OT Community Health Promotion Program

1. OT Community Health Promotion Program 台大職能治療學系 毛慧芬 2011.10.11.

2. Constructing the Lifestyle Redesign Program • Conceptual paths (the complexity of the project) • Pilot studies • A demonstration class • Theoretical readings Understanding of aging, adaptation, and the process of Occupational-analysis

3. 1st Pilot Study • “Living a Meaningful existence in Old Age” (Jackson, 1996) • Purpose: • to identify adaptive strategies used by community-dwelling elderly, who were living successfully in community • Issues in “aging and adaptation”

4. Findings The nature of occupation (i.e. Imagining and doing) • Engaging in occupations saturated with themes of meaning • Exercising control in the selection of occupations • Seizing opportunities to take risks • Modifying the environment to enhance accessibility to occupations • Maintaining social connectedness • Sustaining an occupational temporal rhythm Occasional excitement

5. Occupational Self-Analysis:Self-reflection process • Who you are as occupational beings? • How your child occupations shaped your adult characters? • How the things you do each day contribute to or compromise your health and well-being? How you select occupation each day?  Whether your everyday routines were a sensible plan for achieving goals?

6. 2nd Pilot Study—Needs Evaluation • To explore the concerns (areas in which they perceived they needed help) of the persons targeted for the local participants • To build rapport

7. Qualitative Approaches—through clinical reasoning (not coding) • Collecting rich descriptions • 害怕出門是因門口有障礙 害怕意外，沒有同伴，沒有經驗 • To get the subjective meaning of occupations • To get in-depth picture of the person’s story of himself or herself as an occupational being (which occupation or have the potential to be deeply meaningful?) • Claiming everyday experiences

8. Individual Interview (1) • What do you do each day? • What do you believe are the barriers to doing you would like to do each day? • What things that you are particularly meaningful? • What special issues in daily living are bothering you right now? What creates stress in your life? • What do you think essential for a quality life?

9. Individual Interview (2) • Throughout life, people choose to do certain activities they love. Can you describe the activities that have been most important in your life at each period, beginning with childhood and up to present? • What is it about these activities that you most like to do? What makes them attractive to you?

10. Individual Interview (3) • Do you have daily routines or habits? How important is routine in your life? • What aspects of aging have you found the most challenging? • If you could change anything in your situation, what would you change? • Others…..

11. The USC Well Elderly Study (1996) • 29 elderly persons (20 women, 9 men) • Method of naturalistic inquiry • 1. Generate a summary and any stated adaptive strategy • 2. To develop a typology of life domains • 3. Another senior researcher interview the researcher to confirm it • 4. Another set of researches refined the categories

12. Focus Group • The dynamic process allows participants to be stimulated by and build on each other’s ideas and generate concepts that may not covered in interview. • 聽到同一議題的不同看法或意見利於活動規劃之考量 • For developing the program protocol

13. Guiding Questions (1) • Why would someone want to live in this retirement home? • What makes this residence unique? • What programs and activities are offered here? Which do you recommend and why? • How active are the residents here? • What are the differences between independent, assisted, and nursing care living?

14. Guiding Questions (2) • What modes of transportation do you use? • Where would you like to go? • What stressors or obstacles do you face as a retiree? • What would you like to see changed in your community? Retirement home?

15. Guiding Questions (3) • What are the most meaningful activities that fill your time? • How would you like to use your time better? • If there one thing you could add to your life, what would it be? • What would you like to learn regarding your health and wellness?

16. ADL Adaptation to a multicultural environments Use of free time Grave illness and death Health maintenance Health mobility Personal finances Personal safety Psychological well-being and happiness Relationship with others 10 Concerns To customize a program to the local situation

17. 3st Pilot Study—Meta-analysis • Meta-analysis of the effectiveness of OT for older persons • A highly significant cumulative results (p< .001) (Carlson et al., 1996)

18. Skills of Leader • Facilitation: engaging, clarifying, responding • Data gathering and evaluation: identifying, synthesizing • Action skills: linking, providing resources, modeling

