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BROOKDALE DEMONSTRATION INITIATIVE IN HEALTHY URBAN AGING: BRIDGING THE DIVIDE BETWEEN PUBLIC HEALTH & HEALTHY AGING PREPARED FOR: THE COMMISIONER NEW YORK CITY DEPARTMENT FOR THE AGING EVIDENCE-BASED TOOLKIT: Program Summaries and Implementation Guide LILLIAM BARRIOS-PAOLI COMMISSIONER APRIL 2010 FUNDING PROVIDED BY: OFFICE OF THE MAYOR CITY OF NEW YORK MICHAEL R. BLOOMBERG MAYOR CREATED BY: THE BROOKDALE CENTER FOR HEALTHY AGING & LONGEVITY OF HUNTER COLLEGE/ CUNY 1 About Brookdale Brookdale Center for Healthy Aging & Longevity of Hunter College is a multi-disciplinary center of excellence dedicated to the advancement of successful aging and longevity through research, education, and evaluation of evidence-based models of practice and policy. Founded in 1974 by Dr. Rose Dobrof of the Hunter College School of Social Work, The Brookdale Center for Healthy Aging & Longevity of Hunter College (formerly Brookdale Center on Aging) was one of the country's first multi-disciplinary academic gerontology centers. For over three decades, the Center has taken the lead in identifying the needs of older New Yorkers, developing programs to make New York a better place to grow old, training professionals and paraprofessionals who serve the elderly, and championing both the elderly and policies to promote successful aging. Brookdale Center now serves as a critical bridge between gerontological education, research, policy, practice and advocacy, and is recognized nationally today as a major center of excellence. Acknowledgments We are grateful to the many people whose insights and contributions have informed the development of this toolkit. First and foremost, this toolkit would not have been possible had it not been for the support and leadership of the Department of the Aging (DFTA): Lilliam Barrios-Paoli, Commissioner; Sally J. Renfro, First Deputy Commissioner; Caryn Resnick, Deputy Commissioner; Angeles Pai, Deputy Commissioner, Michael Bosnick, Assistant Commissioner; Marah Rhoades, Assistant Commissioner; and dedicated staff members Jackie Berman, Joyce Chin, Sabrina Ramos, Maeve Rullo, and Ishrat Taleb. Special thanks to DFTA in providing us with information regarding their existing health promotion programs that have been developed to assist older New Yorkers. We appreciate the cooperation of evidence-based study authors and program implementation staff who were instrumental with their cooperation and assistance in providing information regarding aspects of program implementation and descriptions of program costs. We wish to thank the leadership of Hunter College for their support: President Jennifer J. Raab; Provost and Vice President for Academic Affairs Vita Rabinowitz; Dean of the School of Social Work, Jacqueline B. Mondros; Dean of the School of Nursing, Kristine M. Gebbie, and Dean of the School of Public Health, Kenneth Olden. This toolkit would not have been possible without the tireless and invaluable contributions of members of the Brookdale Center for Healthy Aging & Longevity, Hunter College, including (in alphabetical order): William T. Gallo, Nuzhat Mirza, Carmen Morano, and Milagro Ruiz. Funding for this project was provided by the Mayor’s Office and administered by the New York City Department for the Aging. Toolkit Authors: Dana Friedman; Matthew Caron; Lauren Evans; Adriana Valencia; Nina S. Parikh; and Marianne C. Fahs. TOOLKIT TABLE OF CONTENTS User’s Guide for Evidence-Based Toolkit ......................................................................... i Toolkit Section Program Summaries & Implementation Guide Program Summaries of Selected Evidence-Based Arthritis Programs .........Tab 1 Comparison Chart of Evidence-Based Arthritis Programs and Existing DFTA Projects Arthritis Foundation Exercise Program (AFEP) .............................................................................. 1 ESCAPE-knee pain ....................................................................................................................................... 3 Fit and Strong ................................................................................................................................................ 5 Hop with the Hip .......................................................................................................................................... 7 Program Summaries of Selected Evidence-Based Cancer Programs.............Tab 2 Comparison Chart of Evidence-Based Cancer Programs and Existing DFTA Projects Learn Share and Live Program ............................................................................................................... 9 Screen for Life ............................................................................................................................................... 11 Tepeyac Project ............................................................................................................................................ 13 Program Summaries of Selected Evidence-Based Depression Programs ...Tab 3 Comparison Chart of Evidence-Based Depression Programs and Existing DFTA Projects Healthy Identifying Depression, Empowering Activities for Seniors (Healthy IDEAS).... 15 Improving Mood Promoting Access to Collaborative Care Treatment (IMPACT).............. 17 Life Review Therapy ................................................................................................................................... 19 Program to Encourage Active, Rewarding Lives for Seniors (PEARLS) ................................. 21 Psycho geriatric Assessment and Treatment in City Housing (PATCH) ................................ 23 Program Summaries of Selected Evidence-Based Diabetes Programs .........Tab 4 Comparison Chart of Evidence-Based Diabetes Interventions and Existing DFTA Projects Diabetes Education & Prevention with a Lifestyle Intervention Offered at YMCA (DEPLOY) .... 25 Diabetes Health Connection .................................................................................................................... 27 Diabetes Prevention Program (DPP) ................................................................................................... 29 Group Lifestyle Balance (GLB)................................................................................................................ 31 Healthy Changes ........................................................................................................................................... 33 Look After Yourself (LAY) ........................................................................................................................ 35 Look AHEAD (Action for Health in Diabetes) ................................................................................... 37 New Leaf… Choices for Healthy Living with Diabetes ................................................................... 39 Seniors Taking Charge of Diabetes! ...................................................................................................... 41 Starr County Border Health Initiative ................................................................................................. 43 Program Summaries of Selected Evidence-Based Falls Programs .................Tab 5 Comparison Chart of Evidence-Based Falls Interventions and Existing DFTA Projects A Matter of Balance/Volunteer Lay Leader Model ......................................................................... 45 EnhanceFitness............................................................................................................................................. 47 Falls Management Exercise (FaME) ..................................................................................................... 49 NoFalls ............................................................................................................................................................. 51 Step by Step.................................................................................................................................................... 53 Stepping On .................................................................................................................................................... 55 Strategies and Actions for Independent Living (SAIL).................................................................. 57 Tai Chi: Moving for Better Balance ....................................................................................................... 59 Program Summaries of Selected Evidence-Based Heart Disease Programs..... Tab 6 Comparison Chart of Evidence-Based Heart Disease Programs and Existing DFTA Projects Airdie Community Hypertension Awareness & Management Program (A-CHAMP) ........ 61 Eat Better Move More ................................................................................................................................ 63 Health for Your Heart (Salud Por Tu Corazón) ................................................................................ 65 Prime Time Sister CirclesTM ..................................................................................................................... 67 Project Joy ....................................................................................................................................................... 69 Selected Evidence-Based Obesity Programs ............................................................Tab 7 Comparison Chart of Evidence-Based Obesity Programs and Existing DFTA Projects With cross references to above program summaries for DEPLOY, DPP, GLB, and Eat Better Move More, which are appropriate for obesity .................................................................. 71 Implementation Guide .......................................................................................................Tab 8 Introduction to the Implementation Guide ....................................................................................... 73 Implementation Guides for Selected Evidence-Based Arthritis Programs Implementation Sheet for AFEP ....................................................................................................... 75 Implementation Sheet for ESCAPE-knee pain ............................................................................. 77 Implementation & Cost Sheet for Fit and Strong ....................................................................... 79 Implementation & Cost Sheet for Hop with the Hip ................................................................. 81 Implementation Guide for Selected Evidence-Based Cancer Program Implementation & Cost Sheet for Learn Share and Live ......................................................... 83 Implementation Guide for Selected Evidence-Based Depression Programs Implementation & Cost Sheet for Healthy IDEAS ...................................................................... 85 Implementation & Cost Sheet for IMPACT ................................................................................... 87 Implementation Sheet for Life Review Therapy ........................................................................ 89 Implementation & Cost Sheet for PEARLS .................................................................................... 91 Implementation & Cost Sheet for PATCH ...................................................................................... 93 Implementation Guide for Selected Evidence-Based Diabetes Programs Implementation Sheet for GLB .......................................................................................................... 95 Implementation & Cost Sheet for Seniors Taking Charge of Diabetes! ............................. 97 Implementation & Cost Sheet for Starr County Border Health Initiative ......................... 99 Implementation Guide for Selected Evidence-Based Falls Programs Implementation & Cost Sheet for A Matter of Balance/Volunteer Lay Leader Model ....... 101 Implementation & Cost Sheet for EnhanceFitness ................................................................. 103 Implementation Sheet for FaME .................................................................................................... 105 Implementation & Cost Sheet for Stepping On ........................................................................ 107 Implementation Sheet for SAIL ...................................................................................................... 109 Implementation & Cost Sheet for Tai Chi: Moving for Better Balance ............................ 111 Implementation Guide for Selected Evidence-Based Heart Disease Programs Implementation & Cost Sheet for Health for Your Heart (Salud Por Tu Corazón) ............113 Implementation & Cost Sheet for Project Joy ........................................................................... 115 References...............................................................................................................................Tab 9 Appendices ........................................................................................................................ Tab 10 Appendix 1: Evidence-Based Program Logistics Survey Appendix 2: Evidence-Based Program Cost Sheet Toolkit Section Condition-Specific Instruments Section See supplemental toolkit binders Toolkit Section Cross-Cutting Instruments Section See supplemental toolkit binders ToC USER’S GUIDE FOR EVIDENCE-BASED TOOLKIT Purpose According to the Centers for Disease Control and Prevention, the 7 leading preventable chronic conditions among older Americans are: Arthritis Cancer Depression Diabetes Falls Heart disease Obesity In partnership with the NYC Department for the Aging (DFTA), the Brookdale Center for Healthy Aging & Longevity of Hunter College/CUNY (Brookdale) has organized this compendium of selected evidence-based programs targeting prevention and management of these chronic conditions among community-based older adults. These programs are termed evidence-based in that their effectiveness in producing significant health outcomes has been rigorously studied and documented in peer-reviewed scholarly literature. Brookdale has utilized the following methodology in selecting the evidence-based programs described in this toolkit: 1. A systematic review of research studies supporting over 100 evidence-based programs targeting the CDC’s leading 7 preventable chronic conditions was conducted. These programs were selected based on two main criteria: a) programs used scientific study designs (such as randomized-controlled trials) to demonstrate statistically significant health outcomes, and b) programs were primarily tested using older adults as study participants. 2. These programs were reviewed again and limited to 49 community-based interventions that can feasibly be implemented in non-clinical community settings, including the NYC senior centers that DFTA serves. Factors that were considered in determining the feasibility of program implementation included program duration and senior center staffing. 3. Finally, outreach to program staff to obtain implementation materials to be shared with DFTA resulted in the inclusion of 35 programs* in this toolkit. There is growing recognition among policy makers and public health leaders in the field of aging that building evidence for community-based models of healthy and productive urban aging is key in promoting health in far-reaching, cost-effective ways. It is hoped that by disseminating information on the targeted interventions described in this toolkit throughout NYC senior centers, NYC DFTA will substantially reduce rates of chronic disease among older New Yorkers. *This toolkit includes two types of programs – research programs that have been tested in controlled settings, and implementation programs that have been replicated outside of the original research settings. i ToC USER’S GUIDE FOR EVIDENCE-BASED TOOLKIT Instructions The toolkit has 3 main color-coded sections: 1. Program Summaries and Implementation Guide 2. Condition-Specific Instruments 3. Cross-Cutting Instruments The Program Summaries and Implementation Guide presents program details (overview, outcomes, implications), implementation guidelines (fidelity, replicability, sustainability), and costs of each evidence-based program, arranged alphabetically and by condition (Arthritis to Obesity). The Condition-Specific Instruments Section provides the scales that can be used when implementing the condition-specific programs described in the Program Summaries and Implementation Guide . This section has also been arranged alphabetically. For instruments that can be used for multiple conditions, you may refer to the Cross-Cutting Instruments Section . Refer to the toolkit flowchart below for an illustration of how to use this toolkit. ii ToC COMPARISON CHART OF EVIDENCE-BASED ARTHRITIS PROGRAMS Program Name Program Elements Arthritis Foundation Exercise Program (AFEP) Group-based exercise program that includes health education segments and behavioral strategies to promote physical activity between classes. Group/ Individual Group Time (meetings, duration) Meets twice weekly for 1 hour per session for 8 weeks Staff Requirements Instructors are required to: • Undergo day-long AFEP training taught by Arthritis Foundation Master Trainer • Receive CPR and first aid training • Complete two AFEP programs and submit necessary paperwork to Arthritis Foundation Instructors must have the following educational background: • Associate or baccalaureate degree in exercise or related health field or equivalent exercise training and certification preferred • Knowledge of arthritis disease processes, principles of arthritis exercise, etc. • Competence in demonstrating exercises Enabling SelfManagement and Coping with Arthritic Knee Pain through Exercise (ESCAPEknee pain) Rehabilitation program that combines group discussion on specific topics regarding selfmanagement and coping, with an individualized, progressive exercise regimen Group and individual components Meets twice weekly for 1 hour per session for 6 weeks • Instructors undergo program training, but do not need to have PT background • Training involves program education using an instructor manual, as well as program observation Space Requirements Equipment Requirements Room should: • Be large enough for easy movement and space for assistive devices (i.e., walkers, crutches, etc.) • Have adequate acoustics and lighting • Be free of clutter • Be carpeted or have mats for floor exercises Sturdy chairs that do not slide easily and are of different heights, some with arms Gym or hallway • Exercise equipment (i.e., steps, rocker or wobble board, soccer ball, static bike) • Chair • Table • Mat ToC Program Name Fit & Strong Hop with the Hip Program Elements Group/ Individual Time Staff Requirements Space Requirements Equipment Requirements (meetings, duration) • Group and facility-based exercise training program and group problem-solving sessions followed by homebased adherence • Sessions focus on range of motion, resistance training, aerobic walking, and group problem solving sessions regarding self-efficacy for exercise and exercise adherence • Participants develop individualized postintervention exercise plan and log their progress through participating in aerobic activity (usually walking) for 3 days/week for a total of 30 min/day, and participants keep a log of their progress Group Meets 3 times weekly for 90 minutes per session for 8 weeks • Requires national certification (10 types are available) • Instructor may be PT, PT aide, or recreational aide • Instructors attend an eight-hour training to obtain certification Large indoor space for arm stretching, fitness walking • Fitness equipment that are provided at instructor training session (i.e., adjustable ankle cut weight, resistance bands with foam rubber handles) • Floor mats • Music player Group exercise program that involves strength training and lifestyle advice for older adults with osteoarthritis of the hip Group Meets once a week for 1 hour for 8 weeks Instructors must have a background in PT or OT Gym (12-person maximum capacity) Fitness equipment (i.e., leg press, leg raise, sitting rotation, pull down equipment, treadmill, pulleys, Bowflex, or comparable equipment) ToC EXISTING ARTHRITIS HEALTH PROMOTION PROJECT AT NYC DFTA DFTA's Health Promotion Services (HPS) Unit trains senior volunteers to lead health activities at their senior centers and other sites. Each site has the responsibility of selecting appropriate volunteers and then the Health Promotion staff conducts the training on- site. This program has its own curriculum with a set number of training topics. All necessary equipment and forms are provided by DFTA. Once in place, staff monitors the activity on a regular basis to ensure that all program guidelines are adhered to. DFTA Program Name Stay Well Exercise Classes Program Elements • Geared for all seniors, ranging from the fit to those with disabilities • Led by senior volunteers. • Includes aerobic exercises as well as routines designed to enhance balance, build muscle strength (with the use of stretch bands) and aid in the performance of everyday activities • Classes end with stress reduction exercises to help seniors ease the tensions of everyday living Group/ Individual Group Time Staff (meetings, duration) (paid, volunteer) 1 hour per week Center /site identifies suitable candidates. Health Promotion Staff (HPS) implements training on site. Once training is completed, the HPS monitors senior volunteers and classes on an on-going basis Space Requirement Room large enough for all participants to complete all exercise movements Equipment Training materials, certificates, Tee shirts, stretch bands, balls, volunteers buttons, sign-in sheets and envelopes provided by HPS ToC ARTHRITIS Arthritis Foundation Exercise Program (AFEP) PROGRAM OVERVIEW PRIMARY CONTACT Jenni Albright, Acting Project Coordinator [email protected] SECONDARY CONTACT Not applicable WEBSITE www.arthritis.org/chapters/newyork/exercise-program.php PRINT MATERIALS Program brochure is available. Training manual is only available to individuals who attend the training. ACCESS ON WEBSITE Training manual is only available to individuals who attend the training. ASSOCIATED CONDITIONS Not applicable LANGUAGES English, Spanish PROGRAM TYPE An eight-week group-based program (twice weekly sessions) to promote self-management through exercise for sedentary adults with arthritis. PROGRAM DESCRIPTION Duration: 8 weeks Type: Group-based exercise program administered twice weekly for an hour that includes health education segments and behavioral strategies to promote physical activity between classes. Aim: Promote arthritis self-management through exercise; developed by the Arthritis Foundation in 1987 (revised in 1999). OUTCOMES This program reduced pain by 24% and fatigue by 28%, while improving arthritis management self-efficacy by 3%. Those who attended a majority of the classes showed: • 27% reduction in pain • 35% reduction in fatigue • 25% reduction in stiffness • 14% improvement in timed 10-lb lift performance test scores • 15% improvement in chair stands performance test scores • 4% improvement in arthritis self-efficacy Over time (6 months post-intervention), participants: • Maintained improvements in symptoms • However, function and self-efficacy for exercise declined over time IMPLICATIONS • • This program is safe for sedentary older individuals with arthritis intending to start exercising without exacerbating their symptoms. If arthritic adults attend a majority of PACE classes, they may expect improvements in symptoms, self-efficacy for arthritis management, and upper and lower extremity function. Implementation Toolkit – Page 1 ToC ARTHRITIS Study/Intervention Methodology STUDY/INTERVENTION METHODS STUDY/INTERVENTION DESIGN Randomized controlled trial STUDY/INTERVENTION LOCATION 18 sites in urban and rural counties across North Carolina REFERENCE Boutaugh (2003) Callahan et al. (2008) Sample size/characteristics: 346 adults Demographics: Adults aged 18+ were included and mean age of respondents was 70; 90% were female; 75% were White. Inclusion criteria: Self-reported arthritis; currently exercising 3 times a week for 20 minutes/session limited in normal activities due to arthritis or joint symptoms Comparison Groups: Intervention group vs. control group that received the intervention on a delayed basis. Instruments/Measures: • • • • IMPLEMENTATION (FIDELITY, MODIFICATIONS, SUSTAINABILITY) See IMPLEMENTATION SHEET • Chronic conditions were assessed using a modification of the American Academy of Orthopedic Surgeons Musculoskeletal Outcomes Data Evaluation and Management System list of comorbidities. Pain, stiffness, and fatigue (symptoms of arthritis) were measured using a Visual Analog Scale (VAS). Self-reported function was assessed using the disability scale of the 8-item Health Assessment Questionnaire (HAQ). Participants completed 5 performance-based tests of physical function: timed 10-pound lifts, timed chair stands, timed 360degree turn, speed of gait, and 6-minute walk. Physical activity was assessed for type of activity, frequency, and duration over the past 7 days using the Physical Activity Scale for the Elderly (PASE). LIMITATIONS • COSTS Not available • Nonprobability sampling causes participant bias toward selfselection Almost