Evaluation of a Volunteer-led in-home Exercise Program for Home-bound Older Adults

Work 41 (2012) 339354 339DOI 10.3233/WOR-2012-1304IOS Press

Evaluation of a volunteer-led in-homeexercise program for home-bound older adults

Paul Stoleea,, Christine Zazab and Sheila SchuehleincaDepartment of Health Studies and Gerontology, University of Waterloo, Waterloo, CanadabDepartment of Psychology, Wilfrid Laurier University, Waterloo, CanadacVictorian Order of Nurses, Ottawa, Canada

Received 19 July 2010

Accepted 25 March 2011

Abstract. Objective: Exercise programs have been found to have substantial benefits for older persons, but implementing theseprograms with frail homebound seniors is challenging. The project team aimed to evaluate an in-home exercise program for olderadults the Victorian Order of Nurses for Canadas SMART (Seniors Maintaining Active Roles Together) (VON SMART )In-Home Exercise Program in which the exercises are led by trained volunteers. The majority of volunteers were females whoexercise regularly. Over half of the volunteers were 60 years of age or older, and over half had had prior health or fitness training.Volunteers reported receiving multiple benefits from performing their role as an exercise leader.Participants: From January to August, 2009, a total of 59 volunteers, seven Site Coordinators, and 33 home-bound older (meanage: 80 years; SD: 8.8) clients from eight VON sites and one partner organization participated in the evaluation.Methods: Data collection included pre-post quantitative measures of participants physical function, satisfaction surveys ofparticipants, follow up semi-structured interviews of participants, feedback surveys of volunteers and site coordinators, and afocus group interview of site coordinators.Results: The Chair Stand test (p < 0.001), the Reaching Forward test (p = 0.028), the Activities Balance Confidence Scale (p =0.02), as well as measures of activities of daily living (ADL) inside the home (p = 0.001) and outside the home (p = 0.009)showed significant improvement.Conclusions: This evaluation showed that the exercises improved participants strength, flexibility, balance, and ability to performADL. This study provides additional evidence of the benefits of in-home exercise for frail seniors, and supports a role forvolunteers in delivering these programs. The volunteers reported receiving social benefits of meeting new people, being able tosee the difference they helped make in others, as well as personal physical benefits from exercising more.

Keywords: Home exercise, volunteers, frail seniors, physical function

1. Introduction

There is strong evidence that exercise for older adultspromotes health and can delay or reverse functional de-cline [7,26,32,34,50]. The health benefits of exercisefor older adults include increased longevity, reducedrisk of common chronic diseases, and reduced falls [19,

Address for correspondence: Dr. Paul Stolee, Department ofHealth Studies and Gerontology, University of Waterloo, 200 Uni-versity Avenue West, Waterloo, Ontario, N2L 3G1 Canada. Tel.: +1519 888 4567; Fax: +1 519 888 4362; E-mail: [email protected].

35,42,45]. The authors of this paper believe that thesebenefits can in turn enable greater participation in so-cial, volunteer, and occupational activities.

Providing exercise programs in the homewould haveobvious benefits for home-boundand other frail seniorsfor whom travel to a community center or other facilitywould present risks. There is a small but growing litera-ture on home-based exercise programs and while someresults are promising [17,27,28] other studies have pro-duced more equivocal results [9,30,32]. Home-basedprograms have the potential to be a cost-effective op-tion, however most reported programs involve phys-

1051-9815/12/$27.50 2012 IOS Press and the authors. All rights reserved

340 P. Stolee et al. / Evaluation of a volunteer-led in-home exercise program for home-bound older adults

ical therapists [18,27,28], professional exercise train-ers [25,52], or visits to a community center [38,50],all of which would add costs to the programs and limittheir feasibility and generalizability.

From 20052008, the Victorian Order of Nursesfor Canada (VON) implemented both SMART (Se-niors Maintaining Active Roles Together) In-Homeand Group Exercise Programs in sites across Canadawith support from the Ontario Trillium Foundation andthe Public Health Agency of Canada as part of theVONs Functional Fitness Continuum Initiative. Boththe VON SMART In-Home and Group Exercise Pro-grams are designed for seniors who are unable to attendtraditional community fitness programs due to barrierssuch as limited mobility, lack of transportation, limitedfinancial resources, and poor health.

The VON SMART In-Home Exercise Program is avolunteer-led exercise intervention, delivered one-on-one to home-bound older adults (55 years of age andolder) during 12 home visits to engage older adults inphysical activity, regardless of their physical impair-ments. In an initial evaluation of an earlier versionof this program [12], the majority of participants wereable to maintain or improve function following partic-ipation in the program. Based on these findings, theVON concluded that the program was a potentially sig-nificant strategy for reaching homebound older adultswho would not otherwise have had access to exerciseat an appropriate level. In 2008, the VON modified theoriginal exercise program to include a new selection ofexercises.

The key motivation for volunteers to do this as un-paid work is that they see their efforts are making adifference. Being a SMART volunteer is a responsi-ble role with liability and risk, and is challenging andstimulating for them. More than half of the volunteershave past education in health and the majority are in-terested in fitness. The volunteers are aware that theirunpaid participation is critical to the success of the pro-gram because the costs of paying exercise leaders areprohibitive for the system and the clients.

The purposes of this paper are to describe this mod-ified VON SMART In-Home Program and to presentthe methods and results of a pilot evaluation of theprogram.

2. Methods

2.1. Exercise program

The target audience for the VON SMART In-Home Program is potentially frail, isolated communi-

ty dwelling older adults who are managing health andmobility challenges. The programs central goal is toaccommodate the specific needs of those who partic-ipate while encouraging appropriate exercise progres-sion. The selection of exercises included in the VONSMART In-Home Program was guided by a decadeof evaluation. The 15 exercises, developed by the pro-gram partners listed below, have been used internation-ally to promote falls prevention and overall improve-ment in functional fitness.

The VON SMART In-Home Exercise program us-es, with permission, a selection of exercises adaptedfrom Philips-Lifeline and from the Smart Moves pro-gram from SMARTRISK of the Ontario Injury Preven-tion Resource Centre. The exercises included in thenew program are as follows: 1) ankle range of mo-tion; 2) warm-up walk; 3) chair stand; 4) seated row;5) heel/toe raises; 6) side leg raise; 7) modified hipextension; 8) modified push-up; 9) arm raises; 10) tri-ceps push-up; 11) modified abdominal curl; 12) cheststretch; 13) calf stretch; 14) chin-to-chest stretch; and15) independent walking. These exercises are simi-lar to those used previously in exercise programs forseniors [6,8,14,23,32,48,49,52].

