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2012 autumn -- 429 U0210 Topics in Community-based Practice of Occupational Therapy

Community-Based Practice: Definition, Historical Perspective, and Occupational Therapy Roles By Hui-Fen Mao 2012/9/13 1.

What is community-based rehabilitation (CBR)? (http://www.who.int/disabilities/cbr/en/) (WHO Library Cataloguing-in –Publication data) CBR: a strategy for rehabilitation, equalization of opportunities, poverty reduction

and social inclusion of people with disabilities. (2004, Joint Position Paper/International Labour Organization, United Nations Educational, Scientific and Cultural Organization and the WHO)

CBR: implanted through the combined efforts of people with disabilities themselves, their families, organizations and communities, and the relevant governmental and non-governmental health, education, vocational, social and other services. CBR, currently in practice in more than 90 countries around the world, is a comprehensive strategy for involving people with disabilities in the development of their communities. 2. What is the objective of CBR? 1) CBR seeks to ensure that people with disabilities (PWD) have equal access to rehabilitation and other services and opportunities -- health, education and income, and to become active contributors to the community and society at large -- as do all other members of society. 2) To activate communities to promote and protect the human rights of PWD through changes within the community, for example, by removing barriers to participation. 3. Who are the targets? • • • • • • •

People with disabilities Families of people with disabilities Communities Disabled People's Organizations Local, regional and national governments International organizations Nongovernmental organizations (NGO) 1


2012 autumn -- 429 U0210 Topics in Community-based Practice of Occupational Therapy • •

4.

Medical and other professionals Business and industry (private sector)

What kind of activities are included?

A wide range of activities is included beyond medical care and rehabilitation • • • • • • •

Promoting positive attitudes towards people with disabilities Preventing the causes of disabilities Providing rehabilitation services Facilitating education and training opportunities Supporting local initiatives Monitoring and evaluating programmes Supporting micro and macro income-generation opportunities

5. What WHO is doing? With regard to CBR, WHO is supporting Member States in the following areas: • •

Developing guidelines for CBR Conducting regional and country workshops to promote CBR and the guidelines Supporting Member States to initiate CBR and/or strengthening existing CBR programmes

6. What are the essential elements of CBR? 1) National level support through policies, co-ordination and resource allocation 2) Recognition of the need for CBR programmes to be based on a human rights approach. 3) The willingness of the community to respond to the needs of their members with disabilities. 4) The presence of motivated community workers. National level: 1) Policies, legislation, and support to guide the priorities and planning of a CBR programme. i.e. the UN Convention on the Rights of the Child, the UN standard Rules on the Equalization of Opportunities for Persons with Disabilities 2) The mechanism of co-ordinating committee (one or across ministry, health, social affairs, education or labour) 3) Collaboration among all of the sectors (intermediate/distract level where referral 2


2012 autumn -- 429 U0210 Topics in Community-based Practice of Occupational Therapy

services are provided, Non Governmental Organizations, NGO) 4) Allocation of resources Intermediate level—key point for coordination of support to communities CBR managers (i.e. ministry for social affairs), their duties include: Implementing and monitoring of the programme, supporting and supervising the training of workers, linking various community committees, and liaising between the communities and other resources. Community level Representatives of community involving in the planning, implementation and evaluation of CBR programmes. Recognition of the need for CBR, raising the awareness Community involvement: respond the need * sharing information is a key component of CBR 7. Who will be community workers? Local government, Volunteers, PWD, and their family members, NGO, Media‌. Roles: 1) Acts as advocate by making contacts with schools, training centres, work places and other organizations to promote accessibility and inclusion. 2) Provide information about the services available As liaison between the families of PWD and such services * CBR is now recognized by many governments as an effective strategy for meeting the needs of people with disabilities especially who live in rural areas. The expansion of programmes requires training for the people who will involved in the management and delivery of services. 8. What training programmes are needed for CBR? 1) Management training: identify need, co-ordinating with the community and sectors, recording 2) Training for PWDs: to function as liaisons between community and other levels, skills in advocacy, co-ordination, planning and evaluation, and fund raising. 3) Training for service delivery (community workers and the professionals) CBR program / 3


Paradigm Shift: From the Medical Model to the Community Model Public Health, Community Health, and Occupational Therapy By Hui-Fen Mao 2012/9/20 Guiding Questions 1. Do you think there are paradigm shifts occurring in occupational therapy? 2. What are the characteristics of the emerging (

) paradigm in OT?

3. What are the basic components and/ or characteristics of a community practice paradigm in OT? (* Table 2-1: Contrasting Paradigms) 4. What is “Public Health”? What are the strategies usually used in public health? 5. Describe the differences between public health and medical approaches to health and disease.

Discuss the implications of these two approaches with respect to

OT practice. (p.39) 6. What is “community health”? What are included in “community-based approach” to enhance “ community health”? 7.

Describe the national health goals and objectives and potential roles for OT practitioners within the Healthy People framework.


2012 autumn -- 429 U0210 Topics in Community-based Practice of Occupational Therapy

Paradigm Shift: From the Medical Model to the Community Model Public Health, Community Health, and Occupational Therapy By Hui-Fen Mao 2012/9/20 1.

What is paradigm? - An example, pattern, or model - Conceptual framework that allows for explanation and investigation of phenomena. - “ universally recognized scientific achievements that for a time provide model problems and solutions to a community of practitioners” (Tomas S. Kuhn, 1970, in “ The Structure of Scientific Revolutions”)

-

“ consensus-determined matrix of the most fundamental beliefs or assumptions of a field” “ cultural core of the discipline” and “provides professional identity” Two essential characteristics: 1) a sufficiently unprecedented scientific achievement that draws a large number of constituents from competing areas of inquiry, 2) adequately open ended enough to allow for the exploration of solutions to a variety of problems.

2. What can discipline-specific paradigm determine for a profession? - How professionals view their phenomenon of interest - What puzzles, problems, or questions practitioners will seek out in their work - What solution will emerge - What goals will be set for the direction of the profession

3. Describe the positive and negative aspects of having a well-developed paradigm. -

“paradigm effect”: paradigm act as filters of perception When utilized appropriately, it distribute or provide information into meaningful and useful guidelines for practice. The danger is that their potential for limiting problem solving and innovation by constraining thinking and perception.

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2012 autumn -- 429 U0210 Topics in Community-based Practice of Occupational Therapy

4. Do you think there are paradigm shifts occurring in occupational therapy?

5. There are 4 stages of paradigm shifts.

1. Pre-paradigm: Competing schools of thought confronting the same range of phenomena

2. Paradigm : Consensus as to the nature of the phenomenon, problems to be addressed, and methods

4.Crisis resolution through reorganization of the discipline under a new paradigm

External Factors: Social and epistemolo gical demands on the discipline

3.Crisis: Rejection of the old paradigm

6. Paradigm Shifts in OT 1) 18th and 19th centuries: moral treatment 2) 1900~1940--Paradigm of Occupation Crisis (1950) 3) 1960s—Mechanistic Paradigm: more scientific, reductionism (Kinesiology, neurophysiological, and psychoanalytic approaches, exercise, talk groups, treatment technique, modality….) Crisis (1970) 4) 1980-1990s—Emerging paradigm, to understand the complexity of human behavior-- system’s perceptive

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2012 autumn -- 429 U0210 Topics in Community-based Practice of Occupational Therapy

7. What are the characteristics of the emerging ( 

 

) paradigm in OT?

Occupational performance results from the dynamic interaction between the person, the environmental context, and the occupations in which the person engages. A more complex perspective on factors that impact occupational performance All systems and components of systems are organized by levels and operate according to the laws of hierarchy (rather than cause-and-effect relationship)=> Dynamical systems theory: self-organizing processes Input (Open system)=> Throughput=> Output, the interaction of the system with it environment is refined and guided by the feedback process A broader range of potential solutions to occupational performance

8. The definition of public health: (Green and Anderson, 1982) The science and art of preventing disease, prolonging life, and promoting health and well-being through organized community effort for the sanitation of the environment, the control of communicable infections, the organization of medical and nursing services for the early diagnosis and prevention of disease, the education of the individual in personal health, and the development of the social machinery to assure everyone a standard of living adequate for the maintenance or improvement of health. 9. Five phases of the “modern era” of public health: 1) Miasma

phase (1850-1880): garbage collection, public

sanitation, street cleaning, food handling, personal hygiene education 2) Disease control or health protection phase (1880-1920): Organisms causes disease and the science of bacteriology/ inoculations against diseases such as rabies and typhoid fever( ), quarantine to prevent the spread of communicable illnesses 3) Health resources or medical phase (1920-1960): financial resources in construction of hospital, the development of health profession, the biomedical research (OT in medical model expanded significantly)

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2012 autumn -- 429 U0210 Topics in Community-based Practice of Occupational Therapy

4) Social engineering phase (1960-1975): Medicare and Medicaid legislation in 1967 make health care services available to all citizens. Social concerns addressed at the federal level (housing, education, and poverty) 5) Health promotion phase (1975-present): recognition that health problems are attributable to an individual’s lifestyle and behavior (leading causes of morbidity, mortality, and disability—heart disease, cancer, stroke, HIV, and accidents), health promotion efforts—combine social and environmental supports with strategies for health education and behavior changes to prevent disease and disability 10. Health-Care Delivery for Persons with Disabilities 1) Institutionalization 2) Deinstitutionalization and community develop (1975~to late 1980): “homelike settings, professionals are still the planners of service and retained authority/ Guiding principles—developmental theory, to develop skills and behaviors) 3) The era of community membership: focus on community supports to facilitate integration, autonomy, quality of life, and independence / Guiding principles—the adaptation of the environment to meet the individual’s needs, rather than education of the individual to adapt to the environment. Dysfunction is a dynamic interplay between an individual’s limitations and resources and the demands and constraints of the environment. (Systems approach: Social and environmental constraints than inherent in the physical disability) 11. The Vocational Rehabilitation (1980~)—2 models of practice 1) Clinical model of vocational rehabilitation: PWD are unemployed, need to be assessed, counseled,, and treated to make him or her more employable/ to modify or restructure the psychological and vocational skills and behaviors. 2) Ecological or environmental model of vocational rehabilitation: numerous environmental, social,, and economic forces affect the PWD/ to modify all aspects of environment (physical, social,, and political) 12. Compare and contrast the paradigm shifts in OT with those of public health and vocational rehabilitation.

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2012 autumn -- 429 U0210 Topics in Community-based Practice of Occupational Therapy

13. What are the basic components and/ or characteristics of a community practice paradigm in OT? 1) Broader perspectives: Client (vs. Patient), Intervention (vs. Treatment), Funding (vs. reimbursement) 2) “Client”-centered approach to practice: promote participation, exchange information, client decision-making, and respect for choice, focus on the issues which are most important to the person or family 3) The collaborative process to enable the client to identify occupational performance problems, engage in problem solving. * OT’s role—facilitator, educator, and mentor in the process (* Table 2-1: Contrasting Paradigms) 14. Discuss the usefulness of system theory to community practice. (p.31) How to assess the client in the community? (Box 2-1)

=================================================== Public Health, Community Health, and Occupational Therapy 1. What is “Public Health”? “The process of mobilizing local, state, national, and international resources to ensure the conditions in which people can be health.” 4 strategies: 1) Promoting health and preventing disease 2) Improving medical care 3) Promoting health-enhancing behaviors 4) Controlling the environment

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2012 autumn -- 429 U0210 Topics in Community-based Practice of Occupational Therapy

* defined in terms of aims and goals, rather than grounded in a specific of knowledge=> many disciplines involved 2. Terms in Epidemiology * Epidemiology – the study of the distribution, frequencies, and determinants of disease, injury, and disability./ use health statistics, including measures of incidence and prevalence, to estimate disease, injury, and disability in a variety of population groups; analyze the health trends; plan and evaluate public health initiatives; and make informed health policy decisions * Incidence refers to the number of new cases within a specified time frame (a year) * Prevalence refers to the total number of cases at one point in time. => What is the purpose of preventive intervention? To reduce ________ => What is the most effective approach to reduce overall prevalence? * Public health intervention: to modify all types of risk factors and strengthen resiliency or protective factors to enhance the overall health and well-being of population. - To decrease “risk factors”: -- precursors that increase an individual’s or population’s vulnerability to developing a disease…(physical, behavior, or genetic, social, economic, political, and environmental) - To increase “resiliency (

) factors” -- precursors that increase an

individual’s or population’s resistance to developing a disease… * “Health Promotion”—any planned combination of educational, political, regulatory, environmental, and organizational supports for action and conditions of living conductive to the health of individuals, groups, or communities. * “Prevention”—anticipatory action taken to reduce the possibility of an event or condition from occurring or developing, or to minimize the damage that may result from the event or condition if it does not occur “Primary prevention”—focuses on healthy individuals who potentially could be at risk for a particular health problem/ to prevent the disease (example) 6


2012 autumn -- 429 U0210 Topics in Community-based Practice of Occupational Therapy

“Secondary prevention”—focuses on the detection and treatment of disease early on in its preclinical or clinical stages/ to slow the disease process, attempt to cure or control (example) “ Tertiary prevention”—used in the advanced stages of disease (already ill), to limit disability and other complications/ to restore as much functionality as possible, and to prevent further damage (example) 3. Describe the differences between public health and medical approaches to health and disease. Discuss the implications of these two approaches with respect to OT practice. (p.39) 4. What is “community health”? *”Community”—Noninstitutional aggregations of people linked together for common goals or other purposes * “Health”—the blending of a person’s physical, emotional, social, intellectual, and spiritual resources so that he or she can master the developmental tasks necessary to enjoy a satisfying and productive life. * “ Community Health”— the physical, emotional, social, intellectual, and spiritual well-being of a group of people who are linked together in some way 5. What are included in “community-based approach” to enhance “ community health”? 1) Educational intervention 2) Social intervention (economic, political, legal, organization change) 3) Environmental supports 4) The health behavior of a community: actions of any person who may influence health behaviors,, resources or services ( police maker, ill persons, professionals,, employers,…..) 6. Describe the history of the development of national health goals and objectives and potential roles for OT practitioners within the Healthy People framework.

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2012 autumn -- 429 U0210 Topics in Community-based Practice of Occupational Therapy

1) “Healthy People” proposed by the Department of Health, Education and Welfare (Now the Dep. of Health and Human Services) in 1979. - to identify national health goals and discuss health promotion and disease prevention in the US, and efficiently and effective use of the health-care resource - morbidity and mortality can be attributed to four primary elements: 1) Inadequacies in the existing health-care system 2) Behavioral factors or unhealthy lifestyles: the leading cause of death for adolescents and young adults 3) Environmental hazards 4) Human biological factors * Five major health goals according to life span (infants, children, adolescents and young adults, adults, and older adults) 2)

In 1980, “ Objectives for the Nation” -- a total of 226 specific goals A mid course review in 1986

3) “ Healthy People 2000” in 1990: Focus is to improve the QOL, and people’s sense of well-being (rather than just reduction of mortality rate) - Increase the span of healthy life for Americans - Reduce health disparities among Americans (people with low income, disabilities, in minority groups) - Achieve access to preventive health services for all Americans (social and environmental factors) 4) “ Healthy People 2010” in 2000: due to advances in preventive therapies, vaccines and pharmaceuticals, assistive technologies, and computerized systems. * 28 Focus areas (Box 3-1), 467 goals 5) “ Healthy People 2020”

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Framework The Vision, Mission, and Goals of Healthy People 2020 The vision, mission, and overarching goals provide structure and guidance for achieving the Healthy People 2020 objectives. While general in nature, they offer specific, important areas of emphasis where action must be taken if the United States is to achieve better health by the year 2020. Developed under the leadership of the Federal Interagency Workgroup (FIW), the Healthy People 2020 framework is the product of an exhaustive collaborative process among the U.S. Department of Health and Human Services (HHS) and other federal agencies, public stakeholders, and the advisory committee.

Vision—A society in which all people live long, healthy lives. Mission—Healthy People 2020 strives to: Identify nationwide health improvement priorities; Increase public awareness and understanding of the determinants of health, disease, and disability and the opportunities for progress; Provide measurable objectives and goals that are applicable at the national, state, and local levels; Engage multiple sectors to take actions to strengthen policies and improve practices that are driven by the best available evidence and knowledge; and Identify critical research, evaluation, and data collection needs.

Overarching Goals Attain high-quality, longer lives free of preventable disease, disability, injury, and premature death. Achieve health equity, eliminate disparities, and improve the health of all groups. Create social and physical environments that promote good health for all. Promote quality of life, healthy development, and healthy behaviors across all life stages.

www.healthypeople.gov


Healthy People 2020 Framework

The Importance of an Ecological and Determinants Approach to Health Promotion and Disease Prevention Health and health behaviors are determined by influences at multiple levels, including personal (i.e., biological, psychological), organizational/institutional, environmental (i.e., both social and physical), and policy levels. Because significant and dynamic inter-relationships exist among these different levels of health determinants, interventions are most likely to be effective when they address determinants at all levels. Historically, many health fields have focused on individual-level health determinants and interventions. Healthy People 2020 should therefore expand its focus to emphasize health-enhancing social and physical environments. Integrating prevention into the continuum of education—from the earliest ages on—is an integral part of this ecological and determinants approach.

The Role of Health Information Technology and Health Communication Health information technology (IT) and health communication will be encouraged and supported as being an integral part of the implementation and success of Healthy People 2020. Efforts will include building, and integrating where feasible, the public health IT infrastructure in conjunction with the Nationwide Health Information Network; the ONC-Coordinated Federal Health IT Strategic Plan: 2008–2012 and any updates developed by the HHS Office of the National Coordinator; the various aspects of IT to meet the direct needs of Healthy People 2020 for measures and interventions; and health literacy and health communication efforts.

Addressing “All Hazards” Preparedness as a Public Health Issue Since the 2000 launch of Healthy People 2010, the attacks of September 11, 2001, the subsequent anthrax attacks, the devastating effects of natural disasters such as hurricanes Katrina and Ike, and concerns about an influenza pandemic have added urgency to the importance of preparedness as a public health issue. Being prepared for any emergency must be a high priority for public health in the coming decade, and Healthy People 2020 will highlight this issue. Because preparedness for all emergencies involves common elements, an “all hazards” approach is necessary.

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www.healthypeople.gov


Healthy People 2020 Framework

Graphic Model of Healthy People 2020 The FIW developed a graphic model to visually depict the ecological and determinants approach that Healthy People 2020 will take in framing the national health objectives. This particular graphic was designed to emphasize this new approach, and is not meant as a comprehensive representation of all public health issues and societal domains. The graphic framework attempts to illustrate the fundamental degree of overlap among the social determinants of health, as well as emphasize their collective impact and influence on health outcomes and conditions. The framework also underscores a continued focus on population disparities, including those categorized by race/ethnicity, socioeconomic status, gender, age, disability status, sexual orientation, and geographic location.

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www.healthypeople.gov


RESEARCH COMMUNICATION Inhibiting and Facilitating Factors Concerning Breast Cancer Early Diagnosis Behavior in Turkish Women: A Qualitative Study According to the Health Belief and Health Development Models Fatma Ersin*, Zuhal Bahar Abstract Aim: The aim of the present study is to investigate the perceived inhibiting and facilitating factors concerning breast cancer early diagnosis behavior in women over age 40. Method: A qualitative focus group interview method was applied with 43 participating women, in the period between March-April 2010, using a semi-structured interview questionnaire based on the Health Belief Model and the Health Development Model. Content analysis was used to analyse study data. Results: Inhibiting factors such as women’s lack of knowledge regarding breast

negligence, forgetting, feeling of fear, and a fatalistic approach were frequently discussed. Among facilitating factors, informed level, concerned and tolerant health care personnel, free health services, free transportation to hospital, improved appointment system, telephone reminders were included. Conclusion and Recommendations: Focus group interviews were found to be effective in determining inhibiting and facilitating factors concerning the data obtained in the study may be effective in the implementation and maintenance of early diagnosis. Keywords: Barriers - facilitators - health belief model - health development model-nursing 12, 1849-1854

Introduction To ensure participation of women in early diagnosis behaviors of breast cancer by regular self breast examinations is among health promoting activities. Health promotion and disease prevention are basic concepts in basic nursing practice (Fawcett and Gigliotti, 2001). Recognizing the level of knowledge, beliefs and attitudes of women regarding breast cancer early diagnosis behaviors is effective in the applications of training and persuading women accordingly (Champion and Skinner, 2008). In this respect, the Health Belief Model and the Health Development Model can be effectively used in determining perceived inhibiting factors concerning breast cancer early diagnosis behaviors of women. According to the Health Belief Model, when perceived barrier, the person evaluates positive and negative consequences of the behavior. Consequently, he transforms the behavior into action or not. (Hochbaum, 1958). Perceived barriers are stated as the most powerful criterion of the model (Champion and Skinner, 2008). According to the Health Development Model, the perceived barriers of the individuals are important in maintaining the health behaviors directly or indirectly

(Pender et al., 2006). Even though the Health Development Model is not widely used in breast cancer applications, it explained only 75% of the behavior changes in the studies conducted (Pender et al., 2006). Psychological, structural, institutional and sociocultural factors are effective in breast screening rates and also directing women towards breast cancer early diagnosis behaviors (Lee et al., 2007; Remenninck, 2006). Psychological factors include fear of cancer, lack of information about early diagnosis applications, feeling of embarrassment, lack of sensitivity, disruption of family comfort, fear of losing the breast, fear of death, fear of change in the body image (Boraya et al., 2005; Champion et al.,2000; Maxwell et al., 2003; Ogedegbe et al., 2005; Park et al., 2007; Paskett et al., 2006). Among structural factors, lack of health insurance, transportation problems, et al., 2005; Champion et al., 2000). Difficulties in understanding the health care system and language barrier as institutional factors (Remennick, 2006). When we refer the socio-cultural factors; more dominant men in some cultures, dependent position of women upon men, subservient position of women in the family and at home

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and lack of female caregivers (Borrayo et al., 2005; Remennick, 2006), false beliefs and perceptions, and fatalistic approach is seen (Ogedegbe et al., 2005). In addition, it is stated that facilitators (giving information, reminder letters, reminder telephone calls and mails, informative brochures, a home visits, combined interventions) are effective in the implementation and

the Health Development Model were used. The interview questionnaire consisted of open-ended questions and experts were asked for opinion. Some of the questions are hereby: “What are the methods you know for early detection of breast cancer?, What are your reasons for not practicing BSE?, Why don’t you regularly go to doctor for clinical breast examination?, Which requirements of

al., 2009; Champion et al., 2002; Kwok et al., 2005) and underlined that individuals should be conscious in this

easier for you? Interviews were carried out as single sessions. Interviews were continued until any new data was obtained. At the point that no new data was obtained (data saturation), interviews were terminated.

Lee et al (2007) reported women’s breast screening rates would be increased by determining the barriers, and along with appropriate trainings and facilitators. Therefore, it is programs supported by models sould be structured and implemented by nurses in order to increase awareness regarding breast cancer early diagnosis in women, and maintain this behavior on a regular basis (Oliver-Vazquez et al., 2002). In this phenomenological study, it is aimed to investigate the perceived barriers and facilitators of women over age 40 with regard to breast self examination (BSE), clinical breast examination (CBE) and mammography within theoretical context of the Health Belief Model and the Health Promotion Model. The study questions with regard to BSE, CBE and mammography were: What are the women’s perceived barriers?; What are the women’s facilitators?

Materials and Methods

of the district were visited at their homes, and asked for their consent to participate in the study after the aim of the study was explained. Women accepted to participate in the study were invited to the meetings at predetermined time and location. By telephone calls, women were reminded of the time and place of the meeting in the morning of the meeting day. Focus group interviews were carried out by two researchers who were educated on the subject. Tape recorder and interviewer notes were used during face-toface interviews. Before using the recording device, women were asked for consent for recording interviews, and at the beginning of the recording, asking for the consent and aim of the study were repeated. At the time of interviews, the observer research assistant noted interactions among women. At the same time, food and beverages were offered in order to increase participation of the participating women in the interviews. Focus group interviews were lasted for approximately 45 minutes.

The present focus group interview method qualitative study was conducted in the period between 17 March and

Counseling Center in cooperation with the Department of Public Health Nursing, School of Nursing, DEU, provide health related services to women and their families. Women’s Counseling Center and recommended place by municipality.

The study environment consisted of 10 639 women aged over 40, and living in Balcova Region. Criterion sampling method was used. Women who were voluntary to participate in the study and over 40 years of age, not diagnosed as breast cancer, not practiced mammography in the last one year were included in the sampling. We approached women through adress list obtained from

Deductive content analysis methodology was used in the analysis of the study data. Content analysis process consisted of analysing tape-recorded data into volumes, creating matrix analysis, encoding data of the matrix analysis in order to determine the barriers and the facilitators regarding breast cancer early diagnosis behaviors, reviewing the data encoded according to the matrix analysis, reporting the analysis process and the results (Polite and Beck, 2004).

Validity of a qualitative research is evaluated with reliability and transferability (Elo and Kyngas, 2008). Reliability of this study was tested by including the expert opinions in the analysis of data and the participants’ confirmation. For transferability, criterion sampling, sample selection criteria and the data collection method

focus group interviews were conducted, a total of 43 women were approached. Around 7-11 women participated in each focus group interviews. Sociodemographic characteristics of participants are shown in Table 1.

Reliability is evaluated with consistency and

In this study, semi-structured interview questionnaire preapared in the guidance of the Health Belief Model and

2006). For reliability of the study, according to the criteria met, study data was submitted directly with a descriptive approach, more than one researcher were included in the

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Table 1. Sociodemographic Characteristics of the Participants

BSE, some of the women expressed as “

”, while two of the participants noted that they performed once a month following menstruation in the Education bathroom. The women indicated they didn’t know, even Illiterate 25 58.1 didn’t hear about the clinical examination performed by Literate 2 4.7 the health personnel, named CBE. According to one of the Primary school graduate 12 27.9 women, mammography screening should be performed Secondary school graduate 2 4.7 100.0 once a year over the age of 40, while for two other women High school graduate or more 2 4.7 Income every two years. Concerning lack of information, women Income < expenditure 36 83.7 blamed health personnel for not informing enough. Income = expenditure 7 16.3 75.0 The most emphasized concept in all focus group Income > expenditure 0 0.0 interviews was lack of sensitivity, neglecting. Among the prevalent causes leading to neglect participation in the behaviour of early diagnosis of breast cancer, some of same study, more than one researcher worked in obtaining the women discussed feeling no pain, feeling in general data, different researchers cooperated in the analysis of 50.0 healthy, and feeling no need for screening, while a few of the data obtained, in the data analysis pre-established and others mentioned about deeming it unimportant, radiation exposure in mammography, and ignoring their bodies. and SGM were used in the conceptual framework. In the 25.0 Three of the women expressed “ end of the interviews, all data recorded was played for ”, majority of the women underlined “ ”. Five of the women stated that, although consequently reliability of the data was achieved. For the 0 health status had great importance, they didn’t go for their screening, but they should. One of the women expressed characteristics of the participants, the social environment “ ”. In of the research, conceptual framework and data analysis

and the Ethical Committee of School of Nursing, DEU. In order to approach address and telephone information of 40 women living in the region, approval was taken participating women which met the inclusion criteria of the study sampling.

Results a) Psychological Factors: Majority of the women cancer, and as information source about early diagnosis behaviors regarding breast cancer, they pointed out mostly television, also doctors and nursing students. Moreover, diagnosis behaviors and screening timing. On the other hand, some of the women mentioned about the importance of early diagnosis, even underlined potential life-saving impact. Some of the participants claiming that they knew how to perform BSE, did it wrong. Some others stated they knew how to perform BSE, but did not perform at all, while some others claimed they performed BSE, but did not understand what they were doing. One participant said “ ”. Concerning screening timing, almost none of the participating women could state exactly when, how often and how to perform BSE, CBE and mammography. Some of the participating women mentioned about the wory not to feel or detect the mass in practicing BSE. Regarding

out as the most important reason not to perform screening tests. Neglecting, inability to read and write, no one around as a reminder, hectic and intensive housework were other reasons mentioned by different women. Majority of the women discussed the feeling of fear as a reason not to perform screenings. The fear of receiving a diagnosis of cancer was widely uttered. Moreover, some of the women implied that radiation exposure during mammography may also cause cancer. One of the women expressed this fact as “ ”. Six of the women pointed out the fear of death. Women tried to express their feling of fear with phrases like “ ” or “ ”. Especially in two of the focus group interviews, some discomfort felt during the procedure was discussed. Some of the women had no complaints during screening of mammography, while some other experienced pain or discomfort, and commented as “ ”. b) Structural Factors: Majority of the women reported that lack of health insurance and high costs were inhibiting factors concerning early diagnosis behaviors. Women stated they couldn’t easily pay for the screening and expressed as “ ”, “ ”, “ .” Particularly for old women, transportation problems was another barrier. Almost in all focus group interviews, clinics, uninterested and unconcerned health personnel,

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None

Remission

Persistence or recurrence

In order to carry out the research study, approval and

Newly diagnosed with treatment

Number %

Newly diagnosed without treatment

Characteristics


long-lasting procedures, prolonged waiting periods were among the issues frequently mentioned and emphasized. One of the women stated she wouldn’t refer to health institutions and expressed as “

leave the children at home due to their health problems and go to the hopitals for screenings. Irrelevant and intolerant approach of the health personnel was discussed as another barrier for the women. Some of the participants expressed as “ ”, “ ”, “ ”. c) Institutional Factors the health care system is another barrier for women regarding screening. Most of the women reported they didn’t previously practice most of the procedures performed and also didn’t know where these screening procedures were performed. One of the women expressed her situaton as “ I don’t know where to go, how to go, and which procedures to conduct”. d) Socio-Cultural Factors: Throughout focus group interviews, one of the barriers for women to participate in the screening programs was underlined as cultural factors. During interviews, women noted that they should inform their husbands before they visited a doctor and moreover they were not allowed by their husbands to be examined by a male doctor. Some participants emphasized they didn’t paricipate in the screening programs with the feeling of embarrassment, essentially based on traditional structure of Turkish society and religious beliefs. In fact, one of family health center for two years because of the male doctor on duty. Two other women stated it’s not religiously important if the doctor was male or female. She expressed this approach as “

”. Most of the women participating in the study believed cancer is something from the God. They said “ ”, “ ”.

The participating women discussed their participation in breast cancer screening programs and forwarded their proposals, so that they should be informed by education programs, brochures and the media, as well as by seminars and reminders (telephone reminders, home visits) conducted by health care workers. They implied as “ ”, “ ”. In addition, having some disease symptoms was indicated as a facilitating factor. Women suggested that providing free health services regarding breast cancer, facilitated transportation facilities, improved appointment the breast cancer screening programs. Furthermore, they

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noted they necessarily go to doctor when they are called by the health personnel. They expressed as “ ”, “ ”. The women demanded recommendations for screening programs provided by the health personnel, in a friendly and tolerant approach. One of the women expressed their expectations from health personnel as “ i ”, “ ”. Additionally, the women asked to be informed about the procedures in the hospitals, also noted that practicing the screening procedures in a known institution would be more convenient for themselves One of the participants emphasized that, encouraging women is important to emancipate women from men’s oppression, and she pointed out it could be achieved primarily by education. They also noted they would feel better if they could communicate with female doctors with regard to health services. One participant stated “ ”.

Discussion In order to motivate women to participate in the health improvement activities, it is highly important to recognize the inhibiting reasons for women regarding their participations in breast cancer screening programs. In this present study, the perceived barriers of the women were observed to influence their behaviors. Among knowledge of women regarding breast cancer early diagnosis and timing of screening should be mentioned. Similar results were also obtained in other studies (Paskett et al., 2006; Park et al., 2007). As information sources, students. In some studies conducted, participating women reported that they generally get informed through media, friends, and acquaintances (Park et al., 2007; Sadler et al., 2007). The reason for media to be so widely used as an information source by the participating women might be the fact that it is an easily accessible tool, whereas the submission of health services to individuals might be inadequate and unsatisfactory. Furthermore, ignorance and wrong information might have an inhibiting role in the participation of women in breast cancer early diagnosis of individuals regarding breast cancer, and so causing inadequate perceptions of sensitivity and severity. In the present study, lack of sensitivity along with neglecting and forgetting are substantially important barriers. Sensitivity is considerably effective in perceiving the likelihood of developing breast cancer. Almost all women reported they neglected screening programs, and they were not sensitive on this issue, which is supporting some study data (Park et al., 2007). This might be due to the low levels of risk perception of women. Women mentioned about disregarding, forgetting due to workload, ignorance, discomfort felt during the procedure, inevitable


pain and distress occurred in the procedure, the sense of feeling healthy among the reasons leading to negligence, which are also compatible with the data of other studies (Kwok et al., 2005; Ogedegbe et al., 2005). The sense of feeling healthy is considered very important in practicing health protecting behaviors. On this account, the fear of losing current health status and the accompanying worries may inhibit the participation in the screening programs. As a result of insensitivity and negligence, women forget to conduct screening activities, particularly practicing BSE. According to Pender, the importance attributed by the individuals to their own health status had a direct impact on the realization of their own health behaviors. In the realization of health improvement individuals were considerably important, moreover they generally recognized the importance of their health status whenever they became ill or had the feeling of death (Pender et al., 2006). In this present study, the feeling of data in literature (Maxwell et al., 2003; Ogedegbe et al., 2005). On the contrary, the feeling of fear was discussed as a facilitating factor in some other studies (Buki et al., 2004; Borraya et al., 2005; Kwok et al., 2005; Lamyian et al., 2007). In this study, it is observed that, women had the expectation to be stimulated by the health care personnel to conduct screening procedures in terms of breast cancer early diagnosis behaviors. Similar results were obtained in other studies conducted (Maxwell et al., 2003; Paskett et al., 2006; Ogedegbe et al., 2005; Remennick, 2006; Park et al., 2007). Women who discussed particularly transportation facilities and cost of the procedures had lower socioeconomic conditions. Therefore, providing free transportation facilities may ensure screening behaviors of women. As a barrier detected in this study, supports the study data of Remennick (2006). The reasons be based on the fact that they didn’t frequently use health institutions, or else they were illiterate. Similar to other studies, the dominant position of men, the feeling of embarrassment, lack of female health care personnels, wrong beliefs and perceptions, and fatalistic approach were all discussed in this study, as well (Remennick, 2006). In the implementation and maintenance of health behaviors, cultural characteristics and beliefs of Turkish society have great importance. In some studies conducted, beliefs were recognized as a barrier (Borrayo et al., 2005; Remennick, 2006), while in some other studies as a facilitator (Lamyian et al., 2007; Lee et al., 2007). Additionally, demand of the women for a female doctor support was compatible with the data of other studies (Maxwell et al., 2003; Borrayo et al., 2005). Women’s claim for a female doctor may be due to religious factors, or customs and traditions, along with the feeling of embarrassment to show their bodies. and discussed widely among women. In the study of Ogedegbe et al (2005) fatalism was mentioned as an important barrier. “Fatalism” has a place in the religious

beliefs of the Turkish society and for some of the women it may lead to the recognition that she doesn’t have the control of her own health, therefore, it may prevent women in the participation of screening programs. It can be effective if nurses would communicate with women and explain that fatalistic approach has no impact on health improvement practices. In the implementation and maintenance of health, in order to provide an effective health care service, public health nurse should first diagnose the society. Interviews with the individuals are important in the diagnosis of the society. For this reason, this present study is a guide for public health nurses. Being informed by the health care personnel is determined as an important facilitator in this study. In the studies based on the Health Belief Model and the Health Development Model, it is oberved that informed and instructed individuals displayed positive health-related behaviors (Pender et al., 2006; Oliver-Vazquez et al.,

2009; Maxwell et al., 2003; Parlar et al., 2004; Paskett et al., 2006; Taylor, 1998; Tuong-Vi, 2007). In addition to being informed, being reminded by health care personnel (telephone reminders, home visits) was discussed by women as a poitive guidance in terms of participation in

et al (2009) it is reported that home visits as a reminder were not found effective. Furthermore, following focus group interviews, some of the women decided to conduct screening procedures. According to the explanations of the participants, it may be considered that the perceptions positively by these interviews. In various studies similar to this present study, recommendations regarding breast cancer early diagnosis behaviors of women and using effective communication skills of the health personnel are emphasized as facilitating factors in the delivery of health service (Lamyian et al., 2007; Borrayo et al., 2005). The present study data indicated that, in the context of health services provision, besides the efforts of the health care personnel, evaluating the quality of the health services and searching for effective solutions are mandatory in the process of increasing women’s participation in the breast cancer early diagnosis behaviors. Therefore, while providing health services as a public health nurse, recognition and application of the solutions, as well as the barriers, will be a facilitating factor in the implementation of health behaviors. In conclusion, focus group interviews are observed to be effective in determining barriers regarding breast cancer early diagnosis behaviors. This present study is a guide to public health nurses in determining these barriers. Therefore, after determining the barriers in breast cancer early diagnosis behaviors, national and regional training be organized. Randomized controlled studies including training programs for barriers may be conducted.