19. USC Well Elderly Clinical trial • A RCT design • 3 groups (n=361) • OT (lifestyle redesign)(102/122): 2-hr group sessions and another hour a month of individual OT, 60% attend 50% sessions) • Social activities control(100/120): 2¼ hours session per week, activities conducted without professional training (62% attend 50% sessions) • No treatment control (104/119) • 2 cohorts (2nd-- 16 months after the 1st cohort)

20. Timeline for the Well Elderly Study 9 Month Program 2 hrs/week-Small groups 6 Months No contact Pre-test Physical Exam Questionnaires Post-test (306) Questionnaires Follow-up Physical Exam Questionnaires • Primary Outcome Measures • -Functional Status Questionnaires • -Life Satisfaction Index-Z • Center for Epidemiologic Studies (CES) Depression Scale • Medical Outcomes Study Short Forms General Health Survey • RAND 36-item Health Status Survey, Short form-36 15 Months 2 hrs/week-Small groups Utilization of Health Services

21. Participants • 361 seniors (60~89 yr) • From federally subsidized apartment buildings for low-income older adults in greater LA • Living independently • Urban • Multiethnic (30% mandarin Chinese speakers) • 65% women • 73% live alone • 27% with disabilities

22. Implementing the Lifestyle Redesign Program Methods of Delivery • Group Format • Up to 10 seniors for each group, 4 T’s • Skills of Leader: group dynamics/ therapeutic process • Elements of group treatment • Individual Format

23. Group Session • 團體前，成員會分批與治療師見面 • 有會議活動桌、旁邊有餐飲區咖啡桌，每次會準備新奇、健康的點心，成員協助準備 • 15 min warm-up • 介紹主題、促進討論，提供解決策略 • 每4周一次社區外出活動，（針對「外出」主題討論，接續成員自行討論、計畫，安排實際活動）、負責提醒、照相 • 行動後討論，integrate reflections * Predictability and stability with change and growth

24. Group Session Methods for delivering LRP • Presentation • Peer exchange, storytelling • Direct experience-sense of self regulation or control • Personal exploration *運用技巧： • 視為專家，用筆記本、講義、記錄稿

25. Individual Sessions • 9 hours • Home visit • To discuss occupation, describe photos, events in meetings • Puzzle the parts in group sessions with the visit • To encourage deep discussion

26. Process to Change: 4 steps • Acquiring knowledge of the factors related to occupation that promote health and happiness • Perform and reflect on ones feeling and values (Occupational self-analysis) • Overcoming fears by incremental risks in small steps over time • To develop a health-promoting daily routine

27. Results of the Lifestyle Redesign Program Published in the Journal of the American medical Association (JAMA) (Clark et al., 1997), and was invited to address the Am. Med. Assoc. 16th Annual Science reports Conference on Oct. 21, 1997.

28. Primary Outcome Measures • RAND 36-item Health Status Survey, Short form-36: • 8 domains: 1) general health (p=.02) 2) mental health, 3) physical health (p=.008) 4) social functioning (p=.05) 5) role limitations attributable to physical health problems (p=.02) 6) role limitations attributable to physical health (p=.05) 7) Bodily pain (p=.03) 8) Vitality (p=.004) • From Medical Outcomes Study (MOS) Short Forms General Health Survey (p=.05)

29. Primary Outcome Measures • Functional Status Questionnaires(p=.03): • ADL, IADL, social function • Life Satisfaction Index-Z(p=.03): 13 items • Center for Epidemiologic Studies (CES) Depression Scale: 20 items • COPM • Goal Attainment Scale (-2, -1, 0, 1,2) • Standard change scores result from OT

31. 5/15 measures failed to show gain for the OT G’p (ceiling effects) • CES-D • IADL • BADL • Social activity subscales of the Functional Status Questionnaire • RAND SF-36 (high ceilings)

32. Conclusions • Significant benefits for the OT preventive treatment group • Health, function, and QOL • Control groups tend to decline over the study interval

33. What make this program effective? • View of the human as an occupational being • Meaning • An occupation could be meaningful simply because it created a positive experience • Occupation evoked feelings of risk • i.e. The group planed to going out across the street for attending a concert at night. “its not a lot of planning. But it’s more than they’ve ever done in terms of trying out a new program.” • Memorable, and Empowering moment

34. What make this program effective? • Better understand and appreciate the importance of meaningful activity in their lives • Teach how to select and perform activities to achieve healthy and satisfying lifestyle * To break the symbolic threshold(i.e. A depressed woman spent most of the day in bed or watching TV. A bus step to climb aboard a bus to go out) • Learn to alter the approach to everyday activities

35. What make this program effective? • Therapist assess the amount and the meaningfulness of the activities, values, attitudes and goals, and balance within their daily routines.  to make individualized plan  to provide support, education, and to boost their confidence to try something new and embed in their memory that they are still risk taker.