one-third of the participants did not complete at least half of the PACE classes Toolkit – Page 2 ToC ARTHRITIS Enabling Self-Management and Coping with Arthritic Knee Pain through Exercise (ESCAPE-knee pain) PROGRAM OVERVIEW PRIMARY CONTACT Mike Hurley, Principal Investigator [email protected] SECONDARY CONTACT Not applicable WEBSITE www.kcl.a.uk/content/1/c6/04/79/67/es capeprogramme.pdf A six-week (12 sessions) exercise program for adults with knee pain that can be delivered in a group-based format. Includes an emphasis on coping strategies. PROGRAM DESCRIPTION Duration: 6 weeks Type: Rehabilitation program Aim: Combined discussion on specific topics regarding selfmanagement and coping, with an individualized, progressive exercise regimen. Program consisted of 12 PT-supervised sessions offered twice weekly and involved exercise and education on self-management and active coping strategies. OUTCOMES This program reduced pain by 21% and improved self-reported health status by 7%, irrespective of program format (group or individual). PRINT MATERIALS Program handbook is available in print. ACCESS ON WEBSITE Not applicable IMPLICATIONS ESCAPE-knee pain provides a safe, relatively brief intervention for chronic knee pain that is equally effective whether delivered to individuals or groups of participants. ASSOCIATED CONDITIONS Not applicable LANGUAGES English PROGRAM TYPE Research Toolkit – Page 3 ToC ARTHRITIS Study/Intervention Methodology STUDY/INTERVENTION METHODS STUDY/INTERVENTION DESIGN Randomized controlled trial STUDY/INTERVENTION LOCATION 54 inner-city primary care practices in London, UK Sample size/characteristics: 418 adults Inclusion criteria: Reported mild, moderate, or severe knee pain for over six months Demographics: • Adults aged 50+ were included and mean age for the usual care group was 67, 66 for individual rehab, and 68 for group rehab. • Sample was predominantly female: ratio of females to males was 96:44 for usual care, 104:42 for individual rehab, and 94:38 for group rehab. Comparison Groups: Individual rehabilitation and group rehabilitation groups vs. usual primary care control group. Instruments/Measures: • REFERENCE Hurley et al. (2007) • • IMPLEMENTATION (FIDELITY, MODIFICATIONS, SUSTAINABILITY) See IMPLEMENTATION SHEET COSTS • Physical functioning, pain, and stiffness were measured using subscales of the WOMAC. Objective functional performance was assessed by taking the aggregated functional performance time of 4 common activities of daily living. Anxiety and depression were measured using the Hospital Anxiety and Depression Scale (HADS). Self-reported health status was measured by the EuroQol, which was converted into quality-adjusted life years based on utility weights collected in a UK general population sample and a condition-specific patient preference health-related quality of life questionnaire (McMaster Toronto Arthritis [MACTAR]). LIMITATIONS Not applicable Not available Toolkit – Page 4 ToC ARTHRITIS Fit & Strong PROGRAM OVERVIEW PRIMARY CONTACT An 8-week group-based multi-component intervention for older adults with arthritis. Exercise includes range of motion, resistance training, and aerobic walking. Can be taught by certified exercise therapists or physical therapists. SECONDARY CONTACT PROGRAM DESCRIPTION Susan Hughes, Professor, University of Illinois at Chicago [email protected] Pankaja Desai, Project Manager [email protected] WEBSITE www.fitandstrong.org Duration: 8 weeks Type: Group and facility-based multiple-component training program followed by home-based adherence Aim: 2 PT's lead 90-min sessions three times a week on range of motion, resistance training, aerobic walking (60 min) and group problem solving sessions regarding self-efficacy for exercise and exercise adherence (30 min) Staff ask all participants to develop an individualized postintervention exercise plan that incorporates strength training and aerobic activity (usually walking) for at least 3 days per week for a total of 30 min per day, and participants keep a log of their progress. OUTCOMES • PRINT MATERIALS Instructor manual is available. ACCESS ON WEBSITE • Not applicable Improved exercise self-efficacy (5% at 2 months, 1% at 6 months), exercise adherence by 49% (at 2 months), and functional exercise capacity by 13% (at 2 months). Reduced lower extremity stiffness (16% at 2 months, 13% at 6 months) and pain by 14% (at 2 months). IMPLICATIONS • ASSOCIATED CONDITIONS Not applicable • This low cost intervention efficiently targets older adults who are at substantial risk of developing disability and significantly reduces their arthritis pain and stiffness, necessary precursors of functional independence. This program is safe to replicate with this target group. LANGUAGES English PROGRAM TYPE Implementation Toolkit – Page 5 ToC ARTHRITIS Study/Intervention Methodology STUDY/INTERVENTION METHODS STUDY/INTERVENTION DESIGN Random controlled trial Sample size/characteristics: 150 community-dwelling older adults Demographics: Aged 60+; females represented 81.0% of the treatment group and 87.1% of the controls; Whites accounted for 84.6% of the treatment group and 78.6% of controls. Inclusion criteria: Reported knee OA. Comparison Groups: STUDY/INTERVENTION LOCATION Several different senior centers and senior housing residences in Chicago, IL Functioning in training program participants vs. wait list control group. Instruments/Measures: • • REFERENCE Hughes et al. (2004) Hughes et al. (2006) • • IMPLEMENTATION (FIDELITY, MODIFICATIONS, SUSTAINABILITY) See IMPLEMENTATION SHEET • • LIMITATIONS • COSTS See COST SHEET The 10-item Short Portable Mental Status Questionnaire (SPMSQ) was used to screen for presence of moderate to severe cognitive impairment. Self-efficacy for arthritis self-management (exercise, pain, and other symptoms) were measured by using three subscales of efficacy for arthritis self-management scale developed by Lorig and colleagues. Two scales developed by McAuley and colleagues were used to measure self-efficacy for exercise adherence. The Timed-Stands Test was used to assess lower extremity muscle strength and endurance. The 6-min walk test was used to measure functional exercise capacity. The WOMAC was used to examine lower extremity pain, stiffness, and physical function. • • Study design makes it impossible to conclude whether all three components of the intervention (flexibility, aerobic walking, and strength training) are necessary to attain the reported results. Attrition from posttest measurement was higher among control group participants. It was not possible to blind participants in an exercise trial as to their treatment status; therefore, some of the self-reported outcomes may have reflected respondent bias. Toolkit – Page 6 ToC ARTHRITIS Hop with the Hip PROGRAM OVERVIEW An eight-week group exercise program for adults with adults that emphasizes strength training. PRIMARY CONTACT Erwin Tak, Principal Investigator [email protected] SECONDARY CONTACT Not applicable PROGRAM DESCRIPTION Duration: 8 weeks Type: Group exercise program Aim: 1-hour weekly sessions of strength training and lifestyle advice for older adults with OA of the hip OUTCOMES WEBSITE Not available This program reduced pain by 8% and self-reported disability by 29%, while improving hip function by 6% and performanceby 10%, without affecting quality of life or BMI. IMPLICATIONS Study fulfilled a need for older adults with hip OA and provides evidence of the benefit of exercise in the management of hip OA. PRINT MATERIALS Materials are available in Dutch, by request from author. ACCESS ON WEBSITE Not applicable ASSOCIATED CONDITIONS Not applicable LANGUAGES English PROGRAM TYPE Implementation Toolkit – Page 7 ToC ARTHRITIS Study/Intervention Methodology STUDY/INTERVENTION METHODS STUDY/INTERVENTION DESIGN Random controlled trial STUDY/INTERVENTION LOCATION Amersterdam, The Netherlands Sample size/characteristics: 109 independent adults Demographics: • Adults aged 55+ were included, and mean age of experimental group was 67.4 and control was 68.9. • Females represented 29% of experimental group and 35% of controls. Inclusion criteria: Clinically-diagnosed OA. Comparison Groups: Experimental vs. control groups. Instruments/Measures: • REFERENCE • • Tak et al. (2005) • IMPLEMENTATION (FIDELITY, MODIFICATIONS, SUSTAINABILITY) See IMPLEMENTATION SHEET • Subjects rated tolerance and severity of pain in the past month on a 10-cm visual analog scale (VAS). The Harris Hip Score (HHS) assessed hip function. Activity restriction was measured as the time (in seconds) it took to perform 4 functional tasks: 20 m walking with a turn halfway, the timed Up and Go test, ascending and descending stairs, and reaching for toes in a sitting position. Self-reported activity restrictions were assessed using the Groningen Activity Restriction Scale (GARS) and the Sickness Impact Profile (SIP). QOL was measured using a subject-rated generic QOL on a 10-cm VAS and a sum score for 7 questions regarding physical and psychological functioning, evaluation of own health, and happiness/satisfaction in last month. LIMITATIONS COSTS Researchers did not meet the target of 140 patients at the start of the study, which affected its statistical power. See COST SHEET Toolkit – Page 8 ToC COMPARISON CHART OF EVIDENCE-BASED CANCER PROGRAMS Program Name Program Elements Group/ Individual Time (meetings, duration) Staff Requirements Space Requirements Equipment Requirements Learn Share and Live Program • Community-based breast cancer education program that utilizes an existing informal network for lowincome urban elderly • Healthcare professionals train team leaders through short lectures followed by discussion or other interactive activities. • These leaders of lower-income adult housing complexes train lay community women who, in turn, pass along information and support for breast cancer control activities among their peers. Group One-day group lecture, discussion, and interactive activities Instructors must be trained facilitators in order to administer the program Space for 25-30 participants Music player Screen for Life National Colorectal Cancer Action Campaign National multi-year media campaign developed by the CDC and Centers for Medicare and Medicaid Services to promote colorectal cancer education and screening among adults aged 50+ Group National multiyear media campaign Staff are needed to coordinate distribution of media materials Not applicable Media materials Tepeyac Project • Church-based health promotion project aimed at increasing breast cancer screening rates • Promotoras, or peer counselors, deliver bimonthly breast-health education lectures and conduct 13 group discussions with members of four Catholic churches Group Meets twice a month Promotoras (peer counselors) deliver bimonthly breast-health education lectures and conduct 1-3 group discussions with members of four Catholic churches. Space for group discussions • Chairs for group discussions • Access to insurance claim information ToC EXISTING CANCER HEALTH PROMOTION PROJECT AT NYC DFTA DFTA's Health Promotion Services (HPS) Unit trains senior volunteers to lead health activities at their senior centers and other sites. Each site has the responsibility of selecting appropriate volunteers and then the Health Promotion staff conducts the training on- site. This program has its own curriculum with a set number of training topics. All necessary equipment and forms are provided by DFTA. Once in place, staff monitors the activity on a regular basis to ensure that all program guidelines are adhered to. DFTA Program Name Save a Life Campaign Program Elements • Senior volunteers are trained to speak to their peers, family and friends about a variety of important health topics. • Volunteers are provided with key talking points so they are able to share their information with others. • Previous years focused on colon-rectal cancer and the importance of a colonoscopy, and osteoporosis/bone density testing. • This year targets glaucoma, coupled with message of having a complete eye exam. Group/ Individual Group/ one-on-one encounters Time Staff (meetings, duration) (paid, volunteer) 5-15 minute presentations Training open to all Health Promotion Volunteers. Specific workshops and also training by Health Promotion Staff (HPS) on site. Space Requirement Private room for group presentations Equipment Training materials, volunteer buttons, educational materials, sign –in sheets, envelopes. ToC CANCER Learn Share and Live Program PROGRAM OVERVIEW PRIMARY CONTACT Marian Robinson, Health Educator/Ciommunity Liaison [email protected] SECONDARY CONTACT A one-day educational group-based intervention to promote breast cancer screening. Utilizes peer support and informal networks. Tailored to low-income African American women aged 55+. PROGRAM DESCRIPTION Duration: One day Not applicable Type: Community-based breast cancer education program Aim: Program is implemented via an existing informal network for low-income urban elderly. Healthcare professionals train team leaders through short lectures followed by discussion or other interactive activities. These leaders of lower-income adult complexes train lay community WEBSITE www.clemson.edu/fyd/learn_share_live. women who, in turn, pass along information and support for breast cancer control activities among their peers. htm OUTCOMES This program improved breast cancer knowledge by 31% among its participants. By taking part in the program, participants learned that younger women are not at greater risk for developing breast cancer, PRINT MATERIALS Health history activity, program postcard, and 18% found out that a mammogram can detect a breast lump before it is big enough to feel. and program abstract are available. ACCESS ON WEBSITE Program description is available on website. IMPLICATIONS This is an effective program for promoting breast cancer screening among older, urban, primarily minority women. ASSOCIATED CONDITIONS Not applicable LANGUAGES English PROGRAM TYPE Research Toolkit – Page 9 ToC CANCER Study/Intervention Methodology STUDY/INTERVENTION METHODS STUDY/INTERVENTION DESIGN Not available Sample size/characteristics: 80 African American women Demographics: Women aged 55+ were included and 15.8% were aged 55-64 while 21.4% were 65+ Inclusion criteria: Live in subsidized complexes for older adults Comparison Groups: The program was implemented at index (year 1) and replication (year 2) sites. STUDY/INTERVENTION LOCATION St. Louis, MO Instruments/Measures: • • REFERENCE Skinner et al. (1998) Pre and post-tests were administered to assess participant knowledge and perceptions before and after the program. At the end of the program, steering committees were asked to provide suggestions for subsequent follow-up activities to promote screening. LIMITATIONS Not applicable IMPLEMENTATION (FIDELITY, MODIFICATIONS, SUSTAINABILITY) See IMPLEMENTATION SHEET COSTS See COST SHEET Toolkit – Page 10 ToC CANCER Screen for Life National Colorectal Cancer Action Campaign PROGRAM OVERVIEW PRIMARY CONTACT Ann Ward, Principal Investigator [email protected] SECONDARY CONTACT Eugene Lengerich, Principal Investigator [email protected] WEBSITE www.cdc.gov/cancer/colorectal/sfl/ A social marketing/awareness campaign to promote colorectal cancer education and screening among adults aged 50+ in community-based organizations. PROGRAM DESCRIPTION Duration: Mult-year Type: Media campaign Aim: National multi-year media campaign developed by the CDC and Centers for Medicare and Medicaid Services to promote colorectal cancer education and screening among adults aged 50+ OUTCOMES This study demonstrates that over time, community cancer coalitions may increase the local dissemination of material from a national media campaign. IMPLICATIONS PRINT MATERIALS Media campaign materials (i.e, brochures, fact sheets, posters, and print ads) are available in print. Community cancer coalitions can increase the local dissemination of material from a national media campaign in rural Appalachia. ACCESS ON WEBSITE Materials are available on the program website. ASSOCIATED CONDITIONS Not applicable LANGUAGES English, Spanish PROGRAM TYPE Implementation Toolkit – Page 11 ToC CANCER Study/Intervention Methodology STUDY/INTERVENTION METHODS STUDY/INTERVENTION DESIGN Community health intervention/Awareness campaign Sample size/characteristics: 168 community organizations from nine counties Demographics: Adults aged 65+ accounted for 16% of organizations in the coalition arm and 16.5% of the noncoalition arm. Comparison Groups: Compared organizations that had linkages to cancer coalitions (the coalition arm) vs. without linkages (noncoalition arm) STUDY/INTERVENTION LOCATION Northern Appalachia, NY and PA REFERENCE Ward et al. (2006) Instruments/Measures: Community organizations’ participation and interest levels in disseminating the materials to their clients and employees were assessed using bimonthly phone calls with university investigators and weekly calls and monthly meetings with field staff members were used to communicate with coalitions and project leaders.. LIMITATIONS • • • IMPLEMENTATION (FIDELITY, MODIFICATIONS, SUSTAINABILITY) Not available • • Participation rate was relatively low: 29% participation in the coalition arm and 8% in the noncoalition arm Distribution of materials tends to be impersonal, as it was in the noncoalition arm Short duration of the study, which limited the time to work closely with the coalitions Different individuals in the organization may have responded to the initial and follow-up surveys differently, but the research protocol did not require the same person to respond to each survey Limited generalizability given that the study was conducted in rural Appalachian counties in PA and NY only COSTS Not available Toolkit – Page 12 ToC CANCER Tepeyac Project PROGRAM OVERVIEW PRIMARY CONTACT Angela Sauia, Principal Investigator [email protected] SECONDARY CONTACT Not applicable WEBSITE www.clinicatepeyac.org A church-based group intervention to promote breast cancer screening among Hispanic women. Utilizes culturally-tailored print materials and promotoras (peer counselors). PROGRAM DESCRIPTION Duration: Four years Type: Church-based health promotion project Aim: Programs aimed to increase breast cancer screening rates among insured Latinas in Colorado. Printed intervention involved culturally-tailored education packages mailed to 209 Colorado Catholic churches. Promotoras (peer counselors) delivered bimonthly breast-health education lectures and conducted 1-3 group discussions with members of four Catholic churches. OUTCOMES PRINT MATERIALS Brochure, planning guide, and sample church letter are available. ACCESS ON WEBSITE Materials are available on the program website. Promotora participants increased their biennial mammograms by 2%, while women exposed to the printed intervention did not change the frequency of their screenings. IMPLICATIONS For insured Latinas, personally delivering church-based education through peer counselors appears to be a better breast-health promotion method than mailing printed educational materials to churches. ASSOCIATED CONDITIONS Not applicable LANGUAGES English, Spanish PROGRAM TYPE Research Toolkit – Page 13 ToC CANCER Study/Intervention Methodology STUDY/INTERVENTION METHODS STUDY/INTERVENTION DESIGN Community health intervention/Awareness campaign STUDY/INTERVENTION LOCATION Colorado Sample size/characteristics: 8,439 Latina women. Racial/ethnic background of participants was identified based on the enrollment databases of Medicaid and Medicare fee for service (FFS) groups. Demographics: • Women aged 50-69 were included and respondents aged 60-64 represented 28% of those in the printed and promotora interventions, while ages 65-69 accounted for 27% of the printed and 22% of the promotora group. • Latinas can be of any race - 11% of respondents identified themselves as Latinas and 90% were White. Inclusion criteria: Enrolled in Medicare, Medicaid or select HMO's. Instruments/measures: Insurance claims were assessed to determine mammography use and rates. Comparison Groups: REFERENCE Sauia et al. (2007) Printed intervention vs. promotora intervention Instruments/Measures: Not applicable LIMITATIONS • IMPLEMENTATION (FIDELITY, MODIFICATIONS, SUSTAINABILITY) Not available • • Although the interventions were based in churches, outcomes were measured in neighborhoods, with the assumption that a church intervention will diffuse into the community Because this was a pilot project, financial and feasibility constraints limited to four the number of churches in the Promotora Intervention. The fact that the churches were not randomly chosen, but were selected by community-based partner and the promotoras, presents a potential selection bias./ COSTS Not available Toolkit – Page 14 ToC COMPARISON CHART OF EVIDENCE-BASED DEPRESSION PROGRAMS Program Name Program Elements Healthy Identifying Depression, Empowering Activities for Seniors (Healthy IDEAS) • Community-based intervention designed to detect and reduce the severity of depressive symptoms among older adults with chronic health conditions and functional limitations through existing community-based case management services • Provides participants and their caregivers with education about depression treatment and self-care, and active assistance in obtaining further treatment Group/ Individual Individual Time (meetings, duration) Staff Requirements At least 3 face-to-face visits and 3-6 telephone contacts, over a 3-6-month period • Staff need to attend pre-service training sessions about depression and program delivery, as well as in-service and follow-up training to address real-world challenges in working with depressed older adults • Staff training consists of 14-20 hrs of group training by behavioral health specialist using a training DVD • Staff may have various academic backgrounds - BSW/MSW, RN, and Case Managers with varying experience have been trained • Program must be delivered by established case management services staff with up to 3 in-person contacts over 3 months Space Requirements Equipment Requirements None None ToC Program Name Program Elements Improving Mood Promoting Access to Collaborative Care Treatment (IMPACT) • Collaborative care program involving a Depression Care Manager (DCM), who collaborates with a Team Psychiatrist and Primary Care Physician • DCM follows the depressed client's care and treatment on an ongoing basis • Participants electing Problem Solving Therapy (PST) receive 6-8 sessions of brief psychotherapy by DCM Group/ Individual Individual Time (meetings, duration) Staff Requirements 3-6 months of phone contacts every two weeks during intensive phase and once a month until symptoms are stable Several training options available for clinicians and organizations: • Staff can take part in a 10-module online training program based on program's 2-day training conference • Training consists of 15 hours of content that includes audio-annotated PowerPoint lectures, case studies, streaming video and more. The training program is free; however, a small fee is charged if continuing education credit is desired or an in-person training as well • PST is available online or through program's in-person training. Once training is complete, IMPACT will connect agencies with a certified PST trainer who provides case supervision to complete certification as a PST practitioner Required background for Depression Care Manager: • Degree in Nursing, Social Work, Marriage and Family Therapy or Psychology. • Minimum 2 years clinical experience in a Relevant setting Required background for Consulting Psychiatrist: • Licensed, preferably board certified Space Requirements • Private room/space for consultation • 2 chairs Equipment Requirements • Phone • Computer to track client needs, schedules, and progress ToC Group/ Individual Program Name Program Elements Life Review Therapy • Group sessions tailored to focus on a particular life period (i.e., childhood, adolescence, adulthood) with questions designed to prompt specific memories • Seeks to improve mood, decrease depressive symptoms and hopelessness, and increase life satisfaction Group Program to Encourage Active, Rewarding Lives for Seniors (PEARLS) Home counseling sessions and phone contacts for older adults receiving home-based services from community service agencies Individual Psycho geriatric Assessment and Treatment in City Housing (PATCH) • Individual-based program targeting mentally ill elderly residing in urban public housing developments • Trains building staff to identify elderly at-risk for mental disorder, referral to psychiatric RN, and homebased evaluation or treatment • Patients are seen an average 5 times, with 1-hr initial assessments and 30minute follow-up contacts Individual Time (meetings, duration) Staff Requirements Meets once a week for 1 hour for 8 weeks Clinical psychologist or individual trained in life review therapy can administer the program Meets 8 times for 50 minutes each (with 3-6 phone contacts) for 19 weeks Staff are required to attend a 2-day training to administer the program. Training is designed to equip all members of a PEARLS team – both counselors and administrators – to implement the program successfully in their organization Meets 5 times for 1 hour each (with 30minute followup contacts) for 26 months • Project nurse must have an RN degree, experience in psychogeriatric nursing, and knowledge and comfort