Choose to Move: A Health Promoting Physical Activity Intervention Can Also Enhance Social Connectedness

Background: Despite the well-known health benets of physical activity (PA), older adults are the least active citizens. Older adults are also at risk for loneliness. Given that lonely individuals are at risk for accelerated loss of physical functioning and health with age, PA interventions that aim to enhance social connectedness may decrease loneliness and increase long-term PA participation. The objectives of this mixed-method study are to: (1) evaluate whether an evidence-based PA intervention (Choose to Move; CTM) inuenced PA and social connectedness differently among self-identied ‘lonely’ versus ‘not lonely’ older adults and (2) describe features of CTM that promote social connectedness. Methods: Two community delivery partner organizations delivered 56 CTM programs in 26 urban locations across British Columbia. We collected survey data from participants (n=458 at baseline) at 0 (baseline), 3 (mid-intervention) and 6 (post-intervention) months. We conducted in depth interviews with a subset of older adults at baseline (n=43), mid-intervention (n=38) and post-intervention (n=19). Results: PA increased from baseline to 3 months in lonely and not lonely participants. PA decreased from 3-6 months in lonely participants; however, PA at 6 months remained above baseline levels in both groups. Loneliness decreased from baseline to 3 and 6 months in participants identifying as lonely at baseline. Features of CTM that inuence social connectedness include: Activity coach characteristics/personality traits and approaches; opportunity to share information and experiences and learn from others; engagement with others who share similar/familiar experiences; increased opportunity for meaningful interaction; and accountability. Conclusion: PA interventions that focus on social connectedness, through group-based activities can improve the health of older adults by addressing both loneliness and PA. Building social connectedness within a PA intervention for older adults may support long term changes in PA behaviours.


Background
In the next decade, we will experience an unprecedented escalation in the number of older adults in most developed countries worldwide-with an anticipated rise in loneliness (1). Interventions designed to increase long-term physical activity (PA) participation and social connectedness (2) may effectively diminish loneliness. Clearly differentiating among different concepts such as loneliness/social connectedness and isolation/social contact in older adults seems important. However, these intervention outcomes are commonly measured and analyzed together (3).
Social connectedness and loneliness are positioned at opposite ends of a continuum. Social connectedness is de ned as 'feelings of interpersonal connection and meaningful, close, and constructive relationships with others (i.e., individuals, groups, and society). A socially connected person feels that they; (1) care about others and are cared about by others, and (2) belong to a group or community (3). Caring and respect in social relationships prompts a sense of well-being-together they act as a buffer against health problems (4) and catalyze myriad health bene ts. Loneliness is a perceived lack in quality or quantity of one's relationships (5) and predicts various health outcomes, including; systemic in ammation, increased blood pressure, depression, weight gain, smoking alcohol/drug use, and alone time (6)(7)(8)(9)(10). Loneliness is also closely linked with accelerated loss of physical functioning and health with age, and an increased likelihood that an older person discontinues PA over time (11,12).
Researchers advocate for interventions that aim to enhance social connectedness and reduce loneliness in older people, so as to also mitigate an escalation of loneliness at the population level (3,13,14).
Social isolation is de ned as a reduced social network (15,16) It is a quanti able measure of the number and structure of one's relationships (i.e. social, family, and friend contacts) or frequency of interaction with others (i.e. social contact). Social contact is described as physical closeness, interaction (face-toface/ in-person, internet-based, and/or telephone) or touch encounters (17), with others (18,19). Social isolation/social contact are objective constructs whereas social connectedness/loneliness are subjective.
To illustrate, an older person may be alone (i.e., isolated) but still feel a sense of social connectedness.
Conversely, they may be surrounded by people (i.e., have social contact) but still feel lonely (20,21).
In systematic reviews, interventions that aim to positively promote social connectedness and reduce feelings of loneliness among older adults are often grouped with interventions that target social contact/isolation (related but distinct concepts) (22)(23)(24)(25). Differentiating the distinct effect of an intervention on loneliness/social connectedness versus social contact/isolation has for the most part been overlooked.
Mechanisms describe elements of an intervention hypothesized to affect a targeted behaviour [e.g., physical inactivity]. Mechanisms that drive change in loneliness/social connectedness differ from those that affect change in isolation/social contact. Although social isolation/contact may in uence social connectedness/loneliness (26), they are not necessary mediators. Differentiating among these concepts is essential as core elements of interventions may target loneliness/social connectedness in important ways that differ from core elements designed to target social isolation and social contact (27).
Interventions that aim to promote social connectedness in older adults, must clearly distinguish between the effect of intervention elements on social contact versus social connectedness, and the potential moderating relationship between these constructs.

