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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6
Combining interventions in home healthcare
and community settings: effects on
health-related behaviours of older adults
Karla A. Luten Maaike E. Walters Andrea F. de Winter Cees P. van der Schans Sijmen A. Reijneveld Arie Dijkstra
Abstract
Objective. The aim of this study was to assess the effects of combining a home healthcare
intervention and a community-based intervention on physical activity and healthy eating of vulnerable, independent-living older adults living in Eastern Groningen in the Netherlands.
Methods. The study included a controlled pre- and post-test quasi-experimental design
with three conditions: a combination of a home healthcare intervention and a community-based intervention (n=98), a single home healthcare intervention (n=111) and a control condition (n=95). Data were gathered on three time-points, at baseline and at two follow-ups, in the period of September 2011 to December 2012.
Results. The overall effects of the combined interventions were not statistically significant
for any short- or medium-term outcome variable (all p>.06). Comparing the combined interventions with the single home healthcare intervention, small to medium positive differences were found for total physical activity (p=.03; ES=.03), and transport-related physical activity (p=.04; ES=.03), but only in the short term.
Conclusions. For the combined intervention, as compared to the single intervention, for
total and transport-related physical activity we found short-term advantages with small to medium effect sizes. This suggests a major potential for achieving better health and quality of life in vulnerable, independent-living older adults with home healthcare.
Introduction
Most people aged 65 years and older have multiple chronic conditions.1 These health
problems are partially due to an unhealthy lifestyle, including physical inactivity and unhealthy eating.2-4 Physical inactivity and low levels of fruit and vegetable intake add to
the burden of disease (3% and 7% respectively).5 Health benefits can be achieved with fairly
small increases in physical activity.6 Increasing physical activity and improving dietary
behaviour may thus be beneficial for improving health, quality of life and independent living during old age.7,8
Interventions aimed at stimulating a healthier lifestyle seem promising.9,10 The
effects of such interventions to promote changes in lifestyle, i.e., healthy eating and physical activity, depend mainly on including established techniques for behavioural change, mobilising social support, and having a plan to support maintenance of behavioural change.11 Home healthcare can greatly influence health-related behaviour, especially in
older adults, as healthcare professionals frequently visit older adults in their own environment and have gained their trust. This makes healthcare professionals appropriate intermediaries to enhance the health-related behaviour of their clients. For this task, care professionals need training in how to provide preventive activities, including talking with older adults and advising them about their levels of physical activity and fruit and vegetable intakes. As of yet, however, such prevention within the home healthcare setting is inadequate.
A combination of interventions can influence the target population in various ways, suggesting that health promoting interventions might benefit from a combined approach whereby complementary supportive action would enhance the effectiveness of specific interventions.12 As most older adults are also embedded in a community, community-based
approaches could be helpful, mobilising social support to facilitate changes in health-related behaviour.11 Furthermore, such approaches seem to be promising, feasible, and
cost-effective in changing the health-related behaviour of people who are hard to reach.13
However, little is known about the potential added value of combining a home healthcare intervention with a community-based intervention to promote health-related behaviour among vulnerable, independent-living older adults. The aim of this study was therefore to compare the effects of such a combination with a single home healthcare intervention on physical activity and healthy eating of vulnerable, independent-living older adults receiving home healthcare. The study took place in a socioeconomically disadvantaged community in Eastern Groningen in the Netherlands.
Figure 1. Participant flow. HHC = Home healthcare intervention; CB = Community-based
intervention
Methods
Study design and participants
We performed a quasi-experimental study with two experimental groups and one control group, and a pre- and post-test design. The first intervention group received the home healthcare intervention as well as a community based intervention, the second group received only a home healthcare intervention, and the third group received care as usual.14
Participants were recruited by mail and gave their consent by filling out and returning the baseline questionnaire. The Medical Ethical Committee of the University Medical Center Groningen examined the study protocol and considered it unnecessary to submit it for a full ethical assessment because it did not provide a large additional burden to participants and
generally met the requirements of the Helsinki declaration. The study has next been conducted in accordance with the Helsinki declaration.15
Participants (clients) in both intervention conditions and in the control group were vulnerable, independent-living older adults receiving home healthcare. All eligible clients were invited to participate in the study and completed a self-report questionnaire. Clients older than 55 years who were suffering from mental diseases like dementia or receiving palliative care were excluded. We aimed to include 92 participants per condition, based on the intention to measure an increase in use of preventive services by home healthcare clients from 20% to 40% (eta squared effect size about 0.03) with a power of 80%, an alpha of 0.05. Assuming a loss to follow up of 20%, we needed to include 115 home healthcare clients. Questionnaires were sent by mail to the home healthcare clients. Clients received a reward (vouchers of ten euros for a bouquet of flowers at a local florist and for a basket of fruit at a local greengrocery, respectively) for filling out the questionnaires for follow-up retention. See Figure 1. for the participant flow.
