University of Groningen
Development and evaluation of a community-based approach to promote health-related
behaviour among older adults in a socioeconomically disadvantaged community
Luten, Karla
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Publication date: 2017
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Luten, K. (2017). Development and evaluation of a community-based approach to promote health-related behaviour among older adults in a socioeconomically disadvantaged community. Rijksuniversiteit
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120 | S u m m a r y
The aim of this thesis is to report on the development and evaluation of a community-based approach to promote health-related behaviour among older adults in a socioeconomically disadvantaged community. The study took place in Eastern Groningen, a region characterised by an ageing population, many people with low socioeconomic status (SES), and a relatively high prevalence of health problems compared to other regions in the Netherlands. Community-based interventions targeted at older adults in socioeconomically disadvantaged communities are scarce. Such interventions can improve health, participation, quality of life, and ultimately contribute to a reduction in socioeconomic health differences.
Chapter 1: Introduction
The introduction of this thesis provides background information about health and health-behaviour of older adults, socioeconomic health differences, and community-based prevention approaches to reach and have impact on older adults in a socioeconomically disadvantaged community. Furthermore, we describe the role of home healthcare and its professionals in prevention. Finally, we present the Academic Collaborative Centre for Home Healthcare (AWT) Eastern Groningen, in which this study has been performed. At the end of Chapter 1 we present the research objectives, divided into two main themes:
1. Development of a community-based approach:
- To identify sociodemographic, health-related, cultural, and psychological correlates of physical activity among older adults;
- To assess whether correlates of physical activity differ by SES;
- To describe the development of a community-based intervention aimed at promoting physical activity and healthy eating among older adults.
2. Evaluation of a community-based approach:
- To assess the reach and effectiveness of a community-based intervention on physical activity and healthy eating among older adults;
- To evaluate whether the effects of a community-based intervention among older adults vary by sociodemographic, psychosocial and health-related variables; - To assess the effects of combining a home healthcare intervention and a
community-based intervention on health-related behaviours of vulnerable, independent-living older adults receiving home healthcare.
Chapter 2: Correlates of physical activity
In Chapter 2, we describe a study aimed to identify sociodemographic, health-related, cultural, and psychological correlates of physical activity among older adults in a socioeconomically disadvantaged rural area in the Netherlands and to assess whether these correlates of physical activity differ by SES. It showed that having a partner and higher self-efficacy were associated with more total physical activity. More transport-related physical activity was related to younger age, better physical fitness, and being less happy to be a
person from this region (cultural identity). More household-related physical activity was associated with being female, having no (paid) work, less physical fitness, and feeling less connected to this region. And more leisure-time physical activity was related to being male, having a partner, better physical fitness, better overall health, being born and having lived in the region, being happy to be a person from this region, and feeling connected to the region. Associations between low and higher older SES adults hardly differed. Our findings imply that in general strategies to improve physical activity are needed within this target population for different types of physical activity. This study provides input for the needs assessment as the first step of Intervention Mapping (IM) described in the next chapter. Chapter 3: Development of a community-based intervention
In Chapter 3, we describe the development of a community-based intervention aimed at promoting physical activity and healthy eating among older adults in Eastern Groningen. The IM protocol was used to develop the intervention based on evidence- and practice-based input tailored to the target population. An assessment was performed of the problem translated into objectives and determinants related to behavioural change in physical activity and healthy eating. This resulted in a plan for adoption and implementation of the intervention which included a local media campaign, creating a supportive social and physical environment, in co-creation with the target population and health professionals that promoted the campaign. IM was a helpful instrument in developing a feasible, theory- and evidence-based health promotion intervention tailored to a specific target population. The systematic and structured approach provides insight into the relationship between the objectives, methods, and strategies used to achieve a multi-component intervention aimed at reaching and having impact on the individual and creating a supportive environment for behavioural change.
Chapter 4: Reach and effectiveness of a community-based intervention
In Chapter 4, we describe a study on the reach and effectiveness of a community-based intervention in the short and medium term. A quasi-experimental study design was used with an intervention group in one region and a comparable control group in an adjacent region. The intervention included a local media campaign and environmental approaches, and was implemented during a three-month high-intensity period, followed by a six-month low-intensity one. The main outcome measures were changes in physical activity and healthy eating which are assessed in both regions using validated instruments at baseline and three and nine months after the baseline measurement. At the follow-up measurements, the intervention had reached 68 and 69% of the participants in the intervention group, respectively. No significant differences were found between the intervention group and the control group in changes regarding any outcome except for transport-related physical activity at three and nine months follow-up. The study
122 | S u m m a r y
demonstrates that the systematically developed community-based intervention reached a relatively large proportion of the participants, but had only small effects on the levels of physical activity in older adults in the short and medium term.
