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Figure 2 presents a accompaniment diagram of the abstraction architecture and timeframe. We enrolled 572 Hispanic/Latino earlier adults in an exercise affairs and activated a double-blind randomized controlled balloon architecture with two arms: (a) those who accustomed the attribution-retraining chic (treatment group) and (b) those who accustomed accustomed bloom apprenticeship (control group). Antecedent studies detail the ¡Caminemos! appliance and abstraction agreement [39, 60]. The balloon was pre-registered at clinicaltrials.gov (identifier NCT00183014). The UCLA Office for Protection of Research Subjects accustomed the abstraction protocol.



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Overview of abstraction architecture and timeframe

Project agents recruited and enrolled participants amid August 2005 and August 2007 from 27 community-based chief centers amid throughout Los Angeles County that accomplice with the City and/or County of Los Angeles to accommodate chief casework such as bargain mid-day meals, recreational activities, and abetment with amusing needs such as apartment and transportation. Because of the adverse of the Latino citizenry in greater Los Angeles, we absitively not to randomize by site; the chief centers differed abundantly from anniversary added in agreement of armpit basement characteristics and actor socioeconomic status, action level, and anatomic status. In addition, randomization by sites would accept been actual airedale to our association ally (those assigned to a ascendancy accumulation would not accept the abounding intervention) and would crave a abundant beyond sample size. Thus, randomization occurred at the akin of the individual.



We acclimated a two-step agreement that included a contiguous screening with appliance of exclusion belief (Step 1). To be eligible, abeyant participants had to: (a) be 60 years of age or older, (b) self-identify as Latino, (c) be verbally chatty in English or Spanish, (d) be cognitively complete as bent by a six-item cerebral screener [61], (e) be able to airing (the use of advantageous accessories such as canes or walkers was not an exclusion criterion); (f) be physically inactive, which was authentic as agreeable in beneath than 20 min of exercise at atomic three times per week; and (g) be accessible and able to appear account exercise and apprenticeship classes captivated at the chief center. We set our exclusion belief of 20 min 3×/week, which is beneath the recommended levels of 150 min of abstinent acuteness action over the week, because our focus was on those seniors best in charge of starting a walking program. Abeyant participants who were acceptable based on the Footfall 1 screening agreement provided the name of a primary affliction physician who had apparent them in the accomplished year; this physician was beatific a fax anecdotic the abstraction and asked to accelerate a acknowledgment fax if the accommodating had any medical contraindication to accommodating in a walking program. Abeyant participants who capital to accept but had not apparent a physician were offered accessories at bounded doctors’ offices that accustomed sliding calibration payments. We afar spouses or others alive with anyone who was additionally enrolled (due to added accident of contamination) but accustomed spouses/housemates to appear the classes afterwards enrolling (and we did not aggregate any abstracts on them).

After 1 week had anesthetized afterwards cancellation of a fax from the physician advertence a medical contraindication, abeyant participants were arrive to a one-on-one acclimatization affair at the chief center, during which accomplished agents explained the abstraction and acquired accounting abreast accord to participate. Participants were accustomed a pedometer, accomplished to use it, and told to acknowledgment a anniversary later, at which point accomplished bilingual agents calm baseline data. Of 1217 abeyant participants screened, 645 (53.0%) were afar for the afterward reasons: (a) did not accommodated the abstraction belief (n = 301), the best accepted acumen actuality scheduling conflicts due to childcare responsibilities; (b) did not participate in baseline or pedometer training (n = 205); (c) beneath to participate (n = 118); or (d) bootless to complete abreast accord (n = 21) (see Fig. 2).



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Randomization occurred already the participants had appointed their arrangement to accommodate baseline data. We followed an allocation arrangement that randomized at the akin of the alone (instead of chief centers). Participants were randomized application a accidental cardinal arrangement architect application SAS software (SAS Institute, Cary, NC). Our action agents generated the allocation and a staff-member who was not complex in abstracts accumulating notified participants of their appointment to the “red” (control) or “orange” (treatment) accumulation afterwards all baseline abstracts accumulating was completed. Couples were randomized as a assemblage (only one affiliate of the brace was accustomed to accept in the study, but the added affiliate of the brace could participate in all activities added than abstracts collection). Occasionally a abeyant actor would be allotment of our computer randomization but did not complete baseline abstracts collection, arch to a non-equal cardinal of participants for anniversary group.

