Literature Evaluation Table

Translating a Functional Exercise Program for Fall Prevention Among Diverse Older Adults in Urban Medically Underserved Areas:

A Mixed Methods Study Yi-Ling Hu, Marian Keglovits, Emily Somerville, Makenna Snyder, and Susan Stark

The Lifestyle-integrated Functional Exercise Program (LiFE) is proven to have high adherence rates and can significantly reduce falls, but it has not yet been implemented for diverse older adults residing in urban medically underserved (MU) areas. An exploratory sequential mixed methods study was conducted to adapt LiFE and test the adapted program’s preliminary feasibility. Focus groups with MU older adults and service providers were conducted to identify modifications. The new adapted program, Diverse Older Adults Doing LiFE (DO LiFE), was then evaluated with older adults. Thematic analysis revealed health literacy and lack of racial representation as barriers to implementing LIFE in this population. The pilot study showed that DO LiFE was feasible with good retention (89%) and high adherence (81.27%) rates. DO LiFE demonstrated preliminary feasibility for diverse MU older adults. Researchers should proceed to larger studies for translating DO LiFE from research to the community.

Keywords: habit formation, translational research, vulnerable population

Falls among older adults are a serious public health problem. In 2014, falls caused seven million injuries, more than 27,000 deaths, and cost Medicare $50 billion (Bergen, 2016). Given these severe consequences, a variety of fall prevention interventions have been developed for community-dwelling older adults (Gillespie et al., 2012; Moreland et al., 2003). Cumulative evidence in systematic reviews indicates that exercise interventions that address poor balance and decreased muscle strength are among the most efficacious types of interventions to reduce falls (Chase, Mann, Wasek, & Arbesman, 2012; Gillespie et al., 2012; Moreland et al., 2003; Sherrington et al., 2019; Stevens & Burns, 2015). A Cochrane review conducted by Gillespie et al. (2012) found that group-based, structured exercise interventions could significantly reduce the rate of falls (rate ratio [RaR]: 0.68–0.71) and the risk of falling (risk ratio [RR]: 0.78–0.85). This strong evidence has driven the American and British Geriatrics Societies to incorporate exer- cise intervention into their clinical practice guidelines for fall prevention (Panel on Prevention of Falls in Older Persons & Society, 2011). For dissemination and implementation of fall prevention programs, the Centers for Disease Control and Preven- tion (CDC) also provides a list of evidence-based exercise programs for healthcare providers to use in clinical practice and community settings (Centers for Disease Control and Prevention, 2015; Houry, Florence, Baldwin, Stevens, & McClure, 2016). Among the evidence-based programs, structured exercise pro- grams are the most implemented programs in community-based settings such as recreational centers or YMCAs in the United States (Shier, Trieu, & Ganz, 2016; Towne et al., 2015).

However, a large portion of older adults still self-exclude from group-based, structured exercise programs (Simek, McPhate, & Haines, 2012). Compared to other fall prevention strategies such as home modification, 50–73% of older adults are unwilling to

participate in structured exercise programs (Merom et al., 2012; Towne et al., 2015, 2020). Older adults also typically have lower adherence and follow-through rates even if they start structured exercise programs (Hawley-Hague et al., 2014; Rivera-Torres, Fahey, & Rivera, 2019). Cohort studies report that older adults find structured exercise unappealing due to barriers such as low motivation for vigorous activities, low self-efficacy, time con- straints, lack of transportation, and requirement of facility access (Picorelli, Pereira, Pereira, Felício, & Sherrington, 2014; Robinson, Newton, Jones, & Dawson, 2014; Towne et al., 2015; Whitehead, Wundke, & Crotty, 2006; Yardley et al., 2008). Older adults’ unwillingness to participate in and adhere to structured exercise programs limits the effectiveness of evidence-based programs in the real world (Hawley-Hague et al., 2014; McMahon & Fleury, 2012; Sjösten et al., 2007). On the other hand, unstructured exercise programs integrating functional exercises into everyday tasks have emerged, with promising results in recent fall prevention studies (Gillespie et al., 2012; Weber et al., 2018). Although few studies have compared preferences regarding structured and unstructured exercise programs for fall prevention, other physical activity studies have found that physical activity preferences differ by age, gender, and other understudied determinants (Koeneman, Verheijden, Chinapaw, & Hopman-Rock, 2011; Van Uffelen, Khan, & Burton, 2017) and further suggest that a large portion of older adults prefer activities that do not demand scheduled sessions and a fixed time, such as walking programs (Amireault, Baier, & Spencer, 2019; Burton, Khan, & Brown, 2012). If current practice only provides structured exercise programs without reduc- ing the barriers, the problem of low participation will remain, and falls are expected to increase with the growing aging population (Shier et al., 2016; Towne et al., 2015).

