Author: Shuang Wu
Wu, Shuang, 2025 Study on developing and evaluating a multi-stage intervention program for improving exercise adherence among community-dwelling older people with sarcopenia, Flinders University, College of Nursing and Health Sciences
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Objectives:
(1) Phase 1: To explore the exercise adherence and its influencing factors among community-dwelling older people with sarcopenia, and stakeholders’ expectations for exercise programs.
(2) Phase 2: To co-design a multi-stage intervention program with stakeholders to improve exercise adherence.
(3) Phase 3: To evaluate the effectiveness of the program on exercise adherence, exercise psychology, sarcopenia outcomes and quality of life.
Methods:
(1) Phase 1: An explanatory sequential mixed methods design was applied. COM-B model (Capability, Opportunity, Motivation-Behaviour) informed the study. Firstly, a cross-sectional study was conducted among older people with sarcopenia using the convenience sampling method. Descriptive analysis, univariate analysis and regression analysis were employed to describe the exercise adherence, exercise psychology and factors associated with exercise adherence. Subsequently, a descriptive qualitative study using semi-structured interviews was conducted with older people with sarcopenia and their healthcare professionals to understand factors affecting exercise adherence and their expectations for exercise programs. The thematic analysis method was used to analyse the data. Finally, Findings from the quantitative and qualitative results were integrated and discussed based on the joint display approach.
(2) Phase 2: The researcher developed the first draft of the multi-stage intervention program for improving exercise adherence based on findings from Phase 1 and the COM-B model, BCTs (Behaviour Change Techniques), HAPA theory (Health Action Process Approach) and the content of exercise prescription. Then, the draft multi-stage intervention program was revised and adjusted through nominal group method. The intervention program was tested for its safety, feasibility, and acceptability in a pilot study. The findings from the pilot study informed the final modification of the multi-stage intervention program for improving exercise adherence.
(3) Phase 3: A quasi-experimental research design was conducted. From October to November 2024, two community health service centres of the same size and background were assigned to an intervention group or a control group. Participants were allocated based on residency. The control group received routine services and exercise prescription only. The intervention group received routine services and the multi-stage intervention program. The 12-week intervention included both exercise prescription and adherence content. Measures were taken at baseline (T0), post-intervention (T1), and 1-month follow-up (T2). A mixed linear model with intention-to-treat analysis was used.
Result:
(1) Phase 1: (a) Quantitative phase: A total of 335 community-dwelling older people with sarcopenia participated in the survey, their mean age 74.27 (6.33) years and their exercise adherence rate was 44.8%. Walking was the main exercise. The exercise intention was at an upper-middle level, while the exercise behaviour and exercise self-efficacy were at a lower-middle level. The regression analysis showed that exercise intention (OR=1.872, P<0.001), exercise plan (OR=1.121, P=0.019), and exercise self-efficacy (OR=2.014, P<0.001) were statistically significant positive predictors of exercise adherence. (b) Qualitative phase: A total of 27 community-dwelling older people with sarcopenia and 21 healthcare professionals participated in interviews, and 4 themes with 17 subthemes were identified in data analyses. (c) Integrated analysis: 9 integrated results were obtained including 3 convergent, 4 complementary, and 1 unique result. The integrated results found that the overall level of exercise adherence was relatively low, constrained by the influence of capability, motivation, and opportunity. Psychological and behavioural mechanisms including low awareness of sarcopenia that weakened individuals’ cognition about the importance of exercise; declines in physical function contribute to reduced exercise self-efficacy and variability in intention and action planning affected the transition from intention to behaviour.
(2) Phase 2: Firstly, a targeted intervention strategies package containing 19 BCTs for improving exercise adherence were established. Then, the content of adherence intervention based on HAPA theory was developed, which was integrated with exercise prescription content, resulting in first draft of a multi-stage intervention program. The nominal group discussion was conducted to revise the content of the first draft. The pilot study results: The recruitment rate of participants was 83.3%. All five participants completed the pilot programs. Only one case reported shoulder pain but felt normal after rest. The participants raised issues which were considered in the final revision of the program. The final version included three behavioural change stages, four intervention themes, combining exercise adherence intervention content and exercise prescription content involving 20 BCTs.
(3) Phase 3: A total of 72 participants (36 per group) were recruited. No statistically significant differences in baseline (P>0.05). After 12 weeks, the intervention group showed significant improvements in adherence, plan, self-efficacy, physical function tests, and physical quality of life (QOL) (P<0.05). At 1-month follow-up, these improvements were sustained (P<0.05). No significant differences in muscle mass, grip strength, or psychological QoL (P>0.05). No adverse events occurred in either group during the intervention and follow-up periods, and the dropout rate was low. The overall satisfaction of the subjects in the intervention group was 94.1%. In the interview, participants mentioned that multi-stage intervention helped them enhance awareness, strengthen exercise confidence, facilitate plan conduction, improve physical health status, and maintain home-based exercise habits. Suggestions were proposed for improving the intervention content and promoting its sustainable implementation in the community.
Conclusion:
(1) Phase 1: Exercise adherence among community-dwelling older people with sarcopenia remains suboptimal and was influenced by capability, motivation, and opportunity. A multi-stage intervention is needed, from cognitive establishment (through authoritative health education), to exercise initiation (through authoritative health education), and ultimately to habit formation (transitioning from supervised participation to autonomous adherence), in order to gradually enhance exercise adherence.
(2) Phase 2: Based on stakeholder input, literature, and theory, a multi-stage intervention applying behaviour change techniques was co-designed and refined through pilot testing. The program developed in this process is practical, scalable and feasible for implementation.
(3) Phase 3: This multi-stage intervention program can effectively improve exercise adherence, improve exercise psychology, enhance lower limb muscle strength and physical function with sustained effects and high participant satisfaction, showing potential for community application.
Keywords: Older people with sarcopenia; Community-dwelling; Multi-stage; Exercise adherence; Mixed methods; Co-design
Subject: Health & Physical Education thesis
Thesis type: Doctor of Philosophy
Completed: 2025
School: College of Nursing and Health Sciences
Supervisor: Lily Dongxia Xiao