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Healthy Aging Through Active Leisure:Design and Methods of SHAPE—aRandomized Controlled Trial of aNeighborhood-based Walking ProjectK. John Fisher Ph.D. a , M. Anthony Pickering M.S. a & Fuzhong LiPh.D. aa Oregon Research Institute , Eugene , OregonPublished online: 11 Mar 2011.
To cite this article: K. John Fisher Ph.D. , M. Anthony Pickering M.S. & Fuzhong Li Ph.D. (2002)Healthy Aging Through Active Leisure: Design and Methods of SHAPE—a Randomized ControlledTrial of a Neighborhood-based Walking Project, World Leisure Journal, 44:1, 19-28, DOI:10.1080/04419057.2002.9674257
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WORLD LEISURE No. 1/2002 O Copyright by the authors
Healthy Aging Through Active Leisure: Design and Methods of SHAPE - a Randomized Controlled Trial of a Neighborhood-based Walking Project
K. JOHN FISHER, M. ANTHONY PICKERING, FUZHONG LI Oregon Research Institute
Abstract
Although it has been established that health benefits can be gained from low to moderate levels of regular physical activity for all ages, a significant proportion of the elderly population remains sedentary, especially in developed countries. Despite the fact that the elderly population has much to gain from adopting health-promoting behaviors such as regular exercise, significant psychologi- cal, social, and environmental barriers remain. The Senior Health and Physical Exercise (SHAPE) project i s a randomized controlled trial, which adopts an ecological approach to identifying, re- cruiting and promoting physical activity among populations of inactive elderly citizens in an urban setting. Bandura's Social Cognitive Theory incorporating self-efficacy factors, exercise behavior and neighborhood environment, underpins the planning and implementation of this project. This study identifies the heterogeneity of demographic characteristics, and examines related social and environmental influences enhancing or compromising physical activity patterns of seniors. A sam- ple population of 583 healthy but inactive elderly citizens, 65 years and over was recruited from 56 metropolitan neighborhoods for participation in the study. This paper reports on the concep- tual framework, design, neighborhood randomization and recruitment methods of a community- based physical activity program for elderly citizens.
Keywords: Community, Elderly, Exercise, Neighborhood, Older Adults, Walking
Introduction It is now widely accepted that older adults
can obtain significant health benefits through physical activity. Engaging in regular exercise contributes to a host of psychological benefits such as a sense of increased energy, an en- hanced positive attitude, improved sense of well-being and self-esteem, less anxiety and
depression. A range of physical health benefits including enhanced physiological functioning such as muscular strength, balance, power, and aerobic capacity, can also accrue from adopting a regular routine of even moderate intensity exercise (Berger & Mclnman, 1993; Blair & Garcia, 1996; Blair et al., 1989; Bouchard et al., 1994; Buchner et al., 1992;
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K. John Fisher, M. Anthony Pickering, Fuzhong L i
Ettinger, 1996; McAuley & Rudolph, 1995). Given these health benefits, the provision of increased opportunities for the older popula- tion to exercise and be more physically active is likely to be a powerful means of preventing or delaying the onset of costly, chronic degen- erative diseases and enhancing the quality of later life.
Barriers to seniors' participation in physical activity have been well documented and in- clude fears and concerns related to safety and the environment (Clark & Nothwehr, 1999; Sallis & Owen, 1999), lack of social support, insufficient disposable income, and low levels of perceived self-efficacy (Chogahara, O'Brien Cousin, & Wankel, 1998; King, Rejeski, & Buchner, 1998). For such contextual influ- ences, it is imperative that interventions in- clude strategies to manipulate environmental and contextual factors in attempts to improve quality of life measures for the elderly (Sallis, Bauman, & Pratt, 1998). Although the extant literature on adherence and participation has provided valuable data on barriers and sup- ports for physical activity, the vast majority of controlled studies have focused almost entirely on bio-physical and psychosocial variables.