All participants were asked to use a calendar to in-dicate how and when they performed the exercises be-tween the volunteers visits. For example, if a par-ticipant could only perform a particular exercise in amodified way at first, then was able to progress to theunmodified version, that would be recorded on the cal-endar. In this way, the calendars were also a source ofmotivation for the participants, as well as a means oftracking progress (i.e., frequency and repetitions).

VON site coordinators have a college diploma inone of the health/social science disciplines, as well aspost secondary education in volunteermanagement or aminimum two years experience in volunteer leadership.Volunteers for the VON SMART In-Home ExerciseProgram were recruited through the VONs volunteerprogram.

Volunteers ranged in age from 19 to 80 years of age.The typicalVON SMART volunteer is female. Thirtyof the 53 (56%) volunteers who provided their year ofbirth were 60 years of age or older, and 51% (28/55)had extensive previous experience and/or professionalqualifications in either health or fitness (e.g., Nursing,Certified Fitness Instructor, Yoga Instructor). Seventy-six percent of the volunteers (41/54) reported exercisingthree or more times per week, and 78% of volunteers(42/54) exercised for more than 30 minutes per session.

All volunteers are screened by the Site Coordinatorand participate in an orientation and training program.

P. Stolee et al. / Evaluation of a volunteer-led in-home exercise program for home-bound older adults 341

To prepare for their role, volunteers undergo a day anda half education session where they learn how to safelyteach the exercises to clients. The education sessionsare comprised of six education modules as follows: 1)Frailty, Learned Helplessness and Wellbeing; 2) Func-tionally Fit for Home Exercise and Independence;3) Factors Affecting Physical Activity and the Role ofAgeism; 4) Exercise and Fall Prevention; 5) Teach-ing the Exercises, Safety and Exercise Practice; and6) Scope of Practice and Community Referrals. Feed-back on the education sessions showed that volunteersfelt prepared and confident after having completed theeducation sessions.

Although the site co-ordinators did not formally eval-uate the volunteers in this project, they did accompanythe volunteers on first visits, as a mentor, and so theyhad opportunity to observe them and provide them withfeedback at that initial session.

The VON invited eighteen VON sites in Canada toparticipate in the evaluation. Nine VON sites and onepartner organization subsequently participated in theevaluation between January and August 2009.

2.2. Measures

2.2.1. Functional assessment testing of participantsTo evaluate the effectiveness of the new exercise

program, project team members identified a battery ofassessment tools that addressed areas of functioningrelevant to the aims of the exercises and that would befeasible for participants to complete.

The assessments were to be conducted by the SiteCoordinator no more than one week prior to the partic-ipant starting the exercise program (i.e., the Pre-Test)and again no more than one week after the participantcompleted the exercise program (i.e., the Post-Test).The functional assessment battery consisted of stan-dardized functional measures designed for older per-sons.

Berg Balance Scale items: Five items from the BergBalance Scale [5] were used to assess flexibility andlower body strength. These items tested the followingmovements: 1) Standing to sitting, 2) Standing unsup-ported, 3) Sitting unsupported with feet on the floor,4) Standing to sitting, and, 5) Reaching forward. Allfive of these items were scored from 0 to 4, with 0 in-dicating the need for moderate to maximal assistanceand 4 indicating the ability to perform the movementindependently.

Senior Fitness Test Manual items: Additional mea-sures included three tests used in the Senior Fitness Test

Manual developed by Rikli and Jones [43], namely, theChair Sit and Reach test, the Chair Stand test, and theBack Scratch Test. Participants safety was of utmostconcern during data collection. As such, Site Coordina-tors were asked to encourage participants to not attemptor discontinue any test that they (i.e., the participants)felt posed a risk, or made them uncomfortable.

Activities-Specific Balance Confidence Scale: Theassessment also included the Activities-Specific Bal-ance Confidence (ABC) scale, which is a 16-item self-report assessment of balance confidence [41]. Thiswas included because research has found that the to-tal ABC score correlates with measures of gait in theelderly [24].

ADL measurement: For the purposes of the study,the project team developed two 100-point Activitiesof Daily Living (ADL) scales, one of which measuredADL in the home (e.g., dressing, bathing, walkingabout), and one that measured ADL outside the home(e.g., shopping, attending appointments, visiting). The100 point scale was used in order to be consistent withthe 100% confidence scale presented in the ABC scalewhich immediately preceded these ADL items. Theproject team presented the scale as a horizontal line,with vertical ticks marking every 10 points. The an-chors were 0: Not At All Able and 100: ExtremelyAble.

Theory of Planned Behavior measurement: Theproject team developed assessment items designed tomeasure the factors from the Theory of Planned Be-havior [1,2,13,39], as this theory shows that exercisebehavior can be predicted by an individuals intentionto exercise [20]. Intention to exercise is determinedby ones attitude toward exercise (i.e., feelings and be-liefs about exercise), subjective norms (i.e., whetherfamily and friends exercise and feel it is important forthe individual to exercise), and perceived control over(i.e., ability to) exercise. Attitude measures ones be-liefs about the behavior and/or its outcome (e.g., Reg-ular exercise is important for me to remain physicallyfit). Subjective norms measure social influences thatone feels from significant others, for example, whetherfriends and family approve of the behavior, and if theythemselves engage in the behaviour (e.g., My familyand friends exercise regularly.). Perceived behavioralcontrol measures ones perceptions of whether the be-havior is within ones control (how easy or difficult thebehavior is to carry out) (e.g., I am able to completethe exercises I learned in the program on my own athome now that the program is over.). Together, thesethree factors measure intentions, which is the best sin-


gle predictor of a persons behaviour (e.g., I plan tocontinue doing the exercises on my own at home nowthat the program is over.).

Goal Attainment: On the pre-test, participants wereasked to identify any activity that they had difficultydoing that they wanted to be able to do more easily afterthe VON SMART In-Home Exercise Program (e.g.,walk safely from bedroom to bathroom). Participantsgoals were measured by the questionIs there anythingthat you have difficulty doing now that you would like tobe able to do more easily after the SMART In-HomeEx-ercise Program? Most goals related to walking, bal-ance, and general mobility around the house, includingendurance, fear of falling, and reaching. Participantswere then reminded of this activity on the post-test, andwere asked to comment on and rate their ability to dothat activity at the time of the post-test on a 4-pointscale, where 1 = more trouble now, 2 = no change, 3= I can do it better now, but still not as well as I hopeto be able to do it some day, 4= I can do it as well as Ihad hoped to be able to do it.