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be effective in the implementation and maintenance of the breast cancer early diagnosis behaviors. Therefore, organization of national and regional breast cancer screening programs by the nurses, in which facilitators are kept in the forefront, furthermore, collaborations with different disciplines, may be effective in the implementation of health services. In Turkey, we didn’t encounter with the studies conducted about breast cancer early diagnosis behaviors, in which the barriers were first identified, and then initiatives are planned and accomplished, within the theoretical framework of the Health Belief Model and the Health Development Model. In this respect, this present study may lead to future qualitative and randomized controlled studies in nursing, regarding breast cancer early diagnosis behavior.

Lamyian M, Hydarnia A, Ahmadi F, et al (2007). Barriers to and factors facilitating breast cancer screening among Iranian women: a qualitative study. , 13, 1160-9. Lee EE, Tripp-Reimer T, Miller A, et al (2007). Korean American women’s beliefs about breast and cervical cancer and associated symbolic meanings. , 34, 713-20. Maxwell AE, Bastani R, Vida P, et al (2003). Result of randomized trail to increase breast and cervical cancer screening among Filipino American women. , 37, 102-9. Ogedegbe G, Cassells AN, Robinson CM, et al (2005). Perceptions of barriers and facilitators of cancer early detection among low-income minority women in community health centers. , 97, 162-70. Oliver Vazquez M, Ayendez MS, Perez ES, et al (2002). Breast cancer Health Promotion Model for older Puerto Rican women: Results of a pilot programme. , 17, 3-11.

References examination education to the knowledge and attitudes of female students. , 6, 106-11. increasing the participation of women in community breast cancer screening. Cochrane Database of Systematic Reviews 2001, Issue 1. Available from: http://www2.cochrane.org/ reviews/en/ab002943.html. Borrayo EA, Buki LP, Feigal BM (2005). Breast cancer detection among older Latinas: is it worth the risk? , 15, 1244-63. Buki LP, Borrayo EA, Feigal B (2004). Are all Latinas the same? Perceived breast cancer screening barriers and facilitative conditions. , 28, 400-12. Champion V, Skinner C, Foster J (2000). The effects of standard care counseling or telephone/in-person counseling on beliefs knowledge and behavior related to mammography screening. , 27, 1565-71. Champion VL, Skinner CS (2008). The Health Belief Model. In: Glanz K., Rimer B.K., Viswanath K.V., eds. Health Behavior and Health Education: Theory, Research and Practice. 4th ed. San Francisco: Jossey-Bass, Inc. 46-65 Champion V, Skinner C, Menon U, et al (2002). Comparisons of tailored mammography interventions at two months post intervention. , 24, 211-18. Earp JA, Eng E, O’Malley MS, et al (2002). Increasing use of mammography among older, rural African American women: Results from a community trial. , 92, 646-54. Elo S, Kyngas H (2008). The qualitative content analysis process. , 62, 107-15. Fawcett J, Gigliotti E (2001). Using conceptual models of nursing to guide nursing research: the case of the Neuman Systems Model. , 14, 339-45. given by nursing students on womens’ knowledge and practice of breast cancer / breast self examination in a public training center. , 3, 53-7. Hochbaum GM (Subsequently modified by other authors) (1958). Health Belief Model, [ Update 2010 March 17] Available from http://www.courseweb.uottawa.ca/epi6181/ images/Health_Belief_Model_review.pdf. Kwok C, Cant R, Sullivan G (2005). Factors associated with mammographic decisions of Chinese-Australian women. , 20, 739-47.

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, 8, 9-15. and facilitators of Korean women and their spouses in the contemplation stage of breast self-examination. , 30, 78-84. Paskett E, Tatum C, Rushing J, et al (2006). Randomized triracial rural population of women. , 98, 1226-31. Pender N, Murdaugh CL, Parsons MA (2006). Health Promotion Jersey. Polit DF, Beck CT (2004). Nursing research: Principles and methods. (7 ed.). Philadelphia: Lippincott, Williams & Wilkins. Remennick L (2006). The challenge of early breast cancer detection among immigrant and minority women in multicultural societies. , 12, 103-10. Sadler GR, Ko CM, Cohn JA (2007). Breast cancer knowledge, attitudes, and screening behaviors among African American women: the Black cosmetologists promoting health program. , 7, 57. Taylor GJ (1998). Transforming decision making in African American Women: effects of a culturally sensitive breast of Alabama, Birmingham.

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Park et al. BMC Public Health 2011, 11:468 http://www.biomedcentral.com/1471-2458/11/468

RESEARCH ARTICLE

Open Access

Community-based intervention to promote breast cancer awareness and screening: The Korean experience Keeho Park1*, Woi Hyun Hong2, Su Yeon Kye1, Euichul Jung3, Myung-hyun Kim1 and Hyeong Geun Park1 Abstract Background: There are many differences in culture, community identity, community participation, and ownership between communities in Western and Asian countries; thus, it is difficult to adopt the results of community intervention studies from Western countries. In this study, we conducted a multicity, multicomponent community intervention trial to correct breast cancer myths and promote screening mammography for women living in an urban community in Korea. Methods: A 6-month, 2-city community intervention trial was conducted. In the intervention city, 480 women were surveyed at baseline and 7 months later to evaluate the effects of the intervention program. Strategies implemented in the intervention city included community outreach and clinic and pharmacy-based in-reach strategies. Results: This study showed a 20.4-percentage-point decrease in myths about the link between cancer and breast size, a 19.2-percentage-point decrease in myths concerning mammography costs, and a 14.1-percentage-point increase in intention to undergo screening mammography. We also saw a 23.4-percentage-point increase in the proportion of women at the action stage of the transtheoretical model in the intervention city. In the comparison city, smaller decreases and increases were observed. Conclusions: Our study showed the value of an intervention study aimed at reducing belief in breast cancer myths in an urban community in Korea. The invention also made women more likely to undergo mammography in future.

Background Cancer has been the leading cause of death in the Republic of Korea since 1983. Approximately 140,000 people develop cancer annually with 65,000 annual fatalities. Cancer control is an important issue because of the country’s rapidly aging society and the subsequent increased burden of cancer. The National Cancer Screening Program (NCSP) offers Medical Aid users and those National Health Insurance (NHI) beneficiaries who fall within the lower 50 percent income bracket free screening for 5 common cancers–cancer of the stomach, liver, colorectum, breast, and cervix uteri. For NHI beneficiaries in the upper 50 percent income * Correspondence: park.keeho@gmail.com 1 Cancer Information and Education Branch, National Cancer Center, Goyang, Republic of Korea Full list of author information is available at the end of the article

bracket, the maximum cost of a mammogram is 6 dollars. The NCSP recommends biennial mammograms for women over 40 years of age. However, only 49.5% of women act in accordance with these guidelines. Although mass media health communication strategies can effectively promote health education, and influence health awareness, decisions, practices, and care [1], interpersonal communication channels are regarded as highly influential to persuade people to change healthrelated behaviors [2]. In addition, because it is difficult for one-way mass communication strategies driven by the central government to challenge strong beliefs or shifting attitudes [3], the Second Term (2006-2015) of the 10-year Comprehensive Plan for Cancer Control in Korea focuses on the idea of community-based health communication to promote cancer screening.

© 2011 Park et al; licensee BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.


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There are more than 250 Public Health Centers (PHCs) in Korea. These organizations are part of the National Health System and are operated by local governments to prevent and control diseases or tackle hygiene problems at the county/district level. Despite the presence of this strong community-based health service network, most PHCs have struggled to use theory or evidence-based approaches to promote cancer screening. However, with the new emphasis on community-based health communication in the Second Term (2006-2015) of the 10-year Comprehensive Plan for Cancer Control, these PHCs are now looking at ways to gather evidence. One difficulty they face is that most of the research on community campaigns for promoting cancer screening has been conducted in Western countries or in non-Asian populations. As there are many differences in culture, community identities, community participation, and ownership between communities in Western and Asian countries, it is not possible to directly adopt the results of studies from Western countries. In this study, we conducted a community-based intervention study to correct myths related to breast cancer and promote screening mammography for women living in an urban community in Korea, Gunpo. The theoretical framework for the community-based interventions included the PRECEDE/PROCEED model for planning [4] as well as the health belief model (HBM) [5,6], Transtheoretical model (TTM) [7] and social marketing [8]. The PRECEDE/PROCEED model is a popular road map for health promotion programs. The model views health behavior as influenced by both individual and environmental forces, and its 2 parts comprise an educational (PRECEDE) and an ecological diagnosis (PROCEED). Using the model, we conducted social, epidemiological, behavioral, environmental, educational, ecological, administrative, and policy assessment with the help of the Gunpo PHC. We also assessed the factors that predict why people will take action to screen for breast cancer using the HBM; these include susceptibility, seriousness, benefits and barriers, cues to action, and self-efficacy. The stage construct is important because it represents a temporal dimension. In the past, behavior change often was construed as a discrete event. The TTM posits change as a process that unfolds over time, with progress through a series of stages, although frequently not in a linear manner. To stage the mammography, we identified the past history of breast cancer screening, recent breast cancer screening, and future breast cancer screening intention. We chose the social marketing strategy approach to promoting health behavior. We did not merely try to inform people or persuade them to change their behavior, but attempted to sell our services as products. We

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analyzed the target population using segmentation by age and TTM stage of change, and developed intervention activities according to results of the analysis. Because breast screening with the NCSP is free for Korean women aged 40 years and over and because community health education is also free, we regarded “place” and “promotion” as the main elements of the marketing mix (Product, Price, Place, and Promotion) needing to be addressed. Therefore, we adopted an outreach education program and direct mailing as campaign activities. The Gunpo Cancer Screening Project (GCSP) aimed to identify barriers to breast cancer screening and address these barriers in a multicomponent program designed to improve beliefs, attitudes, and screening behaviors for breast cancer.

Methods Survey

We used the HBM and the TTM to develop the questionnaire for our quantitative research into health behaviors. A cross-sectional face-to-face survey using structured questionnaires was conducted with randomly selected sample of 503 women aged 30-69 years who were permanent residents in the intervention city. Selfadministered questionnaires were used to collect sociodemographic data. Survey was conducted to assess predisposing factors such as perceived risk of breast cancer, knowledge on breast cancer and breast screening, perceived severity of breast cancer, awareness of breast cancer screening, perceived barriers to breast cancer screening, satisfaction with recent breast cancer screening, and self-efficacy, and reinforcing factors which are recommendations from physician or pharmacist, past history of cancer and other chronic diseases, past history of benign breast diseases, and family history of breast cancer, and finally enabling factors, for example, perceived cues to action and factors affecting hospital choice for breast cancer screening. This study was approved by the Institutional Review Board of the National Cancer Center. Interviews

Health workers from the health promotion and cancer control program department in the PHC were interviewed in their role as key administrative and policy informants. We explored their current health promotion activities including their cancer control program, policy, enabling factors for the regional cancer control program, perceived barriers to the regional cancer control program, and characteristics of the PHC organization and those staff conducting health promotion. We conducted eleven focus group interviews; questions were based on stages of mammography adoption using the TTM and


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the HBM constructs. The results of both qualitative and quantitative research were used to develop educational materials for small group education sessions. Since this study represents only the quantitative data, we do not report the findings of qualitative research. Message

The main message of the community campaign was that screening mammography can detect masses which are not palpable. We brainstormed messages that matched our communication campaign goal of correcting myths about breast cancer and screening mammography. These were pretested and we revised the message with the members of the Community Advisory Committee. Posters were then drawn up. Target area

Gunpo was selected for the intervention for several reasons. First, the screening rate for breast cancer was about average for Korean PHCs. Second, physical accessibility to clinics or hospitals was not a significant barrier for cancer screening. Third, its geographic and demographic characteristics allowed for generalizability for urban Korea, which is where approximately half of all Koreans live. Fourth, Gunpo is neither too large nor too small to implement a community-based intervention trial with a limited budget. With a land area of 36.38 km2, Gunpo is located in the metropolitan area near Seoul. As of December 2007, it had a total population of 275,351 (men 137,718; women 137,633). Gwang Myeong was selected as a comparison region. We selected it because it has similar geographic and sociodemographic characteristics and because it is far enough away from the intervention city to ensure the presence of a buffer zone should the intervention “contaminate” beyond the intervention city’s boundaries. Gwang Myeong is also located in the metropolitan area around Seoul with a total population of 311,700 (men 155,407; women 156,293) and a land area of 38.50 km2.

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We obtained informed consent from all the participants who were contacted by the study team. Evaluation

We conducted pre-intervention baseline surveys in June 2008. This cross-sectional face-to-face survey using structured questionnaires was conducted with a random sample of 240 women aged 30-69 years from the intervention city and another 240 from the comparison city. Phase 2 began at the conclusion of the intervention delivery, approximately 7 months after the baseline survey was concluded, and involved a followup survey of women. The post-intervention survey was conducted with an independent sample of 240 women from each city. For campaign and non-campaign exposure, we included items for measuring possible non-GCSP campaign activities in the questionnaire. This was done in order to control the confounding effect of those extrinsic activities, which could act as “noise,” and make it more difficult to assess the effectiveness of the main GCSP campaign. For dose-exposure questions, participants were asked 3 questions with a 7-point Likert-type scale for each communication activity. The questions asked: (a) if they had been exposed to the campaign activity for breast cancer screening, ranging from “never seen” to “seen very frequently;” (b) if they had been able to see the activity in detail, ranging from “never could see it in detail” to “could see very detailed information;” and (c) if it was easy to remember the activity, ranging from “could not remember the activity at all” to “could remember the activity very clearly.” Overall media exposure was measured as the average of each respondent’s scores across this 3-item, 7-point Likert-type scale. There was no prompting for these questions. The instrument for measuring campaign exposure modified the framework used by a top advertising agency in Korea. Mammography myths and intention toward

Interventions

To develop effective interventions, we used results from the formative research, additional focus interviews, and input from the Community Advisory Committee. Interventions implemented in Gunpo over 6 months included: (a) posters on apartment billboards; (b) posters in clinic waiting rooms; (c) posters on pharmacy walls; (d) leaflets distributed at street events; (e) direct mailing to promote breast cancer screening; (f) street promotion; (g) outbound calls to women who signed application forms at the street promotions, monthly neighborhood meetings, or small group educational sessions; (h) small group educational sessions; and (i) a blog on breast cancer screening.

Respondents responded to the following 7 statements or questions: (a) most lumps suspicious of breast cancer are painful; (b) women whose breast size is bigger are more likely to get breast cancer; (c) the best time to get a mammogram is when there are breast symptoms; (d) we do not need to get a mammogram when no abnormal signs or symptoms are found in breast self examination; (e) mammograms are expensive; (f) women older than 60 do not need a mammogram; (g) do you intend to get a mammogram within 2 years? These questions were based upon formative research conducted in the first phase. The myth assessment items were included in the questionnaire because they had received lower scores in the formative quantitative survey on breast


Park et al. BMC Public Health 2011, 11:468 http://www.biomedcentral.com/1471-2458/11/468

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cancer awareness, health status, lifestyle, health consciousness, health behavior, knowledge on breast cancer, perceived barriers toward cancer screening, and self efficacy. Stage of mammography adoption by TTM was assessed using women’s responses to the questionnaire on their intention of obtaining a mammogram in the coming 2 years, asking whether they had been screened in the previous 2 years, and looking at their reported history of mammography use in the previous 2 years[7]. Analysis

The basic characteristics on demography and past history of mammography (see Table 1) were calculated separately at baseline and follow-up for both cities. Differences between cities were assessed using c2 tests. We used t-tests to compare campaign recall scores between baseline and follow-up for each city. To assess whether the intervention was related to a beneficial change in myths with respect to breast cancer and screening mammography, c2 tests were used. The intervention’s myth busting effect was assessed using unadjusted logistic regression models. Model factors included TIME (baseline/follow-up), CITY (intervention/comparison), and a TIME by CITY interaction term. This interaction term tested the differential effect of the intervention. To determine which intervention activity was related to correct answers (correct understanding) for 6 questions related to screening mammography, a series of logistic models was fitted. We developed models using forward stepwise logistic regression for the following: subjects’ characteristics; CITY, TIME, CITY by TIME interaction; all of the intervention activities listed in Table 2; other possible non-campaign activities; and all of the 2- and 3-way interactions of these variables with CITY, TIME, and CITY by TIME. Odds ratios and 95% confidence

intervals were produced in the final models. The activities were judged to be related to the outcomes if there were significant 3-way interactions between the activities, CITY and TIME.

Results Sociodemographic variables and past history of mammography of the sample in the pre- and post-intervention surveys are shown in Table 1 by both city and time period. There was no significant age difference between study samples in the intervention and control cities. However, there were more married women in the intervention city at the follow-up, and women in the comparison city had lower levels of educated at both baseline and follow-up. While there were more employed women in the intervention city at baseline, more employed women were in the sample of the comparison city at the follow-up. More women in the intervention city had a mammogram history. At follow-up, recall scores were significantly increased in the intervention city for all campaign activities except for seeing posters in clinic waiting rooms (Table 2). The baseline exposure scores for the intervention city were lower than scores for the comparison city on every activity. Scores for 5 of the 8 activities were significantly increased in the intervention city at follow-up. In addition, the differences in average recall scores between baseline and follow-up were greater in intervention city for all campaign activities. In terms of changes to beliefs in breast cancer myths, there were significant decreases in the proportion of women who believed that bigger breast size raised the likelihood of breast cancer, and in the proportion of women who thought that mammograms were expensive in the intervention city (Table 3). Significant change was also observed in the proportion of those who intended

Table 1 Demographic characteristics by city and time Variable

Intervention

Comparison

Baseline (n = 240) n (%)

Follow-Up (n = 240) n (%)

Baseline (n = 240) n (%)

Follow-Up (n = 240) n (%)

30-39

93 (38.8)

93 (38.8)

90 (37.5)

90 (37.5)

40-49 50-59

83 (34.6) 38 (15.8)

83 (34.6) 38 (15.8)

78 (32.5) 43 (17.9)

78 (32.5) 43 (17.9)

Age (yr)

60-69

26 (10.8)

26 (10.8)

29 (12.1)

29 (12.1)

Currently marrieda

225 (93.8)

239 (99.6)

219 (91.2)

227 (94.6)

Education ≤ 12 yrb

139 (57.9)

135 (56.2)

172 (71.7)

173 (72.1)

Annual household income < $20000

27 (11.2)

7 (2.9)

15 (6.2)

16 (6.7)

Employedc

92 (38.3)

30 (12.5)

66 (27.5)

120 (50.0)

History of mammography (yes)d

147 (61.2)

176 (73.3)

122 (50.8)

128 (53.3)

a

P < 0.05 at follow-up between cities. P < 0.05 at baseline and follow-up between cities.

b c d


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Table 2 Recall scores for community activities by city and time Exposure

Intervention Baseline (n = 240) Mean (SD)

Comparison

Follow-Up (n = 240) Mean (SD)

p value

Baseline (n = 240) Mean (SD)

Follow-Up (n = 240) Mean (SD)

p value

Posters on apartment billboards

2.81 (1.72)

3.54 (1.34)

< 0.001

3.07 (1.40)

3.40 (1.75)

0.023

Posters in clinic waiting rooms Leaflets

3.74 (1.87) 2.55 (1.88)

3.97 (1.32) 3.71 (1.32)

0.128 < 0.001

4.13 (1.77) 2.56 (1.32)

3.85 (1.76) 3.28 (1.87)

0.084 < 0.001

Direct mail

2.50 (1.77)

3.53 (1.39)

< 0.001

2.77 (1.43)

3.06 (1.86)

0.054

Street promotion

1.71 (1.08)

2.68 (1.11)

< 0.001

2.33 (1.14)

2.92 (2.17)

< 0.001

Website (National Cancer Information Center)

1.34 (0.86)

2.48 (1.35)

< 0.001

1.61 (1.01)

1.71 (1.45)

0.382

Outbound call

1.38 (0.76)

2.65 (1.39)

< 0.001

1.70 (1.00)

2.11 (1.65)

0.001

Small group education by GCSP

1.81 (1.22)

3.07 (1.29)

< 0.001

2.30 (1.40)

2.70 (1.95)

0.010

SD, standard deviation; GCSP, Gunpo Cancer Screening Project.

to have screening mammography. However, significant changes in the opposite direction were observed for 4 myths in the comparison city ("most lumps suspicious of breast cancer are painful;” “women whose breast size is bigger are more likely to get breast cancer;” “the best time to get a mammogram is when there are breast symptoms;” “we do not need to get a mammogram when no abnormal signs or symptoms are found in breast self examination”). When we assessed whether there were differential effects of the intervention on the beneficial changes in myths using unadjusted logistic regression models including TIME, CITY, and a TIME by CITY interaction term, significant results were observed for 3 myths ("most lumps suspicious of breast cancer are painful;” “women whose breast size is bigger are more likely to get breast cancer;” “the best time to get a mammogram is when there are breast symptoms”). While no beneficial change was observed in the

comparison for these 3 myths, the intervention city showed a significantly decreased level of belief of those myths. For example, people in the intervention city were 3.87 times more likely to have decreased level of belief of those myths “most lumps suspicious of breast cancer are painful”. Results for our comparison of changes in the TTM stage of mammography adoption between intervention and comparison cities are shown in Table 4. The proportions for contemplation and action when added together increased from 77.1% to 91.3% in the intervention city, while there was a small increase from 82.9% to 90.0% in the comparison city. In particular, there was profound change in the proportion for the TTM action stage in the intervention city. We explored whether the GCSP campaign activities were related to correct understanding of the 6 myths, and to intention regarding screening mammography

Table 3 Percentage of survey respondents reporting outcomes pre- and post-campaign in intervention and comparison cities Outcomes

Intervention

Comparison

Baseline (n = 240) n (%)

Follow-Up (n = 240) n (%)

P

Baseline (n = 240) n (%)

Follow-Up (n = 240) n (%)

P

OR (CI)*

Myth 1-Most lumps suspicious of breast cancer are painful (No)

164 (68.3)

172 (71.7)

0.486

189 (78.8)

127 (52.9)

< 0.001

3.87 (2.21-6.76)

Myth 2-Women whose breast size is bigger are more likely to get breast cancer (No)

108 (45.0)

157 (65.4)

< 0.001

154 (64.2)

116 (48.3)

0.001

4.43 (2.63-7.44)

Myth 3-The best time to get a mammogram is when there are breast symptoms (No)

184 (76.7)

194 (80.8)

0.315

212 (88.3)

165 (68.8)

< 0.001

4.42 (2.31-8.46)

Myth 4-We do not need to get mammogram when no abnormal signs or symptoms are found in breast self examination (No)

214 (89.2)

192 (80.0)

0.008

192 (80.0)

170 (70.8)

0.026

0.80 (0.41-1.56)

67 (27.9)

113 (47.1)

< 0.001

53 (22.1)

90 (37.5)

< 0.001

1.09 (0.63-1.89)

Myth 6-Women older than 60 do not need a mammogram (No)

194 (80.8)

192 (80.0)

0.908

208 (86.7)

199 (82.9)

0.309

1.27 (0.65-2.49)

Do you intend to get a mammogram within 2 years?

185 (77.1)

219 (91.2)

< 0.001

199 (82.9)

216 (90.0)

0.032

1.67 (0.78-3.59)

Myth 5-Mammograms are expensive (No)

*City-by-time interaction effects; OR, odds ratio; CI, confidence interval


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Table 4 Stages of change of mammography adoption in intervention and comparison cities TTM stages

Intervention

Comparison

Baseline (n = 240) n (%)

Follow-Up (n = 240) n (%)

P

Baseline (n = 240) n (%)

Follow-Up (n = 240) n (%)

P

Precontemplation

34 (14.2)

16 (6.7)

< 0.001

35 (14.6)

14 (5.8)

0.006

Relapse Relapse risk

17 (7.0) 4 (1.7)

3 (1.2) 2 (0.8)

2 (0.8) 4 (1.7)

4 (1.7) 6 (2.5)

Contemplation

96 (40.0)

74 (30.8)

92 (38.3)

120 (50.0)

Action

89 (37.1)

145 (60.5)

107 (44.6)

96 (40.0)

TTM, Transtheoretical model

(Table 5 and 6). Possible secular trends and the influence of non-campaign activities were statistically controlled by fitting the multivariate logistic models with the following: characteristics of the subjects; CITY, TIME, CITY by TIME interaction; all of the intervention activities listed in Table 2; other possible non-campaign activities; and all of the 2- and 3-way interactions of these variables with CITY, TIME, and CITY by TIME. When a certain campaign activity in the intervention city has a statistically significant interaction with CITY

by TIME, we understand that the activity is associated with the campaign of the intervention city. Posters on apartment billboards were associated with understanding that the myth “most lumps suspicious of breast cancer are painful” is not true. Clinics or pharmacy waiting room posters were associated with recognizing the untruth of “women whose breast size is bigger are more likely to get breast cancer.” Street promotions and recommendation by physicians or pharmacists were associated with discrediting the myth that “the best time

Table 5 Logistic regression models for factors related to change in myths about screening mammography (n = 480)* Odds ratios and 95% confidence intervals Myth 1

Myth 2

Myth 3

Myth 4

Myth 5 Myth 6

Age (yr) × Time × City 30-39

1.0

1.0

40-49

1.67 (0.70-4.00)

1.08 (0.33-3.57)

50-59

0.34 (0.14-0.84)

0.19 (0.05-0.74)

60-69 Marital status × Time × City (currently married vs. not currently married) Income × Time × City (≥ 20000$ vs. < 20000$)

0.50 (0.18-1.45)

0.13 (0.03-0.53)

5.17 (1.20-22.25) 33.39 (4.67-238.45)

Employment × Time × City History of mammography × Time × City

27.46 (1.97-382.29) 2.48 (1.32-4.63)

TV ads on breast cancer screening × Time × City

0.65 (0.52-0.82)

Radio ads on breast cancer screening × Time × City

0.71 (0.50-1.00)

Newspaper article or ad × Time × City

0.63 (0.46-0.88)

Posters on apartment billboards × Time × City

2.12 (1.47-3.05)

Posters in clinic or pharmacy waiting rooms × Time × City

0.35 (0.18-0.68)

1.40 (1.17-1.68)

Street promotion × Time × City

2.30 (1.53-3.47)

Ad on other websites × Time × City

0.48 (0.31-0.72)

Physician or pharmacist recommendations × Time × City

1.74 (1.29-2.34)

Personal stories of cancer patients × Time × City Small group education by private hospitals × Time × City

1.59 (1.15-2.20)

1.59 (1.03-2.47)

1.78 (1.01-3.16) 0.64 (0.46-0.89)

0.34 (0.20-0.57)

* Only variables that had a time by city interaction term are shown in the table because of the high number of variables involved in the final model.


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Table 6 Logistic regression models for factors related to change in intention toward screening mammography (n = 480) 95% CI for odds ratio Odds ratio

Lower

Marital status (currently married vs. not)

2.03

1.02

Upper 4.02

Household income (≥ 20000$ vs. < 20000$) History of mammography

2.58 4.61

1.39 2.86

4.80 7.42

Radio ads on breast cancer screening

0.84

0.72

0.98

Posters in clinics or pharmacy waiting rooms

1.33

1.17

1.51

Age (yr) × City 30-39

1.0

40-49

0.92

0.47

1.80

50-59

0.41

0.18

0.95

60-69 Outdoor advertising on breast cancer screening in other cities × Time

0.21 1.37

0.09 1.14

0.48 1.64

History of mammography × Time × City

4.92

1.39

17.42

Direct mail × Time × City

1.49

1.00

2.03

Personal stories of cancer patients × Time × City

0.59

0.42

0.84

CI, Confidence interval

to get a mammogram is when there are breast symptoms.” Street promotions were associated with an end to the idea that “we do not need to get a mammogram when no abnormal signs or symptoms are found in breast self examination.” However, no activity was found to be associated with an end to the belief that “mammograms are expensive.” Street promotions and personal stories of cancer patients were associated with dispelling the myth that “women who are older than 60 do not need a mammogram.” In the multivariate logistic regression, marital status, household income, history of mammography, and posters in the waiting rooms of clinics or pharmacies were significantly associated with intention toward screening mammography regardless of the campaign (Table 6). Finally, direct mail was independently associated with intention regarding screening mammography. Conversely, personal stories of cancer patients were inversely associated with intention with regards to screening mammography.

Discussion The goal of this study was to explore the effect of a multifaceted community intervention trial on correcting myths related to breast cancer and screening mammography. The study also aimed to increase women’s intention toward screening mammography, and improve the TTM stage of adoption for screening mammography for women aged 30 years and older. The effects of the intervention tested in this study included a 20.4-percentage-point decrease in myths about the link between breast size and breast cancer, a 19.2-percentage-point decrease in myths about costs for mammography, and a

14.1-percentage-point increase in intention regarding screening mammography. There was also a 23.4-percentage-point increase in the proportion of women at the action stage of TTM. To our knowledge, this is the first multi-city community intervention study to apply multicomponent interventions including direct mail conducted in an Asian country. The campaign achieved many of its aims despite a relatively short duration and low budget (14,250 US dollars). Most components relied on volunteers, low-cost media, and participation in community events. In this community intervention study, the combination of community outreach (posters on apartment billboards, street promotions, direct mailing, and educational sessions) and clinic and pharmacy-based in-reach (posters in clinic waiting rooms or pharmacies and physician or pharmacist recommendations) strategies was related to improve in campaign outcomes. The level of penetration of the intervention was weak to modest. Measurement was complicated by a background effect represented by baseline scores; this was because many agencies and health professionals may promote cancer screening. Also, the possible presence of concurrent communication activities by other projects in a control city may limit the effect of a campaign [9]. Besides, the presence of a concurrent national message could make it difficult for a local campaign to have an additional effect in the intervention city [9]. We could not demonstrate an impact of the intervention on those 4 myths for which there was already a high level of correct understanding. The “ceiling effect” might be playing a role here. On the other hand, there was evidence that GCSP did have effects on myths about breast size and


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cost for mammography, and on intention with regards to screening mammography. Even though there were no significant change in intervention city for myths on breast cancer symptoms and the best time for mammography, we found differential effects of the intervention on the beneficial changes in belief in myths. It is strange that there were also increases or decreases in myths in the comparison city. However, it is possible that there is a secular trend toward change in the control city. When such a trend exists, the effect of a campaign may be attenuated [9]. Specifically, a positive trend could be the result of a concurrent national message or some form of non-campaign communication in the control community. Even though the use of mass media, such as posters or leaflets, can convey simple information and increase knowledge, it can only change behavior if there are facilitating factors [10]. Therefore, we tried to boost interpersonal communication with street promotions, direct mail-outs, and promotion of doctor or pharmacist recommendations. We expected that women who received mail-out material would talk to each other because they had never previously seen such mail on cancer screening. Compared with mass media and more intensive approaches, direct mail interventions may represent a more promising population-based strategy for promoting cancer screening including mammography [11,12]. Direct mail is a relatively efficient and inexpensive way [13] to reach individuals in their homes, including people not typically exposed to mass media [14,15]. In our study, direct mail had impact on intention toward screening mammography. As part of this study, we also conducted fifteen group education sessions; these were held in nearly all apartment complexes in the intervention city over 6 months. The education session consists of following parts; OX quizzes to break the myths related to breast cancer and screening mammography, personified story to raise breast cancer awareness, statistics on breast cancer, symptoms of breast cancer, animation that shows how a mammogram is performed, and discussion on fear related to cancer screening. The education evaluation conducted in the pilot test of sampled residents showed that these education sessions improved the participantsâ&#x20AC;&#x2122; knowledge level about both breast cancer and breast cancer screening. However, the limited number of education sessions might be insufficient to generate the critical mass necessary to impact the whole community. Group education by private hospitals (non-campaign) was negatively related to some outcome variables. This finding might be due to negative attitude toward private hospitals that provide the education sessions with intention to promote their hospitals to recruit more patients.

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Interestingly, personal stories of cancer patients were inversely associated with intention regarding screening mammography. The literature on cancer-related fear, worry, or anxiety, emotion regulation, and screening behavior is increasing. However, a recent review on this subject reported that the findings of the studies were contradictory [16]. Differences in age, ethnicity, and stages of the cancer screening process might explain these discrepancies. Several limitations need to be kept in mind when interpreting our data. This study used only 2 cities and, thus, could not guarantee the internal validity expected of randomized multi-city community intervention trials. Therefore, the results cannot be used to estimate true intervention effects or actual screening rates over time. Even though there are curvilinear functions between campaign effectiveness and campaign length, the duration of our campaign could have been too short to sufficiently impact the community. The inclusion of more cities and longer study duration were not possible because our resources were limited. Another limitation of this study is that baseline exposure scores were lower on every activity in the intervention city. A possible explanation is the inclusion of the comparison city in the World Health Organization Korean Healthy City Network in April 2008. A third limitation is that despite some sociodemographic similarities, such as age and education, at both baseline and follow-up in the intervention and comparison cities, the proportion of employed women and women with a history of mammography was different at baseline and follow-up. This suggests some differences in the baseline and follow-up survey populations in the 2 cities. However, those sociodemographic variables were statistically controlled by multivariate logistic regression including CITY, TIME, and CITY by TIME interaction to see whether the campaign activities in the intervention city had an independent influence on the city when we analyzed the effect of each campaign activity. Therefore, any statistically significant campaign activities can be regarded as independent of other variables, including sociodemographic variables. Because differences in goals, priorities, and values have been frequently found between researchers and communities [17-19], and because such differences could be a major challenge in conducting community campaigns, we tried to harmonize the views of the research team with the community situation and opinions of the community members and public health workers from the studyâ&#x20AC;&#x2122;s outset. Although the main non-individual-level theoretical framework employed in most projects has been based on community organization and development models which assume that community participation and coalitions can create a sense


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of ownership and a synergy of action and outcome that could not otherwise be achieved [20-24], we did not use the community organization model. This was because we thought that the potential of community coalition could be different in terms of the nature of the community issue and its risk. We estimated that the willingness or need for a coalition of community members was not sufficient to use this strategy in our campaign. Another important reason for our decision not to use this strategy was that breast cancer was neither particularly prevalent nor an acutely progressing disease in the intervention city, and few indirect effects were being imposed on the community. Future community intervention trials to improve breast cancer screening should assess the stages of community involvement and coalition before choosing theories to design interventions.

