Active for Life^TM :
Taking a Walking Program for Older Adults to Scale Nationwide

Teresa Ann Keenan, PhD

Dr. Keenan is Research Team Leader, Health in AARP's Knowledge Management Depar^TMent. Suggested citation: Keenan, TA. Active for Life^TM : Taking a Walking Program for Older Adults to Scale Nationwide. Cases in Public Health Communication & Marketing. 2007 June. Available from:

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Abstract

AARP, the nation's largest membership organization with over 37 million members ages 50 and older, sought to determine what motivates midlife and older adults to be more physically active. The organization conducted formative qualitative and quantitative research that provided a more accurate assessment of attitudes about physical activity in this population and knowledge levels about the importance of physical activity and exercise to overall health. With a grant from the Robert Wood Johnson Foundation and monies from the organization itself, AARP began the Active for Life^TM campaign, a social marketing campaign designed to promote the benefits of regular physical activity in two demonstration sites, Madison, Wisconsin and Richmond, Virginia.

At the conclusion of the Active for Life^TM campaign, AARP researchers built on the lessons learned in the 3-year effort and designed a new program model structured around peer support and volunteering. The Five-City Walking Pilot Study was implemented in four experimental sites in the southern United States to test the efficacy of different elements of a walking program: media only (Raleigh), media with step-counters (Columbia), media with peer support (Little Rock) and media with both step-counters and peer support (Montgomery). The fifth site, Richmond, which was one of the two AFL demonstration sites, served as the control site for the Five-City project. At the same time that AARP was leading the Five-City Walking Study, several of its state offices were sponsoring their own walking programs, all of which utilized some of the elements that were found to be effective in earlier work, including an educational kick-off, tracking of steps or minutes walked, weekly contact with participants, and a celebration of achievement at the conclusion of the program.

With a better understanding of motivation, AARP is now focusing its efforts on teasing out sustainability, that is, what keeps individuals active as they age. The organization has initiated partnerships with the Red Hats Society and the National Recreation and Parks Association (NRPA) in an effort to better understand this important question.

Introduction

Much has been written about the declining health patterns of the U.S. population. More people are overweight, suffering from chronic illnesses and sedentary than at any other point in our history (United States Depar^TMent of Health and Human Services, 1999). With nearly six in 10 Americans not participating in regular physical activity and an additional one-quarter reporting that they are completely inactive, the United States is facing a public health crisis (United States Depar^TMent of Health and Human Services, 1996). Research has clearly shown the relationship between physical inactivity and numerous health problems, including high blood pressure, heart disease and stroke, yet messages about the importance of physical activity have either not been heard by the public, or perhaps more likely, have been ignored (Hu, et. al, 2000; Powell, et. al., 1987).

Even with the Surgeon General's 1996 recommendation that healthy adults engage in 30 minutes of moderate-intensity physical activity most days of the week, a large proportion of the U.S. population still does not participate in regular physical activity. Clearly, there is a great need for effective interventions that promote physical activity adoption and maintenance, especially among midlife and older adults, who are more often susceptible to many of the illnesses that afflict the physically inactive.

About AARP

AARP is a nonprofit, nonpartisan membership organization that helps people 50+ have independence, choice, and control in ways that are beneficial and affordable to them and society as a whole. We produce AARP The Magazine, published bimonthly; AARP Bulletin, our monthly newspaper; AARP Segunda Juventud, our bimonthly magazine in Spanish and English; NRTA Live and Learn, our quarterly newsletter for 50+ educators; and our web site, www.aarp.org. AARP Foundation is an affiliated charity that provides security, protection, and empowerment to older persons in need with support from thousands of volunteers, donors, and sponsors. We have staffed offices in all 50 states, the District of Columbia, Puerto Rico, and the U.S. Virgin Islands.

Relevant AARP Research

Research conducted by AARP in 1999 and 2000 underscored several key points. One of the most consistent findings in both AARP's focus groups and national surveys was the ambivalence felt by midlife and older adults who knew many of the benefits of physical activity, yet who were not active. They were extremely conversant with those things that act as barriers to exercise, often mentioning time constraints, safety concerns, cost issues and lack of interest in exercising. They often said they would like to be more active, but they never seemed to get around to it. Another striking finding was the high level of knowledge shown by respondents. Whether questioned about the appropriate amount of exercise for someone their age, or the importance of flexibility, strength training and balance to an overall exercise regimen, respondents were extremely savvy. Clearly, they had heard the messages from the health community, even if they had not yet heeded them.

When it came to a general sense of overall well-being, respondents to AARP's national surveys on physical activity noted that they were quite satisfied with their lives and rated their health highly. They knew the important role of exercise in maintaining good health, and they engaged in a number of healthy activities such as having regular health screenings, trying to control their weight and making efforts to manage stress.

Finally, focus group participants and survey respondents expressed high levels of interest in finding community-based programs that would allow them to integrate physical activity into their daily lives. Those who said they already participated in community-based exercise classes and programs were most likely to lift weights or engage in other strength training activities, take aerobics classes, enroll in swimming classes or walk.