Many researchers (Booth, Owen, Bauman, Clavisi, & Leslie, 2000; Cheadle, Sterling, Schmidt, & Fawcett, 2000; Doucet, Saelens, Sollis, & Strelow, 2001; Lee, Castro Albright, Pruitt & King, 2000; Sallis, et al., 1998) have drawn more attention to the influence of the community environment on physical activity. Soelens (2001) pointed out that psychosocial variables explain less than 50% of the variance in participation in physical activity. Further- more, the author emphasized the important potential of environmental and policy factors for changing exercise behavior. Older adults, who possess an holistic concept of leisure (Howat, Howat, Fisher, & Earle, 1986), and whose leisure choices involve physical activity, have much to gain in terms of life satisfaction, social fulfillment, a sense of challenge and risk, fun and enjoyment, are likely to have im- proved quality of life and well-being (Shephard, 1993). The purpose of this paper is to describe the design and methods of the Senior Health and Physical Exercise (SHAPE)
project, a community-based physical activity project for the elderly.
Physical Activity and the Elderly
Physical Inactivity Physical inactivity among the U.S. popula-
tion is now widespread (Federal Interagency Forum on Aging-Related Statistics, 2000; US Surgeon General, 1996). lnactivity defined here means less than 30 minutes of moderate physical activity (such as brisk walking or rak- ing leaves) on all or most days of the week. National surveillance programs have docu- mented that about one in four adults (more women than men) currently have sedentary lifestyles with no leisure time physical activity (US Surgeon General, 1996). The prevalence of inactivity varies by gender, age, ethnicity, health status, and geographic region, but is common to all demographic groups (see Ta- blel ).
Table 1. US Patterns and Trends for Inactivity*
Males Females
Overall 26.5 30.7 18-29 year olds (%) 18.9 25.4 30-44 year olds (%) 25.0 26.9 45-64 year olds (%) 32.0 32.1 65-74 year olds (%) 33.2 36.6 75 + (%I 38.2 50.5
Source: US Surgeon General, 1996 Note: *Inactivity defined here is defined as less than 30 minutes of moderate physical activity (such as brisk walking or raking leaves) on all or most days of the week (US Surgeon General, 1996).
Current low rates of regular activity in the United States may be partially due to the mis- perception of many that vigorous, continuous exercise is necessary to reap health benefits. Many people, for example, fail to appreciate walking as "exercise" or to recognize the sub- stantial benefits of short bouts (at least 10 minutes) of moderate-level activity (US Surgeon General, 1996). Recent evidence has begun to show that health benefits can accrue from moderate amounts of less inten- sive exercise (Albrechtson, 2001), and that these can be cumulative. A walking program
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Healthy Aging Thr .ough Active Leisure: Design and Methods of SHAPE ...
called "Just Walk It"' sponsored initially by the Australian Heart Foundation in Brisbane, Australia, used volunteer walking leaders from their communities and neighborhoods to successfully recruit and escort small groups of suburban citizens to undertake regular walks in small groups for health, so- cial and recreation purposes (Fisher et al., 1998). Walkers continued to maintain high levels of physical activity participation six months after funding for the program ended (Abernethy et al., 1 997). However, partici- pants had pre-existing high levels of physical activity participation before they signed up for the program (Fisher et al., 1998).
Adult Preferences for Physical Activity Walking has grown in popularity interna-
tionally, and is the most popular form of physical activity among adults of all ages. Ac- cording to a survey published by the China National Sports Council (1 997), walking was top on a list of physical activity preferences. Physical activity rates among older adults in China appear to be quite high compared to many western countries, with people 66-75 evidencing 38.6% participation and 30.7 % for people over 76 (Hong & Lu, 1999). An Australian study also found walking to be the most popular physical activity among adults (Booth, Bauman, Owen & Gore, 1997). In
Figure 1 . Adult Physical Activity Preferences
60%
Adapted from Booth, Bauman, Owen, & Gore. ( 1 997). Preventive Medicine, 26, 13 1 - 137
the USA, walking has been widely reported as the most popular form of physical activity for several years (Centers for Disease Control, 1999, 2000) and is the major activity (69% of men and 75% of women) among older adults (Yusuf et al., 1996). Walking was also found to be an acceptable, accessible activity among sub-groups with a low prevalence of physical activity (Siegel, Brackbill, & Heath, 1 995).
