CHAMPS is a lifestyle PA-promotion program for older adults. The choice-based individually tailored program provides information, skills training, support, and problem solving through a personal planning session, regular telephone follow-up, group workshops, newsletters, activity diaries, and functional fitness assessments. Using principles of social-cognitive theory, trained staff members assist participants to develop and maintain a PA regimen of their choice, based on their health, preferences, readiness to increase activity, ability, and resources. Participants are encouraged to join existing community-based PA classes and programs, develop a regimen on their own (with guidance), or both. They learn how to motivate themselves, overcome barriers, exercise safely, develop a balanced program (endurance, strength training, flexibility, balance, and coordination), and progress slowly.

For CHAMPS III, the University of California, San Francisco (UCSF) partnered with three San Francisco Bay Area community organizations differing in purpose, size, infrastructure, and clientele. The organizations were as follows:

The organizations were selected to represent different organizational models for program diffusion to reach underserved populations. Selection was also based on a history of collaboration with UCSF faculty working in minority health research. Because extensive time is needed to establish an effective relationship with community-based organizations (24,25), this history helped to provide a foundation of trust. We aimed for each organization to provide the program to community members, with UCSF serving in a background role. 

The UCSF team had expertise in social work, exercise physiology, health education, and community work. UCSF's role was to 1) help adapt the program to be as similar as possible to the original, 2) develop new program materials, 3) translate materials into Spanish as needed, 4) provide training, 5) monitor implementation, and 6) conduct program evaluation.

The California Endowment funded the project in November 1999 through its CommunitiesFirst initiative (26). This initiative was not intended to support research, so the goal of CHAMPS III was to develop sustainable programs that met the needs of the communities and organizations. The evaluation was designed to reflect the entire process — from adaptation through implementation. The desire of our three organizations to minimize the burden of assessment (i.e., paperwork) for participants and staff guided many of our choices. We reviewed several program evaluation approaches (27) and selected the Centers for Disease Control and Prevention's Physical Activity Evaluation Handbook (28), which conceptualizes a project as a sequence of steps leading to a specified goal. A logic model describes influential factors, inputs, activities, and initial, intermediate, and long-term outcomes, including links among them. Each step is evaluated, and a feedback loop is included. The logic model is intended as a flexible framework that can be interpreted to fit specific project needs. The Figure presents our interpretation of the logic model for CHAMPS III.

The project included 1 year for planning and adaptation (November 1999 through October 2000) and 2 years for implementation and evaluation (November 2000 through October 2002). Planning and adaptation activities included community focus groups on PA attitudes, preferences, and barriers (29,30); planning meetings; and advisory groups (Figure).

We adapted the program for each organization to maximize safety, feasibility, sustainability, and effectiveness. The original model was not feasible for any of the three organizations selected for this study; thus, during adaptation, we identified the purpose of each component of the original program (e.g., education, motivation) and determined whether it could be achieved in a different way. For example, although grant funding was available, 30th Street did not hire an exercise specialist because it was not sustainable. (Volunteers provide many of their programs.) Adaptations continued during implementation based on participant and staff feedback. Planning outputs for each organization are summarized in Table 1.

One challenge was determining appropriate medical screening procedures based on staffing differences and a reduced capacity for providing individual guidance compared with CHAMPS II. Unique situations also had to be considered; for example, most PA classes at 30th Street were historically available without medical screening or consent. Balancing the need for participant safety with the need to reduce barriers to participation also influenced CHAMPS III procedures. 

The evaluation plan was similar among organizations and included process evaluation to understand adaptation and implementation (31). Every 6 to 12 months, the principal investigator conducted informal, semistructured interviews with staff, volunteers, and directors to obtain their perspective on the successes and challenges of the program and suggestions for improvement. Depending on the project phase, we included additional questions on topics such as collaboration, sustainability, and the program's effect on the organization and community at large.

To measure individual outcomes, interviewers administered the CHAMPS Physical Activity Questionnaire (21,32-34) in English or Spanish at enrollment and 6 months. From these data, we estimated for each cohort the mean number of calories per week expended and hours per week spent in PA. We compared baseline and 6-month data using paired t tests to determine the significance of the changes. Staff also obtained informal input from participants throughout the project, and the Network director conducted a discussion group at the end of the first cohort. The UCSF Institutional Review Board approved a waiver of consent for all evaluation procedures.

Each organization offered a 6-month program, enrolling two to seven cohorts. During implementation, Network and 30th Street required substantial assistance from UCSF staff, whereas Sequoia conducted its entire program using its own resources. Because PA resources were almost nonexistent in Network's community, developing new resources became an essential part of its program.