The labels “red group” and “orange group” were acclimated to “blind” participants to the abstraction architecture and to the primary hypotheses of the study. All participants and agents complex in abstracts accumulating were kept dark to which arm of the abstraction participants were allocated. Because it was acceptable that participants from both accoutrements of the abstraction would apperceive anniversary added and adeptness allocution to one accession about what they had learned, added precautions were taken to abbreviate contamination-biasing after-effects against the absent hypothesis. These safeguards included: (a) befitting all advisers apprenticed of the study’s hypotheses, (b) not allowing the exercise advisers to see the attribution-training chic or beam a accumulation discussion, and (c) already randomized, befitting participants in both accoutrements of the abstraction abstracted throughout the action and abstracts collection. We captivated abstracted exercise classes for orange and red accumulation participants. Participants in both accoutrements of the abstraction were apparent to the aforementioned bulk of agents acquaintance (8 h over 4 weeks for the aboriginal month, 4 h per anniversary for the abutting 11 months, again already every 2 months for the final 12 months of the study).

After acceptable participants were enrolled, provided baseline data, and were randomized into the “red” or “orange” group, they alternate for 4 afterwards weeks in a account 1-h accumulation altercation affair of 8–10 participants led by a bilingual bloom drillmaster who followed the chic for either the allegation retraining (treatment group) or the all-encompassing bloom apprenticeship (control group). The all-encompassing bloom apprenticeship accumulation accustomed a alternation of academic PowerPoint presentations created by action agents on capacity accompanying to chief wellness (e.g. adversity preparedness). In about bisected the sites (14), the accumulation discussions and the exercise classes were captivated on the aforementioned day; at added sites, they were hosted separately. The scheduling was larboard was up to the acumen of the sites.

Exercise program. In accession to the accumulation altercation affair (described in detail below), participants in both accoutrements of the abstraction alone accustomed a 1-h exercise chic (weekly for 4 weeks), which targeted beef strength, endurance, balance, and flexibility. The exercise classes were a adapted adaptation of the EnhanceFitness® Affairs (previously alleged the Lifetime Fitness Program©) administered by Chief Casework (Seattle), advised to be safe for seniors and alms both sitting (chair) and continuing options for anniversary exercise [62]. All EnhanceFitness® sessions are advised to be safe for seniors with a advanced ambit of concrete capabilities.

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A multidisciplinary aggregation of board accumulated allegation approach with amusing cerebral approach to advance a connected chic to be delivered by accomplished bloom facilitators that underscored the abstraction that acceptable physically abeyant should not be an accepted allotment of aging. In one aboriginal session, participants were tasked with advertence the affidavit for actuality comparatively active, and again accomplished to assort the affidavit as either abiding (e.g. actuality old, accepting a medical condition) or arbitrary (e.g. actuality lazy, not accepting a accomplice to exercise with). The accomplished facilitator accomplished participants to change their attributions from those that are abiding (in particular, old age) to those that are mutable, and again to botheration break calm as a accumulation how to abode the arbitrary affidavit for actuality comparatively active. Participants accustomed action affairs to access concrete action and fabricated a “promise” to do a specific action afore the abutting affair (e.g. airing for 15 min every added day). All assay accumulation participants were encouraged to address bottomward how abundant walking/exercise they did anniversary day and animadversion at the alpha of anniversary affair on how able-bodied they kept their “promise.” They additionally recorded any obstacles they encountered and the admeasurement to which they were able to affected the obstacles. Based on abstracts assuming that behavioral changes are added acceptable to be abiding if bodies are accustomed a adventitious to appraise how their behavior accept afflicted [63, 64], at the final amount session, facilitators asked anniversary actor to reflect and animadversion on attitudinal alterations that occurred over the four sessions.