The Importance of Environment as a Predictor of Physical Activity
Many studies of physical activity focus on psychosocial correlates and biophysical pre- dictors of exercise and do not include meas- ures of perceived or actual environmental or contextual variables (Brownson, Baker, Housemann, Brennan, & Bacak, 2001; Lee, et al., 2000). In addition, biomedical and psy- chosocial variables are most suited to assess- ing vigorous rather than moderate exercise and consistently are unable to explain more than 50% of the variance in physical activity participation (Saelens, 2001). From an eco- logical and public health perspective, environ- mental and policy factors have considerable potential improve population health and com- munity participation rates in active leisure and physical activity choices (Brownson, et al., 2001; Friedman, Gordon, & Peers, 1994; Grzywacz & Marks, 2001 ; Ross, 1997; Sallis, et al., 1998). Some research suggests that city planning seems to favor areas of high socio- economic status (SES) in providing more re- sources and facilities for physical activity and at free or low cost compared to areas of lower SES (Estabrooks & Gyurcsik, 2001). Much more research needs to be devoted to this im- portant aspect of urban planning and provi- sion for active leisure for all ages.
The Senior Health and Physical Exercise Project (SHAPE)
The Senior Health and Physical Exercise (SHAPE) project is a research study funded by the National Institute on Aging (NIA), and is designed to study the impact of a neighborhood walking project on the health of seniors through a randomized controlled trial
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K. John Fisher. M. Anthony Pickering, Fuzhong Li
Figure 2. SHAPE Design
64 neighborhoods chosen randomly from total of 93 in Portland, Oregon, USA
1
1 28 pairs matched - SES, density, ethnicity, rate, facilities I Walking Control 280 elderly from 30 303 elderly from 30 neighborhoods. Neighborhoods. Walk with Receive health , 7 for 6 months leader for 6 months
Assessments at baseline, 3-months, 6-months and at 12-months follow up.
in a suburban Pacific Northwest city of the USA (see Figure 2). Of major interest is the impact of various environmental and contex- tual factors on senior participation in regular exercise, which will also be explored and evaluated, along with a cost effectiveness evaluation of the intervention. The study, which began in April 2001, used computer-as- sisted telephone interviewing (CATI) proce- dures to recruit 583 elderly citizens 65 years and over, from 56 neighborhoods in Portland Oregon.
Conceptual framework of SHAPE The conceptual framework that underpins
the design of the SHAPE project is based on Bandura's Social Cognitive theory (Bandura, 1986, 1997) incorporating self-efficacy cognitions as a construct under which multi-level variables related to the individual (self-efficacy, personality), environment (neighborhood facilities, crime rate, popula-
Figure 3. SHAPE - Multilevel Influences Model
Demomaohics Age, sexyrak, SES \
1 \ Outcomes Neighborhood QOL
Walking + Social s u ~ w r t - sustained exerctse
program ~ersonal6
I • Self-efficacy / m ~ a l acliviv self etficlaq
t exereise barriers I I Environmental / Y I ' Neighborhoods facilities /
I Crime rate / Population density /
L - - - - - - - - - - - - J
tion density) and behavior (exercise history and current practices) are guided and meas- ured. The study identifies the heterogeneity of these factors and the extent to which they operate to enhance or compromise healthy exercise behavior measured by regular at- tendance and participation in the walking program. We hypothesize that sustained exer- cise behavior and related quality of life factors resulting from the walking program, will be influenced by changes in perceptions and attitudes about one's environment (neighborhood factors and social support) and perceptions about oneself (self-efficacy, personality). (see figure 3).
Methods
Neighborhood Matching Based on recommendations from the litera-
ture (Booth et al, 1997; Doucet et al., 2001; Lee et al., 2000; Roux et al., 2001; Sallis & Owen, 1999;), we identified five contextual correlates of walking participation for which objective data were available on each neighborhood. These factors were: socio-eco- nomic status (education level, household in- come), neighborhood crime rates (measured as the number of crimes against persons and property), neighborhood facilities (number of recreational facilities - parks, gardens, playing fields per neighborhood acre), ethnicity (per cent white), and senior population density (number of persons 65 or over). The data avail- able allowed us to operationally define these five factors in the following way.
Socio-economic status (SES). To obtain a more suitable indicator of SES than educa- tion or income alone, we used data from the American Family Census Survey compiled by the center for Aging Studies at Portland State University in 1995 for the City of Port- land (Portland State University, 1995). Data for education (% households with post high school education) and low income (% house- holds below $15K) were ranked separately for each neighborhood then averaged to form a single ranked indicator for this vari- able.
