Risk-Reduction Behaviors in Rural Kansas


Rural Americans (RA) report high rates of chronic illnesses and cognitive decline. RAs are

also at risk for social isolation, simply due to their geographical location, infrastructure, and

limited resources. These predisposing factors, among others, contribute to a myriad of health

issues. RAs report higher rates of cardiovascular disease and Type II diabetes\ that are associated

with unhealthy lifestyle behaviors. The KU Alzheimer’s Disease Center (KU ADC) has

developed and implemented an educational curriculum aimed at reducing cognitive decline risk

through healthy lifestyle behavior change. The LEAP! (Lifestyle Enrichment for Alzheimer’s

Prevention) curriculum has been used with older adults in rural Kansas in conjunction with

facilitated exercise to reduce risk factors. The effectiveness of this program has not been

formally evaluated. The KU ADC has determined three aims of this program, including:

1) increasing physical activity of older rural Kansas residents

2) increasing knowledge of Alzheimer’s disease (AD)

3) improve quality of life in older rural Kansas adults

To complete the evaluation process, the project will survey 200 individuals over 12 months. The

aim of this evaluation project is to assess the ability of LEAP! to increase physical activity and

AD risk reduction knowledge among healthy individuals living in the rural Kansas.


Rural Americans (RA) report significantly higher percentages of obesity and chronic

disease than their more populated, urban counterparts1,16. However, rural individuals face

different barriers to physical activity and exercise than their urban counterparts1,11,15. Such

barriers include safety, sidewalk accessibility, misconceptions about physical activity and

exercise, chronic illness, and caregiving responsibilities, among others11, 15.

Knowledge of factors that contribute to a healthy lifestyle may also pose a potential barrier for

RAs15. The belief that physical activity and/or exercise is too strenuous may in fact prevent

individuals from engaging in recommended physical activity necessary to attain a healthy

lifestyle. Clinicians know that exercise, more specifically cardiovascular exercise, has been

shown to be a powerful tool for reducing the risk of chronic diseases and cognitive decline3-10,17.

Obtaining the recommended amount of cardiovascular exercise may pose a greater challenge for

individuals living in rural communities, as they live further away from exercise facilities, and the

presence of sidewalks is often limited.

Given that 50% of all individuals are likely to experience some form of cognitive decline

by age 85, it is imperative that preventive measures be integrated into communities. Rural

populations require such programs to be tailored to their specific needs. There is a greater need for

this type of program in rural Kansas, even though the cost of the program presents a barrier to rural

residents. Alternative funding and pricing structures are currently being investigated. One of the

long-term outcomes is to identify and acquire sustainable funding sources that allow this program to

be delivered free of charge to all rural areas in Kansas.

Background and Significance:

Physical Activity, Exercise, and the Aging Brain

It is well documented that aging results in neurological changes in the human brain.

These changes (white matter atrophy, degeneration, hyper-intensities, etc.) have been directly

linked to common signs of aging such as gait and balance disorders and cognitive decline19, 25,26.

White matter change is prevalent in elderly individuals suffering from Alzheimer’s disease,

Parkinson’s disease and those who have suffered one or more strokes26. Severity of white matter

abnormalities have been linked to severity of gait and balance deficiencies, walking speed and

physical inactivity19.

Exercise has been investigated as a means of slowing down the speed at which these

neurological changes occur. In addition to preventing degenerative neurological changes,

exercise blunts the effects of other deleterious age-related deficits (e.g., sarcopenia, loss of

coordination, impaired glycemia, etc.) and often offers social benefits23,27,28. Exercise offered in

group settings has been shown to have effectively increased physical activity in daily life23 body

composition, muscular strength, quality of life and slow down progression of mild cognitive

impairment in older adults22, 28.

Physical Activity & Exercise, Cognition and AD Risk:

Exercise has successfully been found to improve a multitude of cognitive processes,

including improved cognition, improved brain function efficiency and spared brain volume27.

Both resistance training and cardiovascular exercise positively impact executive functions in

aging adults, with cardiovascular exercise most effective as increasing activity in the frontal and

parietal regions of the brain; regions associated with efficient attention control27.

Women who report higher levels of physical activity throughout a lifetime also

experience lower prevalence of cognitive decline later in life. Both men and women have the

capacity to successfully preserve cognitive function and brain volume through physical activity.

Higher volumes and intensities of physical activity have been directly correlated to improved

neurological function and brain matter17,28,29. Recent findings suggest the cardiovascular fitness

level of an individual, as opposed to the duration of a given workout, is a more specific predictor

of cognitive response in older adults at risk for AD17.

It is not surprising that individuals at risk for other chronic diseases such as diabetes and

obesity are also at higher risk for developing AD. Insulin resistance (Type II Diabetes) appears to

be a good marker for AD risk28, 30. Exercise and diet are lifestyle factors known to help control

blood sugar levels, giving individuals the ability to prevent or reverse Type II Diabetes.

