We conducted our study in the Southeast Seattle neighborhood from March 1, 2005, through July 31, 2006. This neighborhood is largely below the median income for the city and the surrounding county (King County), and when the study began, most of the population aged 65 years or older was from races other than white. An earlier study had demonstrated that the neighborhood had sufficient resources (i.e., older adult-oriented physical activity programs, exercise facilities) to support physical activity for older adults, but demand for such programs was relatively low (9). Before this intervention, the University of Washington's (UW's) Health Promotion Research Center had also been promoting opportunities for seniors to be active (10). While the PALS study was in progress, the research center undertook a related effort to reduce common barriers to physical activity (11).

We decided that developing a program that enhanced existing efforts to improve care of people with diabetes would be most sustainable. After reviewing evidence-based support programs, we chose to import the Active Choices program (8) in a modified format and rename it Physical Activity for a Lifetime of Success, or PALS. The organizations involved were two community clinics, the neighborhood senior center, a community social services provider, and the UW's Health Promotion Research Center. PALS was made available for referral through primary care providers (PCPs). The community clinics had an ongoing quality assurance program, including participation in a collaborative care model to monitor their patients with diabetes (6). An electronic registry had been in place for several years to provide reminders, including a record field addressing physical activity (6). In July 2004, the community clinics adopted the Seattle Rapid Assessment of Physical Activity (RAPA) program (12) to assess physical activity levels for all their older patients with diabetes.

All community partners contributed to the PALS project design. We obtained institutional review board approval from UW. Before the start of the study, participating community clinics mailed a letter to all eligible participants to inform them of the project.

All patients with diabetes aged 65 years or older who had visited a clinic within the previous 18 months were eligible to participate. No a priori clinical reasons for exclusion were defined, but PCPs eliminated any patients who they determined would not be medically suitable because of comorbidities. Comorbidities that precluded participation were profound dementia, severe congestive heart failure, decompensated psychiatric illness, and terminal malignancy. Some patients were excluded because of a lack of interpreter services. Lack of telephone access was also a reason for exclusion.

The PCP referred patients to the PALS program during routine appointments. Patients completed the RAPA questionnaire at their first visit following the start of the study period. This prompted the PCP to review the patient's physical activity level and discuss the benefits of physical activity. The PCP then developed a prescription for physical activity (sample prescription available at http://depts.washington.edu/hprc/docs/parx.pdf ) in collaboration with the patient. To avoid making the process overly complex, we did not formally assess motivational readiness to exercise.

After developing the physical activity prescription, the PCP asked the patient if he or she would be receptive to contact by the PALS community support program. Patients who expressed interest signed a consent form permitting the sharing of their name, contact information, and exercise prescription with community partners. A referral was then faxed to the PALS project coordinator, who arranged an intake interview. If a person decided to participate, additional consent was obtained on the first visit to the senior center.

All clinic patients, regardless of group assignment and interest in participating in the PALS program, received a guide to local activity resources, as well as handouts about the benefits of exercise, tips on safety, and strength and balance exercises.

The PALS program was a motivational support program delivered by older adult volunteers over the telephone. The theoretical framework underlying the program on which PALS is modeled, Active Choices (8), is behavioral, incorporating principles of self-efficacy and tailoring support to an individual's readiness to change. We adapted the Active Choices program in several ways. First, we streamlined volunteer training materials and reduced the literacy level of participant materials. Second, we focused on increasing physical activity levels rather than on heart-rate goals. Third, we hired a PALS coordinator who conducted intake interviews. Fourth, the staff of the neighborhood senior center recruited telephone volunteers from among active older adults already engaged in senior center programs. Training for telephone volunteers was conducted by Active Choices staff who consulted on the PALS project and, later, by the senior center program coordinator.

We made ongoing telephone support available to participants. Except for an initial interview and intake conducted at the senior center, the client participant chose the site to carry out his or her physical activity plan and could include any combination of home- and community-based programs. Participants were encouraged to continue with the PALS program for a minimum of 6 months. Certain barriers to increasing activity were reduced: fees were waived for EnhanceFitness classes (a community-based group exercise program for older adults that originated in the Seattle area) (13), and transportation was offered to group walking sites.

The PALS program was staffed by a half-time project coordinator employed by Senior Services of Seattle/King County and was based at the senior center. Primary skills sought in the coordinator were an ability to communicate effectively, a genuine interest in working with older adults, experience in engaging and motivating volunteers, and a personal commitment to being physically active.

Clinic patients with diabetes were offered the program in a staggered manner, with one set of patients randomly allocated to a group offered PALS participation early, and another to one offered PALS 1 year later. Eligible participants were identified from the diabetes registries of each of the participating community clinics and randomly assigned to the immediate intervention group or to the 1-year, delayed intervention group. People with diabetes who reached age 65 or who newly established care at the beginning of the study were also randomized to the immediate or delayed intervention groups. Those who became newly eligible later in the study period were added to the delayed intervention group. Both these groups of patients are referred to here as "late-added participants."

The primary outcome measure for the PALS study was the participant's level of physical activity, as measured by the RAPA questionnaire (12). RAPA scores of 1–3 correspond to minimal physical activity, scores of 4 and 5 are suboptimal but consistent with some potential health benefit (4), and scores of 6 and 7 are consistent with the U.S. Surgeon General's recommendations (14) for optimal physical activity. RAPA assessments were completed upon enrollment and again at 6 or more months following enrollment.

Our secondary outcome measure was average hemoglobin A1c (HbA1c), which was assessed within 6 months of commencement of the study and at follow-up clinic visits 6 months or more after the study began.

We assessed differences between the two study groups at baseline with two sample t tests for continuous variables and chi-square tests for dichotomous variables. We used the McNemar test for matched pairs to assess differences between RAPA scores at enrollment and at follow-up.

Table 1 shows baseline characteristics of eligible participants, by intervention group. Those randomized to the immediate intervention group were significantly older than those in the delayed intervention group, because many of those who "aged in" on turning age 65 (late-added participants) were added to the delayed intervention group. The groups were otherwise well balanced with respect to sex, race, and language, as well as baseline RAPA scores and HbA1c values. Age, blood pressure, body mass index, or HbA1c did not differ significantly between those who enrolled in PALS and those who did not.

Fourteen of sixty-five persons who were offered the program enrolled (Figure).

Among the 14 PALS participants, the percentage who were sufficiently active increased, although not significantly (Table 2).

Change of HbA1c levels did not differ significantly between immediate intervention participants (average HbA1c decline, 0.1%) and delayed intervention participants (average HbA1c decline, 0.3%).

Time constraints inherent in the outpatient visit were a probable barrier to providers' offering the intervention. This factor may have been responsible for the 20% of potential participants who were never offered the intervention. Opportunities to discuss physical activity during a visit to a health care provider were frequently limited by a more acute medical issue.

Clinic visits may not be an ideal environment in which to engage participants. In addition, motivating seniors to begin exercising is a major challenge.

Because clinic visits may not be ideal settings for engaging participants, UW researchers and community clinics discontinued recruiting during clinic visits. The community clinics' health educator became responsible for contacting patients with diabetes to invite them to participate in PALS. The clinics also lowered the eligibility age for PALS to 50 years.

We are considering conducting focus groups with patients who did not enroll in PALS to understand barriers that prevented them from enrolling and to solicit their ideas about delivering such a program. In addition, we are considering obtaining feedback from PCPs on their perceptions of PALS and perspectives on offering it to patients.

We have shared the findings from this study with key physician providers at each of the community clinics. We also have discussed the findings with the director of the senior center.