2.2.2. Participant satisfaction surveyThe project team obtained participants satisfaction,

perceptions, and attitudes toward the program througha Participant Satisfaction Surveywhichwas given at theend of the 12-week exercise program. This survey con-sisted of 32 questions, 12 of which were open-ended.Questions asked participants to report on exercise atti-tude, behaviour, and intention to exercise on their ownafter the program, reasons for not doing the exerciseson their own, perceptions and satisfaction with the pro-gram, goals, ADL, and level of physical activity. Atthe post-test, the project team reminded participants oftheir goals stated at pre-test and asked Are you able todo this any better now compared to before you startedthe exercise program? The project team also askedparticipants who could be reached to participate in afollow up telephone interview. All those who could bereached were contacted.

2.2.3. Participant follow-up interviewsFollowing completion of the 12-week exercise pro-

gram, all 22 participants for whom we had contact in-formation were invited to participate in a follow-up in-terview. The project team used a semi-structured inter-view guide to ask participants for their perceptions ofthe exercises, barriers and facilitators to exercise, andthe volunteer, as well as their future plans to exercise.The mean duration of the follow-up interviews withparticipants was 14 minutes (SD = 4.7 minutes), witha range of 9 to 25 minutes.

2.2.4. Volunteer follow-up surveyVolunteers completed a survey at the completion of

the exercise program. There were 21 items on thissurvey, six of which were open-ended (see AppendixA). Questions asked about perceptions of preparednessand confidence in volunteers ability to implement theprogram with participants, how many participants theywere matched with, perceptions of various aspects ofthe program and the exercises, perceptions of barri-ers and facilitators to the program, and future plans tovolunteer in this program.

2.2.5. Site coordinator follow-up surveySite Coordinators completed a survey at the com-

pletion of the exercise program. There were 26 itemson this survey, 14 of which were open-ended. Ques-tions assessed Site Coordinators impressions of theprogram, including barriers and facilitators to the pro-gram.

2.2.6. Site coordinator focus group interviewAfter all other data were collected, coordinators also

participated in a telephone interview for their thoughtson the data collection process, participants, and pro-gram. This interview was not planned at the start of theevaluation, but was added because the number of par-ticipants was much lower than initially expected. Inter-view questions were emailed to the Coordinators in ad-vance of the teleconference. The purpose of the focusgroup interview was to explore coordinators overallimpressions about the evaluation and to inquire aboutwhy the numbers of participants were lower than ex-pected. Coordinators were asked about participantsreasons for non-participation in the evaluation or non-completion of the program. Specifically, the projectteam was wondering if there were any differences interms of participants ability to complete the 12-weekprogram, and if there were any demographic differ-ences (e.g., health, age, or living arrangements).

2.3. Sample

Based on the ability to detect a difference of 0.5standard deviations (SDs) in the Chair Reach test [0.5SDs is an accepted guideline for a minimal clinical-ly important difference [36], with alpha = 0.05 (two-tailed) and with beta = 0.20 (80% power), the projectteam calculated that a sample size of 32 participantswho had completed both pre and post-test measureswould be needed. Initially, 108 questionnaires weresent to site coordinators, based on their estimate of how


Table 1Health conditions reported by participants (N = 28)

Condition Number

High blood pressure, Stroke (Cerebrovascular disease) 13Arthritis/Osteoarthritis 12Osteoporosis 9Depression 8Diabetes 7Heart attack, Angina (Cardiovascular disease) 5Other 8

many participants they hoped to have in the program.This number proved to be far too ambitious, and eachsite coordinator was able to enrol only a few partici-pants in the evaluation of the exercise program. Thirty-three participants returned pre-test questionnaires; 26returned post-tests. Twenty-eight participants returneda Participant Satisfaction Survey. The project teamcontacted twenty participants to participate in a follow-up interview; 11 of these consented to participate (fivedeclined, three could not be reached, and one had died).

The average age of participants (based on responsesto the Participant Satisfaction Survey) was 80 years(SD = 8.8; range: 61 to 93 years; 20 participantsanswered this question). More than two-thirds (68%)of the participants were female.

Table 1 lists the health conditions reported by partic-ipants.

Fifty-nine volunteers returned a Volunteer EducationFeedback Survey (although four of those had a lot ofmissing data, and were not usable), and 16 volunteersreturned a Volunteer Follow-Up Survey. It should benoted that not all of the volunteers who completed theeducation session were matched up with a seniors whoparticipated in this evaluation; some volunteers mayhave been on vacation at the time of the evaluation,some volunteers may have been matched with a partic-ipant who had undergone the exercise program before(andwas thus ineligible for the evaluation), and in somecases, a site may have had too few participants to bematched with a volunteer at the time of the evaluation.

Seven (of seven) Site Coordinators returned a Coor-dinator Satisfaction Survey, and five of those partici-pated in a focus group teleconference at the end of datacollection.

2.4. Data collection

Data Collection began in mid-January 2009. Datacollection for the evaluation proved challenging dueto the frailty of the participants, the time constraintsof the Site Coordinators, staff turnover among VONCoordinators, and uncertainties associated with work-

ing with volunteers, especially over the winter months(when some volunteers might take vacation, for exam-ple). Therefore, to increase the number of participants,the original project completion date of June 2009 wasextended until the end of August, 2009.

Site Coordinators provided their estimate of the num-ber of volunteers and participants at their sites. Basedon this estimate, the project team sent out data collec-tion surveys to the sites between January and April,2009. Ten sites agreed to participate in the evaluation:1) Cumberland, Nova Scotia, Canada; 2) Sackville,New Brunswick, Canada1 (all other sites are in Ontario,Canada); 3) Durham County; 4) Greater Kingston; 5)Hamilton; 6) Hastings, Northumberland, Prince Ed-ward County; 7) Perth-Huron Counties; 8) SimcoeCounty; 9) Thunder Bay; 10) Guelph (the GuelphWellington Seniors Association Feeling Better Pro-gram). The first nine of these are VON sites; the projectteam included one partner agency, the GWSA FeelingBetter Program, since they were also implementingthe VON SMART In-Home Exercise Program.

The project team entered and analyzed all quantita-tive data in SPSS version 17.

2.5. Ethics

The evaluation protocol received ethics clearancefrom the Ethics Review Board at the University of Wa-terloo. The project team ensured anonymity and con-fidentiality of participants and volunteers by using IDnumbers (for participants) and month of birth plus thelast 3 digits of telephone numbers (for volunteers).

3. Results

3.1. Functional assessment testing

As Table 2 shows, most participants performed mostof the functional assessment tests on the pre-test andpost-test. As mentioned earlier, the project team askedSite Coordinators to encourage participants to not at-tempt or discontinue any exercise that made them feeluncomfortable, or at risk.

Twenty participants completed their post-test assess-ment of goal improvement. Of these, 17 felt that theyhad improved, especially in confidence and endurance.