One alternative evidence-based exercise program that could address the problem is the Lifestyle-integrated Functional Exercise Program (LiFE). The LiFE is delivered in seven in-home sessions over 12 weeks, during which occupational therapy (OT) interven- tionists help older adults develop tailored, habitual balance, and muscle strength exercise behaviors integrated in the participant’s

Hu is with the Institute of Gerontology, Wayne State University, Detroit, MI, USA. Keglovits, Somerville, Snyder, and Stark are with the Washington University School of Medicine, St. Louis, MO, USA. Hu ([email protected]) is correspond- ing author.

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daily routine and activities (Clemson et al., 2010, 2012; Delbaere et al., 2015; Sherrington et al., 2016). The LiFE helps older adults to form individualized exercise habits by linking training activities closely with individuals’ daily occupations and contexts. Habit formation strategies are used to gradually learn, perform, and integrate 19 balance and muscle-strengthening activities into daily routines. Clemson et al. (2010) developed the program with a team of researchers with backgrounds in OT, gerontology, and physical therapy, and the exercise activities delivered are built on evidence- based recommendations. The essential element of the program is based on task analysis, grading, and adapting activities of daily living and leisure activities in the home, which are typically within the scope of practice of occupational therapists. To deliver the essential components of the program, the interventionist needs to conduct activity analysis with a holistic approach to further help the participant to adopt the program. The active ingredient of the intervention is the use of habit to support behavior change. This is also an approach frequently used in OT practice. The LiFE’s design eliminates time constraints, need for transportation, and access to facilities compared to structured exercise programs. The flexibility and easy-to-adopt approach of LiFE could also motivate older adults who often do not find traditional exercise to be appealing. LiFE has demonstrated high adherence with a signifi- cant reduction in fall rates (31%) and improvements in balance and lower extremity muscle strength for community-dwelling older adults in Australia. The LiFE is included in the CDC fall prevention programs list; however, LiFE has not been translated for the much more diverse aging population in the United States (Weber et al., 2018). Translation of LiFE for a more diverse aging population requires acknowledging the demographic and health program delivery differences between Australia and the United States. Given that the LiFE program materials reflect the racial/ethnic composition of Australia (76.8% White, 14.6% Asian, 2.8% Aborig- inal, 0.7% Black, 5.1% other; Central Intelligence Agency, 2020), which is different from that of the United States (60.1% White alone, 18.5% Latino/Hispanic, 13.4% Black, 5.9% Asian, 2% other; U.S. Census Bureau, 2019), there is a need to study how to deliver LiFE and increase participant representation for a more diverse U.S. older adult population. Due to differences in healthcare systems, U.S. older adult perspectives may also differ from perspectives of Aus- tralians regarding healthcare access and coverage (Blendon et al., 2002). Thus, to retain intervention effectiveness, the fit between LiFE and the delivery context must be explored (Baumann & Cabassa, 2020).

