Ageing of the population impacts many aspects of society including healthcare and social care cost, labour and financial market, housing, and long-term care facilities. Whole-of-society approach is required to promote healthy ageing and improve the life of older people, and community as a whole. The primary aim of the HAPPY program was to maintain and / or improve function and cognition amongst at risk older adults although many robust older adults opted to participate in the exercises. Embedding of the HAPPY program within the population was successful as there was multisectoral collaboration between academia, government, non-profit organisations, and community. Both the Decade of Health Ageing and The World report on ageing and health policy framework for healthy ageing have emphasized the need for multi-sectoral collaboration to ensure that integrated care and primary health services are accessible, person-centred care focussed on common goal of functional ability, and to have opportunity to age in an age-friendly environment including ongoing lifelong learning and ability to contribute to their communities while retaining autonomy and health (3, 19).
With the demographic shift, countries will see increasing numbers of older people with chronic conditions contributing to disability including sarcopenia, frailty, dementia, osteoporosis, and vision / hearing impairment. Social isolation, frailty, dementia, falls, and fractures are associated with increased morbidity and mortality. The prevalence of prefrailty in Singapore is 37%, frailty 6% and half of frail older adults are still independent which is similar to data from nationally representative studies (14, 20). In the rural area in the United States, prevalence of frailty can be as high as 30.4% (21). Frailty is not synonymous with disability or comorbidities. Older adults define successful ageing as being able to maintain physical and cognitive ability whereas disease and productivity are much lower down the list in community surveys (22, 23). Frailty is potentially reversible through personalised multicomponent approach including physical exercise, management of polypharmacy, falls, nutrition, loneliness, cognitive impairment, and depression (4). Similarly, cognitive impairment is also amenable to interventions and demonstrate reversibility through multi-domain approach(24). There are emerging studies to suggest that even low level of physical activity is associated with reduced risk of all-cause mortality (25). Interventions incorporating simultaneous physical, cognitive, and social activities have been effective in improving cognitive function than either interventions alone (12, 26).
Most multicomponent exercise programs have been conducted in trial setting, and while it may be proven to be effective in randomized controlled trials or in observational studies, the translation into public health practice and system change including scalability and sustainability at the population level may still continue to be a challenge and may not produce the intended outcomes seen in trials (27). The HAPPY program is a form of system-based approach to enable successful ageing which was successfully implemented through multi-collaborative approach to co-create sustainable and scalable interventions to achieve high level of physical and mental functioning, stronger social network, and better quality of life. Participants of the HAPPY program significantly improved in their functional ability including cognition, frailty status and physical function especially in the total SPPB scores, balance, and chair-stand domain. This correlated with reduction of falls by two thirds at 3 months. A recent systematic review has shown that interventions which included balance and functional exercise with a total weekly dose of ≥ 3 hours can reduce falls by 42% (28). Another similar successful population level program in County Perry, Missouri involved screening older adults for geriatric syndrome using the rapid geriatric assessment with exercise and cognitive stimulation program which showed improvement in functional status (8).
Older persons, especially women who often outlive their spouse may be at risk of social isolation and loneliness, and financial insecurity. Almost 1 in 2 older adults are known to be at risk of social isolation in Singapore and worldwide(29). Participatory, productive engagement and group-based interventions designed to promote physical activity have been known to increase social connectedness, and reduce loneliness(30). Our community-based intervention program did reduce social isolation by 10% at 3 months with significant increases in LSNS-6 scores. Interestingly, improvement was greatest amongst the participants attending once weekly exercises. One possible explanation may include that they may be busy engaging with friends and family’s at other times.