1The Cumberland and Sackville sites shared the same Site Coor-dinator.


Table 2Functional assessment scores of continuous data shown for the pre-test sample and the post-test sample

Mean pre-test score (SD) Mean post-test score (SD)(n = 33, reduced numbers for (n = 26, reduced numbers foreach test reflect number able each test reflect number ableto complete the test) to complete the test)

Chair stand (# full stands in 30 seconds) 4.7 (SD = 2.8) (n = 26) 6.9 (SD = 2.1) (n = 21)Chair sit and reach (# inches from fingertips to toes) 4.0 inches (SD = 5.6) (n = 28) 5.2 inches (SD = 6.2) (n = 21)Back scratch (# inches fingertips were apart) 8.99 inches (SD = 5.4) (n = 28) 8.93 inches (SD = 4.8) (n = 23)Reaching forward (# inches reached) 5.76 inches (SD = 3.6) (n = 28) 7.86 inches (SD = 4.7) (n = 21)

Berg items (scored from 0 to 4)Sitting to standing 2.9 (SD = 0.56) (n = 29) 3.2 (SD = 1.17) (n = 26)Standing unsupported 3.6 (SD = 0.72) (n = 32) 3.5 (SD = 1.14) (n = 26)Sitting unsupported 3.81 (SD = 0.54) (n = 31) 3.96 (SD = 0.20) (n = 26)Standing to sitting 3.4 (SD = 0.80) (n = 31) 3.5 (SD = 0.65) (n = 26)Reaching forward 2.7 (SD = 0.86) (n = 28) 2.9 (SD = 0.78) (n = 21)Mean total of the 5 BERG items (out of 20) 16.8 (SD = 2.4) (n = 24) 17.4 (SD =1.9) (n = 25)

Self-report scalesABC scale (0100) 43.2 (SD = 19.2) (n = 27) 50.6 (SD = 22.8) (n = 22)ADL at home (0100) 64.8 (SD = 29.1) (n = 30) 78.4 (SD = 25.4) (n = 25)ADL outside the home (0100) 44.00 (SD = 34.6) (n = 30) 62.7 (SD = 30.1) (n = 26)

Participants described gains in their ability to performactivities at home. For example, one client found iteasier to get ready in the morning, and another did notbecome short of breath as easily. Two individuals per-ceived no improvement on their goals, and one partic-ipant reported getting worse. That individual had ex-perienced low blood pressure, falls, and a change inmedication, and had been hospitalized for more than amonth shortly before the post-test.

Table 2 shows the results for the pre-test sample aswell as for the post-test sample. Keep in mind thatthese are the results for the whole pre-test and post-testsamples (i.e., not only the matched pairs). Althoughthere were 33 pre-tests returned, not everyone complet-ed every test. Some participants completed a pre-testbut dropped out of the program, and, therefore, did notcomplete a post-test. The number of participants whocompleted each test is shown. The project team scoredeach of the Berg items on a 0 to 4 scale, with 4 repre-senting higher functioning. The project team added thescores on the five Berg items for a total score out of 20,with higher numbers indicating higher functioning.

3.2. Pre-post comparisons of functional assessmenttest results

Since this evaluation aimed to assess the efficacy ofthe new exercise program, the project team conductedsignificance testing on the results for those who com-pleted the program. Since seven participants did notsubmit both a pre-test and a post-test, it was not pos-sible to do a paired comparison on those individuals.Thus, this next section presents pre-post paired com-

parisons based on the 26 participants who completedboth a pre-test and a post-test.

The project team performed paired t-tests on eachfunctional assessment test for thematched sample to de-termine whether statistically significant improvement(p < 0.05) had occurred. Table 3 summarizes thesecomparisons. For each functional test shown in Ta-ble 3, the number of pairs of participants on whomthe significance test was based is shown beside the testname.

The number of stands on the Chair Stand test im-proved significantly, as did the number of inches thatparticipants could reach forward on the Reach Forwardtest. The total score on the ABC scale improved sig-nificantly.

Scores improved on 12 of the 16 ABC items, and theimprovement in confidence was statistically significantfor four items: walk around the house; reach for a smallcan off a shelf at eye level; walk outside the house to acar parked in the driveway; and get in or out of a car.

The scores on the Chair Sit and Reach test and theBack Scratch test must be interpreted with caution be-cause some Site Coordinators did not use a negativesign when reporting the number of inches away fromthe toes/fingertips, but rather, scored these differencesas a positive sign. We looked at these variables in theirreported form as well as a corrected form. Both arereported in the corrected form. Although both showimprovement, neither of these was statistically signifi-cant.

On average, the total number of functional assess-ment tests that improved from pre-test to post-test was2.4 (SD= 1.7; range: 0 to 6). Only one participant did


Table 3Significance testing of functional assessment scores for matched pre-test and the post-test data

Mean (SD) pre-testscore on matched pairs

Mean (SD) post-testscore on matched pairs

Paired t-test results

Chair stand # Full stands in 30 sec-onds (n = 21)

4.95(SD = 2.7)

6.95(SD = 2.2)

t = 4.32, df = 20p < 0.001

Chair sit and reach (corrected)inches away from toes (n = 19)

4.3 inches(SD = 6.1)


t = 0.145, df = 18,p = 0.89

Back scratch (corrected) # inchesfrom fingertips (n = 22)


8.5 inches (SD = 5.1) t = 1.7, df = 21,p = 0.10

Reaching forward: Number ofinches (n = 17)



t = 2.43, df = 16p = 0.028

Berg items (scored from 0 to 4)Sitting to standing (n = 24) 3.2 (SD = 1.1) 3.2 (SD =1.2) t = 0.00, df = 23,

p = 1.0Standing unsupported (n = 26) 3.6 (SD = 0.70) 3.5 (SD = 1.1) t = 0.42, df = 25,

p = 0.68Sitting unsupported (n = 25) 3.8 (SD = 0.47) 4.0 (SD = 0.20) t = 1.8, df = 24,

p = 0.08Standing to sitting (n = 25) 3.4 (SD = 0.71) 3.5 (SD = 0.65) t = 0.57, df = 24,

p = 0.57Reaching forward (n = 23) 2.65 (SD = 0.83) 2.9 (SD = 0.76) t = 2.01, df = 22,

p = 0.057Mean total of the 5 berg items (totalscore out of 20)(n = 20)

16.95 (SD = 2.4) 17.2 (SD =2.0) t = 4.78, df = 19,p = 0.64

Self-report scalesABC scale (0100) (n = 20) 44.1 (SD = 19.9) 50.7 (SD = 21.1) t = 2.49 (df = 19)

p = 0.02ADL at home (0100) (n = 24) 69.6 (SD = 29.2) 77.5 (SD = 25.5) t = 3.65, df = 23

p = 0.001ADL outside the home (0100)(n = 25)

51.2 (SD = 33.3) 61.2 (SD = 29.8) t = 2.83, df = 24p = 0.009

not improve on any of the tests, and most participantsimprovedon one or two tests. Although not statisticallysignificant, the five items from the Berg Balance Scalechanged in a positive direction.