Conclusions The data presented here indicate a significant decrease in myths about breast size and the cost of mammography. There was also an increase in intention concerning screening mammography and in the proportion of women at the TTM action stage. These findings suggest that the combination of community outreach and clinic and pharmacy-based in-reach strategies could effectively correct myths related to breast cancer and screening mammography. They could also improve intention toward screening mammography and the stage of adoption for screening mammography for women living in urban Asian communities. Even though evaluation of community-based health interventions involving a comparison city as a control region can be laborious and difficult, such approaches are necessary to garner future support from policymakers and other key stakeholders. Acknowledgements This study was financially supported by National Cancer Center Grant 1010131-1. Author details 1 Cancer Information and Education Branch, National Cancer Center, Goyang, Republic of Korea. 2School of Nursing Science, Kyungnam University, Masan, Republic of Korea. 3School of Journalism, Media and Advertising, Sangji University, Wonju, Republic of Korea. Authorsâ&#x20AC;&#x2122; contributions KP participated in the conception and design of the study and drafted the manuscript. WHH and SYK participated in the conception and design of the study. EJ participated in the conception and design of the study. MK and HGP participated in design and analysis of the study. All authors gave final approval for the manuscript submitted for publication.

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Competing interests The authors declare that they have no competing interests. Received: 19 July 2010 Accepted: 14 June 2011 Published: 14 June 2011 References 1. Haider M, Kreps GL: Forty years of diffusion of innovation: Utility and value in public health. Journal of health communication 2004, 9:3-11. 2. Yanovitzky I, Blitz CL: Effect of media coverage and physician advice on utilization of breast cancer screening by women 40 years and older. Journal of health communication 2000, 5:117-134. 3. Seale C: Health and media: an overview. Sociol Health Illn 2003, 25(6):513-531. 4. Green LW, Kreuter MW: Health promotion planning: an educational and environmental approach. 2 edition. Mountain View, CA: Mayfield Pub. Co.; 1991. 5. Becker MH: The Health belief model and personal health behavior San Francisco: Society for Public Health Education; 1974. 6. Rosenstock IM, Strecher VJ, Becker MH: Social learning theory and the Health Belief Model. Health education quarterly 1988, 15(2):175-183. 7. Rakowski W, Dube CA, Goldstein MG: Considerations for extending the transtheoretical model of behavior change to screening mammography. Health Educ Res 1996, 11(1):77-96. 8. Lefebvre RC, Flora JA: Social marketing and public health intervention. Health education quarterly 1988, 15(3):299-315. 9. Hornik RC: In Public health communication: evidence for behavior change. Edited by: Mahwah NJ. L. Erlbaum Associates; 2002:. 10. Corcoran N: Communicating health: strategies for health promotion Los Angeles: SAGE Publications; 2007. 11. Slater JS, Henly GA, Ha CN, Malone ME, Nyman JA, Diaz S, McGovern PG: Effect of direct mail as a population-based strategy to increase mammography use among low-income underinsured women ages 40 to 64 years. Cancer Epidemiol Biomarkers Prev 2005, 14(10):2346-2352. 12. Church TR, Yeazel MW, Jones RM, Kochevar LK, Watt GD, Mongin SJ, Cordes JE, Engelhard D: A randomized trial of direct mailing of fecal occult blood tests to increase colorectal cancer screening. Journal of the National Cancer Institute 2004, 96(10):770-780. 13. Hurley SF, Jolley DJ, Livingston PM, Reading D, Cockburn J, Flint-Richter D: Effectiveness, costs, and cost-effectiveness of recruitment strategies for a mammographic screening program to detect breast cancer. Journal of the National Cancer Institute 1992, 84(11):855-863. 14. Dignan MB, Michielutte R, Jones-Lighty DD, Bahnson J: Factors influencing the return rate in a direct mail campaign to inform minority women about prevention of cervical cancer. Public Health Rep 1994, 109(4):507-511. 15. Richardson JL, Mondrus GT, Danley K, Deapen D, Mack T: Impact of a mailed intervention on annual mammography and physician breast examinations among women at high risk of breast cancer. Cancer Epidemiol Biomarkers Prev 1996, 5(1):71-76. 16. Consedine NS, Magai C, Krivoshekova YS, Ryzewicz L, Neugut AI: Fear, anxiety, worry, and breast cancer screening behavior: a critical review. Cancer Epidemiol Biomarkers Prev 2004, 13(4):501-510. 17. Goodman RM, Wheeler FC, Lee PR: Evaluation of the Heart To Heart Project: lessons from a community-based chronic disease prevention project. Am J Health Promot 1995, 9(6):443-455. 18. Goodman RM, Steckler A, Hoover S, Schwartz R: A critique of contemporary community health promotion approaches: based on a qualitative review of six programs in Maine. Am J Health Promot 1993, 7(3):208-220. 19. Altman DG, Endres J, Linzer J, Lorig K, Howard-Pitney B, Rogers T: Obstacles to and future goals of ten comprehensive community health promotion projects. J Community Health 1991, 16(6):299-314. 20. Merzel C, Dâ&#x20AC;&#x2122;Afflitti J: Reconsidering community-based health promotion: promise, performance, and potential. American journal of public health 2003, 93(4):557-574.


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21. Roussos ST, Fawcett SB: A review of collaborative partnerships as a strategy for improving community health. Annu Rev Public Health 2000, 21:369-402. 22. Butterfoss FD, Goodman RM, Wandersman A: Community coalitions for prevention and health promotion. Health education research 1993, 8(3):315-330. 23. Lasker RD, Weiss ES, Miller R: Promoting collaborations that improve health. Educ Health (Abingdon) 2001, 14(2):163-172. 24. Wandersman A, Valois R, Ochs L, de la Cruz DS, Adkins E, Goodman RM: Toward a social ecology of community coalitions. Am J Health Promot 1996, 10(4):299-307. Pre-publication history The pre-publication history for this paper can be accessed here: http://www.biomedcentral.com/1471-2458/11/468/prepub doi:10.1186/1471-2458-11-468 Cite this article as: Park et al.: Community-based intervention to promote breast cancer awareness and screening: The Korean experience. BMC Public Health 2011 11:468.

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Drieling et al. BMC Public Health 2011, 11:98 http://www.biomedcentral.com/1471-2458/11/98

STUDY PROTOCOL

Open Access

Evaluating clinic and community-based lifestyle interventions for obesity reduction in a lowincome Latino neighborhood: Vivamos Activos Fair Oaks Program Rebecca L Drieling1, Jun Ma2, Randall S Stafford1* Abstract Background: Obesity exerts an enormous health impact through its effect on coronary heart disease and its risk factors. Primary care-based and community-based intensive lifestyle counseling may effectively promote weight loss. There has been limited implementation and evaluation of these strategies, particularly the added benefit of community-based intervention, in low-income Latino populations. Design: The Vivamos Activos Fair Oaks project is a randomized clinical trial designed to evaluate the clinical and cost-effectiveness of two obesity reduction lifestyle interventions: clinic-based intensive lifestyle counseling, either alone (n = 80) or combined with community health worker support (n = 80), in comparison to usual primary care (n = 40). Clinic-based counseling consists of 15 group and four individual lifestyle counseling sessions provided by health educators targeting behavior change in physical activity and dietary practices. Community health worker support includes seven home visits aimed at practical implementation of weight loss strategies within the personâ&#x20AC;&#x2122;s home and neighborhood. The interventions use a framework based on Social Cognitive Theory, the Transtheoretical Model of behavior change, and techniques from previously tested lifestyle interventions. Application of the framework was culturally tailored based on past interventions in the same community and elsewhere, as well as a community needs and assets assessment. The interventions include a 12-month intensive phase followed by a 12-month maintenance phase. Participants are obese Spanish-speaking adults with at least one cardiovascular risk factor recruited from a community health center in a low-income neighborhood of San Mateo County, California. Follow-up assessments occur at 6, 12, and 24 months for the primary outcome of percent change in body mass index at 24 months. Secondary outcomes include specific cardiovascular risk factors, particularly blood pressure and fasting glucose levels. Discussion and Conclusions: If successful, this study will provide evidence for broad implementation of obesity interventions in minority populations and guidance about the selection of strategies involving clinic-based case management and community-based community health worker support. Clinical Trial Registration: ClinicalTrials.gov: NCT01242683

* Correspondence: rstafford@stanford.edu 1 Program on Prevention Outcomes and Practices, Stanford Prevention Research Center, Stanford School of Medicine, Stanford, CA, USA Full list of author information is available at the end of the article Š 2011 Drieling et al; licensee BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.


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Background Obesity-related health and economic burden

There is a pressing need for obesity management strategies to address the growing prevalence of excess weight in the U.S. With 68% of adults overweight (34%) or obese (34%), [1-3] obesity-attributable medical costs in the U.S. average $147 billion per year and account for almost 10% of the total annual medical expenditures [4]. Obesity is strongly associated with higher rates of coronary heart disease (CHD), stroke, and shorter life expectancy, and CHD risk factors (e.g., diabetes and hypertension) [5]. Three-quarters of obese Americans have at least one CHD risk factor reversible through weight loss [6]. Fortunately, even modest, 5-10% reductions in body weight, as opposed to achieving ideal weight, are associated with clinically significant improvements in CHD risk factors [7,8]. Persons of low socioeconomic status (SES) are disproportionately affected by the CHD risk from obesity, in part, because they are less likely to receive adequate clinical care [9,10]. Persons of low SES also face more environmental factors associated with obesity, such as lack of access to healthy foods, high prevalence of high-calorie low-nutrient foods, and limited safe places to exercise [11-15]. Benefits of lifestyle interventions

Intensive lifestyle interventions focused on nutrition and physical activity may effectively promote lifestyle changes that reduce weight and other CHD risk factors, [16,17] but have often not been implemented and evaluated in the low SES communities that most need them. Convincing studies, including the Stanford Heart to Heart Project and the Diabetes Prevention Program, have shown efficacy of intensive individualized lifestyle counseling for sustained weight loss and CHD risk factor reduction [18-23]. Research also shows that lifestyle counseling in groups may be as effective for achieving weight loss [24-26] and more economical compared to individual counseling [25,27]. However, clinic-based lifestyle interventions for weight loss may not sufficiently address environmental barriers in low SES communities [12-15]. Given the profound impact neighborhood characteristics have on weight [28-30], clinic-based lifestyle interventions for weight loss may be enhanced by support in the patientâ&#x20AC;&#x2122;s social environment. A growing body of research suggests that community health workers (CHWs) can connect clinic-based CHD risk management services and the social environment for persons of low SES [31-33]. CHWs are members of local communities who help community members utilize neighborhood resources and develop community resilience. CHWs with training in health care can provide support to extend practical applications of primary care and

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lifestyle interventions into homes and neighborhoods and fill gaps in clinic-based programs, especially around access to resources [32-34]. Despite growing evidence about the effectiveness of intensive lifestyle counseling [18-23] and benefit of CHWs for weight loss and CHD risk factor reduction [31,32,35], few studies compare the benefit of CHW support to clinic-based obesity-reduction interventions [35]. Reducing the enormous clinical consequences of obesity demands that our health care system resolutely integrate the mission of obesity management into clinicbased primary care and community-based programs, particularly in low SES communities. Targeting upstream health behaviors, such as nutrition and physical activity choices, has the potential to reduce adverse obesity-related disease and its economic impacts. Aims

Vivamos Activos Fair Oaks (VAFO) will evaluate the clinical and cost-effectiveness of two lifestyle interventions to reduce body weight among obese Latinos of low SES who are patients of a county health clinic and have additional CHD risk factors. The first intervention provides intensive group and individual lifestyle counseling and case management for weight reduction and is provided by health educators in a primary care clinic (CM arm). The second intervention combines the health educator intervention with CHW support for nutrition and physical activity in participantâ&#x20AC;&#x2122;s home and community (CM+CHW arm). Furthermore, the study aims to compare the two interventions with usual care (UC) and then transition the favored intervention to a sustainable community health program. The study builds on national model programs of successful weight loss, particularly DPP. Implementation also relies on our previous Stanford Heart to Heart clinical trial, the primary care services in the Fair Oaks Clinic of San Mateo, and the community programs developed by El Concilio of San Mateo County [23,36,37].

Methods Study design

The VAFO is a randomized clinical trial in which obese adults with CHD risk are randomized to one of three study arms: UC, CM, or CM+CHW. All study procedures and materials were approved by the Stanford Institutional Review Board (IRB) and an independent IRB serving San Mateo Medical Centers (SMMC). Study setting

The VAFO project is set in the North Fair Oaks neighborhood of San Mateo County and conducted out of the Fair Oaks Clinic, an adult health clinic within the SMMC system. The North Fair Oaks neighborhood is


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an unincorporated 1.2 square mile trapezoidal area surrounded by more affluent cities. Fair Oaks has a population of 15,400 people, of which 69% is Latino and 50% were born outside the U.S [38]. SMMC provides medical service to most low-income residents of the County, but has 35% fewer physicians per 100,000 capita than the national average [39]. The shortage of physicians disproportionately affects local Hispanics, 34% of which earn below 200% of the federal poverty line and rely on county health services [40]. In 2008, 57% of adult San Mateo County residents were overweight (19% obese) and 85% had at least one CHD risk factor [40]. The Fair Oaks neighborhood was chosen because of the high prevalence of low-income Hispanics and a prior partnership between our research group and key stakeholders, including the Fair Oaks Clinic and El Concilio of San Mateo County. Fair Oaks Clinic provides primary care, mental health counseling, and social services. El Concilio of San Mateo County, a communitybased organization, provides nutrition, physical activity, and chronic disease management programs and trains CHWs. In particular, El Concilio operates a diabetes and metabolic syndrome management program in conjunction with the Fair Oaks Clinic.

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Table 1 Participant inclusion and exclusion criteria Inclusion criteria 1.

Age 18 years or older;

2.

Body mass between 30 and 55 kg/m2;

3.

One or more CHD risk factors: a) Systolic blood pressure between 130 and 200 mmHg; b) Diastolic blood pressure between 80 and 105 mmHg; c) Total cholesterol > 180 mg/dL; d) LDL cholesterol > 120 mg/dL; e) HDL Cholesterol < 40 mg/dL; f) Triglycerides > 150 mg/dL; g) HbA1c between 6.0 and 11.5%; h) Fasting plasma glucose between 95 and 400 mg/dL; i) Diagnosis of Type 2 diabetes;

4.

Residing in catchment area of the Fair Oaks Clinic and receiving primary care at Fair Oaks Clinic.

Exclusion criteria 1.

Inability to speak Spanish;

2.

Unwilling to attempt weight loss;

3.

Significant medical co-morbidities, including uncontrolled metabolic disorders (e.g., thyroid, diabetes, renal, liver), unstable heart disease, advanced heart failure, and ongoing substance abuse;

4.

Taking more than 10 prescription medications;

5.

Psychiatric disorders requiring antipsychotics or multiple medications;

Eligibility criteria

6.

Body weight change > 25 lbs. in the preceding 3 months;

Obese Spanish-speaking patients age 18 and older with at least one conventional CHD risk factor (i.e. diabetes, elevated fasting glucose or hemoglobin A1c levels, high blood pressure, elevated lipid levels) are eligible to join the study. Exclusion criteria are designed to: 1) minimize safety concerns; 2) prevent loss to follow-up; and 3) avoid potential contamination between study arms (Table 1).

7.

Pregnant, planning to become pregnant, or lactating less than six months;

8.

Family household member already enrolled in the study;

9.

Current or planned participation in a study that would limit full participation in VAFO;

Recruitment and screening

The target sample size for VAFO is 200 participants randomized during a 15-month period. Participants are recruited for screening by study staff who solicits patients in the clinic or by referral from a primary care provider (PCP). After obtaining PCP approval for medical appropriateness, chart review and telephone screening are performed to assess basic eligibility criteria. Those not excluded receive formal eligibility determination at clinical baseline visits (BV1 and BV2) which both occur within three weeks of randomization. BV1 includes assessment of biomedical eligibility, administration of survey questionnaires, and receipt of a pedometer to track physical activity. BV2 occurs seven to ten days after BV1 and includes review of pedometer data and a fasting blood draw. Following standard human subjects protocol, all participants provide informed consent during the screening process.

10. Refusal of home visits by study staff; 11. Resident of a long term care facility; 12. Plans to move during the study period (24 months postrandomization); 13. Investigator discretion for clinical safety or adherence reasons (e.g., unstable housing, chronic pain that impedes physical activity).

Randomization and blinding

Participants are randomized to one of three arms according to the ratio 1 UC: 2 CM: 2 CM+CHW. After all BV2 data are collected, a blinded data analyst confirms study data completion and randomizes the participant to one of the three arms in permuted blocks stratified by sex, BMI (30-34.9, 35-39.9, or Âą 40), and diabetes status. Follow-up data collection (6, 12, 18, and 24 months) is performed by data collectors blinded to intervention status. Baseline and follow-up measures and data collection

Participant time commitment for all research-related measurements is approximately 2.5 hours at baseline (for telephone screening, BV1, and BV2 combined),


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2 hours each for follow-up clinic visits (6, 12, and 24 month), and 45 minutes for the 18-month telephone assessment (Table 2). Primary and secondary outcomes

Primary hypotheses will be tested based on change in BMI change from baseline to 24 months. Data collected at the interim time points will help assess effects of intensive phase of intervention (baseline to 12 months) and intervention durability throughout the maintenance phase (12 month to 24 months). The primary outcome is change in BMI calculated as kg/m 2 . Weight is collected at BV1 and each follow-up clinic visit using the average of two readings from a digital scale. Height is collected at BV1 using the average of two readings from a wall-mounted stadiometer. Weight and height are both collected from participants in light indoor clothes without shoes. Secondary outcomes measure obesity-related biomedical cardiovascular risk factors. Plasma lipids, glucose,

hemoglobin A1c, and C-reactive protein are collected after an overnight fast. Waist circumference is collected with a tape measure around the waist at the midpoint between the lowest part of the ribcage and the top of the pelvic bone. Resting blood pressure is measured after the patient has sat quietly with feet flat on the floor for five minutes. Three blood pressures are obtained on alternating arms and the mean of the second and third readings is used in analysis. Additional secondary outcome measures include behavioral and psychosocial factors that might moderate the intervention effect. The Obesity Related Problems Scale is administered to understand impacts of obesity on social beliefs and attitudes [41]. The Center for Epidemiologic Studies-Depression Scale is administered to assess prevalence and change in depression [42]. The 6item Food Security Assessment is administered to assess use of food assistance and ability to purchase food [43]. The Pittsburgh Sleep Quality Index [44] and the Strength of Religious Faith Questionnaire are also

Table 2 List of study measures and data collection schedule Follow-up month Baseline

6

12

X

X

18*

24

Clinical Measures Height

X

Weight

X

Waist circumference

X

Blood pressure

X

Fasting blood: Total cholesterol, LDL-C, HDL-C, triglycerides, glucose, HBA1c C-Reactive Protein

X X

X

X

X

X

X

X

X

X X

X X

Questionnaires Physical Activity Readiness Survey

X

Demographic history

X

Employment, Income

X

X

X

X

Modified BRFSS exercise questions

X

X

X

X

Block Brief food Questionnaire

X

X

X

6-item food security assessment Depression Survey (CESD)

X X

X X

X X

X X

Obesity Related Problems Scale

X

X

X

X

Pittsburgh Sleep Quality Index X

Smoking

X

X X

X

X

X

X X

X

X

X

X

X

X

X

X

X

X

X

X

X

X

X

Adverse events Medication use

X X X

X

Researcher designed physical activity and nutrition questions

X X

X

Strength of Religious Faith Questionnaire

X

Pedometer 7 day pedometer log

X

Data extracted from electronic SMMC medical records system Healthcare utilization (hospitalizations, emergency room and outpatient visits)

X

X

X

X

Medications prescribed

X

X

X

X

*18-month visit is conducted by telephone.


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administered [45]. Additional questions designed by the study team assess neighborhood safety and social support networks. Physical activity levels are measured at each clinical assessment point by recording seven days of steps using a pedometer worn by participants and by intervieweradministered physical activity questions adapted from the Centers for Disease Control Behavioral Risk Factor Surveillance System [46]. Dietary intake is assessed by administering the Block Brief Food Questionnaire [47]. Additional physical activity and dietary patterns are assessed by administering questions designed by the study researchers about sedentary activities, fast food consumption, and use of neighborhood physical activity and nutrition resources. Socio-demographic information is collected including education level, place of birth, language spoken at home, employment status and income. Self-reported and medical record data on hospitalizations, emergency room and outpatient visits and prescriptions are assessed for impact on medical resource utilization. Process measures

Reasons for joining and not joining the study are used to evaluate recruitment techniques. Attendance of friends and relatives at intervention visits is assessed to evaluate inclusion of extended social networks. Selfmonitoring forms are collected to assess use of selfregulation tools. Additionally, key informant interviews will be conducted throughout the intervention period to evaluate how the VAFO coordinates with other clinic services and to refine the program for dissemination. Interventions Theoretical basis

The overriding theoretical framework for the intervention is derived from Social Cognitive Theory (SCT) [48] and the Transtheoretical Model (TTM) of Behavior Change. SCT emphasizes the reciprocal determinism between individual, environment, and behavior. TTM recognizes that behavior change is a dynamic process that moves through stages of readiness to change a problem or maintain positive or healthy behaviors. SCT assumes that behavior change is more likely with increased behavior capability, which is strengthened through skill building and self-regulation. Equally important are confidence in performing a given behavior individually (self-efficacy) and with a support group (collective efficacy) and expectations of favorable outcomes (outcome expectations). The use of resources (facilitation) and rewards (incentive motivation) also support behavior change. TTM behavioral strategies emphasize variation by stage of change including experiential processes during initial phases of behavioral adoption and

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behavioral processes during action and maintenance behavior change [49]. Consistent with the ongoing operation of Fair Oaks Clinic, VAFO emphasizes cultural congruence by providing the intervention entirely in Spanish via a bi-cultural staff that includes a CHW who is a member of the Fair Oaks community. At the first CM and ES sessions, VAFO interventionists work with participants to identify their beliefs about the value of achieving healthy weight. The interventions emphasize that healthy weight is achievable through gradual and sustained lifestyle change that prioritizes nutrition and physical activity. Throughout the intervention CM and CHW interventionists remind participants to use fundamental outcome expectations (e.g. improved health and energy to enjoy family) as motivation for daily behavioral choices. After establishing fundamental outcome expectations and a belief in self-efficacy for weight loss, the interventionists focus on knowledge and self-regulation to integrate new skills into daily behavior. At each intervention session participants learn about fundamental nutrition and physical activity skills such as balanced diet, portion control, diverse physical activities with a focus on walking, and shopping skills (Table 3). Application of SCT learning concepts includes educational materials and observing the interventionist perform activities. Additionally, group sessions employ experiential learning techniques including: preparing healthy foods, in-session physical activity, group problem solving and goal-setting, and role-playing with simulated or real-life scenarios for menu ordering, shopping, and portion sizes. CHW support sessions include the previously described techniques and include practicing new skills with the CHW in the home and community. Numerous materials are employed for observational and experiential learning at individual CM sessions. CM and CHW interventionist use fundamental SCT self-regulation concepts to help participants translate knowledge about skills into behavior change. All intervention sessions teach participants goal-setting techniques for creating and maintaining specific, measurable, and obtainable goals with equal attention to nutrition and physical activity. Key self-monitoring techniques used at all intervention sessions include calendars and goals sheets to record health habits. Additionally, prior to the second CHW session, participants take pictures of meals and physical activities which are used to set â&#x20AC;&#x153;photo goalsâ&#x20AC;? and help evaluate accomplishments over the course of the study. Key intervention feedback and reward techniques include: 1) self-reflection that acknowledges negative thoughts and counters them with positive statements; and 2) praise and positive reflection for achieving goals. Both interventions teach participants to prepare to


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Table 3 Required group and community health worker support session topics Group session topics Session #

Physical activity

Nutrition

Educational incentive

1

Overview of healthy nutrition

Overview of exercise

Pedometer

2

Eating healthy on a budget

Being active at home

Fruit and vegetable guide

3

Eating out and fast food

Local exercise resources

Water bottle

4

Portion control and measuring

Hidden times for exercise

Measuring cups

5

Label reading and breakfast

Injury prevention and treatment

Massage tool

6

Healthy drinks

Building strong muscles

Healthy drink ingredients

7 8

Mindful eating and lunch Healthy fast food and dinner

Take a deep breath and relax Exercise with friends and family

Muscle relaxation CD Whole grain pasta Food pamphlet

9

Eating at social events and holidays

Mini holidays for exercise

10

Healthier traditions and review

Review and social dancing

Recipe with ingredients

11

Relapse response

Review and relay games

Motivational letter

12-15

Review relapse response, problem solving, and goal setting

Social support cards and displayable health guides

Community health worker support session topics* Nutrition Beverage inventory, evaluation of milk and water consumption, and goal for healthy beverages Evaluation of fat in cooking and goal for cooking with less fat (steaming, baking, etc.) Evaluation of fruit and vegetable consumption and goal for consuming more fruits and vegetables Evaluation of high calorie foods and goals for reduction of high calorie food or snacking Decision-making for shopping and meal planning Physical activity Chart and practice walking route (at first environmental support session) Identify support network of friends and family members for exercise Identify exercise locations in and around home Select physical activity goal Identify new physical activities to try *Topics may be covered in any order, but must be during the intensive intervention phase.

overcome barriers (e.g. time commitments, family disagreements, economics, behavior relapses) by using problem solving and goal-setting skills. Group sessions use educational incentives such as take home tips sheets and health tools related to the session topic for motivation (Table 3). Later group sessions assume basic knowledge about topics from earlier sessions and increasingly focus on techniques to overcome barriers, maintain healthy behavior, respond to behavior relapse, and reach health goals. CHW sessions are loosely constructed to allow CHWs to address a range of behavioral goals, but must address several specific health topics (Table 3). All intervention sessions promote collective efficacy and self-regulation by helping participants utilize social support networks. Group sessions facilitate the development of social support networks among group members by encouraging interaction outside of group sessions. At group sessions participants also develop collective efficacy and social support through “virtual walking groups.” Individual steps are converted to collective miles traveled and used in a multi-media virtual travel adventure “Steps through the Americas” that presents

health topics within the context of destinations in North and South America. Additionally, group and CHW sessions also promote social support by including family members and friends in session activities. Intervention phases and session structure

Both CM and CM+CHW interventions involve intensive intervention (months 1-12) and maintenance (months 13-24) phases. In order to maintain focus on obesity reduction, VAFO interventionists follow a protocol to refer patients to other health care services (e.g., PCP, mental health, diabetes clinic) and community resources (e.g., health insurance programs, immigration assistance) for issues not directly related to weight loss. Intervention phases

The intensive phase for both interventions includes a more intensive first six months and a less intensive second six months. The first six months includes nine group sessions and one individual CM session. The second six months includes three group sessions and two individual CM sessions. CM+CHW participants receive three CHW sessions during the first six months and two CHW sessions during the second six months. The maintenance phase (months 13-24) includes three group


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Each group session lasts two hours and follows a similar structure with four main components: 1) interactive icebreaker; 2) experiential nutrition activity; 3) experiential physical activity; and 4) closing review and reminders. Individual CM sessions complement group session curriculum and CHW sessions by providing personal counseling for weight reduction goals. Individual sessions each last 30 minutes and include assessment of existing goals, problem solving for barriers and relapses, goal refinement, implementation for appropriate referrals, and evaluation of progress towards long-term goals. CHW sessions expand upon CM sessions with practical implementation of health goals within the home and community. VAFO CHWs are versed in group session curriculum, chronic disease management, and Fair Oaks neighborhood resources. Participant safety

12-month data visit

Intensive Phase Months 0-6 Months 7-12 9 group case 3 group case management management sessions sessions 2 personal 1 personal case case management management sessions session 3 home visit 2 home visit sessions sessions 6-month data visit

Baseline data visit

After receiving PCP approval for the intervention, participants are screened for exclusion criteria and a Physical Activity Readiness Questionnaire is conducted [50]. Adverse Events Screening is administered at each data collection point to monitor for unexpected health events and the onset of new diseases. Staff follows a referral protocol for high blood pressure and PCPs review lab results for out-of-range values as part of their routine practice. Additionally, the study protocol is monitored by two IRBs and a Data and Safety Monitoring Board composed of two physicians and a PhD clinical trial epidemiologist not affiliated with any of the organizations involved in the study.

VAFO uses four strategies to maximize participant adherence and retention: 1) careful eligibility screening; 2) staff-participant rapport building and motivational interviewing; 3) participant incentives at study visits; and 4) flexible scheduling. Quarterly newsletters are sent to encourage retention and capture address changes. Prior to dropping participants from the study, staff follows a protocol to offer modified status options, such as completing forms by phone or collecting weight measurement with a study scale at the participantâ&#x20AC;&#x2122;s home. Sample size

Based on research literature and population trends in weight-gain, we hypothesize weight loss of 6% in CM +CHW arm and 2.5% in CM arm and weight gain of 2% in the UC arm at 24 months post-randomization. The study sample size provides adequate statistical power to test the primary hypothesis that CM+CHW will show greater reductions in BMI over 24 months than CM alone and, in turn, either intervention will produce greater reductions in BMI than UC. A sample size of 200 participants (80 in CM, 80 in CM + CHW, and 40 in UC), is estimated to provide 82% power for detecting 3.5% difference in BMI between the active treatments at alpha = 0.05 (two-sided) while allowing for 15% missing rate for the primary outcome. The sample size also provides greater than 79% power to detect 4.5% or greater difference in BMI between UC and either active treatment at alpha = 0.025. Data analysis

The primary hypothesis is that patients managed through the CM+CHW intervention will show greater reductions in BMI over 24 months than those in CM.

Maintenance Phase Months 13-18 Months 19-24 2 group case 1 group case management management sessions session 1 personal 1 home visit case session management session 1 home visit session

24-month data visit

Session structure

Adherence and retention

18-month data visit

sessions and one individual CM session. CM+CHW participants also receive two CHW sessions (Figure 1).

Figure 1 Schedule of data collection and intervention visits. All participants receive data collection visits. Case management visits are provided to participants in the case management and case management plus community health worker arms. Home visits are provided by community health workers to participants in the case management plus community health worker arm.


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We will model a random-effects regression on an intention-to-treat basis to assess the effects of intervention on BMI over 24 months. A hierarchical random effects model appropriately accounts for clustering of patients by PCP and multiple measurements on individuals over time. Using a randomized effects model, we will estimate the effect of intervention assignment on BMI while controlling for important covariates such as gender, baseline BMI, and diabetes status. All primary and secondary outcome analyses will use Holm’s adjustments for multiple comparisons [51] which is more powerful than the Bonferroni method in adjusting for all pairwise comparisons [52] and for controlling the family-wise error rate. Random-effects regression models will also be used to test secondary hypotheses: 1) Patients in CM or CM +CHW intervention will experience reduced CHD risk through favorable changes in obesity-related risk factors relative to those in usual care; 2) Patients in the CM +CHW intervention will experience smaller increases in BMI from 12 months to 24 months than those in CM; and 3) Change in BMI and other cardiovascular risk factors attributable to the intervention arm will be costeffective relative to usual primary care. Estimation for the cost-effectiveness analysis will include: measurement of costs, measurement of changes in projected quality-adjusted life years, and calculation of a cost-effectiveness ratio for each active intervention compared to usual care. Health care costs associated with CHD over a 10-year period will be derived based on Framingham risk scoring [53,54] Interim analyses will be completed from 12-month data and when 24month data is obtained from half of the sample, with appropriate adjustment for sequential examination of the data. Potential mediators (e.g., treatment adherence, caloric intake, physical activity level) and moderators (e. g., age, gender, country of origin, baseline mental status) of the intervention’s effect on weight change also will be examined. Study participants will be analyzed as randomized (i.e., “intention to treat”) regardless of subsequent intervention adherence. Alternative methods for handling missing data such as multiple imputations will be used for missing outcome data. Data management

The main study database uses research electronic data capture (REDCap) software that simultaneously receives data from multiple computers [55]. Additional databases include: 1) Omron BiLink database for pedometer data; 3) MS Access database for qualitative recruitment data; and 3) NutritionQuest Online database for Block Brief Food Questionnaire data. The data security protocol provides encryption, server-client authentication, and off-site backups to protect patient confidentiality and

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data integrity. Real-time data validation and weekly data quality reports will reduce data errors. Treatment fidelity

To ensure intervention fidelity, VAFO measures compliance and adherence to delivery of program components, the amount of the intervention received by participants, and delivery quality. VAFO staff follows standardized study protocol detailed in procedure manuals for individual counseling sessions, group health education classes, and home health visits. Following this protocol, VAFO staff prepares educational materials, incentives, and learning activities to deliver at specified visits. VAFO staff completes visit forms to record delivery and receipt of program components by participants. Forms and oral feedback from interventionists are reviewed weekly for completion. Deviation from the protocol is discussed at least weekly with senior researchers and aions are taken to keep in congruence with the study protocol. Prior to conducting visits, VAFO staff practices mock sessions and complete a training protocol with senior researchers. Additionally, 2% of intervention sessions are recorded for evaluation by senior staff to ensure that sessions are conducted according to protocol.