After the 4-week “core intervention” period, all participants in both accoutrements of the abstraction accustomed aftereffect (reinforcement) sessions, including both 1-h exercise classes and either the allegation retraining or bloom apprenticeship classes. These accretion classes met account for 11 months afterwards the “core intervention” aeon and every 2 months for an added 12 months (total action duration = 24 months). Both the assay and the ascendancy groups were apparent to according amounts of acquaintance time with abstraction staff. During the accretion sessions, the assay accumulation accustomed exact abutment for the attribution-retraining concepts they had abstruse during the 1-month “core” intervention, while the ascendancy accumulation accustomed new bloom apprenticeship classes.

Bilingual bloom educators were recruited from the accustomed association via academic job postings as able-bodied as chat of mouth. Abstraction cadre accomplished all abeyant bloom educators as accumulation leaders over a 2-day aeon afterward a accepted chic that included accustomed accumulation abetment techniques as able-bodied as step-by-step instructions for anniversary of the four amount sessions as able-bodied as the accretion sessions. Anniversary abeyant bloom drillmaster led a “mock” affair above-mentioned to the alpha of the study; one abeyant bloom drillmaster who did not chase the chic accurately was not accustomed to advance groups. To admeasurement allegiance to the curriculum, all sessions were audiotaped and advised by abstraction cadre to assure that about three key credibility for anniversary affair were emphasized; acknowledgment to accumulation leaders was provided as needed.

Halfway through the intervention, we broadcast a fotonovela (a photo-dramatized abbreviate story) to the assay accumulation that emphasized the abstraction that actuality physically abeyant should not be an accepted allotment of accustomed aging. In the fotonovela, the protagonist, a chief Hispanic/Latina woman, initially states that she is “too old” to exercise but again auspiciously embarks on walking for approved exercise. She concludes, “Even admitting I am not young, I apprehend now that I can ascendancy my bloom and feel bigger by walking.” We adapted the accumulation baton chic to accommodate casual out and discussing the fotonovela.

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We advancing abrasion due to death, illness, or abridgement of interest. We did not acquaintance those who admired to abjure formally from the trial. However, participants who chock-full accessory the affairs were encouraged to abide by blast and through in-person affairs at the chief centers. Back addition absent a discussion, exercise, and/or abstracts collection, we attempted to reengage the being and access data. In such instances, we followed a multifaceted, IRB-approved agreement that guided beat efforts. Overall, appearance ante were 80% for both accoutrements of the intervention. Anniversary accumulation abounding 80% of the accumulation discussions and the exercise classes.

Data accumulating included pedometer readings, an in-person account to accumulate closed-ended assay items, a abrupt concrete exam, and a alternation of achievement measures [65,66,67]. Afterwards baseline, consecutive abstracts collections were conducted at 1, 12, and 24 months, which included commutual questionnaires and appointment pedometer recordings. Such abstracts were calm from 474, 401, and 314 participants, respectively. Afterwards anniversary abstracts accumulating affair a $25 honorarium was provided.

Objective and self-reported measures were acclimated to appraise concrete activity. As an cold measure, the Digiwalker pedometer (Yamax DW-500, New Lifestyles, Inc., Kansas City, MO) was acclimated to account the boilerplate cardinal of accomplish taken aural a 1-week timeframe. It measures vertical accelerations and, back beat over the hip at waist level, accurately annal the cardinal of accomplish taken aural a 3% allowance of absurdity compared to absolute ascertainment and is essentially bigger than self-reporting [39, 68,69,70]. During the weeks back the numbers of accomplish were recorded, anniversary actor met with action agents at the alpha of the week. Action agents acclimated a connected calligraphy to advise participants how to appropriately abrasion and use the pedometer afterwards attractive at the footfall counts; the pedometer was advised as a abstracts accumulating tool, not as a motivator in itself. Agents displace the pedometer to aught and taped the affectation window with a characterization that adumbrated the affair date. The participants were instructed not to accessible their pedometers for the absolute anniversary and to acknowledgment to the chief centermost at the aforementioned time the afterward week. During that time, the participants were asked to abrasion the pedometers at all times (7 days), excluding those times back they slept, swam, or bathed. For anniversary actor in the assay and ascendancy groups, the recorded cardinal of accomplish calm accumulatively over the antecedent 7 days was downloaded to a computer at a audible point during baseline and again at 1, 12. and 24 months. If there were canicule with no recorded steps, it was affected that the pedometer was not beat that day, and that advice was bare back artful the boilerplate cardinal of accomplish over the antecedent 7 non-zero canicule with a minimum of 4 days. If there were no 4 days with non-zero steps, the pedometer abstracts were coded as missing.

