Shih-Fan (Sam) Lin 1 , Jerry W. Lee 2 , Naomi Modeste 2 , & Eric G. Johnson 2

1. 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) Lin1, Jerry W. Lee2, Naomi Modeste2, & Eric G. Johnson2 1San Diego State University & 2Loma Linda University

2. The Prevalence of Falling • 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). BACKGROUND

3. Consequences and Risks of Falling • 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) BACKGROUND

4. Motivation to Attend Fall Prevention Program • 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. BACKGROUND

5. Strength and Balance Training Program • 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). BACKGROUND Static Balance Stance: Up on Toes Strength Training Chair Squat Center of Gravity Shift: Objects on the Floor

6. 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; Li 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 beliefs associated with such a choice. BACKGROUND

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

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

9. Research Questions • How are attitude, subjective norm, and perceived behavioral control related to intentions to attend strength and balance training programs? • How does age relate to intentions to attend strength and balance training programs? • How does age relate to perceptions (attitude, subjective norm, and perceived behavioral control) about strength and balance training programs? • 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? PURPOSE

10. Design and Recruitment • Cross-sectional study design • Study 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. STUDY DESIGN

11. Instruments • A two-stage protocol suggested by Ajzen (2006) was followed • 1st 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 • 2nd Stage: the initial questionnaire was created • Belief questions were added STUDY DESIGN

12. Questionnaire Construction • 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). STUDY DESIGN

13. Questionnaire Content • Cognitive Screening (AD 8) • Screen for participants’ cognitive ability • Theory of planned behavior constructs • Attitude , subjective norm, perceived behavioral control, & behavioral, normative, and control beliefs • Use semantic differential scales and Likert-type scales • 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) • Demographics STUDY DESIGN

14. Continuous Variables • Intention (Scale: 1-8) • Two forms of attitude (Scale:1-8) • 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 • Controllability: belief about their control over the behavior VARIABLES

15. Continuous Variables • Behavioral belief (1-8) • Behavioral belief strength × outcome evaluation • 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% VARIABLES

16. 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. DATA COLLECTION

17. 346 Participants responded to questionnaires Data Cleaning 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

18. Data Analysis • Data were entered and analyzed with SPSS 16.0 • Frequency • 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 ANALYSIS

19. Regressions Basic Model: INT = ATT + SN + PBC Behavioral Beliefs and Outcome Evaluation Attitude Toward the Behavior Intention to Attend SBT Programs Normative Beliefs and Motivation to Comply Subjective Norm Control Beliefs and Perceived Power Perceived Behavioral Control ATT = BB1 + BB2 +BB3 + …BB8 SN = NB1 + NB2 + NB3 + …NB5 PBC = CB1 + CB2 + CB3 + …CB8

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

21. 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). • 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. RESULTS

22. Characteristics of Participants (Cont.) • 81.9% had never engaged in SBT exercises and 81.4% never engaged in Tai-chi exercises. • 61.1% perceived their health status as fair and 23.1% perceived as good. RESULTS

23. Intention Regressed on Attitude, Subjective Norm, and Perceived Behavioral Control (Basic Model) β= 0.19** r = 0.53*** Attitude *p ≤0.05, **p ≤ 0.005, ***p ≤ 0.001 N = Number of participants with complete data. R2 = 0.45***, N = 221 Subjective Norm Intention to Attend SBT Programs β = 0.20* r = 0.57*** Perceived Behavioral Control β= 0.37*** r= 0.64*** Perceived behavioral control has the strongest prediction of intention.

24. Age vs. Theory of Planned Behavior Variables • Perceived behavioral control was the only theory of planned behavior variable that had significant association with age (r = -.14, p = 0.034). RESULTS

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

26. Interaction: Subjective Norm & Age Average Age: 72 (SD = 8.72) Subjective Norm

27. Addition of ABC in the Model • Dependent variable: Intention • ATT, SN, and PBC remained significant • 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). RESULTS

28. 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. RESULTS

29. Relationship Between Intention & ABC Scores 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. Participants’ Balance Maintaining Confidence Intention to Attend SBT Programs Attitude Toward the Behavior Subjective Norm Perceived Behavioral Control

30. 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). • 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. RESULTS

31. R2 = 0.44***, N = 221 Attitude R2 = 0.56***, N = 221 Subjective Norm R2 = 0.59***, N = 221 Perceived Behavioral Control *p ≤0.05, **p ≤ 0.005, ***p ≤ 0.001; N = Numbers of participants with complete data.

32. Significant Interaction: Behavioral Beliefs vs. Outcome Evaluation Likelihood to Improve Mental Health Likelihood to Reduce Fall Risks Likelihood to Receive Gifts After Completing the Program

33. 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

34. Significant Interaction: Normative Beliefs vs. Motivation to Comply Doctors Classmates Community Members

35. Interpretation of Interactions • 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 RESULTS

36. Significant Interaction: Control Beliefs vs. Perceived Power Likelihood to Perform SBT Exercise in a Place that is Familiar to Participants Likelihood to Have Mental Health Declines Likelihood to Have Physical Health Declines

37. 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

38. Intention & Age Effect • Participants’ intentions to attend SBT programs were fairly strong. • 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 different age categories (old, older, oldest). CONCLUSION

39. Determinants of Intention • Attitude, subjective norm, and perceived behavioral control – all significantly and positively correlated with intention. • 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 • Participants having enough willpower to complete the program CONCLUSION

40. Limitations of the Study • Generalizability • 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 LIMITATIONS

41. Recommendations to Increase Recruitment Rate • During the promotion campaign of strength and balance training programs, health care professionals should: • Focus the campaign message on the program’s benefit of helping older adults become more independent in daily life. • 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. RECOMMENDATIONS

42. Recommendations to Increase Recruitment Rate • 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. • 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. • 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. RECOMMENDATIONS

43. Recommendations to Increase Recruitment Rate • 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. • 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. • 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-maintaining confidence and possibly increase their adherence to the SBT programs. RECOMMENDATIONS

44. Recommendations to Increase Recruitment Rate • 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. RECOMMENDATIONS

45. Recommendations to Increase Recruitment Rate • While designing the strength and balance training programs, health care professionals shouldconsider the following: • Conduct the program in a place that is familiar to participants as this will reduce environmental distractions and may alleviate participants’ potential anxiety levels. • 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. • Have participants sign a contract during the enrollment stage of the program to potentially increase participants’ commitment to complete the program. RECOMMENDATIONS

46. Recommendations to Increase Recruitment Rate • 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. RECOMMENDATIONS