Discussion and Conclusions Health consequences of the obesity epidemic make it a primary health care priority. To this end, the USPSTF recommends that clinicians screen adults for obesity and offer intensive lifestyle counseling [56] However, clinical providers have limited training in such counseling and even greater impediments addressing social and environmental factors that influence the development of obesity [28-30]. Similarly, community-based organizations and health promoters acting to reduce environmental barriers are limited in their ability to respond to obesity-related co-morbidities. Coordinated efforts between clinic and community-based obesity interventions may be more effective than either approach alone. The need for congruent efforts is particularly important in low-income communities that experience disproportionate health disparities and environmental barriers [10] VAFO is designed to test interventions that use intensive lifestyle counseling in clinical and community settings to confront obesity-related diseases and barriers in the built environment. Clinic-based health educators provide personal and group CM while community-based CHWs provide direct environmental support in participants’ homes and neighborhoods. Health educators and CHWs are both trained to use SCT, TTM, and experiential learning concepts to promote healthy behaviors. VAFO health educators and CHWs both provide basic chronic disease management and facilitate patient utilization of primary care services and community


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resources. This novel study involves collaboration among academic, community and clinic partners with diverse expertise addressing the obesity epidemic ranging from primary care services and behavioral counseling to community-based exercise and nutrition classes and distribution of fresh fruits and vegetables through low-income food pantries. Results from this study will provide valuable evidence about the efficacy and cost-effectiveness of two behavioral interventions to improve BMI, cardiovascular disease risk factors, and other psycho-social factors. VAFO will contribute knowledge about clinic-based lifestyle counseling and help discern the added benefit of a community-based behavioral intervention provided by CHWs. If proven efficacious, CHW support coordinated with clinic-based primary care CM may be a costeffective and culturally sensitive way to extend evidencebased interventions for obesity reduction into low SES communities. Acknowledgements and Funding This study was funded by National Institutes of Health Grant HL089448. The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Heart, Lung and Blood Institute or the National Institutes of Health. We are indebted to Gloria Flores-Garcia and Drs. Wes Alles, Jeanette Aviles, Christopher Gardner, William Haskell, Abby King, Donna Matheson, Marcia Stefanick, and Marilyn Winkleby for expert guidance on project development; to Dr. Lisa Goldman Rosas for services as project director; to Ernest Ceja, Rosa Gill, Priscilla Padilla, and Gabriela Spencer for services as intervention staff; to Oralia Espinoza, Alexis Fields, and Ulysses Rosas for research assistance and support; to Dr. Dave Ahn and Sreedevi Thiyagarajan for data management; to Diane Castle for assistance with management of project funds; to the Data and Safety Monitoring Board (Dr. Douglas Bauer [Chair], Sandra Bravo [Executive Secretary], Dr. Bud Gerstman, and Dr. Cecilia Gonzalez); to El Concilio of San Mateo County and the San Mateo Medical Center for collaboration and support; and to patients and their family for contribution to the research. Author details 1 Program on Prevention Outcomes and Practices, Stanford Prevention Research Center, Stanford School of Medicine, Stanford, CA, USA. 2Palo Alto Medical Foundation Research Institute, Palo Alto, CA, USA. Authorsâ&#x20AC;&#x2122; contributions RSS and JM conceived of the study and RLD directed its design and implementation. RLD drafted the manuscript and RLD, JM, and RSS all critically reviewed the manuscript for important intellectual content. All authors read and approved the final manuscript. Competing interests RLD and JM declare no financial competing interests. Dr. Stafford reports a consulting relationship with Mylan Pharmaceuticals. Over the past five years, Dr. Stafford reports past honoraria from Bayer, and past grant funding through Stanford University from Procter and Gamble, Bayer, Merck and Company, SmithKlineGlaxo, Toyo Shinyaku, and Wako Chemical USA. All authors declare no non-financial competing interests. Received: 25 January 2011 Accepted: 14 February 2011 Published: 14 February 2011 References 1. Baskin ML, Ard J, Franklin F, Allison DB: Prevalence of obesity in the United States. Obes Rev 2005, 6(1):5-7.

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45. Sherman AC, Simonton S, Adams DC, Latif U, Plante TG, Burns SK, Poling T: Measuring religious faith in cancer patients: reliability and construct validity of the Santa Clara Strength of Religious Faith questionnaire. Psychooncology 2001, 10(5):436-443. 46. CDC: Behavioral Risk Factor Surveillance System Survey Questionnaire. Atlanta, Georgia: U.S. Department of Health and Human Services, Centers for Disease Control and Prevention; 2006. 47. Block G, Hartman AM, Naughton D: A reduced dietary questionnaire: development and validation. Epidemiology 1990, 1(1):58-64. 48. A B: Social Foundations of Thought and Action: A Social Cognitive Theory. Englewood Cliffs, NJ: Prentice Hall; 1986. 49. Prochaska JO, Velicer WF: The transtheoretical model of health behavior change. Am J Health Promot 1997, 12(1):38-48. 50. Thomas S, Reading J, Shephard RJ: Revision of the Physical Activity Readiness Questionnaire (PAR-Q). Can J Sport Sci 1992, 17(4):338-345. 51. Holm S: A Simple Sequentially Rejective Multiple Test Procedure. Scandinavian Journal of Statistics 1979, 6:6. 52. Proschan M: A Multiple Comparison Procedure for Three- and Fourarmed Controlled Clinical Trials. Statistics in Medicine 1999, 18:12. 53. Califf RM, Armstrong PW, Carver JR, D’Agostino RB, Strauss WE: 27th Bethesda Conference: matching the intensity of risk factor management with the hazard for coronary disease events. Task Force 5. Stratification of patients into high, medium and low risk subgroups for purposes of risk factor management. J Am Coll Cardiol 1996, 27(5):1007-1019. 54. D’Agostino RB Sr, Grundy S, Sullivan LM, Wilson P: Validation of the Framingham coronary heart disease prediction scores: results of a multiple ethnic groups investigation. JAMA 2001, 286(2):180-187. 55. Harris PA, Taylor R, Thielke R, Payne J, Gonzalez N, Conde JG: Research electronic data capture (REDCap)–a metadata-driven methodology and workflow process for providing translational research informatics support. J Biomed Inform 2009, 42(2):377-381. 56. Screening for obesity in adults: recommendations and rationale. Ann Intern Med 2003, 139(11):930-932. Pre-publication history The pre-publication history for this paper can be accessed here: http://www.biomedcentral.com/1471-2458/11/98/prepub doi:10.1186/1471-2458-11-98 Cite this article as: Drieling et al.: Evaluating clinic and communitybased lifestyle interventions for obesity reduction in a low-income Latino neighborhood: Vivamos Activos Fair Oaks Program. BMC Public Health 2011 11:98.

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Salehi et al. Nutrition Journal 2011, 10:123 http://www.nutritionj.com/content/10/1/123

RESEARCH

Open Access

Fruit and vegetables intake among elderly Iranians: a theory-based interventional study using the five-a-day program Leili Salehi1,2, Kazem Mohammad3 and Ali Montazeri4* Abstract Background: The benefit of FV intake in old age is well documented. However, there is evidence that old people do not consume enough FV. The purpose of this study was to evaluate the effectiveness of a tailored nutrition intervention that aimed to increase the FV intake among elderly Iranians aged 60 and over. Methods: This quasi-experimental study was performed among a community-based sample of elderly in Tehran, Iran in year 2008 to 2009. Data were collected at baseline and 4 weeks follow-up. At baseline face-to-face interviews were conducted using a structured questionnaire including items on demographic information, stages of change, self-efficacy, decisional balance, daily servings of FV intake. Follow-up data were collected after implementing the intervention. Results: In all 400 elderly were entered into the study (200 individuals in intervention group and 200 in control group). The mean age of participants was 64.06 ± 4.48 years and overall two-third of participants were female. At baseline total FV intake was not differed between two groups but it was significantly increased in the intervention group at posttest assessment (mean serving/day in intervention group 3.08 ± 1.35 vs. 1.79 ± 1.08 in control group; P = 0.001). Further analysis also indicated that elderly in intervention group had higher FV intake, perceived benefits and self-efficacy, and lower perceived barriers. Compared with control group, greater proportions of elderly in intervention group moved from pre-contemplation to contemplation/preparation and action/ maintenance stages (P < 0.0001), and from contemplation/preparation to action/maintenance stages (P = 0.004) from pretest to posttest assessments. Conclusion: This study suggests that the Transtheoretical Model is a useful model that can be applied to dietary behavior change, more specifically FV consumption among elderly population in Iran and perhaps elsewhere with similar conditions.

Background Adequate FV intakes could decrease risk of various chronic diseases such as cancers, cardiovascular disease, diabetes, and stroke [1-6]. The World Health Organization (WHO) dietary guideline recommends the minimum 5-a-day consumption of FV [7]. Individuals have not, as yet, adopted the minimum recommendations to consume five servings of FV per day in spite of all the benefits of FV on improving health and reducing the economic burdens of chronic disease. Based on data obtained from FV * Correspondence: montazeri@acecr.ac.ir 4 Mental Health Research Group, Mother and Child Health Research Centre, Iranian Institute for Health Sciences Research, ACECR, Tehran, Iran Full list of author information is available at the end of the article

intakes in 21 countries (mainly developing countries) only in three countries FV intake met the minimum WHO recommended consumption [8]. The benefit of FV intake in old age is well documented [9-11]. However, there is evidence that old people do not consume enough FV. For instance a study from Canada showed that only about 47% of elderly consume recommend amount of FV [12]. Data from a study of 400 elderly in Iran showed that FV consumption among participations was low. Overall the mean serving of FV consumption eaten per day for the elderly was 1.76 (SD = 1.15) [13]. Another cross sectional study showed that the prevalence of daily FV intake of 5 or more serving was

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37% and the mean daily FV consumption separately was 1.86 ± 0.68 and 2.74 ± 0.83 respectively [14]. Such observations from Iran and elsewhere indicate that there is urgent need for health promotion programs in order to increase FV consumption among elderly population. But, the debate about effectiveness of these programs still remains [15]. It is argued that these programs, at least, should be theory driven if one expects any appropriate changes in dietary behaviors [16]. The Transtheoretical Model (TTM) of behavior change is one of the most popular models for studying behavioral change in health education/promotion programs. This model assumes that health behavior change involves progress through six stages: pre-contemplation (unaware of a problem and/or not intending to change), contemplation (considering a change and thinking about it), preparation (intending to take action in very near future), action (initiating a new behavior), maintenance (in which people strive to prevent relapse), and termination (in which individuals show complete self-efficacy) [17]. Several studies showed that dietary interventions based on stages of change model are effective in increasing FV intake [18-20]. Only a few studies however have been conducted using the TTM for elderly population [21,22]. The purpose of this study was to evaluate the effectiveness of a tailored nutrition intervention that aimed to increase the FV intake among elderly Iranians. According to the report by Iranian Ministry of Health the proportion of elderly (≥ 65) in Iran accounts for 5.4 percent and it is estimated that this rate will be rise to 10.5 percent by 2025 [23]. To our best knowledge this is the first paper from Iran that reports on the topic.

Methods Design and data collection

This quasi-experimental study was performed among a community-based sample of elderly people aged 60 and over in Tehran, Iran in year 2008 to 2009. Data were collected at baseline and 4 weeks follow-up. At baseline faceto-face interviews were conducted with the whole sample using a structured questionnaire including items on demographic information, stages of change, self-efficacy, decisional balance, daily servings of FV intake. Four weeks follow-up data were collected after implementing the intervention. Participants

Of 30 existing elderly centers in Tehran, 10 centers were randomly selected through multistage sampling to represent centers from all 5 main areas in Tehran (2 centers from each area: south, north, east, west and city center). Within the 10 selected centers the membership list for each center was asked and relative to density a systematic sampling method was applied. The selected participants

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contacted and asked if they were willing to participate in the study. Participants were also informed about the study and the number of required meetings during the study. Participants were then randomized to the intervention or the control groups. A health professional not connected to the study carried out the randomization. People in both groups received a four-cession program. Measures

Several instruments were used to collect data: 1. Demographic and anthropometrics Questionnaire

This comprised three sections covering demographic and anthropometrics data including information on age, sex, education, income, marital status, health status (having chronic disease or not) and body mass index (BMI). Chronic disease was indicated by asking each individual to respond to the following question: ‘Do you have any longstanding disease?’ Anyone who responded positively then was asked to name the disease. Weight was measured using the same digital scales [SECA, Calibrated in Iran] while the participants were minimally clothed and not wearing shoes. Height was measured by a tape measure while the respondents were standing and not wearing shoes and the shoulders were in a normal position. BMI was calculated and expressed in kg/m2, and economic status was measured using the asset-based approach developed by Ferguson and colleagues [24] and used in previous cross-national studies of economic status and health in developing countries [25]. According to this scale, 0-3 assets were considered low, 4-6 assets were considered intermediate and 8 or more assets were considered high economic status. The items considered as assets were: television, refrigerator, washing mashing, microwave oven, dish-washer, computer, electrical sweeper, automobile and phone. 2. Stages of change questionnaire regarding FV consumption behavior

This part of questionnaire adapted from the literature [26] and was consisted of five statements by which the participants were categorized into different stages of change: pre-contemplation, contemplation, preparation, action and maintenance. In fact the participants were asked to respond to one question choosing the statement that best described their status. Choices for the response were: (1) I am not currently consuming five servings of FV a day and I am not thinking of doing so in the upcoming six months, (2) I am not currently consuming five servings of FV a day but I plan to do so within the next six months. (3) I am not currently consuming five servings of FV a day but I plan to do so within the next month (4) I am currently consuming five servings of FV a day but I have been doing so for less than six months (5) I am currently consuming five servings of FV a day but I have been doing that for more than six months.


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3. Self-efficacy

Self-efficacy was assessed to measure confidence in one’s ability to persist with FV consumption in various situations. It was assessed using a five item questionnaire developed by Ma et al. [26] and participants were asked to respond to these items: ‘I can keep fruits and vegetables at hand/readily available’; ‘When I have the chance to choose, I can eat the recommended number of servings of fruits and vegetables’; ‘I can shop for a variety of fruits and vegetables’; ‘I can make time to eat fruits and vegetables’; ‘When I eat at home, I can eat more fruits and vegetables’. Each item is rated on a 5-point scale (from not at all confident = 0 to very confident about recommended FV consumption = 5). The total score ranged from 5 to 25 with higher scores indicating a greater degree of self-efficacy.

4. Perceived benefits and barriers regarding FV consumption

This part was generated from previous studies and focus group discussions with convenient sample of elderly individuals. Participants were asked about their perception regarding amount of FV intake. The perceived benefit consisted of 15 items and each item is rated on a 5-point scale ranging from ‘strongly agree’ to ‘strongly disagree’. The perceived barrier consisted of 11 items and each item is also rated on a 5-point scale ranging from ‘strongly agree’ to ‘strongly disagree’. The total score for the perceived benefits ranged from 15 to 75 and for perceived barriers from 11 to 55 (Table 1). 5. Daily FV consumption

The section comprised two parts as follows.

Table 1 Perceived benefits and barriers questionnaire Strongly agree

Agree Neither agree nor disagree

Disagree Strongly disagree

Perceived Benefits I could find any types of FV in my local stores It is better to get all nutrients from FV than taking supplements FV decrease the risk of chronic diseases FV make our diet diverse Eating FV is a good way for treating chronic diseases Eating FV would help me to be less aggressive Eating FV treats constipation Eating FV would help me to maintain my weight FV consumption are recommended by physicians Eating FV cheering my family members Eating FV is common in my culture Eating FV would keep me of sickness Eating FV would help me to live longer I feel that if I eat more FV, I will be more healthy By eating FV, I feel better Perceived Barriers Providing FV is expensive I did not used to eat FV since childhood Eating FV leads to overeating Media advertisements are not about eating FV Eating more FV is not recommended in my culture My family members do not like consumption of FV Eating more FV is difficult for me I have health problems with eating FV (e.g. flatus) I have limitations to provide FV in my meal I do not like taste of FV I do not have time to provide FV Please indicate whether you agree or disagree with the following items when you are deciding on consuming or not to consume FV. Check the best response.


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5.1. Food frequency questionnaire This was consisted of two main questions related to fruits and vegetables (38 items in all) available in Tehran’s markets. Response categories were: never, 1-2 times per week, 3-4 times per week, 5-6 times per week, and every day. Accordingly the respondents were asked to indicate the amount of intake. 5.2. A 24 hour recall participants were asked to estimate their daily servings of FV at breakfast, lunch, dinner, and between meals as snacks or deserts in accordance with a nutrition guideline cards. The nutrition guideline card categorized one serving of vegetables into one of three following groups: (1) one cup of raw green leafy vegetables such as spinach or salad; (2) one-half cup of other vegetables cooked or chopped raw, such as tomatoes, carrots, pumpkin, corn, Chinese Cabbage, beans, or onions; and (3) one half cup of vegetable juice. The nutrition guideline categorized one serving of fruit into one of three groups: (1) one medium size fruit such as an apple, banana, or orange; (2) one half cup of cooked, chopped, or canned fruit; and (3) one-half cup of fruit cup of fruit juice, not artificially flavored. We calculated the daily serving FV consumption for each individual according to information provided from the above-mentioned measures. This included of calculation of weekly consumption of FV based on frequency and portion of each item in the food frequency questionnaire. Then we compared total score of daily FV consumption between two groups. Intervention

Both those randomized to the control group and those randomized to the intervention group received four weekly sessions. The control group sessions focused on general health education and did not include content related to the health benefits of fruits and vegetables, while the intervention group sessions were focused on increasing fruit and vegetable intake. After randomization, those randomized to intervention group were further divided by stages of change and the sessions were then tailored to that stages of change and techniques (processes) associated with the stages of change. The goal of the intervention was to increase participants’ consumption of FV to 5 servings per day. The intervention was composed of four consecutive sessions (one meeting per week). Each session was around 90 minutes in length and included a 40-minute power point presentation, 30 minutes discussion, 10 minutes questions and answers, and 10 minutes reception with FV. (I) The first session was introductory. (II) During the second session, the stages of change for FV intake was assessed in participants in order to deliver the appropriate intervention. Based on each individual’s status at least one tailored technique (according to the Transtheoretical Model) was used:

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(II-a) Participants in pre-contemplation stage completed session that incorporated conscious raising (raising awareness about unhealthy dietary behavior); dramatic relief (react emotionally to warnings about unhealthy dietary behavior. The topics included personal recommendation regarding losing a loved one due to a chronic disease and discussion of nutritional habits associated with this chronic disease; emotional arousal (which is a certain technique that produce increased emotional experiences that can encourage people towards an action. In fact, this process of behavioral change was used to help the participants understand the relationship between lower consumption of FV and increased risk for chronic diseases. The topics included the statistics about the prevalence of the previously mentioned chronic diseases in world and in Iran, the scientific studies relating the protective effect of FV against each of these diseases); and environmental reevaluation (assessing the impact of one’s dietary behavior on family members and others). (II-b) Participants in contemplation/preparation stage completed session that incorporated self-evaluation (which is an assessment of one’s self-image with and without a particular unhealthy habit. The researcher asked the participants who were now consuming 5 servings of FV per day to compare their lifestyle and diet before and after increasing their intake of FV to five or more servings per day); and self-liberation (which is the belief that one can change and have the commitment to act on that belief. Participants were asked to make a plan and set a goal and be committed to that goal). (II-c) Participants in the action/maintenance stage completed session that incorporated helping relationship (which is defined as having a caring, trusted, and accepted person who can give the support and the counseling for the healthy behavior change), stimulus control (removing or countering stimuli that elicit problem behavior), reinforcement management (rewarding oneself or being rewarded by others for making dietary change). (III) During the third session, the content of the second session was reinforced. (IV) The fourth session was planned to help participants anticipate and overcome barriers, increase selfassurance and self-efficacy in addition to improve skills in obtaining and arranging FV. Statistical Analysis

The characteristics of participants in two groups were compared using analysis of variance and x2 tests as appropriate. Responses to the interventions were assessed by calculating changes in fruit and vegetable intake from baseline to 4 weeks, with positive values indicating an increase in consumption at follow-up assessment. Similar analysis was performed for assessment of stages of change


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(posttest data vs. pre-contemplation, contemplation/preparation, and action/maintenance at baseline). The data were analyzed on an intention to treat basis including all 400 participants. Analysis of covariance (ANCOVA) was used, controlling for variables previously shown to be related to FV consumption, namely, age, education, marital status, income, chronic disease and BMI. All analyses were conducted using SPSS 16.0. Alpha level of .05 was used for all statistical tests.

Results

Outcome measures

Change in FV intake

Two main outcomes of the current study were changes in FV intake and to examine the stage transitions.

At baseline total FV intake was not differed between two groups (intervention and control groups) but it was significantly increased in the intervention group at posttest assessment (mean serving/day in intervention group 3.08 ± 1.35 vs. 1.79 ± 1.08 in control group; P = 0.001). The detailed results are shown in Table 3 and Table 4. Pearson correlation also showed significant

Ethics

Ethics committee of Tehran University of Medical Sciences approved the study. All participants singed a consent form.

The study samples

In all 400 elderly were entered into the study (200 individuals in intervention group and 200 in control group). The two groups did not differ in terms of demographic characteristics. The mean age of participants was 64.0 6 (SD = 4.48) years and overall two-third of participants were female (n = 298, 74.5%). The characteristics of participants in the two groups are shown in Table 2.

Table 2 The characteristics of the study sample Total

Intervention group (n = 200)

Control group (n = 200)

No. (%)

No. (%)

No. (%)

Age

P 0.55

60-64

255 (63.8)

120 (65.0)

125 (62.5)

65-69

87 (21.7)

34 (17.0)

53 (26.5)

70-74

47 (11.7)

30 (15.0)

17 (8.5)

≥ 75

11 (2.8)

6 (3.0)

5 (2.5)

Mean (SD)

64.06 (4.48)

63.93 (5.08)

64.2 (3.8)

Female

298 (74.5)

144 (72.0)

154 (77.0)

Male

102 (25.5)

56 (28.0)

46 (23.0)

165 (41.2)

82 (41.0)

83 (41.5)

Gender

Education Illiterate

0.81 0.08

Primary

143 (35.8)

82 (41.0)

61 (30.5)

Junior Secondary

64 (17.0)

23 (11.5)

41 (20.5)

Senior Secondary & above

28 (7.0)

13 (6.5)

15 (7.5)

Marital status Married

230 (55.0)

120 (60.0)

110 (55.0)

Never married/Divorced/widow

170 (45.0)

80 (40.0)

90 (45.0)

Income

0.45 0.03

Low (0-3assets)

306 (76.5)

165 (82.5)

141 (70.5)

Moderate (4-6 asset)

65 (16.2)

22 (11.0)

43 (21.5)

High (8 or more assets)

29 (7.3)

13 (6.5)

16 (8.0)

Employed

54 (13.5)

31 (15.5)

23 (21.5)

Housewife

283 (70.8)

133 (66.5)

150 (70.0)

Retired

63 (15.7)

36 (18.0)

27 (13.5)

< 25

106 (26.5)

56 (28.0)

50 (25.0)

25-29

192 (48)

94 (47.0)

98 (49.0)

≥ 30

103 (25.5)

50 (25.0)

52 (26.0)

Employment status

0.45

BMI

0.79


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Table 3 Comparison of perceived benefits, perceived barriers, self-efficacy and FV consumption between two groups Before

After

Intervention group

Control group

Intervention group

Control group

Mean (SD)

Mean (SD)

P

Mean (SD)

Mean (SD)

P

Perceived Benefits

54.91 (9.29)

56.62 (8.34)

0.21

64.34 (9.11)

57.01 (8.47)

< 0.001

Perceived Barriers

34.23 (8.04)

35.79 (8.29)

0.50

27.32 (8.09)

35.89 (8.72)

< 0.001

Self-efficacy

13.59 (6.41)

12.72 (6.02)

0.22

19.23 (5.72)

12.79 (6.04)

< 0.001

FV Consumption

1.78 (1.21)

1.75 (1.09)

0.17

3.08 (1.36)

1.79 (1.08)

< 0.001

interventional study that applied the TTM to promote FV consumption showed that FV intake in elderly increased from 0.5 to 1.0 serving a day [22]. Another study reported a significant increase in FV consumption; 1.49 serving/day increase when using a theory based intervention [27]. Di Noia et al. conducted the TTM based study with urban African-American adolescents to determine whether the delivery of stage-tailored change process would promote movement through successive stages and effect positive changes in FV consumption, pros, cons and self efficacy and found that the intervention group had greater increase in the perceived pros of eating FV and increase of 0.9 daily serving of FV compared with the control group [28]. Similarly our findings demonstrated that the intervention had positive effect on perceived benefits and barriers, and self-efficacy. We believe the strength of the current study was due to the fact that our intervention not only was drawn from the TTM stages of change, but also it included examination of perceived barriers and self-efficacy. Overall most interventional studies based on the TTM model showed that the interventions have produced positive influence on FV intakes. However, the program developed by Amanda Park indicated that stage-tailored nutrition education produced positive shift in several indicators and mediators of vegetables but not for fruits intake [29]. Our study assessed both fruits and vegetables together. Hence it is better to assess the two items apart in future studies as a match-mismatch test. A study was conducted to test the transtheoretical model applied to fruit intake and failed to support the superiority of stage-matching compared with stagemismatching [30].

correlation between stages of change and benefits, barriers, self-efficacy and FV intake (Table 5). Further analysis of the data performing the analysis of variance adjusting for covariate also indicated that there were significant differences between intervention and control groups Elderly in intervention group had higher FV intake, perceived benefits and self-efficacy, and lower perceived barriers. The results are presented in (Table 6). Change in stage transition

There was no difference at baseline in distribution of the stages of change between the two groups. Larger number of participants fell into the pre-contemplation stage than the other stages. Compared with control group, greater proportions of elderly in intervention group moved from pre-contemplation to contemplation/preparation and action/maintenance stages (c2 = 233.7, P < 0.0001), and from contemplation/preparation to action/maintenance stages (c2 = 8.1, P = 0.004) from pretest to posttest measurements (Table 7).

Discussion This study indicated the efficacy of a TTM-based intervention for increasing fruit and vegetable consumption in elderly. The findings also confirmed that a theory driven program could have effect on stages of change in elderly in order to improve their lifestyle and health behavior. We found an average increase of 1.29 daily servings of fruits and vegetables in the intervention group. The results from current study were very similar to those reported by other investigators. For instance, an

Table 4 Comparison of perceived benefits, perceived barriers, self-efficacy and FV consumption within groups Intervention group

Control group

Before

After

Before

After

Mean (SD)

Mean (SD)

P

Mean (SD)

Mean (SD)

P

Perceived Benefits

54.91 (9.29)

64.35 (9.11)

< 0.001

56.62 (8.34)

57.01 (8.47)

< 0.001

Perceived Barriers

34.23 (8.04)

27.33 (8.09)

< 0.001

35.79 (8.29)

35.89 (8.72)

0.262

Self-efficacy

13.59 (6.41)

19.23 (5.72)

< 0.001

12.72 (6.02)

12.79 (6.04)

0.007

FV Consumption

1.78 (1.21)

3.08 (1.36)

< 0.001

1.75 (1.09)

1.79 (1.08)

0.006


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Table 5 Correlation between stage of change, benefits, barriers, self-efficacy and FV consumption* Stages of change

Benefits

Barriers

Self-efficacy

Stages of change

1

0.213**

-0.181**

0.181**

FV consumption 0.448**

Benefits

0.371**

1

-0.033

0.096

0.237**

Barriers

-0.403**

-0.217**

1

-0.173**

-0.296**

Self-efficacy

0.437**

0.303**

-0.375**

1

0.337**

FV consumption

0.636**

0.355**

-0.402**

-0.485**

1

* Figures above triangle relate to before intervention and figures below triangle relate to after intervention ** Correlation is significant at the 0.01 levels.

Table 6 Analysis of covariance of perceived benefit, perceived barrier, self-efficacy, and FV consumption Source of variance

Type III sum of square

df.

Mean square

F statistic

P

Arm

6846.086

1

6846.086

179.074

< 0.0001

Pretest

15388.664

1

15388.664

402.523

< 0.0001

Age

14.127

1

14.127

0.37

0.544

Education

11.286

1

11.286

0.295

0.587

Marital status

77.527

1

77.527

2.028

0.155

Income

65.055

1

65.055

1.702

0.193

Chronic disease

50.452

1

50.452

1.32

0.251

BMI

41.750

1

41.750

1.092

0.297

Error

14948.144

391

38.231

Arm

5423.038

1

5423.038

174.115

< 0.0001

Pretest

13877.096

1

13877.096

455.545

< 0.0001

Age

38.961

1

38.961

1.251

0.264

Education

80.167

1

80.167

2.574

0.109

Marital status

19.014

1

19.014

0.61

0.435

Income

50.268

1

50.268

1.614

0.205

Chronic disease

2.029

1

2.029

0.065

0.799

BMI

0.172

1

0.172

0.006

0.941

Error

12178.223

391

31.146

Arm

3252.374

1

3252.374

475.144

< 0.0001

Pretest

9563.134

1

9563.134

1.397

< 0.0001

Age

23.900

1

23.900

3.492

0.062

Education

5.188

1

5.188

0.758

0.385

Marital status

1.006

1

1.006

0.147

0.703

Income

30.368

1

30.368

4.436

0.036

Chronic disease

1.022

1

1.022

0.149

0.699

BMI

0.282

1

0.282

0.041

0.839

Error

2676.407

391

6.845

Arm

156.226

1

156.226

294.929

< 0.0001

Pretest

218.617

1

218.617

412.712

< 0.0001

Age

2.400

1

2.400

4.530

0.034

Education

0.017

1

0.017

0.032

0.858

Marital status

1.301

1

1.301

2.456

0.118

Perceived Benefit

Perceived Barrier

Self-efficacy

FV consumption


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Table 6 Analysis of covariance of perceived benefit, perceived barrier, self-efficacy, and FV consumption (Continued) Income

0.055

1

0.055

0.105

0.746

Chronic disease

0.198

1

0.198

0.374

0.541

BMI

0.062

1

0.062

0.118

0.732

Error

207.116

391

0.530

Table 7 Chi-square analysis of between groups differences in posttest stages of change by pretest stages of change* Post test stages of change PC

C/PR

A/M

Intervention (n = 140)

5

117

18

Control (n = 143)

135

8

0

c2 (df)

P

Pretest stages of change PC

0

45

8

Control (n = 50)

0

50

0

233.7 (2)

< 0.0001

8.1 (1)

0.004

A/M** Intervention (n = 7)

0

0

7

Control (n = 7)

0

0

7

Competing interests The authors declare that they have no competing interests. Received: 4 January 2011 Accepted: 14 November 2011 Published: 14 November 2011

C/PR Intervention (n = 53)

Authors’ contributions LS was the main investigator, analyzed the data and involved in drafting the manuscript. KM contributed to the study design and statistical analysis, and supervised the study. AM contributed to statistical analysis, edited the paper and provided the final version. All authors read and approved the final manuscript.

PC = Pre-contemplation, C/PR = Contemplation/Preparation, A/M = Action/ maintenance * The format of table was adapted from [28]. ** Note that it is impossible to progress from action/maintenance.

Limitations Given that all our respondents were members of elderly centers, the findings of this study might not be generalized to all elderly Tehran residents. These elderly might differ from others in Tehran in terms of socioeconomic status, family cohesiveness, social support and availability and access to FV. In addition, it should be noted that our findings on FV intake were based on self-reported information and it might be associated with measurement errors. Conclusion This study demonstrated that the TTM is a useful model that can be applied to dietary behavior change, more specifically FV consumption among elderly populations. Author details 1 Tehran University of Medical Sciences, Center for Community Based Participatory Research (CBPR), Tehran, Iran. 2Alborz University of Medical Sciences, Karaj, Iran. 3Department of Epidemiology and Statistics, School of Public Health, Tehran University of Medical Sciences, Tehran, Iran. 4Mental Health Research Group, Mother and Child Health Research Centre, Iranian Institute for Health Sciences Research, ACECR, Tehran, Iran.

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17. Prochaska JO, Reddind CA, Ever KE: The Transtheoretical Model and stage of change. In Health Behavior and Health Education, Theory, Research and Practice. Edited by: Glanz K, Rimer BK, Lewis FM. San Francisco: Jossey-Bass; 2008:97-121. 18. Alexander GL, McClure JB, Calvi JH, Divine GW, Stopponi MA, Rolnick SJ, Heimendinger J, Tolsma DD, Resnicow K, Campbell MK, Strecher VJ, Johnson CC: A randomized clinical trial evaluating online interventions to improve fruit and vegetable consumption. Am J Public Health 2010, 100:319-326. 19. Horwath CC, Nigg CR, Motl RW, Wong KT, Dishman RK: Investigating fruit and vegetable consumption using the transtheoretical model. Am J Health Promot 2010, 24:324-333. 20. Di Noia J, Prochaska JO: Dietary stages of change and decisional balance: a meta-analytic review. Am J Health Behav 2010, 34:618-632. 21. Bradbury J, Thomason JM, Jepson NJ, Walls AW, Allen PF, Moynihan PJ: Nutrition counseling increases fruit and vegetable intake in the edentulous. J Dent Res 2006, 85:463-468. 22. Greene GW, Fey-Yensan N, Padula C, Rossi SR, Rossi JS, Clark PG: Change in fruit and vegetable intake over 24 months in older adults: results of the SENIOR project intervention. Gerontologist 2008, 48:378-387. 23. United Nations: World Population Ageing: 1950-2050, Countries of area: Iran (Islamic Republic of) , http://www.un.org/esa/population/publications/ worldageing19502050/pdf/113iran(.pdf[accessed 05.05.2008]. 24. Ferguson BD, Tandon A, Gakidou E, Murray CJL: Estimating permanent income using indicator variable. In Health System Performance Assessment: Debates, Methods and Empiricism. Edited by: Murray CJL, Evans DB. Geneva: WHO; 2003:747-760. 25. Chatterji S, Kowal P, Mathers C, Naidoo N, Verdes E, Smith JP, Suman R: The health of ageing population in China and India. Health Affairs 2008, 27:1052-1063. 26. Ma J, Betts NM, Horacek T, Georgiou C, White A, Nitzke S: The importance of decisional balance and self-efficacy in relation to stages of change for fruit and vegetable intakes by young adults. Am J Health Promot 2002, 16:157-166. 27. Steptoe A, Perkins-Porras L, McKay C, Rink E, Hilton S, Cappuccio FP: Behavioral counseling to increase consumption of fruit and vegetables in low income adults: randomized trial. BMJ 2003, 326:855. 28. Di Noia J, Contento IR, Prochaska JO: Computer-mediated intervention tailored on transtheoretical model stages and processes of change increases fruit and vegetable consumption among urban AfricanAmerican adolescents. Am J Health Promot 2008, 22:336-341. 29. Park A, Nitzke S, Kritsch K, Kattelmann K, White A, Boeckner L, Lohse B, Hoerr S, Greene G, Zhang Z: Internet-based interventions have potential to affect short-term mediators and indicators of dietary behavior of young adults. J Nutr Educ Behav 2008, 40:288-297. 30. de Vet E, de Nooijer J, de Vries NK, Brug J: Testing the transtheoretical model for fruit intake: comparing web-based tailored stage-matched and stage-mismatched feedback. Health Educ Res 2008, 23:218-227. doi:10.1186/1475-2891-10-123 Cite this article as: Salehi et al.: Fruit and vegetables intake among elderly Iranians: a theory-based interventional study using the five-aday program. Nutrition Journal 2011 10:123.