Chapter 5: Moderators of physical activity and healthy eating
In Chapter 5, we describe the variation of the effects of a community-based intervention among older adults by sociodemographic, psychosocial, and health-related variables. We found several types of moderators for all outcome variables except for total physical activity, but in particular for transport-related physical activity and fruit and vegetable consumption. Regarding sociodemographic characteristics, gender was a moderator for household-related physical activity, and educational level for transport-related physical activity and fruit and vegetable consumption. Self-efficacy, as a psychosocial variable, was a moderator for transport-related physical activity, leisure-time physical activity, and vegetable consumption. Concerning health-related outcomes, baseline levels of transport-related physical activity and fruit consumption were moderators for transport-transport-related physical activity and fruit consumption. Adjusted for multiple testing, only three moderators persisted: educational level for vegetable consumption, and baseline levels for transport-related physical activity and fruit consumption. These results suggests that the intervention works best for those for whom the intervention was designed for, i.e., older adults who are less active and have an unhealthier diet.
Chapter 6: Effectiveness of combining interventions
In Chapter 6, we describe the study aimed to assess the effects of combining a home healthcare intervention and a community-based intervention on physical activity and healthy eating of independent-living older adults with home healthcare. This combined intervention was compared to two conditions: a single home healthcare intervention, and a control condition: care as usual. We found only significant effects for the combined intervention compared to the single intervention on total and transport-related physical activity in the short term with small to medium effect sizes, although these results disappeared on the medium term. The results in the short term suggest a major potential for achieving better health and quality of life in vulnerable, independent-living older adults receiving home healthcare.
Chapter 7: Discussion and implications
We systematically developed and implemented a structured and evidence-based community-based approach and reached a relatively large proportion of the participants. Despite, only significant effects were demonstrated for transport-related physical activity in older adults on the short and medium term. A possible explanation for the small effects could be that some relevant determinants or strategies may not have been sufficiently included in the developmental process. Next, the implementation of the social and physical
environmental components may have been insufficient to result in behavioural change. Finally, the intensity and duration of the intervening period may have been insufficient to demonstrate major effects. All these explanations are partly related to the availability of human and financial resources.
Regarding vulnerable independent-living older adults receiving home healthcare, combining a home healthcare and community-based intervention appeared to be more effective than a single home healthcare intervention, in the short term. However, these effects of this combined intervention faded out in the medium term. Possibly the intensity and duration were not sufficient to sustain behavioural change in this specific target population. We assume that the intervention would have been more effective if its high-intensity period, especially with the individual support of home healthcare professionals, had been extended, because behavioural change of individuals takes time.
Although the community-based intervention demonstrated minor effects, it can be considered as a promising approach in reaching and having impact on older adults in a socioeconomically disadvantaged community. We think that the following potential core components may have contributed to this success: the multi-component approach, the attention paid to the social environment, the use of a structured framework, the tailoring of content and channel to the target population, and the co-creation with the community.
The AWT consisted of two parts: the collaboration infrastructure and the activities that make use of that infrastructure. The collaboration infrastructure was important in bringing together the field of research and practice within home healthcare, and therefore essential to develop and implement this study. Regarding the contents, the limited effects may be interpreted as that it is hard to improve health-related behaviour in this target population, but also that the collaboration indeed contributed to the effectiveness of health promotion. An active continuation of and investment in the AWT may add to reach sustainable effects.
The findings have some implications for practice and policy, further research, and the AWTs. First, findings support further implementation of the community-based intervention for older adults and of the combined intervention for older adults receiving home healthcare. Extra attention paid to social support by peers and healthcare professionals can reinforce the effects. To reach sustainable preventive interventions, structural financing is needed. Furthermore, collaboration with all relevant local stakeholders is necessary when dealing with population health issues, in particular in such a socioeconomically disadvantaged community. This should be supported by intersectoral policies from the involved stakeholders. Finally, a long-term vision on preventive care is required to increase the quality of evidence-based practices in prevention and so a better quality of life of older adults.