with addressing coexisting medical, social, psychiatric symptoms • Building staff members take part in a structured educational program of monthly presentations led by a staff nurse. Program consists of 7 1-hour teaching modules enabling housing staff to better understand and recognize individuals with mental disorders and to refer residents who may need mental health services. Space Requirements Equipment Requirements Space for face-toface therapy • Tape recorder • Chronometer • Table Clinical psychology degree is recommended • • Sessions are conducted at the client's home Counselors have workstations Computer/laptop None • Phone • Beeper ToC COMPARISON CHART OF EXISTING DEPRESSION HEALTH PROMOTION PROJECTS AT NYC DFTA DFTA's Health Promotion Services (HPS) Unit trains senior volunteers to lead health activities at their senior centers and other sites. Each site has the responsibility of selecting appropriate volunteers and then the Health Promotion staff conducts the training on- site. These programs have their own curricula with a set number of training topics. All necessary equipment and forms are provided by DFTA. Once in place, staff monitors the activity on a regular basis to ensure that all program guidelines are adhered to. DFTA Program Name Program Elements Group/ Individual Stay Well Exercise Classes • Geared for all seniors, ranging from the fit to those with disabilities. • Led by senior volunteers. • Includes aerobic exercises as well as routines designed to enhance balance, build muscle strength (with the use of stretch bands) and aid in the performance of everyday activities. • Classes end with stress reduction exercises to help seniors ease the tensions of everyday living. Group Alert & Alive Discussion Groups • Senior volunteers conduct mental wellness discussion groups. • Participants support each other by sharing experiences that celebrate their lives and the ways they are dealing with the realities of aging. Group Time Staff (meetings, duration) (paid, volunteer) 1 hour per week 1 hour every two weeks Space Requirement Equipment Center /site identifies suitable candidates. Health Promotion Staff (HPS) implements training on site. Once training is completed, the HPS monitors senior volunteers/classes on on-going basis. Room large enough for all participants to complete all exercise movements Training materials, certificates, Tee shirts, stretch bands, balls, volunteers buttons, sign-in sheets and envelopes provided by HPS Center /site identifies suitable candidates. HPS implements training on site. Once training is completed, the HPS monitors volunteers/activity on an on-going basis. Private room for discussion if available. Training materials, volunteer buttons, tote bags, sign-in sheets, envelopes, provided by HPS ToC DFTA Program Name Partner to Partner Program Elements • Based upon the concept that it is easier to talk with someone whose life experiences are similar to one’s own. • Trained senior volunteers act as receptive listeners to their peers and bring attentive and supportive communication skills to their private one-on-one conversations. • As aging and life issues are raised, the trained Partner provides a sure sense of support and understanding, and when requested, advice or referral information. Group/ Individual One –on-one encounters Time Staff (meetings, duration) (paid, volunteer) 10- 15 minute sessions Center/site identifies suitable candidates. Health Promotion Staff (HPS) implements training on site. Once training is completed, HPS meets with volunteers on an ongoing basis Space Requirement None Equipment Training materials, certificates, tote bags, volunteer buttons, sign-in sheets, envelopes, volunteer buttons, provided by HPS ToC DEPRESSION Healthy Identifying Depression, Empowering Activities for Seniors (Healthy IDEAS) PROGRAM OVERVIEW PRIMARY CONTACT Nancy Morrow-Howell morrow-howell@wustledu (713) 798-3850 SECONDARY CONTACT Nancy Wilson [email protected] (713) 798-3850 WEBSITE www.careforelders.org/healthyideas PRINT MATERIALS Addressing Depression in Older Adults Replication and Technical Assistance Information Handout Self-Assisting Readiness for Implementing Healthy IDEAS (Identifying Depression, Empowering Activities for Seniors) Handout Healthy IDEAS Replication Report 3 to 6 month intervention where depression screening and management is incorporated into existing case management services for older adults. Delivered by employees of community service agencies to individual clients. PROGRAM DESCRIPTION Duration: Three-to-six months Type: Community-based intervention Aim: Designed to detect and reduce the severity of depressive symptoms among older adults with chronic health conditions and functional limitations through existing community-based case management services. Participants and their caregivers are provided with education about depression treatment and self-care, and active assistance in obtaining further treatment. Participants also receive coaching and support as they engage in behavioral activation. Typically involves at least three face-to-face visits and three to six telephone contacts. OUTCOMES Program reduced depression, while improving participants' general health status, social and physical activation, and the use of mental health service At 6 month follow-up, program showed: • 39% reduction in depression severity ACCESS ON WEBSITE • 25% increase in the number of participants indicating they Organizational readiness, selfknew how to get help for depression assessment tools, replication guidance, • 29% increase in the number of participants reporting reduced case studies and technical assistance, is available at the Care for Elders website pain www.careforelders.org/healthyideas • 31% increase in the number of participants reporting little or no interference of their physical or emotional health with their ASSOCIATED CONDITIONS social activities Not applicable LANGUAGES English PROGRAM TYPE IMPLICATIONS Non speciality providers can be trained to successfully implement an evidence-based self-management intervention for depression with frail, high-risk, and diverse older adults. Implementation Toolkit – Page 15 ToC DEPRESSION Study/Intervention Methodology STUDY/INTERVENTION METHODS STUDY/INTERVENTION DESIGN One group pre-post study design Sample size/characteristics: 94 participants Demographics: Older adults aged 60+, 79% women, 44% Hispanic Inclusion criteria: Aged 60+ residing within community and receiving services at one of the participating community-based agencies. Ability to understand and communicate verbally, be cognitively intact, and score greater than 5 on the Geriatric Depression Scale-15 item (GDS-15). Comparison Groups: STUDY/INTERVENTION LOCATION Harris County, Texas. Not applicable. Study did not have a control group. All eligible participants (n=94) were able to participate in the study and were not randomized to treatment or control group Instruments/Measures: • • REFERENCE Quijano, et al (2007) • • IMPLEMENTATION (FIDELITY, MODIFICATIONS, SUSTAINABILITY) See IMPLEMENTATION SHEET • COSTS See COST SHEET • Depression severity assessed by the Geriatric Depression Scale15 item (GDS-15) Cognitive impairment measured by the 6-item Mini Mental State Exam Quality of life measured by 3 items (general health perception, bodily pain, and social function) selected from the Medical Outcomes Study Short Form-36 Medical and mental health utilization assessed by four items selected from the Depression PORT II study (a) whether the client has had contact with a medical provider, (b) whether he or she discussed depression with a medical provider, (c) whether he or she was given a prescription for antidepressant medication, and (d) whether he or she had contact with a mental health professional Level of social and physical activity measured by 2 items (a selfreport measure of frequency and duration of physical activity) selected from the Community Healthy Activities Model Program for Seniors (CHAMPS) Knowledge about depression self-management were assessed by four questions (how to identify symptoms of depression, how to make an appointment, what to do if depression symptoms increase, and whether increasing activity will improve depression) selected from the depression self-efficacy portion of a measure used to assess collaborative interventions for chronic illness (Cretin, Shortell, & Keeler, 2004) LIMITATIONS • • • Lack of generalizability Bias caused by attrition Lack of control group Toolkit – Page 16 ToC DEPRESSION Improving Mood Promoting Access to Collaborative Care Treatment (IMPACT) PROGRAM OVERVIEW PRIMARY CONTACT 12-month program conducted by depression care managers with specialized training in the treatment of depression. Education, problem-solving treatment, and support for antidepressant medication management in collaboration with primary care physician is provided to individual clients. SECONDARY CONTACT PROGRAM DESCRIPTION Jürgen Unützer, MD, MPH [email protected] (206) 685-7095 Diane Powers [email protected] (206) 685-7095 WEBSITE www.impact-uw.org PRINT MATERIALS *IMPACT Team Building Worksheet *IMPACT Planning Implemenation Toolkit: Needs Assessment, Planning Grid, Fidelity Measure Worksheet *IMPACT Training Manual ACCESS ON WEBSITE Web cast and free interactive webbased trainings are available to implementers at program website www.impact-uw.org ASSOCIATED CONDITIONS Arthritis, Diabetes Duration: 12 months Type: Collaborative/stepped care disease management program Aim: To obtain a 50% reduction in depression symptoms within 1012 weeks. Collaborative care provided by Depression Care Manager (DCM), Team Psychiatrist and Primary Care Physician. Once participants have started treatment, Depression Care Manager (DCM) follows up in person or by phone approximately every two weeks during intensive phase and approximately monthly until symptoms are stable. Participants electing Problem Solving Therapy (PST) receive six to eight sessions of brief psychotherapy by DCM. OUTCOMES Program reduced depression and health related functional impairment, while increasing rates of treatment response. Program showed: • 49% reduction of major depression at 6 months • 24% reduction in health related functional impairment at 12 months • 45% of participants reported a 50% or greater reduction of depression symptoms at 12 months IMPLICATIONS Program appears to be feasible and significantly more effective than usual care LANGUAGES English, Spanish PROGRAM TYPE Implementation Toolkit – Page 17 ToC DEPRESSION Study/Intervention Methodology STUDY/INTERVENTION METHODS STUDY/INTERVENTION DESIGN Randomized controlled trial STUDY/INTERVENTION LOCATION Sample size/characteristics: 1,801 older adults selected from 18 primary care clinics, randomly assigned to IMPACT intervention (n=906) or to usual care (n=895) Demographics: Mean age 71.2 (s.d.. 7.5 years) 65% were women, 23% were from ethnic minority groups (12 % African American, 8 % Latino, 3% other) Inclusion criteria: Older adults aged 60+, who planned to use one of the participating primary care clinics as the main source of general medical care, and a diagnosis of current major depression or dysthymia disorder according to the Structured Clinical Interview for DSM-IV (SCID). * 18 Primary Care Clinics within Washington, California, Texas, Indiana Comparison Groups: and North Carolina Intervention patients having access to IMPACT depression care manager were compared to usual care group receiving primary care or specialty mental health care REFERENCE Unutzer et al. (2002) Instruments/Measures: • • • IMPLEMENTATION (FIDELITY, MODIFICATIONS, SUSTAINABILITY) Not available • • COSTS See COST SHEET Severity of depressive symptoms assessed using the Symptom Check List 20 (SCL-20) Diagnosis of major depression or dysthymia measured by the Structured Clinical Interview for DSM-IV (SCID) Health-related functional impairment measured by an Index developed from the Sheehan Disability Scale that incorporates impairments in work, family, and other social functioning Health services use was assessed by The Cornell Services Index Patient Health Questionnaire 9 and a web-based clinical information system was used to monitor patient response treatment for up to 12 months LIMITATIONS • • • Study design may have biased program's comparisons in favor of the usual care group. Underestimation of the effectiveness of the intervention compared with usual care outside a research setting. Reliance on self-reports of chronic medical conditions and antidepressant and psychotherapy use. Toolkit – Page 18 ToC DEPRESSION Life Review Therapy PROGRAM OVERVIEW PRIMARY CONTACT Juan Pedro Serrano [email protected] SECONDARY CONTACT Not applicable WEBSITE Not available An 8-week group program for older adults with depression. The program encourages participants to practice retrieving autobiographical memories. PROGRAM DESCRIPTION Duration: 8 week program Type: Interventional Aim: Seeks to improve the mood state, as reflected in decreased depressive symptoms, decreased hopelessness, and increased life satisfaction among older adults with depressive symptomatology by examining the effects of autobiographical retrieval practice. Entails focusing on a particular life period each week-childhood, adolescence, adulthood, and summary and answering 14 tailored questions designed to prompt specific memories. OUTCOMES PRINT MATERIALS Life Review Specific Positive Events Protocol Handout ACCESS ON WEBSITE Not applicable Program decreased number of participants meeting criteria of major depression, as well as hopelessness, while increasing life satisfaction. Program showed: • 25% decrease in the number of participants suffering from major depression • 32% reduction in hopelessness • 44% increase in life satisfaction IMPLICATIONS ASSOCIATED CONDITIONS Not applicable LANGUAGES Practice in autobiographical memory for specific events may be among the components of life review that account for its effectiveness and could be a useful tool in psychotherapy with older adults. Spanish, English PROGRAM TYPE Research Toolkit – Page 19 ToC DEPRESSION Study/Intervention Methodology STUDY/INTERVENTION METHODS STUDY/INTERVENTION DESIGN Randomized controlled trial Sample size/characteristics: 43 older adults Demographics: Older adults aged 65-93. 33 were women and 10 were men. Inclusion criteria: Clinically significant symptoms of depression, no evidence of dementia, and could not be receiving pharmacological treatment for depression Comparison Groups: STUDY/INTERVENTION LOCATION Albacete, Spain Intervention group received the life review intervention while continuing with social services. Control group received social services as usual. Instruments/Measures: • • REFERENCE Serrano et al. (2004) • LIMITATIONS • IMPLEMENTATION (FIDELITY, MODIFICATIONS, SUSTAINABILITY) See IMPLEMENTATION SHEET Depression was measured by the 20-item self-report scale, Center for Epidemiologic Studies Depression Scale (CES-D) Life satisfaction was measured by the Life Satisfaction Index A (LSIA) Hopelessness was measured by the Beck Hopelessness Scale (BHS). • • • No placebo control groups in which participants received the same amount of attention from the therapist but not the autobiographical retrieval practice. Prompting questions during the intervention primarily targeted positive memories No follow-up to learn how long the changes maintained. Sample size was small Not all respondents had major depressive disorder, but did have significant depressive symptoms. COSTS Not available Toolkit – Page 20 ToC DEPRESSION Program to Encourage Active, Rewarding Lives for Seniors (PEARLS) PROGRAM OVERVIEW PRIMARY CONTACT Paul Ciechanowski, MD, MPH [email protected] (206) 685-7285 SECONDARY CONTACT Sheryl Schwartz [email protected] (206) 685-7285 WEBSITE www.pearlsprogram.org/ PRINT MATERIALS PEARLS Toolkit/Manual An individual-based, 19 week intervention for older adults with minor depression. Consisting of eight 50-minute in-home counseling sessions with a trained social service worker followed by 3-6 subsequent telephone contacts. Program helps participants recognize symptoms of depression, meet their recommended levels of social and physical activity, and identify and participate in personally pleasurable activities, complemented with telephone support calls. PROGRAM DESCRIPTION Duration: 19 weeks Type: Home-based, time-limited depression treatment program Aim: To reduce symptoms of depression and improve healthrelated quality of life. Offered to older adults receiving home-based services from community service agencies and who have minor depression or dysthymia. Consists of eight 50-minute in-home counseling sessions with a trained social service worker followed by 3-6 subsequent telephone contacts. The Patient Health Questionnaire 9 (PHQ-9) is administered at the beginning of session to track depression change. OUTCOMES ASSOCIATED CONDITIONS Program reduced depression among participants. Program showed: • 54% of participants reported a decrease in depressive symptoms at 6 months, while 43% participants reported a decrease at 12 months • 36% of participants were more likely to achieve complete remission from depression at 12 months • Overall, greater health-related quality -of-life improvements in functional and emotional well-being. LANGUAGES IMPLICATIONS ACCESS ON WEBSITE Please visit program website at www.pearlsprogram.org/ for electronic PEARLS Toolkit/Manual and training information Not applicable English PROGRAM TYPE Program was found to significantly reduce depressive symptoms and improve health status in chronically medically ill older adults with minor depression and dysthymia. Implementation Toolkit – Page 21 ToC DEPRESSION Study/Intervention Methodology STUDY/INTERVENTION METHODS STUDY/INTERVENTION DESIGN Randomized controlled trial STUDY/INTERVENTION LOCATION Metropolitan Seattle, Washington area. Sample size/characteristics: 138 participants Demographics: Older adults 60+, 79% women, 42% belonged to a racial/ethnic minority (36% African American , 4% Asian American, 1% Hispanic , and 1% American Indian) Inclusion criteria: Aged 60+, receiving services from senior services agencies or living in senior publics housing with DSM-IV minor depression or dysthymia diagnostic criteria. Comparison Groups: Intervention group received problem-solving therapy by PEARLS therapists while control group received no additional services, but letters sent to their regular physicians and social workers reporting their depression diagnosis with recommendations to cont Instruments/Measures: • REFERENCE Ciechanowski et al (2004) • • IMPLEMENTATION (FIDELITY, MODIFICATIONS, SUSTAINABILITY) See IMPLEMENTATION SHEET • Depression was assessed using the Hopkins Symptoms Checklist ( HSCL-20) derived from the revised HSCL-90 Health related quality of life in functional, physical, social and emotional well-being domains was assessed at baseline and 12 months using the Functional Assessment of Cancer Therapy Scale-General (FACT-G) Health care utilization was assessed using the Cornell Services Index 7 NEO neuroticism scale items were administered at baseline, since neuroticism predicts persistence of depression in primary care and an increased risk for late-life depression associated with disability LIMITATIONS COSTS See COST SHEET • • • The sample size was moderate and limited to 1 urban geographical area. Study did not have access to automated health care records, relying instead on self-reported medical comorbidty and health care utilization, which is susceptible to social desirability and recall biases. Study has unequal baseline proportions of dysthymia and minor depression, with intervention participants having a greater proportion of dysthymia at baseline compared with usual care participants. Toolkit – Page 22 ToC DEPRESSION Psycho geriatric Assessment and Treatment in City Housing (PATCH) PROGRAM OVERVIEW PRIMARY CONTACT Peter V. Rabins, MD, MPH [email protected] SECONDARY CONTACT Not applicable WEBSITE Not available PRINT MATERIALS *PATCH Educational Modules Individual-based, 26 month intervention applied in urban public housing developments where building staff are trained to identify seniors at risk for psychiatric disorders. Residents are then screened by a psychiatric nurse, and treatment is provided in residents’ homes as necessary. PROGRAM DESCRIPTION Duration: 26 months Type: Treatment model that combines principles of the Assertive Community Treatment and Gatekeeper models. Aim: Intervention targeted mentally ill elderly persons living in urban public housing developments with the aim of reducing psychiatric symptoms among elderly residents needing care and enabling them to remain in public housing. Intervention's three core elements, include (1) Training of building staff (manager, social workers, groundskeepers, and janitors) to identify those at risk for psychiatric disorder (2) Identification and subsequent referral of potential cases by workers to a psychiatric nurse (3) Psychiatric evaluation and treatment in the residents' homes. Patients are seen an average of 5 times, with most initial assessments taking 1 hour and follow-up contacts averaging 30 minutes OUTCOMES ACCESS ON WEBSITE Program decreased depressive symptoms and psychiatrics symptoms among participants suffering from psychiatric conditions. Program showed: • 8% reduction in depressive symptoms • 34% reduction in psychiatric symptoms ASSOCIATED CONDITIONS IMPLICATIONS Not applicable Not applicable LANGUAGES PATCH intervention was more effective than usual care in reducing psychiatrics symptoms in persons with psychiatric disorders and those with elevated levels of psychiatric symptoms English PROGRAM TYPE Implementation Toolkit – Page 23 ToC DEPRESSION Study/Intervention Methodology STUDY/INTERVENTION METHODS STUDY/INTERVENTION DESIGN Randomized controlled trial STUDY/INTERVENTION LOCATION 6 urban public housing sites for older adults in Baltimore, MD. Sample size/characteristics: 945 older adults Demographics: Older adults 60+. Within intervention group , 77% were women, 89.2% were African-American,10.8% non-black. Within control group, 73% were women and 96.4 were African-American and 3.6 were non-black. Inclusion criteria: All subjects aged 60+, who screened positive (scored 5 or more on the General Health Questionnaire, 17 or less on the MiniMental State Examination, or a score of 2 or more on the CAGE questionnaire were included as well as a 10% random sample of those who screened negative were selected. Comparison Groups: Among the 6 sites, residents in 3 buildings were randomized to receive the PATCH model intervention and residents in the remaining 3 buildings were randomized to receive usual care. REFERENCE Rabins, et al (2000) Instruments/Measures: • • IMPLEMENTATION (FIDELITY, MODIFICATIONS, SUSTAINABILITY) See IMPLEMENTATION SHEET • LIMITATIONS • COSTS Psychiatric symptoms and behavioral disorders were measured by the Brief Psychiatric Rating Scale (BPRS) Changes in mood and measurement of depressive symptoms were assessed by the Montgomery-Asberg Depression Rating Scale (MADRS) Composite measure entitled undesirable moves, included subjects who were evicted or who moved from the building to a nursing home or to a board and care home during the study • Lack of a single standardized treatment as the independent variable Use of non-treated comparison group See COST SHEET Toolkit – Page 24 ToC COMPARISON CHART OF EVIDENCE-BASED DIABETES PROGRAMS Group/ Individual Time (meetings, duration) Staff Requirements Space Requirements Equipment Requirements Program Name Program Elements Diabetes Education & Prevention with a Lifestyle Intervention Offered at the YMCA (DEPLOY) Group-based intensive lifestyle intervention which adapts the Diabetes Prevention Program (DPP) to YMCA's. Group Meets once a week for 1 hour for 16 weeks • The intervention was originally implemented by trained YMCA wellness instructors • Instructors are required to attend a two-day training Space for 8-12 participants to participate in group exercise • Exercise equipment (provided by YMCA) • Instruments to measure body weight, blood pressure, HbA1c levels, total cholesterol, and HDL-cholesterol • Chairs for group meetings Diabetes Health Connection Tailored CD-ROM intervention with one-on-one counseling and follow-up telephone support that emphasizes participant choice in physical activity selection Individual Entails only two sessions: for baseline and follow-up assessment Staff may have diverse educational backgrounds (e.g., OT, public health), but all receive training to become health coaches. This training focuses on motivational interviewing, mock patient interactions, and "shadowing." Space for individuals to use computer (i.e., computer room) • Computer • Program CD • Telephone Diabetes Prevention Program (DPP) • Curriculum-based intensive lifestyle intervention taught by case managers on a oneto-one basis • Aims to reduce weight by 7% and promote at least 150 minutes of weekly physical activity Individual Meets for 16 sessions for 24 weeks This intervention is taught by trained case-managers; no educational background is specified Space for one-on-one discussions. Equipment to measure Hba1c level *This program is a model evidence-based diabetes program upon which other programs have been adapted ToC COMPARISON CHART OF EVIDENCE-BASED DIABETES PROGRAMS Program Name Group Lifestyle Balance (GLB) Program Elements Group/ Individual Time Staff Requirements (meetings, duration) Meets