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Healthy Aging Through Active Leisure: Design and Methods of SHAPE ...
Crime rates. Crime rates per neighbor- hood were obtained from City and county po- lice records. Data for crimes against persons (per person) and crimes against property (per person) accumulated between January 1997 and July 2000 were ranked separately for each neighborhood, then averaged to form a single ranked indicator for this variable.
Leisure/recreation facilities. We tallied facilities by combining data from Portland City Parks and Recreation Department with direct observations. We then created a ratio of the number of facilities per acre for each neighborhood. Neighborhoods were then ranked highest to lowest according to these facilities per acre ratios.
Ethnicity. We ranked neighborhoods using the proportion of white persons in each neighborhood boundary, highest percent white to lowest percent white.
Senior population density. We calculated the proportion of seniors among the total population of each neighborhood from 1995 census data, and divided that figure by the number of acres in the neighborhood. Neighborhoods were ranked highest to lowest on this variable.
Since neighborhood influences on physical activity were central to our study, it was essen- tial that each intervention neighborhood be paired with a control neighborhood whose de- mographic and environmental characteristics were as similar as possible.
The procedure used to match neighbor- hoods and randomly assign them to condition is based on a method called matched random assignment (McDermott & Sarvela, 1999). Initially 64 neighborhoods for the study were selected from a total of 93 Portland neighborhoods, identified by the City of Port- land at the time of the 1990 national census. The neighborhoods are delineated by streets and districts identified by the Portland City Council and each has formed a volunteer committee or neighborhood association to
represent the neighborhood on issues ger- mane to the provision of neighborhood serv- ices and facilities.
Next, with guidance from the literature (Booth et al., 1997; Grzywacz & Marks, 2001; Jones & Owen, 1998; King, Rejeski & Buch- ner, 1998;), we assumed a directional influ- ence on physical activity for three contextual factors, developed from our rankings. We hypothesized that low crime, high SES, and high facilities were likely to be positively associated with walking. We thus averaged the neighborhood rankings for the crime rate, SES, and facilities factors. The 64 neighborhoods were ranked highest to lowest to form a crude "walking friendliness" variable with four categories: high, med-high, med- low, and low.
The 16 neighborhoods within the four categories of walking friendliness were then sorted by ethnicity rankings resulting in a high percent white and low percent white subgroup. Within these eight "ethnicity cat- egorized walker friendliness" subgroups, neighborhoods were ranked according to sen- ior population density.
Matched neighborhood pairs were identi- fied within each of these sub-categories simply by taking two neighborhoods at a time, in or- der. A coin was flipped for each matching pair to determine whether the first or second neighborhood of each pair was assigned to be a walking neighborhood (experimental) or an education only neighborhood (control). Lastly, 28 of the 32 matched pairs were randomly se- lected for inclusion in the study.
Recruitment
Subject recruitment was achieved primarily via telephone, and supplemented by direct mail and referrals. The telephone database consisted of all numbers with addresses from the Portland Metropolitan telephone directory downloaded to a CD-Rom. Non-residential listings (i.e. businesses, schools, government) were excluded. The direct mail list was ob- tained from an inventory of voter registration
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K. John Fisher, M. Anthony Pickering, Fuzhong Li
residences provided by Multnomah County, Oregon (www.co.multnomah.or.us/elect). This list of addresses was also downloaded to a CD-Rom disc. Listings in both databases were sorted into neighborhoods by computer, ac- cording to their street addresses. The voter registration database did not have phone numbers, but had birth dates of residents listed for each address, allowing us to identify households likely to have seniors. Listings from the telephone directory were randomly se- lected using a computer assisted telephone in- terview (CATI) system. Direct mail listings were randomly selected using a computerized ran- dom number generator.
For telephone recruitment, when contact was made within a household, a staff member explained the purpose of the call (to identify seniors possibly interested in participating). If a senior resided in the household permission was requested to send a brochure containing detailed program information. Seniors who accepted the informational brochure were contacted again within a week to determine their level of interest. If interested, they were invited to participate after being screened for project eligibility requirements. Prospective subjects were required to meet the following criteria: (1) 65 years and older, (2) sedentary (3) healthy to the degree that participation in a low stress exercise program would not place them at risk or exacerbate any existing symp- tomatology. Being "sedentary" was defined as not being engaged in regular individual or structured physical activity for at least 1 month prior to the study. During this telephone call, the study purposes and general procedures were also explained. All procedures and protocols were approved by an Institute Re- view Board.
