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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1
Physical activity and healthy eating are health-related behaviours, contributing to overall health and quality of life.1,2 However, although the benefits of these behaviours have been
proven, it has been found that older adults and especially those with lower socioeconomic status (SES) are prone to unfavourable health-related behaviour.3,4 This thesis describes the
development and evaluation of a community-based approach to promote health-related behaviour among older adults in a socioeconomically disadvantaged community. This introductory chapter provides background information on the key concepts and context of the thesis, and presents the research objectives and an outline of the further contents. Health and health-related behaviour in older adults
Chronic diseases, like cardiovascular diseases, type 2 diabetes, and cancer, are now by far the leading causes of death, and their impact is steadily growing.5 Half of Dutch elderly
people who live independently suffer from one or more chronic diseases6 which might
result in disabilities and reduce quality of life.7 While the proportion of older adults
continues to grow, their average life expectancy also increases. As a result, the incidence of health problems and related demands for care, as well as the complexity of individual health problems, are expected to increase.8
Health-related behaviours, such as sufficient physical activity and healthy diet, can help to improve health in older people, thereby promoting the maintenance of physical and social independence, active participation in social life, life expectancy, quality of life, and ultimately reduction of socioeconomic health differences.1,5,7 However, currently a large
proportion of older adults have unhealthy diets as well as low levels of physical activity;9-11
moreover, levels of physical activity continue to decline with increasing age.4 To illustrate,
over 40% of the older people studied did not meet the guidelines for sufficient levels of physical activity,6 more than 70% did not meet the guidelines for fruit consumption, and
nearly 50% did not meet the guidelines for vegetable consumption.9 These figures are even
more unfavourable among those with lower SES,3,12,13 which is one explanation for
socioeconomic health differences. Socioeconomic health differences
Socioeconomic health differences are systematic differences in health and mortality between people with a high and with a low SES.14 SES is usually measured by education,
occupation, employment, income and/ or wealth.15 In health research, educational level is
the most commonly used indicator of SES.16 Significant socioeconomic health differences
are observed, for example, in life expectancy, healthy life expectancy, and health problems.17 In the Netherlands, low-educated people live about seven years shorter than
high-educated people, and the difference in healthy life expectancy can be as high as fourteen years.18 In addition, considerable differences in the prevalence of risk factors are
G e n e r a l i n t r o d u c t i o n | 11
people running greater risks.17-18 Poor health can also put a person in a more unfavourable
social position and therefore contribute to further socioeconomic health differences.18-19
A socioeconomically disadvantaged region: Eastern Groningen
Socioeconomic health differences are often found more intensely in regions with a declining population. This can be explained in at least two ways. First, people who live in regions with a declining population are generally less healthy than residents of other areas, partly due to the less favourable socioeconomic conditions in these regions.19-21 The resulting relatively
higher proportion of people with a lower SES in these regions leads to more unhealthy lifestyles, in particular lower levels of physical activity and less healthy diet, that may contribute to health concerns.22-23 Second, as younger, healthier people migrate to more
urban areas, the proportion of older and less healthy adults increases in non-urban regions with a declining population.20-21
In the Netherlands, attention to socioeconomic health differences has largely focused on socioeconomically disadvantaged neighbourhoods in medium- and large-sized cities. Only recently is attention directed at the more rural areas and borders of the country. One of these rural areas with a declining population in the Netherlands is Eastern Groningen, characterised by an ageing population, a high percentage of people with low SES and a relatively high prevalence of health problems compared to other regions in the Netherlands.20-21 More than 40% of the population in this region is aged 50 or over,
compared to 35% in the wider Dutch population.24 Groningen is one of the Dutch regions
with the highest mortality due to cardiovascular diseases and cancer.25 With respect to SES,
more than 55% of people in Eastern Groningen achieved only low or medium-low educational levels, compared to nearly 40% nationwide.26 Thus, when it comes to investing
in the reduction of socioeconomic health differences, the population of Eastern Groningen is an obvious target. One rational way to approach health problems in a socioeconomically disadvantaged region is to focus more on their prevention through interventions and policies to decrease major risk factors.18
Prevention: a community-based approach
Preventive interventions can help older adults to improve their health-related behaviours, for example, levels of physical activity and healthy eating, to prevent chronic diseases like cardiovascular diseases, type 2 diabetes, and some types of cancer.11,27 Overall health can
thereby be expected to improve, thus positively influencing life expectancy. In addition, preventive interventions can result in longer participation in social activities, maintenance of physical and social independence, and improvement in quality of life in an ageing population.1,11
To change people’s health-related behaviour a broad range of intervention components is needed. These components are aimed at creating a supportive environment for the individual and can be offered through a community-based approach.28,29 Common
components of community-based approaches include: a tailored multi-component approach, intersectoral cooperation, participation of the community, and changes in the social and physical environment.28-30 Community-based approaches are a feasible and
cost-effective way to achieve relatively large health gains, because they reach substantial numbers of people by means of limited resources.31 Such an approach would seem
particularly appropriate for disadvantaged groups with specific needs and barriers,22,29 like
older adults in a socioeconomically disadvantaged community. This group is therefore an important target population for community-based preventive interventions.6
Care for older adults
In recent years, due to changes in needs and social structures, a different approach to health is required since a disease-oriented approach alone is no longer appropriate.32
Industrialized societies are in a transition stage from disease and care to health and behaviour.33 Care is not only about treating but also about preventing diseases and
promoting health-related behaviour in order to improve health, independent living, active participation in social life, and quality of life during old age. Moreover, this policy has been introduced to relieve the expected pressure on the healthcare system.8
Various sectors and professionals are involved in the care of older adults. One sector is home healthcare, whereby care is provided at home by professionals whose main focus is care for older adults and their problems. Home healthcare is a sustainable alternative to unnecessary acute or long-term institutionalisation and makes it possible for individuals to remain in their home and community as long as possible.32 Because they
frequently visit vulnerable older adults in their own environment and have gained their trust, professionals in home healthcare are in a good position to influence health-related behaviours.34 Therefore, home healthcare professionals can be appropriate intermediaries
to enhance the health-related behaviours of their clients. Ideally, vulnerable older adults as yet without home healthcare could also become the focus of a community team and a nearby home healthcare organisation.