This research served as the basis for AARP's new programs designed to motivate midlife and older adults to be more active.

Laying the Groundwork: The Active for Life^TM Campaign

With the award of a three-year, $4.3 million grant from the Robert Wood Johnson Foundation in October 2001, AARP focused its work on developing programs for two communities that were designated as demonstration sites. In May 2002, both organizations officially launched their partnership and unveiled the campaign that was designed to promote the benefits of regular physical activity according to the CDC's guidelines at the time-at least 30 minutes a day of moderate-level physical activity at least five days a week.

Identifying the Target Audience

Since much of the earlier work that AARP had done in the area of physical activity was focused on its youngest audience, those ages 50 to 59, the organization wanted to continue with this group. But much of the work of the Robert Wood Johnson Foundation in the area of health promotion was focused on a larger audience, namely all adults over the age of 50. Key decision makers from the two organizations agreed that the focus for the Active for Life^TM (AFL) campaign would be on all midlife and older adults ages 50 and older, and it would build on the sizable research base of the two organizations.

Identifying Target Market(s)

Initially, AARP wanted to focus its efforts a single community that would have a fairly high number of midlife and older adults, an active AARP state office, a large pool of potential walking program participants and a reasonably-sized minority population. But once it was determined that the Active for Life^TM campaign would also have a sizable evaluation component, decision makers chose to focus on two communities rather than one in order to compare them according to certain community-level characteristics such as availability of community programs and services, a range of transportation options, and a commi^TMent on the part of the community to be "physical activity friendly."¹ For these reasons, Madison, Wis. and Richmond, Va. were selected.

Developing Campaign Goals

The primary goal was to increase physical activity among adults 50+ in Richmond and Madison, with a secondary goal of developing or adapting a model of behavior change that could be broadly implemented and sustained over time, once the results of the pilot campaign had been evaluated.

Identifying Campaign Components

The Active for Life^TM campaign was designed with three major components: marketing communications, partnership building and environmental change.

• The marketing communications pieces were designed to increase general awareness of both the overall AFL campaign and specific community-based programs, and included print or broadcast advertising through television, radio, local magazines and newspapers; direct mail to AARP members; fliers distributed at doctors' offices and community events; and on-going media relations to encourage journalists to report on AFL activities. The production of a consumer-focused brochure, the Be Active for Life Handbook, for becoming more physically active, a Community Resource Guide directing consumers to activities and programs in the demonstration sites and a 10-minute video were also central to the marketing communications component.
• The partnership-building aspect involved identifying potential community partners and building a relationship with them.² Partner organizations included city and county health and recreation depar^TMents, YMCAs, private health clubs, senior centers, mall-walking programs, hospital and health system wellness programs, members of the medical community, employers, churches, walking and biking organizations, and environmental organizations. Partner organizations played a key role in distributing the Community Resource guides and fliers used to promote the Be Active for Life Handbook. Not surprisingly, partner organizations had their own missions, constituencies and resource issues, and were attracted to the project for very different reasons. Their willingness to participate and their levels of involvement varied over time.
• The environmental change component was closely related to the partnership- building piece in that community groups such as neighborhood associations, environmental and safety groups, and city planners who were interested in creating "walkable and bikable" communities all worked together to make this component an integral part of the campaign.

Building and Supporting Campaign Components

Marketing Communications

In the early part of 2002, advertising focused on the need for the 50+ population to be physically active, and on driving requests for the Be Active for Life Handbook. After the launch phase in May and June, marketing shifted to "retail" advertising, supporting specific programs and activities of partner organizations. Given that participants in AARP's message development and message testing focus groups reiterated their preference for seeing as with "real people," not models, participating in exercise at a realistic level, the initial advertising campaign built on this important message. However, when recall testing showed that the initial advertisements were not memorable and that very few respondents could recall the name of the Active for Life^TM campaign, a mid-course correction was made. The second round of advertising, which focused exclusively on walking, tested much better. Advertising included a television commercial, focused on the benefits of walking for overall health that was a tongue-in-cheek spoof of infomercials, while the print ads were based on the notion of a "new magic pill" for walking.

Partnership Building

Partner organizations were actively engaged in not only distributing the Community Resource Guides and promoting the Be Active for Life Handbook, but also in developing new community programs and increasing awareness of the Active for Life^TM campaign. In Richmond, for example, the Depar^TMent of Recreation offered two new Senior Tennis groups and two new walking groups; the Richmond Athletic Club started a free, 12-week fitness and flexibility class for adults age 50 and older; and 10 YMCA branches offered new fitness classes also called Active for Life. In Madison, Employer Health Care Alliance, a group of 160 larger employers serving 33,000 employees, promoted Active for Life^TM to its member organizations. The AARP-sponsored walking campaign had 7,000 participants in Richmond and 5,000 in Madison.