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STUDY PROTOCOL

Open Access

The protocol of a randomized controlled trial for playgroup mothers: Reminder on Food, Relaxation, Exercise, and Support for Health (REFRESH) Program Sarojini MDR Monteiro1,2*, Jonine Jancey1,2, Peter Howat1,2, Sharyn Burns1, Carlie Jones1,2, Satvinder S Dhaliwal1,2, Alexandra McManus3, Andrew P Hills4 and Annie S Anderson5 Abstract Background: Mother’s physical activity levels are relatively low, while their energy consumption is generally high resulting in 58% of Australian women over the age of 18 years being overweight or obese. This study aims to confirm if a low-cost, accessible playgroup based intervention program can improve the dietary and physical activity behaviours of mothers with young children. Methods/Design: The current study is a randomized controlled trial lifestyle (nutrition and physical activity) intervention for mothers with children aged between 0 to 5 years attending playgroups in Perth, Western Australia. Nine-hundred participants will be recruited and randomly assigned to the intervention (n = 450) and control (n = 450) groups. The study is based on the Social Cognitive Theory (SCT) and the Transtheoretical Model (TTM), and the Precede-Proceed Framework incorporating goal setting, motivational interviewing, social support and self-efficacy. The six month intervention will include multiple strategies and resources to ensure the engagement and retention of participants. The main strategy is home based and will include a specially designed booklet with dietary and physical activity information, a muscle strength and flexibility exercise chart, a nutrition label reading shopping list and menu planner. The home based strategy will be supported by face-to-face dietary and physical activity workshops in the playgroup setting, posted and emailed bi-monthly newsletters, and monthly Short Message Service (SMS) reminders via mobile phones. Participants in the control group receive no intervention materials. Outcome measures will be assessed using data that will be collected at baseline, six months and 12 months from participants in the control and intervention groups. Discussion: This trial will add to the evidence base on the recruitment, retention and the impact of community based dietary and physical activity interventions for mothers with young children. Trial Registration: Australian and New Zealand Clinical Trials Registry ACTRN12609000735257

Background Overweight and obesity are important public health concerns. The percentage of Australian women of childbearing age that are overweight or obese has significantly increased over the past decade. In 2007, 44% of Australian women aged between 25 and 34 years were overweight or obese compared to only 26% in 1995 [1]. * Correspondence: S.Monteiro@curtin.edu.au 1 Western Australian Centre for Health Promotion Research, School of Public Health, Curtin University, Western Australia, Australia Full list of author information is available at the end of the article

Childbearing aged women are an important target group for dietary and physical activity interventions as they are at an increased risk of long-term overweight and obesity [2]. Women’s increased risk of overweight and obesity after their first and subsequent pregnancies is associated with overweight or obesity prior to pregnancy [3,4], gestational weight gain above the recommended guidelines [5,6], failure to lose gestational weight in an appreciable timeframe or excessive postpartum weight retention [7] and interpregnancy weight gain [8].

© 2011 Monteiro et al; licensee BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.


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Overweight and obese childbearing aged women appear to have a disproportionate risk of maternal, intrapartum, peripartum, neonatal, and postpartum complications [9,10]. If this weight gain continues after childbearing, women will be at increased risk of obesity related chronic conditions such as type II diabetes, high blood pressure, dyslipidaemia, cardiovascular disease and the risk of several major cancers [10]. In addition, maternal obesity may have deleterious effects on the neonate such as macrosomia, increased risk of a range of structural anomalies and of still birth [11]. Research indicates that the mechanisms for interpregnancy and 12 months postpartum weight gain can be due to a range of factors such as lack of nutrition knowledge [12], poor dietary habits and physical inactivity [13,14]. For example, research shows that 96% of females aged 2534 and 94% of females aged 35-44 consume inadequate fruit or vegetables when compared to the Australian dietary guidelines [1]. Furthermore, despite the known health benefits of physical activity, 30% of women aged between 24 and 34 do not do any exercise, while 44% participate in low intensity activity [1]. The barriers to mothers adopting the recommended physical activity behaviours include lack of social support, lack of time, lack of energy and motivation, procrastination, lack of self-efficacy and childcare and financial constraints [15,16]. The influences on eating habits include convenience, cost, lifestyle preferences, confusion around food messages, nutrition knowledge and environmental factors [17]. Furthermore, common postpartum physical symptoms such as fatigue, headaches, nausea, backache and urinary or bowel problems can inhibit mothers following a healthy diet and physical activity plan [18]. Mothers are an important group within the family unit as they are generally the primary caregiver and help to shape the attitudes and behaviour of their children with respect to food and physical activity. Overweight and obese children are twice as likely to become overweight and obese adults when compared to normal weight children [19]. Mothers can prevent children from becoming overweight and obese as they play a major role in determining the family mealtime environment, and managing the amount and type of food available [20]. Thus, efforts to interrupt this cycle of obesity by targeting interventions at mothers are vital from both a public health perspective. Dietary and physical activity interventions could provide benefits to the mother, her future pregnancies and subsequent generations from becoming overweight and obese [21]. Currently, there are few studies that have reported the effectiveness of behavioural interventions designed to improve physical activity and dietary behaviours [22-26] in mothers with young children. These studies have included small samples and have incorporated limited

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evaluation measures [23-25], even though the evidence suggests that after childbirth mothers are ready to change behaviours associated with overweight and obesity [27,28]. This paper describes the protocol of a randomized controlled trial to improve the physical activity and nutrition behaviours of mothers with young children (between 0 and 5 years of age) attending playgroups.

Methods/Design Study design

The study is a community based 12 month randomized controlled trial. The study is designed according to the recommendations of the CONSORT statement for randomized trials of nonpharmacologic treatment [29]. The REFRESH study will be conducted over three years (Figure 1). The first year will include formative research, development of the evaluation framework and the intervention. In the second year, participants will be recruited, the intervention will be implemented and data will be collected from participants. The final year will include data collection, data analysis and review of the intervention. Study aim

The REFRESH study aims to evaluate the effect of a six month physical activity and nutrition randomized controlled trial for mothers with young children attending playgroups in Perth, Western Australia (WA). The REFRESH program will focus on behaviour change to meet the Australian physical activity guidelines, by encouraging increased in levels of vigorous, and moderate physical activity, the number of steps taken each day and muscle strength exercises [30,31]. The REFRESH program will also aim to encourage behaviour change to meet the Australian dietary guidelines (improve nutritional intake by increasing fruit, vegetable and fibre intake and decreasing fat and added sugar intake) [32]. Settings

Playgroups in Australia are informal regular community groups that are set up for babies, toddlers and pre-school children (0 to 5 years). The purpose of a playgroup is to encourage play among children to enhance their social, emotional, physical and intellectual development. Parents and carers also find it a valuable resource as they help establish support networks. Playgroups are run by volunteer parents and carers who get together once a week for a couple of hours. They are held at a variety of venues such as libraries, child and maternal health centres, church halls, kindergartens and schools. Playgroups are supported by National and State organisations [33]. The REFRESH project will be conducted in collaboration with Playgroup WA Inc. [34], as the playgroup will be used as the setting to recruit mothers and implement the project.


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Figure 1 REFRESH Study Design.

Recruitment and randomisation process

A stratified random sampling procedure will be adopted to recruit participants from 560 playgroups embedded in 106 suburbs (neighbourhoods) within the Perth metropolitan area. Stratification will be conducted by suburb geographical location and Socio-Economic Indexes For Area (SEIFA) scores. SEIFA scores are values derived from income, education level, employment status and skill level [35]. The suburbs will then be randomly assigned to either the intervention group or the control group using a table of random numbers. Control and intervention group suburbs will be arbitrarily matched for low and medium levels of socio-economic status based on the SEIFA scores. The senior Playgroup WA Inc. staff will make phone calls to all registered playgroup leaders, explain the REFRESH project and obtain permission for

project staff to contact the playgroup. Project staff will visit the playgroup to further explain the project, obtain consent and allocate participants to the intervention or control group. Intervention group participants will also complete the Physical Activity Readiness Questionnaire [36] and provide a medical certificate if deemed necessary before commencing the program. Inclusion criteria

Study participants will need to be: (a) women aged 18 or over registered with Playgroup WA Inc.; b) have a child between 0 to 5 years; (c) healthy to the extent that participation in a low-stress physical activity program would not place them at risk; (d) not taken part in any research that involves physical activity or nutrition within the last five years; and (e) not on a special diet.


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Sample size determination

In order to detect a 20% difference in physical activity at 80% power and 5% level of significance, sample size of 310 mothers of young children are required at the 6-months post-intervention survey in each of the intervention and control groups. A small effect size (0.2) [37] is assumed for studies on behavioural effects due to the influence of extraneous variables and the subtleties of human performance. Allowing for an attrition rate of 30%, 900 mothers of young children will be recruited into the study. Sample size calculations were determined using Power Analysis and Sample Size software [38]. Data collection

Process data will be collected during the implementation of the intervention. The playgroup is a novel setting for the recruitment and delivery of health promotion interventions for mothers with young children. Therefore, the process evaluation will be a key component of the programâ&#x20AC;&#x2122;s evaluation. This will be conducted with both the participants and the project staff, providing two perspectives on the program delivery and content. Outcome data will be collected at baseline, six months and 12 months. At baseline control group participants will be hand delivered a self-completion questionnaire at the playgroup along with a self-addressed envelope and measuring tape to record waist and hip measurements. The intervention group will be provided all of the above and a pedometer to record the number of steps taken each day. At six months the control group participants will be hand delivered a self-completion questionnaire at the playgroup along with a self-addressed envelope. The intervention group will be provided all of the above and a pedometer to record the number of steps taken each day. At 12 months the control and intervention group participants will be posted a self-completion questionnaire with a selfaddressed envelope. Blinding

It is not possible to blind study project staff to the randomisation process, however, the participants will be blinded as to whether they are in the study or control group. The assessor will be blinded until the comparative data analysis is conducted. Participants will be given codes when recruited and these codes will be used throughout the implementation of the study. The participant codes will be revealed only at the six and 12 month comparative data analysis. Statistical analysis

Data collected will be coded and analysed using the Statistical Package for the Social Sciences computer statistical software [39]. Descriptive statistics will first be used to summarise participantsâ&#x20AC;&#x2122; demographic and health

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characteristics. For the hierarchical data (repeated measurements of individuals) collected over the one-year observational period, multi-level repeated measures analyses and multivariate logistic regression analyses will be used extensively in the statistical analyses. Intervention group

To facilitate the development of the intervention and to ensure adherence to its timeline, the implementation of the intervention will be organised into four stages. Stage 1

Intervention development A literature review of nutrition and physical activity community based interventions for mothers with young children, pregnant and postpartum women has been conducted and will be continuously updated. Relevant behaviour change theories reviewed including the Social Cognitive Theory (SCT) [40], Transtheoretical Model (TTM) [41] and motivational interviewing [42] will support the development of a multi-strategy intervention [43]. Previous qualitative data obtained from Perth playgroup mothers will be used to ascertain the barriers and facilitators to healthy eating and being physically active, as well as their preferred intervention strategies [44]. The Precede-Proceed model will be used to organise the behaviour change theories and formative research data into an appropriate nutrition and physical activity behaviour change program [45,46]. Stage 2

Recruitment of staff The program will be staffed by Health Science graduates, who will deliver the face-to-face workshop styled information and skill building sessions. Recruitment of the health promotion, nutrition and sport science graduates will be conducted via local universities and relevant professional associations. Stage 3

Staff training Staff will receive intensive training on the application of the Australian dietary and physical activity guidelines [31,32], and behaviour change theories including motivational interviewing. They will receive a comprehensive training manual on the delivery of the face-to-face workshop sessions. The staff will also receive ongoing support via email and phone by an accredited dietician, human movement specialist, health promotion specialist and the project coordinator. Stage 4

Delivery of intervention in playgroup settings The intervention will be delivered over six months. Interventions that aim to address multiple risk factors such as nutrition and physical activity show more positive outcomes when multiple intervention strategies are used to reach the target audience [43,47]. Hence the intervention group participants will receive four strategies: face-to-face workshop information and skill development session; mailed or emailed newsletters; SMS reminders on the


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main messages of the REFRESH program; and a homebased component. Delivery of face-to-face workshops The intervention group participants will receive six workshop sessions over six months (one session a month). Each session will be conducted for 30 minutes by project staff during the playgroup session at the playgroup venue. Workshops will focus on enhancing knowledge, attitudes and skills to enable informed decision making about nutrition and physical activity behaviours (Table 1). Delivery of newsletters The intervention group participants will receive six newsletters via post or email over six months (one newsletter a month, one week after each face-to-face workshop session). The newsletters will be in an informal format and will contain myth dispelling information on nutrition and physical activity.

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Delivery of SMS reminders The intervention group participants will receive 18 SMS reminders via mobile phones over six months (reminders to attend the faceto-face workshop sessions and nutrition and physical activity motivating messages). Delivery of home based component The intervention group participants will receive home based resources at each of the face-to-face workshop sessions to support the content of the REFRESH program. The home based components will include a specially tailored program booklet, pedometer, menu planner fridge magnet, a shopping list with food label reading tips, a muscle strength and flexibility exercise chart fridge magnet, a physical activity diary and an ‘extra’ food record sheet. The workshops will offer an opportunity for these resources to be explained and for questions to be answered.

Table 1 REFRESH Intervention Session (Week)

Session Details

Participant resources/interactive activities

1 (Week 1)

1. Introduction to Refresh Program 2. Overview of healthy eating and being physically active 3. Focus nutrition: fruits, vegetables and water • Guidelines • Benefits/barriers/overcoming barriers

1. Resources: • Program booklet • Healthy recipe booklet • Session one information summary pamphlet 2. Interactive activity: • Determine participant program needs

2 (Week 5)

1. Focus behaviour change: • Stages of change • Goal setting: long and short term goals 2. Focus physical activity: aerobic • Guidelines • Benefits/barriers/overcoming barriers 3. Focus nutrition: five food groups and ‘extra’ foods • Guidelines • Benefits/barriers/overcoming barriers

1. Resources: • Pedometer • Family dinner and physical activity planner (fridge magnet) • ‘Extra’ food record sheet • Session two information summary pamphlet 2. Interactive activity: • Playgroup 10,000 steps per day challenge

3 (Week 9)

1. Focus behaviour change: • Review established short term goals • Set new short term goals 2. Focus physical activity: Muscle strength and flexibility exercises • Guidelines • Benefits/barriers/overcoming barriers

1. Resources: • Muscle strength and flexibility exercise card (fridge magnet) • Physical activity diary • Session three information summary pamphlet 2. Interactive activity: • Muscle strength and flexibility exercises • Integrated exercises “

4 (Week 13)

1. Focus behaviour change: • Review established short term goals • Set new short term goals 2. Focus nutrition: • Healthy eating messages • Menu planning • Food label reading • Making sense of nutritional claims

1. Resources: • Shopping list with healthy shopping tips • Comparing packaged food per 100 g (fridge magnet) • Session four information summary pamphlet 2. Interactive activity: • Reading packaged food labels • Developing a daily menu

5 (Week 17)

1. Focus behaviour change: • Review established short term goals • Set new short term goals • Overcoming relapses 2. Focus nutrition: fats and sugars • Recommended intake • Benefits/barriers/overcoming barriers

1. Resources: • Session five information summary pamphlet 2. Interactive activity: • Modifying recipes • Healthy cooking methods

6 (Week 21)

1. Focus behaviour change: • Review established short term goals • Social support 2. Focus nutrition: Fibre and Glycemic Index • Recommended intake • Benefits/barriers/overcoming barriers

1. Resources: • Session six information summary pamphlet 2. Interactive activity: • Modifying recipes • Healthy cooking methods


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Control group

The control group participants will not receive any intervention materials. Their only contact with the project will include completing the questionnaires at the three data collection periods. Process measures Participant process evaluation

The REFRESH booklet will be assessed by the participants in terms of attractiveness, comprehension, personal relevance, believability, and legibility [48]. Workshop and staff feedback sheets will be provided to participants to assess the content and workshop delivery methods in the playgroup setting. Participants will be invited to comment on the REFRESH programâ&#x20AC;&#x2122;s impact on their physical activity and nutrition behaviours and to provide suggestions for improvements to the intervention [49]. Staff process evaluation

The staff will provide feedback on the playgroup as a setting for health promotion programs. This evaluation will focus specifically on the playgroup characteristics, and the skills deemed necessary to deliver workshops in this setting. Staff will also provide feedback on working with mothers as a target group within the playgroup setting, what the mothers want to learn about nutrition and physical activity and common myths mothers report. Staff will also maintain a diary of their perceptions related to the delivery of the face-to-face workshop sessions, and responses by participants to the session content and activities.

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Self-efficacy for nutrition and physical activity behaviours will be assessed. Nutrition and physical activity self-efficacy will be assessed using items from previously validated instruments [52]. Validated questions will also confirm participantsâ&#x20AC;&#x2122; stages of change regarding fruit and vegetable consumption [60]. Social support for physical activity will be assessed based on items from the Sallis et al. instrument [51]. General physical and mental health will be measured by The Medical Outcomes Study Short-Form Health Survey (SF-8) [61]. SF-8 is a standard international generic instrument of health status. It comprises two summary scales - the physical component summary (PCS) score and the mental component summary (MCS) score. Demographic characteristics will include gender, age, educational level, country of birth, marital status, socioeconomic status, financial status and co-morbidities. Anthropometric measures will include self-reported height and weight, waist and hip girth. A recent study has confirmed that self report measures are suitable for such studies when a correction factor is applied [62]. Height, weight, waist and hip girth measurements will be conducted by research staff on a random subsample of 100 participants from the intervention group. Calculations of differences between self reported and research staff measured data will be undertaken to identify a correction factor based on the methodology of Dhaliwal et al. [62].

Outcome measures

Ethics The project protocol has been approved by the Curtin University Human Research Ethics Committee (approval number HR 186/2008).

The self-administered questionnaire will be comprised of instruments which have been previously validated and tested for reliability [50-52], and will undergo further reliability testing prior to its use at baseline. Physical activity will be measured by The International Physical Activity Questionnaire (IPAQ) [53]. This instrument has been accepted as the physical activity measurement tool in many settings and is specifically designed for population-based prevalence studies. Muscle strength exercise assessment will be based on recommendations from the American Heart Association and Australian physical activity guidelines [54]. Physical activity knowledge will be assessed by a modified version of the American Adultâ&#x20AC;&#x2122;s Knowledge of Exercise Questionnaire [55]. Dietary intake will be measured using a modified version of the Fat and Fibre Barometer [56]. The New South Wales Government questionnaire will be used to measure soft drinks, fruit juice and snack consumption [57]. Added sugar consumption will be assessed using the 2005 National Health Interview Survey [58]. Nutrition knowledge will be assessed by a modified version of the General Nutrition Knowledge Questionnaire [59].

Discussion The REFRESH project is unique in using playgroups for a lifestyle intervention. The playgroup environment is an innovative setting for health promotion for mothers with young children, as it offers an exciting avenue to reach this target group and support behaviour change. The recruitment of participants through playgroups is beneficial as it will encourage all playgroup members to register for the program, thereby not just recruiting those who are motivated to adopt health enhancing behaviour [63]. The program will provide an opportunity for a variety of strategies to be implemented and evaluated. This evaluation data will be collected from participants in their own communities and not in a research centre, making the program relevant to the community based population and not just a clinical group. The project will provide guidelines for the development, implementation and evaluation of a minimal intervention home-based tailored physical activity and nutrition program. The information gathered will be valuable in helping to identify and address the barriers to participating in physical activity


Monteiro et al. BMC Public Health 2011, 11:648 http://www.biomedcentral.com/1471-2458/11/648

and nutrition programs for this target group. The project has the potential, to reduce chronic disease and enhance mental health for mothers of young children in the playgroup setting. Acknowledgements and funding The authors are grateful to the REFRESH project staff, Mr Steve Pratt, Dr Christina Pollard and Professor Brian Oldenburg for their contributions to the project. This study is funded by the Australian National Health and Medical Research Council (NHMRC) project grant. Author details 1 Western Australian Centre for Health Promotion Research, School of Public Health, Curtin University, Western Australia, Australia. 2Centre for Behavioural Research in Cancer Control, Curtin University, Western Australia, Australia. 3 Curtin Health Innovation Research Institute, Curtin University, Western Australia, Australia. 4Griffith University and Mater Medical Research Institute, Queensland, Australia. 5Centre for Public Health Nutrition Research, University of Dundee, Dundee, UK. Authors’ contributions SM coordinated the project, led the design of the REFRESH program and drafted the manuscript. JJ, PH, SB, CJ, SD, AM, AH and AA designed the study and revised the manuscript. All authors read and approved the final manuscript. Competing interests The authors declare that they have no competing interests. Received: 8 July 2011 Accepted: 16 August 2011 Published: 16 August 2011 References 1. National Health Survey: Summary of results, Australia 2007-2008. [http:// www.abs.gov.au]. 2. Rooney BL, Schauberger CW, Mathiason MA: Impact of perinatal weight change on long-term obesity and obesity-related illnesses. Obstet Gynecol 2005, 106:1349-1356. 3. Gunderson EP, Murtaugh MA, Lewis CE, Quesenberry CP, West DS, Sidney S: Excess gains in weight and waist circumference associated with childbearing: The Coronary Artery Risk Development in Young Adults Study (CARDIA). Int J Obes 2004, 28:525-535. 4. Soltani H, Fraser RB: A longitudinal study of maternal anthropometric changes in normal weight, overweight and obese women during pregnancy and postpartum. Br J Nutr 2000, 84:95-101. 5. Linne Y, Rossner S: Interrelationships between weight development and weight retention in subsequent pregnancies: the SPAWN study. Acta Obstet Gynecol Scand 2003, 82:318-325. 6. Siega-Riz AM, Viswanathan M, Moos MK, Deierlein A, Mumford S, Knaack J, Thieda P, Lux LJ, Lohr KN: A systematic review of outcomes of maternal weight gain according to the Institute of Medicine recommendations: birthweight, fetal growth, and postpartum weight retention. Am J Obstet Gynecol 2009, 201:339, e331-314. 7. Gore SA, Brown DM, West DS: The role of postpartum weight retention in obesity among women: a review of the evidence. Ann Behav Med 2003, 26:149-159. 8. Villamor E, Cnattingius S: Interpregnancy weight change and risk of adverse pregnancy outcomes: a population-based study. Lancet 2006, 368:1164-1170. 9. Ramachenderan J, Bradford J, McLean M: Maternal obesity and pregnancy complications: A review. Aust and N Z J Obstet Gynaecol 2008, 48:228-235. 10. Ryan D: Obesity in women: a life cycle of medical risk. Int J Obes 2007, 31:S3-S7. 11. Ruager-Martin R, Hyde M, Modi N: Maternal obesity and infant outcomes. Early Hum Dev 2010, 86:715-722. 12. Nuss H, Freeland-Graves J, Clarke K, Klohe-Lehman D, Milani TJ: Greater nutrition knowledge Is associated with lower 1-year postpartum weight retention in low-income women. J Am Diet Assoc 2007, 107:1801-1806.

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13. Oken E, Taveras EM, Popoola FA, Rich-Edwards JW, Gillman MW: Television, walking, and diet: associations with postpartum weight retention. Am J Prev Med 2007, 32:305-311. 14. Devine CM, Bove CF, Olson CM: Continuity and change in women’s weight orientations and lifestyle practices through pregnancy and the postpartum period: the influence of life course trajectories and transitional events. Soc Sci & Med 2000, 50:567-582. 15. Nash M: “You don’t train for a marathon sitting on a couch": Performances of pregnancy ‘fitness’ and ‘good’ motherhood in Melbourne, Australia. Women’s Studies International Forum 2010, 34:50-65. 16. Lewis B: Mothers reframing physical activity: family oriented politicism, transgression and contested expertise in Australia. Soc Sci & Med 2005, 60:2295. 17. Nitzke S, Freeland-Graves J: Position of the American Dietetic Association: Total diet approach to communicating food and nutrition information. J Am Diet Assoc 2007, 107:1224-1232. 18. Webb DA, Bloch JR, Coyne JC, Chung EK, Bennett IM, Culhane JF: Postpartum physical symptoms in new mothers: their relationship to functional limitations and emotional well-being. Birth 2008, 35:179-187. 19. Singh AS, Mulder C, Twisk JWK, van Mechelen W, Chinapaw MJM: Tracking of childhood overweight into adulthood: a systematic review of the literature. Obes Rev 2008. 20. Williams LK, Veitch J, Ball K: What helps children eat well? A qualitative exploration of resilience among disadvantaged families. Hlth Edu Res 2011, 26:296-307. 21. Oken E: Maternal and Child Obesity: The Causal Link. Obstet Gynecol Clin North Am 2009, 36:361-377. 22. Hartman MA, Hosper K, Stronks K: Targeting physical activity and nutrition interventions towards mothers with young children: a review on components that contribute to attendance and effectiveness. Public Health Nutr 2010, FirstView:1-18. 23. Keller C, Records K, Ainsworth B, Permana P, Coonrod DV: Interventions for weight management in postpartum women. J Obstet Gynecol Neonatal Nurs 2008, 37:71-79. 24. Kuhlmann AKS, Dietz PM, Galavotti C, England LJ: Weight-management interventions for pregnant or postpartum women. Am J Prev Med 2008, 34:523-528. 25. Amorim AR, Linne Y, Lourenco PM: Diet, exercise, or both, for weight reduction in women after childbirth (review). Cochrane Database Syst Rev 2007. 26. National Institute for Health and Clinical Excellence: Dietary interventions and physical activity interventions for weight management before, during and after pregnancy. NICE: Public Health Guidance 27 2010. 27. Keller C, Allan J, Tinkle MB: Stages of change, processes of change, and social support for exercise and weight gain in postpartum women. J Obstet Gynecol Neonatal Nurs 2006, 35:232-240. 28. Krummel DA, Semmens E, Boury J, Gordon PM, Larkin KT: Stages of change for weight management in postpartum women. J Am Diet Assoc 2004, 104:1102-1108. 29. Boutron I, Moher D, Altman D, Schulz K, Ravaud P: Extending the CONSORT statement to randomized trials of nonpharmacologic treatment: explanation and elaboration. Ann Intern Med 2008, 148:295-309. 30. Pollock ML, Franklin BA, Balady GJ, Chaitman BL, Fleg JL, Fletcher B, Limacher M, Pina IL, Stein RA, Williams M, Bazzarre T: Resistance Exercise in Individuals With and Without Cardiovascular Disease: Benefits, Rationale, Safety, and PrescriptionAn Advisory From the Committee on Exercise, Rehabilitation, and Prevention, Council on Clinical Cardiology, American Heart Association. Circ J 2000, 101:828-833. 31. Egger G, Donovon R, Swinburn B, Giles-Corti B, Bull FC: Physical activity guidelines for Australians: Scientific background report. A report by the University of Western Australia and The Centre for Health Promotion and Research Sydney for the Commonwealth Department of Health and Aged Care. Canberra 1999. 32. Department of Health and Ageing: Food for health: dietary guidelines for Australians, a guide to healthy eating. Canberra 2005. 33. Playgroup Australia Australia Inc.: Annual Report. Perth 2010. 34. Playgroup Western Australia Inc.: Communities enriched through playgroups: Annual report 2009-2010. Perth 2010. 35. Australian Bureau of Statistics: Census of population and housing: socioeconomic indexes for areas (SEIFA) 2006, information paper. Information paper 17 Canberra: Australian Bureau of Statistics; 2008, 17.


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36. Thomas S, Reading J, Shephard RJ: Revision of the Physical Activity Readiness Questionnaire (PAR-Q). Can J Sport Sci 1992, 17:338-345. 37. Cohen J: Statistical power analysis for the behavioural sciences Hillsdale, NJ: Lawrence Erlbaum Associates; 1987. 38. Power Analysis Sample Size. [http://www.ncss.com/pass.html]. 39. Coakes S, Steed L, Ong C: SPSS: analysis without anguish: version 17 for Windows Qld: John Wiley & Sons Australia Ltd; 2010. 40. Glanz K, Rimer BK, Lewis FM: Health behaviour and health education: theory, research and practice San Francisco: Jossey-Bass; 2002. 41. Prochaska JO, Diclemente CC: Stages and Processes of Self-Change of Smoking - toward an Integrative Model of Change. J Consult Clin Psychol 1983, 51:390-395. 42. Resnicow K, DiIorio C, Soet J, Borrelli B, Ernst D, Hecht J, Thevos A: Motivational interviewing in medical and public health settings New York: Guilford Press; 2002. 43. Walker LO: Managing excessive weight gain during pregnancy and the postpartum period. J Obstet Gynecol Neonatal Nurs 2007, 36:490. 44. Jones C, Burns S, Howat P, Jancey J, McManus A, Carter O: Playgroup as a setting for nutrition and physical activity interventions for mothes with young children: exploratory qualitative findings. Health Promot J Austr 2010, 21:92-98. 45. Howat P, Brown G, Burns S, McManus A: Use of the PRECEDE-PROCEED Framework to guide planning and evaluation for health promotion Sydney: Oxford University Press; 2008. 46. Green L, Kreuter M, (Eds): Health program planning: an educational and ecological approach. New York: McGraw Hill;, 4 2005. 47. Walker L, Kim S, Sterling B, Latimer L: Developing health promotion interventions: a multisource method applied to weight loss among lowincome postpartum women. Public Health Nurs 2010, 27:188-195. 48. Burke L, Howat P, Lee A, Jancey J, Kerr D, Shilton T: Development of a nutrition and physical activity booklet to engage seniors. BMC Res Notes 2008, 1:1-7. 49. United States Department of Health and Human Services: Making health communication programs work; a planner’s guide. Book Making health communication programs work; a planner’s guide National Institutes of Health; 1992. 50. Forsén L, Nina Waaler L, Vuillemin A, Chinapaw MJM, van Poppel MNM, Mokkink LB, Willem van M, Terwee CB: Self-Administered Physical Activity Questionnaires for the Elderly: A Systematic Review of Measurement Properties. Sports Med 2010, 40:601-623. 51. Sallis J, Grossma R, Pinski R, Patterson T, Nader P: The development of scales to measure social support for diet and exercise behaviours. Prev Med 1987, 16:825-836. 52. Sallis J, Pinski R, Grossman R, Patterson T, Nader P: The development of self-efficacy scales for healthrelated diet and exercise behaviors. Health Educ Res 1988, 3:283-292. 53. Craig C, Marshall M, Sjostrom A, Bauman A, Booth B, Ainsworth M, Pratt U, Ekelund A, Yngve J, Sallis J, Oja P: International physical activity questionnaire: 12 country reliability and validity. Med Sci Sports Exer 2003, 35:1381-1395. 54. Haskell W, Lee I, Pate R, Powell K, Blair S, Franklin B, Macera C, Heath G, Thompson P, A B: Physical activity and public health: updated recommendations for adults from the American College of Sports Medicine and American Heart Association. Circ J 2007, 116:1-13. 55. Morrow JR, Krzewinski-Malone JA, Jackson AW, Bungum TJ, FitzGerald SJ: American adults’ knowledge of exercise recommendations. Res Q Exerc Sport 2004, 75:231-237. 56. Wright J, Scott J: The fat and fibre barometer, a short food behaviour questionnaire: reliability, relative validity and utility. Aust J NutrDiet 2000, 57:33-39. 57. Flood VM, Webb K, Rangan A: Recommendations for short questions to assess food consumption in children for NSW Health Surveys City: NSW Centre for Public Health Nutrition; 2005. 58. Centre for Disease Control and Prevention: 2005 National Health Interview Survey. Book 2005 National Health Interview Survey National Center for Health Statistics; 2006. 59. Hendrie GA, DN C, Coveney J: Validtion of the General Nutrition Knowledge Questionnaire in an Australian community sample. Nutr and Diet 2008, 65:72-77. 60. Jalleh G, Lin C, Donovan RJ: Evaluation of the make smoking history ‘Sugar 9Sugar’ campaign: wave 23. Book Evaluation of the make smoking

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history ‘Sugar Sugar’ campaign: wave 23 Perth: Centre for Behavioural Research in Cancer Control, Curtin University; 2009. 61. Saris-Baglama R, Dewey C, Chisholm G, Chisholm B, Plumb E, King J, Kosinski M, Bjorner JB, Ware JE: SF-8™ Health Survey. QualityMetric Inc; 2007. 62. Dhaliwal SS, Howat P, Bejoy T, Welborn TA: Self-reported weight and height for evaluating obesity control programs. Am J Health Behav 2010, 34:489-499. 63. Treweek S, Pitkethly M, Cook J, Kjeldstrøm M, Taskila T, Johansen M, Sullivan F, Wilson S, Jackson C, Jones R, Mitchell E: Strategies to improve recruitment to randomised controlled trials (Review). Cochrane Database Syst Rev 2010, 4. Pre-publication history The pre-publication history for this paper can be accessed here: http://www.biomedcentral.com/1471-2458/11/648/prepub doi:10.1186/1471-2458-11-648 Cite this article as: Monteiro et al.: The protocol of a randomized controlled trial for playgroup mothers: Reminder on Food, Relaxation, Exercise, and Support for Health (REFRESH) Program. BMC Public Health 2011 11:648.

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Program Development for Community-Based Practice By Hui-Fen Mao

2012/10/11

1. Program Development --Including planning, development of implementation strategies, and evaluation. * “Program” vs. “Clinical service” -- Systematic efforts to achieve preplanned objectives such as changes in knowledge, attitudes, skills, and behaviors to maintain or improve function and /or health (health promotion and education) in a number of settings (schools, worksites, community agencies…). Program Planning 2. Principles of Program Planning - A process of establishing priorities, diagnosing causing of problems, and allocating resources to achieve objectives. 1) Plan the process (preplanning): overlook the success approach—who should be involved OT , when the planning should occur, what process will be followed , what internal and external resources (attitudes, policies, available expertise, time, space, money, priorities) , and fit with the organization’s mission. OT 2) Plan with people: - “the principle of relevance” * “Successful programs begin by considering the perceived needs of clients.” - “ the principle of participation” (to enroll the clients with more active role) “The more effective meeting the goal as the clients more actively involved.”(provide feedback active role in design….) - “ the concept of collaboration”: (stakeholders share the same goals and interest) *Advantages-- duplication of effort, more creative problem solving, better services. PT

1


3) Plan with data: knowledge in issue and associated factors (population/ environment), quantitative information (i.e. existing programs) / qualitative (attitude, beliefs, or barriers) 4) Plan for performance: (long-range planning) (i.e. routine services,

OT)

5) Plan for priorities: greatest need or effect

6) Plan for evaluation: “Doing right things” .

“Doing things right”.

