This study examined whether or not short-term improvements in exercise involvement were maintained 8 months following a home-based arthritis self-management intervention as well as the moderating role of individual characteristics in the maintenance of behavior change. Results showed that behavior changes observed immediately after the self-management intervention for variety and frequency of exercise were maintained 8 months following completion of the intervention despite apparent decreases in exercise involvement. Furthermore, long-term maintenance was not moderated by individual characteristics. Among the three subtypes of exercises assessed, only changes in walking remained statistically significant with participants reporting walking even more frequently 8-months after the program.
These results are congruent with some studies on maintenance of involvement in exercise after self-management interventions [4
]. Given the rigorous study design, we propose that maintenance is related directly to the "quality of the content" of the intervention [40
]. First, participants were strongly encouraged to take daily walks in their homes and immediate surroundings. They were shown, during the intervention, that walking is an "easy-to-do" exercise that can be performed anywhere, at any time. This demonstration and the verbal persuasion may have supported participants in their maintenance of exercise. Secondly, participants highly valued "increasing walking frequency or distance" in the personal contracts implemented during the intervention. Given that these contracts stay with participants after the intervention as "reminder" of the importance of staying active, they might have supported their exercise maintenance. Finally, during the intervention, participants received an exercise hand-out with examples of stretching and strengthening exercises. Even though these types of exercises were not maintained across time, this sheet might also been an exercise "reminder" which might have influence exercise maintenance. Together, the hand-out, the encouragement received, and the personal contract may have had a long-term impact on motivating people to stay active, to get out of the home, and even to use resources to exercise.
However, given that maintenance of intervention changes are usually precarious, other strategies could be implemented. First, even if social reinforcement by interventionists did not have significant impact on exercise maintenance, we propose that such reinforcement should be delivered by the practitioner intervening with participants because interventionists are the ones who know and understand participants and with whom the participant shares a bond of trust. Secondly, new exercise information could be sent periodically to participants in order to strengthen the value of staying physically active as well as to provide a new series of home exercises. Finally, considering the absence of maintenance of stretching and strengthening activities, the new version of the I'm Taking Charge of My Arthritis! intervention, now includes additional hand-out exercise sheets. In fact, it is possible that participants became bored with repeating the same six stretching and strengthening activities provided on the exercise hand-out and decided to walk instead because it is easier and more pleasant. These changes may help future participants maintain intervention benefits.
In addition to the previous results, it also interesting to note that even though short-term changes in weekly exercise frequency were moderated by economic status and depression, no individual characteristics played a moderating role in the maintenance process. This finding is in contrast to others studies [41
] who highlight functional limitations, comorbid situation, depressives symptoms, gender [43
], self-efficacy, and perceived behavioral control [45
] as predictors of maintenance of health behavior. Such results have important implications for setting and timing of intervention. In fact, our long-term results imply that when interventions result in changes, everyone, regardless of their individual characteristics can maintain them.
Despite these findings and interpretations, several limitations of the study should be mentioned. Participants may have demonstrated social desirability bias in responding to interviews and thus reported more exercise than they actually performed. Similarly, other variables not measured in our study (i.e., social support by the family or involvement in other activities) might explain greater maintenance of exercise involvement. Furthermore, limitations to the RCT were discussed elsewhere [18
] and included the self-reported measures and the relatively small number of participants. Additional limitations are the long-term follow-up wherein no experimental manipulation was done between post-intervention-1 and post-intervention-2, which limits interpretation of the findings. Furthermore, the sample of the current study was composed predominantly of females and thus calls into question its generalizability. However, as other studies have shown [12
], females are more likely to suffer from arthritis than males (54% versus 37% in Canada for older adults) thus likening the study context to a real-world situation.
Nevertheless, considering the frail and housebound nature of the target population and the large variety of positive impacts exercise can have on their health, the current findings remain encouraging. Moreover, the low to moderate levels of pre-intervention exercise of this population and the significant improvements and some long-term maintenance of exercise behaviors support the notion that providing such interventions on a wider scale could have significant benefits in the management of disability. Interventions at home may facilitate learning and adoption of health behaviors.
To our knowledge, this is the only study conducted entirely on housebound older adults with arthritis for the purpose of evaluating a home-based self-management intervention. Health promotion interventions such as I'm Taking Charge of My Arthritis! can support the plight of homebound older adults with arthritis who must deal with arthritis symptoms on a daily basis.