3.3. Participant satisfaction survey

Twenty-eight participants completed and returned aParticipant Satisfaction Survey. As Fig. 1 shows, par-ticipants rated the overall VON SMART In-HomeExercise Program as Very Good (mean = 4.1; SD =0.85) on the 5-point scale from Poor to Excellent. Thisquestion read Overall, how would you describe theVONSMART In-HomeExercise Program? The oneindividual who rated the program as Fair commentedthat there were a lot of exercises.

The project team assessed overall satisfaction withthe VON SMART In-Home Exercise Program with a7-point Likert scale from Extremely Dissatisfied to Ex-tremely Satisfied, with Neither Satisfied nor Dissatis-fied in the middle. (This question asked Overall, howsatisfied are you with the VON SMART In-HomeExercise Program?) One participant was Extremely

Dissatisfied, one was Somewhat Dissatisfied, 18 wereVery Satisfied, and six were Extremely Satisfied. Theindividual who was Extremely Dissatisfied did not pro-vide any comments in the open-ended questions. It ispossible that this individual inadvertently marked thewrong end of the scale.

Although none of the questions specifically askedabout the participants satisfaction with their volunteer,when asked for comment, 6/25 participants specificallymentioned their volunteer. Overall, comments relatedto the participants enjoyment of having the volunteercome to their home each week:

[I] liked [the] volunteer coming every week [that] kept me motivated.My volunteer was very helpful and made the ex-ercise fun.

The benefits extended beyond help and motivationwith the exercises; social benefits were obvious in thetwo comments about the good personality match be-tween participants and volunteers.

The project team asked participants if they had ad-ditional comments that they would like to make about


Fig. 1. Participants overall rating of the VON SMART In-Home exercise program.

the program. Ten participants provided positive com-ments, such as:

Valuable asset for people. Helped me from de-clining too fast.Great program that will benefit a lot of people whocant attend a group program.Great to be able to have a one on one match.I think it is a great program and I hope I willcontinue with the exercises although it wont beas pleasurable without the motivator. It would begood to have some kind of follow-ups or renewalspossible.

One person commented that the exercises could bemore strenuous after 3 weeks.

The project team asked participants to rate how easyor difficult it was for them to do the exercises as partof the Satisfaction Survey (i.e., after the program wascompleted). Figure 2 shows their responses.

Four participants reported completing the exerciseson their own (i.e., at times other thanwhen the volunteerwas present) once/week, nine reported exercising ontheir own 23 times/week,and eight reported exercisingon their own 4 or more times per week.

Eleven participants reported not doing specific ex-ercises. Two participants mentioned the chest stretch,and two mentioned the wall push-up. Others did notspecify or were unclear in their response. The reasonsprovided for not doing specific exercises were pain,paralysis, COPD, stroke, and inflammation. There was

a strong correlation between reported frequency of ex-ercise with participants plans for continuing the exer-cises (5-point Likert scale) now that the program wasover (r = 0.57, p = 0.002).

When asked to list two things that participants reallyliked about the VON SMART In-Home Exercise Pro-gram, participants had numerous positive things to re-port. Comments specified the volunteers, the exercises,and the organization of the program itself. Sixteen outof the 25 participants who responded to this questioncommented on the volunteers, in particular, that theywere good, encouraging, had similar interests, and thatthe visits from volunteers were something participantslooked forward to. Nine participants commented pos-itively on the exercises themselves. Specifically, com-ments related to walking, and getting outside, and thatthe program was motivating: exercises get you goingin the morning, exercises are something to look for-ward to eager to do, I exercised more knowing thatthe VON would be in later and if I wasnt in the pro-gram, I wouldnt be exercising at all. Five participantscommented that the program made them feel better;anywhere from generally feeling better and stronger tospecific benefits, such as helpedmy knees, tightenedmy belly, helped my hip and back, loosened myshoulders, and improved their ability to walk fartherand for longer periods of time. Two participants statedthat they liked how well the program was organized,and that they could work at their own pace.


Fig. 2. Participants rating of how easy or difficult the exercises were for them.

When asked if they would like to make any othercomments about the program, participants most com-monly responded that the program was worthwhile andhad many benefits, such as the benefit of the companyof the volunteers as well as physical benefits. A fewparticipants commented good work and keep it up,and other participants commented that they learned dif-ferent things, that they want to do the program again,and that they hope the program will be available tomore people.

Five participants made suggestions for improving theprogram. These suggestions related to increasing thenumber of volunteers, and increasing the intensity ofthe exercises gradually (walking time could be length-ened perhaps to 4 minutes and perhaps to 5 as strengthand balance improve, persons who are mobile couldwork up to more strenuous activity). One participantwho had started with the previous 10 exercise programfound it difficult to change to the new 15 exercise pro-gram.

Table 4 provides participant responses to Likert-scaled questions measuring attitude, subjective normsand intention to exercise.

Another question on the patient satisfaction surveydealt with whether the program met expectations. Theprogram met the expectations of 22 of the 23 partic-ipants who answered this question. One participantcommented definitely, looked after my expectationswith having stroke, I am limited in what I can do. Two

participants commented that it presented more exercis-es than they had expected.

Compared to before the VON SMART In-HomeExercise Program, six participants stated that their ADLwas Much Improved, 15 said it was Somewhat Improvedand six said it was the Same, No Worse, No Better. Noone rated their ADL at Home as Somewhat Worse orMuch Worse.

Compared to before participating in the VONSMART In-Home Exercise Program, participantscurrent ability to complete ADL outside the home wasconsideredMuch Improved (n = 1), Somewhat Im-proved (n = 14), the Same (n = 11), and SomewhatWorse (n = 1). No one rated their ADL as MuchWorse. Compared to before participating in the VONSMART In-HomeExercise Program, participants rat-ed their current health as Much Improved (n = 4),Somewhat Improved (n = 15), or the Same (n = 7).No one rated their health as Somewhat Worse or MuchWorse. These ratings are consistent with the report-ed pre-post improvements (using the 0 to100 scale) inADL at home and outside the home reported in Tables 2and 3.

