Impact of Health Promotion Interventions on Quality of Life of the Elderly in an Australian Community - Research Proposal Example

RESEARCH PROPOSAL Topic: Impact of health promotion interventions on quality of life of elderly in an Australian community and nursing home setting I. Introduction and Theoretical Framework The population of elderly people worldwide is growing continuously. Almost 13% of the population in Australia was aged over 65 years in 2007, and this percentage is expected to increase to 22% by 2030. (Australia statistical profile, 2009) It is a known fact that there is a general decline in health related quality of life as people age. Short & Leon state that many older people experience some degree of inability while performing instrumental activities of daily living (IADL) (as cited in Whittle and Goldenberg, 1996) such as using the telephone, shopping, preparing meals, housekeeping, taking medications, or managing transportation needs and financial affairs. Successful performance of these activities however, is fundamental to maintaining their independence (Whittle and Goldenberg, 1996). The main purpose of healthcare in the elderly is to achieve the maintenance of good health conditions, to ensure that these individuals can maximize their active life, in the environment they live in, with physical, mental and social autonomy and independence (Santos, Barlem, daSilva, Cestari, & Lunardi, 2008). It is important to conduct health promotion activities among the elderly population to help them improve their quality of life. Rather than emphasizing on a disease or disability, health promotion emphasizes on prevention. The purpose of health promotion activities is to help elders manage their condition better and also to ensure that they avoid activities that increase their chances of further disability. Health promotion activities provide a very holistic approach to meeting the diverse needs of the elderly population. One of the fundamental goals of health promotion is to facilitate the well-being of older adults on an ongoing basis. Ruffing-Rahal states that despite the fact that older adults suffer from chronic diseases, cognitive impairment, and functional limitations, the choices of health promotion lifestyle can help minimize health problems and lead to enhanced health outcomes (as cited in Wang, 1991). They synthesized five areas of significance for health promotion in older adults: most older adults believe themselves to be active and in good health condition despite the presence of chronic diseases and disabilities; older adults are motivated to learn about aging and health conditions; older adults can be transformed into knowledgeable participants and managers of their own self-care by using health promoting strategies; health promotion can facilitate older adults’ living independently; and health promotion for older adults can diminish morbidity and impairment. Health promotion in older adults can therefore be considered as ‘‘an intervention with important payoffs in terms of both cost saving and quality of life’’ (as cited in Wang, 1991) Few major health promotion efforts have been directed toward old people. Several myths exist that discourage their inclusion in such efforts. (Kutner et al., 1992) These myths include the following: 1. health promotion means the prevention of disease rather than improving health status; 2. old people are unable to tolerate health promotion interventions, for example, exercise regimens; 3. old people are rigid and not able or willing to change their health attitudes, behaviors, or lifestyles; 4. it is difficult to recruit old people into studies and hard to evaluate; 5. behavioral or lifestyle changes in late life will have only minimal impact on the health and functioning of old people; 6. intervention is not cost effective for the elderly (Kutner et al., 1992) However, because most old people have at least one chronic disease or disability, it is even more important to target them for health promotion efforts to help them maintain function. While disease prevention will always be an important goal, maintenance of function is an equally important and cost-effective objective for health promotion efforts for old persons (Kutner et al., 1992) No published studies on health promotion in the elderly have studied the impact of health promoting activities on quality of life from the perspective of functional status, ability to maintain independent living in the community, symptom management, and psychological wellbeing assessed on the basis of mastery, autonomy, control, and positive relations with others among elderly patients in Australia. Quality of life is a major criterion for evaluating health and medical interventions. Assessing quality of life among old persons is difficult. (Kutner et al., 1992) II. Research Question What is the impact of health promotion on: 1) functional status, 2) ability to maintain independent living in the community, 3) symptom management, and 4) psychological wellbeing assessed on the basis of mastery, autonomy, control, and positive relations with others. III. Selection of Subjects A total of 100 elderly aged above 65 years will be included in the study. 