Physical Literacy-based Intervention (PLBI) for Older Adults: A Cluster Randomized Controlled Trial Study Protocol
Phase: NA
Conditions: Competence, Physical Activity, Knowledge, Attitudes, Practice, Motivation, Confidence, Self, Peer Group
Sponsor: Chinese University of Hong Kong

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Title: Physical Literacy-based Intervention (PLBI) for Older Adults: A Cluster 
Randomized Controlled Trial Study Protocol 
 
NCT number: NCT06137859 
 
Date of document: 24/08/2024 
 
 

Physical literacy-based intervention (PLBI) for older adults: A cluster randomized 
controlled trial study protocol 
 
Study Protocol and Statistical Analysis Plan 
 
Physical literacy-based intervention (PLBI) 
Because people are in different stages of life and diverse settings, there should be 
a variety of physical literacy programs conducted by sports, educational, or social 
security systems throughout the physical literacy journey. Researchers have made great 
efforts in PLBI targeting adolescents within school settings (1). The efficacy and 
effectiveness of other interventions (e.g., family, community, public health, sport) have 
yet to be proven (2). As a result, older adults have been neglected in previous PLBI. 
Currently, there is no common framework or model to measure physical literacy in older 
adults. Canada has set up a guiding model in order to enhance the physical literacy of 
older Canadians. This model consists of five components, namely policy, community, 
organizational, interpersonal, and intrapersonal (3). The draft Australian Sports 
Commission Physical Literacy Standard has been used as a PLBI guideline with four 
domains (physical, psychological, social and cognitive), which could be applied 
throughout the course of an individual’s life (4). Since little is known about the 
development of physical literacy among the older adults of Hong Kong and elsewhere in 
the world, the present study proposes to use a PLBI for developing physical literacy and 
to chart the physical literacy level among older adults in Hong Kong. In this connection, 
the following PLBI program and activities have been designed in the intervention of this 
proposed study. 
 
Part 1: Weekly-based functional fitness training (WBFFT) 
Functional fitness is focused on building a body capable of doing real-life 
activities in real-life situations, which is in line with the actual needs of the elderly. 
Physical function declines up to 4% per year after the age of 65, and research has shown 
the positive effect of a 20-week intervention to increase functional fitness among older 
adults (5). Another study implemented a 12-week comprehensive golf training program 
for older adults (6), which also stressed the importance of the functional fitness 
improvement program. Hagströmer et al. (7) examined the effects of twice-weekly (12 
weeks in total) intensive aerobic exercise on physical function and quality of life after a 
subacute stroke, which showed improved aerobic capacity, walking, balance, health-
related quality of life, and patient-reported recovery (8). Yang et al. (9) identified strong 
evidence supporting a program of combined exercises (e.g., resistance, cardiovascular, 
and functional training) to effectively improve mobility in older adults. Weekly-based 
exercise programs have therefore been widely adopted by fitnessrelated interventions to 
promote health. 
In this proposed study, participants will receive a 12-week duration of functional 
fitness training in daycare centers, which will be implemented twice a week (one during 
the week, another one at the weekend). The 60-minute per session training series will be 
delivered and guided by qualified elderly health and fitness instructors recruited from the 
professional national association in Hong Kong, who will be provided with a workshop 
(3 - 6 hours, 2 sessions) before this intervention. The workshop will be designed and 

delivered by the research team. The first session will focus on the physical literacy of 
older adults and the second session will focus on how to lead functional fitness training 
under the FITT principle (Frequency, Intensity, Time, Type; and how they relate to 
cardio, strength, stretching and injury prevention) for older adults. A further important 
issue that will be mentioned is related to ensuring the safety of older adults during the 
whole intervention, which will emphasize the process-oriented outcomes and 
encouragement to participation, rather than the product oriented assessments. Meanwhile, 
the main goal of functional training is to improve the range of joint motion, increase 
muscle strength and flexibility, and boost blood circulation in a safe and acceptable 
manner. Therefore, symmetry training together with cardiovascular training is the core of 
the training program. Examples of the main training activities include cardio-fullbody 
exercises (e.g. move adherence to the music training, including running, jogging, dancing 
movements, etc.), upper body exercises (e.g. bench press, rowing and lifting), lower body 
exercises (e.g. squatting and lateral hurdle jumps with tap-sensitive pods) and sensory 
integrative training (e.g. shooting training with an electronic sensory wall). 
 
