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EnhanceFitness 

Program Description

EnhanceFitness is a multicomponent, group physical activity program that aims to help older adults at all levels of 

fitness become more active, energized, and empowered to sustain independent lives and prevent functional 

decline. The program includes 1-hour classes that are held two or three times per week in a variety of settings, 

including community centers, senior housing facilities, YMCA facilities, and retirement communities. Each class, 

which can accommodate groups of up to 25, includes a workout session that is conducted by certified, trained 

exercise instructors. Each session includes a 5- to 10-minute warmup phase that incorporates balance exercises to 

stimulate blood flow to muscles, 15–20 minutes of strength training with soft ankle and wrist weights, 20 minutes 

of walking or aerobic activity, and a flexibility and cooldown phase. Fitness checks are conducted at baseline and 

4-month intervals to measure participant progress in upper- and lower-body strength and endurance. 

To participate in the program, interested individuals must register and receive clearance from their personal 

physician. Instructors must be certified by a nationally recognized fitness association and attend a 1.5-day 

EnhanceFitness instructor training.

Descriptive Information

Areas of Interest Health and wellness

Outcomes

Review Date: December 2011

 Functional health and well-being

 Depressive symptoms

 Health care costs

Ages 

 61–74 (Older adult)

 75–84 (Older adult)

 85+ (Older adult)

Genders 

 Female

 Male

Races/Ethnicities  White

 Race/ethnicity unspecified

Settings

 Community-based organization

 Senior center

 Other community settings

Geographic Locations Suburban

Funding Partially/fully funded by Administration on Aging

Adverse Effects No adverse effects, concerns, or unintended consequences were identified by the 

developer.
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Implementation History

The EnhanceFitness pilot study began in 1993 at Northshore Senior Center in Bothell, 

Washington, and the program was first implemented in 1995. The intervention was 

disseminated across Washington State, beginning in 1997, and then in other States, 

beginning in 2000. Approximately 550 sites across 32 States have implemented 

EnhanceFitness with over 25,000 participants.

Adaptations No population- or culture-specific adaptations were identified by the developer. 

Quality of Research

Review Date: December 2011 

Documents Reviewed 

The documents below were reviewed for Quality of Research. The research point of contact can provide 

information regarding the studies reviewed and the availability of additional materials, including those from 

more recent studies that may have been conducted. 

Study 1

Wallace, J. I., Buchner, D. M., Grothaus, L., Leveille, S., Tyll, L., LaCroix, A. Z., & Wagner, E. H. (1998). 

Implementation and effectiveness of a community-based health promotion program for older adults. Journal of 

Gerontology: Medical Sciences, 53A(4), M301–M306. PubMed abstract available at 

http://www.ncbi.nlm.nih.gov/pubmed/18314570

Study 2

Ackermann, R. T., Cheadle, A., Sandhu, N., Madsen, L., Wagner, E. H., & LoGerfo, J. P. (2003). Community 

exercise program use and changes in healthcare costs for older adults. American Journal of Preventive Medicine, 

25(3), 232–237. PubMed abstract available at http://www.ncbi.nlm.nih.gov/pubmed/14507530

Outcomes 

Outcome 1: Functional Health and Well-Being 

Description of Measures

Functional health and well-being were assessed with the 36-Item Short Form Health 

Survey (SF-36). The SF-36 is composed of eight scales:

 Physical functioning. Respondents indicated the extent that their health now 

limited them in activities that might be done during a typical day (e.g., lifting 

groceries, climbing stairs, bending or kneeling, walking, bathing or dressing), with 

response options ranging from “no, not limited at all” to “yes, limited a lot.”

 Role limitations due to physical health. Respondents indicated whether they had 

problems with their work or other regular daily activities as a result of their physical 

health during the past 4 weeks. Respondents answered “yes” or “no” to scale 

items asking whether they cut down the amount of time spent on work or other 

activities, accomplished less than they would like, were limited in the kind of work 

or other activities, and had difficulty performing the work or other activities.

