Risk-Reduction Behaviors in Rural Kansas
Abstract
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.
Introduction:
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
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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:
Self-Efficacy
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.