Part 2: Mastering physical literacy class (MPLC) 
A 30-minute MPLC program will be conducted by experienced elderly health and 
fitness instructors after WBFFT. This MPLC program aims to enhance the knowledge 
and understanding of physical literacy. Referring to the newly developed consensus 
statement (10), the MPLC includes the following five domains related to the relationship 
with movement and physical activity throughout life: 
i. 
Why physical literacy matters – improves health, well-being and quality of 
life.  
ii. 
Understanding physical literacy – value, enjoy and engage in physical 
activity for life.  
iii. 
Everyone’s physical literacy is different – their individual needs and 
experiences of movement and physical activity. 
iv. 
Building physical literacy – think, feel, move and connect with others. 
v. 
How experience affects physical literacy – people, places and spaces 
around us. 
 
Part 3: Daily-based reflective writing (DBRW) 
Daily-based reflective writing or keeping a journal has been widely used in 
interventions targeted at older adults, especially within the affective domain. Life review 
through writing, which includes written or verbal prompts to encourage writing about 
one’s life in a systematic, chronological way irrespective of emotional content is a 
valuable intervention that can be used in occupational therapy practices with the elderly. 
Previous randomized controlled trials have shown support for the therapeutic benefits of 
emotional disclosure through writing in not only adults with chronic illness but also in 
healthy adults (11). 
At the end of the baseline stage of this proposed study, each participant of the 
intervention group will receive a template notebook for daily-based reflective writing. 
The required columns consist of the daily diet, physical activity, mood and sleep quality. 
Participants will be required to write down their behavior in this notebook daily. In each 
week’s functional training course, there will be a life-sharing session, where the 

participants will be reminded to bring their notebooks and share their daily activities with 
others. They will receive feedback, advice and encouragement from the instructor and 
each other. The notebook will be collected during the last week of the intervention. 
 
Part 4: Buddy peers support group (BPSG) 
Providing strong social support for older people in Hong Kong may lead to a high 
level of relatedness that may increase well-being and better physical health (12). The 
BPSG introduced in this program may greatly increase social support which will be 
shown to be a key determinant of adherence to the exercise programs and create a 
commitment to achieve specified levels of physical activity (13). 
In this proposed study, peer-support groups with buddy members will be arranged 
in each daycare center. Three pairs of buddies and hence about 6 participants will be 
formed per group. A total of 6 buddy pairs and 2 groups will be formed per daycare 
center. Buddy peers will encourage each other to do functional exercises regularly or to 
perform functional exercises together. The time and place for the practice will be decided 
among buddy members. A member in each group will be nominated as the leader to assist 
in the liaison and coordination of group activities. The group will perform weekly group-
based functional exercises, and the time and place for the practice will be decided among 
group members. The group will be encouraged to hold monthly gatherings with their 
fitness instructor in order to strengthen social support. 
 
Study design 
A two-arm cluster randomized controlled trial will be employed in this proposed 
study (see details in Fig 1). According to the Social Welfare Department of Hong Kong, 
there are 98 daycare centers for the elderly in 2023 (14). Daycare centers for the elderly 
located in 3 regions in Hong Kong will be invited to participate in the intervention. The 
PLBI will be conducted for twelve weeks. 
 
Sample size and participants 
The required sample size is calculated based on the hypothesized effect sizes, and 
the likely rates of participant drop-out for the outcomes. The estimated sample size is 198 
with an effect size of 0.25, α of 0.05 and power of 0.95 (15). With the anticipation of a 
20% participant drop-out rate, this led to a required number of 120 participants per group. 
Therefore, 10 daycare centers for the elderly in Hong Kong will be invited to participate 
in this study. 
 