- By systematic collection and analysis program and client information. - Built into the program design and spelled out in the program plan 7) Plan for measurable outcomes: clear objectives with some baseline data/ match the objectives (ADL, QOL, Care load) 3. Planning Process

(Table 6-1, p.99, Fig. 6-1, p. 100)

1) Preplanning – - Identify/state the problem and the target population - Identify existing information regarding issue of concern (from data, professional judgment, observation, existing literature, concerned individuals, or agencies). - Answer the key questions of who, what, and why - Assess the internal and external resources and barriers - Determine the goals of, and an approach for, the need assessment 2) Needs assessment: 3 sources of data for needs assessments * Table 6-2 Data collection methods for needs assessment - Literature review - Secondary data

2


- Survey (simple, meaningful, reliable) - Group process (open forums, focus groups, nominal group), build rapport * Select methods related to: characteristics of the target group, the type of information desired, resources available, the amount of interaction desired with the audience. 3) Data analysis and interpretation (more than an statistical exercise) - less on inferential statistics, more on identification of need, risk, seriousness of a problem, and access to services - interpret findings, set priorities regarding needs, suggest ways of addressing needs, to provide the direction and rationale for program planner to develop an effective intervention. 4. Program Plan Development: based on a merging of the findings of the needs assessment, theories, and available resources 1) The role of theoryâ&#x20AC;&#x201D;the assumption of the cause of problem and best way to change, no single theory 2) Putting the plan together: a. Goalsâ&#x20AC;&#x201D;quantify statement of a desired change in the status of a priority health need. Long term and broad in scope. Not directly measurable, bet attainable. b. Objectivesâ&#x20AC;&#x201D;specific, measurable *who/what(action/performance)/when(time frame)/how much(to what degree/standard of performance/level) (table 6-3) (Please list examples.) - Health objective: changes of the health status - Program objective: address the process of the intervention (new service plan) - Learning objective: address the knowledge, attitudes, or skills the program will attempt to effect to encourage specific behaviors - Behavioral (impact) objective: to describe what the program will encourage people to do to reduce risk or improve health. Reflect the program strategies. 3


- Resource objective: address the material support or essential services the program plans to provide c. Strategies—ecological perspective in health promotion, beyond the individual level for the effectiveness, influenced by the environment (reciprocal causation) *Ecological health promotion Planning Model (Simon-Morton et al, 1995)--5 societal levels: Factors to consider - Intrapersonal—individual characteristics that influence behavior (knowledge, attitude…) - Interpersonal—family, friends, peers, and groups that provide social identity, support, and role definition Organizational—agencies and their rules, regulations, policies, procedures, programs, and resources Community—social networks, norms, trends, and standards that constrain or promote desired action Public policy—local or central government policies, laws, and programs that regulate or support desired action (Examples: table 6-4, 6-5) d. Evaluation plan—include stakeholders, potential clients and clients * Steps for developing an evaluation plan: (P.113) * Level of evaluation: process, impact (intermediate effect), and outcome (long-term effect) (Table 6-6) * Characteristics and distinctions among the levels of program evaluation 4) Program Evaluation - to investigate the effectiveness to optimize the outcomes, efficiency, and quality of health care 5. Program Implementation -- Steps

(p.115) 4


6. Program Evaluation At program level not individual level 7. Institutionalization Study Questions 1. (Assume a program) What steps would you take to assess need? Who would 2. 3. 4. 5.

you involve? What questions would you want answered? How would you use occupational therapy concepts to shape an intervention strategy for a specific population? Write a goal, two learning objectives, and two behavioral objectives for this program. For the same program, describe possible interventions at each of the five societal levels. List several specific pieces of information you would record to conduct process evaluation of your program.

5


2008/04/23

1

OT Community Health Promotion Program


 Theoretical readings

Understanding of aging, adaptation, and the process of Occupational-analysis

 Pilot studies  A demonstration class

 Conceptual paths (the complexity of the project)

Constructing the Lifestyle Redesign Program

2


 Issues in “aging and adaptation”

 to identify adaptive strategies used by community-dwelling elderly, who were living successfully in community

 “Living a Meaningful existence in Old Age” (Jackson, 1996)  Purpose:

1st Pilot Study

3


4

 Engaging in occupations saturated with themes of meaning  Exercising control in the selection of occupations Occasional  Seizing opportunities to take risks excitement  Modifying the environment to enhance accessibility to occupations  Maintaining social connectedness  Sustaining an occupational temporal rhythm

Findings

The nature of occupation (i.e. Imagining and doing)


5

 Who you are as occupational beings?  How your child occupations shaped your adult characters?  How the things you do each day contribute to or compromise your health and well-being? How you select occupation each day?  Whether your everyday routines were a sensible plan for achieving goals?

Occupational Self-Analysis: Self-reflection process


 To explore the concerns (areas in which they perceived they needed help) of the persons targeted for the local participants  To build rapport

2nd Pilot Study—Needs Evaluation

6


 Claiming everyday experiences

 To get in-depth picture of the person’s story of himself or herself as an occupational being (which occupation or have the potential to be deeply meaningful?)

 To get the subjective meaning of occupations

 Collecting rich descriptions

Qualitative Approaches—through clinical reasoning (not coding)

7


 What do you do each day?  What do you believe are the barriers to doing you would like to do each day?  What things that you are particularly meaningful?  What special issues in daily living are bothering you right now? What creates stress in your life?  What do you think essential for a quality life?

Individual Interview (1)

8


ď&#x20AC; Throughout life, people choose to do certain activities they love. Can you describe the activities that have been most important in your life at each period, beginning with childhood and up to present? ď&#x20AC; What is it about these activities that you most like to do? What makes them attractive to you?

Individual Interview (2)

9


10

 Do you have daily routines or habits? How important is routine in your life?  What aspects of aging have you found the most challenging?  If you could change anything in your situation, what would you change?  Others…..

Individual Interview (3)


 1. Generate a summary and any stated adaptive strategy  2. To develop a typology of life domains  3. Another senior researcher interview the researcher to confirm it  4. Another set of researches refined the categories 11

 29 elderly persons (20 women, 9 men)  Method of naturalistic inquiry

The USC Well Elderly Study (1996)


 For developing the program protocol

 The dynamic process allows participants to be stimulated by and build on each other’s ideas and generate concepts that may not covered in interview. 

Focus Group

12


 Why would someone want to live in this retirement home?  What makes this residence unique?  What programs and activities are offered here? Which do you recommend and why?  How active are the residents here?  What are the differences between independent, assisted, and nursing care living?

Guiding Questions (1)

13


14

 What modes of transportation do you use?  Where would you like to go?  What stressors or obstacles do you face as a retiree?  What would you like to see changed in your community? Retirement home?

Guiding Questions (2)


 What are the most meaningful activities that fill your time?  How would you like to use your time better?  If there one thing you could add to your life, what would it be?  What would you like to learn regarding your health and wellness?

Guiding Questions (3)

15


16

Health mobility Personal finances Personal safety Psychological wellbeing and happiness  Relationship with others    

To customize a program to the local situation

 ADL  Adaptation to a multicultural environments  Use of free time  Grave illness and death  Health maintenance

10 Concerns


17

 Meta-analysis of the effectiveness of OT for older persons  A highly significant cumulative results (p< .001) (Carlson et al., 1996)

3st Pilot Study—Meta-analysis


 Facilitation: engaging, clarifying, responding  Data gathering and evaluation: identifying, synthesizing  Action skills: linking, providing resources, modeling

Skills of Leader

18


 2 cohorts (2nd-- 16 months after the 1st cohort) 19

 OT (lifestyle redesign)(102/122): 2-hr group sessions and another hour a month of individual OT, 60% attend 50% sessions)  Social activities control(100/120): 2¼ hours session per week, activities conducted without professional training (62% attend 50% sessions)  No treatment control (104/119)

 A RCT design  3 groups (n=361)

USC Well Elderly Clinical trial


Physical Exam Questionnaires

Follow-up

No contact

6 Months

-RAND 36-item Health Status Survey, Short form-36

Utilization of Health Services

20

-Medical Outcomes Study Short Forms General Health Survey

-Center for Epidemiologic Studies (CES) Depression Scale

-Life Satisfaction Index-Z

-Functional Status Questionnaires

Primary Outcome Measures

Questionnaires

Post-test (306)

15 Months 2 hrs/week-Small groups

Questionnaires

Physical Exam

Pre-test

2 hrs/week-Small groups

9 Month Program

Timeline for the Well Elderly Study


     

Living independently Urban Multiethnic (30% mandarin Chinese speakers) 65% women 73% live alone 27% with disabilities

 361 seniors (60~89 yr)  From federally subsidized apartment buildings for low-income older adults in greater LA

Participants

21


 Individual Format

 Up to 10 seniors for each group, 4 T’s  Skills of Leader: group dynamics/ therapeutic process  Elements of group treatment

Methods of Delivery  Group Format

Implementing the Lifestyle Redesign Program

22


 integrate reflections * Predictability and stability with change and growth

 15 min warm-up   4

 

Group Session

23


*

 Presentation  Peer exchange, storytelling  Direct experience-sense of self regulation or control  Personal exploration

Group Session Methods for delivering LRP

24


 9 hours  Home visit  To discuss occupation, describe photos, events in meetings  Puzzle the parts in group sessions with the visit  To encourage deep discussion

Individual Sessions

25


26

 Acquiring knowledge of the factors related to occupation that promote health and happiness  Perform and reflect on ones feeling and values (Occupational self-analysis)  Overcoming fears by incremental risks in small steps over time  To develop a health-promoting daily routine

Process to Change: 4 steps


Published in the Journal of the American medical Association (JAMA) (Clark et al., 1997), and was invited to address the Am. Med. Assoc. 16th Annual Science reports Conference on Oct. 21, 1997.

Results of the Lifestyle Redesign Program

27


 From Medical Outcomes Study (MOS) Short Forms General Health Survey (p=.05) 28

 8 domains: 1) general health (p=.02) 2) mental health, 3) physical health (p=.008) 4) social functioning (p=.05) 5) role limitations attributable to physical health problems (p=.02) 6) role limitations attributable to physical health (p=.05) 7) Bodily pain (p=.03) 8) Vitality (p=.004)

 RAND 36-item Health Status Survey, Short form-36:

Primary Outcome Measures


 Standard change scores result from OT

 COPM  Goal Attainment Scale (-2, -1, 0, 1,2)

 Life Satisfaction Index-Z (p=.03): 13 items  Center for Epidemiologic Studies (CES) Depression Scale: 20 items

 ADL, IADL, social function

 Functional Status Questionnaires (p=.03):

Primary Outcome Measures

29


4%

Limitations in work and activities due to emotional problems Other areas

4~6% better

2%

 6%

Vitality

14%

13%

Physical health

Control group 

5 of 8 general categories 1%

SF-36

OT group

30


   

CES-D IADL BADL Social activity subscales of the Functional Status Questionnaire  RAND SF-36 (high ceilings)

5/15 measures failed to show gain for the OT G’p (ceiling effects)

31


 Control groups tend to decline over the study interval

 Health, function, and QOL

 Significant benefits for the OT preventive treatment group

Conclusions

32


33

 An occupation could be meaningful simply because it created a positive experience  Occupation evoked feelings of risk  i.e. The group planed to going out across the street for attending a concert at night. “its not a lot of planning. But it’s more than they’ve ever done in terms of trying out a new program.”  Memorable, and Empowering moment

 View of the human as an occupational being  Meaning

What make this program effective?


34

 Better understand and appreciate the importance of meaningful activity in their lives  Teach how to select and perform activities to achieve healthy and satisfying lifestyle * To break the symbolic threshold (i.e. A depressed woman spent most of the day in bed or watching TV. A bus step  to climb aboard a bus to go out)  Learn to alter the approach to everyday activities

What make this program effective?


35

ď&#x20AC;&#x201E; to make individualized plan ď&#x20AC;&#x201E; to provide support, education, and to boost their confidence to try something new and embed in their memory that they are still risk taker.

ď&#x20AC; Therapist assess the amount and the meaningfulness of the activities, values, attitudes and goals, and balance within their daily routines.

What make this program effective?


36

ď&#x20AC;&#x201A; May help people organize their overall everyday pattern of occupation )

ď&#x20AC; Themes of meaning often guide the manner in which occupations are chosen and performed.

What make this program effective?


 Occupational storytelling or storymaking  To make personal Life History video

 2 ways:

37

 An evolving process– refashioned against the background of new challenges or sociocultural changes.  Persons continually engage in creating and revising their life narrative.

 Life narratives provide another context for understanding meaning.

What make this program effective?


 38

 “People have the potential to reorder their patterns of occupations from states of disequilibrium to more complex, stable patterns” (Jackson et al., 1998)  There is no designed protocol, but to provide knowledge and facilitate experiences => greater insight into their occupational choices  Deaf => T’s I can talk to people now” =>

 Dynamic Systems Theory

What make this program effective?


39

 Focus on the goal of helping people experience healthy and satisfying lives by maximizing their ability to successfully accomplish everyday activities (occupations)  Productive or meaningful occupation was the core of OT  Involve physical, psychological elements

 Doing therapy

Occupational Therapy


40

 What are the contributions of work and leisure to physical health, happiness, and QOL?  What constitutes a healthy balance of work, rest, and leisure on a typical day?

 Sample Questions

 the critical role of daily activities in promoting health  a sense of well-being in our lives on the nature of occupation and its effects on human beings

 Academic discipline: a systematic study of the form, function, and meaning of occupation  Focus on

Occupational Science


41

 Active participation in occupation is life itself. (life satisfaction)  Yerxa (1989) --“individuals are most true to their humanity when engaged in occupation”

 Occupation is life itself

Conceptual Foundation


 Occupation has a place in preventive care 42

 Occupation inducing vision of a future life worth living because, through participation in occupation, they begin to comprehend the possibilities available to them

 Occupation can create new visions of possible selves and life changes

Conceptual Foundation


43

ď&#x20AC; Engaging occupation affects the physical, mental health, and life order and routine.

Conceptual Foundation


44

 285 of 361 followed (79%)  Signed change scores  (Follow-up – minus pre-test score)  Analysis of covariance to test for change score differences between the OT and the control groups  Regression analysis to impute value for the missing data  OT gains were retained:  (effective size at follow-up / effective size at post-test)

(J of Gerontology, PSYCHOLOGICAL SCIENCES, 2001, 56B, No.1, p60-63)

Embedding Health-Promoting Changes into the Daily Lives of Independent-Living Older Adults: Long-Term Follow-up of OT Intervention


effect 0.29 (0.02 to 0.52)

 90% (0.29/0/32) of the magnitude of OT treatment gains was retained over the follow-up interval

 10 measures at follow-up:

 effect size:0.32 (0.2 to 0.47)

45

 5 of 7 variables: sig. beyond the 0.05 level  2 variables: marginally sig at the 0.1 level  10 measures positive at post-test

Results


46

 9-months OT program:$548 per subject, $68 for controls  Postintervention healthcare cost:  OT group ($967)  Active control group ($1,726)  Passive control group ($3,334)  Combined control groups ($2,593)

 Telephone interview 163 elderly  OT G’p/ Social G’p(Active control)/ No T’t G’p (Passive control)  Results:

Cost-effectiveness of Preventive Occupational Therapy for IndependentLiving Older Adults (JAGS 2002, 50:1381-1388)


47


=> Cost effectiveness

 OT group ($10,666)  Active control group ($7,820)  Passive control group ($13,784)

 A 4.5% QUALY differential, p<.01  The cost per QUAL estimated

 Quality of life Index

48


Journal of Community Health, Vol. 29, No. 6, December 2004 (! 2004)

THE EFFECTIVENESS OF A HEALTH PROMOTION PROGRAM FOR THE LOW-INCOME ELDERLY IN TAIPEI, TAIWAN I-chuan Li, DNS, RN

ABSTRACT: This study assessed the effectiveness of a health promotion program for low-income elderly provided by trained low-income home health aides. Indicators of the effectiveness of this program included improvement in physical health, psychosocial health and functional status, including activities of daily living (ADL) and instrumental activities of daily living (IADL) as well as changes in perceived health promotion needs. This evaluation study used a single group pre- and post-test experiment design. After informed consent forms were signed by participants, 89 purposively selected low-income elderly (aged 64–96) completed pre-test structured surveys, while 60 participants (aged 68–96) completed post-test surveys. Post-test scores indicated improved nutritional status (paired t ¼ 2.64, p < .05) and chore management of IADL abilities (paired t ¼ 2.83, p < .01). No significant difference in psychosocial status were found between pre- and post-test scores. Perceived needs for health promotion services decreased after the intervention. The results show that the health promotion services were effective in improving health status and decreasing perceived needs for services among low-income elderly in Taipei. Recommendations based on this study for developing services for the low-income elderly must take health promotion intervention into consideration. KEY WORDS: health promotion; program evaluation; low-income elderly.

INTRODUCTION The elderly population aged 65 to 84 is the fastest growing cohort in Taiwan.1 Persons aged 65 and over have increased from 7.0% of the total population in 1993 to 9.02% in 2002.2 Projections suggest that about 15% of Taiwan’s population will be 65 years of age or older by 2021. With advanced age, health impairment and disability increases. According to Wu, more than 70% of people over 65 have at least one I-chuan Li is Associate Professor of Community Health Nursing at National Yang-Ming University, Taipei, Taiwan. Requests for reprints should be addressed to Dr. I-chuan Li, Institute of Community Health Nursing, National Yang-Ming University, 155 Li-Nau St. Sec.2, Taipei 112, Taiwan, ROC; e-mail: icli@ym.edu.tw.

511 0094-5145/04/1200-0511/0 ! 2004 Springer ScienceþBusiness Media, Inc.


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chronic medical condition and about 5.4% of them require assistance with activities of daily living.3 In Taipei, about 12,073 persons, or 1.13% of the population, were classified as low-income in 2002. People in poverty have increased from 0.7% in 1998 to 1.13% in 2002. This growth can, to some extent, be attributed to rising unemployment rates and to changes in the labor market which have resulted in an increase in the number of people in low-paid employment.4 These figures are certainly low, however, as regulations for defining who falls below the poverty line are rigid. According to the Directorate General of Budgets, Accounting and Statistics, the poverty line has been calculated as 60% of the average per capita consumption expenditure during the past year. For example, in the second half of 1999 and in 2000 the minimum income required to be considered above the poverty line in Taipei is 11,625 TWD per month (about 322.91 USD).5 Old age ranks among the leading causes of poverty,6 and there is evidence to demonstrate the connection between poverty and old age, sickness and disability.7–9 Low-income people have higher mortality rates, shorter life expectancies and lose more years of life due to various diseases than do people who are not poor.10 Also, those living in poverty experience more chronic medical conditions along with symptoms of illness and disease, and they are more likely to have activity limitations.11 Taiwanese low-income elderly are especially less likely to engage in health promotion and are much more likely to be pessimistic about their health, leading to chronic health problems such as hypertension.12,13 The low-income elderly have poorer health due to difficulties in accessing basic requirements for good health such as adequate housing, food, water supply and medical and health care services.12,14–16 Furthermore, policy makers have been reluctant to acknowledge the links between poverty and ill health; anti-poverty policies in Taiwan have put too much emphasis on financial assistance not enough on self-care, independence and healthy lifestyles. Even more, most studies on poverty in Taiwan analyze its structure, but very few look at social and health needs. While the focus of poverty in the West has shifted in recent years from ill health to ‘‘lifestyle’’ and ‘‘health promotion,’’ i.e. smoking, unhealthy diet and lack of exercise,14 low-income populations are still seldom sampled or included in intervention studies of health promotion.17 Thus, the challenge for public health nurses is to promote health in conditions of poverty. Health promotion means different things to different people. Health promotion strategies can be extremely beneficial in the maintenance of functional health, especially for the elderly, as diminished func-


I-chuan Li 513

tional health status is the primary cause of loss of independence.18 According to Kate, health promotion has been categorized into three activities: prevention, protection and health education.13 Prevention would include screening for hypertension and physical examination. Protection would include such things as non-smoking and the provision of attractive leisure activities to improve fitness and social health. Health education is an act of communication that might include information about the body and how to look after it, or information about health services. The low-income elderly do not have the time or energy to devote to health promotion activities while struggling to meet the basic needs for living. Health promotion services to the elderly can increase their quality of life and their ability to independently manage their daily living activities. There is a need, therefore, to develop effective programs to: a) address health promotion activities for use by the low-income elderly; and b) to evaluate the effectiveness of these health promoting activities. The purpose of this study was to assess the effectiveness of health promotion services to the low-income elderly upon changes to their health status, activities of daily living and perception of health promotion. More specifically, this study: 1. Examined differences between scores on physical health before and after the implementation of a health promotion program for low-income elderly participants; 2. Examined differences between scores on psychosocial health before and after the implementation of a health promotion program for low-income elderly participants; 3. Examined differences between perceived health promotion needs before and after the implementation of a health promotion program for low-income elderly participants.

METHODS Sample Selections Names and addresses of low-income elderly people were obtained from the Social Welfare Department in Taipei. Inclusion criteria were that subjects were low-income elderly in the Peitou area of Taipei aged 65 or over living at home and receiving government assistance. One hundred and sixty persons living in the research areas met these criteria and were approached by the principal investigator, who


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obtained the consent of 90 of them by telephone. A letter of consent describing the study was given to all subjects and signed by them or, if unable to sign due to illiteracy or physical disability, by their families. Sixty subjects completed the 8-month study. Thus, 89 subjects completed the pre-test questionnaire and 68% (60/89) of them completed both the pre- and post-tests. Study Design This study was approved by the Human Subjects Committee of the Veterans General Hospital in Taipei City, and used one group preand post-test experiment. Low-income elderly participants were evaluated prior to and after participating in the program. A follow-up survey was conducted with the participants 8 months after intervention. Intervention During the period of intervention, subjects received an 8-month program utilizing direct personal visits by trained low-income workers as well as phone-counseling by five graduate nursing students. This was a project on health promotion services for the low-income elderly in the Peitou district of Taipei conducted from 1998 to 1999. The principal investigator received the assistance of the Taipei Social Welfare Department in developing the health promotion programs. The project was carried out in two phases: a) training the low-income workers; and b) developing a program for the workers to provide health promotion services to the low-income elderly. During the first phase, 30 workers received 40 hours of training over a period of 2 weeks. Content included methods for communicating with elderly people, ways to maintain a healthy lifestyle, illness prevention, nutrition, exercise and medication. Five graduate nursing students, also experienced clinical nurses, taught the classes and supervised skill acquisition. The second phase consisted of developing a program for assigning this same group of workers to positions providing health promotion services to the low-income elderly. Six types of services provided by trained low-income workers based upon the results of the needs assessment of subjects surveyed by five graduate nursing students were as follows: medical (referral services), nursing (nursing referral services and screening for hypertension), home-making services (meal delivery, assistance in feeding, assistance in bathing, assistance in going outside, clean-


I-chuan Li 515

ing house, assistance in shopping and assistance in medical visits), caring services (personal greeting, telephone greeting and assistance in leisure activity), health education (reminders to take medications, nutrition and regular physical examination), and financial assistance services (referral for financial assistance, information about dentistry or hearing aides and financial consultation). The program consisted of five levels of services determined by the frequency of home visits required (every 2 weeks, once a week, two visits per week, three to four visits per week or daily visits) that were based upon an individual’s health status. Included were activities of daily living, instrumental activities of daily living and family support. Each visit could not last longer than 2 hours, as per government regulations. The principal investigator decided the level of intervention needed according to the results of needs assessment and phone-counseling performed by the graduate nursing students. She met with the workers at the beginning of each week to discuss the subjects’ conditions and difficulties confronted during the last week, and also provided needed updates. On-the-job training was provided based on the suggestions of the workers about content/ skills needed. Measurement Structured questionnaires were the primary sources of measurement. The instruments obtained information by means of a selfreport. Assessments were made based upon the following indicators: 1) demographic profile; 2) health status, including physical and psychosocial aspects; 3) functional status, including activities of daily living (ADL) and instrumental activities of daily living (IADL); and 4) perceived health promotion needs, including medical, nursing, home-making services, caring services, health education and financial assistance. Demographic Profile Information on age, gender, educational status, marital status and living arrangement. Physiological Health Status The physiological health status scale developed by Li et al. (2001) to assess chronically ill patients’ health status was modified to suit the low-income elderly of this study.19 The original scale consisted of 19 questions. Experts recommended retaining five questions that related to the patients’ mobility, while the other 14 questions provide data


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concerning vision, hearing, respiration, nutrition, sleep, circulation, comfort, excretion, speech, genito-urinary function, gross appearance, chewing, cognition and skin integrity. Responses were rated on a 5-point Likert scale ranging from 1 (best health) to 5 (worst health), and scores ranged from 14 to 70. A Cronbach alpha coefficient was used to assess the internal consistency of this health status instrument. It was .87. Psychosocial Health Status After reviewing the related literature,20 and interviewing lowincome elderly, the current researcher developed a psychosocial health status tool comprised of five questions: emotional stability, interaction with neighbors, emotional status over the past week, arguments and fights with families during the past week and ways of dealing with emotional disturbances. These questions were rated on a 5-point Likert scale ranging from 1 (best health) to 5 (worst health); scores ranged from 5 to 25. A Cronbach alpha coefficient was used to assess the internal consistency of this health status instrument. It was .74. ADL and IADL Subjectsâ&#x20AC;&#x2122; ADL and IADL were measured using a Katz scale. Five questions were used to assess ADLs: eating, bathing, moving between bed and wheelchair, personal hygiene and dressing. Five IADL questions were assessed: household tasks, shopping, food preparation, laundry and letter writing. A 3-point Likert scale ranging from 1 (better ability) to 3 (worse ability) was used to rate ADL and IADL. The Cronbach alpha for ADL and IADL were .99 and .98, respectively. Perceived Health Promotion Needs The researcher developed this instrument after reviewing the literature regarding to health promotion and needs for low-income elderly.13,14 In this study, perceived health promotion needs were divided into six categories: medical, nursing, home-making services, caring services, health education and financial assistance required for health needs. The first subscale contained one question related to medical referral services, and two questions on skilled nursing services (nursing referral service and screening for hypertension). Seven questions comprised home-making services (meal delivery, assistance in feeding, assistance in bathing, assistance in going outside, cleaning house, assistance in shopping and assistance in medical visits). The subscale for needs of caring services contained three questions: personal greeting, telephone greeting and assistance in leisure activity. The subscale on health education ser-


I-chuan Li 517

vices contained three questions: reminders to take medications, nutrition and regular physical examination. The financial assistance subscale was comprised of three questions: referral for financial assistance, information about dentistry or hearing aides and financial consultation. To examine content validity, the researcher invited five experts (three professionals in geriatric nursing and two experts in social work) to evaluate the questionnaires using a 5-point Likert scale; a higher score meant the questions were clearer and more relevant. The mean score for questions on the demographic profile, physiological and psychosocial health, ADL and IADL were all above 4.5, showing good content validity. The content validity for the perceived health promotion needs instrument was 3.8. Data Collection Procedure A consent letter explaining the study was given to all potential participants, and subjects were requested to sign a consent form. Five graduate nursing students, registered nurses with clinical experience in teaching hospitals, conducted face-to-face interviews pre- and post-intervention in the subjectsâ&#x20AC;&#x2122; homes. The principal investigator provided two 3-hour training sessions for them at the beginning of the data collection period. Explanations of the purposes of the study and how to administer the instruments were provided. Throughout the study, the principal investigator worked with the five students to clarify questions about the interviews and data collection. The pre-test and final interviews were conducted at each subjectâ&#x20AC;&#x2122;s home. The students read the questions to the subjects and scored the results according to the responses.

RESULTS Demographic Characteristics and Health Status The demographics of the 89 subjects are shown in Table 1. The average age was 76.8 years, with a range between 64 and 96. The majority of the subjects were male (68.5%), single (43.8%) and lived alone (31.5%). Over the half of the subjects (62.9%) had not completed their elementary school education. Chi-square was used to compare differences between groups at pre- and post-intervention. There were no statistically significant differences between groups (p > .05).


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TABLE 1 Demographic Characteristics of Low-income Elderly in Study Pre-test (n = 89)

Post-test (n = 60)

Variables

n

%

n

%

Gender Male Female

61 28

68.5 31.5

40 20

66.7 33.3

Marital status Single Married Widow/widower Divorce Other

29 30 21 6 3

43.8 22.5 23.6 6.7 3.4

24 15 17 3 1

40.0 25.0 28.3 5.0 3.4

Education Less than elementary Elementary More than+elementary

56 16 17

62.9 18.0 19.1

34 14 12

56.7 23.3 20.1

Living arrangements Alone With family With relatives and family Institutionalized Other

28 23 31 6 1

31.5 25.8 34.8 6.7 1.1

23 17 10 10 0

38.3 28.3 16.6 16.6 0

Descriptive statistics were used for presenting demographic characteristics of low-income elderly.

The subjects of the study were physically healthy; their mean scores for physical health status ranged from 1.06 to 1.77 (SD ¼ .29–1.28) before the program was implemented and ranged from 1.02 to 1.90 (SD ¼ .13–1.23) at the completion of the program (1 represented the ‘‘best’’ level and 5 the ‘‘worst’’ level of health) (Table 2). Among the 14 physical condition questions, the nutrition scores on the pre-test had a mean of 1.77 (SD ¼ 1.28). Two-third of the subjects had normal eyesight and hearing, while one-third wore corrective eyeglasses. Many of the subjects were emotionally stable (46.1%) and had a positive attitude about managing their emotional problems. Nearly 85% of the subjects were able to carry out ADLs. Few elders had difficulties with eating, bathing, moving, hygiene, dressing or


I-chuan Li 519

TABLE 2 Comparisons of Physical Health Status From Before and After Health Promotion Program (n = 60) Pre-test

Post-test

Paired t-test

Item

Mean

SD

Mean

SD

t*

p

Nutrition Sleep Circulation Comfort Sight Hearing Excretion Speech Urination Appearance Chewing Cognition Respiration Skin integrity

1.77 1.63 1.57 1.53 1.46 1.45 1.37 1.29 1.28 1.27 1.24 1.16 1.09 1.08

1.28 1.04 1.20 1.00 .74 .75 1.04 .73 .96 .56 .75 .58 .29 .38

1.23 1.58 1.22 1.90 1.49 1.31 1.26 1.24 1.32 1.17 1.17 1.17 1.02 1.08

.65 1.12 .53 1.23 .82 .62 .66 .68 .92 .38 1.38 .53 .13 .34

2.64 1.11 .703 ).725 ).206 1.069 .741 .167 ).725 .240 .216 ).206 1.0 .250

.0142** .274 .486 .472 .838 .279 .463 .868 .472 .812 .830 .838 .323 .810

Paired t tests were used to compare the differences between pre- and post-test for physical health status. * Pair-t test; **p < .05.

undressing. The mean IADL scores were higher than those of the ADLs, revealing that subjects were less independent in regard to IADL abilities (Table 3). Outcomes of the Implementation of the Health Promotion Program Paired t-tests were used to compare differences in health status, including physiological, psychosocial, ADLs and IADLs, throughout the program. Improvement occurred in scores for comfort, sleep, sight, bowel function, speech, appearance, chewing and respiration, though these changes were not statistically significant. The only area in which a significant difference was found between pre- and post-evaluation scores was for nutrition (paired t Âź 2.64, p < .05) (Table 2). There was


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TABLE 3 Comparisons of ADLs and IADLs From Before and After Implementation of Health Promotion Program (n = 60) Pre-test

Post-test

Item

Mean

SD

Mean

SD

Paired t*

p

ADL Eating Bathing Moving Hygiene Dressing and undressing IADL Household tasks Shopping Food preparation Laundry Chore management

1.13 1.06 1.13 1.18 1.15 1.15 1.43 1.34 1.34 1.38 1.35 1.79

.39 .28 .43 .47 .47 .47 .60 .66 .66 .68 .66 .89

1.08 1.05 1.07 1.15 1.07 1.07 1.29 1.15 1.25 1.27 1.25 1.51

.30 .22 .31 .41 .31 .31 .51 .45 .58 .58 .58 .73

)1.070 )1.000 )1.000 )1.427 – – .08 .22 .73 ).52 ).68 2.83

.289 .321 .321 .159 – – .936 .830 .472 .607 .499 .007**

*Paired-t test; **p < .05.

no statistically significant difference in subjects’ psychosocial status between pre- and post-evaluation scores. Post test scores showed improvements in all ADLs, but the changes were not statistically significant (Table 3). The only area which saw a significant difference among IADLs between pre- and post-evaluation scores was chore management (paired t ¼ 2.85, p < .05). Six kinds of health promotion services were assessed using paired t-tests to compare the differences between pre- and post-test for ADLs and IADLs compare differences between the pre- and post-test: medical, nursing, home-making services, caring services, health education and financial assistance services (Table 4). The following services had significant differences of perceived health promotion service needs between the pre- and post-test: medical services referral (paired t ¼ )3.90, p ¼ .000), screening for BP (paired t ¼ )2.41, p ¼ .016), assistance in going outside (paired t ¼ )2.49, p ¼ .014), cleaning house (paired t ¼ )2.53, p ¼ .011), assistance in medical visits, (paired t ¼ )2.50, p ¼ .012), personal greeting (t ¼ )2.41, p ¼ .016), telephone greeting (paired t ¼ ) 6.00, p ¼ .000), assistance in


I-chuan Li 521

TABLE 4 Comparisons of expressed needs about health promotion services from before and after implementation of health promotion program (n = 60) Pre-test (n)

Post-test (n)

Mean difference

Paired-t

p

Medical services Referral

27

11

)9

)3.90

.000***

Nursing services Nursing referral Screening for BP

11 58

3 36

)8 )22

)1.68 )2.41

.096 .016*

Home-making services Meal delivery Assistance in feeding Assistance in bathing Assistance in going outside Cleaning house Assistance in shopping Assistance in medical visit

7 2 4 10 18 6 28

0 0 2 1 3 0 10

)7 )2 )2 )9 )15 )6 )18

)1.73 )1.00 )0.58 )2.49 )2.53 )1.41 )2.50

.083 .317 .564 .014* .011* .157 .012*

Caring services Personal greeting Telephone greeting Assistance in leisure activity

55 53 46

24 2 9

)31 )51 )37

)2.41 )6.00 )4.31

.016* .000*** .000***

Health education Reminders to take medications Nutrition Regular physical examination

33 41 60

9 1 24

)24 )40 )36

)2.60 )5.19 )3.53

.009** .000*** .000***

26 20

4 4

)22 )16

.00 1.00 )2.32 .020*

35

1

)36

)4.60

Item

Financial assistance Referral Information about dentistry or hearing aides Financial consultation

.000***

Paired t tests were used to compare the differences between pre- and post-test for perceived health promotion services. *p < .05; **p < .01; ***p < .001.

leisure activity (paired t ¼ )4.31, p ¼ .000), health education for reminders to take medicine (paired t ¼ )2.60, p ¼ .009), nutrition education (paired t ¼ )5.19, p ¼ .000), regular physical examination (paired t ¼ )3.53, p ¼ .000), information about dentistry or hearing aides


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(paired t ¼ )2.32, p ¼ .020) and financial consultation (paired t ¼ )4.60, p ¼ .000) (Table 4). DISCUSSION The percentage of subjects living alone in this study was 31.5%, which was much higher than was found in the elderly by population in Taipei (14.0%) during the same year. They require more attention to their health status and care needs in order to delay being institutionalized.22 The majority of subjects had a good level of physical health and a higher level of independence in ADLs and IADLs in this study. In studies reported in the United States and in Taiwan, the majority of elderly living alone enjoyed good physical health and had higher scores for ADL and IADL.23,24–25 Thus, maintaining a healthy and satisfactory life and keeping up functional capacity are very important for the elderly. Health promotion is the best way to promote self-reliance, to increase optimal well-being and to achieve personal completion.26 In this study, the ability of chore management could be improved significantly after implementation of the health promotion program through a service provider strategy. Malnutrition was a common health problem in this study, and is also a significant problem for those living in poverty worldwide. According to McCally et al., malnutrition affects about 2 billion people living in poverty worldwide.27 Thus, among numerous approaches for improving the health of poor populations, the most essential task is to ensure the satisfaction of basis human needs, including shelter, clean air, safe drinking water and adequate nutrition.27 It is also the basic task for public health nurses to promote health for low-income persons.9 The causes of malnutrition can go beyond having insufficient funds for monthly living expenses; social or environmental barriers, such as inadequate diet due to the lack of health information or living alone and not having a supportive system for an adequate diet. Fortunately, nutritional status improved after implementation of the current health promotion program. Possible reasons for the low nutritional status were that some subjects did not have anyone to help them and they lacked nutritional health education.28 Home health workers in this study carried out services of health education, food preparation, shopping and meal delivery. Welfare policy for the low-income elderly, especially for those who live alone, should focus upon providing home making services to assure that these include nutritional services.


