Study design and participants

A single-group, quasi-experimental, pre-post-test study design was applied in three rural villages in western coastal Yunlin County. Originally, we sought to evaluate the efficacy of the ISC program by comparing ISC participants (treatment group) with a group of older adults who were not offered ISC participation (control group). After the conclusion of the three-month study period and data collection, we planned to offer the ISC program to the control villages. However, community leaders in the participating communities objected to control group participation and requested ISC program administration for their communities as well. Thus, a designated control group was not included in this study.

Participants were recruited from three rural community activity centers between June and August 2020. The nurse-led research team designed the ISC program and trained CCW collaborators prior to conducting the program. The ISC program comprised of a standardized protocol of modified Baduanjin exercise combined with three recreational breathing games. Typically, traditional Baduanjin consists of eight separate activities; however, due to the complexity three of these sections, we developed a modified Baduanjin exercise protocol that eliminated these sections and was shortened to five parts. In addition to participation in Baduanjin, older adults were provided with games, tools, and toys from their childhood and were offered recreational activities and lunch before returning home. Each week, the ISC program was designed and conducted by the research team. ISC programming lasted approximately 90 min, including 30 min of modified Baduanjin exercise, 30 min of table tennis, blowing games, and elephant-trunk paper flute (similar to a common pulmonary rehabilitation game), and 30 min of karaoke competition (a type of interactive entertainment developed in Japan in which participants sing along to recorded music using a microphone). Furthermore, we video recorded these sessions and shared ISC activities with other CCWs via YouTube in order to train them for the subsequent four days of activities each week. The inclusion criteria were as follows: (1) able to access the community center by walking or transportation (2) able to communicate in Mandarin or Taiwanese, and (3) agreed to participate in this study and signed the informed consent form.


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    Demographic characteristics and health-related behaviors included age, sex, education level, occupation, and living arrangement. Based on the previous studies [1,2,3], participants were asked questions regarding five health-related habits: (a) Cigarette smoking: “Do you smoke cigarettes?” Participants were classified as “non-smoker” if they reported having never smoked; “smoker” if they reported that they were current smokers or they smoked previously and had ceased smoking, (b) “Do you live with smokers?” Participants were categorized according to their response “yes” or “no.” For the following four items, responses were combined and categorized as never/seldom and usually/always: (c) Intake of vegetables: “How often do you consume three portions of vegetables (about 1.5 bowls) per day?“ (d) Intake of fruit: “How often do you consume two portions of fruit (about one bowl) per day?“ (e) Intake of water: “How often do you consume at least 1500 mL of water per day? (f) Regular exercise: “How often do you engage in exercise for at least 30 min, times per week?”

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    Lung function tests were performed by a certified respiratory therapist and experienced technician (MH, first author) using an automated flow-sensing spirometer (Pony Fx-EN13485, the new generation of desktop lung function tester developed by COSMED) based on the American Thoracic Society recommendations [9]. Three indices were frequently used by the clinicians to identify airway diseases: (1) forced expiratory vital capacity (FVC), which refers to the total amount of air that an individual can exhale in one breath, (2) predicted FVC value (%), and (3) forced expiratory volume in one second (FEV1)/FVC ratio (%) [10].

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    Health-related fitness assessment was based on measures for the implementation of National Fitness Testing by the Ministry of Sports Education for older adults. The assessment checklist primarily focused on evaluation of the participants’ cardiopulmonary function and physical fitness using the following metrics: (a) upper limb muscle strength and endurance (duration times of biceps arm flexion for 30 s); (b) leg muscle strength and endurance (duration times of sitting and standing for 30 s); (c) cardiorespiratory endurance (duration times of raising the knee and stepping on the spot for 2 min); (d) shoulder softness (back grasp test); (e) lower limb softness (sitting on the chair and bending forward); (f) static balance ability (standing on single foot with the eyes open); (g) physical agility and dynamic balance ability (standing from a chair, moving around objects, and returning to the chair). According to the standardized test by the Ministry of Sports Education [8], points were based on the participant’s sex and age, wherein values 1, 2, 3, 4, and 5 were considered very weak, weak, normal, good, very good, respectively. We assessed the health condition, including parameters such as blood pressure and pulse rate, prior to beginning the study program.

Procedure and ethical consideration

This study was performed in accordance with the Declaration of Helsinki and was approved by the institutional review board of the ethical committee of Chang Gung Memorial Hospital Foundation (IRB: 202000109B0). Participants who agreed to participate in the study provided informed consent in the form of a written consent form. Illiterate participants provided informed consent following oral presentation of the written consent form which was then signed by their guardian or companion following their permission to sign on their behalf.

Before conducting the study, the research team (including one family physician, two nursing staff, one respiratory technician, one physical therapist, and five senior nursing students) conducted a general health assessment via a checklist (including measurement of the participants’ blood pressure and temperature, and asking questions such as: How are you feeling today? Did you have breakfast?) to determine whether he/she was eligible to participate in this program. The checklist was recorded and continued by a CCW for another four days per week. The study’s purpose and procedures were explained to all participants, three village leaders, and all CCWs. The village leader sent messages regarding the information and invited individuals to participate in this study. Upon agreeing, one-to-one measurement was conducted at each community activity center before and after this study.

The research team described the study procedures to all participants, including opening the windows, wearing surgical facemasks except when drinking water or participating in recreational breathing games, keeping social distance, the procedure of the lung function test, and health-related fitness [21, 22]. The ISC program was 90 min per day, five days a week for 12 weeks. On day 1, after the research team demonstrated the procedures, and each CCW followed the ISC protocol with the recorded video material for the other four days. Besides, the three CCWs were taught how to assist older adults in checking their blood pressure via the automated oscillometric monitor (Omega 1400; Orlando, Florida, USA) every morning, temperature, frequent hand hygiene, drinking water, and using the toilet during each session. During the post-test, we asked a general question to all participants “how do you feel/are you satisfied with this program?” The answer was descriptively recorded.

Data analysis

Based on a two-tailed t-test (Cohen, 1992), the sample size was set at 55, which was calculated by the G*power version, when the effect size = 0.4, α = 0.05, and power = 0.90. Due to the limited literature concerning similar interventions, we opted to use a medium effect size to calculate the sample size. Considering the 20% retraction rate, 82 participants were recruited for this study. The paired t-test was used to compare the mean difference in the physiological biomarkers (e.g., blood pressure, waistline, body mass index, three lung function parameters, and health-related fitness changes). Data analyses were conducted using SPSS 20 (IBM SPSS, Armonk, NY: IBM Corp).

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