Physical literacy-based intervention group (PLBI) 
Inclusion criteria will be: 1) those aged 65 to 74 years old who are registered in a 
daycare center/unit for the elderly in Hong Kong, 2) the ability to walk eight meters 
without assistance (16), and 3) able to read and write. Exclusion criteria will include 1) 
neurological disease which impairs mobility, cardiovascular disease which results in 
shortness of breath or angina on walking up one flight of stairs, and 2) cognitive 
impairment. Participants’ cognitive function will be screened by the Chinese Mini-
Mental State Examination (17, 18), and those who score below 24 will be excluded. 
The research team will randomly send a series of email messages and invitation 
letters to daycare centers in accordance with their district via a computer-generated 

randomization sequence (GraphPad Software, Inc.) by a statistician who is blinded to the 
allocation of participating daycare centers. After the daycare centers agree to participate, 
a leaflet package, which describes the theoretical background, timeframe, and main 
objectives/learning goals, will be delivered to the staff of daycare centers. Then an 
introductory meeting with staff will be held to illustrate practical details related to the 
intervention. The proposed program will be publicized in the participating elderly 
daycare centers through posters and pamphlets, where the efficacy and benefits of PLBI 
will be briefly outlined. Recruitment will follow by setting up counters supported by the 
staff in the participating centers. Those who express interest will have their eligibility 
screened through a short questionnaire based on the inclusion and exclusion criteria. 
More detailed information about the study will be given to the eligible participants. 
Written informed consent will be obtained. 
 
Control group 
Participants will follow the inclusion and exclusion criteria of the PLBI group. 
Participants will not receive PLBI intervention treatment. However, participants in the 
control group will be given the same treatment (program and activities) after all data has 
been collected. 
 
Outcome measures 
Assessment or charting progress in relation to physical literacy is essential, as this 
will help clarify policymakers’ understanding of the concept as well as individuals’ 
appreciation of their physical literacy journeys, and how they might develop physical 
literacy through a lifespan (2). Physical literacy is an individualized personal journey so 
any assessment trying to support this journey should be relative to the individual and their 
progress and must reflect the changes over time (19). Therefore, this study will adopt 
both objective and self-reported measures to cover the elements and domains of physical 
literacy. Participants will be evaluated at baseline (week 0), post-intervention (week 12), 
and at a 6-week follow-up (week 18). All of them will be conducted at daycare centers 
for the elderly. The self-reported measurements will be administered by research 
assistants while the objective measurements will be performed by certified physical 
fitness assessors and health professionals who are blinded to the randomization for 
avoiding bias. 
 
Objective measure (primary outcomes) 
Physical competence 
The Short Physical Performance Battery (SPPB) will be used to measure the 
physical competence within the physical literacy of older adults (16). Huang et al. (18) 
suggested using a combined and comprehensive kit of assessment tools to measure 
physical competence, and the SPPB was reported to be able to measure complex 
capabilities with excellent test-retest reliability, especially in community-dwelling older 
adults. It is a group of measures that combines the results of the gait speed, chair stand 
and balance tests, which consist of balance, a timed eight-foot walk and chair stands. The 
scores range from zero (worst performance) to 12 (best performance). It has been used as 
a predictive tool for possible disability and can aid in monitoring function in older 
people. The reliability of SPPB has been reported as ICC = 0.75 – 0.89 for all measures. 

Daily behavior 
Accelerometers (Actigraph wGT3X-BT) will be used to measure the physical 
activity engagement levels of participants, and are categorized as sedentary, light, 
moderate and vigorous. Data was collected in 60 s epochs to account for elderly people’s 
natural activity levels, as it was shown to present the most acceptable classification 
accuracy for accelerometer use among older adults (20). The cut-points developed by 
Aguilar-Farías et al. was applied to identifying intensity levels (20). Participants will 
wear accelerometers at the waist to measure their physical activity engagement levels for 
at least 8 hours per day, for seven consecutive days. 
 
Self-report measures (secondary outcomes) 
Demographic information 
Demographic information including age, gender, BMI (height and weight), 
education, and socio-economic status will be included in the starting part of the 
questionnaire set, in order to acquire personal characteristics for further analysis. 
 