Next, an appointment for the baseline as- sessment was scheduled to take place either at the subject's home, or at the SHAPE office, depending on the preference of the subject. At baseline assessment, research assistants facili- tated completion of informed consent paper- work and administered the screening test for mental competence (Pfeiffer, 1975) before
subjects were asked to complete the actual health survey. To be included in the study, all participants were required to pass the mental status test. Only subjects in the walking condi- tion were required to obtain a medical clear- ance from a qualified health care provider. Similar processes were used for recruiting and assessing intervention and control subjects. Only the script descriptions describing the walking program (intervention) or the senior health study (control) were modified. Control subjects received $10 for completing their sur- veys.
If filling a neighborhood group (walker or control) was unsuccessful after exhausting the telephone number database (3 or more un- successful calls), direct mail was sent to households obtained from voter registrations. In situations where telephone and direct mail did not fill a neighborhood group other recruiting methods, including contacting neighborhood church groups, neighborhood associations, dropping flyers and brochures in mail boxes, and door-to-door canvassing were used. All subjects who expressed interest in participating in the study were screened and provided with program information using the same basic telephone scripts and informa- tional materials, regardless of how they were initially contacted.
Intervention Group Following subject recruitment and base-
line assessment, subjects residing in walking neighborhoods joined their group of neighborhood peers and two walking leaders who had been trained by the investigators and research staff. The walking groups held an ini- tial group meeting where participants and leaders were introduced and the group de- cided on a designated time and place to meet. Walkers were also provided an informational booklet describing the benefits of walking, in- struction about what to do before commenc- ing an exercise program, precautionary medi- cal advice, information on proper shoes and clothing, and examples of warm up and stretching exercises. Groups then met three times a week, for six months. Sessions lasted
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Healthy Aging Through Active Leisure: Design and Methods of SHAPE ...
approximately one hour and consisted of a stretching and slow movement warm-up, a 30-minute "leisurely, but purposeful" walk in or near their neighborhood, and a short cool down. Heart rates (HR) and ratings of per- ceived exertion (RPE) (Noble, Borg, Jacob, Ceci, & Kaiser, 1983) were assessed on every outing by one of the leaders immediately fol- lowing the walk.
Throughout the program, walkers also re- ceived monthly education materials relevant to senior health from a commercial newsletter warehouse and a bimonthly SHAPE newslet- ter. They also received various rewards and in- centives including attendance certificates, wa- ter bottles and a t-shirt with emblazoned SHAPE logo.
Education Control Group The comparison groups received a home-
based education only program. The educa- tional materials were identical to those given to walkers in the intervention group and con- sisted of commercially produced newsletters relevant to senior heolth, which emphasize heart disease prevention and healthy living, including diet and exercise promotion. The educational materials were mailed to com- parison group participants at their home ad- dress on a monthly basis during the 6-month intervention period. Participants in this condi- tion were encouraged to continue their usual daily activities.
Walking Leaders Walking guides or leaders were recruited
from the community by local newspaper ad- vertising. The leaders were paid $30 each week for leading the three-times-weekly walk- ing events. Leaders and their assistants were interviewed and selected based on their hav- ing a pleasant outgoing personality, coopera- tive leadership attitude, empathy for seniors, and the support for the goals of the project. Leaders were required to attend a five-hour training and orientation which included tips from an experienced walking leader, CPR training, clarification of emergency proce- dures, guidelines for creating and selecting
walking routes, instructions about keeping at- tendance records, and administering simple measures of exercise intensity (taking subjects' heart rates and their estimates of perceived exertion - the RPE). They also received a de- tailed handbook that (a) describes the pro- gram, (b) informs them of their duties and tasks, and (c) provides information that ena- bles them to vary the walking routes, and to develop and maintain group rapport, cohesion and incentives for walkers. They were then as- signed to a specific neighborhood walking group under the discretion of the Project Coor- dinator.
Matching and Recruitment Results
Neighborhood Matching As shown in table 2, our statistical analyses
(independent t-tests) indicated no significant differences in means between the walking and control neighborhoods on the five characteris- tic factors used to match the neighborhoods.