36. What make this program effective? • Themes of meaning often guide the manner in which occupations are chosen and performed. • May help people organize their overall everyday pattern of occupation （家庭觀--聚會時先將碗盤分好)

37. What make this program effective? • Life narratives provide another context for understanding meaning. • An evolving process– refashioned against the background of new challenges or sociocultural changes. • Persons continually engage in creating and revising their life narrative. • 2 ways: • Occupational storytelling or storymaking • To make personal Life History video

38. What make this program effective? • Dynamic Systems Theory • “People have the potential to reorder their patterns of occupations from states of disequilibrium to more complex, stable patterns” (Jackson et al., 1998) • There is no designed protocol, but to provide knowledge and facilitate experiences => greater insight into their occupational choices • Deaf =>尋找與外界接觸方式，大聲說話，談論自己私事，少與外人應對。有機會，T’s 鼓勵個案負責與司機接觸 “I can talk to people now” =>希望配好一點助聽器，常搭車外出參加活動 • 從很小的改變開始

39. Occupational Therapy • Doing therapy • Focus on the goal of helping people experience healthy and satisfying lives by maximizing their ability to successfully accomplish everyday activities (occupations) • Productive or meaningful occupation was the core of OT • Involve physical, psychological elements

40. Occupational Science • Academic discipline: a systematic study of the form, function, and meaning of occupation • Focus on • the critical role of daily activities in promoting health • a sense of well-being in our lives on the nature of occupation and its effects on human beings • Sample Questions • What are the contributions of work and leisure to physical health, happiness, and QOL? • What constitutes a healthy balance of work, rest, and leisure on a typical day?

41. Conceptual Foundation • Occupation is life itself • Active participation in occupation is life itself. (life satisfaction) • Yerxa (1989) --“individuals are most true to their humanity when engaged in occupation”

42. Conceptual Foundation • Occupation can create new visions of possible selves and life changes • Occupation inducing vision of a future life worth living because, through participation in occupation, they begin to comprehend the possibilities available to them • Occupation has a place in preventive care

43. Conceptual Foundation • Engaging occupation affects the physical, mental health, and life order and routine.

44. Embedding Health-Promoting Changes into the Daily Lives of Independent-Living Older Adults: Long-Term Follow-up of OT Intervention (J of Gerontology, PSYCHOLOGICAL SCIENCES, 2001, 56B, No.1, p60-63) • 285 of 361 followed (79%) • Signed change scores • (Follow-up – minus pre-test score) • Analysis of covariance to test for change score differences between the OT and the control groups • Regression analysis to impute value for the missing data • OT gains were retained: • (effective size at follow-up / effective size at post-test)

45. Results • 5 of 7 variables: sig. beyond the 0.05 level • 2 variables: marginally sig at the 0.1 level • 10 measures positive at post-test • effect size:0.32 (0.2 to 0.47) • 10 measures at follow-up: • effect 0.29 (0.02 to 0.52) • 90% (0.29/0/32) of the magnitude of OT treatment gains was retained over the follow-up interval

46. Cost-effectiveness of Preventive Occupational Therapy for Independent-Living Older Adults (JAGS 2002, 50:1381-1388) • Telephone interview 163 elderly • OT G’p/ Social G’p(Active control)/ No T’t G’p (Passive control) • Results: • 9-months OT program:$548 per subject, $68 for controls • Postintervention healthcare cost: • OT group ($967) • Active control group ($1,726) • Passive control group ($3,334) • Combined control groups ($2,593)

48. Quality of life Index • A 4.5% QUALY differential, p<.01 • The cost per QUAL estimated • OT group ($10,666) • Active control group ($7,820) • Passive control group ($13,784) => Cost effectiveness