Environmental Change

In Richmond, as part of the environmental change component, an African- American church hosted an Active for Life^TM environmental assessment introduction and training session, and then conducted subsequent environmental audits of the surrounding community with the support of project consultants from the University of North Carolina-Chapel Hill. In Madison, environmental and safety organizations helped to create a "Tour de Traffic" in which selected policy makers and community opinion leaders were put on a bus and taken around town to see firsthand the challenges the built environment posed to physically active lifestyles, especially for people 50 and over.

Evaluating Campaign Components

Marketing Communications

Research was designed by AARP and the Robert Wood Johnson Foundation to determine the effectiveness of the marketing communications pieces in four areas:

• Increasing awareness and knowledge of the CDC's physical activity recommendations
• Increasing awareness and knowledge of specific physical activity choices in the community
• Changing attitudes toward the appropriateness of physical activity for midlife and older adults that are supportive of increasing levels of physical activity
• Influencing behavior change, in this case, by increasing levels of physical activity.

Partnership Building

Evaluating the partnership building component involved measuring whether the campaign succeeded in three areas:

• Increasing awareness among individuals in the two demonstration communities of the physical activity choices available to them and others over age 50
• Increasing the number of physical activity choices made available by community partners
• Leading community partners to make a commi^TMent to sustain the project after the conclusion of the grant period.

Environmental Change

The research focus for the environmental component was intended to determine if the campaign was successful in four areas:

• Increasing public awareness of the relationship between physical activity, the built environment and health
• Increasing awareness among selected community leaders and policy makers about the topic
• Increasing activism on the topic
• Aiding in the development of policies to support sustained behavior change at the population level.

As is shown in Table 1, a number of contractors and AARP staff worked on a variety of projects over the course of the 3-year campaign that were designed to evaluate its different aspects. In some cases, the Robert Wood Johnson Foundation had selected vendors with whom they had existing contractual relationships; in other cases, AARP followed its standard competitive bidding process to select contractors who would focus on one aspect of the campaign.

Table 1 List of Active for LifeTM Contractors
Marketing Communications
Fleishman-Hillard	media outreach and advisory
Mapes & Ross	recall of original advertising campaign
International Communications Research (ICR)	recall of original advertising campaign; surveys on walking
MSW Research	materials tests
Princeton Survey Research Associates (PSRA)	surveys about changes in knowledge, atttitudes and behavior
RoperASW	surveys about changes in knowledge, atttitudes and behavior
Partnership Building/Coalitions
The Sutton Group	focus groups; in-depth interviews with community partners
University of North Carolina-Chapel Hill	technical support
Livable Communities/ Environmental Change
University of North Carolina-Chapel Hill	technical support
Bonney & Company	focus groups

For example, Princeton Survey Research Associates was hired by the Robert Wood Johnson Foundation to conduct a multi-wave survey in the two demonstration cities, Madison and Richmond, and in two control sites, Winston-Salem, N.C. and Lincoln, Neb. They fielded surveys at four points during the campaign: at baseline, six months, one year and two years. Additionally, researchers from the University of North Carolina-Chapel Hill were hired because AARP had no in-house expertise on environmental change and they worked extensively on all aspects of the environmental component. Staff from The Sutton Group conducted in-depth interviews with community partners at two points during the campaign, while Bonney & Company held a number of focus groups dealing with physical activity and the built environment. Staff from Fleishman-Hillard, AARP's public relations firm, developed and implemented a media outreach program, and served in an advisory capacity throughout the campaign.

Determining Campaign Success

Marketing Communications

According to data from Fleishman-Hillard, there were more than 22 million media impressions,³ slightly more than half of which were in national media and the reminder in the local media of Madison and Richmond. Media stories were consistently judged to be on message and made extensive use of AARP and AFL spokespersons. In a separate analysis done by AARP, the AFL campaign was shown to have garnered over one million "earned media" impressions of six broadcast and 13 print pieces.⁴

Partnership Building

Partner organizations in both Madison and Richmond committed to continuing to offer programs and services for midlife and older adults. In Richmond, for example, the AARP Virginia State office and Bon Secours Health System agreed to continue to support the Joy Program (for African-American women), and the AARP Virginia State office was awarded $40,000 from the national office as part of its membership outreach efforts. In Madison, the Senior Games made a commitment to maintain a 10 percent increase in participation among midlife and older adults.

Additionally, health clubs, local YMCAs and other organizations re-vamped their offerings for those over age 50 and increased their outreach efforts into this population, and various coalitions, committees and task forces formed and pledged to continue the work of AFL in Madison and Richmond.

Environmental Change

Results from Madison and Richmond suggested that individuals were aware of the relationship between a physically active lifestyle and a built environment that encourages it. For example, the distribution in Madison of 5,000 brochures by AARP staff and community partners about pedestrian safety coincided with a billboard campaign about the "pedestrian flag project" which stressed that pedestrians in Wisconsin have the right-of-way in crosswalks.