Intervention conditions
Home healthcare intervention
The home healthcare intervention included training the home healthcare professionals in how to provide preventive activities during client visits and thus enhance the health-related behaviour of their clients by increasing related determinants. Specifically, the professionals were trained in how to raise the issue of physical activity and nutrition during encounters with their clients and how to do this in a supportive way using motivational interviewing and persuasive communication. Furthermore, they learned how to motivate the client to continue with a healthier lifestyle, even after a relapse. The training consisted of three 4-hour sessions and was executed within a timespan of six months, between baseline (T0) and the first follow-up (T1) measurement. The training materials consisted of newly developed training booklets, a health-related behaviour-checklist and a registration tool. The checklist and registration tool were developed to aid the home healthcare professional in providing preventive activities. Prevention also received extra emphasis during the regular work meetings attended by home healthcare professionals and their supervisor. See Walters et al. for a full description of the development and contents of the training.14
Community-based intervention
The community-based intervention aimed at stimulating physical activity and healthy eating by increasing related determinants. It was developed for older adults and included multiple components such as a local media campaign (e.g., posters, radio spots, advertorials and press reports) and environmental approaches (e.g., promotion by peers and professionals, and a market including local activities). Stakeholders (professionals and older adults) were involved in the development and implementation of the intervention. The implementation
included several strategies, using local channels where possible. The intervention period consisted of a high-intensity stage of three months (between T0 and T1) followed by a low-intensity stage of six months (between T1 and T2). All strategies were executed in the first three months. In the following low-intensive period most of the strategies were again executed, but less frequently. The intervention has been described elsewhere in more detail.16
Control condition: care as usual
Home healthcare professionals in the control condition received no additional training and provided their clients care as usual. No elements of the local media campaign or environmental approaches were executed in the control condition.
Measures and procedure
Clients received a self-report questionnaire to assess background characteristics and outcome variables, i.e., physical activity and fruit and vegetable consumption.
Background characteristics included gender, age, educational level, general health
status, Body Mass Index (BMI) and received home healthcare in hours per week. Educational level was dichotomised: 1) no education, primary education, or primary lower professional education (low); 2) intermediate general or intermediate professional education, higher general or higher professional education and university (higher). General health status was measured by the following question: ‘How would you rate your health in general?’ with five answering options ranging from ‘excellent’(1) to ‘poor’(5). BMI (weight/ (height)2) was calculated by measuring the weight and height of the client.
Physical activity was measured with Short QUestionnaire to ASsess
Health-enhancing physical activity (SQUASH). The SQUASH measures habitual activity and has been shown to be reliable and valid for use in adult populations.17 Three fields of physical activity
were included: transport-related physical activity, household-related physical activity and leisure-time physical activity as well as total physical activity in minutes per week.
Healthy eating was operationalised as fruit and vegetable consumption, measured
in grams per day of four items. Participants indicated their intake of vegetables, vegetable salad, fruit and fruit juice in days per week and amounts consumed. Two continuous variables were composed: fruit consumption included fruit and fruit juice, and vegetable consumption included vegetables and vegetable salad.
Data were gathered in three districts at three time-points: a baseline measurement (T0) from September to November 2011, the first effect measurement (T1) from April to June 2012, and the second effect measurement (T2) from October to December 2012.
Statistical analyses
First, the groups were compared on the basis of their background characteristics, as were the participants who participated during follow-up and those who dropped out during the study. The statistical significance of the differences was tested with chi-square tests for categorical variables and with one-way between-group analysis of variance (ANOVA) for continuous variables.