Context
In partnership with British Columbia (BC) Ministry of Health, we co-created a community-based, exible, scalable health promoting PA intervention called Choose to Move (28). In collaboration with key community stakeholders we scaled up CTM across the province of BC, Canada in three phases [2016][2017][2018][2019][2020]. In Phases 1 and 2 (Jan 2016-May 2017) CTM effectively enhanced PA, mobility, social isolation and diminished feelings of loneliness in older adults (29). Our implementation evaluation demonstrated that CTM could be effectively adapted to context (30) and implemented at scale by trained activity coaches in collaboration with key community recreations organizations with established reach to older adults (29,30).

Aims and objectives
The aim of our mixed-method study is to evaluate whether older adult's perceptions of loneliness modify the effect of CTM on PA and social connectedness outcomes.
Our speci c objectives are twofold; (1) to evaluate whether CTM in uenced PA differently among older adults who identi ed as lonely versus older adults who identi ed as not lonely; (2) to describe features of CTM components most likely to promote social connectedness.

Choose to Move
Elsewhere we described the CTM intervention, implementation and evaluation frameworks that guide our work (28,29,31), the bene ts of CTM on PA and social connectedness (29) and factors that in uenced implementation (30). Brie y, CTM is a 6-month, choice-based health promoting PA program that supports low active older adults to become more physically active and socially connected. In Phase 3, delivery components of CTM were: (1) a one-on-one consultation, and (2) regular phone call 'check-ins'-with an activity coach, (3) regular motivational group meetings (groups) with other CTM participants (up to 12 participants/group), led by an activity coach. Activity coaches received [online] standardized CTM training. Delivery 'dose' of program components was greater in the rst three months (active phase: oneon-one, seven phone calls, four group meetings) and tapered off in the last three months (taper phase: three phone calls; Figure 1).
During the one-on-one consultation participants set personal PA goals, created an action plan, problem solved barriers to participation, received social support and were provided PA and health-related information. The personalized action plan was aligned with each participants' interests, abilities, income, and available resources. Activity coaches facilitated groups (4 x 1 hour each) on a monthly basis. During the group meeting, the activity coach presented information designed to promote PA and provided an opportunity to develop relationships (e.g., support, companionship) among group members. Participants were given the opportunity to participate in group or paired discussions, shared their experiences and connected with others. Individual phone check-ins provided opportunities for activity coaches to discuss progress and setbacks and to adjust their action plans accordingly.

Participants
Of 534 CTM participants who enrolled in CTM, 458 (86%) consented to participate in the evaluation. Eligibility criteria were; aged ≥ 60, English speaking, and low physically active (self-reported < 150 min/week of PA), no contraindications to PA participation (Physical Activity Readiness-Questionnaire+ (33) or physician clearance). Recruitment strategies included local promotions (e.g., program guides, posters, and information sessions), media advertisements (e.g., newspaper, radio, and social media) and word of mouth.

Quantitative
We collected survey-based data from all participants. Participants completed questionnaires at Motivational Group Meetings (0, 3 months) or at home (6 months, returned via mail). Participants who missed a group meeting were mailed a survey package (returned via mail).