Compared to before participating in the VONSMART In-Home Program, participants rated theircurrent level of physical activity. Two participants re-ported being Much more physically active, 14 partici-pants reported being Somewhat more physically active,9 participants reported being the Same with no changein level of physical activity, and one participant report-


Table 4Participants attitudes and intentions toward exercising

Strongly disagree Disagree Neutral Agree Strongly agree N

Overall, I enjoyed doing the exercises. 0 1 2 9 10 22Regular exercise is important for seniors to remain physicallyfit.

0 0 0 14 13 27

Regular exercise is important for seniors to remain healthy. 0 0 0 13 14 27Regular exercise is important for me to remain physically fit. 0 0 0 11 16 27Regular exercise is important for me to remain healthy 0 0 0 14 13 27I plan to continue doing the exercises on my own at home nowthat the program is over.

0 1 2 17 7 27

I plan to continue to participate in other exercises programs(e.g., VON SMART Group Program, those offered at theYMCA, Seniors Centre, private gym).

3 6 8 8 2 27

I am able to complete the exercises I learned in the program onmy own at home now that the program is over.

0 0 5 13 8 26

I am able to participate in other exercises programs (e.g., VONSMART Group program, those offered at the YMCA, SeniorsCentre, private gym).

5 7 6 5 2 25

My family and friends exercise regularly. 3 1 8 13 0 25My family and friends think that it is important for me toexercise.

1 1 1 11 12 26

I am interested in participating in other exercise programs. 2 2 9 10 3 26

ed being Somewhat less physically active. No one re-ported being Much less physically active than beforethe program.

Eleven participants reported having been encouragedto participate in the VON SMART Group ExerciseProgram, 13 reported not having been encouraged todo so, and one was unsure.

Fourteen participants reported having been provid-ed with information regarding other organized physicalactivity programs that they might be able to participatein, 10 reported not having been provided with such in-formation, and two were unsure. Two participants re-ported becoming involved with a new organized phys-ical activity (e.g., bowling, golf, curling, line dancing)since starting the VON SMART In-Home ExerciseProgram. None of the participants had resumed orga-nized activities that they previously had to give up sincestarting this program.

3.4. Participants follow-up interviews

Following completion of the 12-week exercise pro-gram all 22 participants for whomwe had contact infor-mation were invited to participate in a follow-up tele-phone interview. Of these, 11 consented to participate,five declined, three could not be reached, one was de-ceased, and two had not yet completed the program.The mean duration of interview was 14 minutes (SD= 4.7 minutes), with a range of 9 to 25 minutes. Theproject team used a semi-structured interview guide toask participants for their perceptions of the exercises,

barriers and facilitators to exercise, and the volunteer,as well as their future plans to exercise.

The interview data revealed that the social compo-nent of the program was an important motivator forparticipants. Participants provided very positive com-ments on the volunteers. They enjoyed the volunteerscompany, and appreciated the volunteers expertise.Having someone doing the exercises along with theparticipant was helpful. As one participant stated: thevolunteer did [the] exercises with me, which helped,otherwise Id fluff off. In some cases the spouse didthe exercises with the participant, but for others, thespousewas not able tomotivate a participantwhowouldreadily co-operate with the volunteer. Several partici-pants emphasized the social component, one of whomsaid that she arranged for three other women from herbuilding to join her and the volunteer, to make it moresocial.

Participants mentioned several benefits from the ex-ercises in the interviews, including the elimination ofleg cramps, increased strength, more flexibility, im-proved balance, and increased confidence and energy.As one participant stated: when doing the exercisesyou dont hesitate to reach up on a top shelf to getsomething because you know you can do it. Anotherparticipant stated This is exactly what I need., andanother stated that the exercises helped me to get onwith my life.

Only four participants had comments on what theydid not like about the program. One participant statedthat the time of the volunteers visit (late afternoon)


made it more difficult to participate, as that person wasready for a nap at that time. The other two commentedon specific exercises. Another participant commentedabout the program ending: with a senior like thatto stop abruptly like that was a big let down. . . if itssomething to keep him stronger, it needs to be keptup. . . he cant do the exercises on his own.

Most (8 of 11) participants were continuing to ex-ercise regularly on their own at home, and two wereexercising sporadically. One spouse explained that shetries, but her husband does not co-operate with her.

3.5. Volunteer follow-up survey

Most (11 of 16) of the volunteers who respondedto the follow-up survey were matched with one client.Four volunteerswere matchedwith two clients, and onevolunteer was matched with three clients. Most (13)volunteers spent between one and two hours per weekvolunteering in this program, and three volunteeredmore than two hours per week. The time commitmentwas less than expected by two volunteers, and as muchas expected by 14 of 16 volunteers.

Two volunteers rated the exercises as Good, 11 vol-unteers rated them as Very Good, and 3 volunteers ratedthem as Excellent. The mean rating was 4.1 (SD =0.57) on the 5-point scale.

Eleven volunteers provided their views on whatmakes it difficult for clients to seek community exer-cise programs. Comments related to the clients ac-cess to community programs (i.e., lack of transporta-tion, mobility difficulties, and fear of falling) as wellas the availability of programs (not enough programs,insufficient awareness of programs).

Nine volunteers provided their views on what wouldmake it easier for participants to seek community ex-ercise programs. Most comments related to improvingawareness through advertising.

3.6. Site coordinator satisfaction survey

Seven Site Coordinators completed the CoordinatorSatisfaction Survey at the end of data collection at theirsite. Six had had experiencewith the previous exercisesused in the VON SMART In-HomeExercise Programand four Coordinators had taught the new educationmodules twice.

The Site Coordinators overall impression of the newVON SMART In-Home Exercise Program was pos-itive. No-one rated the new program as Poor or Fair;two Site Coordinators rated it as Good; three rated it as

Very Good; and one rated it as Excellent, for an overallaverage rating of 3.8 out of 5 (SD = 0.75).

In terms of the functional assessment tools, two SiteCoordinators indicated they would like to change theBack Scratch test (which one stated was difficult forclients to understand and do) and one indicated theywould like to change the Leaning Forward with Out-stretched Arms test, as it was difficult to measure andshaky. Two Site Coordinators indicated that the func-tional assessment tools revealed just how frail some ofthe participants are. As one Site Coordinator stated:

I got upset and nearly teary with the multiple ques-tions. It put down in black and white how limitedshe is. Another caregiver was overwhelmed with16 questions.

Site Coordinators generally rated the exercise pro-gram itself as good or very good, in terms of its abilityto meet the exercise needs of participants (mean ratingof 3.6/5, SD: 1.0) and to improve the physical func-tioning of participants (mean rating of 3.7/5, SD: 0.8).Site Coordinators rated the ease of teaching the newexercises as 3.7/5 (SD = 0.8) on a 5-point scale (1 =Not At All Easy and 5 = Extremely Easy).