for 12 sessions for 12 weeks Space Requirements Equipment Requirements • Intervention addressing safe weight loss and physical activity • Shortens the 16-session Diabetes Prevention Program (DPP) to 12 sessions, and is delivered by two trained "preventionists" - one dietician and one exercise specialist Group Healthy ChangesTM by NCOA Group-based educational program on topics of diabetes, nutrition and physical activity, with a secondary aim of providing social support Group Meets for 26 sessions lasting 90 minutes each This intervention is taught by trained group facilitators; no educational background is specified Space for group sessions None Look After Yourself (LAY) Structured group-based educational program that promotes diabetes selfmanagement through education and motivational components necessary for behavior change Group Meets one a week for 2 hours per session for 8 weeks This intervention is delivered by nurses specializing in diabetes, who are trained to conduct the intervention Space for group sessions Equipment to measure Hba1c levels and BMI • • Originally implemented by one dietician and one exercise specialist, although any health professional may implement this program Health care professionals must attend a 2-day training at the University of Pittsburgh Medical Center • • Room with table and chairs Private area for weigh-in's • Calorie/fat-tracking book • Pedometer • Measuring cups/spoons • Scale ToC COMPARISON CHART OF EVIDENCE-BASED DIABETES PROGRAMS Group/ Individual Time (meetings, duration) Program Name Program Elements Look AHEAD (Action for Health in Diabetes) • Intensive lifestyle intervention involving group and individual meetings led by intervention teams consisting of dieticians, psychologists, and exercise specialists • Adaptation of the Diabetes Prevention Program, or DPP, with the goal of 7% weight loss in the first year through reduced caloric intake and physical activity of 175 minutes per week Group and individual components Year-long program that involves 3 group and 1 individual meetings during months 1-6, and 1 group session every 2 weeks and 1 individual session during months 7-12 New Leaf. . . Choices for Healthy Living with Diabetes Group and individual-based program tailored to African Americans that uses community diabetes advisors to emphasize physical activity, healthy diet, and diabetes selfcare. Group and individual components Year-long program that involves 2-3 hours of individual counseling, 4.5 hours of group counseling, and 2 hours of telephone contact. Staff Requirements Space Requirements Equipment Requirements This intervention is implemented by a team of diverse professionals - dieticians, psychologists, and exercise specialists. Space for group and individual sessions, as well as fitness test Equipment to measure heart rate, respriatory rate, blood pressure, HbA1c levels, fasting serum glucose, total serum cholesterol and triglycerides, and HDL and LDL cholesterol The individual-based clinic component is led by a health counselor, and the group-based community component is led by a community diabetes advisor (CDA) who is a nonprofessional peer counselor. When this program was first studied, CDAs were African American women with type 2 diabetes, who had a general knowledge of diabetes, and who received training on how to conduct the New Leaf program Space for group and individual sessions, as well as exercise session • Equipment to measure fitness (Caltrac accelerometer), weight, glycosylated hemoglobin, and blood lipids • Fitness equipment (i.e., treadmill) • Telephone for counseling ToC COMPARISON CHART OF EVIDENCE-BASED DIABETES PROGRAMS Program Name Program Elements Group/ Individual Time (meetings, duration) Staff Requirements Space Requirements Equipment Requirements Seniors Taking Charge of Diabetes! • Community-based intervention that focuses on improving daily adherence to diabetes self-management behaviors, glucose control, and physical activities • Incorporates daily meal planning and interactive games Group Meets for 8 sessions over 4 months., with 8 additional sessions on increasing intake of fruits and vegetables This intervention is delivered by trained group leaders; no educational background is specified Space for lectures, food demonstrations, and chair exercises • Food for demonstrations • Ball and bands for chair exercises Starr County Border Health Initiative • Education and support group intervention tailored to Mexican culture • Involves 3 months of weekly instructional sessions on nutrition, self-monitoring of blood glucose, exercise, and other self-care topics, and 6 months of biweekly support group sessions to promote behavior changes. • Participants are accompanied to sessions by a family member or friend Group Meets for 52 contact hours for 12 months, including 3 months of weekly educational sessions and 6 months of biweekly support group sessions • This intervention is implemented by a team of dieticians, nurses, and community health workers • Trainers are not required to be certified diabetes educators • Community health workers are trained to provide logistical support • Room with table and chairs for 15 participants • Access to kitchen preferred • DVD or VCR • Pedometers (provided by program staff) • Glucometers (provided by program staff) ToC EXISTING DIABETES HEALTH PROMOTION PROJECT AT NYC DFTA DFTA's Health Promotion Services (HPS) Unit trains senior volunteers to lead health activities at their senior centers and other sites. Each site has the responsibility of selecting appropriate volunteers and then the Health Promotion staff conducts the training on- site. This program has its own curriculum with a set number of training topics. All necessary equipment and forms are provided by DFTA. Once in place, staff monitors the activity on a regular basis to ensure that all program guidelines are adhered to. DFTA Program Name Know Your Numbers Program Elements • Senior volunteers are trained to help their peers understand the implications of their blood pressure readings, as well as the results of their glucose and cholesterol tests. • The training curriculum has been revised to make it more userfriendly for prospective volunteers. • Plans are to mail a flyer announcing the availability of this program in mid- January. Group/ Individual Group/ On-on-one encounters Time Staff (meetings, duration) (paid, volunteer) 5-15 minute presentations Center/site identifies suitable candidates. Health Promotion Staff (HPS) conducts training on site. Once training is completed, HPS meets with volunteers on an on-going basis. Space Requirement Private room for group presentations Equipment Training materials, certificates, tote bags, volunteer buttons, educational materials, sign-in sheets, and envelopes, provided by HPS ToC DIABETES Diabetes Education & Prevention with a Lifestyle Intervention Offered at the YMCA (DEPLOY) PROGRAM OVERVIEW PRIMARY CONTACT Ronald T. Ackermann, MD, MPH [email protected] SECONDARY CONTACT Not applicable WEBSITE Not available PRINT MATERIALS A 16-session group-based intensive lifestyle intervention for obese adults with diabetes risk factors. The curriculum is based on the Diabetes Prevention Program, and is delivered by trained YMCA wellness instructors. The program aims to reduce weight through improved diet and exercise. PROGRAM DESCRIPTION Duration: 16 sessions over 16 weeks Type: A group-based intensive lifestyle intervention, involving groups of 8-12 people Aim: To adapt the Diabetes Prevention Program (DPP) for wider dissemination using the YMCA network and wellness instructors. Following the core training, participants are encouraged to meet twice weekly at their preferred community location to exercise. OUTCOMES • • This program reduced weight by an average of 6%, and improved cholesterol (-22mg/dl), although changes in blood pressure were not significant. Weight loss and reduction in cholesterol were sustained at the 12 to 14 month follow-up. The curriculum, as well as information on trainings, will be available through the IMPLICATIONS Centers for Disease Control (CDC) in There are approximately 2,500 YMCA facilities serving 10,000 rural, Spring 2010. suburban and urban communities in the U.S. This study points to feasibility of nationwide dissemination of a beneficial and costACCESS ON WEBSITE effective approach to diabetes prevention. Not applicable ASSOCIATED CONDITIONS Obesity Pre-Diabetes LANGUAGES English PROGRAM TYPE Research Toolkit – Page 25 ToC DIABETES Study/Intervention Methodology STUDY/INTERVENTION METHODS STUDY/INTERVENTION DESIGN Pilot randomized controlled trial STUDY/INTERVENTION LOCATION Two semi-urban YMCA facilities in Indianapolis IN REFERENCE Ackermann and Morero (2007); Finch et al. (2009); Ackermann et al (2008) Am J Prev Med. IMPLEMENTATION (FIDELITY, MODIFICATIONS, SUSTAINABILITY) Not available Sample size/characteristics: 92 participants Demographics: controls were more often women (61% vs. 50%) and of nonwhite race (29% vs. 7%). The mean age in the intervention group was 56.5 (s.d. 9.7), and 50% of participants in the intervention group were women, 2% Hispanic, 4% African American, 93% white, and 2% other. Inclusion criteria: BMI ≥ 24; ≥2 diabetes risk factors; and random capillary blood glucose of 110–199 mg/dL. Comparison Groups: Participants in the intervention group were compared to a control condition that received approximately 5 minutes of advice, supplemented by the National Diabetes Education Program's Small Steps Big Rewards to Prevent Diabetes materials. Instruments/Measures: After 6 and 12 months. • Body weight • Blood pressure • HbA1c • Total cholesterol, and HDL-cholesterol LIMITATIONS • • • Pilot study; significant differences at baseline between control and intervention groups. Participants in the intervention group only attended approximately 57% of all possible classes. With only 2 matched YMCA sites, it was not possible to adjust for clustering by intervention site. COSTS Not available Toolkit – Page 26 ToC DIABETES Diabetes Health Connection PROGRAM OVERVIEW PRIMARY CONTACT D.K. King, M.S., OTR [email protected] SECONDARY CONTACT Not applicable WEBSITE Not available A 2-session CD-ROM-based physical activity intervention for adults with diabetes. This intervention involves two one-on-one sessions combined with telephone support. The program assists participants in designing a physical activity plan that emphasizes participant choice in activity selection. PROGRAM DESCRIPTION Duration: On-on-one sessions conducted at baseline and two months Type: CD-ROM-based intervention to improve physical activity Aim: Tailored CD ROM intervention with one-on-one counseling and follow-up telephone support that emphasized participant choice in physical activity selection OUTCOMES • • • PRINT MATERIALS A CD-ROM of the intervention is provided. No additional print materials are required. ACCESS ON WEBSITE Not applicable This intervention improved moderate intensity physical activity and strength training. Proportion engaging in moderate intensity physical activity increased by 33%. Strength training as measured by kcals/kg/hr increased by 227%. IMPLICATIONS A computerized assisted program with health coaching can be used to assist adults with type 2 diabetes to develop a physical activity plan combining aerobic and strength training. ASSOCIATED CONDITIONS Not applicable LANGUAGES English PROGRAM TYPE Research Toolkit – Page 27 ToC DIABETES Study/Intervention Methodology STUDY/INTERVENTION METHODS STUDY/INTERVENTION DESIGN Randomized controlled trial STUDY/INTERVENTION LOCATION Adults recruited from 42 primary care physicians in Denver metropolitan area REFERENCE King et al. (2006) IMPLEMENTATION (FIDELITY, MODIFICATIONS, SUSTAINABILITY) Not available Sample/study characteristics: 335 adults randomized to a computerassisted tailored self-management intervention (n=174) or to a health risk appraisal with feedback control group (n=161). Demographics: Mean age was approximately 61 for both groups (s.d. 11.3). 76.5% were white, and 17.8% were Hispanic. 50.2% in both groups were female. Inclusion criteria: Participants were at least 25 years of age and had diagnosed type 2 diabetes for 6 months or more; able to read and write in English; and able to perform moderate level physical activity. Comparison Groups: Participants in the comparison condition completed an interactive computerized health risk appraisal at baseline and received feedback and brief generic health counseling. At the 2 month follow-up visit, they discussed their diet and physical activity goa Instruments/Measures: • CHAMPS questionnaire to measure physical activity at baseline and 2 months. LIMITATIONS • • Reliance on self-report. Inability to measure whether results will extend beyond 2 months. COSTS Not available Toolkit – Page 28 ToC DIABETES Diabetes Prevention Program (DPP) PROGRAM OVERVIEW PRIMARY CONTACT DPP Coordinating Center George Washington University Biostatistics Center 6110 Executive Blvd. Suite 750 Rockville, MD 20852 An intensive lifestyle intervention program for obese adults with pre-diabetes. 16 sessions are delivered over 6-months by a case manager on a one-on-one basis. The sessions focus on reducing weight through improved diet and exercise. PROGRAM DESCRIPTION Not applicable Duration: 16 sessions within a 24-week period. Participants were evaluated for an average of 2.8 years following the intervention. Type: Individual-based intensive lifestyle intervention Aim: 16-lesson curriculum taught by case managers on a one-onone basis. The goals of the intervention were 7% weight loss and at least 150 minutes of physical activity per week. WEBSITE OUTCOMES SECONDARY CONTACT http://www.bsc.gwu.edu/dpp/index.htm lvdoc This intervention decreased weight, decreased caloric intake and fat intake, improved blood glucose, and reduced the incidence of diabetes. In the lifestyle intervention group: PRINT MATERIALS • 50% achieved weight loss of at least 7% of body weight, and Print materials can be requested through 74% met the goal of 150 minutes of physical activity per week. the Diabetes Prevention Program • Normal fasting glucose values improved in the first year. Coordinating Center, or they may be • Daily energy intake decreased by a mean of 450 kcal. downloaded directly from the website. • Average fat intake decreased by 7% of total fat intake. ACCESS ON WEBSITE • Incidence of diabetes decreased by 58%. Chapters from the curriculum are available as pdfs on the study repository website IMPLICATIONS http://www.bsc.gwu.edu/dpp/index.htmlv • Diabetes can be prevented or controlled in those with doc. impaired glucose tolerance using intensive lifestyle intervention or metformin. • The lifestyle intervention was more effective than metformin. ASSOCIATED CONDITIONS Obesity Pre-Diabetes LANGUAGES English and Spanish PROGRAM TYPE Research Toolkit – Page 29 ToC DIABETES Study/Intervention Methodology STUDY/INTERVENTION METHODS STUDY/INTERVENTION DESIGN Randomized Controlled Trial STUDY/INTERVENTION LOCATION US Sample size/characteristics: 3,234 adults with diabetes attending one of 27 clinical centers. Demographics: 67.7% were women. 54.7% were white, 19.9% were African American, 15.7% were Hispanic, 5.3% were American Indian, and 4.4% were Asian. Mean age was approximately 50.6 (s.d. 10.7). Inclusion criteria: at least 25 years of age; BMI of 24 or higher; impaired glucose tolerance. Comparison Groups: Participants in the intensive lifestyle intervention also received a placebo, and were compared to those receiving standard recommendations plus metformin, and to participants receiving standard lifestyle recommendations plus placebo. Instruments/Measures: REFERENCE Diabetes Prevention Program Research Group (2002); Wylie-Rosett et al. (2006) for cost effectiveness. • • • HbA1c Self-reported physical activity using the Modifiable Activity Questionnaire. Dietary intake using modified version of Block food-frequency questionnaire. LIMITATIONS IMPLEMENTATION (FIDELITY, MODIFICATIONS, SUSTAINABILITY) Not available COSTS Not available Toolkit – Page 30 ToC DIABETES Group Lifestyle Balance (GLB) PRIMARY CONTACT M. Kaye Kramer, DrPH, MPH, BSN, CCRC Director, Diabetes Prevention Support Center University of Pittsburgh Diabetes Institute [email protected] SECONDARY CONTACT Miriam Seidel, MS, RD, LDN [email protected] WEBSITE PROGRAM OVERVIEW A 12-session group-based intensive lifestyle intervention for obese adults with components of the metabolic syndrome. The curriculum is based on the Diabetes Prevention Program. Trained “preventionists” deliver the program which emphasizes weight loss through improved diet and exercise. PROGRAM DESCRIPTION Duration: 12 sessions over 12 weeks Type: A group-based, intensive lifestyle intervention Aim: Intervention addressing safe weight loss and physical activity. The 16 session Diabetes Prevention Program (DPP) was shortened to 12 sessions over 12 weeks. The goals remained 7% weight loss, and weekly physical activity of 150 min. Intervention was delivered by two trained "preventionists" -- one dietician and one exercise specialist. https://diabetesprevention.upmc.com/d iabetesPrevention_Contact.htm OUTCOMES This intervention reduced weight, abdominal obesity, and PRINT MATERIALS hypertension. Changes in blood lipids were not significant, and In order to receive the curriculum, health blood glucose increased. care professionals must attend a 2-day • Nearly half lost at least 5% and one third lost at least 7% of training at the University of Pittsburgh their body weight. Medical Center. • 88% maintained weight loss at 6 months. ACCESS ON WEBSITE • Proportion with abdominal obesity decreased over time (90% Information for health care professionals at baseline, 82% at 3 months and 68% at 6 months). interested in the 2-day trainings is • Proportion with hypertension decreased over time (68% at available through the following website: baseline, 58% at 3 months and 48% at 6 months). https://diabetesprevention.upmc.com/dia • Proportion with glucose greater than or equal to 100 mg/dl betesPrevention_ProfessionalServices.h tm increased over time (42% at baseline, 51% at 3 months and 61% at 6 months). ASSOCIATED CONDITIONS Obesity Pre-Diabetes LANGUAGES English PROGRAM TYPE IMPLICATIONS • • One of the first studies attempting to translate the DPP to an urban medically underserved community. One of the few studies demonstrating sustained improvements in weight loss and reduction in components of metabolic syndrome in a community setting. Research Toolkit – Page 31 ToC DIABETES Study/Intervention Methodology STUDY/INTERVENTION METHODS STUDY/INTERVENTION LOCATION Sample size/characteristics: Residents from 11 targeted neighborhoods were screened for metabolic syndrome (n=573) and n=185 eligible participants were invited. Of these, n=88 took part in the intervention. Demographics: Mean age was 54 years (s.d. 10.5). 84.1% were female, and 74.7% white. Inclusion criteria: BMI ≥ 25; had physician's consent to exercise; and at least 3 of 5 components of the metabolic syndrome. REFERENCE LIMITATIONS STUDY/INTERVENTION DESIGN One group pre-post study design Community-based recruitment in 11 Comparison Groups: medically underserved neighborhoods in Not applicable Pittsburgh, PA (flyers were posted in Instruments/Measures: churches, physicians offices, worksites and storefronts, and ads were placed in • Clinical endpoints: height, weight, waist circumference, blood newspapers) pressure, blood glucose, triglycerides, and HDL cholesterol. The authors note that the information collected on physical activity and dietary intake was not used due to inaccuracies. Seidel et al. (2008) • • • Lack of accuracy in self-reporting of physical activity and food consumption. Study was underpowered to detect certain differences. Lack of Randomized Controlled Trial design. IMPLEMENTATION (FIDELITY, MODIFICATIONS, SUSTAINABILITY) See IMPLEMENTATION SHEET COSTS Not available Toolkit – Page 32 ToC DIABETES Healthy Changes™ by NCOA PROGRAM OVERVIEW PRIMARY CONTACT Julie Kosteas, Senior Program Associate, Center for Healthy Aging c/o National Council on Aging [email protected] SECONDARY CONTACT Not applicable WEBSITE http://www.healthyagingprograms.org/ content.asp?sectionid=30&ElementID =11 PRINT MATERIALS A 26-session group-based educational program for adults with diabetes. The intervention is delivered by trained leaders, and emphasizes education, motivation, goal-setting, social support, and making connections to community resources. PROGRAM DESCRIPTION Duration: 26 sessions lasting approximately 90 minutes each Type: Group-based educational intervention Aim: To provide education on the topics of diabetes, nutrition and physical activity, and to provide social support. OUTCOMES Not applicable IMPLICATIONS This link has all of the information necessary to replicate Healthy Changes • Appropriate for use in community settings such as senior http://www.healthyagingprograms.org/res centers, community centers,congregate meal sites, and ources/MP_HealthyChanges.pdf churches. Cambios Saludables (the Spanish version) is also available online http://www.healthyagingprograms.com/co ntent.asp?sectionid=30&ElementID=239 Provided in electronic format are: - User Manual for group leaders (English); Background information (English); - User manual (Spanish) ACCESS ON WEBSITE Note: toolkit available at NCOA website http://www.healthyagingprograms.org/co ntent.asp?sectionid=68 ASSOCIATED CONDITIONS Not applicable LANGUAGES English and Spanish PROGRAM TYPE Implementation Toolkit – Page 33 ToC DIABETES Study/Intervention Methodology STUDY/INTERVENTION METHODS STUDY/INTERVENTION DESIGN Not applicable Not Applicable Comparison Groups: Not applicable Instruments/Measures: • STUDY/INTERVENTION LOCATION • Not applicable • REFERENCE NCOA. • • IMPLEMENTATION (FIDELITY, MODIFICATIONS, SUSTAINABILITY) Not available Demographic variables and self-reported measures of BMI, body weight and height. Behavioral endpoints including a general measure of eating patterns and physical activity. The items were taken from the 9-item Summary of Diabetes Self-Care Activities (SDSCA), as well as additional items from Kate Lorig's Stanford Patient Education Exercise Behavior questionnaire. Quality of Life was measured using the National Health Interview Survey Self-Rated Health single item asking respondents to rate their perceived general health. Psychosocial outcomes were measured using Kate Lorig's Stanford Patient Education Research Center Self Efficacy for Diabetes measure. Use of community resources/patient empowerment was measured using the Chronic Illness Resources Survey. LIMITATIONS Not applicable COSTS Not available Toolkit – Page 34 ToC DIABETES Look After Yourself (LAY) PROGRAM OVERVIEW PRIMARY CONTACT Professor Helen Cooper Department of Community and Child Health Faculty of Health and Social Care, University of Chester [email protected] SECONDARY CONTACT Not available An 8-session group-based intervention for adults with diabetes delivered by trained diabetes nurses. The program uses a structured empowerment-based approach. Prior to implementing this program please contact Professor Helen Cooper for permission (see information at left). PROGRAM DESCRIPTION Duration: Two-hour sessions once per week for eight weeks Type: A structured group-based educational program Aim: To promote diabetes self-management through education plus motivational components necessary for behavior change. OUTCOMES WEBSITE Not applicable PRINT MATERIALS Provided in electronic format is the "Teaching Pack" for group facilitators. ACCESS ON WEBSITE Not applicable This intervention improved self-monitoring activity, as well as psychological attitudes and attitudes toward treatment effectiveness. However the effect on blood glucose, diet, exercise, and BMI was not significant. • Self-monitoring significantly increased at 12 months (+25% ). • Psychological attitudes improved at 6 months (+2%) and at 12 months (+2%). • Attitudes toward treatment effectiveness improved at 6 months (+.3% ). IMPLICATIONS • • The intervention was inexpensive and highly adaptable to real-world settings. Demonstrates the importance of improving other outcomes, not just clinical markers such as HbA1c. ASSOCIATED CONDITIONS Not applicable LANGUAGES English PROGRAM TYPE Research Toolkit – Page 35 ToC DIABETES Study/Intervention Methodology STUDY/INTERVENTION METHODS STUDY/INTERVENTION DESIGN Randomized Controlled Trial STUDY/INTERVENTION LOCATION 3 hospital diabetes outpatient clinics in UK Sample size/characteristics: n=89 were randomized (n=53 to the educational group and n=59 to the usual care group). Demographics: Participants ranged in age from 35-73, with a mean age of 59. 