 Role limitations due to emotional problems. Respondents indicated whether they 

had problems with their work or other regular daily activities as a result of any 
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emotional problems (e.g., feeling depressed or anxious) during the past 4 weeks. 

Respondents answered “yes” or “no” to scale items asking whether they cut 

down the amount of time spent on work or other activities, accomplished less 

than they would like, and did not do work or other activities as carefully as usual.

 Social functioning. Respondents rated the extent that physical health or 

emotional problems interfered with their normal social activities during the past 

4 weeks, with response options ranging from “not at all” to “extremely.”

 Bodily pain. Respondents rated how much bodily pain they had during the past 

4 weeks, with response options ranging from “none” to “very severe,” and how 

much the pain interfered with normal work, with response options ranging from 

“not at all” to “extremely.”

 Emotional well-being. Respondents rated the extent that they felt nervous, down 

in the dumps, calm and peaceful, downhearted and blue, and happy during the 

past 4 weeks, with response options ranging from “none of the time” to “all of 

the time.”

 Energy/fatigue. Respondents rated the extent that they felt full of pep, had a lot 

of energy, felt worn out, and felt tired during the past 4 weeks, with response 

options ranging from “none of the time” to “all of the time.”

General health perceptions. Respondents rated their general health, with response 

options ranging from “poor” to “excellent,” and whether they got sick a little easier 

than others, were as healthy as anybody they knew, expected their health to get 

worse, and had excellent health, with response options ranging from “definitely 

false” to “definitely true.”

Key Findings

In a randomized controlled trial (RCT), individuals at a senior center were randomly

assigned to an intervention group, which participated in the 6-month EnhanceFitness 

program, or a wait-list control group. After the 6-month period, participants in the 

control group were allowed to join the workout sessions, and participants in the 

intervention group were allowed to continue, as desired.

At the 6-month follow-up, after controlling for baseline levels of functional health and 

well-being as well as demographic variables, intervention group participants had 

better functional health and well-being relative to control group participants in six of 

the eight scales of the SF-36: role limitations due to physical health (p = .007), role 

limitations due to emotional problems (p = .02), social functioning (p = .006), 

emotional well-being (p = .001), energy/fatigue (p = .02), and general health 

perceptions (p = .001).

Studies Measuring 

Outcome Study 1

Study Designs Experimental

Quality of Research Rating

(0.0–4.0 scale) 3.5
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Outcome 2: Depressive Symptoms 

Description of Measures

Depressive symptoms were assessed with the Center for Epidemiologic Studies 

Depression Scale (CES-D), a 20-item self-report instrument designed to measure 

common symptoms that have occurred during the past week, such as poor appetite, 

hopelessness, pessimism, and fatigue. Respondents rated each item on a scale from 

0 (no presence of symptoms) to 3 (presence of symptoms most or all of the time). 

Scores range from 0 to 60, with lower scores indicating the presence of fewer 

symptoms.

Key Findings

In an RCT, individuals at a senior center were randomly assigned to an intervention 

group, which participated in the 6-month EnhanceFitness program, or a wait-list 

control group. After the 6-month period, participants in the control group were 

allowed to join the workout sessions, and participants in the intervention group were 

allowed to continue, as desired.

At the 6-month follow-up, after controlling for baseline levels of depressive 

symptoms and demographic variables, intervention group participants had lower 

scores on the CES-D than control group participants (p = .001).