Moreover, in both Madison and Richmond, activism increased around issues of "livable communities" due in large part to a small group of committed volunteers who worked with consultants from the University of North Carolina-Chapel Hill to conduct audits of the "walkability" and "bikability" of their neighborhoods. In both cities, strong partnerships were formed with city traffic engineering staff who committed to the audit projects and who sought environmental changes.

Changes in Knowledge, Attitudes, and Behavior

Results from AARP's own surveys that were fielded at the conclusion of the walking campaign showed significant increases from pre-campaign to post-campaign in five of the six knowledge and attitude measures in Madison and in two of the six measures in Richmond (see Table 2). However, six months later, in Madison, only two measures remained statistically significant: message recall of physical activity and message recall of walking. In Richmond, two new measures showed notable changes, both dealing with message recall.

In terms of behavior change, results were less encouraging, as increased ownership of step-counters was the only change noted in Madison and which logically should be attributed in large part to the step-counter giveaway. It remains to be seen whether these changes will hold over time. It may be as Marcus et. al. (1998) suggested: recall of mass media campaign messages may be generally high, but have very little impact on changing behavior.⁵

Table 2 Results from AARP Active for LifeTM Walking Surveys
Madison, Wisconsin		Wave 16 (n=407) Baseline		Wave 2 (n=402) Post-Campaign		Wave 3 (n=401) Six months later
Knowledge and Attitudes
Knowledge of 30-minute "walking prescription"		50%		51%		53%
Knowledge of 5 times per week Rx		39%		45%7		41%
Message recall of physical activity message		61%		76%		79%
Recall of physical activity message sponsor		7%		20%		7%
Message recall of walking message		45%		60%		66%
Recall of walking message sponsor		5%		21%		6%
Behavior
Walk 21-30 minutes on a "usual" day		19%		24%		27%
Walk 5 or more times per week		64%		58%		58%
Walk "every day" to frequent destination		34%		34%		28%
Own step-counter		16%		27%		26%
Richmond, Virginia	Wave One8 (n=404) Baseline		Wave 2 (n=403) Post-Campaign		Wave 3 (n=400) Six months later
Knowledge and Attitudes
Knowledge of 30-minute "walking prescription"	47%		45%		46%
Knowledge of 5 times per week Rx	37%		41%		39%
Message recall of physical activity message	53%		52%		62%
Recall of physical activity message sponsor	8%		23%		7%
Message recall of walking message	42%		47%		59%
Recall of walking message sponsor	4%		17%		6%
Behavior
Walk 21-30 minutes on a "usual" day	21%		24%		26%
Walk 5 or more times per week	52%		48%		51%
Walk "every day" to frequent destination	45%		34%		35%
Own step-counter	13%		17%		13%

Moving Forward: Focusing on Different Types of Programs

Armed with results from the 3-year Active for LifeTM campaign, AARP staff began to develop walking programs that could be used in a variety of settings. Since the original campaign was not designed to tease out the separate effects of the different campaign components, but rather to determine the overall effectiveness of the campaign, at its conclusion interest developed at AARP for pilot testing a new program model structured around peer support and volunteering. AARP developed a new research plan, incorporating the ability to determine the individual effects of different interventions and launching peer support-based walking programs in new sites. Additionally, the focus on walking galvanized partners, provided a single focal point, and ensured a larger reach than the earlier focus on increasing different types of physical activities.

Modifying the Program Model: the Five-City Walking Pilot Study

This new project, the Five-City Walking Pilot Study, began in August 2004 and took place in Raleigh, N.C.; Little Rock, Ark.; Columbia, S.C.; and Montgomery, Ala., cities that were selected based on their similarities with Richmond, one of the two AFL demonstration sites. All were southern state capitals, similar in terms of total population, size of minority population, percentages of midlife and older adults, and median household income.

A research pilot was designed and implemented in four experimental sites to test the efficacy of different elements of a walking program: media only (Raleigh), media with step-counters (Columbia), media with peer support (Little Rock) and media with both step-counters and peer support (Montgomery). The fifth site, Richmond, served as the control site for the project

AARP worked with ICR/International Communications Research of Media, Pa. to design a population-level evaluation campaign across the five cities. Telephone interviews were conducted in four separate waves, with a variety of activities and events occurring between waves one and three (see Table 3). Wave one interviews took place June 3 through 22 among a representative sample of adults age 50 and older in the five cities prior to either the promotional campaign or the program launch. Wave two interviews occurred July 15 through August 16, once the promotional campaign had ended and before the launch of the program. Wave three interviews took place between September 13 and October 14, 2004, at the end of the walking program. Wave four interviews occurred between April 4 and May 12, 2005 and were designed to gauge whether changes that were noted earlier in the study held over time or if additional changes occurred.