Daily behavior 
International Physical Activity Questionnaire – short form is the short version of 
the International Physical Activity Questionnaire used to measure self-reported physical 
activity levels. They will be required to report on the total duration of different types of 
physical activity which lasted at least 10 uninterrupted minutes in the last 7 days. 
Example item included: During the last 7 days, how many days did you do vigorous 
physical activities? 
 
Knowledge and understanding 
Montreal Cognitive Assessment (MoCA) is a 30-question brief and sensitive test 
used for detecting Alzheimer’s disease and measuring executive functions and multiple 
cognitive domains. It is widely adopted for older adults and will be used to assess 
knowledge and understanding of physical literacy among the elderly. MoCA-B is a 
revised MoCA test. The Chinese Version of MoCA-B tests nine cognitive domains 
(executive function, language, orientation, calculation, conceptual thinking, memory, 
visual perception, attention, and concentration), and has been reported as a reliable 
cognitive screening test across all education levels in Chinese elderly adults (21), with 
high acceptance and good reliability. 
 
Physical literacy 
The perceived Physical Literacy Instrument (PPLI) is a 9-item instrument which 
is used to measure the perceived physical literacy of different individuals (22, 23). Three 
subscales are “sense of self and self-confidence”, “self-expression and communication 
with others” and “knowledge and understanding” which were identified as key attributes 
of physical literacy (4). Participants responded to the instrument on a 1 to 5 Likert scale 
(1 = strongly disagree and 5 = strongly agree). Sum et al. (22) confirmed that the three-
factor validity (RMSEA = 0.08; CFI = 0.94 and SRMR = 0.04) and convergent validity 
(CR = 0.72 - 0.78; AVE = 0.43 - 0.54) of the PPLI was satisfactory. 
 
Motivation and confidence 

Perceived Well-being Scale (PWB) contains 14 items with 7 points which will be 
used to measure participants’ motivation and confidence (24). It is a short and convenient 
measure for use with community-based and institutionalized elderly. Example items 
include: (a) I am often bored (psychological well-being); (b) I am in good shape 
physically (physical wellbeing). The validity of PWB is sufficiently high to justify being 
used with the elderly, in particular in longitudinal and intervention studies. 
 
Buddy Peers Support 
A 5-item Friend Support for Exercise Habit Subscale of the validated Social 
Support for Diet and Exercise Behavior Scale will be used (25). Five questions are 
“exercise with me”, “offered to exercise with me”, “gave me reminder to exercise”, “gave 
me encouragement to stick with my exercise program”, and “changed their schedule so 
we could exercise together”. Participants responded to the instrument on a 1 (none) to 5 
(very often) Likert scale. Sallis et al. (25) confirmed that the sub-scales are with high 
acceptance and good reliability. 
 
Data analysis 
SPSS version 28 for Windows will be used for data analysis. Internal consistency 
reliability coefficients (Cronbach alpha) will be calculated for all sub-scales within the 
psychometric questionnaires. A cut-off score of 0.7 will be used to determine acceptable 
reliability. Descriptive statistics (means and standard deviations) will be calculated for 
participants’ primary and secondary outcomes (objective and self-reported) at three-time 
points. Multilevel modeling methods were used to account for the clustered nature of the 
data. Specifically, we used three-level (time within older adults within daycare center) 
regression analyses to examine the effects of group (experimental vs control), time 
(baseline, post-test and follow-up), and the group–time interaction (i.e., “intervention 
effect”) on the primary and secondary outcomes. Covariates such as age, gender, BMI, 
education, and socioeconomic status will be included in the analysis. Bonferroni post hoc 
analyses will be conducted to determine contributing factors to the significance of F 
values, and the confidence level will be set at 95% to maintain statistical reliability for all 
the analyses. 
 
Evaluation plan 
At post-intervention, in-depth interviews of a group of 8 - 12 participants will be 
conducted to explore their experiences in participating in the intervention, the level of 
satisfaction with the intervention, and the barriers and expediters in performing the PLBI 
as instructed. DBRW will also be material for evaluation analysis. The reasons why 
participants dropped out of the study will also be recorded. Additionally, participants will 
be invited to fill in a process evaluation survey which assesses their level of involvement 
and level of satisfaction with the intervention. 
 
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