Factors Influencing Taiwanese Older Womens Intention to Attend

Factors Influencing Taiwanese Older Women's Intention to Attend Strength and Balance Training (SBT) Programs: A Guide to Increase Recruitment Rate of SBT Programs Shih-Fan (Sam) Lin 1, Jerry W. Lee 2, Naomi Modeste 2, & Eric G. Johnson 2 1 San Diego State University & 2 Loma Linda University

The Prevalence of Falling BACKGROUND One third of older adults aged 65 and over fall at least once a year in the U. S. (CDC, 2006). According to the National Health Research Institutes (2007) in Taiwan, the prevalence rate of falling adjusted for age and sex rose from 18. 7% in 1999 to 20. 5% in 2005. The statistics in Taiwan show that falling is the second most common cause of death resulting from injuries (National Health Research Institutes, 2007). 2

BACKGROUND Consequences and Risks of Falling among older adults is associated with other problems (Yardley, Donovan-Hall, Francis, & Todd, 2007): ◦ ◦ ◦ physical injuries and fears of falling premature admissions to nursing care facilities restricted mobility limited independence distress The majority of older adults do not realize their potential risk for falling and neglect to report their falling events to their physicians (American Geriatric Society et al. , 2001). ◦ Less than two third of respondents felt that they were personally at risk for falls. (Wiens, Koleba, Jones, & Fenny, 2006) 3

Motivation to Attend Fall Prevention Program BACKGROUND Older adults who were informed of their risk for falling, were more likely to perform fall risk reduction behaviors (Ness, Gurney, & Ice, 2003). ◦ having vision checked ◦ attending exercise programs ◦ eating a calcium-rich diet Yardley et al. (2006) found that older adults in six European countries were motivated to attend fall prevention programs by a range of perceived benefits (e. g. enjoyment, independence, and mood) and not just reduction of fall risks. 4

Strength and Balance Training Program BACKGROUND Strength and balance training (SBT) programs are intended to reduce older adults’ risks of falling or actual occurrences of falls through exercises that facilitate muscle strength in legs and improve postural control (Yardley et al. , 2007). Strength Training Chair Squat Static Balance Stance: Up on Toes Center of Gravity Shift: Objects on the Floor 5

BACKGROUND Effectiveness and Participation of SBT Programs SBT programs are effective in reducing risks of falling and fears of falling (American Geriatric Society et al. , 2001; Liu-Ambrose et al. , 2004; Sattin et al. , 2005; Yardley et al. , 2007). The effectiveness of SBT programs depends largely upon the rate of participations. ◦ The rate of participation is quite low – over half of participants in several studies refused to join SBT programs (Yardley et al. , 2007). Yardley et al. (2007) revealed that women and older respondents in their study were less inclined to participate in SBT programs. ◦ Effects of gender and age not assessed in the study ◦ It is essential to understand what prompts women’s choice to attend the program and to learn how age might influence the 6

Purpose of the Study Explore how Taiwanese older adults’ attitudes and beliefs toward SBT programs will affect their intentions to attend such programs. constructs of theory of planned behavior to predict Taiwanese older adults’ intention to participate in SBT programs. PURPOSE Utilize Examine how age relate to older adults’ perceptions and intentions to attend SBT programs. 7

Theory of Planned Behavioral Beliefs and Outcome Evaluation Attitude Toward the Behavior Normative Beliefs and Motivation to Comply Subjective Norm Control Beliefs and Perceived Power Perceived Behavioral Control Intention to Attend SBT Programs Behavior Actual Behavioral Control 8

PURPOSE Research Questions 1. How are attitude, subjective norm, and perceived behavioral control related to intentions to attend strength and balance training programs? 2. How does age relate to intentions to attend strength and balance training programs? 3. How does age relate to perceptions (attitude, subjective norm, and perceived behavioral control) about strength and balance training programs? 4. How are behavioral beliefs, normative beliefs, and control beliefs associated with strength and balance training programs related to attitude, subjective norm, and perceived behavioral control, respectively? 9

Design and Recruitment Cross-sectional STUDY DESIGN Study study design Site ◦ Taiwan Silver College of Presbyterian Church Suang Lien Branch (TSCPCSL) – provide education to those who wish to learn in late-life. Recruitment ◦ All participants were recruited from the study site ◦ Flyers & the school administrator encouraged participation Inclusion Criteria ◦ Aged 55 and over ◦ Cognitively intact Need to be able to understand informed consent and questionnaire. 10