Table 3 Intervention Design
Sites
	Wave 1		Wave 2		Wave 3	Wave 4
Richmond	Overall Control Site Baseline	------	------	------	Post-Campaign Measure 2	Post-Campaign Measure 3
Raleigh	Media Control Site Baseline	Walking Promotion Campaign	Post-Campaign Measure 1	------	Post-Campaign Measure 2	Post-Campaign Measure 3
Columbia	Baseline	Walking Promotion Campaign	Post-Campaign Measure 1	Walking program with step-counters	Post-Campaign Measure 2	Post-Campaign Measure 3
Little Rock	Baseline	Walking Promotion Campaign	Post-Campaign Measure 1	Walking program with peer support	Post-Campaign Measure 2	Post-Campaign Measure 3
Montgomery	Baseline	Walking Promotion Campaign	Post-Campaign Measure 1	Walking program with step-counters and peer support	Post-Campaign Measure 2	Post-Campaign Measure 3

Launching the New Walking Programs

Kick-off events were held in Montgomery, Columbia, and Little Rock, the three sites that offered walking programs, and were lead by trained health/fitness professionals. Initial pre-program data for each participant was collected and ground rules for participation were discussed. Program participants were given tips for keeping motivated and staying hydrated, along with a "Walking, Who Knew?" t-shirt to celebrate their participation.

• In Columbia, the site with the step-counter-based walking program, participants were given a step-counter, a copy of the Physical Activities Workbook and information about walking trails in their community.
• In Little Rock, where the focus was on peer support, participants were given a copy of the Physical Activities Workbook, a weekly walking journal to record their exercise, information about walking trails in their community and motivational tips. Participants were also asked to register with an exercise buddy (or buddies) with whom they agreed to walk for the duration of the program.
• In Montgomery, the site which combined the step-counter- and peer-support aspects, participants were given a step-counter and the Be Active for Life Handbook along with information on community trails and community resources. As in Little Rock, participants were asked to register with an exercise buddy.

The programs aimed to motivate participants to either increase the number of steps they walked (with a step-counter-based program) or to increase the amount of minutes they walked (with a peer-support-based program) over time.

Evaluating the New Walking Programs

The Five-City Walking Pilot evaluation consisted of two components:

• A series of population-level telephone surveys designed to gather information about respondents' attitudes toward exercise and physical activity, participation in community-level programs and services, participation in different types of physical activity, attitudes about the suitability of their communities for walking, and awareness of the 10-week walking campaign.
• Surveys distributed to participants in the walking program (in Montgomery, Columbia and Little Rock) designed to gather information about individuals' knowledge and awareness of the campaign in their community and their patterns of walking.

Determining Success at the Community Level

Respondents' recall of the messages about the importance of walking improved significantly between survey waves two and three in Montgomery, Columbia and Little Rock but decreased in Raleigh (see Tables 4-8). In wave four, message recall increased even further in the three cities with programmatic interventions, suggesting that the key points of the walking program's message stuck in respondents' minds even after the conclusion of the 10-week program.

Table 4 Changes in Selected Variables, Wave One through Wave Four Richmond: Overall Control Site
	Wave 1 (n=493)9	N/A	Wave 3 (n=367)	Wave 4 (n=400)
Awareness
Message recall of walking message	43%	-----	46%	49%
Recall of walking message sponsor	3%	-----	3%	1%
Knowledge and Attitudes
Knowledge of 30-minute walking Rx	45%	-----	57%	44%
Knowledge of 5 times per week Rx	14%	-----	9%	17%
Participation in PA Classes
Currently Participate	16%	-----	14%	17%
Have ever Participated	28%	-----	24%	23%
Knowledge and Use of Step-Counters
Correct name	34%	-----	42%	-----
Own a step-counter	16%	-----	20%	-----
Behavior
Walk 5 or more times last week for at least 30 minutes	21%	-----	23%	24%
Engage in moderate activity 5 or more days last week	24%	-----	15%	22%

Table 5 Changes in Selected Variables, Wave One through Wave Four Raleigh: Media Only
	Wave 1 (n=501)10	Wave 2 (n=402)11	Wave 3 (n=367)12	Wave 4 (n=400)13
Awareness
Message recall of walking message	45%	40%	37%	48%
Recall of walking message sponsor	-----	1%	1%	1%
Knowledge and Attitudes
Knowledge of 30-minute walking Rx	49%	50%	57%	50%
Knowledge of 5 times per week RX	15%	17%	15%	14%
Participation in PA Classes
Currently Participate	19%	17%	20%	18%
Have ever Participated	37%	32%	35%	34%
Knowledge and Use of Step-Counters
Correct name	47%	48%	57%	-----
Own a step-counter	20%	22%	26%	-----
Behavior
Walk 5 or more times last week for at least 30 minutes	26%	24%	22%	36%
Engage in moderate activity 5 or more days last week	23%	22%	21%	23%