Retirees who are retired from workforce may spend more time in “ruleless role” where they can contribute to the society in the form of volunteering. Volunteerism in the HAPPY program is a good example of “productive ageing” and “meaningful engagement” contributing to the betterment of senior communities through “do-it-together” approach. The proportion of older adults who volunteer in the US have increased by 65% since 1974, and older adults are known to commit twice the time to volunteer activities (31). There are multiple benefits of volunteering including better physical health, better chronic disease control and functional status, lower mortality, better cognitive and mental health, improved perceived health and better social network (32). This was corroborated by HAPPY leaders where many saw improvement in their chronic disease control (33). Our program showed that structured training and assessment of the volunteers with periodic quality monitoring did produce similar cognitive outcomes to the health coaches conducting the exercises. The SPPB scores including the balance, chair-stand and gait domain scores for the groups led by health coaches showed greater improvement compared to HAPPY leaders, and possible reasons for this may be gaps in training on physical function aspect. The training was focused mainly on improving cognition. In addition, there was no specific training provided on exercises for different muscle groups, mitigating falls risk and theoretical aspect of physical exercise besides the stretching and cooling down exercises.
The public health impact of the HAPPY program has been described according to RE-AIM framework covering effectiveness, reach, adoption, implementation, and maintenance (34). The success of the HAPPY program is attributed to the concerted shared accountability and sustained collaboration between different stakeholders to co-create, co-own the initiative, and the role of academia in providing directions based on available evidence and evaluation. Certified HAPPY leaders were acknowledged, and their efforts celebrated in different platforms to ensure sustainability and scalability of the program. However, more can be done in regularly upskilling the HAPPY leaders in different aspects such as falls prevention, frailty screening, detecting red flags amongst older adults and incentivizing them with vouchers or similar to keep them motivated. There needs to be an agile, inspirational, and innovative leadership and team to drive the program on the ground.
Implementing country wide healthy ageing initiatives has its own challenges. One of the biggest challenges in clinical trial or observational studies is drop-outs. At 3 months, the drop-out rate was 33.4%%, and 6 months 49.0%. However, there were many new participants who continued to join and eventually joined as HAPPY leaders. There was no follow-up on the dropouts to see if they had a medical reason, life event or other reasons related to the dual task exercise itself. Language barrier in a multiracial country like Singapore can be a barrier to group activities, and participants did drop out when they could not understand the instructions. Like many other community-based programs, 75% of the participants were females. Future evaluations should include male preferences and motivational factors. Continuing to motivate HAPPY leaders also remained a challenge. In addition to motivation, health coaches had to ensure new dual-task exercises being introduced. Incentivizing them may keep them motivated and sustain behavioral change. Of the 625 trained HAPPY leaders, 85% continue to lead or co-lead the groups. While the program did reduce overall social isolation, only a few of the groups felt responsible for team members’ wellness and had longing for togetherness or “kampung spirit”.
During Covid-19 pandemic physical distancing requirement, the HAPPY program was converted to virtual and only 40% of the participants surveyed were digital ready and remained socially connected (35). Community-based program can only be made possible with fixed groupings to allow for better track and trace ability once restrictions are lifted post Covid-19 pandemic. In the current state, HAPPY programs in the senior care and senior activity centers are ongoing with limited number of participants, safe distancing, and strict infection control practice in place.
We do not have the profile of volunteers, but it is known that older adults are more likely to volunteer if they are married and have a spouse who also volunteers, work part time and highly educated. With reinforcement of retirement age in certain countries, greater volunteering opportunities and benefits, and the fact that people are living longer post-retirement, policymakers should provide incentives and promote paid “productive ageing”.
Healthy ageing initiatives within the community and the ability to age well with dignity and purpose can be made a reality, but commitment is required from multiple sectors with joint accountability. Evidence suggests that even non-healthcare professionals can be trained to screen for frailty, decline in intrinsic capacity and cognitive impairment, and implement necessary interventions. The WHO Integrated Care for Older People, ICOPE handbook Guidance and Rapid Geriatric Assessment which are both available in digital form are examples of person-centred assessment and management pathway that can be administered in primary care or community to prevent and /or enable early detection of age-related diseases (36, 37). Community re-design for healthy ageing should provide integrated social and healthcare and improve social connectivity, access to lifelong learning, financial security, and opportunity for “productive ageing”.