Feedback from participants and staff and other factors such as community interest resulted in some early recruitment and program modifications. For example, at Network and 30th Street, the initial recruitment plan was adapted to provide "rolling" or ongoing enrollment to accommodate individuals who wanted to join after the program was underway. 

Table 2 shows how each program in CHAMPS III differed from CHAMPS II in several areas, including staffing, duration, and components offered, and the manner in which the components were provided. The lack of an exercise specialist and other health professionals to offer the one-on-one program components at 30th Street and Network represented a major change from CHAMPS II to CHAMPS III, and the program was shortened from 1 year to 6 months. Of the components offered in CHAMPS II, the following three were included at all CHAMPS III organizations: functional fitness testing, group workshops, and PA resource directories. Functional fitness assessments were conducted at two sites by volunteers or other participants for educational, planning, and motivational purposes only.

Only Network provided newsletters but in a modified form. 30th Street created a program bulletin board to display announcements and information. The personal planning session and ongoing telephone support were not offered by any organization because of staffing and budget constraints. In CHAMPS II, these two components enabled personal attention and individualized guidance through discussion of topics such as readiness to change, exercise safety, barriers to PA, resources, and goal setting. Even Sequoia found these components too labor-intensive despite having appropriate staff. Elements from these components were included in CHAMPS III group workshops whenever possible. All organizations used occasional reminder telephone calls; Network also provided check-in calls when participants missed activities. New features were added to some programs, such as a weekly program-based exercise class at Network. This class provided informal support activities, such as sending get-well cards to fellow participants.

Table 3 summarizes the characteristics of participants at the three organizations, which enrolled a total of 321 people; most (76% to 97%) were women. A broad age range was represented: 24% to 52% were aged 75 years and older. Each organization had a different ethnic mix: of Network's enrollees, 90% were African American; of 30th Street's enrollees, 84% were Latino. Sequoia had difficulty recruiting lower-income and minority groups; however, of its enrollees, 33% were nonwhite. Participants at 30th Street had low educational levels; more than half had less than a high school education. At Sequoia, just over 10% had less than a high school education; education was not assessed at Network because community input indicated that the question was too sensitive. Each organization promoted some events to the community at large (or the entire senior center); therefore, the reach of each program sometimes extended beyond the people who formally joined.

Intermediate outcomes were measured at the organizational, participant, and community levels immediately after the intervention was completed.

Organization-level outcomes

Each program was unique, and offerings changed as the program evolved and new cohorts were enrolled; thus, the number of activities that were offered varied. Network's cohorts could attend seven or eight exercise- and health-related workshops and a weekly exercise class. Functional fitness tests were offered two times per cohort. Special events like potluck luncheons were held occasionally. 30th Street offered to each cohort six exercise-related workshops, two to three additional exercise- and health-related presentations, five to seven The Doctor Is In sessions (a question-and-answer forum with a physician about exercise and various medical conditions), and one to four special events such as celebrations of participants' program completion. Participants could complete fitness testing one or two times. Sequoia's program at each senior center consisted of eight workshops, including two functional fitness testing sessions and a celebration at completion of the program.

We obtained input on intermediate organization-level outcomes from staff and administrators through process evaluation. A Network administrator noted that although the organization primarily focused on frail elders, CHAMPS III provided an opportunity to reach seniors who were not homebound or as frail as its typical client. The project also brought together public and nonprofit community organizations.

30th Street administrators reported positive organization-level changes such as enhanced awareness among staff, volunteers, and seniors of the benefits of PA as well as increased participation in their ongoing exercise classes (open to all 30th Street attendees). The emphasis on increasing PA also attracted younger seniors to the center. Some local physicians referred patients to 30th Street because of increased program awareness. Because of low participation among men, 30th Street hosted a men's conference on the benefits of PA and sought information on what might help them become more active. Efforts were then initiated through the city's recreation and parks department to develop activities suggested by the men. New partnerships provided a channel for sharing information on topics such as potential funding or community resources. Both 30th Street and Network gained access to several academic programs that provided student interns.

Sequoia's new approach of offering programs at community senior centers (rather than at its own site) led to increased community awareness and appreciation. Sequoia created new partnerships and strengthened existing ones with several senior centers; they are committed to working together to help maintain seniors' independence.