Instruments two-stage protocol suggested by Ajzen (2006) was followed STUDY DESIGN A 1 st Stage: two focus groups were conducted prior to the development of actual questionnaire ◦ Use open-ended questions ◦ Elicit behavioral, normative, and control beliefs associated with SBT programs ◦ Saturation of responses was reached after interviewing 12 students (6 males and 6 females) from the study site. ◦ Conduct content analysis – belief items used in questionnaire 2 nd Stage: the initial questionnaire was created 11

Questionnaire Construction STUDY DESIGN Pilot test of the questionnaire ◦ Tested on a convenience sample of 15 students from the study site. ◦ Participants made recommendations regarding questionnaire format and wording ◦ Finalize questionnaire according to comments received The finalized questionnaire was translated into a Chinese version utilizing the back translation process (Jones, Lee, Phillips, & Jaceldo, 2001). 12

Questionnaire Content 1. Cognitive Screening (AD 8) STUDY DESIGN • Screen for participants’ cognitive ability 2. Theory of planned behavior constructs • Attitude , subjective norm, perceived behavioral control, & behavioral, normative, and control beliefs • Use semantic differential scales and Likert-type scales 3. Balance-maintaining confidence • Activities-specific Balance Confidence Scale-Chinese (Mak, Lau, Law, Cheung, & Wong, 2007) • Assesses an individual’s confidence in performing 16 activities of daily living without losing one’s balance or becoming unsteady (higher scores mean greater confidence) 13

Continuous Variables (Scale: 1 -8) Two forms of attitude (Scale: 1 -8) VARIABLES Intention ◦ Instrumental: worth or usefulness of the specific behavior ◦ Experiential: affect or feeling toward the behavior Two forms of subjective norm (Scale: 1 -8) ◦ Descriptive: whether referent others approve or disapprove of the behavior ◦ Injunctive: whether referent others themselves engage in the behavior Two forms of perceived behavioral control (Scale: 1 - 8) ◦ Perceived capability: perceived difficulty in performing the behavior 14

Continuous Variables Behavioral belief (1 -8) ◦ Behavioral belief strength × outcome evaluation VARIABLES Normative belief (1 -8) ◦ Normative belief strength × motivation to comply Control beliefs (1 -8) ◦ Control belief strength × perceived power Age (demographic) Activities-specific balance confidence (ABC) scores ◦ On a scale of 0 -100% 15

DATA COLLECTION Data Collection Procedures All data collection occurred in the study site. The investigator guided participants to complete informed consents and questionnaires. Collection of signed informed consent prior to data collection. 16

Data Cleaning 346 Participants responded to questionnaires 5 were eliminated due to inadequate cognitive ability Those responded to <80% of total questions were eliminated Those who responded to <50% of questions in each main section were eliminated 341 Participants 248 Participants Missing data were treated with Expectation Maximization Algorithms 26 Males (10. 5%) 221 Females (89. 1%) One did not report gender 17

Data Analysis Data were entered analyzed with SPSS 16. 0 Frequency ANALYSIS ◦ Distribution of categorical demographic variables Central tendency measures ◦ Age ◦ Balance-maintaining confidence Multiple Linear Regression ◦ Prediction of intention ◦ Prediction of attitude, subjective, norm, and perceived behavioral control 18

Regressions Behavioral Beliefs and Outcome Evaluation Basic Model: INT = ATT + SN + PBC Attitude Toward the Behavior Normative Beliefs and Motivation to Comply Subjective Norm Control Beliefs and Perceived Power Perceived Behavioral Control ATT = BB 1 + BB 2 +BB 3 + …BB 8 SN = NB 1 + NB 2 + NB 3 + …NB 5 PBC = CB 1 + CB 2 + CB 3 + …CB 8 Intention to Attend SBT Programs 19

Regressions With addition of ABC: INT = ATT + SN + PBC + ABC Attitude Toward the Behavior Participants’ Balance Maintaining Confidence Subjective Norm Basic model: INT = ATT + SN + PBC Intention to Attend SBT Programs ABC = ATT + SN + PBC Perceived Behavioral Control With addition of age: INT = ATT + SN + PBC + AGE Age 20