Individuals willing to participate in structured cardiovascular exercise thus have the power to

both improve insulin sensitivity and inhibit cognitive decline. This powerful tool is both free to

the individual and readily adaptable to each person’s fitness level.

Rural America and Physical Activity & Exercise:

Rural Americans face unique barriers to physical activity and exercise1, 11, 15, 16.

Addressing these barriers is imperative, as RAs report higher prevalence of obesity and chronic

diseases than urban Americans. RAs also report lower attainment of education, less daily

physical activity (both by choice and due to chronic health conditions), higher all cause death

rates and greater use of tobacco products among all ages. Risk reduction education is essential to

address and preclude further health disparities in these underserved communities.

Common barriers faced by RAs are sidewalk availability, indoor walking spaces, safety,

lack of community attachment and lack of companionship among others11, 15, 31. These barriers

PRVM 835_students’ last names_ Increasing Alzheimer’s Disease Risk-Reduction Behaviors in

Rural Kansas_5-7-2017


must be considered when designing AD risk reduction education and exercise intervention

strategies. Individuals who are rural, less educated and over the age of 70 show particularly

sedentary behavior11. When compared to urban dwelling citizens, RAs have higher body mass

indices, less regular physical activity, more numerous perceived barriers to physical activity and

less access to resources and education11, 15, 31. These rural populations are at higher risk for

developing AD, as well as a myriad of other chronic health conditions. For this reason, this

investigation will attempt to provide a means of combatting the exceptional number of perceived

barriers and confounding risk factors RAs face.

Behavior Change Education for Alzheimer’s Prevention:

The KU Alzheimer’s Disease Center (KU ADC) has developed and implemented an

educational curriculum aimed at reducing cognitive decline risk through healthy lifestyle

behavior change. The LEAP! (Lifestyle Enrichment for Alzheimer’s Prevention) curriculum has

been used with older adults in rural Kansas in conjunction with instructor-led exercise. LEAP!

Foundations is a 6-week interactive education program that offers older adults (age 50+) the

opportunity to learn about the many lifestyle behaviors that impact AD risk. This curriculum

translates the latest biomedical research results into practical strategies that can be applied to

everyday life. Throughout the 6-week program, participants learn about the importance of

exercise, physical activity, social engagement, cognitive engagement, nutrition, sleep and stress

management and the links between these lifestyle factors and AD risk. Numerous opportunities

are offered during each education session to try various risk reduction strategies related to each

lifestyle factor. The effectiveness of this program has not been formally evaluated.

Evaluation Theory:


Considering the education and exercise interventions that this program will focus on, the

use of social cognitive theory which includes self-evaluation, self-observation, self-reaction, and

self-efficacy are determinants for participants to be motivated and attain their goal. For the sake

of this project, the focus is on self-efficacy which defines their ability to perform specified tasks

considering their beliefs and interpretations32.This model, used in this evaluation process is

useful in modifying the program interventions to be specific to the program participants for

better compliance and anticipated outcomes.

Figure 1: Program evaluation framework (USDHH, 1999)

Evaluation of this program is inclusive of

multiple theories and models that may suggest

effective ways to influence and change behaviors

33. The population in this project is influenced by

several factors that impact its participation in the

LEAP! Program. To obtain positive outcomes,

this evaluation process incorporates an

interaction of multiple levels of determinants that

impacts the success of the participant. The framework used in this project includes 6 steps which

are practical and nonprescriptive tools34.

The first step of this framework is to engage stakeholders who are a key part of the

program operation and are encouraged to be invested and buy into the program. Next, we must

describe the program needs, resources, design, goals, and purpose in a clear and meaningful way

to the target audience of this program. Third, we need to ensure the evaluation design

incorporates the participants, methods, and purpose of the program. Credible evidence, including

use of surveys to indicate quality, quantity, and indicators of program operation must be

collected. Based on the previous step, we must justify conclusions based on existing or new

analysis, interpretations, or recommendations provided. And finally, we will use and share

lessons learned by disseminating feedback and following up with action plans for future program

improvement. The central theme of this model represents an approach that is participantcentered. This evaluation standard has been used in previous studies and supports application to

the LEAP! Program. The evaluation standard is education specific to this population. The

evaluation standards are organized into 4 groups: utility- to ensure satisfaction; feasibility- to

ensure evaluation is viable; propriety- to ensure evaluation is ethical; and accuracy-to ensure

information is comprehensive and true to the goals and aims34.

The Social Cognitive Theory (Figure 2.) asserts that a multitude of factors affect an

individual’s desire, abilities, and behaviors as they relate to specific tasks. As stated previously,

RAs perceived unique barriers to healthy lifestyle behaviors when compared with non-rural

dwelling individuals. Understanding the unique barriers, perceptions and experiences is

imperative to this program.

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