Second, the effects of the interventions on total physical activity, the three domains of physical activity, and fruit and vegetable consumption at follow-up were evaluated in two ways for the short term, and then again for the medium term. First, the main effects of condition were tested. Second, contrasts between the three conditions were then analysed. For both types of analyses we used analyses of covariance (ANCOVA) and adjusted for age, gender, educational level. Furthermore, we adjusted for the baseline assessments of the outcome variable corresponding with the outcome variable that was tested (e.g., when total physical activity at T1 was the outcome variable, total physical activity at baseline was included as a covariate). P-values <.05 were treated as significant (two-tailed). Effect size (ES) was measured by using the partial eta squared (η2). A small
effect is about η2=0.01, a medium effect is about η2=0.06, and a large effect is about
η2=0.14.18 Analyses were performed using SPSS 20.0 for Windows.
Results
Background characteristics
Background characteristics of the sample by condition are given in Table 1. The groups did not differ significantly on these variables, except for educational level (p=.001): participants in the control group more often had a low level of education. When comparing all participants with those who dropped out at T1 or T2, no significant differences were found for any background characteristic and any outcome variable of physical activity and fruit and vegetable consumption at baseline.
Table 1. Background characteristics of home healthcare clients at baseline
HHC + CB HHC Control
n=98 n=111 n=95 p
Age (mean (SD) in years) 79.1 (8.8) 78.9 (9.2) 79.4 (8.6) 0.89
Gender (% women) 70.4 64.0 75.8 0.18
Educational level (% low) 64.9 74.8 88.0 0.001* General health status (% excellent/ (very) good) 35.7 24.3 35.1 0.13 BMI (mean (SD) in kg/m2) 27.5 (4.9) 28.0 (5.6) 27.8 (5.6) 0.81
Home healthcare (mean (SD) in hrs/wk 5.4 (4.5) 4.7 (4.0) 5.2 (4.0) 0.42 HHC: home healthcare intervention; CB: community-based intervention; SD: standard deviation; * Statistically significant p<.05
Effects of the interventions
Table 2 shows the short-term effects (T1) of the interventions on the different domains of physical activity and fruit and vegetable consumption of home healthcare clients. The overall effects (for all three groups) on all outcome variables were not significant (all p>.06). When the effects of combined home healthcare and community-based intervention were compared to effects of the single home healthcare intervention, significant differences were found for total physical activity (p=.03; ES=.03), and transport-related physical activity (p=.04; ES=.03): The amount of activity of those within the combined home healthcare and community-based condition improved (201 and 25 minutes more per week), while the activity of those within the home healthcare condition worsened (35 and 37 minutes less per week).
Comparison of the combined home healthcare and community-based intervention condition to the control condition showed that the contrast analyses were marginally significant for three of the four measures of physical activity. First, on total physical activity, participants in the combined intervention improved by 201 minutes per week, while in the control group this was only 12 minutes per week (p=.06; ES=.03). Second, on household-related physical activity, participants in the combined intervention condition improved by 85 minutes per week, while in the control group there was a decline of 8 minutes per week (p=.06; ES=.03). Third, the leisure-time physical activity of participants in the combined intervention condition improved by 70 minutes per week, while in the control group there was a decrease of 29 minutes per week (p=.06; ES=.03).
Table 3 shows the medium-term effects (T2) of the interventions on the different outcome variables. None of the main effects on any outcome were significant (all p>.25). In addition, none of the contrasts between the combined intervention condition and the single home healthcare intervention condition were significant (all p>.45), as were none of the contrasts between the combined intervention condition on the one hand and the control condition on the other hand (all p>.19).
Discussion
The aim of this study was to assess how a combination of a home healthcare intervention and a community-based intervention, as compared with only a home healthcare intervention, would affect the physical activity and eating habits of vulnerable, independent-living older adults. In this quasi-experimental study, for total and transport-related physical activity we found significant short-term differences in favor of the combined intervention, with small to medium effect sizes. Promoting a physically active lifestyle will not only prevent chronic diseases but may also result in prolonged participation in social activities, improved health, and a better quality of life.8 However, our obtained
results faded out in the medium term. For short and medium term changes in vegetable and fruit consumption no intervention effects were found.