In preparation for a larger trial and eventual translation of LiFE for the more diverse in-need population in the United States, we chose to target older adults residing in medically underserved areas (MU) in St. Louis area. The MU older adults traditionally have less access to health prevention programs and have the lowest adher- ence rates to structured exercise programs (Frohlich & Potvin, 2008; Health Resources & Services Administration, 2016; Towne et al., 2015). To develop an adapted program for the local com- munity, the program needs to be tailored to the local population. In the study region, the demographics of targeted MU neighborhoods are predominantly Black (demographic composition in St. Louis region: 45.6% Black, 44.1% White, 2.96% Latino/Hispanic, <6% other; Data USA, 2020), but this program can be further adapted for other populations, such as Latino/Hispanic older adults, in future studies. A mixed methods approach was selected to explore the possibility of translating LiFE for local MU older adults (Creswell & Plano Clark, 2011). The mixed methods design included a qualitative study to explore the perspectives of MU older adults

and a quantitative study to test the feasibility of the adapted program. Using these two forms of data can bring greater insight into how LiFE can be translated for MU older adults than would be obtained by either type of data separately. The two-stage adaptation process was guided by the cultural adaptation framework, which is commonly used in health prevention studies to retain critical components of an original program while determining to what extent the program should change (Barrera & Castro, 2006; Barrera, Castro, & Steiker, 2011; Barrera, Castro, Strycker, & Toobert, 2013). We selected our feasibility outcome measures based on the Adaptation Framework and the Reach, Effectiveness, Adoption, Implementation, and Maintenance Framework, which were chosen to guide the adaptation process and plan for future implementation (Barrera & Castro, 2006; Barrera et al., 2011, 2013; Glasgow, Lichtenstein, & Marcus, 2003; Glasgow, Vogt, & Boles, 1999). To our knowledge, this is the first study to adapt LiFE for diverse older adults in MU areas in the United States. We hypothesized that the adapted LiFE program would be feasible for MU older adults.

Methods An exploratory sequential mixed methods study was conducted to adapt LiFE. In Stage 1, we qualitatively gathered information from MU older adults and OT service providers about their acceptance of LiFE. A grounded theory approach was selected because of the lack of knowledge regarding MU older adults’ perspectives on the LiFE program. Qualitative results were used to develop the initial adapted program—Diverse Older Adults Doing LiFE (DO LiFE). In Stage 2, a single-group pilot study tested the feasibility of DO LiFE. Quantitative results from the pilot study were used to confirm the feasibility of DO LiFE. Last, we interpreted both qualitative and quantitative results to conclude whether DO LiFE was feasible and acceptable for local MU older adults. All study materials, written informed consent forms, and procedures were approved by the Washington University in St. Louis Human Research Ethics Board.

Stage 1. Gather Information and Develop the Adapted Program

The MU older adults were recruited by convenience sampling. Flyers were distributed at senior apartments and senior centers in MU areas, identified by zip code (Health Resources & Services Administration, 2018). Inclusion criteria were (a) age 65 or older and (b) living in senior apartments or participation at senior centers in MU areas. A trained moderator (Susan Stark) and two research assistants conducted the focus groups. Participants reviewed LiFE materials, and a semistructured discussion guide was used to address their impressions about LiFE. We asked the following open-ended questions in the focus groups: (a) What is your initial reaction to using this program for fall prevention among the community-dwelling older adult population attending senior cen- ters/in your building? (b) What changes do you think should be made to this program to best fit your needs? (c) What would make you accept this program more? All focus groups were audio recorded and transcribed verbatim, with notes taken by the research assistants. Transcripts were analyzed using thematic analysis and were coded by research assistants independently (Braun & Clarke, 2006). The lead author used the constant comparison method to code the transcripts and identify themes. Another trained research assistant independently coded the transcripts and then compared codes/themes. In the final stages of the analysis, the senior

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researcher analyzed and checked the credibility of the final codes/ themes with the team. Data collection continued until saturation was reached.

We used purposeful sampling to recruit local OT service providers. Inclusion criteria were (a) working as an OT practitioner, (b) at least 1 year of experience working with older adults, and (c) experience working in MU areas in greater St. Louis area. Participants received a Delphi survey (Hsu & Sandford, 2007; Verhagen et al., 1998) by e-mail that included the same open-ended questions as the focus group discussion guide. Responses were summarized using thematic analysis (Hasson, Keeney, & McKenna, 2000; Hsu & Sandford, 2007). Themes that reached consensus were used to adapt LiFE.