Demographic characteristics
All participants completed a demographic survey at baseline that provided age category (60-74, ≥75 years), sex (male, female), self-reported height and weight (to calculate body mass index; kg/m 2 ), educational attainment (secondary school or less, at least some trade/technical school or college, at least some university), ethnicity (Asian, white, other), number of chronic diseases (0, 1, ≥2), self-rated health (very poor, poor, fair, good, excellent), self-e cacy for increasing PA and accessing recreation centre services (1 item each; not at all, slightly, moderately, quite or very con dent), social support for PA received from family or friends (1 item each; yes, no, not sure) and capacity for mobility (no/any di culty walking 400 m and/or climbing one ight of stairs (34).

Physical activity
At each measurement time point participants self-reported PA using a single item questionnaire: "In the past week, on how many days have you done a total of 30 minutes or more of physical activity, which was enough to raise your breathing rate? This may include sport, exercise, and brisk walking or cycling for recreation or to get to and from places, but should not include housework or physical activity that may be part of your job" (35).

Loneliness
We used a three item questionnaire (LQ-3) with a 3 point scale to assess loneliness (36). Questions asked were, "how much of the time do you feel: (1) you lack companionship; (2) left out; (3) isolated from others" (often (3), some of the time (2), hardly ever (1)). The overall score re ects the sum of the three items (range 3-9); higher scores indicate higher levels of loneliness. We classi ed participants as "lonely" if they responded "some of the time" or "often" to any of the 3 components on the questionnaire and as "not lonely" if they responded "hardly ever (or never)" to all 3 components (37).

Social isolation
We assessed isolation using a three-item questionnaire (38) with a six point scale. The 3 items are summed to create an overall social isolation score (range 0-15); lower scores indicate greater levels of social isolation. We classi ed participants as "socially isolated" if they reported low levels of interpersonal interaction (once/month or less) (39). We de ned that operationally as those who answered once/month or less for all 3 questions.

Analysis
We used Stata v13.1 for all quantitative analysis. We rst assessed differences in socio-demographic characteristics between participants who identi ed as lonely versus not-lonely at baseline using Chisquared or Fisher's exact test (categorical variables: sex, age category, ethnicity, education, chronic conditions, mobility limitations) and unpaired t-tests (continuous variables: BMI).
To assess whether PA and social connectedness differed by participants' loneliness status at baseline, we used general linear mixed effects models with time (0, 3, 6 months) as a categorical predictor (29). In model 1 we included sex and baseline loneliness (dichotomous measure; lonely vs. not lonely) as xed effects. In model 2 we included additional covariates: age category, delivery partner, baseline mobility limitation, number of chronic conditions, education and BMI category (<30, ≥30 kg/m 2 ). In both models we added xed effects sequentially and tested interactions with time after the addition of each xed effect. With the exception of baseline loneliness*time, interactions were retained in the model only if the Wald test (40) was signi cant (p<0.05). We assessed model t graphically using residual plots. Adjusted values were calculated at each time point using the margins command in Stata with a Bonferroni adjustment to account for multiple comparisons between and within loneliness groups.

Interviews
We conducted in depth semi-structured interviews by phone with a subset of older adults at baseline (n=43), 3 months (n=38) and 6 months (n=19). Participants were randomly selected from those who consented to the interview component. Interviews took approximately 15-30 minutes. If interview participants dropped out, the Research Coordinator asked why they withdrew and about barriers to participation. Questions included in the interview guide were created based on the relevant literature and expert opinion. Interview topics included feedback on the three intervention components (one-on-one consultation, motivational group meetings, check-ins); facilitators and barriers to committing and adhering to their Action Plan; continuing PA after CTM (Table 1).

Analysis
We reviewed transcripts using framework analysis; framework analysis is well suited to research that has speci c questions, a pre-designed sample and a priori issues (41). Framework analysis is heavily based in, and driven by, the original accounts and observations of the people it is about. It allows within-case and between-case analysis (42). In the analysis, data are sifted, charted and sorted as per key issues and themes using ve steps: 1. familiarize; 2. identify a thematic framework; 3. index; 4. chart; and 5. map and interpret (41,42). We brie y discuss each step below. We fully transcribed each interview verbatim. First, the lead author read through the transcripts to become more familiar with the interviews (familiarize). Second, we developed a preliminary thematic framework, consisting of themes and sub-themes. Third, the lead author used coded interviews based on the thematic framework, and coded full paragraphs to not lose contextual meaning. Fourth, we held a series of team meetings to discuss data and identify common themes. We adopted the constant comparison method (43) to compare and contrast themes within and across groups. This revealed similarities and differences in the data. We compared responses between participants who were lonely with participants who were not lonely. Finally, we examined similarities and differences between lonely and not lonely participants.
We used a number of strategies to reinforce the rigor of our study. They were--cross-checking full transcripts against original audio les for quality and completeness; re exive memoing throughout data generation and data analysis processes; and "member re ections" (44). We also created an audit trail to record all key procedural and analytical decisions made throughout the study (45,46).