Our findings that the combined intervention gave better outcomes than did the single intervention confirmed findings of other studies.19 Although literature about the
added value of a combined as compared to a single intervention is scarce, a broad multi-component approach appears to be effective in changing health-related behaviour.11 Along
with the multi-component approach, the larger timespan of follow-up described by Greaves et al.11 could explain the increased effects of their review as compared with the timespan
of our study. Advantages of the combined condition for total and transport-related physical activity faded out on the medium term. This can be explained by the decrease in the intensity of the interventions after the first follow-up. Possibly the intensity was not sufficient to maintain the obtained results in this specific vulnerable target population. The fading out effect is in line with previous research on changing health-related behaviour.20
As for fruit and vegetable consumption, the combined intervention had no additional short- or medium-term effects when compared to the single home healthcare intervention. However, fruit and vegetable consumption increased in general for all conditions in the short and medium term. This unintentional effect could be because filling out the questionnaire increased the client’s awareness of his own consumption. However, relatively high intakes of fruit and vegetables were also measured at baseline in all conditions. National figures on these intakes demonstrate considerably lower amounts.21
This could be because participants tend to overestimate their fruit and vegetable consumption.22
Strengths and limitations
The strengths of this study are that we compared three conditions, that we used multiple time measurements and that we had a reasonable response to follow-up, taking into account the age and related fragility of the target population. Some limitations should, however, be mentioned. First, data were collected by self-report questionnaires, which may add measurement error; however, to our knowledge no more objective measure of detailed
physical activity is available for this specific population of vulnerable older adults. A second limitation was that the single intervention group and the group with care as usual were partly exposed (8.1% respectively 11.6%) to the campaign in the community-based intervention; the distance between the regions was small, possibly resulting in contamination. The exposure could also be because some professionals from the intervention region as well as the control region both work at the same home healthcare organisation. Another reason could be unintended exposure to the community-based intervention. A third limitation is the power of this study. Although starting with a sufficient number of respondents at baseline, we have lost a reasonable amount of them during the first and second effect measurements. Despite this lower number, we found significant results of the interventions. However, this also means that certain relevant effects of the interventions could have been missed. Finally, we performed a quasi-experimental study without formal randomisation. However, the assignment of districts to conditions was not related to characteristics of the group of professionals or of the clients but to logistical issues. Moreover, home healthcare professionals remained working in the team and district they used to work in, making bias unlikely.
Recommendations
Because a combined intervention demonstrated significant short-term effects on physical activity, we recommend using such a combination instead of a single home healthcare intervention. More research is necessary to assess whether even stronger effects could be achieved by a prolonged and highly intensive combination of interventions. Such effects could, for example, be expected if greater numbers of people were to be reached by the community-based intervention. In this study fewer than half of the respondents reported having seen or heard of the campaign of the community-based intervention.
In addition, preventive activities need to be better integrated into the daily work of home healthcare professionals. During the intervention period a vigorous start was made, but to improve such integration into daily work, prevention should be embedded in the focus and policies of the organisation. This requires a long-term vision within the home healthcare organisation.
Conclusions
In conclusion, the combination of a home healthcare intervention and a community-based intervention showed a significant difference on total and transport-related physical activity in older adults compared to the single home healthcare intervention in the short term. This result provides major potential in achieving a better health and quality of life in vulnerable, independent-living older adults.
References
1. Anderson G. Chronic care: making the case for ongoing care. Robert Wood Johnson Foundation. 2010. http://www.rwjf.org/content/dam/farm/reports/reports/2010/ rwjf54583. Accessed: June 13, 2014.
2. Artaud F, Dugravot A, Sabia S, Singh-Manoux A, Tzourio C, Elbaz A. Unhealthy behaviours and disability in older adults: Three-City Dijon cohort study. BMJ. 2013; 347: f4240.
3. Win S, Parakh K, Eze-Nliam CM, Gottdiener JS, Kop WJ, Ziegelstein RC. Depressive symptoms, physical inactivity and risk of cardiovascular mortality in older adults: the Cardiovascular Health Study. Heart. 2011; 97(6): 500-505.
4. Vogel T, Brechat PH, Lepretre PM, Kaltenbach G, Berthel M, Lonsdorfer J. Health benefits of physical activity in older adults: a review. Int J Clin Pract. 2009; 63(2): 303-320.
5. Lim SS, Vos T, Flaxman AD, Danaei G, Shibuya K, Adair-Rohani H, AlMazroa MA, Amann M, et al. A comparative risk assessment of burden of disease and injury attributable to 67 risk factors and risk factor clusters in 21 regions, 1990–2010: a systematic analysis for the Global Burden of Disease Study 2010. The Lancet. 2012; 380, No. 9859: 2224-2260.