56% were male. Inclusion criteria: Patients were 21-75 years old, with diagnosed type 2 diabetes for at least 1 year, and were connected to the healthcare system. Comparison Groups: The comparison group received usual care. Instruments/Measures: • • • REFERENCE Cooper et al. (2008) • • IMPLEMENTATION (FIDELITY, MODIFICATIONS, SUSTAINABILITY) Not available Clinical measures: HbA1c, BMI, and drug treatment. Diabetes integration questionnaire to assess attitudes regarding diabetes and its treatment. Personal models of diabetes questionnaire to assess beliefs about treatment effectiveness, seriousness and personal control. Summary of diabetes self-care activities questionnaire to assess exercise, diet and self-monitoring. Focus groups to assess the educational process and real-life effects of the intervention. LIMITATIONS Selection bias -- may have drawn patients who were more compliant and more willing to change behavior. COSTS Not available Toolkit – Page 36 ToC DIABETES Look AHEAD (Action for Health in Diabetes) PROGRAM OVERVIEW PRIMARY CONTACT Mark Espeland, PhD [email protected] SECONDARY CONTACT Not applicable WEBSITE https://www.lookaheadtrial.org/public/h ome.cfm A one-year intensive lifestyle intervention for obese adults with diabetes. The intervention is based on the Diabetes Prevention Program and involves both group and individual meetings to encourage weight loss through improved diet and exercise. The intervention is led by teams consisting of dieticians, psychologists and exercise specialists. PROGRAM DESCRIPTION Duration: One year. During Months 1-6, participants met in three group sessions and one individual session per month. During Months 7-12, participants met in group sessions every other week and had one individual session per month. Type: An intensive lifestyle intervention (a modification of the Diabetes Prevention Program, or DPP) involving group and individual meetings led by intervention teams consisting of dieticians, psychologists, and exercise specialists. Aim: Goal of 7% weight loss in first year through reduced caloric intake and physical activity of 175 minutes per week. OUTCOMES Obesity This intervention reduced weight, reduced waist circumference, increased physical activity and fitness, improved blood glucose, decreased blood pressure, and reduced the proportion with metabolic syndrome. • In the intervention group: • 55% met the goal of >7% weight loss and 38% met the goal of >10% weight loss. • Waist circumference decreased by 6 cm. • Fitness improved by 16%. • HbA1c decreased by .64% and fasting glucose decreased by 22 mg/dl. • The proportion of participants with metabolic syndrome decreased by 15%. • Blood pressure decreased -- mean systolic by -7 mmHg and diastolic by -3 mmHg. LANGUAGES IMPLICATIONS PRINT MATERIALS Print materials may be accessed through the website. ACCESS ON WEBSITE Intervention materials and handouts are available electronically at this website: https://www.lookaheadtrial.org/public/ds pMaterials.cfm ASSOCIATED CONDITIONS English PROGRAM TYPE Research • • Clinically important weight loss and improvement in CVD risk factors is possible in adults with type 2 diabetes using intensive lifestyle intervention. This is the first large clinical trial to compare an intensive lifestyle intervention to a support and education group. Toolkit – Page 37 ToC DIABETES Study/Intervention Methodology STUDY/INTERVENTION METHODS STUDY/INTERVENTION DESIGN Randomized Controlled Trial STUDY/INTERVENTION LOCATION 16 centers in the U.S. Sample size/characteristics: 5,145 individuals aged 45-74 were assigned to the Intensive Lifestyle Intervention (ILI) (n=2,570) or to the Diabetes Support and Education (DSE) (n=2,575) comparison group. Demographics: In the ILI group, 59.3% were women; 63.1% were white, 15.5% were African American, 5.1% were American Indian, 1.1% were Asian, 13.2% were Hispanic, and 1.9% were other. Mean age was 58.6 (s.d. 6.8). Inclusion criteria: Adults with type 2 diabetes between the ages of 45 and 74; BMI > 25 or BMI > 27 if taking insulin; HbA1c < 11%; blood pressure < 160 systolic, and < 100 diastolic mmHg; triglycerides <600 mg/dl; and adequate performance on physical activity assessment. Comparison Groups: REFERENCE Look AHEAD Research Group (2007) one year results; Look AHEAD Research Group (2003) study design. IMPLEMENTATION (FIDELITY, MODIFICATIONS, SUSTAINABILITY) Not available The intervention group was compared to a diabetes support and education condition. This condition received the same pre-randomization diabetes session as the intervention group, in addition to three additional group sessions throughout the year involving Instruments/Measures: • • • Weight, height, prescriptions, self-reported incidence of myocardial infarction, stroke, transient ischemic event, percutaneous transluminal coronary angioplasty, or coronary artery bypass graft. Fitness using a submaximal exercise test. HbA1c, fasting serum glucose, total serum cholesterol and triglycerides, and HDL and LDL cholesterol, and blood pressure. LIMITATIONS COSTS Not available Several additional years of data will be needed to determine whether weight loss is maintained and to determine its effect on CVD risk factors, and to determine whether these changes will result in decreased risk for cardiovascular events. Toolkit – Page 38 ToC DIABETES New Leaf. . . Choices for Healthy Living with Diabetes PROGRAM OVERVIEW PRIMARY CONTACT Tarisha Cockrell CDC Wisewoman Program [email protected] SECONDARY CONTACT A one-year intervention for African Americans with diabetes. The intervention involves a clinic-based individual component plus a peer educator component taught by “CDAs” or community diabetes advisors. The intervention emphasizes physical activity, diet and diabetes care. PROGRAM DESCRIPTION Duration: One year. Involves 2-3 hours of individual counseling, 4.5 hours of group counseling, and 2 hours of telephone contact. Type: A clinic-based individual component plus peer educator component (led by CDAs or community diabetes advisors) Aim: The intervention was tailored to African Americans. It emphasized 1) physical activity of moderate intensity 30 minutes a WEBSITE day, 2) a dietary component to decrease total and saturated fat intake and to improve control and distribution of carbohydrate http://www.centertrt.org/index.cfm?fa=wwinterventions.i intake, and 3) a diabetes care component addressing various ntervention&intervention=newleaf&pag aspects of diabetes self-care. e=intent Thomas C. Keyserling, MD, MPH [email protected] PRINT MATERIALS Print materials may be accessed through the website. Provided in electronic format are: - two documents providing an overview of the New Leaf program. ACCESS ON WEBSITE Program materials are available through the following website: http://www.centertrt.org/index.cfm?fa=wwinterventions.int ervention&intervention=newleaf&page=i ntent OUTCOMES This intervention improved physical activity and diabetes health knowledge, although there was no impact on blood lipids, weight, mental well-being, or blood glucose. • Physical activity, as measured by accelerometer, increased by 15%. • Diabetes health knowledge improved by 15%. IMPLICATIONS New Leaf is associated with modest enhancement in physical activity among overweight sedentary older African American women with type 2 diabetes. ASSOCIATED CONDITIONS Not applicable LANGUAGES English PROGRAM TYPE Research Toolkit – Page 39 ToC DIABETES Study/Intervention Methodology STUDY/INTERVENTION METHODS STUDY/INTERVENTION DESIGN Randomized Controlled Trial STUDY/INTERVENTION LOCATION Primary care practices in central North Carolina. Sample size/characteristics: n=200 were randomized to clinic+peer educator intervention (n=67), clinic only intervention (n=66), or to minimal intervention (n=67). Demographics: African American women; overall mean age was 58.5 years. Inclusion criteria: African American women ≥ 40 years of age with type 2 diabetes onset at ≥ 20 years of age with no history of ketoacidosis. Comparison Groups: Participants in the clinic+peer educator group were compared to a clinic only group and to a minimal intervention group. Instruments/Measures: • • REFERENCE • • • IMPLEMENTATION (FIDELITY, MODIFICATIONS, SUSTAINABILITY) Not available COSTS Not available Physical activity was measured using a Caltrac accelerometer. Dietary intake was measured using a series of three 24-hour recall telephone-administered calls using the Minnesota Nutrition Data System. Weight, glycosylated hemoglobin, and blood lipids. Diabetes Knowledge Scale. Diabetes health status instrument which included items from two validated scales -- Mental Well-Being and Social WellBeing. LIMITATIONS • • Authors do not believe results on dietary intake to be valid because of inaccuracies and underreporting of dietary intake observed. Caltrac may have underestimated physical activity, although this bias is consistent across groups. Toolkit – Page 40 ToC DIABETES Seniors Taking Charge of Diabetes! PROGRAM OVERVIEW PRIMARY CONTACT Mary Ann Johnson, PhD [email protected] SECONDARY CONTACT A group-based educational intervention for older adults with diabetes (8 sessions delivered over 4 months). The sessions focus on improving daily adherence to diabetes self-management behaviors, glucose control, and physical activity. The intervention incorporates daily meal planning and interactive games. PROGRAM DESCRIPTION http://livewellagewell.info/study/materi als.htm Duration: Eight sessions delivered over four months. Some also attended eight additional sessions on increasing intake of fruits and vegetables. All 16 sessions included physical activity. Type: A statewide community-based intervention based on the Health Belief Model and National Standards for Diabetes SelfManagement. Aim: This intervention focused on improving daily adherence to diabetes self-management behaviors, glucose control, and physical activities. The intervention incorporated daily meal planning and interactive games. PRINT MATERIALS OUTCOMES Not applicable WEBSITE Not applicable This intervention improved several behaviors related to diabetes self-management, and reduced blood glucose. The following improved by approximately 1 day per week: • Number of days in the past week followed a healthy eating plan • Followed an eating plan prescribed by a doctor • Ate five or more fruits and vegetables per day • Spaced carbohydrates evenly • Checked feet, tested blood sugar as recommended by a doctor, and inspected insides of shoes. • HbA1c decreased for the whole sample by .25% and for those with baseline HbA1c levels of > 8.0% the mean decrease of 1.15% was clinically significant. LANGUAGES IMPLICATIONS Print materials may be accessed through the website. Provided in electronic format are: - User manual for group leaders - Bingo games - Bingo pieces ACCESS ON WEBSITE Intervention materials are available through the following website: http://livewellagewell.info/study/materials .htm ASSOCIATED CONDITIONS English PROGRAM TYPE A low cost, low-intensity intervention can be implemented in senior centers to improve self-management behaviors, and HbA1c. Implementation Toolkit – Page 41 ToC DIABETES Study/Intervention Methodology STUDY/INTERVENTION METHODS STUDY/INTERVENTION DESIGN One group pre-post study design STUDY/INTERVENTION LOCATION 39 senior centers in Georgia Sample size/characteristics: 851 seniors enrolled in the study, and 351 of these had diabetes. 261 completed the pretest and HbA1c, and 144 completed the pretest, HbA1c and post-test. Demographics: The mean age was 74, 84% were female, 42% were white, and 52% were black. Inclusion criteria: Adults attending senior centers, mainly for congregate meals, who received clearance from a physician to participate. Homebound elders were excluded, as were those who were unable to understand informed consent, answer pre- and post-test questions, or participate in the intervention. Comparison Groups: This study used a convenience sample and compared people who received the pre-test only to those who completed the pre-test, intervention and post-test. Instruments/Measures: REFERENCE Pre-and post-test questionnaires/measures: • Diet and health practices related to diabetes were assessed with 12 questions from the Summary of Diabetes Self-Care Activities. • HbA1c. IMPLEMENTATION LIMITATIONS Speer et al. (2007) (FIDELITY, MODIFICATIONS, SUSTAINABILITY) See IMPLEMENTATION SHEET • • Additional research is needed to determine the factors critical to the success of the intervention and to evaluate whether the same results would be obtained in other sub-populations. Contamination: many participants also took other health education classes. COSTS See COST SHEET Toolkit – Page 42 ToC DIABETES Starr County Border Health Initiative PROGRAM OVERVIEW PRIMARY CONTACT Sharon A. Brown, RN, PhD, FAAN [email protected] SECONDARY CONTACT Not applicable WEBSITE Not available A group-based intervention for adults with diabetes, tailored to Mexican-American culture (52 contact hours over 12 months). The intervention emphasizes nutrition, self-monitoring of blood glucose, exercise, and other self-care topics. PROGRAM DESCRIPTION Duration: 52 contact hours over 12 months Type: Education and support group intervention tailored to Mexican culture Aim: The intervention involved 3 months of weekly instructional sessions on nutrition, self-monitoring of blood glucose, exercise, and other self-care topics and 6 months of biweekly support group sessions to promote behavior changes. Participants were accompanied by family member or friend. OUTCOMES • PRINT MATERIALS Provided in electronic format is the Intervention Manual for group leaders. Set of seven DVDs to accompany the curriculum is available for $35, in English or Spanish, by contacting Dr. Sharon Brown. ACCESS ON WEBSITE Not applicable • • • This intervention lowered blood glucose and improved diabetes knowledge. At 6 months, the mean HbA1c decreased by 1.01%. Fasting blood glucose decreased from baseline to 6 months by 28 mg/dl. Diabetes knowledge improved by 14% from baseline to 3 months. IMPLICATIONS Demonstrates that behavioral intervention that is tailored to adults with low resources, low literacy, and Mexican culture can be effective. ASSOCIATED CONDITIONS Not applicable LANGUAGES English or Spanish PROGRAM TYPE Research Toolkit – Page 43 ToC DIABETES Study/Intervention Methodology STUDY/INTERVENTION METHODS STUDY/INTERVENTION DESIGN Randomized controlled trial STUDY/INTERVENTION LOCATION Starr County Texas (on border with Mexico) REFERENCE Brown et al. (2002) Sample size/characteristics: Mexican Americans n=126 participated in the treatment group and n=126 participated in the wait-list control group. Demographics: Mexican American. In the intervention group, 60% were female. The mean age was 54.7 (s.d. 8.2) with a range of 35-71. Inclusion criteria: Participants had a diagnosis of type 2 diabetes, were between 35 and 70 years of age, and had type 2 diabetes diagnosis after 35 years of age. Comparison Groups: Participants were compared to a wait-list control group. Instruments/Measures: • • • Diabetes-related knowledge and health beliefs. Language-based acculturation determined at baseline. Weight, height, BMI, 10-hour fasting blood glucose, HbA1c, cholesterol, and prebreakfast and supper blood glucose 3 times per week using a home monitoring device. LIMITATIONS None identified IMPLEMENTATION (FIDELITY, MODIFICATIONS, SUSTAINABILITY) See IMPLEMENTATION SHEET COSTS See COST SHEET Toolkit – Page 44 ToC COMPARISON CHART OF EVIDENCE-BASED FALLS PROGRAMS Program Name Program Elements Group/ Individual Time (meetings, duration) Staff Requirements Space Requirements Equipment Requirements A Matter of Balance/Volunteer Lay Leader Model Community-based structured group intervention which aims to reduce fear of falling and associated restrictions in activity levels among older adults Group Meets twice weekly for 2 hours per session for 4 weeks • Master Trainers attend a training and teach coaches (volunteers or paid staff), who then teach the classes • No educational requirements are necessary Space for chairs set up in a circle for 8-12 participants • Chairs • DVD player • 2 DVD's (provided by the program) EnhanceFitness Community-based group exercise program that emphasizes moderate intensity aerobic conditioning, strength training, flexibility, and balance exercises Group Meets three times weekly for 1 hour per session for 6 months Instructors are required to: Indoor space for participants to extend arms • • • • • • • Be certified in American Council on Exercise (ACE) or American College of Sports Medicine (ACSM), a nationally-recognized fitness program, or have a related college degree (exercise science, physiology, or PT) • Obtain current first aid and CPR certification • Have experience teaching older adult group exercise classes • Have 2 months of experience teaching an EnhanceFitness class Fitness equipment Armless chairs CD player and CDs Stopwatch Cone Tape measure ToC Program Name Falls Management Exercise (FaME) NoFalls Program Elements Group/ Individual • Group exercise classes and home-based exercises that are individually-tailored and focused on ‘righting’ or ‘correcting’ the necessary skills to avoid a fall • Focuses on dynamic balance, strength, bone, endurance, flexibility, gait and functional skills, and backward-chaining and functional floor exercises. • Home exercises are aimed at reducing asymmetry in strength of lower limbs Group • Group-based exercise, home hazard management, and vision improvement aimed at improving flexibility, leg strength, and balance • Involves participant eye care referrals for those whose vision tests below predetermined criteria and who are not receiving corrective treatment Group Time (meetings, duration) Staff Requirements Group and home exercise sessions conducted twice weekly for 36 weeks. Each group session lasts one hour and home exercises are performed twice weekly for 20-40 minutes each Instructors are required to obtain: • Level 4 National Vocational Qualifications (NVQ)-level training • Post-Qualifying Endorsed training with the Chartered Society of Physiotherapists Meets once weekly for 1 hour per session for 15 weeks Instructors must be trained exercise professionals Space Requirements Equipment Requirements Space for 20 participants • Chairs for balance exercises • Mats for floorwork • Therabands • Ankle/free weights • Steps • Space for group exercise sessions • Home modifications are conducted in seniors' homes • Chairs • Vision test chart Several educational requirements exist for the various staff members in this program, including Postural Stability Instructors, exercise instructors, leisure managers, physiotherapists, OTs, therapy/rehab/support works, and health managers ToC Program Name Program Elements Group/ Individual Time (meetings, duration) Staff Requirements Space Requirements Equipment Requirements Step by Step • Falls awareness campaign, individual risk assessments, and suggestions for individuals to report concerns to primary care physicians. • Aims to raise awareness of evidence-based fall prevention programming in senior centers by enhancing knowledge and behaviors of staff and members, and by enhancing relationships between senior centers and relevant local clinicians Group and individual components 7-week period at a predetermined community venue, followed by a follow-up home visit within 6 weeks of the final program session Instructors must be trained in program delivery Space for group and individual sessions Chairs Stepping On • Multifaceted communitybased program using a small-group learning environment • Aims to improve fall selfefficacy, encourage behavioral change, and reduce falls • Focuses on improving lowerlimb balance and strength, promoting home and environmental and behavioral safety, encouraging regular visual screening and correcting visial impairments, and encouraging medication review Group Meets once weekly for 1 hour per session for 7 weeks, with a follow-up occupational therapy home visit Community Class Leaders are required to: • receive 3-year certification after being trained in the program • conduct at least one Stepping On class yearly • provide evidence of providing classes on an ongoing basis in order to be re-certified after 3 years Master Trainers must be healthcare professionals (RN, NP, PA, OT, PT) with knowledge of falls prevention Space for 12 participants to perform strengthening exercises • Display table • Ankle weights ToC Program Name Program Elements Group/ Individual Time (meetings, duration) Staff Requirements Space Requirements Equipment Requirements Strategies and Actions for Independent Living (SAIL) • Nurse-designed multifactorial falls prevention program delivered by community health workers to older adult clients receiving community home support services • Uses a checklist and action plan to reduce falls and fallrelated injuries through education, routine exercise, environmental modification, and physical and occupational therapy Group 6-month program • Trainers need to undergo program training • Trainers must be qualified health professionals who have worked in home support services for older adults (i.e., PT, OT, RN, MSW) • Most of the program is delivered in homes of older adults • Also requires training space for 20 facilitators, home health professionals, and community health workers • Fall surveillance and risk screening tools • Access to Excel spreadsheet • Laptop projector for trainings Tai Chi: Moving for Better Balance Community-based fall prevention program focusing on the use of Tai Chi to prevent falls Group Meets once weekly for 1 hour per session for 12 weeks • Instructors are required to attend a 1-2 day training by Oregon Research Institute trainers to obtain certification • No educational requirements Space for 15 participants • Chairs • DVD player (optional) • Attendance sheet ToC EXISTING FALLS HEALTH PROMOTION PROJECT AT NYC DFTA DFTA's Health Promotion Services (HPS) Unit trains senior volunteers to lead health activities at their senior centers and other sites. Each site has the responsibility of selecting appropriate volunteers and then the Health Promotion staff conducts the training on- site. This program has its own curriculum with a set number of training topics. All necessary equipment and forms are provided by DFTA. Once in place, staff monitors the activity on a regular basis to ensure that all program guidelines are adhered to. DFTA Program Name Stay Well Exercise Classes Program Elements • Geared for all seniors, ranging from the fit to those with disabilities • Led by senior volunteers. • Includes aerobic exercises as well as routines designed to enhance balance, build muscle strength (with the use of stretch bands) and aid in the performance of everyday activities • Classes end with stress reduction exercises to help seniors ease the tensions of everyday living Group/ Individual Group Time Staff (meetings, duration) (paid, volunteer) 1 hour per week Center /site identifies suitable candidates. Health Promotion Staff (HPS) implements training on site. Once training is completed, the HPS monitors senior volunteers and classes on an on-going basis Space Requirement Room large enough for all participants to complete all exercise movements Equipment Training materials, certificates, Tee shirts, stretch bands, balls, volunteers buttons, sign-in sheets and envelopes provided by HPS ToC FALLS A Matter of Balance/Volunteer Lay Leader Model PROGRAM OVERVIEW PRIMARY CONTACT Patti League, Wellness Specialist [email protected] SECONDARY CONTACT Not applicable WEBSITE A four-week (twice weekly sessions) community-based structured group cognitive behavioral intervention to reduce fear of falling and promote activity among older adults. PROGRAM DESCRIPTION Duration: 4 weeks Type: Community-based structured group intervention Aim: Eight 2-hour sessions scheduled twice a week aimed at reducing fear of falling and associated restrictions in activity levels among older adults OUTCOMES www.mainehealth.org/pfha This program produced the following changes: www.mainehealth.org/mh_body.cfm?id • Improved levels of intended activity by 5% =432 • Improved mobility control by 7% www.bu.edu/hdr/products/balance/ma • Improved falls efficacy by 6% nual.html • Improved perceived falls management (7% at 6 wks, 3% at 6 mths, and 12% at 12 mths. However, the program did not affect the number of fallers, or the number of falls, at any study period (6 wks, 6 mths, or 12 mths). PRINT MATERIALS Informational video, packet, Master Trainer brochure, participant survey, IMPLICATIONS replication report, and sample exercises Short-term changes can be achieved in maladaptive attitudes and are available in print. beliefs about falling and in activity levels and functioning. ACCESS ON WEBSITE Materials are available on program website. ASSOCIATED CONDITIONS Not applicable LANGUAGES English PROGRAM TYPE Implementation Toolkit – Page 45 ToC FALLS Study/Intervention Methodology STUDY/INTERVENTION METHODS STUDY/INTERVENTION DESIGN Randomized controlled trial Sample size/characteristics: 434 older adults Demographics: Aged 60+; 89.6% were female; 90.8% were White. Inclusion criteria: Living in 40 senior housing sites in the Boston metropolitan area; reported fear of falling and associated activity restriction; absence of any major physical or health condition that would preclude participation in the intervention. Comparison Groups: STUDY/INTERVENTION LOCATION 40 senior housing sites in Boston, MA Intervention group vs. social contact control Instruments/Measures: • • • REFERENCE Tennstedt et al. (1998) LIMITATIONS • IMPLEMENTATION (FIDELITY, MODIFICATIONS, SUSTAINABILITY) See IMPLEMENTATION SHEET The Falls Efficacy Scale was used to measure fear of falling. The abbreviated Sickness Impact Profile (SIP) assessed changes in participants' behavior due to health problems. The Intended Activity scale, developed for this study, asked subjects to rate how sure they are that they will perform various activities in the coming week. • Used self-report to collect data on numbers of falls for intervals ranging from 6 weeks to 12 months, and therefore, the number of falls in this study might have been underreported. The one-session attention control condition did not make it possible to control entirely for the effect of social contact on attitudinal and behavioral changes in the intervention group. In other words, it is possible that the supportive atmosphere and interaction of the group intervention contributed to the observed changes in fears about falling. COSTS See COST SHEET Toolkit – Page 46 ToC FALLS EnhanceFitness PROGRAM OVERVIEW PRIMARY CONTACT Brenda Barkey, National Program Coordinator [email protected] SECONDARY CONTACT Susan Snyder, Vice President [email protected] WEBSITE www.projectenhance.org/admin_enha ncefitness.html PRINT MATERIALS Training materials are available to licensed affiliates. ACCESS ON WEBSITE Implementation steps presentation is available on the program website. A group exercise program (three times per week for 60 minutes) for older adults. Emphasizes moderate intensity aerobic conditioning, strength training, flexibility and balance exercises. PROGRAM DESCRIPTION Duration: 6 months Type: Community-based group exercise program Aim: Supervised classes that meet three times per week for 1 hour; classes emphasize moderate intensity aerobic conditioning, strength training, flexibility, and balance exercises. OUTCOMES This program improved fitness test performance for all participants, irrespective of their initial test scores. It also improved self-rated health for all participants. • Improved strength as measured by two functional tests: • Increased scores on chair stands test by 43% at 4 mths, 48% at 8 months. • Increased scores on arm curl test by 11% at 4 mths, 6% at 8 mths • Improved flexibility by 9% at 4 mths. • Improved functional mobility (13% at 4 and 8 mths) • Improved self-rated health by 5% at 8 mths. IMPLICATIONS Older adults can maintain and/or improve physical function through participation in EnhanceFitness ASSOCIATED CONDITIONS Not applicable LANGUAGES English PROGRAM TYPE Implementation Toolkit – Page 47 ToC FALLS Study/Intervention Methodology STUDY/INTERVENTION METHODS STUDY/INTERVENTION DESIGN One group pre-post study design STUDY/INTERVENTION LOCATION WA, TX, ME, MI, CA, Washington, D.C., GA, NY, and SC Sample size/characteristics: 2,889 older adults Demographics: • Mean age of respondents was 75.5 years. • 80.5% were female. • The sample included 1,844 Whites, 219 Blacks, 209 Asians, 117 Hispanics, and 418 Others. 