Participants
Our nal sample size at baseline was 452 participants [6 participants did not complete baseline surveys]. We summarize socio-demographic characteristics in Table 2. As previously reported (29), most participants identi ed as women (77%), lived in medium to large urban centres (77%), had at least some post-secondary education (75%), no mobility limitations (57%) and identi ed as white (86%). Speci c to these analyses, 58% of participants identi ed as lonely at baseline (n=261). Those who identi ed as lonely were more likely to be women and reported lower self-rated health compared to same-age peers ( Table 2). Less than 1% of participants (n=4) identi ed as socially isolated at baseline. Given the low prevalence of socially isolated participants in this group we were unable to explore the combined moderating in uence of loneliness and social isolation; therefore, we focused solely on loneliness. Among participants who dropped out of CTM (n=49), withdrew from the evaluation (n=2) or missed an evaluation timepoint (n=51), the proportion who identi ed as lonely was similar between those who withdrew from, and those who remained in the study (58%).

Physical activity
Results were similar for minimally and fully adjusted models, thus we focus on the fully adjusted model here (Table 3). At baseline, PA levels were similar between participants who identi ed as lonely and not lonely (mean difference: -0.2 days/week (95% CI, -0.6, 0.3). PA increased signi cantly during the active intervention phase (baseline to 3 months) in both lonely and not lonely participants. PA decreased signi cantly from 3-6 months (in the taper phase) in lonely participants only. However, PA at 6 months remained above baseline levels in both groups.

Loneliness
Results were similar for minimally and fully adjusted models, thus we focus on the fully adjusted model here (Table 3). By de nition, loneliness scores at baseline were different between participants identifying as lonely and not lonely; this between-group difference was maintained at 3 and 6 months. Loneliness decreased from 0-3 months in participants who identi ed as lonely at baseline; lower loneliness scores were maintained at 6 months. There was no change in loneliness from 0-3 months in the 'not lonely group. However, loneliness increased signi cantly in this group at 6 months.

Qualitative
We describe features within each of the three CTM intervention components that may in uence social connectedness (Table 4). We use the term 'features' as this incorporates the 'core-functions/active ingredients' as well as other contextual factors that in uence social connectedness. Interview participants were men (n=16) and women (n=27), aged 60-75 (n=33) or 75+ (n=10) who identi ed as lonely (n = 25), not lonely (n = 16) or did not respond (n = 2). We present participant responses by time point (baseline, 3 months and 6 months), and whether participants identi ed as lonely or not. Compared with not lonely participants, lonely participants more often discussed social connectedness when asked about features of CTM. Not lonely participants placed more emphasis on features of CTM known to in uence PA (e.g., PA lectures). We focused our analysis on features of CTM that potentially in uenced social connectedness (e.g., opportunity to share information).

Delivery components
One-on-One Consultation Participants deemed the activity coach as essential to effectively deliver all three CTM components and to in uence social connectedness. Participants' described distinct activity coach characteristics/personality traits and approaches that likely in uenced social connectedness.
Participants enjoyed being able to connect with an activity coach during the one-on-one consultation, and work with them to design a personalized action plan. This process enacted feelings of being listened to and cared for and supported development of a meaningful relationship between participants and their activity coach. The activity coach-participant relationship spurred feelings of motivation and encouragement.
(Not lonely, baseline) Oh, I really like it because it's designed individually for me and [name of Activity Coach] is really easy to talk to and very personable. And so, yeah, when we had our one-hour session on Thursday where we discussed and made the plan for this coming week. And so when she said would you be interested, she was full of ideas. And she was good at taking my ideas and adjusting them. It's personalized. So, yeah, which made it very manageable.
(Not lonely, mid-intervention) Yeah, oh, so for the Choose to Move, yeah, having to be accountable, that's an important thing for me, I nd that once I make the commitment and I just--really didn't want to disappoint anyone else, as well as myself.