Characteristics of Participants Average age: 72 (SD = 8. 72, SE = 0. 56). Most well represented religious groups: 54. 8% Buddhists and 23. 1% Christians (compared to 4. 1% of Christians living in Taiwan). RESULTS The education level was quite high (80% with high school or higher degrees) – compared to 5 years (elementary school) of education among older adults in general public. 65. 6% had never fallen on the ground during last year; 18. 6% had fallen once and 11. 3% had fallen twice. Average balance-maintaining confidence: 73. 3% (SE = 1. 36) – similar to 71. 6% found among community dwelling older adults in Hong Kong. 21

Characteristics of Participants (Cont. ) 81. 9% had never engaged in SBT exercises and 81. 4% never engaged in Taichi exercises. perceived their health status as fair and 23. 1% perceived as good. RESULTS 61. 1% 22

Intention Regressed on Attitude, Subjective Norm, and Perceived Behavioral Control (Basic Model)*p ≤ 0. 05, **p ≤ 0. 005, ***p ≤ 0. 001 β = 0. 19** Attitude N = Number of participants with complete data. r = 0. 53*** β = 0. 20* Perceived Behavioral Control β = 0. 37*** r = 0. 57*** r = 0. 64*** R 2 = 0. 45***, N = 221 Subjective Norm Intention to Attend SBT Programs Perceived behavioral control has the strongest prediction of intention. 23

Age vs. Theory of Planned Behavior Variables behavioral control was the only theory of planned behavior variable that had significant association with age (r = -. 14, p = 0. 034). RESULTS Perceived 24

Addition of Age in the Model variable: Intention ATT, SN, and PBC remained significant. RESULTS Dependent Only SN x Age interaction term is significant 25

Interaction: Subjective Norm & Age 0. 50 0. 46 0. 40 Intention Scores 0. 30 0. 20 Younger Age (-1 SD); around age of 63 0. 10 0. 00 -0. 03 -0. 10 Average Age: 72 (SD = 8. 72) -0. 20 -0. 30 Older Age (+1 SD); around age of 81 -0. 33 -0. 40 (-1 SD) (+1 SD) Subjective Norm 26

Addition of ABC in the Model Dependent variable: Intention ATT, SN, and PBC remained significant RESULTS ABC positively and significantly correlate (r=0. 28, p≤ 0. 001) with intention, but the relationship disappeared after the inclusion of TBP variables in the model (β=0. 02, ns). 27

RESULTS ABC Regressed on Theory of Planned Behavior Variables Dependent variable: Participants’ balance-maintaining confidence (ABC) score Only PBC significantly predicts ABC score ◦ The correlation between ABC scores and intention was mainly mediated by the impact of balance confidence on perceived behavioral control. 28

Relationship Between Intention & ABC Scores Participants’ Balance Maintaining Confidence The correlation between ABC and intention was mainly mediated by the impact of balance confidence on TBP constructs with the strongest influence on perceived behavioral control. Intention to Attend SBT Programs Attitude Toward the Behavior Subjective Norm Perceived Behavioral Control 29

Comparison of Religious Group We examined the interactions of religion and other study variables for all models directly predicting intention for the two largest religious groups in our sample (Christians and Buddhists). RESULTS No significant interactions between religion and any other independent variable examined in these regressions. ◦ The predictors of intention were not different between Christian and Buddhist participants. The relatively high proportion of Christians in our sample is not a threat to generalizability. 30

β 0. 36 *** 0. 17 0. 14 0. 07 0. 08 -0. 07 -0. 04 0. 06 r 0. 63 *** 0. 60 *** 0. 52 *** 0. 51 *** 0. 47 *** 0. 42 *** 0. 36 *** 0. 30 *** Outcome Beliefs Become more independent in daily life Improve physical health condition Increase social activities Improve mental health condition Reduce risk of falling Reduce fear of falling Receive gift from the instructors after completion of the program Produce minor pains in the body R 2 = 0. 44***, N = 221 Attitude β 0. 40 *** 0. 31 *** 0. 03 0. 01 0. 06 r 0. 70 *** 0. 67 *** 0. 65 *** 0. 64 *** 0. 61 *** Referent Others Family Doctors Friends Classmates Community members R 2 = 0. 56***, N = 221 Subjective Norm β 0. 27 * 0. 23 ** r Control Beliefs 0. 72 *** Program in place familiar to participants 0. 69 *** Being able to control the amount of exercises participants do in the program 0. 64 *** Have enough willpower to complete the program 0. 70 *** Program in place convenient to participants 0. 65 *** Have free time in the next 6 months 0. 40 *** Declines in mental condition 0. 59 *** Exercise in a group setting where participants could be around their peers 0. 37 *** Declines in physical condition R 2 = 0. 59***, N = 221 Perceived Behavioral Control 0. 15 * 0. 11 0. 08 0. 04 0. 01 -0. 02 *p ≤ 0. 05, **p ≤ 0. 005, ***p ≤ 0. 001; N = Numbers of participants with complete data. 31

