Lessons and limitations
A strength of this project was the use of the COM-B model to identify health behaviour gaps and to design a project to influence positive behaviours among older adults. Our quality improvement project followed the recommendation of a recent systematic review that suggested a multifactorial approach in promoting physical activity among community-dwelling older adults.38 Our project had successfully addressed the gaps of the group exercise programme in automatic motivation, reflective motivation, physical opportunity and psychological capability domains of the COM-B model.
Rewards can change behaviour through physiological arousal and encourage learning, although effectiveness varies between individuals.39 This project demonstrated that indirect monetary reward sufficed in achieving automatic motivation in improving physical activity participation among the older adults, which was similar to direct monetary incentives used in a recent randomised controlled trial among working adults.40 A similar effect was noted in an earlier national initiative, the National Steps challenge, which was designed to encourage citizens to be physically active through rewards such as grocery vouchers.41 This phenomenon could be explained through the Maslow’s hierarchy of needs model and food is a basic need in the model,42 especially for older adults who may have a limited budget for meeting their primary needs.
This project used delayed reward and found that a higher proportion of older adults maintained regular exercise. The timing that rewards are given could influence the maintenance of desired behaviour.43 If the reward was given too early (immediate), the participants were less likely to stay engaged in the physical activity, whereas when reward was delayed, participants were three times more likely to maintain their physical activity.43 Delayed reward is also a long-term motivator because it can maintain novelty and interest.39
In a recent systematic review, the authors concluded that the use of self-regulatory strategies to achieve behaviour change were insufficient and had low efficacy in achieving desired change.44 Furthermore, a large randomised controlled trial, the LIFE study, showed that a structured exercise programme of moderate intensity carried out with supervision and at home was superior to a health education strategy in improving physical health for longer-term benefits.45 Thus, direct information sharing lacked significant physical health benefits for the older adults. That said, equipping participants with knowledge is a component in the COM-B model. Similar to other established behaviour change models, the COM-B model uses motivational interviewing to empower participants with self-reflection strategies.30 46 According to Copeland et al, motivational interviewing achieved behaviour change through the development of components such as improved self-efficacy, self-control, motivation and planning. Furthermore, trained users of motivational interviewing could have a direct influence on health outcomes.46
Health ambassadors played a pivotal role in engaging the older adults for behaviour change in our project. Similarly, a recent health behaviour change programme used ambassadors to drive physical activity and dietary habits to achieve desired behaviour change.47 This was possible because the ambassadors had more communication time with the participants in our study. A society rich in communication technology usage such as social media access with mobile communication devices could strengthen health message communication.48
The benefits of group exercises extend beyond physical health gains, which included psychosocial aspects of health. The social opportunity for the older adults to interact allowed the development of friendship, reducing loneliness and formation of interest groups. In a recent systematic review, the availability of social support increased physical activity participation.49 The importance of social opportunity among older adults was best reflected in a recent meta-analysis, which pooled studies of older adults who lived in isolation and especially those who lived alone were at increased risk of early death.50 Although the endpoint of the project was to achieve increased exercise participation, future projects could explore health outcomes of the participants. Exercise participants should live longer and healthier lives, thus achieving the national vision of healthy and active ageing.
Despite the success of the project, it had a few limitations. Successful engagement of older adults requires manpower. A drop in the number of attendees was noticed on the days when the programme coordinator was unavailable to support the programme. Further, we could not continuously monitor the motivational interviewing conducted by the health ambassadors after the initial training phases. In future, a surrogate measure through monthly review of participant drop-out or regression in the stages of change could help to assess the efficacy of motivational interviewing by the health ambassadors. Finally, this programme was not designed for a pandemic which did not allow ongoing follow-up.