Community-based Psychosocial–Exercise Intervention Benefits Racial/Ethnic Minority Older Adults
Key findings
- 307 older adults, mostly racial/ethnic minorities, participated in a randomized controlled trial of a concurrent mental health and exercise training intervention offered at community organizations by specially trained paraprofessionals
- At treatment completion, the intervention group showed small but statistically significant improvements on certain measures of physical function and mood
- The intervention continued having significant effects six months after treatment completion
- Half of participants attended more than half of both the psychosocial and exercise sessions, and 79% reported being very satisfied with the intervention
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According to 2017 U.S. Census Bureau projections, it's expected that by 2040, one-third of older adults in the U.S. will belong to racial/ethnic minority groups. Already, according to Migration Policy Institute data, more than one-fifth of U.S. older adults have limited English proficiency, and 12% are immigrants.
Studies show that immigrant older adults exhibit worse mental health than native-born older adults, and black, Asian and Latino older adults are at a higher risk for disability in activities of daily living and mobility than their white counterparts. Yet programs that combine cognitive–behavioral therapy and physical exercise are not typically offered in languages other than English or tailored to a variety of cultural groups.
A randomized, controlled, blinded study led by Margarita Alegría, PhD, chief of the Disparities Research Unit at Massachusetts General Hospital, found that concurrent mental health and exercise training, offered by specially trained paraprofessionals in community-based organizations, improved mood symptoms and physical functioning. The results are reported in The American Journal of Geriatric Psychiatry.
Study Methods
The trial assessed 307 participants at community-based organizations and clinics that serve low-income minorities or immigrants in Massachusetts, New York, Florida or Puerto Rico. Eligibility criteria were age ≥60; fluency in English, Spanish, Cantonese or Mandarin; minor to moderate disability on the Short Physical Performance Battery (SPPB); and a score ≥5 on either the Patient Health Questionnaire (PHQ-9), the Generalized Anxiety Disorder 7-item Scale (GAD-7) or the Geriatric Depression Scale short form (GDS-15). All instruments used in the study were translated into relevant languages.
Half of the participants were 75 or older and all but 10% were racial/ethnic minorities. At baseline, 58% rated their physical health as poor or fair, 87% reported chronic conditions and 70% identified as immigrants, with 66% speaking a primary language other than English.
After a two-hour baseline assessment, the participants were randomly assigned (1:1) to one of the following groups:
- Positive Minds–Strong Bodies intervention: 10 individual sessions over six months that were focused on psychoeducation, noticing and overcoming unhelpful thoughts, mindfulness, cognitive restructuring and creating a self-care plan, plus 36 sessions of small-group exercise training per week over 12 to 14 weeks
- Control condition: A call by research staff every two weeks to administer the PHQ-9, GAD-7 and a five-item suicide questionnaire; empathetic support if the participant expressed concern; and a booklet about caring for one's own mental and physical health
Follow-up interviews were conducted at two, six and 12 months by research assistants who were blinded to the participant's study condition.
Intent-to-Treat Analysis
At treatment completion (six months), the intervention group showed significant improvement on the Hopkins Symptom Checklist (HSCL-25), which measures psychosocial distress, but not the GAD-7. With regard to physical function, the intervention group showed significant improvement in the SPPB total score and the function component of the Late-Life Function and Disability Instrument (LLFDI), but not the World Health Organization Disability Assessment Schedule 2.0 (WHODAS 2.0). The effect sizes were small.
At 12 months, the effect of the intervention on the SPPB became nonsignificant. The effect size on the LLFDI was slightly greater, although not significantly different from the six-month result. The effect of the intervention on the WHODAS 2.0 became significant, and there was still an improvement on the HSCL-25. The intervention still had no effect on the GAD-7 score except among participants who were fully adherent to the protocol.
Intervention Acceptability
78% of participants attended at least six Positive Minds sessions, 53% attended ≥19 Strong Bodies sessions and 49% of participants met both thresholds. 79% of participants reported being very satisfied with their sessions.
Addressing Health Disparities
It seems to be possible to slow the decline of physical function with age, at least partially, independent of the participant's ethnicity and despite the presence of mental health conditions. By moving culturally competent services into the community, the Positive Minds–Strong Bodies intervention may address the great unmet need for disability services in older adult populations. In particular, the program addresses racial/ethnic disparities in service access and service quality.
Some participants noted barriers to attending sessions due to medical appointments, not feeling well enough or lack of transportation to the community organization. To improve compliance, the researchers plan to offer Strong Bodies by video, especially during winter months, to help participants build a routine and desire for exercise starting at home.
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