Studies Measuring 

Outcome Study 1

Study Designs Experimental

Quality of Research Rating

(0.0–4.0 scale) 3.5

Outcome 3: Health Care Costs 

Description of Measures

Health care costs were assessed through inpatient utilizations (i.e., percentage of 

individuals hospitalized), number of primary care visits, and three summary cost 

variables: total, inpatient, and primary care costs. Primary care costs were all direct 

and indirect costs associated with visits or telephone calls (by primary care or 

preventive medicine personnel) that were related to direct patient care or to 

preventive services or risk factor reduction counseling. Data were obtained from the 

administrative database of a health maintenance organization (HMO). All costs and 

utilizations occurring between a patient’s first EnhanceFitness class visit (i.e., the 

index date, which occurred in October 1998 or later) and December 31, 2000, were 

used. Participants in the control group were assigned an index date that was identical 

to that of their matched participant.

Key Findings

In a retrospective study, two matched cohorts—an exposure cohort and a control 

cohort—were sampled from patients who were aged 65 or older and continuously 

enrolled in a large, mixed-model HMO in Washington State. The exposure cohort 

included all eligible HMO enrollees who participated in EnhanceFitness at least once. 

A frequency matching procedure based on age and gender was used to select three 

enrollees who had never participated in EnhanceFitness to serve as controls for each 

program participant.
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The average increase in annual total health care costs per patient was less for the 

exposure cohort ($642) than for the control cohort ($1,175) (p = .05). After adjusting 

for differences in age, gender, enrollment date, comorbidity index, and preexposure 

cost and utilization levels, total health care costs for the exposure cohort were 94.1% 

that of the costs for the control cohort. However, for patients in the exposure cohort 

who participated in EnhanceFitness once or more weekly (on average), total adjusted 

follow-up costs were 79.3% that of patients in the control cohort.

Studies Measuring 

Outcome Study 2 

Study Designs Quasi-experimental

Quality of Research Rating

(0.0–4.0 scale) 3.6

Study Populations 

The following populations were identified in the studies reviewed for Quality of Research.

Study Age Gender Race/Ethnicity 

Study 1

 61–74 (Older adult)

 75–84 (Older adult)

 85+ (Older adult)

 73% Female

 27% Male

 99% White

 1% Race/ethnicity unspecified

Study 2

 61–74 (Older adult)

 75–84 (Older adult)

 85+ (Older adult)

 75.3% Female

 24.7% Male

Data not reported/available

Quality of Research Ratings by Criteria (0.0–4.0 scale) 

Criterion 

Ratings 

Outcome 1 Outcome 2 Outcome 3 

Reliability of Measures 3.6 3.6 3.6

Validity of Measures 3.6 3.6 3.5

Intervention Fidelity 3.2 3.2 3.8

Missing Data and Attrition 3.4 3.4 3.5

Potential Confounding 

Variables 3.4 3.4 3.6
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Criterion 

Ratings 

Outcome 1 Outcome 2 Outcome 3 

Appropriateness of Analysis 3.8 3.8 3.9

Overall Rating 3.5 3.5 3.6

Study Strengths 

In the RCT, well-known and well-referenced instruments with good reliability and validity were used. In the 

retrospective study, administrative data, which are generally reliable, were collected from an HMO. Data on utilization 

and cost have strong validity. Fidelity was maximized through multiple methods, including the use of a standardized 

tool to provide annual assessments of instructors’ performances, participant evaluations, class protocols, trainer and 

coordinator manuals, in-person training of instructors and master trainers, annual instructor workshops, a video, and 

Web-based modules of the actual class and fitness checks. In the RCT, fidelity checks of new instructors demonstrated 

that adherence to the intervention protocol was excellent. The retrospective study controlled for the dose of the 

intervention by separately examining intervention participants who attended class at least once per week and 

intervention participants who attended class less than once per week. Attrition and missing data in the RCT were 

minimal, and appropriate analytical techniques were used to address them. Also in the RCT, baseline health and 

functional status comparisons between study completers and noncompleters indicated no significant differences 

between the groups with the exception of social functioning scale scores, which were substantially lower for 

noncompleters. Because the retrospective study used administrative data, there were no issues regarding missing 

data and attrition. In the RCT, most of the confounding variables were controlled for, including important 

demographic characteristics and most prior health care utilization patterns. EnhanceFitness was offered to all 

participants after the 6-month trial, which helped to mitigate sample selection bias. In the retrospective study, three 

control individuals were matched to each intervention participant by age and gender. Potential confounds were 

considered, including baseline lifestyle, readiness to change lifestyle, preexposure cost and utilization variables, 

health status, and comorbidity. Cost data were collected over a baseline period of at least 1 year before the HMO 

began offering the intervention. Appropriate methods were used to analyze the data in both studies.