Four of the seven Site Coordinators stated that therewere exercises they did not like. Two did not likethe chest stretch, one did not like the triceps exten-sion against the wall, one did not like the calf stretch,and one thought that leaning through a doorway wasambiguous.

Two Site Coordinators made suggestions for chang-ing the exercises. One suggested using a chair witha handle for the triceps exercise. Another Site Coor-dinator suggested that clients with cognitive impair-ment have trouble with these two [chest stretch, calfstretch] sometimes a safety issue would suggest basicchest stretch and seated calf stretch.

The project team asked site Coordinators to identifytwo things they liked about the new exercises. Fiveof the seven Site Coordinators provided responses tothis question. They described the exercises as easy tofollow, challenging, and providing good upper bodystrength. Also mentionedwere the picture page and thestretches. The project team also asked site Coordinatorsabout suggestions for improving the overall programexperience, and overall comments about the exercises.Site coordinators had the following comments, whichreflected that while the exercises were designed forfrail, older persons, many program participants foundthem very challenging:


they [the exercises] are too difficult and too manyexercises for the truly frail and very frail MANYare dropping out! By the time you get halfwaythrough they are tired.The calendar is too complicated keep it to 10exercises MAX; Omit: side leg raise triceps pushup more tested exercises modified hip exten-sion aggravates their backs program needs to besimplified.

All seven Site Coordinators commented on whatmakes it more difficult for participants to seek commu-nity exercise programs, and what would make it easierfor them to do so. Responses to both questions relatedmainly to improving participants access to programs which is difficult due to lack of transportation, poor ac-cess to program information, cost, and lack of availableprograms. As one Site Coordinator stated:

other than the VON SMART In-Home ExerciseProgram, there are no community exercise pro-grams that would meet their needs.

One Site Coordinator noted that buy-in from recog-nized health professionals would be helpful.

Additional comments that Site Coordinators madeabout the VON SMART In-Home Exercise Programwere that it was a great and well rounded programand that they just need to educate participants and pro-mote the program. One Site Coordinator commented:

the people who make it through the 12 week pro-gram are very determined and committed to the pro-gram but they are often not as frail as those whodrop out.

3.7. Site coordinator focus group interview

Five Site Coordinators provided their overall impres-sions during the teleconference focus group interviewand also some information that explainedwhy the num-bers were lower than expected. One Site Coordina-tor on the call was new to the program and had takenover for another Site Coordinator part way through theevaluation term.

Throughout the evaluation, and during this wrap-upinterview, the project team asked site Coordinators toprovide information on those who declined or droppedout of the study, so that the team could determine thereasons for non-participation or non-completion of theprogram. Specifically, the project team was wonderingif there were any differences in terms of their abilityto complete the 12-week program, and if there were

any demographic differences (e.g., health, age, or liv-ing arrangements). Some Site Coordinators found nodifferences among those who agreed to participate inthe evaluation and those who did not. One Site Coordi-nator felt that participants who did not want to be partof the evaluation were much more frail and nervousabout starting the exercise program.

Site Coordinators also noted that the participantswho self-referred were more likely to consent to par-ticipate in the evaluation, and more committed to com-pleting the program than those referred by a health pro-fessional.

One Site Coordinator reported that some physiother-apists perceived the VON exercise program as compe-tition at a time of cut-backs in physiotherapy referrals,and so they do not refer seniors to this exercise program.Although the number of referrals was not a problem formost Site Coordinators, having too few volunteers wasa common problem for all.

Because of anecdotal information that the projectteam received throughout the study, the team also askedSite Coordinators if the participants were doing the ex-ercises between volunteer visits. In many cases, SiteCoordinators doubted whether the submitted log sheetswere accurate, since the numbers were too convincing.There is no way to verify the accuracy of this informa-tion because the project team received the informationby self-report.

Although data collection was a struggle throughoutthe evaluation, during the wrap-up interview, Site Co-ordinators stated that participants liked the programand were happy to be in it. The Site Coordinators ex-plained a lot of the struggles with data collection re-lated to the lack of time Site Coordinators had for thisprogram. All Site Coordinators divide their time be-tween the VON SMART In-Home Exercise Programand several other programs (e.g., Foot Care). This lackof time compromised the Site Coordinators abilities tocarry out evaluation responsibilities. For example, insome cases, tests were scored incorrectly, and follow-up surveyswere not handed out to the volunteers. Also,even though the project team sent repeated remindersto Site Coordinators, they did not always inform theresearchers when participants completed the program.This meant that the project team could not always timethe follow-up interviews accurately.

Lack of time may also have been a factor in thatout of the 18 sites that were invited to participate, onlyeight VON sites agreed.

The project team also asked Site Coordinators tocomment on whether they thought this exercise pro-


gram was suitable for this population (too easy, too dif-ficult) and to comment on the length of the program (12weeks). The Site Coordinators all thought the programwas suitable. No one thought that the exercise pro-gram was too demanding for participants, since modi-fications were made for participants who could not docertain exercises. Site Coordinators agreed that the preand post functional assessment was not too difficult forparticipants; however they also agreed that it was toolengthy.

4. Conclusions

Overall, this evaluation found that the volunteer-ledVON SMART In-Home Exercise Program yieldedpositive gains for a frail home-bound population of se-niors who were committed to the program. Participantsimproved on some of the functional assessment tests aswell as the self-reported measures of ADL and balanceconfidence (i.e., the ABC scale). Most participants al-so reported benefits from the program in terms of thegoals they had identified for themselves. Despite thelimitations encountered during the data collection pe-riod, these data were able to show significant improve-ments in the health of participants, including benefitsin strength, flexibility, balance, and ability to performADL.

It is encouraging that the evaluation found statistical-ly significant improvements in a sample that was small-er than anticipated. According to the ABC scale, andmany comments from participants, balance improvedas a result of the exercises.

Research has shown that exercise benefits both thephysical health [15] and mental well-being [51] of old-er persons, which in turn improves their functional in-dependence and quality of life. The evidence also sug-gests that exercise programs that challenge balance andthat provide a more substantial level of activity than awalking program, produce greater benefits [44]. Im-provements in balance would be particularly importantin reducing the risk of falls [31].

Participants attitudes toward the exercises were pos-itive, as they showed good attitudes toward exercis-ing, and good intentions toward exercise. This findingis promising, since the Theory of Planned Behaviourshows that intention to exercise is a good predictor ofexercise behaviour [20,39].