Stage 2. Pilot Test for Feasibility of Adapted LiFE

A single-group study was conducted to test the feasibility of the adapted LiFE program. An OT interventionist obtained written informed consent, administered pretests, conducted seven inter- vention home visits, and administered the posttest immediately after the last visit. Participants were recruited through flyers and recruitment sessions at a low-income senior apartment building (different from focus group recruitment) in an MU area. Inclusion criteria were (a) age 60 or older, (b) living independently, and (c) self-report of a slip, trip, or fall in the past 12 months or were “concerned or worried about falling in the future.” Exclusion criteria included (a) Short Blessed Test score of 10 or higher, indicating memory and attention deficits (Katzman et al., 1983); (b) inability to stand independently with a walking device; and (c) self-report of a serious health condition for which exercise is contraindicated. No sample size justification was needed because of the pilot nature of this study (Moore, Carter, Nietert, & Stewart, 2011).

Feasibility outcomes included reach, adherence, fidelity, acceptance, and preliminary efficacy. Reach included recruitment (consented participants divided by screened participants) and retention (number of participants who completed the program divided by number of enrolled participants) rates. Adherence was defined as the average percentage of exercise activities achieved during the intervention period, as recorded in an activity planner. Fidelity was calculated as the average percentage of key compo- nents delivered throughout the intervention period using a checklist derived from the original trainer’s manual (Clemson, Munro, & Singh, 2014).

Acceptance was derived from the question: “Are you satisfied with the program [DO LiFE]?” rated on a 7-point Likert scale (1 = very unsatisfied, 7 = very satisfied) asked at the last session. A follow-up interview further explored satisfaction. Repeated themes that emerged from the interview notes were summarized to refine DO LiFE.

Preliminary efficacy outcomes including habit formation, balance, and muscle strength were selected based on the fall literature and efficacy of LiFE as a fall prevention program. Outcomes were measured at baseline and posttest. Habit formation was measured by the Self-Report Behavioral Automaticity Index (SRBAI; Gardner, Abraham, Lally, & de Bruijn, 2012). Partici- pants rated DO LiFE activities on a 7-point Likert scale (1 = strongly disagree, 7 = strongly agree), where higher scores indicate stronger habit formation. Balance was measured by the Tinetti Performance-Oriented Mobility Assessment (POMA), which is a common measure for at-risk older adults in fall prevention research (Lusardi et al., 2017). The POMA is a 16-item measure with a

maximum score of 28, where a higher score is indicative of more independence (Tinetti, 1986). Lower extremity muscle strength was measured by manual muscle testing measuring isometric muscle strength of the hip extensor, knee flexor, and ankle dorsi- flexor/plantarflexor muscle groups. Manual muscle testing is the most commonly used method for measuring muscle strength among clinicians in the community (Cuthbert & Goodheart, 2007). Scores range from 1 to 5, with 5 being normal strength and 1 being no muscle contraction.

Descriptive statistics were used to describe demographics of participants and feasibility outcomes (SPSS, version 24.0). To present the trend of preliminary efficacy outcomes, we used Wilcoxon signed-rank tests and estimated effect size r due to the small sample size and unnormalized distribution (Fritz et al, 2012; Rosenthal, 1991, p. 19).

Results Stage 1. Gather Information and Develop the Adapted Program

Seventeen MU older adults (mean age 72.7 ± 9.9, six males, 15 Black) and seven service providers (mean age 35.9 ± 11.9, two males, one Black) were recruited. The demographics of participants reflected the demographics of targeted MU neighborhoods (96% Black, <1% other racial groups; The Health Resources and Services Administration, 2016). Overall, both older adult and OT provider participants perceived the LiFE program to be acceptable but indicated that the program needed adaptation. Two main themes emerged from the results: health literacy and representations of racial/ethnic diversity.

Theme 1: Health literacy should be addressed upon introducing the program. When older adult participants were asked about their initial reaction to the LiFE program, participants suggested that providing information they can understand from the beginning is critical. They also noted that interventionists should allow time for older adults to comprehend the information, or older adults may not successfully engage in the program. “Some people are slow to be involved. Sometimes it takes some longer than others : : : .When people don’t understand something, they have the tendency to shy away” (Mr. T, age 67, older adult).