Study Weaknesses 

In the RCT, Cronbach’s alpha values for the study sample were not assessed. Although the retrospective study used 

administrative data, which are generally reliable, there was no discussion about how the HMO assesses the reliability 

of its administrative data. The authors of the study article for the RCT did not adequately describe how participants 

were randomized to the intervention or control group. The retrospective study compared those who enrolled in the 

intervention with matched HMO members who were not enrolled in the intervention during the same time period. 

However, because data were unavailable, certain important variables that impact cost analysis (e.g., participant’s 

weight, diet, and use of tobacco) could not be used in matching or controlled for in analyses. There were no controls 

for economic status, which could affect outcomes.
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Readiness for Dissemination

Review Date: December 2011 

Materials Reviewed 

The materials below were reviewed for Readiness for Dissemination. The implementation point of contact can 

provide information regarding implementation of the program and the availability of additional, updated, or 

new materials.

Program Web site, http://www.projectenhance.org/enhance%C2%AEfitness_.aspx

Senior Services, Project Enhance. (2005). EnhanceFitness attendance sheet [Form]. Seattle, WA: Author.

Senior Services, Project Enhance. (2006). EnhanceFitness health history form. Seattle, WA: Author.

Senior Services, Project Enhance. (2006). EnhanceFitness program evaluation [Form]. Seattle, WA: Author.

Senior Services, Project Enhance. (2007). EnhanceFitness fitness checks [Form]. Seattle, WA: Author. 

Senior Services, Project Enhance. (2007). EnhanceFitness participant information form. Seattle, WA: Author. 

Senior Services, Project Enhance. (2009). EnhanceFitness: A guide to successfully implementing EnhanceFitness, 

EF I & II / 2009 edition. Seattle, WA: Author. 

Senior Services, Project Enhance. (2009). EnhanceFitness: Instructor manual, EF I & II / 2009 edition. Seattle, WA: 

Author. 

Senior Services, Project Enhance. (2009). EnhanceFitness: Master trainer curriculum, EF I & II / 2009 edition.

Seattle, WA. Author. 

Senior Services, Project Enhance. (2009). Preparing your site for EnhanceFitness. Seattle, WA: Author.

Readiness for Dissemination Ratings by Criteria (0.0–4.0 scale) 

Criterion Rating 

Implementation Materials 4.0

Training and Support 4.0

Quality Assurance 3.8

Overall Rating 3.9
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Dissemination Strengths 

The comprehensive manuals developed for instructors, master trainers, and site coordinators are detailed and user 

friendly. Roles are clearly defined for program administrators and other program staff. Forms, activity guidelines, and 

task instructions for effective program implementation are well organized. Marketing materials, funding strategies, 

and tips for recruitment are well developed and presented for use. Training provides many opportunities for 

participants to practice program concepts before implementation. The online training materials are well organized 

and easy to download. Training materials also include clear differentiation of the roles and responsibilities for 

instructors, master trainers, and site coordinators. The program requires the use of a database to track participant 

outcomes at baseline and every 4 months thereafter. Implementer self-assessment forms are provided to support 

fidelity monitoring. Ongoing support for master trainers helps to ensure program fidelity.

Dissemination Weaknesses 

The importance of fidelity and procedures for ensuring fidelity are not emphasized throughout all materials.