Recruitment A subject was considered successfully re-
cruited and enrolled if he/she completed a baseline assessment, (N=583, i.e. 280 walk- ers, 303 controls). On average, approximately 228 CAT1 (telephone) calls were required to recruit a single walker into the study, and ap- proximately 138 CAT1 calls to recruit a control subject. CAT1 efforts resulted directly in 199 and 246 subjects for the walker and control groups respectively. An additional 30 walkers and 37 controls agreed to participate when referred by someone originally contacted via CAT1 (most often these were eligible spouses of enrolled subjects). Direct mail provided 27 walkers and 14 controls. Other direct contacts yielded five walkers and three controls. Nine- teen walkers and three controls were recruited to the study by word-of-mouth.
Summary and Conclusions Despite our increased knowledge about the
benefits of exercise for psychological and physiological health, it remains a challenge to find ways to encourage older adults to become more physically active. If health benefits of ex-
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K. John Fisher, M. Anthony Pickering, Fuzhong Li
Table 2. Characteristics of 64 Portland Neighborhoods Matched on Five Contextual Factors
Walking Education Neighborhoods Neighborhoods t P
(N = 32) (N = 32) M SD M SD
Socio-Economic Status % Households with total household income < 15K 0.225 0.096 0.229 0.100 -0.1 33 0.894 % Adults with post high school education 0.3 18 0.153 0.337 0.165 -0.479 0.634
Crime Crimes against persons per person 0.050 0.033 0.057 0.048 -0.704 0.484 Crimes against properly per person 0.275 0.120 0.367 0.294 -1.643 0.108
Facilities Focilities per acre 2.130 0.388 2.087 0.224 0.543 0.589
Ethnicity %White 0.792 0.1 64 0.81 5 0.157 -0.580 0.564
Senior Population Density Seniors (65 + years) per acre
ercise are to be realized, it is important for health professionals to focus on feasible and effective physical activity and exercise inter- vention strategies that can be widely dissemi- nated to the older population, preferably at low cost to the participating individuals and to the community.
The SHAPE project is one of the first con- trolled studies of its kind that has considered using environmental and psychasocial meas- ures to predict physical activity among the eld- erly. The significance of this study lies in i t s ex- ploration of the impact and effectiveness of neighborhood walking programs, focusing on individual and neighborhood level factors, on the psychological and physical health of older adults, as well as the feasibility of establishing self supporting regular walking groups for eld- erly citizens. Overall, the proposed social-con- textual model will examine the importance of self-referent, neighborhood, and demographic factors on elderly physical activity behavior, ex- amining how changes in these factors influ- ence changes in physical activity participation (increases, decreases, maintenance, cessa- tion) throughout the course of the walking program, and for 6-months after the program ends. In addition, the model will examine the extent of homogeneity in physical activity par-
ticipation among members from the same walking group and from the same neighborhood and will allow us to determine the extent to which broader contextual influ- ences affect the physical activity behavior of neighborhood members.
A high percentage of older adults are sed- entary, and walking has become the most popular and prevalent physical activity choice for this age group. Once completed, this re- search project will provide a better under- standing of the influence of environmental and psychological characteristics on the exer- cise behavior patterns in older individuals, and the concomitant effects on their health and quality of life.
Acknowledgements
We gratefully acknowledge the comments from Roland Lamarine, Yvonne Michael, Vince Nethery, and Ruth Rowland on earlier drafts of this paper.
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K. JOHN FISHER, Ph.D.,
M. ANTHONY PICKERING, MS.,
FUZHONG LI, Ph.D.
Oregon Research Institute, Eugene, Oregon.
All correspondence should be addressed to: K. John Fisher, Ph.D., Research Scientist, Oregon Research Institute, 1715 Franklin
Blvd., Eugene, Oregon, USA. 97403. Tel (541 -1 484-21 23. Fax (541 -) 484-1 108.
Email: [email protected]
Portions of this paper were presented at the World Leisure Asio Regional Conference
on "Social Development, Leisure and the Older Person"
Shanghai, China, April 24-29, 2001
Preparation of this work is supported by Grant No. AG 175 10, and in part by Grant No. AG 18394 from the National Institute on Aging.
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