6. Ekelund U, Ward HA, Norat T, Juan J, May AM, Weiderpass E, Sharp SS, Overvad K, et al. Physical activity and all-cause mortality across levels of overall and abdominal adiposity in European men and women: the European Prospective Investigation into Cancer and Nutrition Study (EPIC). Am J Clin Nutr. 2015; 101(3): 613-621.
7. Beswick AD, Rees K, Dieppe P, Ayis S, Gooberman-Hill R, Horwood J, Ebrahim S. Complex interventions to improve physical function and maintain independent living in elderly people: a systematic review and meta-analysis. The Lancet. 2008; 371(9614), 725-735.
8. Nelson ME, Rejeski WJ, Blair SN, Duncan PW, Judge JO, King AC, Macera CA, Castaneda-Sceppa, C. Physical activity and public health in older adults: recommendation from the American college of sports medicine and the American heart association. Circulation. 2007; 116: 1094-1105.
9. Hecke AV, Grypdonck M, Beele H, Vanderwee K, Defloor T. Adherence to leg ulcer treatment: Changes associated with a nursing intervention for community care settings. EWMA Journal. 2010; 10(3): 36.
10. Lightbody E, Watkins C, Leathley M, Sharma A, Lye M. Evaluation of a nurse-led falls prevention programme versus usual care: A randomized controlled trial. Age Ageing. 2002; 31(3): 203-210.
11. Greaves CJ, Sheppard KE, Abraham C, Hardeman W, Roden M, Evans PH, Schwarz P, the IMAGE Study Group. Systematic review of reviews of intervention components associated with increased effectiveness in dietary and physical activity interventions. BMC Public Health. 2011; 11: 119-130.
12. Jepson R, Harris F, Platt S, Tannahill C. The effectiveness of interventions to change six health behaviours: a review of reviews. BMC Public Health. 2010; 10: 538.
13. Garrett S, Elley CR, Rose SB, O’Dea D, Lawton BA, Dowell AC. Are physical activity interventions in primary care and the community cost-effective? A systematic review of the evidence. Br J Gen Pract. 2011; 61(584): e125-133.
14. Walters ME, Dijkstra A, de Winter AF, Reijneveld SA. Development of a training programme for home health care workers to promote preventive activities focused on a healthy lifestyle: an intervention mapping approach. BMC Health Serv Res. 2015; 15(1): 1-12.
15. WHO. (2016). Declaration of Helsinki. http://www.who.int/bulletin/archives/ 79(4)373.pdf. Retrieved: June 12, 2016.
16. Luten KA, Reijneveld SA, Dijkstra A, de Winter AF. Reach and effectiveness of an integrated community-based intervention on physical activity and healthy eating of older adults in a socioeconomically disadvantaged community. Health Educ Res. 2016; 31(1): 98-106.
17. Wendel-Vos GC, Schuit AJ, Saris WHM, Kromhout D. Reproducibility and relative validity of the short questionnaire to assess health-enhancing physical activity. J Clin Epidemiol. 2003; 56(12): 1163-1169.
18. Cohen J. Statistical Power Analysis for the Behavioral Sciences: 2nd ed. Hillsdale, NJ: Lawrence Erlbaum Associates, 1988.
19. Shaw K, O'Rourke, Del Mar C, Kenardy J. Psychological interventions for overweight and obesity. Cochrane Database Syst Rev. 2005; 2.
20. Skender ML, Goodrick GK, Del Junco DJ, Reeves RS, Darnell L, Gotto AM, Foreyt JP. Comparison of 2-year weight loss trends in behavioral treatments of obesity: Diet, exercise, and combination interventions. J Am Diet Assoc. 1996; 96: 342-346.
21. Van Rossum CTM, Fransen HP, Verkaik-Kloosterman J, Rethans-Buurma EJM, Ocke MC. Dutch National Food Consumption Survey 2007-2010: Diet of children and adults aged 7 to 69 years. Bilthoven: Rijksinstituut voor Volksgezondheid en Milieu (RIVM), 2011.
22. Lechner L, Brug J, de Vries H. Misconceptions of fruit and vegetable consumption: Differences between objective and subjective. J Nutr Educ Behav. 1997; 29: 313-320