OT service providers also suggested that health literacy be addressed when introducing the LiFE program to MU older adults.

Health beliefs and health literacy need to be addressed first : : : .In my experience, the real challenge is that inactivity has become a lifestyle, and many individuals fail to appreci- ate or agree that they can do anything to prevent falls or maintain mobility. So health beliefs and health literacy are the major barriers. (Ms. C, age 58, community service provider)

Additionally, older adult participants emphasized that interventionists should communicate with older adults and ensure that they under- stand the LiFE program. Because participants need to learn multiple exercise activities, practice the exercise activities in their daily routine, and use the activity calendar for self-monitoring, MU older adults need guidance and demonstration to become familiar with the program.

Make sure we are on the same page, you know, the person you’re talking to, you let them know this, and they let you

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know that, and then you start [the program.] (Mrs. M, age 66, older adult)

My therapist came in to treat me for my vertigo and my imbalance, and she did exactly the things that you said, she walked me through simple things that I can do to make me better : : : .Well, that makes sense, you know. (Ms. H, age 90, older adult)

OT service providers were also aware of the complexity of the LiFE program and mentioned that they need sufficient time to work with MU older adults.

Assuming that older adults have access to an occupational therapist, and assuming that the therapist can spend a rea- sonable amount of time developing the LiFE plan with the older adult. I understand that there may be time constraints in all health settings, so learning how to quickly establish a plan is essential. (Mr. P, age 29, supportive housing program)

In answering the question of what changes should be made to this program to best fit the needs of MU older adults, the older adults in our focus group suggested changing the text-heavy user manual. Older adults were concerned that the 100-page LiFE user manual would lower their motivation to begin the program. “A whole lot of people can’t read and write, and sometimes that becomes a problem. They wouldn’t understand what’s going on unless their neighbor told them what’s going on” (Mr. T, age 67, older adult).

Theme 2: The program should use materials that represent racial/ethnic diversity. There was a consensus to adapt the pictures and graphics to reflect the demographics of the local population, who are predominantly Black. Older adults found the user manual with pictures of only White older adults less appealing and reported that they would prefer pictures representing their community. The OT service providers had similar opinions to update the pictures to be more representative of the local population.

The picture should look like us. Like people of color? (Mod- erator) Yes. (Mrs. T, age 66, older adult). (Please) improve the pictures and graphics. (Mr. P, age 29, supporting housing program)

Initial adaptation of LiFE. Based on the qualitative results, we first addressed health literacy concerns by adding or substituting graphics for text-heavy content to reduce the original 100 pages to 37. For example, Figure 1 is a new graphic introducing LiFE (originally a three-page paragraph). Second, we used images of Black older adults to better reflect the MU older adults in the study region (Greever-Rice et al., 2018). Eighty percent of the pictures in the new user manual include Black older adults compared to none in the original manual.

The adapted program, Diverse Older Adults Doing LiFE (DO LiFE), was developed. DO LiFE retains all components and procedures of the original LiFE and is delivered with the new user manual. In DO LiFE, an OT interventionist conducts seven in- home intervention sessions over 12 weeks. The first five sessions occur weekly, and the last two sessions are every 2 weeks and 1 month apart, respectively. In the intervention sessions, OT inter- ventionists help participants gradually learn principles of balance and muscle strengthening activities, embed the exercise activities into their daily routines with an activity planner, and use habit formation strategies such as goal setting and self-monitoring to

repeat the embedded activities. Finally, the materials of DO LiFE were approved by Dr. Clemson, the original author of LiFE.

Stage 2. Pilot Test for Feasibility of DO LiFE

In Stage 2, we recruited eight MU older adults (mean age 66.4 ± 5.6) with diverse racial and educational backgrounds to test the feasibility of DO LiFE (Table 1). The composition of this small sample did not reflect the local neighborhood’s demographics, but all participants had resided in this neighborhood for more than a

Figure 1 — Tailored information of a graphic demonstrating DO LiFE in the user manual.