Costs

The cost information below was provided by the developer. Although this cost information may have been 

updated by the developer since the time of review, it may not reflect the current costs or availability of items 

(including newly developed or discontinued items). The implementation point of contact can provide current 

information and discuss implementation requirements.

Implementation Materials 

Item Description Cost 

Required by 

Developer 

EnhanceFitness license (includes 1.5-day, on- or off-site 

instructor training for up to 15 participants; instructor 

manual; site coordinator manual; participant forms; and 

instructor review forms)

$3,000 per site, 

plus trainer travel 

expenses if 

necessary

Yes

Annual fee for sites providing classes

$500 per site for 

the first year; $50 

per site for each 

subsequent year

Yes

Soft wrist and ankle weights for 21–27 participants $800 per site Yes

Annual Online Data Entry System user fee $200 per user No
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Item Description Cost 

Required by 

Developer 

2-day, on- or off-site master trainer training

$2,000 per site 

(up to 15 

participants), plus 

trainer travel 

expenses if 

necessary

Yes

2-day, online training modules Included in cost 

of license No

Annual instructor workshop Included in cost 

of license No

Technical assistance via Webinar, phone, or email at any 

time or in person at the time of the on-site training

Included in cost 

of license No

Quarterly conference calls Included in cost 

of license No

Program evaluation consultation Included in cost 

of license No

Other Citations

Athena Healthcare Communications. (2000). Models of care for senior health. Chicago, IL: Author.

Belza, B., Snyder, S., Thompson, M., & LoGerfo, J. (2010). From research to practice: EnhanceFitness, an 

innovative community-based senior exercise program. Topics in Geriatric Rehabilitation, 26(4), 299–309.

Cress, M. E., Moore, T. L., Johnson, M. A., & Quinn, M. E. (2003). Community-based aerobic and strength training 

improves physical function in underserved elders. Medicine and Science in Sports and Exercise, 35(5, Suppl.), S195.

Kaplan, A. (2002, May). Reversing the trend: Chronically ill seniors’ health improves in community program. In 

P. Q. Schoeni (Ed.), Accelerating change today for America’s health (pp. 32–34). Washington, DC: National 

Coalition on Health Care and Institute for Healthcare Improvement.

Moore, T. L., Cress, M. E., Johnson, M. A., & Quinn, M. E. (2003). Physical function and health status in 

underserved older adults. Medicine and Science in Sports and Exercise, 35(5, Suppl.), S224.

Moore, T. L., McCamey, M. A., Johnson, M. A., Quinn, M. E., & Cress, M. E. (2004). An evidence-based exercise 

program can be implemented in a community of underserved elders. Medicine and Science in Sports and 

Exercise, 36(5, Suppl.), S193.
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Moore-Harrison, T. L., Johnson, M. A., Quinn, M. E., & Cress, M. E. (2009). An evidence-based exercise program 

implemented in congregate-meal sites. Journal of Physical Activity and Health, 6(2), 247–251. PubMed abstract 

available at http://www.ncbi.nlm.nih.gov/pubmed/19420403

Snyder, S., & Belza, B. (2005, April). Eliminating disparities in communities of color through the Lifetime Fitness 

Program [Abstract]. Preventing Chronic Disease, 2(2). Available at 

http://www.cdc.gov/pcd/issues/2005/apr/04_0142j.htm

Translational Work

EnhanceFitness was started through a research study by Senior Services in collaboration with the University of 

Washington Health Promotion Research Center. The pilot study began in 1993 at Northshore Senior Center in 

Bothell, Washington, and was supported in part by grants from the Centers for Disease Control and Prevention, 

the National Institute on Aging, and the Health Services Research and Development Service of the Department 

of Veterans Affairs. As a result of subsequent training grants and feasibility studies, EnhanceFitness was 

disseminated beyond study sites in King County, Washington, in 1997 and nationally in 2000 to hundreds of 

locations in a wide variety of facilities. Expansion was facilitated by the program’s turnkey package, which 

provides all tools needed for successful implementation. EnhanceFitness has been recognized through awards 

from the U.S. Department of Health and Human Services, the U. S. Administration on Aging (AoA), the 