50 of these subjects will be from the XYZ institute for the elderly in ABC, Australia. These will include elderly who can walk/move and are not confined to the bed. 50 subjects will be from the local community. These will include elders who are living alone or with care givers and those who can walk/commute to the community center to attend the health promotion program. Only literate elderly will participate in the study. IV. Methodology Four sessions of health promotion education program will be conducted. These will include sessions on healthy lifestyle; chronic disease prevention and symptom management with a focus on arthritis, heart attacks, and stroke; medication education, and nutrition. These sessions will be conducted by nursing staff. Brochures will be provided to aid understanding of the content. These session will be conducted at a community center for senior citizens and also at the institution for elderly. The education sessions will be of one hour duration and will be conducted over a period of four weeks. The health promotion behavior questionnaire will be administered as a pre test in the first session and two weeks after the last session to check for application of the knowledge gained. Data collection and assessment will be similar to that of Kutner et al. (1992) Data to be collected to assess demographics and health behaviors will include age, sex, race, education, marital status, residence type and length, persons lived with, work activities, smoking, drinking, sleep problems, hospitalization, and physician visits in the past year. Weight and height will also be measured for all subjects. Katz index of independence in activities of daily living and the Instrumental activities of daily living scale will also be administered to all subjects (Appendix 1 and 2). Data regarding chronic conditions will also be recorded using medical records or self report. History of myocardial infarctions, stroke, diabetes, and arthritis will be recorded. Development of a new questionnaire is a long process and will require a lot of time which may not be feasible for during the time duration of the study. To deal with this, the questionnaire to be used for this study will include questions from already existing questionnaires that test for functional status, ability to maintain independent living in the community, symptom management, and psychological wellbeing assessed on the basis of mastery, autonomy, control, and positive relations with others. Subscales from the Sickness Impact Profile (SIP) that assess body care and movement, ambulation, and physical mobility will be included. The questionnaire will also include questions from the Medical Outcomes Study (MOS) Short-Form Health Survey (Appendix 3). The five subscales of this tool measure limited role functioning as a result of physical health, mental health, and social functioning. The subscales also measure bodily pain and general health perceptions. The short version of the Yesavage Geriatric Depression Scale (Appendix 4) will be used for the nursing home subjects because the Yesavage instrument only requires a yes or no response to items and is therefore considered to be easier to complete. The Center for Epidemiologic Studies Depression (CESD) Scale (Appendix 5) will be used for elders living in the community. Since none of these scales cover symptom management, the effect of health promotion on this aspect will be assessed on the basis of structured interviews V. Statistics Descriptive statistics will be used to describe all aspects of demographic data and health status. To reveal differences in the health behavior and quality of life between the institutionalized elderly and those at home before and after the health promotion activities, paired t-tests will be carried out. The level of significance will be set at p < 0.05 VI. Limitations of the study The multi-dimensionality inherent in quality of life measurement could impact the results of the study. Health-promotion interventions directed to specific physical domains may significantly affect functional status as well as other dimensions