Participant-level outcomes 

Of the 321 participants enrolled in the three programs, 207 completed baseline and 6-month follow-up questionnaires. Six-month changes in PA are shown in Table 4, indicated by changes in estimated caloric expenditure per week and hours spent per week in PA. A trend toward increased PA was observed at Network (+481 kcal/week, P = .08; +1.9 hrs/week, P = .10) and Sequoia (+437 kcal/week, P = .06; +2.0 hrs/week, P = .08). No statistically significant change in caloric expenditure was observed at 30th Street, but there was a trend toward decreased duration (−1.4 hrs/week, P = .09). For the total sample among organizations (n = 207), there was a trend toward increased caloric expenditure (+213 kcal/week, P = .10). The overall 6-month response rate at Sequoia was low (52%), with 83 of 160 participants completing the follow-up questionnaire; thus, results may not represent all people participating in the Sequoia program. The response rate at Network was 85% (53/62), and the response rate at 30th Street was 72% (71/99).

Network obtained an informal evaluation by participants through a one-time discussion group after being in the program for about 6 months. Most of the feedback was positive. For example, the participants particularly liked the group exercise, fellowship, and a chance to meet new people. They felt that the program "helped them help themselves" and perceived both physical and mental benefits. Constructive criticism was also provided; participants felt that the classes and workshops were too short, and they wanted more exercise equipment such as treadmills. 

Community-level outcomes

At Network, new partnerships with other community organizations developed, enhancing PA resources for seniors. As noted previously, there were no exercise classes available in the Bayview Hunters Point community at the beginning of the program. By the end, there were six: three offered by the local community college, one beginner pool-exercise class, and one African American line-dancing class, in addition to the program's exercise class. One intern helped start a walking group that developed into a partnership between the program, the city's recreation and parks department, and Network's interfaith volunteer group. All of these exercise resources were formally or informally associated with Network's program. Program participants regularly attended the community college classes and helped keep enrollment high enough to sustain the classes. Seniors and staff in Network's program successfully advocated for new chairs, improved lighting, and regular cleaning of the gymnasium where some classes were held. Some enrollees became formally involved with the Trust for Public Land in developing a new community park. The Trust approached the seniors to conduct programs in the park, plan clean-up and planting days, and promote these activities in their community.

At 30th Street, a new tai chi class was offered twice weekly and became affiliated with the program, with an average attendance of nearly 40. During the project, Sequoia's staff learned from participants that there was a need for fall prevention; some participants dropped out because they were afraid of falling. Sequoia developed and started teaching fall-prevention and strength-training classes at three senior centers. The new program attracted new clients. One senior center organized a fitness advisory board to determine which fitness and health classes should be offered.

Each program received news media attention that helped expand its reach into the community, although most attention was for Network. A local community newspaper published four articles about PA and Network's program, and the program was featured on KQED (National Public Radio) in a prime-time report. The line-dancing class was featured by the San Francisco Chronicle. For 30th Street, a local Spanish-language newspaper included an article about PA for seniors and the 30th Street program.

Long-term outcomes are defined as those that were measured 1.5 years after the funding for CHAMPS III ended. Ultimately, the success of diffusion programs is determined by their sustained availability to community members; all organizations in CHAMPS III are continuing efforts to promote PA for older adults, despite funding challenges.

At Network, five community dance and exercise classes have continued. In addition, Senior Strutters, a performance group that evolved from the African American line-dancing class, often performs at community events. Because of the increased number of seniors at the city recreation and parks department's facility where the program class is held, the department provided a staff member to help with set-up and registration, and an employee now teaches the class, which may help the class continue. Network staff maintains the monthly PA resource calendar discussed previously. These are substantial accomplishments, because the entire program is run by the seniors who volunteer their time to promote and coordinate the program and sustain the exercise classes created in their community; no staff is currently paid to coordinate the program.

30th Street obtained funding for 2 years to continue and expand its program. The grant supported a bilingual Wellness Services Coordinator dedicated to the program and provided for two treadmills. In the new program, physician consent was obtained using a new form that enables physicians to indicate which classes offered at 30th Street are appropriate for each individual. This allows the coordinator, without being a trained exercise professional, to tailor the program to some extent for each participant. In addition, 30th Street's tai chi class has continued, and a second advanced class has been added.

At Sequoia, efforts have shifted to providing the Mature & Secure From Falls program. Sequoia Hospital offers these programs at no charge. The program has developed into a 6-week community-based class series and has been presented at more than 20 sites in San Mateo County. Sequoia also convened the San Mateo County Fall Prevention Task Force, where 27 organizations providing services to seniors are working to increase awareness about the need for fall prevention and to develop related resources.