Significant Interaction: Behavioral Beliefs vs. Outcome Evaluation Low Outcome Evaluation (-1 SD) High Outcome Evaluation (+1 SD) 1. 5 1. 0 Attitude Scores 0. 80 0. 66 0. 5 0. 31 0. 22 0. 04 0. 00 0. 11 -0. 28 -0. 35 -0. 44 -0. 49 -0. 57 -1. 0 (-1 SD) (+1 SD) Likelihood to Improve Mental Health (-1 SD) (+1 SD) Likelihood to Reduce Fall Risks (-1 SD) (+1 SD) Likelihood to Receive Gifts After Completing the Program 32

Interpretation of Interactions Among people who thought the outcome of mental health improvement less likely, a low evaluation of the mental health outcome was associated with more negative attitude toward the SBT program. • As perceived likelihood that the program would reduce risk of falling increased, the attitude toward SBT programs grew more favorably regardless individuals’ evaluation of the outcome. • When individuals highly evaluated receiving a gift after program completion, the greater the perceived likelihood of the gift, the more positive the attitude toward the programs. However, for individuals who evaluated such gifts more negatively, an increased perceived likelihood of a gift was associated with a more negative attitude toward the program. RESULTS • 33

Significant Interaction: Normative Beliefs vs. Motivation to Comply Low Motivation to Comply (-1 SD) High Motivation to Comply (+1 SD) Subjective Norm Scores 1. 50 1. 07 1. 00 0. 94 0. 87 0. 50 0. 22 0. 00 -0. 15 -0. 11 -0. 50 -0. 18 -0. 34 -0. 53 -0. 61 -0. 62 -0. 56 -1. 00 (-1 SD) (+1 SD) Doctors (-1 SD) (+1 SD) Classmates (-1 SD) (+1 SD) Community Members 34

Interpretation of Interactions RESULTS The more participants believed that referent others want them to engage in SBT programs, the higher the subjective norm score. This relationship is stronger among individuals who have higher motivation to comply. This is true for all the referent others: doctors, classmates, and community members 35

Significant Interaction: Control Beliefs vs. Perceived Power This Control Factor Would Make Less Positive Impact to Attendance of SBT Programs (-1 SD) Perceived Behavioral Control Scores This Control Factor Would Make More Positive Impact to Attendance of SBT Programs (+1 1. 50 SD) 1. 14 1. 00 0. 43 0. 50 0. 00 -0. 50 0. 09 -0. 64 0. 46 -0. 04 0. 37 0. 44 -0. 07 -0. 59 -0. 85 -0. 75 -1. 00 (-1 SD) (+1 SD) Likelihood to Perform SBT Exercise in a Place that is Familiar to (-1 SD) (+1 SD) Likelihood to Have Mental Health Declines (-1 SD) (+1 SD) Likelihood to Have Physical Health Declines 36

Interpretation of Interactions Those who evaluated performing exercise in a familiar place as having more positive impact on program attendance, an increase in the likelihood of this factor is associated with stronger perceived behavioral control. • For participants who evaluated that having a mental/physical decline in the future would have more hindering impact on program attendance, the greater the likelihood of future mental/physical declines, the weaker the participants’ perceived behavioral control. RESULTS • 37

Intention & Age Effect Participants’ intentions to attend SBT programs were fairly strong. CONCLUSION ◦ This does not guarantee a high rate of participation. Although a non-significant result, age was negatively correlated with intention. ◦ Focus the promotion of SBT programs to individuals with more advancing age (high risk & lack intentions). Age was significantly and negatively correlated with perceived behavioral control. ◦ Need to find solutions to increase older adults’ perceived ability to attend SBT programs. Provide optimal dose of exercise that tailors to individuals in 38 different age categories (old, older, oldest).