Table 1 Participant Demographics of Stage 2 Pilot Study

Participant demographics n (8)

Female 4

Black 3

Chronic conditions

Arthritis 8

Emphysema or chronic bronchitis 4

High blood pressure and heart trouble 4

Diabetes 1

Cancer 1

Stroke 1

Education level

Less than 12th grade 2

Some college, no degree 2

Associate or higher degree 4

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year. The recruitment rate was 44% (25 screened, 11 completed an in-home visit; Figure 2). We encountered recruitment difficul- ties in the first 4 months, with only two participants willing to join the study. New recruitment strategies were developed that empha- sized (a) flexible scheduling and no penalty for dropping out; (b) DO LiFE as a nonstrenuous, structured exercise program; and (c) small incentives ($5 gift card per visit). By applying these strategies, recruitment was achieved in the following 3 months. The retention rate was 89%. One participant dropped out after two visits due to health and time constraints (“had a lot of other health problems going on”).

The overall adherence rate was 81.27% (Table 2). Health issues (pain, sickness, emergency room visit, glaucoma surgery, and depression) were cited as reasons for lower adherence. An average of 89% of key components were delivered by the therapist (range: 64–100%) throughout the intervention. The main reason for nondelivered activities was canceled visits. The mean satisfaction score was 6.89 ± 0.38. In the follow-up interview, participants reported reasons for high acceptance, including “easy to start,” flexibility of the program, weekly visits, and helping them build a habit to do the exercise activities.

At posttest, we observed positive trends in habit formation and balance (Table 3). Participants showed a trend of forming habits to do the DO LiFE activities with a medium effect size and improved balance with a large effect size. There was a ceiling effect for lower extremity muscle strength because all participants had the highest level (normal) among all muscle groups at both pretest and posttest.

Discussion This mixed methods study confirmed the feasibility of translating LiFE for MU older adults in St. Louis. The qualitative results, such as tailoring information, guided the program adaptation process: an adapted LiFE program for MU older adults in the United States (DO LiFE) was created with fidelity to the original program. Pilot testing demonstrated acceptable reach, high adherence, good fidel- ity, and high acceptability. There were also positive trends among preliminary efficacy outcomes to develop exercise habits and improve strength and balance.

Using the combined interpretation of both qualitative and quantitative results, the DO LiFE program achieved retention of all components of the original program and adapted materials that were tailored to local diverse older adults residing in MU areas. The adaptation process in this study echoes processes of other studies implementing evidence-based programs in real-world settings, wherein tailoring programs to fit the needs of diverse individuals is critical (Domenech Rodríguez, Baumann, & Schwartz, 2011; Marsiglia & Booth, 2015). DO LiFE was specifically adapted for Black MU older adults; researchers targeting other MU areas with different racial compositions and cultural backgrounds should further adapt DO LiFE for their local population regarding the target population’s specific barriers and program delivery contexts (e.g., Latino/Hispanic older adults may have language barriers, different cultural norms, etc.).

We compared key outcomes with the original program (Clemson et al., 2010) and three feasibility studies adapting LiFE for other populations (Burton, Lewin, Clemson, & Boldy, 2014; Fleig et al., 2016; Keay, Saich, & Clemson, 2015). Burton et al. (2014) adapted LiFE for older adults receiving a restorative home care service, a short-term service for older adults to regain independence after illness or injury, in Australia. Fleig et al. (2016)

Figure 2 — The flow of participants in the Stage 2 pilot study.

Table 2 Adherence Rate per Session of All Participants

Session

ID 1 2 3 4 5 6 7 Mean

1 93 93 100 94 100 93 100 96

2 100 100 100 100 94 88 97 97

3 87 100 100 100 64 100 75 89

4 100 71 100 76 83 100 100 90

5 0b 50 33b 67 100 100 67 59b

6 64 100 100 67 33a 0a 0a 60

7 97 95 87 87 85 92 94 91

8 64 68 10a 100 50 83 88 66 aLow adherence rate due to health issues. bLow adherence rate due to psychologi- cal reasons (depression).