Table 6 Changes in Selected Variables, Wave One through Wave Four Montgomery: Step-Counters and Peer Support
	Wave 1 (n=501)	Wave 2 (n=402)	Wave 3 (n=341)	Wave 4 (n=402)
Awareness
Message recall of walking message	34%	39%	50%	52%
Recall of walking message sponsor	1%	7%	9%	1%
Knowledge and Attitudes
Knowledge of 30-minute walking Rx	44%	47%	47%	46%
Knowledge of 5 times per week RX	13%	12%	15%	16%
Participation in PA Classes
Currently Participate	13%	11%	15%	17%
Have ever Participated	32%	34%	35%	31%
Knowledge and Use of Step-Counters
Correct name	33%	34%	35%	-----
Own a step-counter	14%	18%	15%	-----
Behavior
Walk 5 or more times last week for at least 30 minutes	23%	22%	18%	23%
Engage in moderate activity 5 or more days last week	22%	17%	18%	20%

Table 7 Changes in Selected Variables, Wave One through Wave Four Little Rock: Peer Support
	Wave 1 (n=500)	Wave 2 (n=403)	Wave 3 (n=360)	Wave 4 (n=401)
Awareness
Message recall of walking message	44%	46%	53%	60%
Recall of walking message sponsor	2%	1%	8%	1%
Knowledge and Attitudes
Knowledge of 30-minute walking Rx	40%	49%	49%	54%
Knowledge of 5 times per week Rx	12%	13%	16%	14%
Participation in PA Classes
Currently Participate	18%	13%	18%	12%
Have ever Participated	27%	28%	28%	29%
Knowledge and Use of Step-Counters
Correct name	39%	39%	43%	-----
Own a step-counter	17%	16%	19%	-----
Behavior
Walk 5 or more times last week for at least 30 minutes	24%	22%	23%	19%
Engage in moderate activity 5 or more days last week	20%	23%	23%	25%

Table 8 Changes in Selected Variables, Wave One through Wave Four Columbia: Step-Counters
	Wave 1 (n=501)	Wave 2 (n=402)	Wave 3 (n=359)	Wave 4 (n=401)
Awareness
Message recall of walking message	36%	41%	46%	51%
Recall of walking message sponsor	1%	2%	1%	1%
Knowledge and Attitudes
Knowledge of 30-minute walking Rx	41%	44%	56%	45%
Knowledge of 5 times per week RX	12%	13%	17%	14%
Participation in PA Classes
Currently Participate	19%	18%	18%	23%
Have ever Participated	30%	35%	37%	32%
Knowledge and Use of Step-Counters
Correct name	35%	40%	43%	-----
Own a step-counter	17%	19%	21%	-----
Behavior
Walk 5 or more times last week for at least 30 minutes	21%	26%	20%	21%
Engage in moderate activity 5 or more days last week	21%	19%	16%	18%

However, in wave four, contrary to expectation, message recall also increased significantly in Raleigh. This is surprising given that Raleigh was the site selected for "just" a media campaign and suggests that perhaps something else was happening in that community during the period between mid October 2004 and April 2005.

• Montgomery: Message recall improved significantly between waves two and three in Montgomery (39% to 50%), then increased even further in wave four (50% to 52%). Unfortunately, no additional changes were noted in Montgomery at the community level.
• Little Rock: Knowledge of the 30-minute prescription, a key message of the campaign, increased significantly from wave one to wave two in Little Rock, leveled off at wave three and then increased again at wave four, suggesting that additional changes were taking place in the community. It may be that residents of Little Rock were much more conscious of the Surgeon General's physical activity recommendations, especially since their governor at the time, Mike Huckabee, sponsored his own weight loss campaign, which received extensive media coverage.
• Columbia: Knowledge of the 30-minute prescription message increased 15-percentage points from wave one to wave three in Columbia, but then dropped back to baseline levels at wave four. While this decline was disappointing for those who designed the program, it was not surprising, and was consistent with much of the social marketing literature. Very often changes are noted in knowledge and attitudes during the course of a social marketing campaign, only to dissipate when the campaign ends and the key message is no longer being reinforced.
• Richmond and Raleigh: Results from the control sites were somewhat puzzling since media recall was expected to decline. However, in both cities, there were significant increases in knowledge of the 30-minute prescription message from wave one to wave three, suggesting that perhaps there were other influences in the communities conveying the same message about the Surgeon General's guidelines for physical activity in addition to the messages from AARP's walking program. Alternatively, it may be that the key message was so self-evident to some audiences that their recall was not attributable to the AARP campaign or to any other. As in Columbia, however, knowledge dropped back to baseline in wave 4.

Determining Success at the Individual Level

As noted earlier, AARP used pre-/post-campaign measures to assess whether walking program participants changed their walking behaviors over the course of the 10-week program. Researchers at AARP developed and distributed surveys to participants at the launch of the Five-City Walking Pilot. Follow-up surveys were also developed and mailed to participants approximately one week after the conclusion of the programs. In total, baseline surveys were collected from 1,154 participants (283 in Columbia, 366 in Montgomery, and 505 in Little Rock). Post-program surveys were received from 480 participants, for an overall response rate of 42 percent.