of quality of life. It is important to identify differential intervention effects in these domains. Investigators must be aware of possible generalized effects of the interventions. For example, physical exercise to increase muscle strength may affect weight, emotional function, and cognitive function. Multi-dimensional assessment covering all functional domains could detects potential secondary effects of the interventions. (Kutner et al., 1992) However, carrying out such a multi dimensional assessment is beyond the scope of this study. The second type of issue related to the measurement of QOL involves the characteristics of elderly respondents. Do the study participants have visual or cognitive losses that dictate selection of particular types of instruments or particular data collection strategies? To what extent do elders' responses reflect age-specific reference points, such as comparisons to others of the same age? To what extent are such reference end points applied similarly across the total population of study participants? (Kutner et al., 1992) Since this is a very small study population, these factors will not be considered. The third type of issue is age related. Interventions may prepare participants to age more successfully, so that they are better able to cope with each new stage of the aging process. These effects may not be observed for 5 or 10 years. Thus, it is important to measure parameters across various time spans to be able to assess changes in quality of life more accurately. (Kutner et al., 1992) However, due to the short time span of this study, long term measurements of this nature will not be conducted. This study is also limited in terms of the number of participants. Additionally, since the study is conducted in only a very small geographic location, the results cannot be generalized to the entire population. The study also does not take into account urban-rural, gender, or ethnic differences that could impact the final outcome. The study is not expected to raise any ethical concerns or issues. Appendix 1 Katz Index of Independence in Activities of Daily Living Activities Points (1 or 0) Independence (1 Point) NO supervision, direction or personal assistance Dependence (0 Points) WITH supervision, direction, personal assistance or total care BATHING Points: __________ (1 POINT) Bathes self completely or needs help in bathing only a single part of the body such as the back, genital area or disabled extremity (0 POINTS) Need help with bathing more than one part of the body, getting in or out of the tub or shower. Requires total bathing DRESSING Points: __________ (1 POINT) Get clothes from closets and drawers and puts on clothes and outer garments complete with fasteners. May have help tying shoes. (0 POINTS) Needs help with dressing self or needs to be completely dressed. TOILETING Points: __________ (1 POINT) Goes to toilet, gets on and off, arranges clothes, cleans genital area without help. (0 POINTS) Needs help transferring to the toilet, cleaning self or uses bedpan or commode. TRANSFERRING Points: __________ (1 POINT) Moves in and out of bed or chair unassisted. Mechanical transfer aids are acceptable (0 POINTS)Needs help in moving from bed to chair or requires a complete transfer. CONTINENCE Points: __________ (1 POINT) Exercises complete self control over urination and defecation. (0 POINTS) Is partially or totally incontinent of bowel or bladder FEEDING Points: __________ (1 POINT) Gets food from plate into mouth without help. Preparation of food may be done by another person. (0 POINTS) Needs partial or total help with feeding or requires parenteral feeding. Total Points: ________ Score of 6 = High, Patient is independent. Score of 0 = Low, patient is very dependent. Katz S., Down, TD, Cash, HR, et al. (1970) progress in the development of the index of ADL. Gerontologist 10:20-30. Copyright The Gerontological Society of America. Reproduced by permission of the publisher. Appendix 2 Appendix 3 Appendix 4 Appendix 5 Medical Outcomes Study:  36-Item Short Form Survey Instrument RAND 36-Item Health Survey 1.0 Questionnaire Items 1. In general, would you say your health is: Excellent 1 Very good 2 Good 3 Fair 4 Poor 5 2. Compared to one year ago, how would your rate your health in general now? Much better now than one year ago 1 Somewhat better now than one year ago 2 About the same 3 Somewhat worse now than one year ago 4 Much worse now than one year ago 5 The following items are about activities you might do during a typical day. Does your health now limit you in these activities? If so, how much? (Circle One Number on Each Line) Yes, Limited a Lot Yes, Limited