82 participants elected not to report their ethnic group affiliation. Comparison Groups: Initial performance was compared to age- and gender-based norms to classify participants as within or at or above normal limits (WNL and BNL) Instruments/Measures: • REFERENCE Belza et al. (2006) • IMPLEMENTATION (FIDELITY, MODIFICATIONS, SUSTAINABILITY) See IMPLEMENTATION SHEET COSTS The Functional Fitness Test was used as a performance measurement which measures strength (arm curl, 30-second chair stand), flexibility (chair sit-and-reach, back scratch), endurance (six-minute walk, two-minute step test), and functional mobility (eight foot up-and-go). The Short Form-12 (SF-12) Health Survey summary scores for the physical component summary (PCS-12) and mental component summary (MCS-12) were used as measures of perceived health status. LIMITATIONS • • See COST SHEET • • • Results are susceptible to biases associated with observational studies: bias related to loss to follow-up data (testing nonparticipation) and selection bias (recruitment was not population-based). Uncertainty as to the generalizability of the findings to those older adults who are less functional, as the current study involved primarily higher functioning older adults living in the community. Blind assessments were not conducted, and as such there might be concern about internal validity. The use of an instructor to administer the performance tests may have a biasing effect. The full benefits of the program were not measured as EF has an aerobic component, yet an aerobic measure was not included. Toolkit – Page 48 ToC FALLS Falls Management Exercise (FaME) PROGRAM OVERVIEW PRIMARY CONTACT Dawn Skelton, Reader in Aging and Health, Glasgow Caledonian University & Coordinator of ProFaNE (Prevention of Falls Network Europe) [email protected] SECONDARY CONTACT Not applicable WEBSITE www.laterlifetraining.co.uk A program for community-dwelling older adults that emphasizes balance, strength, endurance, flexibility, and other skills to avoid a fall for use in a group setting, as well individualized home exercises. Tailored to women. PROGRAM DESCRIPTION Duration: 36 weeks Type: Individualized and tailored group and home exercise intervention. Aim: Group exercise classes that are balance-specific, individuallytailored and targeted for training on dynamic balance, strength, bone, endurance, flexibility, gait and functional skills, and aimed at ‘righting’ or ‘correcting’ skills to avoid a fall, backward-chaining and functional floor exercises. Home exercises, 20–40 minutes in duration and performed twice a week, that are aimed at reducing asymmetry in strength of the lower limbs. OUTCOMES PRINT MATERIALS Falls diary card is available in print. ACCESS ON WEBSITE Not applicable This program reduced number of falls by 31% and the number of fallers by 30%. IMPLICATIONS Tailored, balance-specific group and home exercise can prevent falls in people at high risk. ASSOCIATED CONDITIONS Not applicable LANGUAGES English PROGRAM TYPE Research Toolkit – Page 49 ToC FALLS Study/Intervention Methodology STUDY/INTERVENTION METHODS STUDY/INTERVENTION DESIGN Randomized controlled trial Sample size/characteristics: 81 independent-living, community-dwelling women Demographics: Age 65+ and mean age was 72.8. Inclusion criteria: History of three or more falls in the previous year; had known medical reasons for falls. Comparison Groups: Intervention vs. control groups. STUDY/INTERVENTION LOCATION Manchester, United Kingdom Instruments/Measures: Subjects were asked to record falls in daily falls diaries that were returned to investigators for examination every two weeks. LIMITATIONS Not applicable REFERENCE Skelton (2005) IMPLEMENTATION (FIDELITY, MODIFICATIONS, SUSTAINABILITY) See IMPLEMENTATION SHEET COSTS Not available Toolkit – Page 50 ToC FALLS NoFalls PROGRAM OVERVIEW PRIMARY CONTACT Lesley Day, Principal Investigator [email protected] SECONDARY CONTACT Not applicable WEBSITE www.monash.edu.au/muarc/projects/n ofalls PRINT MATERIALS Program manual and falls diary are available in print. ACCESS ON WEBSITE Program materials may be purchased from the program website. Intervention to reduce risk of falling among community-dwelling older adults. Involves group-based exercise (weekly class for 1hour for 15 weeks), home hazard management, and vision correction for those with uncorrected visual impairment. PROGRAM DESCRIPTION Duration: 15 weeks Type: Group-based exercise, home hazard management, and vision improvement Aim: Group-based exercise intervention involves a weekly exercise class of one hour for 15 weeks, supplemented by daily home exercises that are designed by a physiotherapist to improve flexibility, leg strength, and balance. Home hazards are removed or modified either by the participants themselves or via the City of Whitehorse's home maintenance program. Participants are referred to their regular eye care provider, general practitioner, or local optometrist, to whom the vision assessment results are given If their vision tests below predetermined criteria and if he or she is not already receiving treatment for the problem identified. OUTCOMES • • ASSOCIATED CONDITIONS Not applicable LANGUAGES English PROGRAM TYPE Implementation Participants who received the combined intervention (exercise, home hazard management, vision improvement) saw a 14% reduction in falls Participants who received the exercise program improved their balance. IMPLICATIONS • • Group-based exercise was the most potent single intervention tested, and the reduction in falls among this group seems to have been associated with improved balance. Falls can be further reduced by the addition of home hazard management or reduced vision management, or both of these. Toolkit – Page 51 ToC FALLS Study/Intervention Methodology STUDY/INTERVENTION METHODS STUDY/INTERVENTION DESIGN Randomized controlled trial Sample size/characteristics: 1,090 Australian-born independent-living older adults Demographics: Adults aged 70-84; 59.8% were women. Inclusion criteria: Living at home. Comparison Groups: STUDY/INTERVENTION LOCATION Whitehorse, an urban community in Melbourne, Australia Eight groups were compared -- exercise, home hazard management, vision improvement, exercise + home hazard management, exercise + vision, vision + home hazard management, all three interventions, and no intervention. Instruments/Measures: Participants reported falls using a monthly postcard calendar system to record daily falls outcome. LIMITATIONS REFERENCE Day et al. (2002) • • Participants were not blinded to group assignment, so the possibility of differences in self reporting bias exists. Participants differed somewhat from the general older population living at home, so the findings lacked generalizability to the general population. IMPLEMENTATION (FIDELITY, MODIFICATIONS, SUSTAINABILITY) Not available COSTS Not available Toolkit – Page 52 ToC FALLS Step by Step PROGRAM OVERVIEW PRIMARY CONTACT Dorothy Baker, Principal Investigator [email protected] SECONDARY CONTACT Not applicable WEBSITE www.fallprevention.org A 7-week intervention at senior centers, complemented by a home risk assessment to reduce risk of falls. Involves group classes, social marketing, screening, and provision of instructions for risk reduction. PROGRAM DESCRIPTION Duration: 7 weeks Type: Consciousness-raising educational pieces and individual assessments on personal risk factors Aim: Includes posters, print media, closed-circuit television, group classes, and screenings at health fairs, followed by individual assessments on personal risk factors, instructions on risk reduction, and suggestions for reporting concerns to primary care physicians. Aims to embed evidence-based fall prevention programming in senior centers by enhancing knowledge and behaviors of staff and members, and by enhancing relationships between senior centers and relevant local clinicians. OUTCOMES PRINT MATERIALS This program increased the proportion of older adults at senior centers scheduling individual fall risk assessments by 4% within the first 18 months of its operation. ACCESS ON WEBSITE IMPLICATIONS Training manual must be purchased from website. Training manual must be purchased from website. ASSOCIATED CONDITIONS Not applicable • • The challenges of integrating evidence-based fall-prevention programming into existing senior center services can be negotiated by collaboration among senior center administrators, health providers, the center membership, and researchers. Senior centers may be important venues to reach older adults with fall prevention programming. LANGUAGES English PROGRAM TYPE Implementation Toolkit – Page 53 ToC FALLS Study/Intervention Methodology STUDY/INTERVENTION METHODS STUDY/INTERVENTION DESIGN One group pre-post study design STUDY/INTERVENTION LOCATION Nine senior centers in New Haven, CT Sample size/characteristics: Intervention took place within nine senior centers serving an estimated 11,700 older adults (20-325 a day). Inclusion criteria: Sought senior centers with active administrators and diverse membership to participate in the project. All centers were located in towns with a relatively high older adults population. Demographics: Six of the centers served predominantly White suburban communities, two served urban Hispanic communities, and one served an urban Black community. Comparison Groups: Not applicable Instruments/Measures: A tabulation of participants' monthly reports were used to measure individual scheduling of fall risk assessment. REFERENCE Baker, et al. (2007) *Program was adapted by Tinetti et al. (2008) LIMITATIONS Not applicable IMPLEMENTATION (FIDELITY, MODIFICATIONS, SUSTAINABILITY) Not available COSTS Not available Toolkit – Page 54 ToC FALLS Stepping On PROGRAM OVERVIEW PRIMARY CONTACT Jill Ballard or Jana Mahoney at [email protected] or [email protected] 61-2-9351-9372 SECONDARY CONTACT Lindy Clemson, Principal Investigator [email protected] 61-2-9351-9372 WEBSITE Not available A 7-week program with 2-hour educational and exercise sessions conducted in small groups on a weekly basis, complemented by a home risk assessment to reduce risk of falling. Involves exercise and encourages visual screening and medication review. PROGRAM DESCRIPTION Duration: 7 weeks Type: Multifaceted community-based program using a small-group learning environment Aim: Program aims to improve fall self-efficacy, encourage behavioral change, and reduce falls. Key aspects of the program are improving lower-limb balance and strength, improving home and community environmental and behavioral safety, encouraging regular visual screening, making adaptations to low vision, and encouraging medication review. OUTCOMES • • PRINT MATERIALS Training manual is available in print. ACCESS ON WEBSITE Not applicable This program reduced falls by 31% (for males in particular) and improved falls efficacy by 7%. It also increased protective behavioral practices among participants. IMPLICATIONS Stepping On offers a successful fall-prevention option using cognitive-behavioral learning in a small group environment. ASSOCIATED CONDITIONS Not applicable LANGUAGES English PROGRAM TYPE Implementation Toolkit – Page 55 ToC FALLS Study/Intervention Methodology STUDY/INTERVENTION METHODS STUDY/INTERVENTION DESIGN Randomized controlled trial Sample size/characteristics: 310 community residents Demographics: Aged 70+, 74% women in both intervention and control groups Inclusion criteria: Men and women aged 70+ and older who had had a fall in the previous year or were concerned about falling. Comparison Groups: STUDY/INTERVENTION LOCATION Sydney, Australia Intervention group vs. control group that received up to two social visits from an occupational therapy student Instruments/Measures: • • REFERENCE Clemson et al. (2004) *Stepping On is currently being adapted by the University of Wisconsin. IMPLEMENTATION (FIDELITY, MODIFICATIONS, SUSTAINABILITY) See IMPLEMENTATION SHEET • • • • • COSTS See COST SHEET Functional measure of mobility and balance were assessed by the Get-up and Go Test Balance with eyes open and closed was measured by the Rhomberg test Perception of health across mental and physical health domain was measured by the Short Form (SF-36) Health Survey Confidence in avoiding falls when performing basic activities of daily living was assessed by the Modified Falls-Efficacy Scale (MFES) Efficacy beliefs over a more a wider range of functional tasks were assessed by Mobility Efficacy Scale (MES) Identification of which aspects of daily lives are troubling were measured by the Physical Activity Scale for the Elderly (PASE) and the Worry scale Falls Behavioral (FaB) Scale for older people was developed specifically for this study to evaluate behavioral factors that could potentially protect against falling. LIMITATIONS The study was not designed to detect an effect in subgroups, and therefore such results should be interpreted with caution. Toolkit – Page 56 ToC FALLS Strategies and Actions for Independent Living (SAIL) PROGRAM OVERVIEW PRIMARY CONTACT Vicky Scott, Senior Advisor, Falls & Injury Prevention [email protected] 604-587-7850 ext. 4846 SECONDARY CONTACT A 6-month intervention to reduce risk of falling among homebound adults. The group-based intervention is delivered by community health workers, and involves exercise, modification of the home environment, and action planning. PROGRAM DESCRIPTION Duration: 6 months Type: Nurse-designed multifactorial intervention for homebound older adults delivered by community health workers (CHWs) Aim: One-day training session for CHWs (falls overview, proven fall-prevention strategies, and use of the Falls Prevention Checklist and Action Plan), followed by six months of evidence-based interventions with home support clients using the Falls Prevention WEBSITE Checklist and Action Plan. Aims to reduce falls and fall-related www.injuryresearch.bc.ca/categorypag injuries among adult clients receiving community home support es.aspx?catid=1&subcatid=7 services. Sepia Sharma, Regional Coordinator, Fall & Injury Prevention [email protected] 604-587-7850 ext. 4846 OUTCOMES PRINT MATERIALS This program reduced falls by 43% (by 44% for frequent fallers) and fall-related fractures by 86%. Training materials are currently available IMPLICATIONS only for use in British Columbia and have not been adapted for use outside • Intervention is an effective and inexpensive falls prevention of the province. strategy for frail recipients of home support services. ACCESS ON WEBSITE Not applicable • Home care nurses can become facilitators and trainers in assisting CHWs to conduct first-level risk detection for falls, respond to falls assessment needs, and provide ongoing quality assurance and evaluation of such efforts. ASSOCIATED CONDITIONS Not applicable LANGUAGES English PROGRAM TYPE Implementation Toolkit – Page 57 ToC FALLS Study/Intervention Methodology STUDY/INTERVENTION METHODS STUDY/INTERVENTION DESIGN One group pre-post study design STUDY/INTERVENTION LOCATION British Columbia, Canada Sample size/characteristics: 51 community health workers, and 70 home support clients Demographics: community health workers: Aged 20 -62, 98% women, home support clients: Aged 47-100, 79% female Inclusion criteria: CHWs participation included having at least two eligible clients with whom the workers could apply their training. Home support clients needed to be ambulatory, receiving publicly funded home support services, and able to complete pre and posttests Comparison Groups: Not applicable Instruments/Measures: • REFERENCE • Scott (2006) • IMPLEMENTATION (FIDELITY, MODIFICATIONS, SUSTAINABILITY) See IMPLEMENTATION SHEET SAIL training for (CHWs) was evaluated using a questionnaire and knowledge test administered before and after the 7-hour session. Falls Prevention Checklist and Action Plan (C&A) were measured in two areas: frequency of reported fall risk and ranking of the risks according to whether actions were taken to reduce risk. Pretest and Posttest measures collected information on prior falls. LIMITATIONS Without randomization of participants and a large sample size, caution must be used in generalizing these findings to the broader population of CHWs and home support clients. COSTS Not available Toolkit – Page 58 ToC FALLS Tai Chi: Moving for Better Balance PROGRAM OVERVIEW PRIMARY CONTACT Fuzhong Li, Research Scientist [email protected] SECONDARY CONTACT Not applicable WEBSITE www.healthyaging.ori.org/taichidis/taic hidis.html PRINT MATERIALS Training booklet and implementation plan/steps are available in print. ACCESS ON WEBSITE Materials and informational videos are also available on program website. A 12-week community-based program (twice weekly) for older adults that involves tai chi exercise in a group setting for falls prevention. PROGRAM DESCRIPTION Duration: 12 weeks Type: Community-based fall prevention program developed for use in community based organizations such as senior centers. Aim: Twice-weekly 1-hour classes that includes warm-up exercises (5-10 min), practice of individual forms of the 8-form tai chi program (40-45 min), and cool-down exercises (5 min). Copies of the videotape or DVD and user's guidebook are distributed to all participants. OUTCOMES This program reduced falls by 29%, number of fallers by 28%, and recurrent falls by 55%. It also improved performance on several physical performance measures. Specifically, the program produced the following changes among participants: • Improved function reach scores by 6.4% • Improved up and go test scores by 3.1% • Improved chair stand test scores by 5% • Improved 50-foot speeded walk test scores by 5% IMPLICATIONS • ASSOCIATED CONDITIONS Not applicable LANGUAGES • Evidence-based tai chi programs, such as Tai Chi- Moving for Better Balance can be implemented in urban and rural community settings. Program indicated it has good reach, an excellent adoption rate, and good program fidelity and maintenance. English PROGRAM TYPE Implementation Toolkit – Page 59 ToC FALLS Study/Intervention Methodology STUDY/INTERVENTION METHODS STUDY/INTERVENTION DESIGN Randomized controlled trial Sample size/characteristics: 140 physically inactive, community-dwelling adults Demographics: Aged 70 to 92, 85.7% women, 95.7% White. Inclusion criteria: Aged 60+, physically mobile, and without severe mental deficits Comparison Groups: Intervention group vs. usual care STUDY/INTERVENTION LOCATION Portland, OR Instruments/Measures: • • REFERENCE • Li et al. (2005) The primary outcome measure of falls was assessed using fall counts, recorded by each participant in a daily ‘‘fall calendar.’’ Physical performance and quality-of-life were measured by functional reach test, up and go test, time to rise from a chair, the 50-foot speed walk, and the Short-form 12-item Physical and Mental Health Summary Scale (SF-12). Fear of falling was assessed by the Survey of Activities and Fear of Falling in the Elderly (SAFFE). LIMITATIONS • IMPLEMENTATION (FIDELITY, MODIFICATIONS, SUSTAINABILITY) See IMPLEMENTATION SHEET • Although the program results were promising, continued efforts are needed to address several translation, implementation, and evaluation issues, such as the implementation of the program in diverse community setting and the long-term effects of the intervention falls. Other needs include measuring program sustainability, at both the services provider level and by the instructors, and conducting cost-benefit, cost-utility, or cost-effectiveness analyses of the program. COSTS See COST SHEET Toolkit – Page 60 ToC COMPARISON CHART OF EVIDENCE-BASED HEART DISEASE PROGRAMS Program Name Program Elements Group/ Individual Time (meetings, duration) Staff Requirements Space Requirements Equipment Requirements Airdrie Community Hypertension Awareness & Managemt Program (A-CHAMP) • Community-based blood pressure awareness program that aims to improve awareness and management of hypertension • Consists of training sessions on hypertension and other modifiable cardiovascular risk factors; instructions on how to interpret blood pressure information; and screening sessions and hands-on training in blood pressure measurement using an automated BpTRU device Group Meets twice weekly for 2 hours per session for 4-6 months Instructors must be health professionals such as RNs, nurse educators, MDs, or pharmacists to deliver the program Indoor space for group sessions • Chairs • Automated BpTRU device to provide demonstrations • Computer and database to record changes in antihypertensive therapy between initial and final assessments Eat Better Move More • Integrated nutrition and exercise program that consists of mini-talks and group nutrition and physical activity sessions • Encourages participants to record their food choices and number of steps taken each day as a review of each week’s nutrition and physical activity mini-talks. Group Meets 12 times for 30-minute mini-talks and twice-weekly group nutrition and physical activity sessions • Facilitator or leader guides sessions and activities. While nutritionists or RDs are ideal facilitators, PTs and certified fitness professionals may also lead the program • Staff or volunteers help to collect Tips & Tasks sheets and encourage participants to set individual step goals • If Tips & Tasks data are used to show improvements, additional help may be needed to collect and analyze records at the start of each session Indoor space for minitalks, and group nutrition and physical activity sessions None ToC Program Name Program Elements Group/ Individual Time (meetings, duration) Staff Requirements Space Requirements Equipment Requirements Health for Your Heart (Salud Por Tu Corazón) • Community-based outreach program delivered by community health workers to aimed at reducing cardiovascular disease among Latinos. • Also includes home risk assessments, phone contacts, and provider referrals for health screenings Group 6-month program that includes 8 2hour group sessions for 2-3 months, followed by home risk assessments, phone contacts, and referrals to health care providers for health screenings • Instructors attend a 5-8 day training in Su Corazon Su Vida curriculum taught by experienced community health workers • Instructors need a minimum high-school education Space for 15-20 participants Equipment/materials to measure blood pressure, BMI, and waist circumference Prime Time Sister CirclesTM (PTSC) • Curriculum-based group health intervention tailored to African American women • Targets cardiovascular risk factors through discussions of spirituality, self-esteem, and self-prioritiziation Group Meets once weekly for 90 minutes per session for 10 weeks • Instructors are trained in program delivery. • No educational requirements are needed to become an instructor Indoor meeting room for 8-13 participants • Chairs for group discussions • Projector for presentations Project Joy • Church-based nutrition and physical activity program tailored to African American churgoing women • Consists of group education and discussion sessions, nutrition education modules (i.e., cooking demonstration), and physical exercise Group Meets once weekly for 90 minutes per session for 20 weeks Instructors must obtain CPR certification in order to administer the program Indoor meeting room and space for exercises • • • • Portable scale LCD projector Computer CD/MP3 player and music ToC COMPARISON CHART OF EXISTING HEART DISEASE HEALTH PROMOTION PROJECTS AT NYC DFTA DFTA's Health Promotion Services (HPS) Unit trains senior volunteers to lead health activities at their senior centers and other sites. Each site has the responsibility of selecting appropriate volunteers and then the Health Promotion staff conducts the training on- site. Each of these programs, with the exception of the Big Apple Senior Strollers, has its own curriculum with a set number of training topics. All necessary equipment and forms are provided by DFTA. Once in place, staff monitors the activity on a regular basis to ensure that all program guidelines are adhered to. DFTA Program Name Program Elements Group/ Individual Time Staff (meetings, duration) (paid, volunteer) Keep on Track Blood Pressure Monitoring Program • Senior volunteers are trained to measure the blood pressure of their peers. • Adhering to a training manual and protocol revised by DOH&MH, the volunteers offer basic counseling which helps participants understand the significance of their readings. • Participants with questions about their readings are advised to check with their doctor. Group 1.5 hours every two weeks Big Apple Senior Strollers Walking Clubs • Strollers count the number of steps they take during each walk using pedometers. • Clubs are presented with certificates listing total number of steps accumulated by all members every October. Group Once a week or more Center/site identifies suitable candidates. Health Promotion Staff (HPS) implements training on-site. Once training is completed, the HPS monitors volunteers/activity on an on-going basis. Center/site selects suitable volunteers Space Requirement Private space when available. Room for blood pressure measurers and clerical team. Walking Route decided by volunteers Equipment Training materials, certificates, tote bags, blood pressure machines, large cuffs, volunteer buttons, sign in sheets, envelopes, Participant and Tracking cards, , supplied by HPS Educational materials, volunteer buttons, pedometers, sign-in sheets, envelopes, provided by HPS ToC DFTA Program Name Know Your Numbers Program Elements • Senior volunteers are trained to help their peers understand the implications of their blood pressure readings, as well as the results of their glucose and cholesterol tests. • The training curriculum has been revised to make it more user-friendly for prospective volunteers. • Plans are to mail a flyer announcing the availability of this program in mid- January. Group/ Individual Group/ On-on-one encounters Time Staff (meetings, duration) (paid, volunteer) 5-15 minute presentations Center/site identifies suitable candidates. Health Promotion Staff (HPS) conducts training on site. Once training is completed, the HPS meets with volunteers on an on-going basis. Space Requirement Private room for group presentations Equipment Training materials, certificates, tote bags, volunteer buttons, educational materials, sign-in sheets, and envelopes, provided by HPS ToC HEART DISEASE Airdrie Community Hypertension Awareness & Managemt Program (A-CHAMP) PROGRAM OVERVIEW PRIMARY CONTACT Charlotte Jones, Principal Investigator [email protected] SECONDARY CONTACT Not appllicable WEBSITE www.libin.ucalgary.ca/documents/cha mp/Champ_Airdrie.pdf Community-based screening sessions and education for older adults provided in a group setting over 4-6 months. Two-hour training session designed to raise awareness and management of hypertension and other modifiable cardiovascular disease risk factors. PROGRAM DESCRIPTION Duration: 4-6 months Type: Community-based blood pressure (BP) program for older adults Aim: Aims to improve awareness and management of hypertension; includes two 2-hour training sessions on hypertension and other modifiable cardiovascular risk factors; instructions on how to interpret blood pressure information; and screening sessions and hands-on training in blood pressure measurement using an automated BpTRU device OUTCOMES • PRINT MATERIALS Program information and presentation are available. • • ACCESS ON WEBSITE Materials are available on the website. IMPLICATIONS • ASSOCIATED CONDITIONS Not applicable This program reduced BP by 11% and improved adherence to diet and exercise recommendations by 41%. It also produced a 20% increase in medication use among those with diabetes and a 15% among those without diabetes. 46% and 60% of participants with and without diabetes, respectively, reached BP targets by participating in the program. • A-CHAMP raised awareness, and identified and managed seniors with hypertension. This program was effective and feasible in improving awareness and control of hypertension. LANGUAGES English PROGRAM TYPE Research Toolkit – Page 61 ToC HEART DISEASE Study/Intervention Methodology STUDY/INTERVENTION METHODS STUDY/INTERVENTION DESIGN One group pre-post study design Sample size/characteristics: 406 residents of Airdrie Demographics: Aged 65+; 54% were female. Inclusion criteria: Individuals whose family physician and pharmacy were located in city of Airdrie. Comparison Groups: Not applicable Instruments/Measures: STUDY/INTERVENTION LOCATION • Airdrie, Alberta, Canada REFERENCE • Jones et al. (2007) IMPLEMENTATION (FIDELITY, MODIFICATIONS, SUSTAINABILITY) Not available The primary outcome was feasibility of the program, defined as a minimum of 30% of Airdrie seniors attending at least one of the sessions held between September and November 2005 and, for subjects identified with elevated BP at these sessions, a minimum of 30% assessed by a pharmacist and/or physician. Secondary outcomes included the change in systolic BP between the first session and the final follow-up session (held in March 2006), as well as pharmacy database-documented change in antihypertensive therapy between initial and final assessments. LIMITATIONS • • • Study design was uncontrolled, and inferences on causality need to be made with caution Very short-term (4-6 months) BP end points There were barriers to participant identification and subsequent management COSTS Not available Toolkit – Page 62 ToC HEART DISEASE Eat Better Move More PROGRAM OVERVIEW PRIMARY CONTACT Nancy Wellman, Principal Investigator [email protected] SECONDARY CONTACT Not applicable WEBSITE Not available A six-month group intervention for older adults that integrates nutrition and physical activity education. Also encourages walking through step-counting activities. PROGRAM DESCRIPTION Duration: 6 months Type: Integrated nutrition and exercise program Aim: Encourages older adults, to live longer, healthier lives by being physically active, eating nutritious diets, obtaining preventive screenings, and making healthful choices such as not smoking. Includes 12 weekly sessions incorporating mini-talks (up to 30 min each) and twice-weekly activities for group nutrition and physical activity sessions, as well as “Tips & Tasks” sheets, in which participants checked off food choices and recorded the number of steps taken each day to briefly review the week’s nutrition and physical activity mini-talks. OUTCOMES PRINT MATERIALS Guidebook is available in print. ACCESS ON WEBSITE Not applicable ASSOCIATED CONDITIONS Obesity LANGUAGES English PROGRAM TYPE Research This program improved diet and increased physical activity among participants. • 73% reported an advancement of at least one nutrition stage of change • 75% reported an advancement of at least one physical activity stage of change • 24% reported improved health status. • 31% increased their daily intake of fruit • 37% increased their daily intake of vegetables • 33% increased their daily intake of fiber • 35% increased number of daily steps taken • 45% increased number of blocks walked • 24% increased number of stairs climbed • 9% increased number of days walked • Program improved Timed Up and Go scores by 9.4% • Program satisfaction was 99%. IMPLICATIONS • • This easy-to-implement program improves diets and activity levels. Program has been tested in a variety of community sites nationwide that serve diverse older populations, including members of racial/ethnic minority groups. Toolkit – Page 63 ToC HEART DISEASE Study/Intervention Methodology STUDY/INTERVENTION METHODS STUDY/INTERVENTION DESIGN One group pre-post study design Sample size/characteristics: 999 older volunteer participants Demographics: Adults aged 60+; 82% women; 25% AA, 4% Latino, 6% Native American, and 7% Asian. Inclusion criteria: Able to walk with/without assistive devices; can complete a consent form. Comparison Groups: STUDY/INTERVENTION LOCATION PA, CA, OK, MI, IL, FL, MA, WA, WI, VA REFERENCE Wellman et al. (2007) IMPLEMENTATION (FIDELITY, MODIFICATIONS, SUSTAINABILITY) Not available COSTS Not available Not applicable Instruments/Measures: • • • • • Functional ability measured using Nutrition Screening Initiative Checklist (10-item screening tool with questions on illnesses/diseases, appetite, tooth loss/mouth pain, economic hardship, involuntary weight loss/gain, and functional limitations). Nutrition and health questionnaire was adapted from Performance Outcomes Measures Project Congregate Meals Survey. Physical activity (PA) questionnaire included Modified Baecke Questionnaire for Older Adults, which assesses household and leisure activities. Functional ability was quantified using the Timed Up and Go test, which has been shown to be correlated with risk of falling. Nutrition and PA questionnaires included a “stage-of-change” question; participants selected from 5 statements reflecting stages of change: precontemplation, contemplation, preparation, action, and maintenance. LIMITATIONS • • • • Completion rates differed significantly according to site All of the participants were self-selected volunteers There were no control groups in this demonstration project As a result of the extensive and time-consuming data collection process associated with the project, the implementation costs incurred at the 10 study sites are not representative of actual program costs. Toolkit – Page 64 ToC HEART DISEASE Health for Your Heart (Salud Por Tu Corazón) PROGRAM OVERVIEW PRIMARY CONTACT Hector Balcázar, Regional Dean, Professor, UT School of Public Health, El Paso Regional Campus [email protected] SECONDARY CONTACT Not appllicable WEBSITE Not available A 6-month community-based educational program consisting of 8 group sessions; delivered by promotores de salud (community health workers) to raise awareness of cardiovascular disease. Tailored to Hispanics. PROGRAM DESCRIPTION Duration: 6 months Type: Community-based outreach program Aim: Aimed at reducing the burden of morbidity and mortality associated with cardiovascular disease among Latinos. Includes a series of educational sessions from the NHLBI hearthealth curriculum called Your Heart, Your Life. Promotores de salud (community health workers) deliver 7 of 8 curriculum lessons in 2-hour sessions within a 2-3-month period, conduct risk assessments through home visits and phone contacts, and provide educational sessions and referrals to health care providers for health screenings. OUTCOMES PRINT MATERIALS Training materials are available. • • ACCESS ON WEBSITE Not applicable • This program increased heart-healthy behaviors by 18% and referrals for blood pressure and cholesterol screenings. Promotores referred 74% of participants to health care providers for blood pressure screening and 81% for blood cholesterol screening. 96% expressed a very high level of satisfaction with the program. IMPLICATIONS ASSOCIATED CONDITIONS • Not applicable LANGUAGES English, Spanish PROGRAM TYPE Implementation • • The community outreach model worked well in the seven pilot programs because of the successes of the promotores and the support of the community-based organizations. Successes of this program stemmed in part from the train-thetrainer approach. Promotoria, as implemented in this program, has the potential to be integrated with a medical model of patient care for primary, secondary, and tertiary prevention. Toolkit – Page 65 ToC HEART DISEASE Study/Intervention Methodology STUDY/INTERVENTION METHODS STUDY/INTERVENTION DESIGN One group pre-post study design (pilot study) Sample size/characteristics: 223 participating Latino families (320 individual family members) of various ages Demographics: Most promotores were women aged 20-67; the average age was 41. Comparison Groups: Not applicable STUDY/INTERVENTION LOCATION 7 sites in California, Illinois, New Mexico, Texas, and Rhode Island. Instruments/Measures: • • REFERENCE Balcazar et al. (2005) Changes in heart-healthy behaviors among family contact persons were assessed using a 35-item self-report survey with a 4-point scale for assessing family habits, which included items on the frequency with which families engaged in exercise and eating a low-sodium diet. To evaluate the extent to which the program effected change in awareness, knowledge, and behavior, data were collected using an evaluation tool called ¡Cuéntamelo! (Tell Me About It!). LIMITATIONS Not applicable IMPLEMENTATION (FIDELITY, MODIFICATIONS, SUSTAINABILITY) See IMPLEMENTATION SHEET COSTS See COST SHEET Toolkit – Page 66 ToC HEART DISEASE Prime Time Sister CirclesTM (PTSC) PROGRAM OVERVIEW PRIMARY CONTACT Marilyn Gaston & Gayle Porter, CoPrincipal Investigators [email protected] [email protected] SECONDARY CONTACT Not appllicable WEBSITE http://gastonandporter.org/sistercircles/sister-circles.html PRINT MATERIALS Program packet is available. ACCESS ON WEBSITE Training manual must be purchased from website. ASSOCIATED CONDITIONS Not applicable LANGUAGES English PROGRAM TYPE Implementation A 10-week curriculum-based, structured culture- and genderspecific group health intervention in which 8-13 women meet for 90 minutes/session with peers to improve physical activity and diet and reduce stress. Tailored to African American women. PROGRAM DESCRIPTION Duration: 10 weeks Type: Curriculum-based, structured culture- and gender-specific group health intervention. Aim: Assist mid-life African-American (AA) women to decrease the major risk factors of physical inactivity, poor nutrition, and stress which contribute to CVD by having 8-13 women meet for 90 minutes/session with mid-life AA women who have with group facilitation experience, to discuss spirituality, self-esteem, prioritizing themselves first, stress, nutrition and exercise, CVD, and diabetes. OUTCOMES This program improved diet, exercise, stress management, and selfefficacy. • Increased participation in aerobic exercise by 52% at 10 weeks, 30% at 6 months, and 69% at 12 months. • Increased consumption of nutritious foods by 20% from baseline to 10 weeks. • Increased the proportion reporting an overall change in diet to prevent disease - 63% of participants at 10 weeks, 98% at 6 months, and 100% at 12 months. • Increased the proportion using stress management strategies - 63% at 10 weeks and 66% at 12 months. • Increased screenings - 60% increased annual mammograms and 54% increased in blood pressure checks. • 83.7% felt that positive changes could be maintained over their lifetime. • Participants developed more positive attitudes about their ability to control their health outcomes since participating in the program - 87% reported this at 10 wks, 77% at 6 mths, and 84% at 12 mths. IMPLICATIONS This study demonstrates the effectiveness of PTSC in modifying health-related knowledge, attitudes and certain high-risk behaviors in mid-life African-American women. Toolkit – Page 67 ToC HEART DISEASE Study/Intervention Methodology STUDY/INTERVENTION METHODS STUDY/INTERVENTION DESIGN Nonrandomized trial with contemporary controls Sample size/characteristics: 134 African-American women Demographics: Women older than 35 were included and mean age was 54.4. Comparison Groups: Intervention vs. control groups STUDY/INTERVENTION LOCATION 11 sites in Illinois, Washington, DC, Florida, and Maryland. Sites included four churches, a state health education center, a mental health center, a community center, a hospital, a feminist bookstore, a predominantly African-American college and a social club. REFERENCE Gaston et al. (2007) Instruments/Measures: • • • • • IMPLEMENTATION (FIDELITY, MODIFICATIONS, SUSTAINABILITY) Not available COSTS Not available Perception of overall health was assessed using a single item Likert rating of participants' health in comparison to other women their age. A 13-item instrument, adapted from a 2002 AARP survey, was given to assess health and wellness (self-care) behavior such as checking blood pressure, eating healthily, managing stress, and discussing health improvements with others. A 19-item nutrition measure was used as a pre-/postmeasure of the women's daily or weekly nutritious foods and eating habits. The women were given a seven-item inventory to rate the level of importance they placed on engaging in selected health-related behaviors. Focus groups were held with the participants of two of the PTSC groups to obtain some in-depth qualitative data in selected areas of concern such as barriers to completing goals. LIMITATIONS • • • Generalizability of the study's findings may be limited because of the small sample sizes and the nonrandom nature of the women's recruitment and assignment to the intervention and comparison groups Given that the participants were mostly college-educated, middle-income women, these findings may not be generalization to less-educated, poor women Use of self-report data, which are always susceptible to social desirability bias. Toolkit – Page 68 ToC HEART DISEASE Project Joy PROGRAM OVERVIEW PRIMARY CONTACT Lisa Yanek, Project Director [email protected] SECONDARY CONTACT Not appllicable WEBSITE Not available A 20-week church-based nutrition (cooking) and physical activity (30 minute exercise classes) intervention held weekly in groups to reduce cardiovascular risk. Facilitated by health educators and church lay leaders. Tailored to African American women. PROGRAM DESCRIPTION Duration: 20 weeks Type: Church-based nutrition and physical activity (PA) program Aim: Reduce cardiovascular risk in urban communities where most AA women are regular churchgoers by having group sessions, led by female AA health educators, begin with a weigh-in and group discussion, followed by a 30- to 45-minute nutrition education module that included a taste test or cooking demonstration, and 30 minutes of moderate intensity aerobic activity. Lay leaders offer weekly sessions after the first 20 weeks are over. OUTCOMES PRINT MATERIALS Session presentation, handout, questionnaire, and program CD are available. ACCESS ON WEBSITE Not applicable ASSOCIATED CONDITIONS This intervention reduced weight by 1 lb, waist circumference by nearly 1 inch, blood pressure by about 2 mmHg, and improved diet among participants. Moreover, women who lost about 20 lbs had even larger, clinically meaningful changes in risk outcomes. • Reduced dietary energy intake by 117 kcal • Reduced dietary total fat intake by 8 g • Reduced sodium intake by 145 mg • Women in the intervention groups who lost an average 20 lbs a year were more likely to lose even more weight (nearly 20 lbs) one year post-intervention. IMPLICATIONS • Not applicable LANGUAGES English PROGRAM TYPE • Intervention participants achieved clinically important improvements in cardiovascular disease risk profiles one year after program initiation, which did not occur in the self-help group. Church-based interventions can significantly benefit the cardiovascular health of African American women. Implementation Toolkit – Page 69 ToC HEART DISEASE Study/Intervention Methodology STUDY/INTERVENTION METHODS STUDY/INTERVENTION DESIGN Randomized controlled trial STUDY/INTERVENTION LOCATION 16 churches in Baltimore, MD Sample size/characteristics: 529 AA women Demographics: Women aged 40+ were included and mean age was 53.1. Inclusion criteria: Not pregnant or planning in the coming year; had not had myocardial infarction or stroke in the past 6 mths; had not felt chest pain or angina requiring use of nitroglycerine in the past 6 mths; did not have cancer currently under treatment; not undergoing renal dialysis; able to obtain permission to participate in program from physicians. Comparison Groups: Standard behavioral group intervention, standard intervention supplemented with spiritual strategies, or self-help strategies (control group). Instruments/Measures: • REFERENCE Yanek et al. (2001) IMPLEMENTATION (FIDELITY, MODIFICATIONS, SUSTAINABILITY) See IMPLEMENTATION SHEET • • • • • • • COSTS • See COST SHEET • Weight measured using calibrated digital scale with participant wearing light indoor clothing and no shoes. Height measured with set square against a straight wall. BMI calculated as weight (kg) divided by height (m)2. Bioelectrical impedance used to assess % total body fat based on resistance and reactance measurements. Waist circumference measured using guidelines of the National Obesity Expert Panel Report. Blood pressure (BP) measured with mercury sphygmomanometer. Total cholesterol, HDL cholesterol, triglycerides, and glucose measured via blood samples. Block Food Questionnaire administered to assess dietary nutrient intake. Smoking status was self-reported and verified by measured exhaled carbon monoxide using a Vitalograph EC50 CO monitor. PA assessed using Yale PA Survey, from which energy expenditure was calculated. LIMITATIONS Not applicable Toolkit – Page 70 ToC COMPARISON CHART OF EVIDENCE-BASED OBESITY PROGRAMS Program Name Group/ Time Program Elements Individual (meetings, duration) Diabetes Education & Prevention with a Lifestyle Intervention Offered at the YMCA (DEPLOY) Group-based intensive lifestyle intervention which adapts the Diabetes Prevention Program (DPP) to YMCA's. Group Meets once a week for 1 hour for 16 weeks • The intervention was originally implemented by trained YMCA wellness instructors • Participants are also encouraged to meet twice weekly outside of class to exercise, at a community facility such as a YMCA Space for 8-12 participants to participate in group exercise • Exercise equipment (provided by YMCA) • Instruments to measure body weight, blood pressure, HbA1c levels, total cholesterol, and HDL-cholesterol • Chairs for group meetings Diabetes Prevention Program (DPP) • Curriculum-based intensive lifestyle intervention taught by case managers on a oneto-one basis • Aims to reduce weight by 7% and promote at least 150 minutes of weekly physical activity Individual Meets for 16 sessions for 24 weeks • This intervention is taught by trained case-managers. • No educational background is specified Space for one-on-one discussions. Equipment to measure Hba1c level *This program is a model evidence-based diabetes program upon which other programs have been adapted Staff Requirements Space Requirements Equipment Requirements ToC Program Name Group/ Time Program Elements Individual (meetings, duration) Staff Requirements Space Requirements Equipment Requirements Eat Better Move More • Integrated nutrition and exercise program that consists of mini-talks and group nutrition and physical activity sessions • Encourages participants to record their food choices and number of steps taken each day as a review of each week’s nutrition and physical activity mini-talks. Group Meets 12 times for 30minute mini-talks and twice-weekly group nutrition and physical activity sessions • Facilitator or leader guides sessions and activities. While nutritionists or RDs are ideal facilitators, PTs and certified fitness professionals may also lead the program • Staff or volunteers help to collect Tips & Tasks sheets and encourage participants to set individual step goals • If Tips & Tasks data are used to show improvements, additional help may be needed to collect and analyze records at the start of each session Indoor space for minitalks, and group nutrition and physical activity sessions None Group Lifestyle Balance (GLB) • Intervention addressing safe weight loss and physical activity • Shortens the 16-session Diabetes Prevention Program (DPP) to 12 sessions, and is delivered by two trained "preventionists" -- one dietician and one exercise specialist Group Meets for 12 sessions for 12 weeks • Originally implemented by one dietician and one exercise specialist, although any health professional may implement this program • Health care professionals must attend a 2-day training at the University of Pittsburgh Medical Center • Room with table and chairs • Private area for weighin's • Calorie/fattracking book • Pedometer • Measuring cups/spoons • Scale ToC COMPARISON CHART OF EXISTING OBESITY HEALTH PROMOTION PROJECTS AT NYC DFTA DFTA's Health Promotion Services (HPS) Unit trains senior volunteers to lead health activities at their senior centers and other sites. Each site has the responsibility of selecting appropriate volunteers and then the Health Promotion staff conducts the training on- site. Each of these programs, with the exception of the Big Apple Senior Strollers, has its own curriculum with a set number of training topics. All necessary equipment and forms are provided by DFTA. Once in place, staff monitors the activity on a regular basis to ensure that all