Motivational Group Meetings
Motivational Group Meetings were overwhelmingly considered of great value to create and sustain social connections. Participants described features within the Motivational Group Meetings that in uenced social connectedness. These included: the distinct characteristics/personality traits and approaches taken by the activity coach; opportunities to share information and experiences and learn from others; engage with others who share similar/familiar experiences; and increased opportunity for meaningful interaction.
Feature:Activity coach characteristics/personality traits and approaches thought to in uence social connectedness included being positive, offers encouragement, engages, accommodates, calls participants by name, accepting, observant, careful, and motivates. (Lonely, post-intervention) She [activity coach] is so positive and she's so encouraging. And she really knows her stuff. Because she really tries to engage everybody in--she knows everybody and she knows everybody's progress and ability. She is encouraging that way 'cause she knows when someone is taking it slower 'cause--sprained ankle or not feeling well that day. And so she does that in the CTM too where she, you know, like, caters it kind of individually and often as a group. And it's really hard to explain. But you do feel like you're getting individual attention even though you're also in a group getting to know everybody else.
Feature:Opportunities to share information and experiences and learn from others in uenced social connectedness as it promoted interactions between participants, encouraged the exchange of phone numbers, provided personal introductions, engaged participants in paired and group discussions to share information on community resources. Social connectedness indicators: feelings of belonging (e.g., bonding, getting to know everybody), feeling cared for (e.g., recognition), and meaningful relationships (e.g., communication and companionship, support, someone to talk to, not doing things on your own).
Participants discuss how they enjoyed activities that offered them the opportunity to share information and experiences with other group members. Being able to learn from others created a sense of bonding, belonging and being cared for, and developed meaningful relationships.
(Lonely, mid-intervention) Well, everybody got to share what they did from the last meeting, and then--like, every time, like, what we did and then if there were problems and what we plan to--like, exactly what was in the email, but we said it out loud so everybody could hear. And I think everybody--it was quite helpful, I think. When they had a solution to--or everybody said, oh yeah, that happened to me. Or--it was like bonding. So, it was nice, and everybody got to speak, and it was encouraged. And I don't think anybody was really quiet about it. So, I think everybody enjoyed sharing. Yeah, and it was nice to speak up and see if other people felt the same way sometimes.
(Lonely, mid-intervention) I liked the meeting. I liked the fact that other people shared their di culties. It makes me feel not so alone.
(Not lonely, post-intervention) There are so many people out there in our age group that would bene t from this if they knew about it. It's--so many of us people in, you know, in their 60s feel uncomfortable going to a gym because it's, you know, full of 20 year olds and you feel like you don't belong. And this--with our instructor it just made us feel like we were part of a group like everybody else. It was a good feeling.
Sharing/learning opportunities within Motivational Group Meetings were considered a more fruitful way to in uence social connectedness than were 'lecture' style sessions.
(Not lonely, post-intervention) But it might be nice to have actually had a--even if it was just a get together with the group, just to see how everybody else did. I know that one lady was wanting--she had joined the group with the purpose of, you know, nding someone else to exercise with. Which is a good thing too. But there wasn't a lot of social opportunity, I think, because we got information. We were given--there was a video and there was talks and exercises and discussions about things that you did individually. But we really didn't have a lot of opportunities to sort of talk to one another. And that's [inaudible] I think everybody's fairly shy. But it may be something that they could throw in, maybe halfway and again at the end. A little social time, a tea or something. And just everybody could sort of talk about how they're doing things. 'Cause we learn from what some of the other people were doing too. So that was a good thing Feature:Engage with others who share similar/familiar experiences (e.g., goals, ailments) in uenced social connectedness by promoting emotional and informational support to participants and offering space to share common characteristics or life experiences--this fostered a sense of belonging and companionship.