The Yale Concrete Action Assay (YPAS) [71] was acclimated to admeasurement self-reported perceptions of concrete action in earlier adults beyond a advanced ambit of undertakings. The YPAS has two sections that accomplish three scores. First, participants are asked to appraise the absolute time spent on a account of 25 activities in a archetypal anniversary during the antecedent month. Second, participants address the abundance and continuance of concrete action in bristles audible dimensions: active activity, leisure walking, moving, standing, and sitting. The aboriginal area is acclimated to account a absolute time arbitrary basis (total time spent accomplishing any of the listed activities) and an action amount arbitrary basis (total time spent accomplishing anniversary action assorted by a kcal acuteness cipher and summed over all activities). The additional area is acclimated to access an appraisal for the action ambit arbitrary score, affected by abacus the time spent in anniversary ambit by a weight that ranges from 5 for active action to 1 for sitting and again abacus the abounding totals beyond all bristles action dimensions. The Spanish adaptation of the YPAS has been begin to be a accurate and reliable admeasurement of action for earlier adults [72].

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The ERA-12, a adapted adaptation of the ERA-38 [73], measures age-expectations in earlier adults with approved believability and authority [74]. Affirmation suggests that earlier adults’ perceptions of crumbling access their added bloom outcomes [75,76,77]. The assay consists of 12 questions, apery three domains of expectations (four items each): accustomed health, brainy health, and cerebral function. A absolute account for crumbling expectations is acquired by accumulation all 12 items [74]. Sub-scale and absolute array on the ERA-12 ambit from 0 to 100, with college array advertence college crumbling expectations for physical, cognitive, and brainy functioning; lower array announce lower expectations associated with physical, cognitive, and brainy abatement [74]. Centralized bendability believability estimates for all scales were appear to beat 0.74 [74].

This apparatus consists of four items and uses a Likert calibration (1, not at all confident, to 10, absolutely confident) to admeasurement a person’s aplomb in his or her adeptness to consistently appoint in moderately accelerated exercise three to four times per anniversary in the approaching (1-, 2-, 4-, and 8-weeks) afterwards exacerbating preexisting symptoms. This calibration has been translated into Spanish adaptation and begin to be a accurate and reliable admeasurement of self-efficacy for exercise in earlier adults (α = .92) [78].

The OEE is a nine-item calibration that measures the aftereffect expectations for exercise amid earlier adults [79]. Aftereffect expectations are the behavior that accustomed out a specific behavior—in this case, exercise—will advance to a adorable aftereffect (e.g. accident weight, bargain glucose levels) or perceived allowances (e.g. activity active or relaxed). Such expectations accept been begin to be absolutely associated with exercise behavior [80]. OEE array ambit from 1 to 5, with 1 evocative of low aftereffect expectations for exercise, and 5 evocative of able aftereffect expectations for exercise. The OEE calibration has able centralized bendability (α = .89) and absolute affirmation appearance abutment for its believability and authority [79]. The affirmation of authority indicates that those who acclimatized consistently had college OEE array than those who did not (F = 31.3, p < .05) [79]. Moreover, a statistically cogent accord was begin amid aftereffect expectations and self-efficacy expectations (r = .66) [79].

Sociodemographic measures, bloom status, and akin of acculturation were included as abeyant confounders. The sociodemographic factors adjourned were age, sex, education, conjugal status, and income. The bloom cachet measures included anatomy accumulation basis (BMI), medical comorbidities, and concrete and brainy affection of life.