Table 3 Preliminary Outcomes From Pre- and Posttests

Pretest Posttest

Preliminarily outcomes Mean SD Mean SD Z Effect size r

Habit formation (SRBIA) 15.88 4.32 19.00 6.57 1.62 0.41

Balance (POMA total score) 20.75 6.43 23.75 4.68 2.38 0.59

Note. SRBIA = the Self-Report Behavioral Automaticity Index; POMA = Performance-Oriented Mobility Assessment.

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adapted LiFE into a group-based format for community-dwelling older adults in Canada, and Keay et al. (2015) adapted LiFE for older adults with low vision in the United States.

Compared to other LiFE studies, we recruited older adults from MU areas and sampled a group with varied racial backgrounds, education levels, and health statuses. None of the other LiFE studies reported participants’ racial/ethnic backgrounds, and a few reported education levels (Keay et al., 2015) or health conditions (Clemson et al., 2012). The original LiFE pilot study reported that 46% of eligible participants enrolled (Clemson et al., 2010), and the other studies did not report recruitment rates (Burton et al., 2014; Fleig et al., 2016; Keay et al., 2015). We regard our 44% recruitment rate as acceptable compared with other health-promotion studies recruit- ing MU older adults (26–43%; Towne et al., 2015). We further developed similar recruitment strategies to those of other studies recruiting an MU population (Parra-Medina et al., 2004; Schrop et al., 2006). We also found that DO LiFE had a good retention rate (89%), similar to other LiFE studies (72–94%; Burton et al., 2014; Clemson et al., 2010; Fleig et al., 2016; Keay et al., 2015).

The overall adherence rate for DO LiFE was high (81%) during the intervention period. Only the original study reported an adher- ence rate (47% over 6 months). In the original study, LiFE activities were coded to correspond with structured exercise controls and were then transformed to equivalence percentages (e.g., doing LiFE 6–7 days per week is equivalent to doing structured exercise three times per week and equals a 100% adherence rate; Clemson et al., 2012), whereas we divided achieved exercise activities by planned exercise activities. Using Clemson’s method, the overall adherence rate of this study would be 93%. Nonetheless, the adherence rate was high compared to adherence in other studies for underserved populations (Stineman et al., 2011). Treatment fidelity was not reported by other LiFE adaptation studies. The acceptability of the DO LiFE program was high, consistent with other studies (Burton et al., 2014; Clemson et al., 2010, 2012; Fleig et al., 2016; Keay et al., 2015).

The preliminary outcome findings of improved balance concur with other LiFE studies (Burton et al., 2014; Clemson et al., 2010, 2012; Keay et al., 2015). However, the average POMA score at pretest was 20.75, indicating a sample with low fall risk (POMA scores ≤19 indicate fall risk). As for muscle strength, there was a ceiling effect for the manual muscle testing, suggesting that precise measures such as dynamometers should be used in future studies (Aramaki et al., 2016; Mentiplay et al., 2015).

Limitations of this study include sampling selection bias, self- rated fidelity, and unblinded raters. Selection bias may have occurred in both stages of this study. The MU older adults and service providers agreed to join this study and may have been more motivated to engage in research studies than the overall MU population. There was a risk of bias in fidelity because the interventionists self-rated the delivered tasks. Unblinded raters also pose a threat to bias outcomes. However, despite the limita- tions, the purpose of adapting LiFE for MU older adults was achieved. Future research should consider refining participant inclusion criteria for fall risk and/or selecting sensitive measures before proceeding to larger effectiveness trials.

Conclusion This study is the first step to translate LiFE for a diverse older adult population in the United States. The adapted program, DO LiFE, has been developed to serve as an alternative to structured exercise programs. DO LiFE demonstrates good feasibility among diverse older adults residing in MU areas and has potential for future

implementation. The results from the pilot study are promising; in the next phase, DO LiFE will be tested for feasibility and efficacy in a larger randomized controlled trial.

Acknowledgments

The study was supported by the St. Louis Project Grant from the Civic Engagement Fund of the Gephardt Institute for Civic and Community Engagement at Washington University in St. Louis, MO. Special thanks to Jamie Tate, Kristina Vance, Kaitlin Kaufmann, and Kelsey Filippini for assisting with the studies.

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