I-chuan Li 523

According to Ahluwalia et al.’s study, low-income families were less likely to draw support from their neighbors as compared to close family members and friends,28 inducing the problem of food insufficiency. Thus, suggestions raised in their study included establishing and supporting social networks between neighbors and providing appropriate education and counseling regarding food sufficiency. Some ways of accomplishing this may include mobilizing existing social networks and strengthening communities to interact with public and private service providers to address food insufficiency issues in their communities. Anti-poverty policy in Taiwan, then, should put nutrition the top priority in order to allocate the appropriate funds and resources for low-income people. Innovative approaches are needed, such as the development of partnerships between private and public sectors and between low-income persons and their neighborhoods to promote nutritional health. Low-income people may feel more isolated from neighbors due to long-term economic hardships.29 As Wilkinson, and Kawachi and Kennedy have stated, relative poverty is associated with a breakdown in social cohesion.30–31 The results of this study reveal that regular physical examinations was the most perceived health need. However, Hung and Lin’s study on health status and the needs of the elderly living alone show that 56.6% of subjects had never had any kind of health examination, in spite of the fact that annual periodic physical examinations for people older than 65 years are covered by the social welfare policy. The study reported that the lack of transportation and information about physical examinations were reasons that the elderly did not make use of the service.12 However, barriers for the unmet need of physical examination for the low-income elderly are unknown, as there are few published research articles on this topic. The need for physical examinations could be satisfied through health promotion programs, initiated by this study, which would provide transportation and information services. Checking blood pressure was another need perceived by subjects in the study, indicating that the majority of the subjects understood its benefits and importance. After implementing the health promotion program, trained workers checked subjects’ blood pressure in their homes, which was a significant improvement over the previous situation. Thus, home-based health promotion services can satisfy subjects’ needs by addressing individual needs through assessment, referral and support. The most commonly expressed needs for health promotion services for the low-income elderly can be satisfied through these health promotion services, especially caring, home-making and educational services. Suggestions for reshaping welfare policy for the low-income elderly


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must take the promotion of health intervention into consideration (instead of merely financial assistance) in order to prolong their independence in carrying out daily living activities. Based on low-income elderly status, perceived needs of health promotion and the effectiveness of a health promotion program, several recommendations can be made to improve independence and satisfy the needs of low-income elderly. 1. Raise public and policymaker awareness of the likelihood that low-income elderly living alone may become helpless in their homes, and promote activism within a community. Thus, anti-poverty policies in Taiwan should not be focused only upon financial assistance, but should integrate public and private, and formal and informal resources, especially providing home-based personnel services in order to prolong independency. 2. In this study, personal contact with trained health workers has been found to satisfy most of the perceived needs for health promotion services. Home workers, trained volunteers, neighbors or family members should be involved in health promotion intervention in order to decrease the social isolation of the low-income elderly.

ACKNOWLEDGMENTS The author thank the Taipei Welfare Department for funding and assisting this program. Special thanks to all low-income workers and elderly for participating in this study.

REFERENCES 1. 2. 3. 4. 5. 6. 7.

Department of Health, the Executive Yuan. Department of Health and Sanitation Statistics for 2001. Taipei: Executive Yuan, 2002, pp 1–30. Ministry of the Interior. Statistics and Analysis on Low-Income Family and Life Assistance 1999. Taipei: Executive Yuan, 2000, pp 26–38. Wu SZ, Chiou CJ. The exploration of related factors of nursing care problems in home health care patients. J Nurs Res 1997; 5:279–89. Li CY. Discussion of Social Assistance Act. Community Dev J 2001; 95:143–47. Department of Auditing. ROC Social Indicator Statistics: Personal Income Distribution Survey Report. Taipei: Executive Yuan, 2002, pp 18–26. Department of Social Welfare, Taipei City Government. General Report on Low-income Family. Taipei: Executive Yuan, 2002, pp 1–36. LeClere B, Soobader MJ. The effect of income on the health of selected US demographic groups. Am J Public Health 2000; 92:1892–7.


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8. 9. 10. 11. 12. 13. 14. 15. 16. 17. 18. 19. 20. 21. 22. 23. 24. 25. 26. 27. 28. 29. 30. 31.

Department of Social Welfare, Taipei City Government. General Report on Low-income Families, 1998. Taipei: Executive Yuan, 1999, pp 5–38. Reutter L, Neufeld A, Harrison MJ. Public perceptions of the relationship between poverty and health. Can J Public Health 1999; 90:13–18. Wilkins R. Mortality by Neighborhood Income in Urban Canada, 1986–1991. Poster presented at the Conference of the Canadian Society for Epidemiology and Biostatistics (CSEB). Newfoundland: St. John’s, 1995. Roberge R, Berthelot JM, Wolfson M. The Canadian Fact Book on poverty 1998. The Canadian Council on Social Development, Ottawa,ON, Canada. 1995. Bai SC. The Social Welfare for the Elderly. Taipei: San-Min, 1996, pp 25–8. Kate Y. Health, health promotion and the elderly. J Clin Nurs 1996; 5:241–8. Daykin N, Naidoo J. Poverty and health promotion in primary health care: Professionals’ perspectives. Health Soc Care Commun. 1997; 5:309–17. Williamson DL, Fast JE. Poverty and medical treatment: When public policy compromises accessibility. Can J Public Health 1998; 89:120–4. Wieck KL. Health promotion for inner-city minority elders. J Commun. Health Nurs 2000; 17:131–9. Minkler M, Schauffler H, Clements-Nolle K. Health promotion for older Americans in the 21st century. Am J Health Promot 2000; 14:371–9. Pandula CA. Development of the health promotion activities of older adults measure. Public Health Nurs 1997; 14:123–8. Li IC, Lien IN, Lin YC. Long-term care services needs for spinal-cord injury patients in Taiwan. J Nurs Res 2001; 9:127–38. Jou YH, Yang WS, Chuang YL. Stressor in late life, social supports, and the mental and physical health of the elderly. J Soc Sci Philos 1998; 10: 227–65. Chiao JW, Huang LH. The relationship of life style and hypertension of middle- and old-aged from low-income families in An-Kang community, Taipei, Taipei city. J Nurs Res 1995; 3:341–51. Campion EW. Home alone, and in danger. N Engl J Med 1996; 334:1738–9. Huang LH, Lin YC. The health status and needs of community elderly living alone. J Nurs Res 2002; 10:227–35. O’Connor M. The self-perceived health needs of the rural elderly who live alone. J Med Sci 1992; 161:108–11. Hsiung HF. Health Status, Social Support and Related Factors Among Community Elderly Live Alone. Taipei: National Taiwan University, 1998, pp 1–112. Palank CL. Determinants of health-promotive behaviors. Nurs Clin North Am 1991; 26: 815–28. McCally M, Haines A, Fein O, Addington W, Lawrence R, Cassel C. Poverty and ill health: physicians can and should, make a difference. Ann Intern Med 1998; 129:726–33. Ahluwalia IB, Dodds JM, Baligh M. Social support and coping behaviors of low-income families experiencing food insufficiency in North Carolina. Health Edu Behav 1998; 25:599–612. Li SH. The study of daily life stress, social support and coping of low-income woman—An example of FuMing community. Taipei: National Yang-MingUniversity, 2000, pp 1–121. Wilkinson D. Socioeconomic differentials in health: a renew and redirection. Soc Psychol Quart 1990; 53:81–99. Kawachi I, Kennedy BP. Health and social cohesion: why care about income inequality. Bri Med J 1997; 344:1037–40.


Guiding Questions for Fieldworks: 1. 2.

(the problem and the target population) 3~7

3. 1) Plan the process— 2) Plan with people— 3) Plan for priorities— 4) Plan for evaluation— 4. 5. 6. 7.

(how to approach to achieve the goal?)

measurable outcomes?

(Goals) (Objectives) (resources)? barriers

?

(5 societal levels --intrapersonal, interpersonal, organizational, community, public policy)

Assume a program 1. What steps would you take to assess need? Who would you involve? What questions would you want answered? 2. How would you use occupational therapy concepts to shape an intervention strategy for a specific population? 3. Write a goal, two learning objectives, and two behavioral objectives for this program. 4. For the same program, describe possible interventions at each of the five societal levels.


2012 autumn -- 429 U0210 Topics in Community-based Practice of Occupational Therapy

Adult Day Care Program By Hui-Fen Mao 1.

2012/10/25

What is the need for adult day-care programs? - “Aging in Place” -- US 1980/ Taiwan 1999

95% live in community (1990 US. Census Bureau), 95% elderly prefer to live at home 94 65 59.95 85.90% ( ) -

Providing needed health, medical, social, respite, and rehabilitation services while allowing the elderly to remain at home

2. Definition: ( National Institute on Adult Day Care, NIAD, 1990) - Adult day care program—a community-based group program designed to meet the needs of functionally impaired adults through an individual plan of care. It is a structured, comprehensive program that provides a variety of health, social, and related support services as well as the support for caregivers, within a protective setting during any portion of a day but less than 24-hour care…..assists its caregivers to continue caring for an impaired member at home. - Adult day care services (ADS) are a community-based program intervention that provides health, nutrition, and social services, frequently for older adults, at congregate sites during daytime hours. - Day services can be divided into three models: the medical model, the social model, and the combined model (Kirwin & Kaye, 1993; van Beveren & Hetherington, 1998). 3. Goals of the adult day-care programs : 1) Promote the person’s maximum level of independence 2) Maintain the person’s present level of functioning as long as possible, preventing or delaying deterioration.

1


2012 autumn -- 429 U0210 Topics in Community-based Practice of Occupational Therapy

3) Restore and rehabilitate the person to the highest possible level of functioning 4) Provide support, respite, and education for families and other caregivers 5) Foster socialization and peer interaction * Different terms: Day treatment, Day health care, Day hospitals -- for younger adults with disabilities * Common goal-- enabling clients to function as effectively and independently as possible within the context of their community (AOTA, 1986) * Benefit form fun, friendship, acceptance, new experiences, and improved quality of life * Concern the essential humanity of the individual and the quality of life in spite of disability 1) Each person as a unique individual with strength and weakness, yet with a potential for growth and development 2) A holistic approach to the individual, recognizing the interrelationship among physical, social, emotional, and environmental aspects of well being 3) Promote positive attitudes and a positive self-image, restoring, maintaining and stimulating capacities for independence * Productivity, self-directness, active participation, and faith in the patientâ&#x20AC;&#x2122;s potential are concerned. 4. Development of adult day care: - 1942 Day care program for mental health in Solvents - First developed: in England during 1958: Day hospital (Nurse and OT) - Older Americans Act of 1965â&#x20AC;&#x201D;1st adult day care program to facilitate early hospital discharge for chronically ill elderly patients who required continued restorative services

2


2012 autumn -- 429 U0210 Topics in Community-based Practice of Occupational Therapy

- 1970 Medicare demonstration project, growing soon (1974~1988: 18~1700 centers - Extended concept to include emphasis on stimulation, activity, and the support services needed to maintain the person in community following rehabilitation - Since 1980, a quick growth in the development of specialized or special-purpose centers for younger adults with physical dysfunction, MR, DD,, Mental health needs, person with HIV 5. Development of adult day care in the Taiwan: - 1990

, 1993

- 2004 -

23

15

1987 2610

- 2008

â&#x20AC;Ś.

(i.e. 1989:

12

259

6

2 )

10.7%

63

2004

18.3%

6. Population served - Participants: reflects the activity orientation and purposefulness - With multiple chronic illnesses and specific functional impairment - Survey 847 centers in US (1986): Cognitive impairment requiring supervision (45.4%) or constant supervision (19.8%), mobility limitations (17.3), behavior disruptive (7.6%), DD (10.1%), incontinence (7.8%) - related to the specific program 7. Adult day care program models: Health/ Social/ Supportive services - 21% medical model, 37% used the social model, and 42% were a combination of the two, 20% of the programs were dementia specific (the Robert Wood Johnson (RWJ) Foundation Partners in Caregiving program, 2003) - Service content: *health-related services (weight monitoring, BP checks, and medication 3


2012 autumn -- 429 U0210 Topics in Community-based Practice of Occupational Therapy

administration) 100% * personal assistance (meals, toileting, incontinence care, walking, and wheelchair use) 100% * social services 80% * nursing services such as tube feeding, wound care, catheter care 50% * baths or showers 1/3 * dental services, ophthalmology, and podiatry services less than 19% - 3 types of services: Basic/ professional/ medical - Depends on program’s emphasis, or philosophy and the needs of participants and their caregivers Basic service: general nursing, supervision of personal hygiene, lunch, and referral to community agencies. 1) Health or Medical or Restorative model-- rehabilitation -

Participants: with unstable health conditions and specific functional impairments (Alzheimer’s disease, Parkinson’s disease, RA, CVA, MS) Day treatment, Day health care, Day hospitals Usually in hospital, rehab. centers, skill nursing facilities Short-term treatment and timely discharge, refer to programs of social model Content of services:  Nursing care, therapies on a consult or contract basis, medical social work, therapeutic recreation, and adapted social or recreational activities  Available medical services--physical assessments,, psychiatry, dentistry, podiatry

- funded through Medicaid or private insurance 2)

Social model -- recreation and socialization - Primary goal-- prevention - Participants: with stable health conditions or may be at risk due to social isolation, lack of family support, physical frailty. 4


2012 autumn -- 429 U0210 Topics in Community-based Practice of Occupational Therapy

- Content of services: 

-

-

Basic provision of meals, transportation, recreation,, and social meetings.  Screen or periodic health monitoring Funded under the Social Security Act or Title III of the Older Americans Act (feudal grant to state agencies for the provision of nutrition and social services) =>

Supportive Maintenance model -- prevention 7. Occupational Therapy Roles * Philosophically, OT and adult day care both emphasize individual potential for growth and development, and a holistic integration of the mental, physical, social, emotional, spiritual, and environmental aspects of well-being. 1) Direct-care clinician - medical/restorative emphasis: (case example, p.167-8) 2) Activity program coordinator - assess the interests of each participant to determine the activity needs and preferences, develops an activities plan (individual or group activities). 3) Case manager - function as the liaison between the clinical staff and client/family, coordinates the client’s health needs. - advocate for the participant: screening, leads the interdisciplinary team in preparing and regularly updating a comprehensive treatment plan, monitors intervention by other team members, assesses community support services, and functions as the family or caregiver liaison. (AOTA, 1991) 4) Consult - Use OT’s expertise in the development and delivery of day-care services (activity adaptation, environmental design, group process, and training 5


2012 autumn -- 429 U0210 Topics in Community-based Practice of Occupational Therapy

paraprofessional staff, to enhance the quality of the program, developing specific programs or assisting staff in solving existing or potential problems.) -Key elements: Understanding of organizational theory and dynamics, proficiency in effective communication, the ability to diagnose problems and offer appropriate solutions or strategies. 5) Administrator - responsible for the financial management, regulatory compliance, and marketing of the facility as well as program planning, implementation, and evaluation. 9. The Future - growing needs - growing knowledge of the impact of activity on health status - attitude toward using day care program - policy maker: awareness, transportation problem, , fund support - cost-effectiveness (time and money)

,

, 1999 1

,181 -229

:

• –

13

8

6


2012 autumn -- 429 U0210 Topics in Community-based Practice of Occupational Therapy

(1) (2)

(3)

(4) (5) (6)

(7) (8) (9) (10)

_________________________________________________________ Outcomes of Adult Day Services for Participants: A Conceptual Model (Dabelkoand Zimmerman. Journal of Applied Gerontology, 2008, 27: 78)

•What about individual programs makes a difference? •The positive effect of adult day services (ADS) –on caregivers (Gaugler et al., 2003; Lawton, Brody, & Saperstein, 1989; Montgomery & Borgatta, 1989; Zarit, Parris Stephens, Townsend, Greene, & Leitsch, 1999; Zarit, Stephens, Townsend, & Greene, 1998)

–on participants remains unclear –Outcome vs. Process * Studies of ADS Effects

7


2012 autumn -- 429 U0210 Topics in Community-based Practice of Occupational Therapy

• Improved caregiver adaptation? – by reducing subjective burden, role overload, worry, anger, and depression (Gaugler et al., 2003; Lawton et al., 1989; Montgomery & Borgatta, 1989; Zarit et al., 1998; Zarit et al., 1999). • Improved client functioning? – little or no effect on physical functioning of participants – improvement primarily in subjective well-being such as morale, mood, and satisfaction * Programs that emphasize psychosocial support instead of rehabilitation may be a better match for client needs •Delayed nursing home placement? –the risk of nursing home placement increases with the number of days individuals with AD (McCann et al., 2005) Logic Model •a practice-based systematic examination of services and outcomes that is useful for field research. •focuses on the “target, means, and ends” of a purposeful intervention. •A logic model identifies goals, objectives, inputs, methods, intermediate results, and outcomes (Alter & Egan, 1997).

Proposed Model to Study Participant Services and Outcomes in Adult Day Services

•RCT: too challenge •Well-structured, repeated studies based on specific conceptual models. –Collecting individual-level data to tell the stories of individual experiences whose functional health and psychosocial needs can be met through ADS. –Alternative data collection methods, such as face-to-face interviews and behavioral observations, and designs such as repeated measures.

8


2012 autumn -- 429 U0210 Topics in Community-based Practice of Occupational Therapy

NEEDS

SERVICE ELEMENTS

PROXIMAL OUTCOMES

DISTAL OUTCOMES

PSYCHOSO

Activities

Maximizing

Emotional w ell-being

CIAL

Relationships with staff and other independence/control

(lower depression and

DOMAIN OF

clients

Personal growth

anxiety)

INFLUENCE

Helping roles for the program

Positive relationships

and other clients

with others

Social work wervices

Increased sense of purpose in

(advocacy, care management,

life increased sense of

crisis intervention)

self-acceptance (Ryff, 1989)

PHYSICAL

Rehabilitation therapy

Less assistance needed

Physical well-being

FUNCTION

Personal assistance

with ADLs Less Assistance

(lower health care

ING

Medical services

Needed with IADLs

utilization and

DOMAIN

(podiatry, dental services,

Reduced Nutritional Risk

positive perceived

OF

ophthalmology, etc.)

INFLUENC

Nursing services (tube feeding,

E

wound care, etc.)

health)

Nutritional Services

Figure 1.

Proposed Model to Study Participant Services and Outcomes in Adult Day Services

NOTE: Mediating variables: demographics, primary caregiver relationship, health diagnosis/events, enrollment, and cognitive functioning. ADLs = activities of daily living; IADLs = instrumental activities of daily living.

References Baumgarten, M., Lebel, P., Laprise, H., Leclerc, C., & Quinn, C. (2002). Adult day care for the frail elderly. Journal of Aging and Health, 14(2), 237-259. Zimmerman Dabelko H.I. & Zimmerman J.A.(2008). Outcomes of Adult Day Services for Participants: A Conceptual Model. Journal of Applied Gerontology, 27: 78-92. Gaugler, J. E., Jarrott, S. E., Zarit, S. H., Stephens, M. P., Townsend, A., & Greene, R. (2003). Adult day service use and reduction in caregiver hours: Effect on stress and

9


2012 autumn -- 429 U0210 Topics in Community-based Practice of Occupational Therapy

psychological well-being for dementia caregivers. International Journal of Geriatric Psychiatry, 18, 55-62. Gaugler, J. E., & Zarit, S. H. (2001). The effectiveness of adult day services for disabled older people. Journal of Aging and Social Policy, 12(2), 23-47. Hedrick, S. C., Rothman, M. K., Chapko, M., Ehreth, J., Direher, P., & Inui, T. S. (1993). Summary and discussion of methods and results of the Adult Day Health Care Evaluation Study. Medical Care, 31, SS94-SS103. Leitsch, S. A., Zarit, S. H., Townsend, A., & Greene, R. (2001). Medical and social day services programs. Research on Aging, 23(4), 473-498. McCann, J. J., Hebert, L. E., Li,Y.,Wolinsky, F. D., Gilley, D. W., Aggarwal, N. T., et al. (2005). The effect of adult day care services on time to nursing home placement in older adults with Alzheimer’s disease. The Gerontologist, 45(6), 754-763. Robert Wood Johnson Foundation. (2003). Special reports—The role of adult day services. Retrieved from http://www.rwjf.org/news/special/adultdayEvolution.jhtml Weissert, W. G., Lesnick, T., Musliner, M., & Foley, K. A. (1997). Cost savings from home and community-based services: Cost savings from Arizona’s Medicaid long-term care program. Journal of Health Politics, Policy & Law, 22(6), 1329-1357. Weissert, W. G., Wan, T., Livieratos, B., & Katz, B. (1980). Effects and costs of day-care services for the chronically ill. Medical Care, 18, 567-584. Zank, S., & Schacke, C. (2002). Evaluation of geriatric day care units: Effects on patients and caregivers. Journals of Gerontology: Psychological Sciences, 57B(4), 348-357. Zarit, S. H., Parris Stephens, M. A., Townsend, A., Greene, R., & Leitsch, S. A. (1999). Patterns of adult day service use by family caregivers: A comparison of brief versus sustained use. Family Relations, 48, 533-361. Zarit, S. H., Stephens, A. P., Townsend, A., & Greene, R. (1998). Stress reduction for family caregivers: Effects of adult day care use. Journals of Gerontology: Social Sciences, 53B(5), S267-S277.

10


Independent Living Program By Hui-Fen Mao * Who need the independent living program? 1. Independent Living Movement (1960s and 1970s) -- Definition: “Control over one’s life based on the choice of acceptable options that minimize reliance on others in making decisions and performing everyday activities. -- Philosophy: freedom of choice and equality for person with disability, -- Concepts: normalization (not group home or nursing home), freedom of choice, full participation in society (not in the handicap section), and access to the physical environment (rather than change individual). -- A needs for persons with disabilities to have more autonomy, better services, and self-determination. -- bridge the gap between “medical rehabilitation and vocational programs”, to live independently in the community -- Community orientation: not focus on ADL/IADL training (for living at home), but on housing, personal attendant management, transportation, and physical access to the community -- Legislation (p. 177, Table 10-1) 1) 1973 the Rehabilitation Act, 2) 1978 Federal involvement and provide funding, 3) 1986: Criteria: a) a physical and/or mental disability which poses a substantial handicap to independence or community integration, b) a reasonable expectation the consumer will be able to achieve independence with service. 2. Independent Living Model -- Consumer is the primary decision maker to determine the service participating -- Goal: far exceed ADL performance, seeking self-direction and full integration into society

1


-- Focused problems: not to solve the limited physical, mental, or emotional status of the individual, but as an in accessible environment, the negative attitudes of others, and even the rehabilitation process itself. --Solutions: Self-help, consumer control, removal or barrier and disincentives, peer counseling, and advocacy (not from the professional and client relationship) 3. Independent Living Programs --Community-based service and advocacy organization -- To achieve and maintain independent lifestyle -- Non profit, nonresidential, and consumer controlled (PWD involved in program development and service provision) (vs. programs to facilitate the independent living) -- Referral sources: service providers (medical treatment services, sheltered workshops, ATD supplier) 4. Types of Independent Living Programs 1) Independent Living Center-- must provide 4 services: A. Information about the referral to agencies supplying applicable services (housing, transportation, attendant care) B. Peer counseling C. Advocacy services D. Independent living skill training * nonprofit, nonresidential, and consumer controlled (51% making decision) 2) Independent Living Transitional Program: -- Goal: to move the more dependent situation to independentâ&#x20AC;Ś. -- Focus in independent living skill training (i.e. transportation, money management, social skillâ&#x20AC;Ś.) -- Goal-oriented, time-linked, and not necessarily consumer controlled 3) Independent Living Residential Programs -- live-in programs directed by provide services (attendant care and transportation) -- A variety of arrangement: several persons in a home or apartment, motel or dormitory-type buildings * Only 6% o ILP are exclusively residential

2


5. Variations among Independent Living Programs - Service Delivery Method: Contract basis (48%), referral basis (7%), both methods (43%) (Bowen, 1994) -- Population: serve one population (28%), different disabilities (72%), from younger adults with physical disabilities => all ages persons with cognitive and emotional disabilities 6. Personnel -- Board of directors (advisory committees): set policies and establish rules for the program -- Directors: responsible for the total operation and the primary spokesperson for the program -- Assistant directors: assist in program planning and overseeing operations, developing or supervising individual program -- the coordinator of personnel attendant service: recruitment, training, referral, and placement of attendants -- the coordinator of independent living skill training program -- Financial benefit counselor 7. OT Role in Independent Living Programs (1993, AOTA) -- OT with the understanding of the dynamic interplay between the individual and environment -- be familiar community resource to make appropriate referrals, support the philosophy, and be an advocate of consumer autonomy -- work as consultant, on a referral basis, or as an employee -- as an OT or as an ind. Living specialist, a case manager, an administrator or as an advocate for persons with disabilities 8. Evaluation and Intervention Planning -- COPM -- Collaboration with the clients is critical * Others? How about the restorative treatment techniques? 9. Documentation -- Individualized written independent living plan (IWILP): list of the services to be used, identify specific goals, responsibilities of consumer and a representative of the ILP.

3


Hospice 1. Concepts of Hospice Care -- perspectives from dying person’s individual need -- easing the dying process  Philosophy : the National Hospice Organization (NHO) states:  Dying is a normal process.  Hospice is neither to hasten nor postpone death. Rather , hospice exists to affirm “life” by providing support and care for those in the last phases of incurable disease so that they can live as fully and comfortably as possible.  Hospice promote the formation of caring communities that are sensitive to the needs of patients and their families, so that they may be free to obtain that degree of mental and spiritual preparation for death . 2. OT and Hospice: advocate the use of open-systems approaches to create supportive environment -- To assist the adaptation of stages of dying: 1) denial, 2) anger, 3) bargaining, 4) depression, 5) acceptance -- To effectively respond to the environment demands -- Enhance the sense of control and quality of life -- Facilitating engagement of the mind, body, and spirit at the end of life is very rewarding, to sense the continuity of life: * Meaning and Meaningfulness * Death and Dignity * Family as the Unit of Care * Grief and Bereavement (reaction to loss)

3. The Hospice Team - RN*, SW, clergy, Dr. PT, OT, ST, RT, dietitians, pharmacists, and volunteer. 4. Hospice Intervention Planning -- OT tools: adaptation and occupation, occupation needs, goals, and desires of clients and their families guide intervention planning -- Treatment principles: short-term, meaningful, and easily attainable goals 1) Arouse interest, confidence, and courage 2) Apply systematically based on evaluation data 4


3) Graded according to capabilities, which changes over time 4) Focus on health vs. pathology 5) Emphasize the expression of emotions 6) Provide a total program of care

Voluntary Program 1. Identifying A Need  How many volunteers are needed and what skills should they have?  Is there support for the program?  Acceptance of staff numbers?  What aspects of the program cam volunteers assist?  What kind of training needed? 2. Job Descriptions  What will they do ?  How many hours per week or month?  What is the duration of the obligation?  To whom are the volunteers responsible?  Are there any costs to the volunteers?  What are the qualifications for each job?  What skills are required to do it?  To select a volunteer coordinator ( bridge, advocate, interpreter, trouble shooter, leader, mediator…  Recruiting  Screening  Training (initial orientation, general education about the served population, specific skills)  Job placement  Rewards and benefits

5


Journal of http://jag.sagepub.com/ Applied Gerontology

Outcomes of Adult Day Services for Participants: A Conceptual Model Holly I. Dabelko and Jennifer A. Zimmerman Journal of Applied Gerontology 2008 27: 78 DOI: 10.1177/0733464807307338

The online version of this article can be found at: http://jag.sagepub.com/content/27/1/78 Published by: http://www.sagepublications.com

On behalf of:

Southern Gerontological Society

Additional services and information for Journal of Applied Gerontology can be found at: Email Alerts: http://jag.sagepub.com/cgi/alerts Subscriptions: http://jag.sagepub.com/subscriptions Reprints: http://www.sagepub.com/journalsReprints.nav Permissions: http://www.sagepub.com/journalsPermissions.nav Citations: http://jag.sagepub.com/content/27/1/78.refs.html

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>> Version of Record - Feb 6, 2008 What is This?

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Outcomes of Adult Day Services for Participants: A Conceptual Model Holly I. Dabelko Jennifer A. Zimmerman The Ohio State University

Adult day programs provide nutritional, health, social, and recreational services for older adults during daytime hours. The heterogeneity of programs, participants, and funding sources creates challenges in defining and measuring participant outcomes of adult day services. There appear to be two main domains of influence that adult day programs can have on participants: physical health functioning and psychosocial well-being. The study of the psychosocial benefits of adult day services to participants has been neglected. The purpose of this article is to review current empirical literature and to propose a new conceptual model for examining the participant outcomes in adult day services programs, taking into consideration the variability in participant needs and program design and delivery. The model includes service elements that are related to psychosocial well-being and physical functioning, and these elements relate to specific physical and psychosocial proximal and distal outcomes. Further areas for research are suggested. Keywords: adult day care; adult day services; outcomes

Increasingly, health and social service agencies must demonstrate participant outcomes for accreditation and funding purposes. Tools for practitioners and researchers to document the effect of interventions are lacking in the research literature. A need exists to better describe and conceptualize individual and programmatic outcomes that practitioners can implement in practice settings and that researchers can test empirically (Proctor, Rosen, & Rhee, 2002). Outcome taxonomies based on logical connections between the intervention and outcomes are more likely to capture differences made AUTHORS’ NOTE: The authors would like to thank Dr. Rhonda J. V. Montgomery, Helen Bader Endowed Professor of Applied Gerontology and professor of sociology, University of Wisconsin– Milwaukee, and Dr. Virginia Richardson, professor, The Ohio State University College of Social Work, for their assistance with the development of this model. The authors would also like to thank Erica Drewry, executive director, and the staff at Heritage Day Health Centers, Columbus, Ohio, for their support of this project. This project was funded by the John A. Hartford Foundation Faculty Scholars Program, administered by the Gerontological Society of America. Journal of Applied Gerontology, Vol. 27 No. 1, February 2008 78-92 DOI: 10.1177/0733464807307338 © 2008 The Southern Gerontological Society

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Dabelko, Zimmerman / Adult Day Services

79

by interventions versus which data are available and convenient. In addition, capturing the nature of the intervention as well as the outcome will result in information that is helpful in refining and developing the elements of the intervention and ultimately understanding what works for whom under what circumstances. The positive effect of adult day services (ADS) on caregivers has been demonstrated (Gaugler et al., 2003; Lawton, Brody, & Saperstein, 1989; Montgomery & Borgatta, 1989; Zarit, Parris Stephens, Townsend, Greene, & Leitsch, 1999; Zarit, Stephens, Townsend, & Greene, 1998), but the effect on participants remains unclear (Gaugler & Zarit, 2001). Previous studies have been largely atheoretical, have not included process measures, and have focused on outcomes of interest to funders. Specifically, past evaluation studies have not been able to consistently document the effect of ADS on the functional health of participants or the ability of ADS to delay nursing home placement (Gaugler & Zarit, 2001). However, practice knowledge suggests that some of the most important outcomes of ADS on participants, such as psychosocial benefits, have not been widely studied. Not only do we need to understand the effect of ADS, but we need to understand what about individual programs makes a difference. The purpose of this article is to present a new model to examine the effect of ADS on older adult participants. This model includes service processes to determine their effect on participant outcomes and also includes mediating variables to better understand what works for whom under what circumstances. The proposed model identifies two main domains of influence that ADS can potentially have on participants considering both traditional evaluation measures and effects reported through practice knowledge. Present is a series of mediating factors, such as demographics and cognitive status, that influence physical and psychosocial outcomes. Determining the effect of services on individuals is a complex process that includes many variables. This model provides an avenue to examine the connections between services provided and individual outcomes. In addition, the focus of this model is on participants of ADS, not their caregivers. Important work is being done in this area by Gaugler and Zarit (2001), Montgomery and Borgatta (1989), Zarit et al. (1998), and others, but the development of a model to examine outcomes of caregivers who use ADS is beyond the scope of this article. We believe the first step to building knowledge about ADS as an intervention in long-term care is to develop a carefully constructed conceptual model for empirical testing. Our intention is to present a starting place, a conceptual model that can be developed, challenged, and refined.

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Definition ADS are a community-based program intervention that provides health, nutrition, and social services, frequently for older adults, at congregate sites during daytime hours. Day services can be divided into three models: the medical model, the social model, and the combined model (Kirwin & Kaye, 1993; van Beveren & Hetherington, 1998). Centers operating under the medical model include skilled assessment, treatment, and rehabilitation goals. The social model center focuses on socialization and preventive services (van Beveren & Hetherington, 1998). A combined model has elements of both a social and medical model depending on individual client needs. Despite these categories, there are significant within-model variations in service delivery. The emphasis of the proposed conceptual framework is on the mixed model.

Current Literature Participant Outcomes Based on a comprehensive literature review, Gaugler and Zarit (2001) organized previous research into three outcome areas: improved caregiver adaptation, improved client functioning, and delayed nursing home placement. Research has shown that ADS has been effective in improving caregiver adaptation by reducing subjective burden, role overload, worry, anger, and depression (Gaugler et al., 2003; Lawton et al., 1989; Montgomery & Borgatta, 1989; Zarit et al., 1998; Zarit et al., 1999). The benefit of ADS on participants has not been as consistently documented. Specifically, there have been mixed results in previous studies examining the improvement of client functioning among ADS participants (Gaugler & Zarit, 2001). Researchers have found little or no effect of ADS on physical functioning of participants (Gaugler, 1999; Hedrick et al., 1993; Weissert, Wan, Livieratos, & Katz, 1980). With the exception of Hedrick et al.â&#x20AC;&#x2122;s 1993 study of Veterans Affairs (VA) medical centers, improvement seems to be primarily in subjective aspects of well-being such as morale, mood, and satisfaction (Baumgarten, Lebel, Laprise, Leclerc, & Quinn, 2002; Zank & Schacke, 2002). Programs that emphasize psychosocial support instead of rehabilitation may be a better match for client needs (Gaugler & Zarit, 2001). The psychosocial effect of ADS has not been studied extensively. Previous studies have not always demonstrated that ADS delay nursing home placement (Gaugler, 1999; Hedrick et al., 1993). Delay in institutionalization

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may be difficult to document because the overall rates of institutionalization in these studies have been low (Weissert et al., 1980; Weissert, Lesnick, Musliner, & Foley, 1997). Weissert and Hedrick (1994) suggest that ADS may have some delaying effect on nursing home placement if provided to those at most risk of institutionalization. In addition, it is difficult to operationalize “delay in institutionalization.” Gaugler and Zarit (2001) suggest that delayed institutionalization may not be an appropriate goal of ADS. McCann et al. (2005) found that the risk of nursing home placement actually increases with the number of days individuals with Alzheimer’s disease attend ADS. They suggest that those older adults and caregivers who use ADS may have a higher proclivity to institutionalize than those who do not.