(Lonely, baseline)
There were other people in the class that, when we all introduced ourselves, were having the same kind of struggles I had, the same kind of goals and were people that I thought, hmm, okay. There's somebody I could probably call; see how they're doing because they're like me.

(Lonely, mid-intervention)
Well, companionship or--communication and companionship with the other people who are attending. Yeah, these weren't people that I knew prior. It just--I think it's just more supportive when there are other people that you're hearing are dealing with issues too that are similar, um-hum.
Feature:Increased opportunity for meaningful interaction may in uence social connectedness. Participants enjoyed the more frequent interactions during the active phase ( rst 3 months) of Choose to Move and felt the decline in motivational group meetings over the later months (taper phase) negatively in uenced their sense of social connectedness.
Social connectedness indicators: feelings of belonging (e.g., bonding, getting to know everybody), and meaningful relationships (e.g., interaction and companionship, support) (Lonely, mid-intervention) Well, I think name (activity coach) did say they were continuing for three more months for checking in on us, right. And I'd assume it's through email, right, that it wasn't over. But it would have been nice, I think, to do it one last time, to end the program, just for a goodbye. I guess it's because I like the group maybe too, yeah.
(Lonely, post-intervention) It was nicer when we met more frequently, I think. I think that was--yeah, 'cause we met--the rst while we were meeting once a week, then once every two weeks and then it got to the month. I think the interaction for some people is a good thing. Through the winter that was really nice to have that group to go back to every few weeks, that other group, yeah. I think maybe a little more interaction would be good.

Check-Ins
Participants' describe distinct Activity Coach characteristics/personality traits and approaches that likely in uenced social connectedness. Participants also spoke to how being held accountable in uenced their sense of social connectedness.
Feature:Activity coach characteristics/personality traits and approaches may have in uenced social connectedness by being personable (easy to talk to), positive, someone who offers encouragement, accommodates, is accepting, motivates, provides accountability, approachable, high energy, makes sure to be available, takes time, listens, and is thoughtful.
Social connectedness indicators: feeling cared for (e.g., listened too, understood) and meaningful relationships (e.g., accountability) (Lonely, mid-intervention) Well, I think if they were serious about trying to get more physical in their activity and--slowly and realistically and with support from the class and the instructor. And also, like, personal checks, either how would they prefer, email, face-to-face or phone call. So, I think it's a really good follow-up, because a lot of times you get lost in the programs or it doesn't seem like anybody cares, so you don't care.
(Not lonely, mid-intervention) Especially the encouragement. I mean, that's the main thing anyway for me. 'Cause I live alone and it's easy to not do anything. So, it's very nice when someone phones you up and says, how are you doing and, you know, can I help you in any way, get some ideas together and stuff like that. So that helps a great deal (Not lonely, mid-intervention) The phone calls are very encouraging. So that helps a lot. Yeah, she's [activity Coach] fabulous. Really is a dear friend already so--wonderful lady, and a very good encourager Feature:Accountability in uenced social connectedness by providing participants a sense of responsibility to the Activity Coach and to themselves. The pre-planned check-in offered a consistent point of contact for participants that many looked forward to. Participants were accountable to the Activity Coach, which motivated and encouraged participants to engage in activity.
Social connectedness indicators: meaningful relationships (e.g., accountability) (Lonely, mid-intervention) I mean, she's right on top of it because she'll make--actually make an appointment for you. So that's a good thing too, right. Because like I said, because I'm so busy doing stuff, that way I already--it's sort of pre-planned. I know she's going to be phoning on that day, approximate time and all that. So, it's not like I-you know, so I already know that's going to take place, and that's great, yeah (Lonely, post-intervention) Well, I thought it was good. And she was excellent, and she made sure before she hung up that we had a date set and I had it written in my calendar. A date and time that she would call her next call. So, all the time when you're--if you weren't doing something, in your head you know oh, you--I've got to tell [name of Activity Coach] that I haven't been doing anything. So, it's just that little guilt trip there too, I guess