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Demographic variables included age in years and sex (male [reference group], female). Absolute ethics were created back capturing the covariates of apprenticeship (no ancestry completed [reference group], ≤eighth grade, or some aerial academy and above), assets akin (<US$20,000 [reference group], US$20,000 or more, missing income), and conjugal cachet (never affiliated [reference group], married, separated/divorced, or widowed).

BMI was affected as weight(kg)/height(m)2 and classified as angular (< 18.5), accustomed (18.5 to < 25), ample (25 to < 30), or adipose (30 or higher). Because there were almost few angular participants (n = 4), we accumulated this accumulation with those of accustomed weight in the analyses.

Because medical comorbidities affect bloom outcomes, participants adumbrated the attendance of 16 disorders application a self-administered check modeled afterwards the Charlson Comorbidity Basis [81]. These included any of the afterward conditions: (a) aerial claret pressure; (b) affection attack; (c) congestive affection failure; (d) stroke; (e) diabetes; (f) arthritis; (g) hip fracture; (h) breach of wrist, arm, or spine; (i) lung disease; (j) alarmist disease; (k) cancer; (l) Parkinson’s disease; (m) coronary avenue bypass surgery; (n) Alzheimer’s ache or dementia; (o) depression; and (p) anxiety. Any adumbrated action accustomed a account of 1 and was added calm with absent conditions, which were apparent as 0. The absolute account was advised as a connected measure, with array alignment from 0 to 16.

The 12-Item Short-Form Bloom Assay (SF-12) provides a all-encompassing admeasurement of bloom cachet by analytical eight bloom concepts: concrete functioning, role limitations due to bloom problems, actual pain, accustomed health, vitality, amusing functioning, role limitations due to affecting problems, and brainy bloom [82]. The apparatus generates basic summaries for concrete and brainy bloom through a arch apparatus analysis. Although SF-12 yields norm-based array for two ample aspects of health—physical and mental—all items are acclimated to account both arbitrary measures, with a college account apocalyptic of a bigger bloom accompaniment [83].

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SASH identifies low and aerial levels of acculturation, which frequently refers to the action of cultural and cerebral change that occurs through intercultural acquaintance [84, 85]. SASH uses a 12-item assay to admeasurement accent use, media, and indigenous amusing relations on a four-point calibration [86]. Responses are averaged beyond the items, and array ambit from 1 to 4, with college array apery greater acculturation. An all-embracing boilerplate account of 2.99 differentiates beneath acculturated respondents (≤ 2.99) from the added acculturated (> 2.99).

To appraise the success of the randomization, we affected anecdotic statistics for sociodemographic factors, bloom status, acculturation levels, and pedometer abstracts at baseline for those who were in the assay and ascendancy groups. After-effects for connected variables were generated as mean ± SD, and, for the absolute variables; after-effects are accustomed as calculation and allotment in anniversary category. Comparisons amid assay and ascendancy groups were performed with t-test (continuous variables) or chi-square analysis (categorical variables). All analyses were performed application STATA SE 14.2.

Differences in assimilation amid the assay and ascendancy accoutrements were activated application log-rank test. Two sample t-tests were acclimated to assay the connected variables over time amid the assay and ascendancy arms.

To analysis the primary abstraction antecedent apropos the aftereffect of the behavioral action on the assay compared to the ascendancy groups over time, we complete a again mixed-effects beeline corruption [87, 88] to assay longitudinal changes in the aftereffect variables as a aftereffect of the exercise chic and the attribution-retraining component. Again mixed-effects regressions acquiesce for an diff cardinal of observations beyond individuals, which is an advantage over ambiguous beeline models. Again mixed-effects corruption models additionally handle nested abstracts inherent to again observations aural individuals. All aftereffect measures were advised as connected variables. The corruption models included assay group, time in years, and the alternation of accumulation and time, as able-bodied as agreement for baseline covariates—sociodemographic factors, bloom status, and acculturation levels. Accidental furnishings for the ambush were included to acquiesce individuals to alter in the antecedent baseline values. In adjustment to facilitate the estimation of corruption after-effects accompanying to the pedometer data, decidedly the alternation effects, we advised the beeline predictions acquired with the “margins” command and the contrasts involving agency variables and their interactions application the “contrast” command.

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