Results from surveys of the program participants suggest that it is the combination of the step-counter and peer-based walking groups that is most motivating. As shown in Table 9, respondents in Montgomery showed the highest gains in terms of the number of minutes spent in physical activity, with the percentage of respondents citing 31-45 minutes increasing 13-percentage points (25% to 38%) and those noting 46-60 minutes increasing 11-percentage points (14% to 25%). In Columbia, the percentage of respondents citing 31-45 minutes, 46-60 minutes, and 60 minutes or more all increased from the pre- to post-program survey, although not significantly. A similar pattern was also found in Little Rock.

The step-counter got the participants interested in walking, but the camaraderie and sociability of the walking groups kept them moving. To be most effective in changing behavior, that results indicate that walking programs should include both elements.

Table 9 About how many minutes do you spend in physical activity?
	Columbia Step-Counters		Montgomery Combined		Little Rock Walking Groups
	Pre  (n=283)	Post (n=122)	Pre (n=366)	Post (n=161)	Pre  (n=505)	Post (n=197)
< 10 minutes	12%	4%	11%	2%	13%	4%
11-20 minutes	12%	5%	14%	6%	12%	8%
21-30 minutes	25%	22%	24%	16%	24%	27%
31-45 minutes	20%	26%	25%	38%	23%	27%
46-60 minutes	19%	26%	14%	25%	18%	25%
60+ minutes	12%	17%	11%	13%	10%	10%

Other elements found to be useful in the Five-City Walking Pilot were the 10-week duration of the program; the educational kick-off; assignment of walk leaders or walking buddies; tracking of steps or minutes; a weekly motivational "touch" point with the group leader; and a celebration of achievement at the conclusion of the program.

Offering Walking Programs with Unique State Components

In addition to the Active for LifeTM campaign and the Five-City Walking Pilot, AARP also sponsored walking programs in several states, all of which utilized some of the elements that were found to be effective in earlier work. For example, in 2004, 12 AARP state offices opted to offer walking programs, with launches scheduled from early May through mid-December, and in 2005, nearly twice as many state offices offered walking programs to individuals in their states.

• Hawaii: In 2005, Hawaii's walking program began with 13 kick-off events in various parts of the state. Participants were invited to the kick-off event via a state office mailing, and exercise training was provided on-site. They were asked to increase their steps each week by at least 10 percent, and were given a step-counter as a motivational and tracking device. As a state-based variant, participants wrote themselves encouraging post cards which the AARP Hawaii state office mailed to them every two weeks to help keep them motivated. Hawaii's walking program also allowed for the inclusion of "participating groups," which consisted of local organizations with 10 or more participants. Each "participating group" had a group leader who was responsible for contacting participants every other week and managing the group.
• New Hampshire: The New Hampshire state office launched 10-week programs in 2005 with three motivational "touches" and honorary walk leaders including the mayor of Manchester, the president and chief executive office of the Manchester-based Catholic Medical Center, and the president of Southern New Hampshire University. State office staff sent weekly tip sheets and motivational ideas to participants.
• North Carolina: In 2005, AARP North Carolina enticed its chapters to complete for the longest combined distance walked by program participants. Each participant was asked to turn in the number of steps they walked to a chapter walking coordinator by the 27th of each month. The coordinator submitted the total number of steps to the state office. Rewards for the most number of steps taken per chapter were given out quarterly.

In 2006, AARP focused its walking program and attendant research on a few "laboratory" states to hone intervention efficacy and to concentrate on behavior change. Three unique interventions were implemented in Colorado, Rhode Island and Montana, and programs in each of these states included certain core elements such as a kickoff/ launch activity and a celebration event at the conclusion of the 10-week program along with specific state-based strategies.

• Colorado: AARP Colorado launched its walking program in June 2006 at the Denver Botanic Garden. The walking program was linked with other AARP activities such as Colorado's 8th Annual AARP Presents Summer Fitness Walks and T'ai Chi and "Summer Tuesdays." Participants were given 10 pre-stamped postcards with different motivational messages for each week. They were also asked to record the days and minutes they spent exercising each week and to include this information on the postcard. A winner was selected in a weekly raffle from among those who returned their postcards the AARP. In addition, the "Summer Tuesdays" event provided the context for weekly face-to-face contacts among participants.
• Rhode Island: AARP Rhode Island launched its walking program in April 2006 at the Roger Williams Boathouse in Providence. The kickoff included a fundraiser for Meals on Wheels and a Chi walking demonstration, and concluded with group walks in the park where the boathouse is located. After the kickoff, walking clubs and groups were formed and met on a weekly basis with their captains for a weekly walk.
• Montana: AARP Montana launched its walking program in 2006 at 62 senior centers and wellness events at various locations throughout the state over the course of the year. Montana kickoff events included a 30-minute motivational program and a 10-minute presentation on the value of upper body strength training with resistance bands. Montana highway maps were distributed and participants were urged to begin with a "Walk around Montana," a total of 1,724 miles (the distance across the state) or 3,448,000 steps. Group members summed their steps each week and marked off the miles on the map to gauge
progress.