a Little No, Not limited at All 3. Vigorous activities, such as running, lifting heavy objects, participating in strenuous sports [1] [2] [3] 4. Moderate activities, such as moving a table, pushing a vacuum cleaner, bowling, or playing golf [1] [2] [3] 5. Lifting or carrying groceries [1] [2] [3] 6. Climbing several flights of stairs [1] [2] [3] 7. Climbing one flight of stairs [1] [2] [3] 8. Bending, kneeling, or stooping [1] [2] [3] 9. Walking more than a mile [1] [2] [3] 10. Walking several blocks [1] [2] [3] 11. Walking one block [1] [2] [3] 12. Bathing or dressing yourself [1] [2] [3] During the past 4 weeks, have you had any of the following problems with your work or other regular daily activities as a result of your physical health? (Circle One Number on Each Line) Yes No 13. Cut down the amount of time you spent on work or other activities 1 2 14. Accomplished less than you would like 1 2 15. Were limited in the kind of work or other activities 1 2 16. Had difficulty performing the work or other activities (for example, it took extra effort) 1 2 During the past 4 weeks, have you had any of the following problems with your work or other regular daily activities as a result of any emotional problems (such as feeling depressed or anxious)? (Circle One Number on Each Line) Yes No 17. Cut down the amount of time you spent on work or other activities 1 2 18. Accomplished less than you would like 1 2 19. Didn't do work or other activities as carefully as usual 1 2 20. During the past 4 weeks, to what extent has your physical health or emotional problems interfered with your normal social activities with family, friends, neighbors, or groups? (Circle One Number) Not at all 1 Slightly 2 Moderately 3 Quite a bit 4 Extremely 5 21. How much bodily pain have you had during the past 4 weeks? (Circle One Number) None 1 Very mild 2 Mild 3 Moderate 4 Severe 5 Very severe 6 22. During the past 4 weeks, how much did pain interfere with your normal work (including both work outside the home and housework)? (Circle One Number) Not at all 1 A little bit 2 Moderately 3 Quite a bit 4 Extremely 5 These questions are about how you feel and how things have been with you during the past 4 weeks. For each question, please give the one answer that comes closest to the way you have been feeling. How much of the time during the past 4 weeks . . . (Circle One Number on Each Line) All of the Time Most of the Time A Good Bit of the Time Some of the Time A Little of the Time None of the Time 23. Did you feel full of pep? 1 2 3 4 5 6 24. Have you been a very nervous person? 1 2 3 4 5 6 25. Have you felt so down in the dumps that nothing could cheer you up? 1 2 3 4 5 6 26. Have you felt calm and peaceful? 1 2 3 4 5 6 27. Did you have a lot of energy? 1 2 3 4 5 6 28. Have you felt downhearted and blue? 1 2 3 4 5 6 29. Did you feel worn out? 1 2 3 4 5 6 30. Have you been a happy person? 1 2 3 4 5 6 31. Did you feel tired? 1 2 3 4 5 6 32. During the past 4 weeks, how much of the time has your physical health or emotional problems interfered with your social activities (like visiting with friends, relatives, etc.)? (Circle One Number) All of the time 1 Most of the time 2 Some of the time 3 A little of the time 4 None of the time 5 How TRUE or FALSE is each of the following statements for you. (Circle One Number on Each Line) Definitely True Mostly True Don't Know Mostly False Definitely False 33. I seem to get sick a little easier than other people 1 2 3 4 5 34. I am as healthy as anybody I know 1 2 3 4 5 35. I expect my health to get worse 1 2 3 4 5 36. My health is excellent 1 2 3 4 5 VII. References Australia statistical profile (2009). , Retrieved May, 11 2009, from OECD.Stat Extracts, website of Organization for Economic Cooperation and Development: http://stats.oecd.org/wbos/viewhtml.aspx?queryname=18144&querytype=view&lang=en Whittle, H. & Goldenberg, D. (1996). Functional health status and instrumental activities of daily living performance in noninstitutionalized elderly people. Journal of Advanced Nursing, 23 (2),  220-227. Santos, S. S. C., Barlem, E. L. D., daSilva, B. T., Cestari, M. E., & Lunardi, V. L. (2008) Health promotion for the elderly: gerontogeriatric nursing commitment. Acta Paul Enfer, 21(4), 649-53. Wang, H. (1999). Predictors of health promotion lifestyle among three ethnic groups of elderly rural women in Taiwan. Public Health Nursing, 16(5), 321–328. Kutner, N. G., Ory, M. G., Baker, D. I., Schechtman, K. B., Hornbrook, M. C., & Mulrow, C. D. (1992). Measuring the quality of life of the elderly in health promotion intervention clinical trials. 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