interaction model, with minutes walked at baseline as the covariate. The interaction term in this model examined whether the effect of TLC differs according to minutes walked at baseline. These differences were described by contrasting predicted means from the model for the TLC and control groups to different levels of minutes walked at baseline. Results of the analysis were transformed back to the original scale of minutes walked for presentation. For stage of change, study groups were compared through x2 analysis on the percentage of subjects who increased their stage from baseline to 3 month or remained in the highest stage at both baseline and 3 months. Also, groups were compared on change in stage through the Wilcoxon rank sum test. The two-tailed P < .05 was taken for significance.
RESULTS There were no significant differences between the groups based on age, number of co-morbidities, Stage of Adoption of Physical Activity, and minutes walked over the 4 recall days at baseline (Table 1). In a multivariate model controlling for minutes walked at baseline and treatment group, sex was not significantly related to minutes walked at followup (P = .879), nor did the effect of TLC differ for males and females (P = .374). This analysis had low power of showing a gender effect, however, given the small numbers of males in the sample. Overall, there was no significant difference in the proportion of women Table 1. DESCRIPTION AT BASELINE
OF THE TLC-ACT
AND
CONTROL
TLC-ACT
Age (mean f sd) Number of co-morbidities Stage of adoption (%) Contemplation Preparation Action Maintenance Minutes per week walked at baseline (%) O-30 31-60 61-120 121+ TLC-ACT,
Telephone-Linked
Communication-Activity
Counseling
GROUPS Control
(n = 20)
(n = 32)
66.3 + 4.4 3.4 + 2.4
67.4 + 5.8 2.8 + 1.8
40 40 20 0
66 22 3 9
30 20 15 35
22 6 19 53
P
.481 .280 ,192
.345
and
Tracking;
SD, standard
deviation.
JARVIS
ET AL:
TELEPHONE-LINKED
COMMUNICATION
27
who increased their stage of change (60% for TLC, and 69% of control women). For women in the contemplation stage (the earliest stage represented by our sample), however, TLC was seen to have an effect. Of the women in TLC-ACT, 88% (7/S) showed an increase in stage, compared with 62% (13/21) of those in the control group (P < .05 by the Wilcoxon rank sum test). Similar results were observed for minutes walked at followup. The significant interaction in the analysis of covariance model (P = .036) indicates that although TLC has an effect on minutes walked, the effect varies depending on minutes walked at baseline. Examination of the adjusted mean walk times shows that TLC has greatest impact for those reporting little walking at baseline. For women reporting no walking at baseline, TLC-ACT users had increased walk time at 3 months of 50 minutes (P < .02). For women who reported walking 60 minutes or more at baseline, there was no statistically significant difference between baseline and followup comparing the two groups (Table 2). TLC-ACT users were very satisfied with the system. Analysis of user’s satisfaction data shows a high TLC-ACT user satisfaction score with the mean of 8.6 (where 1 = very dissatisfied and 10 = very satisfied); 74% of the women rated their satisfaction with TLC-ACT as 10 of 10. TLC users’ perceived benefit score was 7.5 of 10; 63% of the women rated the benefit of TLC as 10 of 10.
DISCUSSION Reducing physical inactivity in the elderly population is one of the Year 2000 objectives.” Although numerous studies have documented the health benefits of regular exercise,‘-4,7-‘0,20 the majority of the elderly women remain sedentary, and little remains known about the effective means to stimulate exercise behavior in this population. We sought to develop an intervention that encourages elders to engage in moderate physical activity that could be used at home and which cost the same as making a local telephone call. Our goal was to encourage sedentary elders to walk for 60 minutes over the course of a week. We were able to demonstrate, in the most sedentary women, a significant effect of TLC-ACT on walking for exercise. The women also found TLC-ACT to be beneficial to their health and enjoyed using the system. The study was conducted with a relatively small number of individuals followed for a 3-month period. This limiting factor did not allow us to substantiate the long-term effects of the intervention. Given these results, using a Table 2. AVERAGE
MINUTES
WALKED
Minutes
AT 3 MONTHS*
Walked per Weekat Follow-up
TLC-ACT
Control
(n = 20)
(n = 32)
Minutes Walked per Week at Baseline
Pt
0 15 30 60 120 *Analysis tP value
28
WOMEN’S
124 139 146 156 168
of covariance adjusted for minutes walked based on contrast of predicted means from
HEALTH
ISSUES
VOL.
7, NO.
37 65 84 113 156 at baseline. the analysis
1 JANUARY/FEBRUARY
of covariance.
1997
.019 ,031 ,062 .225 ,797
telecommunication system like the TLC seems to be a viable option care delivery organizations. It is reasonable to suggest, therefore, should be studied with a larger number of users for longer periods
for health that TLC of time.
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