Interprogram and Intraprogram Variability Previous studies on the outcomes of ADS have ascribed a “black box” approach to evaluation, neglecting the examination of how or why a program works. We need to find out who gets what and what works for whom. Without measuring the details of the specific service elements provided, this approach does not allow for an understanding of the feasibility, efficacy, and effectiveness of the intervention (Schilling, 1997). With significant variation in service delivery on a programmatic level and on an individual level, logically connecting activities and outcomes is critical for programmatic development and improving client services. Understanding the specific interventions received by individuals and the resulting outcomes will assist in strengthening individualized service planning and the development of best practices by providers. Although ADS programs are typically described as providing assistance in a protective setting by offering a variety of planned activities to support the social and health needs of older adults, there is significant variability in which services are provided. The most recent census of ADS programs was conducted by the Wake Forest University School of Medicine through the Robert Wood Johnson (RWJ) Foundation Partners in Caregiving program. Nationally, they found that 21% of the centers were based on the medical model, 37% used the social model, and 42% were a combination of the two models. Overall, 20% of the programs were dementia specific (RWJ Foundation, 2003). The RWJ study found that the majority of the centers provided health-related services, such as weight monitoring, blood pressure checks, and medication administration. The majority also provided personal assistance with meals, toileting, incontinence care, walking, and wheelchair use. Only a third provided baths or showers. Less than 19% provided dental services, ophthalmology, and podiatry services. About half

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provided nursing services such as tube feeding, wound care, catheter care, and so on. About 80% of the programs provided social services (RWJ Foundation, 2003). What activities were included in the â&#x20AC;&#x153;social servicesâ&#x20AC;? category is unclear. In addition, information about social work activities and the number of social work professionals employed within centers was not collected. The inter- (center by center) and intra- (individual by individual) variability pose significant challenges in documenting participant outcomes. Although the RWJ study documents what services are offered by centers, it is less clear how many individuals actually use these services within centers. There appears to be substantial variability on the programmatic level and the individual level in the amount of psychosocial support provided by adult day programs. Few previous studies have operationalized the psychosocial activities provided by day programs. Cameron, DiFazio, and Regan (1997) created a four-item social behavioral assessment specifically for ADS assessment and evaluation. The validity of this instrument is limited given that each item is measured with single questions. The assessment provides a very limited description of the nature and the frequency of communication, social behavior, and participation in activities. No systematic efforts were made to examine the reliability and validity of this measure. Despite these limitations, Cameron et al. (1997) did find a positive effect. The RWJ study and previous studies (Conrad, Hanrahan, & Hughes, 1990; Leitsch, Zarit, Townsend, & Greene, 2001; Weissert et al., 1990) have described activities on an aggregate level but have not specifically tied programmatic elements to individual participation and outcomes. Although particular services are identified as being provided, not all participants receive these services. Understanding the nature of individual experiences within programs will help determine what is working for whom and if the program is being implemented as intended.

New Model Justification Competition for scarce resources for long-term care results in the need for more effective evaluations and documentation of the effect of services. ADS, like other providers of long-term care, are moving toward outcomeoriented data collection and evidence-based funding (Clauser & Bierman, 2003; Lynch, Estes, & Hernandez, 2005). Careful consideration of program activities and the examination of meaningful outcomes are necessary to Downloaded from jag.sagepub.com at NATIONAL TAIWAN UNIV LIB on November 23, 2011


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demonstrate the effect that programs are having on participants. Funding needs can then be justified through clearly described and conceptualized outcome studies. In addition, program administrators are increasingly seeing the benefits of tracking outcomes to improve program development and services. It is important that programs are measuring the relevant outcomes and identifying where additional service development should occur. Outcomes studies that examine the effect of ADS on participants have emphasized functional health changes and delayed institutionalization. This emphasis results from public reimbursement opportunities that are tied to reducing the cost and use of more expensive health services and from a focus on outcomes for which data are easily available. Rosen, Proctor, and Staudt (2003) caution against identifying outcomes as meaningful simply because the measures are available and convenient. As a result of program eligibility requirements emphasizing physical functioning, psychosocial changes have been neglected and not well documented. Remarkably, this lack of documentation has occurred within a context of rich practice knowledge that supports the psychosocial benefits of ADS to participants, such as positive relationships with others, sense of purpose in life, and feeling valued. Access to both public and private funding for ADS has been connected to functional abilities and typically has been measured by level of support needed with activities of daily living (ADLs) and instrumental activities of daily living (IADLs). Functional disability has been connected to using long-term care services, and the objective of funders has been to pay for the least costly and nonrestrictive care, which is believed to be home and community-based services. What has not been recognized by funders and accrediting bodies is the connection between psychosocial well-being and physical health and service utilization. As previously noted, studies of adult day participant outcomes have not connected participant needs and services to specific outcomes. It is extremely difficult to document whether a change that occurred with a participant is directly related to a program. Randomized clinical trails are not feasible in many cases of intervention research. The intervention research process begins with conceptual models designed and developed through pilot studies and then refined through larger scale implementation using longitudinal measurements within agency settings (Schilling, 1997). Modeling program processes by understanding cause-and-effect connections between treatment variables and outcomes enables evaluators to understand the difference between program implementation and theoretically how the program is intended to work (Chen & Rossi, 1987).

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Logic Model The logic model provides a helpful framework to guide the examination of service outcomes (Alter & Egan, 1997) by describing how a program theoretically is intended to work. The benefits of using the logic model in program evaluation are well documented (Chen & Rossi, 1987; Julian, 1997; Julian, Jones, & Deyo, 1995; Lipsey & Pollard, 1989). The logic model suggests that individual needs should be congruent with programmatic services and that program outcomes should reflect services provided. It focuses on the â&#x20AC;&#x153;target, means, and endsâ&#x20AC;? of a purposeful intervention. A logic model identifies goals, objectives, inputs, methods, intermediate results, and outcomes (Alter & Egan, 1997). It is a practice-based systematic examination of services and outcomes that is useful for field research. Specifically, the logic model was selected because it can be individualized by programmatic services and elements easily. Unlike existing health care utilization models such as Andersen and Newman (1973) and others, the logic model takes into account the nature of the individualâ&#x20AC;&#x2122;s experience within the program or intervention. Figure 1 is an application of this model to ADS. The proposed model to study participant services and outcomes in ADS includes needs, service elements, proximal outcomes, and distal outcomes. The two main domains of influences are psychosocial and physical functioning. The model should be read from left to right by rows with needs being associated with service elements. The service elements are associated with proximal outcomes, which are service impacts closely tied to specific service elements. These proximal outcomes are then associated with more global changes, distal outcomes that are not as directly related to the service elements. For operationalization purposes, the model includes the psychosocial and the functional health domains of influence in two independent rows. However, examination of the interrelatedness of these two concepts should be included to capture a complete picture of participant outcomes.

Needs of Participants Based on previous research (Baumgarten et al., 2002; Gaugler & Zarit, 2001; McCann et al., 2005; Zank & Schacke, 2002) and practice knowledge, there appear to be two general intended domains of influence ADS has on participants: (a) psychosocial and (b) physical functioning. These domains reflect general client needs. Within this proposed model, it is

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Personal Growth Positive Relationships with Others

Relationships with Staff and other Clients

Helping Roles for the Program and other Clients

(Ryff, 1989) Less Assistance Needed with ADLs Less Assistance Needed with IADLs Reduced Nutritional Risk

Rehabilitation Therapy

Personal Assistance

Medical Services (podiatry, dental

Nutritional Services

Nursing Services (tube feeding, wound care, etc.)

etc.)

services, ophthalmology,

Increased Sense of Self-Acceptance

Social Work Services (advocacy, care management, crisis intervention)

Increased Sense of Purpose in Life

Maximizing Independence/Control

PROXIMAL OUTCOMES

Activities

SERVICE ELEMENTS

Physical Well-being (lower health care utilization and positive perceived health)

Emotional Well-being (lower depression and anxiety)

DISTAL OUTCOMES

Figure 1. Proposed Model to Study Participant Services and Outcomes in Adult Day Services NOTE: Mediating variables: demographics, primary caregiver relationship, health diagnosis/events, enrollment, and cognitive functioning. ADLs = activities of daily living; IADLs = instrumental activities of daily living.

PHYSICAL FUNCTIONING DOMAIN OF INFLUENCE

PSYCHOSOCIAL DOMAIN OF INFLUENCE

NEEDS


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assumed that specific psychosocial and physical functioning needs will be identified on an individual level such as depression, anxiety, assistance with mobility, nutrition, and so on. As required by program policies and public and private third-party payers, adult day staff conduct initial assessments of participant needs during an intake process. Assessments are not standardized across all programs and are typically based on program eligibility requirements. Because of the emphasis of funders on physical functioning, the use of standard assessment tools emphasizing psychosocial needs of participants is limited. A more accurate picture of participant needs would be gained if psychosocial assessments were included within the standard assessment processes. The national census of ADS conducted by Wake Forest found that 43% of participants needed assistance with toileting, 37% with walking, and 24% with eating. Centers reported that 14% of all participants had chronic mental health issues, and a regional study found that 20% of ADS participants had a mental health diagnosis (Richardson, Dabelko, & Gregoire, in press). Because of the reluctance of individualsâ&#x20AC;&#x201D;older persons in particularâ&#x20AC;&#x201D;to report and selfidentify mental health issues, this number is probably much higher. Finally, the reason individuals seek home- and community-based services is to address issues of functional disabilities, which are often associated with mental health issues (Marengoni et al., 2004; Ormel et al., 1998). Despite the limited recognition by third-party payers of the connection between physical and mental health outcomes, there is increasing evidence that physical health and mental health are closely associated. psychosocial distress is associated with negative physical health outcomes in a wide range of illnesses across various age groups (Institute of Medicine, 2001). Poor mental health is a risk factor for chronic physical conditions associated with aging such as stomach problems, arthritis, high blood pressure, and so on. Using the MacArthur Foundationâ&#x20AC;&#x2122;s midlife national survey, Keyes (2005) found that chronic disease increased with age and is more prevalent in adults with poor mental health. Poor emotional health is also associated with recovery in functional ability after a stroke, heart attack, or hip fracture (Ostir et al., 2002).

Service Elements Service elements include programming, services, and experiences available to participants of ADS. Service elements included in this model under the psychosocial domain of influence were selected from the research literature and from focus group data that were collected as part of a larger study administered by the Gerontological Society of America and funded through Downloaded from jag.sagepub.com at NATIONAL TAIWAN UNIV LIB on November 23, 2011


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the John A. Hartford Foundation. The focus group was conducted with 11 key informants employed by four ADS programs located in Central Ohio. The 11 individuals in the convenience sample were selected because of their expertise in the daily operations of ADS and their commitment to future involvement in a larger longitudinal study. Of the 11, 4 were social workers, 3 were activity professionals, 3 were administrators, and 1 was a nurse. Participants were asked which services provided by their programs improve participantsâ&#x20AC;&#x2122; psychosocial well-being. Lists were generated under the categories of psychosocial well-being identified by Ryff (1989) including personal growth, relationship with others, maximizing independence, self-acceptance, and purpose in life. These constructs have been previously examined in an assisted living environment but not within the context of ADS. Ryff constructs were used because of the apparent fit between these elements of well-being and ADS services. A miscellaneous psychosocial category was added for elements that the group felt crosscut the existing categories. Once the group reached consensus that a comprehensive list was developed, each individual voted for the top three most important influences on the psychosocial well-being of their ADS participants. Three main categories of services emerged from this ranking: activities, relationships with staff and other clients, and participation in a helping role for the program (i.e., watering plants and handing out name tags) and other program participants (i.e., assisting particular individuals with meals and activities). In addition, social work services are included in the service elements that influence psychosocial well-being. Social work services within ADS have not been clearly defined in previous literature. Johnson, Sakaris, Tripp, Vroman, and Wood (2004) highlight advocacy, care management, and crisis intervention as the major responsibilities of social workers in ADS. Additional study needs to occur to clarify these roles and the effect of these and other social work services on outcomes. The service elements associated with the physical functioning domain of influence were selected from the RWJ census and include rehabilitation therapy, personal assistance, medical services, nursing services, and nutritional services. Information concerning social work services was not collected in the census.

Proximal and Distal Outcomes We propose psychosocial proximal outcomes that include maximizing independence/control, personal growth, positive relationships with others, sense of purpose in life, and self-acceptance (Ryff, 1989). In addition, we propose the standard physical functional health and nutrition measures that Downloaded from jag.sagepub.com at NATIONAL TAIWAN UNIV LIB on November 23, 2011


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have been used in previous studies such as ADLs, IADLs, and nutritional risk. Existing measures of these areas are widely available (see Kane & Kane, 2000). The distal outcomes include the emotional and physical well-being indicators that are commonly used in social and health services, such as anxiety, depression, health care utilization, and perceived health. Many measures exist that have strong validity and reliability that can be used to measure these constructs (see Kane & Kane, 2000). It is proposed that the effect of the psychosocial and physical functioning of ADS participants is mediated by a number of additional variables such as demographics, caregiving relationship, health diagnosis/events, nature of enrollment (number of days, for how long), and cognitive functioning. Measuring these issues will allow practitioners and researchers to better understand which elements of the intervention work, and for whom. Building knowledge around who is best served by which program elements will support program development and individualized care planning. In addition, it recognizes the individual variation of need and program experience. Particular participant profiles and corresponding service plans may emerge. The purpose of this model is to provide a beginning framework that individual programs can adjust and change based on their own participants, program services, practice knowledge, and new research. Consumer satisfaction or quality expectations have not been included in this model because the authors believe that the phenomenon of program or service satisfaction is not an outcome or the result of programmatic interventions on an individual, but a parallel experience to program impact. For example, two individuals may experience similar changes in physical and emotional well-being and assess their satisfaction of the program at very different levels. Satisfaction measures how well a program is doing administratively, not how well the intervention is resulting in a positive change to an individual, family, group, or community. Researchers have attempted to link client or patient satisfaction with health outcomes with mixed results (Alazri & Neal, 2003; Corral & Abraira, 1995; Covinsky et al., 1998). Satisfaction may act as a variable associated with achieving successful outcomes instead of a contributing factor to a successful outcome.

Future Directions The first step in developing interventions that support the health and well-being of individuals is to conceive and create conceptual models that link interventions with meaningful outcomes (Proctor et al., 2002). Careful Downloaded from jag.sagepub.com at NATIONAL TAIWAN UNIV LIB on November 23, 2011


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development, refinement, and testing of these models are critical steps to the development of interventions (Schilling, 1997) that improve or maintain the health and well-being of older adults and others. The proposed logic model applied to ADS should be tested empirically to ascertain the utility of the model from a practice and research perspective. In addition, within the environment of scarce financial resources for health and social services, this model should be assessed for issues of cost and benefits as well as for whether the information examined will help inform public policy-making decisions. These elements could be conceptualized as external environmental influences as part of the model. The cost and benefit assessment should include an examination of the influence of psychosocial well-being on physical functioning. Specific psychosocial measurements that relate to physical health issues should be developed. Examining the effect of ADS on participants is a complex process because individual participants face life-changing events daily and programs change and adapt to staffing needs and other programmatic realities. Significant interprogram and intraprogram experiences call for complex data collection schemes that are costly and time intensive. The ability to conduct clean, randomized controlled studies is extremely challenging within health and human services. Building our knowledge around what works for whom under what circumstances can only come with well-structured, repeated studies based on specific conceptual models. Collecting individual-level data to tell the stories of individual experiences within ADS will further inform us about individuals whose functional health and psychosocial needs can be met through ADS. The proposed model should be tested empirically through alternative data collection methods, such as face-to-face interviews and behavioral observations, and designs such as repeated measures. Because of the complexity of the model, particular threads within the model could be tested individually. In addition, qualitative elements connecting individual needs, service elements, and outcomes should be identified. Finally, the interaction between the two proposed domains of influence should be studied.

Conclusion A lack of tools for practitioners and researchers to document the effect of interventions has been identified. In addition, the demonstration of participant outcomes is becoming more critical for accreditation and funding purposes within health and social service agencies. These factors have led to a need to evaluate programs based on logical connections between the intervention and participant outcomes to further refine and develop the Downloaded from jag.sagepub.com at NATIONAL TAIWAN UNIV LIB on November 23, 2011


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elements of the intervention and to understand what works for whom under what circumstances. We suggest using the logic model to connect individual needs to programmatic services as a way to improve on past evaluations of ADS, which have struggled to examine the effect of services on participants. In addition, past evaluations of ADS have largely ignored psychosocial benefits to participants, which practice knowledge has suggested are some of the most important outcomes of ADS and are increasingly being recognized as associated with physical functioning. By looking directly at services and outcomes for participants, including the importance of psychosocial outcomes, we can better understand the effect of ADS and what it is about specific programs that makes a difference for participants.

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Hedrick, S. C., Rothman, M. K., Chapko, M., Ehreth, J., Direher, P., & Inui, T. S. (1993). Summary and discussion of methods and results of the Adult Day Health Care Evaluation Study. Medical Care, 31, SS94-SS103. Institute of Medicine. (2001). Health and behavior: The interplay of biological, behavioral, and societal influences. Washington, DC: National Academy Press. Johnson, J., Sakaris, J., Tripp, D., Vroman, K., & Wood, S. (2004). The role of social work in adult day services. Journal of Social Work in Long-Term Care, 3(1), 3-13. Julian, D. A. (1997). The utilization of the logic model as a system level planning and evaluation device. Evaluation and Program Planning, 20(3), 251-257. Julian, D. A., Jones, A., & Deyo, D. (1995). Open systems evaluation and the logic model: Program planning and evaluation tools. Evaluation and Program Planning, 18(4), 333-341. Kane, R. L., & Kane, R. A. (2000). Assessing older persons. New York: Oxford University Press. Keyes, C. L. M. (2005). Chronic physical conditions and aging: Is mental health a potential protective factor? Ageing International, 30(1), 88-104. Kirwin, P. M., & Kaye, L. W. (1993). A comparative cost analysis of alternative models of adult day care. Administration in Social Work, 17, 105-122. Lawton, M. P., Brody, E. M., & Saperstein, A. R. (1989). A controlled study of respite service for caregivers of Alzheimer’s patients. The Gerontologist, 29(1), 8-16. Leitsch, S. A., Zarit, S. H., Townsend, A., & Greene, R. (2001). Medical and social day services programs. Research on Aging, 23(4), 473-498. Lipsey, M. W., & Pollard, J. A. (1989). Driving toward theory in program evaluation: More models to choose from. Evaluation & Program Planning, 12, 317-328. Lynch, M., Estes, C. L., & Hernandez, M. (2005). Chronic care initiatives for the elderly: Can they bridge the gerontology-medicine gap? Journal of Applied Gerontology, 24, 108-124. Marengoni, A., Aguero-Torres, H., Cossi, S., Ghisla, M. K., Martinis, M. D., Leonardi, R., et al. (2004). Poor mental and physical health differentially contributes to disability in hospitalized geriatric patients of different ages. International Journal of Geriatric Psychiatry, 19(1), 27-34. McCann, J. J., Hebert, L. E., Li, Y., Wolinsky, F. D., Gilley, D. W., Aggarwal, N. T., et al. (2005). The effect of adult day care services on time to nursing home placement in older adults with Alzheimer’s disease. The Gerontologist, 45(6), 754-763. Montgomery, R. J. V., & Borgatta, E. F. (1989). The effectiveness of alternative support strategies on family caregiving. The Gerontologist, 29, 457-464. Ormel, J., Kempen, G. I. J. M., Deeg, D. J. H., Brilman, E. I., van Soderen, E., & Relyveld, J. (1998). Functioning, well-being and health perception in late middle-aged and older people: Comparing the effects of depressive symptoms and chronic medical conditions. Journal of the American Geriatrics Society, 46(1), 39-48. Ostir, G. V., Goodwin, J. S., Markides, K. S., Ottenbacher, K. J., Balfour, J., & Guralnik, J. M. (2002). Differential effects of premorbid physical and emotional health on recovery from acute events. Journal of the American Geriatrics Society, 50(4), 713-718. Proctor, E., Rosen, A., & Rhee, C. W. (2002). Outcomes in social work practice. Journal of Social Work Research and Evaluation, 3(2), 109-123. Richardson, V. E., Dabelko, H. I., & Gregoire, T. (in press). Adult day centers and mental health care. Social Work in Mental Health. Robert Wood Johnson Foundation. (2003). Special reports—The role of adult day services. Retrieved from http://www.rwjf.org/news/special/adultdayEvolution.jhtml Rosen, A., Proctor, E. K., & Staudt, M. (2003). Targets of change and interventions in social work: An empirically-based prototype for developing practice guidelines. Research on Social Work Practice, 13(2), 208-233. Downloaded from jag.sagepub.com at NATIONAL TAIWAN UNIV LIB on November 23, 2011


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Ryff, C. D. (1989). Happiness is everything, or is it? Explorations on the meaning of psychological well-being. Journal of Personality and Social Psychology, 57, 1069-1081. Schilling, R. F. (1997). Developing intervention research programs in social work. Social Work Research, 21(3), 173-180. van Beveren, A. J. B., & Hetherington, R. W. (1998). The one percent solution: A basis for adult day program development? Activities, Adaptation & Aging, 22(4), 41-52. Weissert, W. G., Elston, J. M., Bolda, E. J., Zelman, W. N., Mutran, E., & Mangum, A. B. (1990). Adult day care: Findings from a national survey. Baltimore: Johns Hopkins University Press. Weissert, W. G., & Hedrick, S. C. (1994). Lessons learned from research on effects of community-based long-term care. Journal of the American Geriatrics Society, 42, 348-353. Weissert, W. G., Lesnick, T., Musliner, M., & Foley, K. A. (1997). Cost savings from home and community-based services: Cost savings from Arizonaâ&#x20AC;&#x2122;s Medicaid long-term care program. Journal of Health Politics, Policy & Law, 22(6), 1329-1357. Weissert, W. G., Wan, T., Livieratos, B., & Katz, B. (1980). Effects and costs of day-care services for the chronically ill. Medical Care, 18, 567-584. Zank, S., & Schacke, C. (2002). Evaluation of geriatric day care units: Effects on patients and caregivers. Journals of Gerontology: Psychological Sciences, 57B(4), 348-357. Zarit, S. H., Parris Stephens, M. A., Townsend, A., Greene, R., & Leitsch, S. A. (1999). Patterns of adult day service use by family caregivers: A comparison of brief versus sustained use. Family Relations, 48, 533-361. Zarit, S. H., Stephens, A. P., Townsend, A., & Greene, R. (1998). Stress reduction for family caregivers: Effects of adult day care use. Journals of Gerontology: Social Sciences, 53B(5), S267-S277. Article accepted July 12, 2007 Holly I. Dabelko, MSW, PhD, is an assistant professor and Hartford Geriatric Social Work Faculty Scholar in the College of Social Work at The Ohio State University. Her research examines the effect of adult day programs and other community-based services on older adults and caregivers with particular attention to implications for service providers and program development. Jennifer A. Zimmerman, MSW, MA, is a research associate in the College of Social Work at The Ohio State University. Her recent research has included psychosocial benefits of adult day services and risk assessments within child welfare. Her research interests include measures of wellness as related to older adults and aging.

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______________ _______________ / _ / _

______

________ _ ____ __________________

25% 0:

4:

(4) 3:


Test=>Intervention=>Retest

Dynamic assessment

Criterion--referenced Criterion (

FIM,PASS)

Criterion--referenced + Dynamic assessment Criterion

--


█ 4.

█ 3. 3 2 1 0

3

2.

4 3 2 1 0

2 1 0

3 2 1 0

1.

)

(

/█

)

(

(5)


2 1 0 2 1 0

█ 8.

3 2 1 0

█ 6.

█ 7.

3 2 1 0

█ 5.

(6)


/

/ G P

normal spasticity flaccid

NA G F P NA G F P NA

F

normal abnormal NA

N F T

___

G P Z

(7)


/

normal abnormal NA

normal spasticity flaccid

N F T

G P Z

(8)


NA NA NA NA

intact █ impaired intact █ impaired intact █ impaired

NA

intact █ impaired intact █ impaired intact █ impaired NA intact █ impaired

NA

(9)


1:1

1 Max.

0 Total

1:1

2 Mod.

3 Min.

5 Ind. 4 Stand-by.

(10)


impaired

NA

G █F P G █F

P

intact █ impaired NA █ intact impaired NA █ intact impaired NA ___________________________

█ intact

intact █ impaired

intact █ impaired

NA

NA

(11)


0

0

0

0

0

1.

2.

3.

4.

5.

A.

(12)

1

1

1

1

1

10

,

2

2

2

2

2

,

1

5

5

, 10

3

3

3

3

3

10

10

,

, 5


0 0 0 0 0 0

7.

8.

9.

10.

11.

12.

50

0

6 to 11

6

(13)

1

1

1

1

1

1

1

9

12

2

2

2

2

2

2

2

3

3

3

3

3

3

3


5. 6.

3. 4.

2.

1.

:

(14)


1. 2. 3. 4.

:

(14)


2. 3. 4. 5. 6.

1.

: 100

=>

(14)


(progress) (safety)

(function) (causes)


2. 3. 4.

1.

-

(Long-term goal) – (Long(Short--term goal) – (Short

/

(function)

/

/

(

)


Mod. Ass.

--

/

â&#x20AC;&#x201C;

Standby assistance

(function)

(

)


3. 4.

1. 2.

(remediation/ restoration) (compensation) MODE:: strategies for solving ADL Disability: MODE (Method) (Object) (Device) (Environment-- physical/social) (Environment


3.

2.

1. => 100

1. 2. Home program:

(14)


6.

1.

5.

1. 2.

4.

2. 3.

1. 2.

4.

(14)


:

,

P █ 2. 4. 6.

____________

____________________________________

F

_____________________________________________

1. 3. 5.

:█G :

(15)


2.

– –

– –

activity analysis


1. 2. 3. 4. 5. 6. 7. 8. 9.

Encouragement Non--directive verbal cues Non Directive verbal cues Gestures Task or environment rearrangement (i.e. setset-up) Demonstration Physical guidance Physical support Total activity completion by another

Cueing (Prompting) system

â&#x20AC;&#x201C; breaking a task down into functional units â&#x20AC;&#x201C; breaking a task down into discrete, sequential steps


– – –

3.


– – – –

10. ADL/ Home safety/Home program

9.


1

,

,


2

Purposes/ Goals  Target population/ criteria for services  Related regulations  Programs or services  Available resources  Service barriers and how to overcome  Factors that influence the use of service  Outcome and outcome measures  Other suggestions

Content


3


4


5


6

OT

OT

Purposes/ Goals (for OT )


7

2001

1998 (

10%)


8

???

2008

2003

?

(40%, 30%,

10

)


9

/

Related regulations


10

/


11

2

1~2

8~9

20 1


12

OT


13

/


14

/

OT


15

(


16

Target Population/Criteria of service


17

2 3

1 70 95

70


18

ADL

94~95 > >

>


19

Home-Bound

OT BI: 30~80)


20

3


21


22

-


23


24


25


26


27


28


29


30

PT


31

OT

PT


32

 


33


34

2.

1.

1) 2)

:


1.

35

)

(

(1)


3. 4.

2.

36

(2)


37


38

OT


39

155 276

97(1-11) 98

100

) 220/221

149

96(2-12)

/

354

95(1-8)(10-12)

99(

246

175

94(9-12)

93(10-12)

793/333

577

313

364

528

368

387


40

40

91

63

97

98

194

96

153

116

348

365

165

95

661 462

164

92

452

152

104

91

676

94

135

90

733

462

52

89

649

93

74

88

BI

34.5

31.1

17.5

21.4

27.2

1.7

1.8

1.8

2.2

3

4

4.3

5

14.1

8.8


41

• •

41

(

,

)

73.0

15.9


OT

42

:

OT 500

/

why?


• •

43

OT

ADL


44

Service barriers and how to overcome


45

2006 2006 ( ):929

2306


46

• 2004: :1100 • 2009: :1000 • 2004~2009 GDP 14,663~15,509(

(1/2)

6%

)


47

:

500

:3 /

(10%

)


48

62.9% 28.6% 5.7% 0.0% 2.9%


49

OT

7 14 7 1


50

(1/2)


51

(2/2)


52


53


54

OT


55

OT


56

Thanks for your attention.

What is your suggestions?


57

)

A systematic, quantitative observation of outcome indicators at a particular point in time.

The repeated measurement of outcome indicators over time that permits inferences.

Outcome monitoring

Outcome Measurement

Outcome(


58

To measure the impact of the treatment To modify practice guideline to provide the value and quality of the service 

Clients and families Therapist Funding agencies

Essential Need


59

Outcome-Based Quality Improvement 79 items 12 areas: Living arrangements, supportive assistance, sensory, integumentary, respiratory, elimination, neuro-emotional-behavioral status, ADL, IADL, medications, equipment management, and emergent care

Medicare’s OASIS: Standardized Outcome and Assessment Information Set for Home Health Care (Shaughnessy, Crisler, & Schlenker, 1995)


60

ď&#x20AC;&#x201A;

Minimum Standards for Domiciliary Physical and Occupational Therapy Services

Program Evaluation


2.

1.

2)

1)

(

61

:

)


62

1.

• )

(1)

(


2.

63

(2)


3.

(3)

:

(2)

• •64

(1) users’ guide

(2)


65

4.

(3)


66

5.

(4)


67


68


69

(PT/OT)


70

(PT/OT)

58 18.5 53.8 23.7 85.4

88 19.0 56.0 31.8 82.3

76.7

46.7

60.0

20.0

30


71

58 45.5 52.7 1.8 30.9 69.1 0

88 45.9 52.9 1.2 33.4 66.7 0

0

62.1

37.9

0

53.3

46.6

30


72

29.1 69.1 1.8 29.1 69.1 1.8 49.1 45.5 5.5

31.0 65.5 3.6 31.0 65.5 3.6 44.0 52.4 3.6

0

65.5

34.4

6.9

58.6

34.4

6.9

58.6

34.4


73

(2-12 )


74

(2-12

)

51 196 3.84


75

22/29


76


77


78

7

99 BI 38.13(SD=25.4) 30 67 42.9% 80 76 48.7% 8.4%

(N=35)

OT


79

EQ-5D

1

1

2

1

2

3

6


80

(

)

(

60 ) 66 3.58 5.07

FIM

BI

67 5.37 8.00

100

67 1.94 3.29

(PASS) 36

100 63 7.6508 9.63053

EQ5D)


81

?

85.71%

100%

100%

71.43%

50 100%

OT

28.57%

14.29%


82

C2

C1

28.57% 42.86% 28.57% 0% 100%

100%

0%

28.57%

57.14

14.29


C4

83

C3

100%

0%

57.14%

28.57%

14.29%

28.57% 28.57% 42.86% 0% 100%


84

C5

C6 57.14% 0% 42.86% 0% 100%

14.28% 42.86% 42.86% 0% 100%


85

:6 1

123

171 1.5

111 :5


86

• 8 • 11 • 2 • 3

6  48  62

--33

¼

29

--116


87

C5

C4

57.14% 28.57% 14.29% 100%

85.71% 0% 14.29% 100%


88


89


90

(

)


91


92


93


94


95

OT

4.

3.

2.

1.

OT

2.

1.

3.

2.

1.


96

ADL

94~95 > >

>


97

(for

Home-Bound

OT BI: 30~80)


98

3


99

Randomized Control Trial)


100


101

6

3


102

*

*

• • •

--

(

:

(

4 2

|

3 6 :

) )


103

6

(single blind)

â&#x20AC;&#x201D;

3


104

(BADL) (IADL)

(Outcome Measures)


105

52

22

: 19

30

30 (0~40 )

20 (10~40 ) 3.1 : 9.4

3


106


107


108


109

(

3

)


110

(

)

(floor effect)


Rehabilitation therapy service for stroke patients living at home: systematic review of randomised trials (Lancet, 2004, vol.363, p.352-356)

111

55-75.7 yrs (mean 70 yrs)  Baseline BI: mild to moderate disability (BI 14~18 of 20 points)

14 trials (1617 patients)  OT PT mixed therapy  Subjects:


112

could be beneficial, the health gain is fairly modest (no other intervention can do at this stage)

⇓ the odds of deteriorating in ADL ( odds ratio 0.72 [95% CI .57-.92], p=.009)  ⇑ ability to do ADL (standard mean diff. 0.14 [95% CI .02-.25], p=.02)  Every 100 p’t, 7 [95% CI 2-11], would not deteriorate


113

A. Comprehensive OT: some B. Training skills combined with assistive devices: some C. Advice/instruction regarding assistive devices: strong D. Counseling of primary care giver: insufficient

OT for community dwelling elderly people: a systematic review (Age and Ageing, 2004, 33(5), 453-460) ≥ 60years, live independently 17 studies, 4 intervention categories


114

Sig. on functional mobility, social participation, QOL*(for 15 months)  9 months after baseline randomization

OT for well elderly

A. Comprehensive OT (1)


ď&#x20AC;&#x201A;

115

- OT 1~15) : :

6 (S.D.= 3.3, range:

, : 91 BADL, IADL

: 5.8

: 94

July 24, p. 278-280)

Occupational Therapy for Stroke Patients Not Admitted to hospital: A randomized controlled trial (THE LANCET: 1999, vol. 345,

A. Comprehensive OT (2)


116

and handicap,

OT

,

disability

EADL (median score: 16 vs. 12, p<0.01) BADL (median score: 20 vs. 18, p<0.01) General Health Questionnaire 28 (ns.) The Carer Strain Index (1 vs. 3, p<0.05)

:

OT


Dementia

117

ď&#x20AC;&#x201A;

For the primary care giver of elderly (>65 yrs) with mild-moderate dementia ď&#x20AC;&#x201A; Intervention: 10 sessions, 5 weeks OT (cognitive and behavior intervention)

Effects of Community OT on QOL, Mood, and Health Status in Dementia Patients and their Caregivers: A RCT (J Gerontology: Medical Sciences, 2007, 62, 1002~1009)

(3)


118

All significant and last for 12 months

P’t QOL*  Caregivers’ QOL* (Dementia QOL)  P’t Mood (Cornell Scale for Depression, CSD)  Caregiver Mood (CES-D)  P’t and caregivers’ health status (GHQ-12)  Caregiver’s sense of control (Mastery Scale)

Outcome: (baseline, 6 wks, 12 wks)


119

1999)

Maintaining independence and reducing Home Care Costs (Mann, et al, Arch Fam Med 8,

Reducing mortality for vulnerable older people (Gitlin,et al., JAGS, 2006)  Task Self-efficacy in mobility-impaired adults (Sanford, et al., JAGS, 2006)  Outdoor mobility (Logan, et al, BMJ, 2008)

Other Studies: Examples


120

ď&#x20AC;&#x201A;

Strong evidence for the efficacy of training skills combined with a home hazard assessment ď&#x20AC;&#x201A; Decrease of fall for high risk of falling for 12 months ď&#x20AC;&#x201A; Functional ability for 6 and 12 months

B. Training skills combined with assistive devices


ď&#x20AC;&#x201A;

-

121

: 12

Home visits by an Occupational Therapist for assessment and modification of environmental hazards: A randomized trial of falls prevention (J Am Geriatr Soc: 1999, vol. 47: 1397-1420) - OT : 264 , : 266 : / /

OT


122

OT

85(48%) 43(24%) 38(21%) 26(15%) 23(13%) 22(12%) 21(12%)

49% 54% 75% 60% 58% 19% 67%


123

OT

:

- 16% - 17% 5 : : - 12

:

OT

50 %

36% 45% (p<.05)

/


124

Home assessment and modification, provision of assistive devices, instruction in strategies of problem solving, energy conservation, safe performance, fall recovery techniques, balance and muscle strengthening

Reduce mortality risk  Improve functional mobility

Outcome;

Intervention:

C. Advice/instruction regarding assistive devices


125

Insufficient evidence for the efficacy  Only improve p’ts functional mobility  Implication: only counseling is not sufficient.

D. Counseling of primary care giver


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