Determinants of Intention Attitude, subjective norm, and perceived behavioral control – all significantly and positively correlated with intention. CONCLUSION ◦ Perceived behavioral control had strongest predicting power of intention The most influential predictor of attitude: becoming more independent in daily life. Family and doctors were two referent groups that had independent prediction of subjective norm. Three dominant control factors significantly predicted perceived behavioral control. ◦ SBT programs in familiar place ◦ Participants being able to control amount of exercise desired 39

Limitations of the Study Generalizability LIMITATIONS ◦ Healthy and adequately educated participants ◦ Lack random selection of target population ◦ Only women were included Artificially lowered intention as women lack intention to attend SBT programs Volunteer effects No follow up on participants’ actual attendance to strength and balance training programs ◦ Limiting the study’s ability to assess the correlation between intention and actual behavior 40

RECOMMENDATIONS Recommendations to Increase Recruitment Rate During the promotion campaign of strength and balance training programs, health care professionals should: 1. Focus the campaign message on the program’s benefit of helping older adults become more independent in daily life. 2. Focus the promotion of the program to individuals in the more advanced age range as this group of people are generally at higher risks of falling and lack adequate intention to participate in such programs. While the old-old (70 -79) and the oldest-old (80+) groups are less likely to ambulate around the community or have the strength to exercise compared to the young old (60 -69), health care professionals should consider designing home-based and age-appropriated exercise intervention for these particular groups of individuals. Recruitment materials should emphasize the fact that the intervention requires no traveling to an exercise site and exercises are designed appropriately for their age. 41

RECOMMENDATIONS Recommendations to Increase Recruitment Rate 3. Stress the likelihood of mental health improvement as an outcome of the program to increase the positive attitude among older adults who place less positive value on mental health improvements. 4. Inform potential participants that mental or physical health declines will not prevent them from attending the SBT program as the program is tailored to participants with various levels of mental and physical health. 5. Emphasize the programs’ potential to reduce fall risks and strengthen older adults’ perceived value of fall risk reduction in order to maximize participants’ positive attitude toward program participation. 42

RECOMMENDATIONS Recommendations to Increase Recruitment Rate 6. Inform potential participants who highly value a gift after program completion about a forthcoming gift to increase their positive attitude toward program participation. For those who evaluate receiving gifts less positively, health care professionals should ask if there is anything that could be substitute as an incentive to participate in the program. 7. Provide realistic depiction of the program during campaign period by broadcasting a video that illustrates examples of strength and balance training exercises performed in the program. 8. Emphasize how safeguards have been implemented in the program to prevent potential falls during the exercise class as this will reduce fear of falling among potential participants and possibly increase their willingness to attend SBT programs. Assessment of balance confidence at the beginning of the program is also important because this will allow instructors to provide special attentions to individuals with less balance- 43

RECOMMENDATIONS Recommendations to Increase Recruitment Rate 9. Provide potential participants with a list of myths about attending a strength and balance training program and encourage the potential participants to pass on the information to relatives, friends, or neighbors whom they consider their opinions are important. This strategy to promote attendance will possibly be more beneficial for the young-old group as they still retain an adequate social network. For the old-old and oldest-old groups who lack an adequate social network, health care professionals should help them expand their social network by assigning counselors or social workers who can regularly contact them and encourage their engagement in strength and balance exercises. 44

RECOMMENDATIONS Recommendations to Increase Recruitment Rate While designing the strength and balance training programs, health care professionals should consider the following: 1. Conduct the program in a place that is familiar to participants as this will reduce environmental distractions and may alleviate participants’ potential anxiety levels. 2. Provide lessons that deal with the skills needed to strengthen participants’ perseverance to complete the program (e. g. use of relaxation skills to resist temptation to quit exercising) as this may reduce the attrition rate of the program. 3. Have participants sign a contract during the enrollment stage of the program to potentially increase participants’ commitment to complete the program. 45

RECOMMENDATIONS Recommendations to Increase Recruitment Rate 4. 5. Allow participants to choose the amount of exercise they wish to perform as this may allow participants to feel that they have adequate control over their own program. This should be advertised in the recruitment materials to increase potential participants’ desires to attend SBT programs. Health care professionals are strongly advised to first develop the SBT programs then create the recruitment materials to allow potential participants to have an in-depth understanding of what the program may entail. Provide appropriate dose of exercise to participants across different age groups (young-old, old-old, and oldest old) and various levels of physical and mental conditions as this can increase their perceived ability to accomplish the SBT program. 46