Discussion
We sought to disentangle related but distinct constructs that contribute to social and mental health of older adults-social connectedness/loneliness and social contact/isolation. To do so we speci cally heeded the call to clarify features of interventions that in uence social connectedness. We further extend the current literature, as we identify key indicators of social connectedness that likely moderate this in uence. Finally, our ndings support the need for choice-based, group-focused interventions that aim to in uence PA and social connectedness for older adults in community based settings.
Developed countries have described an 'epidemic of loneliness' sweeping major cities (47). In the United Kingdom loneliness was identi ed as a key public health priority by appointing a 'Loneliness Minister', implementing a loneliness strategy for Scotland (48) and launching its 'Campaign to End Loneliness' (www.campaigntoendloneliness.org) which targets older adults. Given the close links with loss of physical functioning and overall health, taking action to counter loneliness is timely and important. We differentiated between lonely and not lonely participants to better understand how these feelings might affect health behaviours. It was telling that more than half (58%) of older adults in our study identi ed as lonely at baseline. Lonely participants placed greater emphasis on features of program delivery, such as activity coach characteristics, that likely in uence their social health (social connectedness). Not lonely participants more often focussed on features that in uence their physical health (PA). However, participants universally identi ed features within each component of CTM that contributed to social connectedness.
Activity coach characteristics/personality traits were the nexus of CTM program effectiveness-and in uenced social connectedness across all CTM components. Activity coaches were considered key to older adult participation (30) and effectiveness of CTM (phases 1 and 2) on mobility, social connectedness, loneliness and PA (29). Speci c characteristics/traits that appeared to in uence feeling socially connected were; being personable (easy to talk to), positive, accommodating, encouraging, accepting, observant, careful, motivating, and approachable. By identifying speci c traits, we 'drill down' into meaningful aspects of how activity coaches respond to the needs and concerns of participants to generate feelings of social connectedness. For example, activity coaches called every participant by name so older adults got to know each other; they encouraged participants to share their experiences which cultivated a sense of bonding and belonging among the group. In traditional tness classes the tness leader role is more technical and prescriptive (49), whereas CTM activity coaches were less prescriptive serving more as a recreational 'champion' (50) by encouraging participants to do what they chose to do (and to stick with it). CTM activity coach training included elements of social support and building a sense of community to enhance social connections-ideas that they could embed into their delivery approach. We were unable to nd previous studies that described characteristics, skillsets and approaches of activity coaches that were likely to in uence participant level outcomes-speci cally, social connectedness (47).
In the motivational group meetings participants described the importance of sharing information and experiences, learning from others and engaging with others who shared similar/familiar experiences.
Their perceptions distinguished between a group of older adults in a room receiving a 'lecture' about aspects of health versus embedding strategies that foster interaction and communication among the group. Oral or video presentations may reduce social isolation by increasing social contact, but may not generate feelings of being cared for, belonging or the development of meaningful relationships. Social connectedness was facilitated when participants were partnered with others who shared similar experiences. In our study shared experiences cultivated feelings of belonging (e.g., not alone, companionship) --key indicators of social connectedness. Older adults may be more 'comfortable' and feel more 'supported' when exercising with others who are perceived to be similar to them (51).
In a recent systematic review (52), people described as more lonely were less physically active. We noted a signi cant decline in PA from month 3 to 6 of the program in the lonely group. We attribute this (from interviews) to the reduced number of motivational group meetings and one-on-one meetings with the activity coach during this 'taper' period. Lonely participants valued motivational group meetings as they also fostered social connections (e.g., feeling cared for, belonging, meaningful relationships); lonely participants expressed a desire for more motivational group meetings. At baseline more women (61%) than men (48%) identi ed as lonely. PA levels of women were more likely than men to be in uenced by loneliness (53). This speaks to the need for gender sensitive implementation approaches; group-rather than individual-based interventions may more effectively in uence social connectedness in lonely women.
To maintain bene ts for communities and populations beyond the initial stage of implementation, participation in community health promotion programs must be sustained over the long term (54,55).
'Booster sessions' offered over the longer term that provide opportunities for groups to meet may counter the known decline in lonely participants PA and social connectedness. However, studies that formally evaluated effective ways to sustain bene ts after participation in PA interventions over the longer term are scarce (56).
Check-ins were instrumental in developing meaningful relationships between older adults and their activity coach. However, given check-ins are resource intensive [activity coach made multiple attempts to connect with participants], strategies that optimize connectedness while diminishing intervention costs should be explored. Not surprisingly, motivational group meetings were the core component that in uenced social connectedness. Thus, it may be prudent to adapt CTM to decrease the number of phone check ins and increase the number of motivational group meetings. Group meetings that focus on content that creates opportunity to share, learn and engage with others with familiar experiences may be the best means to enhance social connectedness within and outside the program (e.g., lunch dates, tea time).