Evaluating the Success of AARP's State-Based Walking Programs

Findings from participants' surveys showed that AARP's walking initiatives were successful in motivating participants to increase the amount of exercise they perform. For example, respondents reported increasing both the number of days per week and the number of minutes per day that they exercise after the walking programs began. Additionally, the percentage who said they don't exercise declined over time. Respondents also reported being more active at the conclusion of the 10-week programs than they were at the beginning, with decreases noted in the percentages who said they are not active and increases in the percentages who said they are active and who said they have been active for a long time. Large majorities of respondents also said they are extremely or very likely to continue walking in the future.

High percentages of respondents to the state-level follow-up surveys said they found the step-counter that they received at the launch to be either extremely or very helpful in getting them started with walking, keeping them motivated to stay active and helping them keep track of their progress. Unfortunately, over half said they stopped using the device during the course of the program, either because it didn't work or because they forgot to use it. It may be that the step-counter is a useful device in motivating participants to start walking, but its utility decreases over time. The experience of simply relating time and distance walked may suffice after one has calibrated his/her walking to a step-counter, and may render the device unnecessary.

Tying It All Together: Moving from Motivation to Sustainability

The information gathered on walking-from the Active for LifeTM campaign, the Five-City walking pilot and the state-level walking programs-suggests that a "one size fits all" approach will not work and underscores the difficulty of motivating individuals to be more active. Potential walkers need to be motivated to begin (perhaps with a tool such as a step-counter), enticed to continue (perhaps with an incentive such as a "Walking, Who Knew?" shirt), and rewarded for their effort (perhaps with a celebration or a nominal prize). But, additionally, many seem to need the companionship and camaraderie that comes with being a part of a larger unit, as in the case of Montgomery's walking groups. Many stick to a routine, even if it has gotten a bit stale, because they receive regular reinforcements, as was the case with the participants in New Hampshire's walking program who received weekly tip sheets in the mail. And many walk longer and more often if they can do so in a pleasant environment, such as the Colorado walkers who met weekly at the Denver Botanic Gardens. AARP's efforts in this area have been shown to be successful in motivating midlife and older adults to be more active during the course of the 10-week walking program, but perhaps predictably, their motivation (and activity level) drops once the program ceases. AARP is now focusing its efforts on teasing out sustainability, that is, what motivates individuals to become more physically active as they age and to keep being active over time. In 2007, AARP has initiated partnerships with the Red Hat Society and the National Recreation and Parks Association (NRPA) in an effort to better understand this important question.

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Footnotes

• 1 Potential sites were ranked according to a number of factors-percentage age 50 and older, size of AARP membership, state obesity and physical inactivity rates, current and potential community partners, environmental assets, diversity of community, crime and pedestrian deaths, and media diversity—with the final sites selected via a KT Decision Analysis.
• 2 AARP normally refers to such community relationships as collaborations. For purposes of this case, however, the term partnerships better conveys the intended nature of the relationships that were developed.
• 3 "Impressions" refer to the number of publications which carry a story multiplied by the circulation of each of the publications.
• 4 There are generally two types of media: earned media and paid media. Earned media refers to media coverage which is gained by doing something that garners media interest, while paid media refers to coverage that is purchased.
• 5 See Marcus et. al, Physical activity interventions using mass media, print media, and information technology, American Journal of Preventive Medicine, 15(4): 362-377, 1998. They reviewed 28 studies of media-based interventions and found that although message recall was high, it did not translate into changes in physical activity behavior.
• 6 The baseline survey was fielded September 3-19, 2003, the first post-campaign survey was fielded December 9-30, 2003, and the final post-campaign survey was fielded May 10-24, 2004.
• 7 Statistically significant differences (at p<.05) are shown in bold.
• 8 The baseline survey was fielded September 3 through October 9, the first post-campaign survey was fielded December 10-28, 2003, and the second post-campaign survey was fielded May 6-24, 2004.
• 9 With samples of approximately 400 respondents, there needs to be a difference of +/- seven percentage points for statistical significance.
• 10Wave One survey was fielded June 4-24, 2004.
• 11 Wave Two survey was fielded July 15-August 14, 2004.
• 12 Wave Three survey was fielded September 13-October 14, 2004.
• 13 Wave Four survey was fielded April 4-May 12, 2005.

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References

Hu, F. B., et. al. Physical activity and risk of stroke in women. Journal of the American Medical Association. 283: 2961, 2000.

Marcus, B. et. al Physical activity interventions using mass media, print media, and information technology. American Journal of Preventive Medicine, 15(4): 362-377, 1998

Powell, K. E., et. al. Physical activity and the incidence of coronary heart disease. Annual Review of Public Health. 8: 253-287, 1987.

U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion. Physical Activity and Health: A Report of the Surgeon General. Atlanta, GA: U.S. Department of Health and Human Services, Public Health Service, CDC, National Center for Chronic Disease Prevention and Health Promotion, 1996.

U.S. Department of Health and Human Services, Public Health Service, Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion, Division of Nutrition and Physical Activity. Promoting Physical Activity: A Guide for Community Action. Champaign, IL: Human Kinetics, 1999.