Fragility Clinical Trial
Official title:
Testing an Occupation-Based Cultural Heritage Intervention in Long-Term Care Facilities
The goals of the proposed research were to:
1. describe the person and environment characteristics and activity patterns of residents
in long-term care (LTC) facilities;
2. modify the evidence-based, occupation-based cultural heritage intervention (OBCHI)
grounded on the results of Aim 1;
3. test the effectiveness of the OBCHI intended to facilitate adaptation to relocation
into LTC facilities relative to a usual activities group;
4. determine the cost-effectiveness of the intervention conducted by in-house staff
compared to the control group; and
5. examine person and environment factors as potential moderators of the relationship
between treatment condition and adaptation outcomes.
Specific Aims
Primary Aims
1. Describe the person and environment characteristics and activity patterns of residents
in LTC facilities.
2. Modify the OBCHI grounded on the evidence-based results of Aim 1 specific to these
facilities and residents.
3. Test the effectiveness of the OBCHI conducted by activity department staff, relative to
usual activities, as measured by quality of life, activity engagement, and social
participation.
H1a-c: Those receiving OBCHI will have significantly greater improvement in
a) quality of life, b) activity engagement, and c) social participation at
post-intervention relative to those receiving usual activities.
H2a-c: Those receiving OBCHI will have greater maintenance of improvements in a)
quality of life, b) activity engagement, and c) social participation at 1-month
follow-up, relative to those receiving usual activities.
4. Determine the cost-effectiveness of the intervention in terms of quality adjusted life
year (QALY) and other health factors.
H3: When OBCHI is proven to be more effective in promoting quality of life than usual
activities, the investigators will expect the OBCHI to produce a higher QALY at a lower
cost per QALY.
H4: Between these two mutually exclusive treatments, the OBCHI intervention will be
more efficient (more effective and less costly) or cost saving with a negative
incremental cost-effectiveness ratio (ICER) when compared to those receiving usual
activities.
Exploratory Aim
5. Examine person characteristics (i.e. cultural heritage, life experiences social
support, resilience, depression, and resident demographics [age, gender, ethnicity])
and select environment characteristics (i.e., participant perceptions of the
intervention and facility) as potential moderators of the relationship between
treatment condition (OBCHI versus usual care) and change in adaptation outcomes from
pre- to post-intervention.
Table 1. Timeline of Person/Environment Factors, Outcomes and Tools
Person Characteristics Tools Baseline 1 wk. post 1 m. follow-up
Cognitive Screen SPMSQ x
Life Experience Interview x
Social Support Yesterday Interview x x x
Resilience Resilience Scale x
Depression GDS-15 x x x
Environment Characteristics
LTC Facility Setting Site Demographics x
Resident Perceptions SCES x x x Intervention Evaluation (midway) x
Staff Perceptions Questionnaire x x
Outcomes
QoL QOLI/SF-12 x x x
Cost Effectiveness SF-12 x x x
Activity Engagement and Social Participation Yesterday Interview x x x
Significance
As the need for LTC increases with the steady growth of older adults, relocation into
residential settings will grow. About 70 percent of persons over 65 will require spending
time in LTC services, with 40 percent requiring nursing home care for a period of time.
Relocation is moving from one permanent home to another permanent home which is sometimes
precipitated by an illness and considered a significant life event. Skinner noted a forced
relocation could have disturbing effects upon the elderly including loss of social and
community connections. However, even with a planned relocation, encountering this new and
unfamiliar environment requires the older person to rethink the ways in which his or her
life will differ with adjustment duration of a few weeks to several years. Many factors
determine the ways in which this 'new life' will evolve including: past adaptive strategies
and life experiences, family support systems, socioeconomic resources, and cultural values.
Moving from a familiar environment to an unfamiliar one involves adaptation, regardless of
age. Adaptation is a process involving interaction between the person and environment.
Indicators of successful adaptation to LTC have included: developing a sense of identity and
place, having care needs met, knowing and being known to other residents, maintaining or
developing social networks, continuity of lifestyle, and maintaining control over life
situations. As defined for this study, adaptation is a normal process by which a person
encounters a perceived challenge in the environment and is able to successfully manage that
challenge as measured by increased quality of life, activity engagement and social
participation. Central to adaptation is the cultural heritage that an individual brings to
the LTC facility upon relocation. Because culture is the learned beliefs, values, customs,
actions, communication, and life ways of an individual, it can be expected to permeate all
aspects of life in a residential facility. Attention to an individual's cultural heritage
has begun to make in-roads to the daily life routines encountered in these facilities.
Acknowledgement of the resident's culture is a major contributing factor to his/her quality
of life (QOL). However, QOL is a complex construct and has been used synonymously with terms
like well-being, life satisfaction, and functional health. Lawton asserted that QOL is a
collection of dimensions comprised of both objective and subjective factors which may
include all or some of the following: behavioral competence, objective environment,
perceived QOL, psychological well-being, and health-related status. Other factors associated
with QOL include: interaction with family and friends, personal qualities, room and meal
items, number of health problems, staff-resident ratios and continuity of care. These
findings attest to the importance of a person-environment 'match' when QOL issues for
residents are considered.
Incorporating meaningful activity and social connections into the lives of elders that have
been circumscribed by illness and disability is particularly important to QOL.
Gerontological literature concerning the activities of elders has concentrated upon personal
care and instrumental activities and how they contribute to health and functional status.
These obligatory tasks are essential to one's survival, but perhaps even more significant to
an elder's well-being are those discretionary activities involving social and meaningful
occupations; such findings support the proposition that activity and social support systems
are important in mediating the impact of illness on well-being.
In summary, the relationship of relocation, culture, adaptation, QOL, activity engagement,
and social participation is reflected in outcomes where failure to provide culturally
competent and culturally sensitive care have occurred. With increasing diversity of the US
population, practitioners are challenged to deliver culturally competent services and to
improve the QOL for diverse LTC residents.
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Allocation: Randomized, Endpoint Classification: Efficacy Study, Intervention Model: Parallel Assignment, Masking: Open Label, Primary Purpose: Treatment
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