Participants made very positive comments about thevolunteers who led their exercise program, and felt thatthe home visits by the volunteerswere key to sustaining

participation. Social contact with the volunteers washighly valued; some participants were able to increasethe social component by finding other persons to jointhem in the exercises [16]. Some participants were ableto increase the social component by finding other per-sons to join them in the exercises. The VON SMARTIn-Home Exercise Program would be too costly for thehealth care system and the client, if volunteers werenot involved. The volunteers are motivated by the chal-lenge and responsibility of this work and benefit them-selves socially by building relationships, having socialcontact, and learning new skills.

We believe the volunteer-led aspect of this programis particularly noteworthy. The comparatively low costof using volunteers makes this program more feasi-ble, and therefore, potentially more sustainable, than aprofessionally-led program. Although this evaluationdid not include a cost analysis, we note that econom-ic evaluations in the hospital sector have found sub-stantial economic benefits associated with the use ofvolunteers [22]. Further, there is strong evidence thatvolunteering has benefits for the volunteers as well asfor the clients they serve [3,10]. These benefits maybe greater for older volunteers [47], as were most ofthe volunteers participating in the VON SMART In-Home Exercise Program. Although there have beensome reports on use of volunteers in osteoporosis pre-vention [29] and on implementation of volunteer lead-er initiatives in physical activity leisure programs [40],there has been limited published research on the im-plementation and outcomes of volunteer-led exerciseprograms. The role of volunteers is a matter of con-siderable policy and societal importance [21] and hasbeen identified as a priority for further research [37].

This evaluation indicates that there is a need for in-home exercise programs for homebound seniors. Italso shows that it is important to explore measuresthat would improve participants commitment to an ex-ercise program. This improvement could be accom-plished through written and/or public commitmentsfrom the participants and by encouraging the partici-pants to share their exercise plans and progress withfriends or family members. These strategies may helpto sustain the exercises between volunteer visits, andfollowing the completion of the program. Efforts aimedat improving participants adherence to daily exercisebetween volunteer visits during the program seem war-ranted. Research on cognitive dissonance shows thatpublicly declaring ones attitude toward a particular be-haviour is likely to result in the individual followingthrough with that behaviour [4]. Therefore, it would be


important to continue to ask participants about theirattitude toward exercise, and for those with a positiveattitude, it would be important to remind them of thison a weekly basis. It may also be beneficial to post avisual reminder of their expressed positive attitude. Byasking about attitude toward exercise, volunteerswouldhave the opportunity to address any negative attitudesthat participants express.

As has been found by other researchers, the projectteam found implementation of this program to be chal-lenging, and drop-outs were common among a groupof frail older persons [17,18,32]. It is important to notethat, in general, the means shown on the entire pre-testsample of 33 individuals were lower than those shownfor the pre-test in the paired sample (i.e., the sampleof those who completed the program), because the pre-test sample included individuals who dropped out ofthe program. When comparing the mean from the en-tire pre-test sample (n = 33) and the pre-test scoresfrom only those who completed the program (n = 26),it is apparent that the scores from the individuals whodropped out pulled down the mean scores for the en-tire sample on the pre-test. The higher means on thepre-test from the paired sample (i.e., sample of onlythose who completed the program) suggests that thosewho completed the program were in somewhat betterhealth than those who did not complete the program.This finding was supported by the Site Coordinatorscomments that the program worked best for those whowere motivated, committed to the program, and not asfrail. Those who dropped out of the program are animportant part of the target population who requiredthe in-homevolunteer visits. Keeping these individualsin the program may be difficult due to health reasonswhich may be beyond the scope of the VON SMARTIn-Home Exercise Program.

Several factors should be considered in future studiesof this or similar exercise programs. First, the programis targeted at a frail older population, many of whomwere in poor health. As a result, it may be inevitablethat potentially eligible participants will decline to par-ticipate, and that others will find the exercise programtoo difficult to sustain. Additional research on waysto minimize refusals and drop-outs would be valuable,but it may be that a lack of refusals and drop-outs is asign that the programs are not being offered to all thosewho could potentially benefit. Second, the originalsample size estimates were based on initial expressionsof interest in participation by the sites; however it wasdifficult to sustain commitment to the protocol amongthe Site Coordinators. Despite repeated reminders and

requests, several Site Coordinators did not follow theprotocol as it was outlined. Several Site Coordinatorsopted out of the evaluation before it even began. Third,high staff turnover and lack of sufficient time for re-search were challenges for this evaluation. Resourceconstraints and staff turnover are likely to continue tobe challenges in implementing and sustaining these ex-ercise programs. The positive results of this evaluationmay support efforts at making the program a priorityfor Site Coordinators, volunteers and potential partici-pants.

Research on persuasion shows that making a com-mitment in writing and/or in public improves compli-ance because people feel the need to behave consistent-ly with their commitment in order to avoid feeling un-comfortable for contradicting themselves [11,36]. Thisresearch suggests that volunteers may want to ask par-ticipants to sign a written commitment to continue toexercise between volunteer visits. Alternatively, vol-unteers could advise participants to tell an exercisebuddy (or 23 friends or family members) that theyare going to exercise daily, between volunteer visits.The exercise buddies could then help keep the partici-pant motivated by checking in with them on a daily oralmost daily basis. This support could then continueafter the volunteer visits have stopped.

Greater support for continuation of exercising be-yond the VON SMART In-Home Exercise Programas well as efforts aimed at improving participants ad-herence to daily exercise after the program has end-ed, are warranted. At the end of the VON SMARTIn-Home Exercise Program, Site Coordinators and vol-unteers have the opportunity to inform participants onthe VON SMART Group Exercise Program and otheravailable community exercise programs, and can en-courage participants to make use of these services.

Despite the data collection and implementation chal-lenges encountered, the results of this evaluation in-dicated the benefits of the exercises on participantsstrength, flexibility, balance, and ability to performADL, as well as benefits to the volunteers. This studyprovides additional evidence of the benefits of in-homeexercise for frail seniors, and supports a role for volun-teers in delivering these programs.

Acknowledgements

This studywas supported by a grant fromVONCana-da through their project funding from the Public HealthAgency of Canada Population Health Fund. Loret-


ta Hillier, MA, contributed to the development of thestudy methods including the design of the interviewguides and questionnaires, as well as completion of theinterviews of participants. Esther Russell, M.P.H., as-sisted with the analysis of the quantitative data. We aregrateful to the participants, volunteers and Site Coordi-nators of the VON SMART In-HomeExercise Programin Cumberland, Sackville, Durham, Greater Kingston,Hamilton, Hastings, Northumberland, Prince EdwardCounty, Perth-Huron, Simcoe County, Thunder Bay,and the Guelph Wellington Seniors Association fortheir participation in this evaluation.

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Evaluation of a Volunteer-led in-home Exercise Program for Home-bound Older Adults