Limitations
We acknowledge volunteer and recruitment bias as the reach of partner organizations was primarily to a white middle-class (on average) constituency. Given our relatively homogeneous sample, results cannot be generalized to older adults who are marginalized by virtue of sex, gender, geography, socio-economic status, health status and/or ethnicity (29). We randomly selected older adults to participate in interviews.
However, as in our previous pre-post, hybrid effectiveness study, participants were not randomly assigned to group. In future, our ndings should be replicated in a study purposely designed to evaluate the independent and combined effects of loneliness and social isolation on PA. Conversely the direct or mediating effect of PA on loneliness and social isolation warrants further attention.

Conclusions
First, strategies that counter the epidemic of loneliness that plague older adult populations in many developed countries, are long overdue. Second, health promoting interventions that were effective at small scale must be scaled up to promote physical, social and mental health at the population level.
Strategies to scale-out CTM-implement, test, improve, and sustain an evidence-based intervention as it is delivered to new populations and/or through new delivery systems that differ from those in effectiveness trials'--are in order (57). Third, to honor the central tenets of equity, diversity and inclusion, health promoting programs like CTM must be adapted for older adults who are marginalized by virtue of their sex, gender, geography, socio-economic status, health status and/or ethnicity. Finally, COVID-19 has dramatically altered how older adults engage-physical distancing may forever be a part of any recreational program. Thus, exible interventions such as CTM that can be delivered in person or quickly adapted for virtual delivery (e.g., via Zoom) may be the way of the future. The unintended health consequences related to social isolation and loneliness emanating from public health measures (physical distancing put in place to eradicate transmission of -have yet to be fully realized. all study procedures. All participants provided informed written consent prior to providing data. Consent for publication: We con rm that this manuscript has not been published elsewhere and is not under consideration by another journal. All authors have approved the nal manuscript Availability of data and materials: The datasets used during the current study are not publicly available as stipulated in our participant consent forms but are available from the corresponding author on reasonable request.

Abbreviations
Competing interests: The authors claim no con ict of interest.
Funding: This work was supported by a Grant-in-Aid from the BC Ministry of Health as well as a Canadian Institutes of Health Research project grant (PJT-153248). Dr. Sims-Gould is supported by a New Investigator award from the Canadian Institutes of Health Research and a Scholar award from the Michael Smith Foundation for Health Research. The supporting source/ nancial relationships had no such involvement in study design; collection, analysis, and interpretation of data; writing of the report; or the decision to submit the report for publication.
Authors' contributions: TF: data analysis and interpretation, manuscript writing. LN: study design, data collection oversight, data analysis, manuscript writing. JSG: study concept and design, data interpretation, manuscript writing. CO: study concept and design, data interpretation, manuscript writing HM: study concept and design, data interpretation, manuscript writing. All authors have read and approved the nal manuscript. TF had full access to all of the data in this study and takes complete responsibility for the integrity of the data and the accuracy of the data analysis.

Baseline
3-month follow up 6-month follow up Why did you decide to join this program?
How is this program working for you?
How did the last three months of Choose to Move go for you?
What (if anything) is appealing to you about this program?
What are your favourite parts of the program?