Washington Coalition for Promoting Physical Activity, and the National Council on Aging. Three implementations 

of EnhanceFitness have been documented: the adoption of EnhanceFitness for use (1) among low-income 

populations in 12 southern States, (2) at six sites on the island of Kaua‘i, and (3) by a large nutrition provider for 

implementation at 15 congregate meal sites for senior citizens in Portland, Oregon. Two of the implementers—

the 12 southern States and Kaua‘i—received 3-year grants from AoA to plan and implement the adoption of 

EnhanceFitness in their communities. The implementation among congregate meal sites was part of Arthritis in 

Focus, a study funded by a grant from the Northwest Health Foundation. Additional partners comprise multiple 

individuals and organizations, including hospitals, universities, and other national associations (the National 

Council on Aging, the United Way, and the Area Agency on Aging). 

EnhanceFitness classes are held in existing locations within communities, including community centers, senior 

housing facilities, places of worship, and county buildings. Participants are recruited through informational 

sessions and distribution of print materials (e.g., flyers, brochures, door hangers, table signs, newspaper 

articles). The program also is promoted through monthly calendars, Web sites, and newsletters. Most sites tend 

to implement EnhanceFitness with fidelity and offer 1-hour classes several times per week. Some sites make 

small adaptations to the program. For example, participants in southern States received additional physical 

health assessments. Positive outcomes in physical functioning and well-being were reported for all 

implementation sites, either anecdotally or through statistical analyses of data. These outcomes included 

improvements in participants’ agility and balance, upper-body strength, and lower-body strength. Participants 

reported that they felt better, had more energy and agility, and experienced fewer aches and pains, and 

implementers reported seeing improved flexibility, increased physical activity, and increased camaraderie 

among program participants. Maintenance and dissemination of EnhanceFitness in these sites continue through 

the use of presentations, brochures, and Web-based announcements. Maintaining existing partnerships and 

collaborations is key, including keeping partners aware of the program’s progress. To support the program, sites 
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may seek new grant funds; charge participant fees; secure donations from local gyms, hospitals, businesses, and 

other senior agencies; and offer corporate sponsorships as an employee benefit.

Site With 

Translational 

Work 

Articles Describing Site’s Translational Work, by Category 

Planning/ 

Partners Adoption 

Reach/ 

Recruitment Implementation Effectiveness Maintenance 

Southern 

States Article 1 Article 1 Article 1 Article 1 Article 1 Article 1

Kaua‘i Article 2 Article 2 Article 2 Article 2 Article 2 Article 2

Congregate 

meal sites in 

Portland, OR

Article 3 — Article 3 Article 3 Article 3 Article 3

Article 

Number Article Reference 

1 Neighborhood Centers Inc. (n.d.). Replication report: Activity Centers for Seniors. Bellaire, TX: 

Author.

2 

Sugihara, N., Watanabe, M., Tomioka, M., Braun, K. L., & Pang, L. (2011). Cost-benefit estimates of 

an elderly exercise program on Kaua‘i. Hawai‘i Medical Journal, 70(6), 116–120. PubMed abstract 

available at http://www.ncbi.nlm.nih.gov/pubmed/22162608

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Roth, E. (2008). Implementing a community-based exercise program in congregate meal sites: 

Perspectives from site managers (Unpublished master’s thesis). University of Washington, Seattle.

Contacts

To learn more about implementation, contact:

Susan Snyder, M.S.

Senior Services

(206) 727-6297

msusans@seniorservices.orga

To learn more about research, contact:

Basia Belza, Ph.D., R.N., FAAN

University of Washington

(206) 685-2266

mbasiab@uw.edu

Additional program information can be obtained through the following Web site(s):

http://www.projectenhance.org/enhance%C2%AEfitness_.aspx