ABSTRACT

The population of older adults in the United States is growing disproportionately, with corresponding medical, social and economic implications. The number of Americans 65 years and older constitutes 13.7% of the U.S. population, and is expected to grow to 21% by 2040. As the adults age, they are at risk for developing chronic illness and disability. According to the Centers for Disease Control and Prevention, 5.7 million Americans have heart failure, and almost 80% of these are 65 years and older. The prevalence of heart failure will increase with the increase in aging population, thus increasing the costs associated with heart failure from 34.7 billion dollars in 2010 to 77.7 billion dollars by 2020. Of all cardiovascular hospitalizations, 28.9% are due to heart failure, and almost 60,000 deaths are accounted for heart failure. Marked disparities in heart failure persist within and between population subgroups. Living with heart failure is challenging for older adults, because being a chronic condition, the responsibility of day to day management of heart failure principally rests with patient. Approaches to improve self-management are targeted at adherence, compliance, and physiologic variables, little attention has been paid to personal and social contextual resources of older adults, crucial for decision making, and purposeful participation in goal attainment, representing a critical area for intervention. Several strategies based on empowerment perspective are focused on outcomes; paying less attention to the process. To address these gaps between research and practice, this feasibility study was guided by a tested theory, the Theory of Health Empowerment, to optimize self-management, functional health and well-being in older adults with heart failure. The study sample included older adults with heart failure attending senior centers. Specific aims of this feasibility study were to: (a) examine the feasibility of the Health Empowerment Intervention in older adults with heart failure, (b) evaluate the effect of the health empowerment intervention on self-management, functional health, and well-being among older adults with heart failure. The Health Empowerment Intervention was delivered focusing on strategies to identify and building upon self-capacity, and supportive social network, informed decision making and goal setting, and purposefully participating in the attainment of personal health goals for well-being. Study was feasible and significantly increased personal growth, and purposeful participation in the attainment of personal health goals.

Background: Community engagement has contributed to disease control and elimination in many countries. Community engagement in malaria elimination (ME) on Aneityum Island has been sustained since its introduction in the early 1990s. Capacity developed within this population has led to a health empowered community response. Health Empowerment Theory (HET) can account for the innovative community actions and capacity development efforts taken to realize and sustain meaningful changes in well-being. This study used the HET framework to investigate participant perceptions of ME efforts on the island focusing on two HET elements, personal and social-contextual resources. The purpose of this study was to explore the role of empowerment as a critical element of community engagement.

Methods: Six focus group discussions, ten key informant interviews and 17 in-depth interviews were conducted in July 2012 on Aneityum. Both deductive and inductive approaches to qualitative content analysis were used to identify themes, which were condensed, coded and classified based on the HET elements above.

Results: Awareness and use of personal and social-contextual resources played an important role in ME efforts. Most participants shared their knowledge to prevent malaria reintroduction. Many participants reported their skills needed for behavioral maintenance, problem-solving or leadership. Participants who perceived a threat took preventive actions even in the dry season. Community leaders focused on second generation capacity development. A local health coalition provided ME services. Members of networks were sources of information and assistance. Face-to-face was the preferred method of communication. Barriers to engagement (e.g., financial difficulties, health literacy issues and underdeveloped infrastructure) were minimized through active collaboration and mutual assistance.

Conclusions: In the community engagement continuum, health empowerment develops incrementally overtime as people gain their knowledge and skills, form coalitions and develop collaborative networks (social capital) to make decisions and take action for change. Community engagement, which facilitates local personal and social-contextual resource development, has potential for ME and multilevel empowerment through community-based capacity development processes. These self-empowered communities have written and will continue to write a ‘prescription’ for sustaining high levels of engagement.

Greater than half of older adults who are admitted to an acute care setting experience delirium with an estimated cost between four to twenty billion dollars annually in the United States. As a strategy to address the gap between research and practice, this feasibility study used the Roy Adaptation Model to provide a theoretical perspective for intervention design and evaluation, with a focus on modifying contextual stimuli in a Trauma Intensive Care and a Trauma Orthopedic Unit setting. The study sample included older hospitalized patients in a Trauma Intensive Care and a Trauma Orthopedic setting where there is a greater incidence for delirium. Study participants included two groups, with one group assigned to receive either a music intervention or usual care. The music intervention included pre-recorded music, delivered using an iPod player with soft headsets, with music self-selected from a collection of music compositions with musical elements of slow tempo and simple repetitive rhythm that influence delirium prevention. For the proposed study a music intervention dose included intervention delivery for 60 minutes, twice a day, over a three day period following admission. Physiologic variables measured included systolic blood pressure, diastolic blood pressure, heart rate, and respiratory rate, which were electronically monitored every four hours for the study. The Confusion Assessment Method was used as a screening tool to identify delirium in the admitted patients. Specific aims of this feasibility study were to (a) examine the feasibility of a music intervention designed to prevent delirium among older adults, and (b) evaluate the effects of a music intervention designed to prevent delirium among older adults. Findings indicate there was a significant music group by time interaction effect which suggests that change over time was different for the music and usual care group.

Unintentional falls among community dwelling older adults are a common, serious and potentially preventable public health problem. In the United States, the annual incidence of fall related injuries per 100,000 persons was 4,616 in 2001, rising to 5,252 in 2008. The annual incidence of fall related deaths per 100,000 persons was 29.3 in 2000, rising to 41.86 in 2006. Older adults are particularly vulnerable to falls as they age. Potential consequences include fractures, emergency room, hospital and nursing home admissions, dependence, confusion, immobilization, depression, and death. Significant modifiable fall risk factors include muscle weakness, gait problems, and balance problems. While researchers have demonstrated the positive effects of balance and leg-strengthening physical activities, the majority of older adults do not engage in them, and the rate of falls continues to increase. Older adults participate in regular physical activity and fitness activities less often than younger populations; disparities are greater among those who are poor and living in rural communities. While knowledge about causes, risk factors, and efficacious physical activity to prevent falls has grown exponentially in the last several decades, bridging the gap between research and practice continues to be a challenge. As a strategy to address the gap between research and practice, this feasibility study utilized a tested theory, the wellness motivation theory, to address motivation for behavioral change in combination with instruction for physical activities proven to reduce fall risk. The study sample included rural, community dwelling older adults at risk of falls. The study included an innovative mobile computer to measure physical activity behavior and to augment motivational content of the intervention. Specific aims of this feasibility study were to: (a) examine the acceptability, demand, and implementation of the wellness motivation intervention (WMI) as well as the technology augmenting the WMI; and (b) evaluate the efficacy of the WMI to influence awareness of social contextual resources, behavioral change processes, physical activity, and fall risk. The WMI delivered in combination with proven multicomponent balance and strength activities was feasible and effectively increased motivation for behavioral change (social support from friends, awareness of social contextual resources, behavioral change processes) and physical activity behavior, and decreased fall risk among rural, community-dwelling older adults at risk of falls in this study. This study is the first step in a program of research focusing on enhancing motivation for physical activity that reduces falls and frailty among older adults.