Combining interventions in the general community with interventions in the home healthcare setting could have the added value of targeting different levels, using a wider range of strategies. In addition, this combination may better reach target populations like vulnerable older adults. To promote long-term changes in health-related behaviours, combined interventions at multiple levels may be necessary.35
G e n e r a l i n t r o d u c t i o n | 13
Academic Collaborative Centre for Home Healthcare
Academic collaborative centres aim to improve cooperation between research, education, practice, and policy so as to increase the quality of life of citizens; they do this by collecting new knowledge and evidence and translating this to daily practice. In such collaboration the focus is on generating practice-based evidence and evidence-based practice related to home healthcare-related issues. The new evidence should contribute to more effective practices and policies.
The Netherlands Organisation for Health Research and Development (ZonMw), initiated the research program ‘PreventieKracht dicht bij Huis’ (2009-2012). As part of this research program, the Academic Collaborative Centre for Home Healthcare (AWT) Eastern Groningen was established, a collaboration between the University Medical Centre Groningen, the Hanze University of Applied Sciences Groningen, the University of Groningen, and Zorggroep Meander. The AWT Eastern Groningen focuses on preventing dependency and decreased quality of life due to health problems and disabilities in older adults. However, evidence-based practice of such prevention in home healthcare is limited and practical knowledge is badly needed. The knowledge obtained in the AWT will contribute to evidence-based home healthcare aimed at improving health-related behaviours in older adults, enabling them to maintain independent living, social participation, and quality of life.
Objectives of this thesis
The overall aim of this thesis is to report on the development and evaluation of a community-based approach to promote health-related behaviours among older adults in a socioeconomically disadvantaged area in the Netherlands. This aim has been translated into six 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 such an intervention 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 independent-living older adults receiving home healthcare.
Outline of the thesis
The outline of the thesis is based on the sequential steps of the Intervention Mapping protocol based on evidence- and practice-based input.36 Chapter 2 describes the results of
the quantitative cross-sectional study as input for the needs assessment. Six-hundred older adults were invited to participate in this study, 244 (40.6%) of whom participated. This study focused specifically on the correlates of physical activity. Chapter 3 provides an overview of the development of a community-based intervention using the procedure of Intervention Mapping. Chapter 4 presents the reach as well as the short- and medium-term effects of the community-based intervention on physical activity and healthy eating. The pre- and post-test quasi-experimental study design included a baseline and two follow-up measurements. In total, 1500 older adults were invited to participate, 643 (42.9%) of whom participated at baseline: 430 in the intervention condition and 213 in the control condition. Retention at up was 88.5% for the first up and 87.7% for the second follow-up. Chapter 5 describes the potential moderators of physical activity and healthy eating in the community-based intervention. In this study we used the data from the baseline and the second follow-up measurement of the effectiveness study. We tested sociodemographic, psychosocial, and health-related variables at baseline as potential moderators of the effects of the conditions. Chapter 6 reports the effects of a combined home healthcare and community-based intervention on physical activity and healthy eating of home healthcare clients. In total, we approached 699 clients, of whom 304 (44%) provided short-term data, and 196 (28%) provided medium-term data. We used a 3-arm pre- and post-test quasi-experimental study design with a combined intervention (baseline n=98), a single home healthcare intervention (baseline n=111), and a control group (baseline n=95). Participant retention rates in the conditions ranged from 55% to 79%. The last chapter, Chapter 7, summarises and discusses the main results and proposes implications for practice and policy, future research, and the AWT.
G e n e r a l i n t r o d u c t i o n | 15
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