program guidelines are adhered to. DFTA Program Name Program Elements Group/ Individual Time Staff (meetings, duration) (paid, volunteer) Keep on Track Blood Pressure Monitoring Program • Senior volunteers are trained to measure the blood pressure of their peers. • Adhering to a training manual and protocol revised by DOH&MH, the volunteers offer basic counseling which helps participants understand the significance of their readings. • Participants with questions about their readings are advised to check with their doctor. Group 1.5 hours every two weeks Big Apple Senior Strollers Walking Clubs • Strollers count the number of steps they take during each walk using pedometers. • Clubs are presented with certificates listing total number of steps accumulated by all members every October. Group Once a week or more Center/site identifies suitable candidates. Health Promotion Staff (HPS) implements training on-site. Once training is completed, the HPS monitors volunteers/activity on an on-going basis. Center/site selects suitable volunteers Space Requirement Private space when available. Room for blood pressure measurers and clerical team. Walking Route decided by volunteers Equipment Training materials, certificates, tote bags, blood pressure machines, large cuffs, volunteer buttons, sign in sheets, envelopes, Participant and Tracking cards, , supplied by HPS Educational materials, volunteer buttons, pedometers, sign-in sheets, envelopes, provided by HPS ToC DFTA Program Name Know Your Numbers Program Elements • Senior volunteers are trained to help their peers understand the implications of their blood pressure readings, as well as the results of their glucose and cholesterol tests. • The training curriculum has been revised to make it more user-friendly for prospective volunteers. • Plans are to mail a flyer announcing the availability of this program in mid- January. Group/ Individual Group/ On-on-one encounters Time Staff (meetings, duration) (paid, volunteer) 5-15 minute presentations Center/site identifies suitable candidates. Health Promotion Staff (HPS) conducts training on site. Once training is completed, the HPS meets with volunteers on an on-going basis. Space Requirement Private room for group presentations Equipment Training materials, certificates, tote bags, volunteer buttons, educational materials, sign-in sheets, and envelopes, provided by HPS ToC EVIDENCE-BASED OBESITY PROGRAMS You may consult the Program Summaries for the following evidence-based programs that would be appropriate for adults with obesity: Condition Program Name Diabetes Diabetes Education & Prevention with a Lifestyle Intervention Offered at the YMCA (DEPLOY) Heart Disease Eat Better Move More Diabetes Diabetes Prevention Program (DPP) Diabetes Group Lifestyle Balance (GLB) Toolkit – Page 71 Toolkit – Page 72 ToC INTRODUCTION TO THE IMPLEMENTATION GUIDE Outreach to program directors, principal investigators, and project staff associated with the evidence-based programs described in this toolkit was conducted in mid-March to obtain information regarding program implementation in community settings. Program staff were allotted five weeks to respond to a six-item survey covering topics related to program fidelity, replicability, and sustainability. Detailed cost information was requested (e.g., personnel cost breakdown including position, annual salary, percent time/FTE, program salary, and salary sub-total); supplies/expendable equipment cost breakdown (including items, unit costs, quantities, and supplies sub-total); and nonexpendable equipment cost breakdown (including items, unit costs, quantities, and non-expendable equipment sub-total) to understand the associated expenses to implement selected programs (see Appendices for a copy of the Evidence-Based Program Logistics Survey and Cost Sheet). The survey was e-mailed directly to the Project Director or other program staff of 34* programs. After 10 days, a reminder e-mail was sent to respondents who had yet to reply to our initial inquiry. The response rate was 52.9%. The following summaries report practical implementation information and related costs for the 18 programs who responded, with information derived from publicly available sources for 3 additional programs. *Please note that while 35 programs have been included in this toolkit, the Diabetes Priority Program was not contacted to complete the survey and cost sheet because this program serves as a model program upon which many of the other evidence-based diabetes programs have been based. Toolkit – Page 73 Toolkit – Page 74 Back ToC Staff Requirements Arthritis Foundation Exercise Program (AFEP) Certification Instructors are required to: • Undergo day-long AFEP training taught by Arthritis Foundation Master Trainer • Receive CPR and first aid training • Complete two AFEP programs and submit necessary paperwork to Arthritis Foundation Arthritis Education • Associate or baccalaureate degree in exercise or related health field or equivalent exercise training and certification preferred • Knowledge of arthritis disease processes, principles of arthritis exercise, etc. • Competence in demonstrating exercises Program Fidelity Quality Assurance Instructors are trained by Arthritis Foundation Master Trainers Space Maintenance Resources Room should: • Be large enough for easy movement and space for assistive devices (i.e., walkers, crutches, etc.) • Have adequate acoustics and lighting • Be free of clutter • Be carpeted or have mats for floor exercises Equipment Sturdy chairs that do not slide easily and are of different heights, some with arms Funding Implementation Notes Sustainability The source of this implementation information is Ellen Schneider of the UNC Institute on Aging. Toolkit – Page 75 Back ToC Arthritis Foundation Exercise Program (AFEP) Project Cost Information is not available Toolkit – Page 76 Arthritis Back ToC Staff Requirements Enabling Self-Management and Coping with Arthritic Knee Pain Through Exercise (ESCAPE-knee pain) Certification Program training involves program education using an instructor manual, as well as program observation Arthritis Education Instructors undergo program training, but do not need to have PT background Program Fidelity Quality Assurance • Instructors are provided with education and booklet, and observe course being run by Master Trainers • Instructors are observed when delivering the program Maintenance Resources Gym or hallway Space Funding Equipment • Exercise equipment (i.e., steps, rocker or wobble board, soccer ball, static bike) • Chair • Table • Mat UK charity body (Arthritis Research UK) Sustainability Review session is provided 4 months after the program ends to reinforce messages Implementation Notes Toolkit – Page 77 Back ToC Enabling Self-Management and Coping with Arthritic Knee Pain Through Exercise (ESCAPE-knee pain) Project Cost Information is not available Toolkit – Page 78 Arthritis Back ToC Staff Requirements Fit and Strong Arthritis Certification • National certification is required; 10 types are available nationwide • Instructors may be physical therapists (PTs), PT aides, or recreational aides • Instructors are required to attend an 8-hour training None required Education Program Fidelity Quality Assurance Master Trainer visits the class at week 3 or 4 and meets with instructor Space Maintenance Resources Large indoor space for arm stretching, fitness walking Funding • Federal grants • Future state Administration on Aging (AOA) initiatives Equipment • Fitness equipment that are provided at instructor training session (i.e., adjustable ankle cut weight, resistance bands with foam rubber handles) • Floor mats • Music player Sustainability Program to be included in future AOA initiative and possible partnerships with providers Implementation Notes Toolkit – Page 79 Back ToC Fit and Strong Arthritis Project Cost Information Duration 8 weeks Program Characteristics Sessions 24 Participants 15 Personnel Costs Title Not available Salary % Time Offering Cost $9,070 Fringe Rate % $ Item Description Ankle weights Exercise bands Participant manuals Exercise mats CD player and exercise music Unit Cost Quantity Total $22 $5 $30 $40 $85 15 15 15 15 1 $330 $75 $450 $600 $85 Expendable Equipment/Supplies Item Description Copies of recruitment materials Copies of program materials for participants Consultants Unit Cost Quantity Total $20 $30 2 15 $40 $450 Description $0 Total $0 Non-Expendable Equipment Cost/Person $605 $1,540 $490 $3,840 Cost Certified exercise instructor. 8-hour instructor training, 48 hours to conduct Fit and Strong , 8 hours to develop negotiated adherence contracts = 64 hours (@$30/hour) = 2 iterations @ $1,920 $3,840 Other Costs Description $3,200 Cost License fee for lead site. Training, access to interactive website for outcomes and attendance tracking, instructor hotline, and fidelity site visits from Fit and Strong team Annual renewal fee for lead site. Toolkit – Page 80 $3,000 $200 Back ToC Staff Requirements Hop with the Hip None Arthritis Certification Quality Assurance Space Gym (12-person maximum capacity) Resources Instructors must have a background in PT or OT Program Fidelity None Maintenance Education Funding Research fund - Netherlands Equipment Fitness equipment (i.e., leg press, leg raise, sitting rotation, pull down equipment, treadmill, pulleys, Bowflex, or comparable equipment) Sustainability Program participants have been recruited from provider groups, home care agencies, or other sources Implementation Notes Toolkit – Page 81 Back ToC Hop with the Hip Arthritis Project Cost Information Duration 8 weeks Program Characteristics Sessions 9 Participants 12 Personnel Costs Title Not available Salary % Time Offering Cost $1,889 Fringe Rate % $ Item Description Program instruction guidelines Manual for physical therapist Unit Cost Quantity Total $34 $67 2 1 $68 $67 Expendable Equipment/Supplies Item Description Exercise manuals for participants Consultants Unit Cost Quantity Total $33.75 12 $405 Description Cost Not available $ Description Cost Other Costs Participant recruitment. $1,349 Toolkit – Page 82 $0 Total $0 Non-Expendable Equipment Cost/Person $157 $135 $405 $0 $1,349 Back ToC Staff Requirements Learn Share and Live Cancer Certification Instructors must be trained facilitators Program Fidelity Quality Assurance None Space Resources Space for 25-30 participants Maintenance None required Education Funding Grants and research funds Music player Equipment Sustainability Program has been adapted by community-based organizations (i.e., Cooperative Extension) Implementation Notes Toolkit – Page 83 Back ToC Learn Share and Live Cancer Project Cost Information Duration varies Program Characteristics Sessions varies Personnel Costs Participants 50 Offering Cost $11,900 Title Salary % Time Fringe Rate % Total Project Coordinator $38,000 0.25 0.11 $10,545 Unit Cost Quantity Total $85 $7 3 50 $255 $350 Non-Expendable Equipment Item Description Breast models Breast beads Expendable Equipment/Supplies Item Description Notebooks DVD's Consultants Unit Cost Quantity Total $6 $6 50 50 $300 $300 Description Cost Trainers. Provide facilitation. $150 Description Cost Not available $ Other Costs Toolkit – Page 84 Cost/Person $238 $10,545 $605 $600 $150 $0 Back ToC Staff Requirements Healthy IDEAS (Identifying Depression Empowering Activities for Seniors) Certification • Pre-service training about depression and program delivery • In-service and follow-up training to address real-world challenges in working with depressed older adults • 14-20 hours of group training by behavioral health specialist using a training DVD • Program must be delivered by established case management services staff with up to 3 in-person contacts over 3 months Depression Education Instructors may have various educational backgrounds - BSW or MSW, nurses, and case managers with varying experience have been trained Program Fidelity Quality Assurance • Trainers are observed after pre-service training using a Staff Skills Checklist • Follow-up coaching/training to build confidence in staff, address questions or barriers that staff are encountering, and prevent “drift” in staff skills Resources None Space Funding None Maintenance • Older Americans Act case management programs through Area Agencies on Aging • Older Americans Act Family Caregiver Support Programs through state and local agencies • Medicaid home and community-based services case management programs • State-funded case management • United Way nonprofit case management programs • SAMHSA mental health funding to states Equipment Sustainability • Agencies wishing to implement the program receive a toolkit that guides them in establishing partnerships with key mental health providers • Program supervisors become certified after they implement the program so they can train new staff Implementation Notes Toolkit – Page 85 Back ToC Healthy IDEAS (Identifying Depression Empowering Activities for Seniors) Project Cost Information Duration Program Characteristics Sessions Participants Offering Cost $5,119 Personnel Costs Title Not available Salary % Time Fringe Rate % $ Item Description Binder of materials for staff Client education materials (per participant) Unit Cost Quantity Total 30$ $1 1 1 $30 $1 Expendable Equipment/Supplies Not available Consultants Unit Cost Quantity $ $0 Cost Behavioral health provider/educator @ $75/hour for 2 – 3 hours (2.5 hours on average) Clinical coach. Reinforce staff skills in program delivery (includes meetings with staff and supervisors for follow-up training and individual support, 8-12 hours extra for agencies without clinical expertise or partnerships with mental health providers); includes round-trip travel from Houston, lodging, meals to train 25 case managers. $1,000 @ $100/hour for 10 hours and $900 travel. $188 $0 $2,088 $3,000 Cost Toolkit – Page 86 $31 $1,900 Other Costs Healthy IDEAS program fee and technical assistance package $0 Total Description Description Cost/Person Total $0 Non-Expendable Equipment Item Description Depression $3,000 Back ToC Improving Mood Promoting Access to Collaborative Care Treatment (IMPACT) Certification Staff Requirements • 10-module training program in IMPACT care that is based on the program’s two-day training conference is available online. • Program covers 15 hours of content that includes audio-annotated PowerPoint lectures, case studies, streaming video and more. The training program is free; however, a small fee is charged if you want continuing education credit. • PST is available online or through program's in-person training. Once training is complete, IMPACT will connect agencies with a certified PST trainer who provides case supervision to complete certification as a PST practitioner Depression Education Required background for Depression Care Manager: • Degree in Nursing, Social Work, Marriage And Family Therapy or Psychology. • Minimum 2 years clinical experience in a Relevant setting Required background for Consulting Psychiatrist: • Licensed, preferably board certified Program Fidelity Quality Assurance • Fidelity Scale is available on line at http://impact-uw.org/implementation/planning.html • In addition to implementing the key components, we encourage providers and organizations implementing or adapting IMPACT to measure the effectiveness of their program to convince themselves that they are achieving their goals. Below are the quality indicators that we recommend. The goal for indicators 1-5 should be to implement them with at least 75% of eligible patients. The goal for indicator 6 should be to achieve this with at least 50% of eligible patients. 1. Depression screening 4. Measurement of treatment outcomes 2. Diagnosis (PHQ-9) 5. Adjustment of treatment based on outcome 3. Initiation of treatment 6. Symptom reduction (PHQ-9) Space Maintenance Resources • Private room/space for consultation • 2 chairs Funding Federal funding for original project None Equipment Sustainability Implemented with federal funding throughout country, including New York City Implementation Notes The source of this Cost Sheet information is the IMPACT program website. Toolkit – Page 87 Back ToC Improving Mood Promoting Access to Collaborative Care Treatment (IMPACT) Project Cost Information Duration Program Characteristics Sessions Participants Offering Cost $7,050 Personnel Costs Title Not available Salary % Time Fringe Rate % $ Not available Unit Cost Quantity $ Item Description Not available Consultants Unit Cost Quantity $ $0 Cost IMPACT Implentation Center consultation. Consultation and technical assistance via telephone/e-mail in the adaptation of IMPACT for various settings, design of the program, and implementation planning. Rate: $150/hour (assumption for this cost sheet is 3 hours) IMPACT training by 1-2 Implementation Center staff members. 1-2 day training meeting. Rate: $500/day for travel to and from training location + $750 for each training day (assumption for this cost sheet is 2 days of training) Booster training. Additional training on specific topics (i.e., grief and bereavement, etc.) can be offered via webinar. The number, content, and duration would be mutually agreed upon. Rate: $150/hour of trainer time + $25/hour per webinar connect Problem-solving treatment (PST) training. Trainees are paired with certified PST trainer who listens to audio recordings of selected PST sessions with patients and gives feedback to trainers prior to the next session. Typically takes 3-6 sessions for trainers to be certified. Rate: $150/hour of supervision, typically 1-1.5 hours of listening time." Post-Implementation consultation and technical assistance. Rate $150/hour, assumption is 3 hours. Program evaluation. Provided by Dr. Unutzer and implementation center team. Rate $150/hour, assumption is 3 hours. $450 $4,550 $475 $225 $450 $450 $2,500 Cost Toolkit – Page 88 $0 $2,500 Other Costs Care Management Tracking System. Web-based tracking tool to assist with tracking of care management. $0 Total Description Description $0 Total $0 Expendable Equipment/Supplies Cost/Person Total $0 Non-Expendable Equipment Item Description Depression $2,500 Back ToC Staff Requirements Life Review Therapy Depression Certification Instructors must be clinical psychologists and/or trained in life review therapy Quality Assurance Space Resources Space for face-to-face therapy Maintenance Clinical psychology degree is recommended Program Fidelity None Federal grants Education • Tape recorder • Chronometer • Table Funding Equipment Sustainability Implementation Notes Toolkit – Page 89 Back ToC Life Review Therapy Depression Project Cost Information is not available Toolkit – Page 90 Back ToC Staff Requirements Program to Encourage Actove, Rewarding Lives for Seniors (PEARLS) Certification Staff are required to attend a 2-day training to administer the program. Depression Education None required Training is designed to equip all members of a PEARLS team – both counselors and administrators – to implement the program successfully in their organization. Program Fidelity Quality Assurance Agencies wishing to use the program are encouraged to use the PEARLS fidelity instrument Space Maintenance Resources • Sessions are conducted at the client's home • Counselors have workstations Funding • County levy money • State discretionary money (Senior Services Act) • State Medicaid money Computer/laptop Equipment Sustainability • Program has partnered with communitybased organizations • Program relies on county funding Implementation Notes Seattle's Aging & Disability Services contracts with agencies who provide counseling and psychiatric supervision services. Personnel costs cited in this cost sheet were based on a community-based organization's staff salaries, which are generally higher than that of PEARLS counselors. Toolkit – Page 91 Back ToC Program to Encourage Actove, Rewarding Lives for Seniors (PEARLS) Project Cost Information Duration 19 weeks Depression Program Characteristics Sessions 8 Personnel Costs Participants 88 Offering Cost $90,548 Title Salary % Time Fringe Rate % Total PEARLS counselor PEARLS counselor PEARLS counselor PEARLS counselor PEARLS counselor $11,495 $11,495 $11,495 $15,105 $16,675 1 1 1 1 1 0.1925 0.1925 0.1925 0.32 0.32 $13,708 $13,708 $13,708 $19,938 $22,010 Non-Expendable Equipment Item Description Not available Unit Cost Quantity $ Item Description Not available Consultants Unit Cost Quantity $ Description $83,072 $0 Total $0 Expendable Equipment/Supplies Cost/Person $1,029 $0 Total $0 $4,048 Cost Psychiatric supervision. Psychiatrist provides supervision to PEARLS counselors twice a month $4,048 Other Costs Description $3,429 Cost Mileage reimbursement. Database fees. $1,449 $1980 Toolkit – Page 92 Back ToC Staff Requirements Psychogeriatric Assessment and Treatment in Congregate Housing (PATCH) Certification • Building staff members take part in a structured educational program of monthly presentations led by a staff nurse. • Program consists of 7 1-hour teaching modules enabling housing staff to better understand and recognize individuals with mental disorders and to refer residents who may need mental health services. Depression Education Project nurse must have: • Nursing degree with experience in psychogeriatric nursing • Knowledge and comfort with addressing coexisting medical, social, and psychiatric symptoms Program Fidelity Quality Assurance Training manuals are constructed to ensure that all program providers adhere to certain training protocol Maintenance Resources None Space Funding • Phone • Beeper State funds (Baltimore Mental Health Systems) Equipment Sustainability Program relies on direct government or foundation support Implementation Notes Toolkit – Page 93 Back ToC Psychogeriatric Assessment and Treatment in Congregate Housing (PATCH) Project Cost Information Duration 52 weeks Program Characteristics Sessions Participants Offering Cost $46955 Personnel Costs Title Nurse Psychiatrist Social worker Salary % Time Fringe Rate % Total $65000 $140000 $63700 .017 0.10 0.5 0 $1,105 $14,000 $31,850 Non-Expendable Equipment Item Description Not available Unit Cost Quantity $ Not available Consultants Unit Cost Quantity $ $0 Cost Not available $ Description Cost Not available $ Toolkit – Page 94 $46,955 $0 $0 Total Description Other Costs Cost/Person #DIV/0! Total $0 Expendable Equipment/Supplies Item Description Depression $0 $0 Back ToC Staff Requirements Group Lifestyle Balance Diabetes Certification Instructors are required to attend a two-day training Quality Assurance Space • Room with table and chairs • Private area for weigh-in's Resources Minimum BA in health or related field (i.e., RN, RD, exercise, or health education) Program Fidelity None Maintenance Education Funding • • • • Federal (Department of Defense) Equipment Calorie/fat-tracking book Pedometer Measuring cups/spoons Scale Sustainability • Program has partnered with communitybased organizations such as the YMCA, primary care physicians, health plans, hospitals, and work sites • Program training has been offered as a graduate-level course at the University of Pittsburgh Implementation Notes The University of Pittsburgh Diabetes Institute only provides program training as part of ongoing research projects Toolkit – Page 95 Back ToC Group Lifestyle Balance Diabetes Project Cost Information is not available Toolkit – Page 96 Back ToC Staff Requirements Seniors Taking Charge of their Diabetes Certification Program training None required Quality Assurance Space Resources Space for lectures, food demonstrations, and chair exercises Maintenance Education Program Fidelity None State funds Diabetes Funding Equipment • Food for demonstrations • Ball and bands for chair exercises Sustainability Program materials are publicly accessible for anyone in the state and anyone with internet access to use Implementation Notes Toolkit – Page 97 Back ToC Seniors Taking Charge of their Diabetes Project Cost Information Duration 16-32 weeks Diabetes Program Characteristics Sessions 8 Personnel Costs Participants 25 Offering Cost $5,110 Title Salary % Time Fringe Rate % Total Educator $40,000 .05 0 $2,000 Non-Expendable Equipment Item Description Exercise bands Unit Cost Quantity Total $2 25 $50 Expendable Equipment/Supplies Item Description Food for demonstration Handouts Evaluation handouts Consultants Unit Cost Quantity Total $20 $10 $2 8 25 25 $160 $250 $50 Description Cost/Person $204 $2,000 $50 $460 $2,600 Cost Trainer. Provides program training; includes travel/lodging @ $600/day, honorarium= $2000 for first day, $1000 for additional days, ongoing consultation if desired on program evaluation @ $200/hour $2,600 Other Costs $0 Description Cost Not available $ Toolkit – Page 98 Back ToC Staff Requirements Starr County Border Health Initiative Extended version of the program (12 months) Certification • Trainers are not required to be certified diabetes educators • Community health workers are trained to provide logistical support Quality Assurance Space Resources • Room with table and chairs for 15 participants • Access to kitchen preferred Maintenance Education Trainers are typically nurses or dietitians Program Fidelity Random visits by research staff Funding Diabetes Federal (National Institutes of Health) Equipment • DVD or VCR • Pedometers (provided by program staff) • Glucometers (provided by program staff) Sustainability Program components have been disseminated by nurses and dietitians in clinics and healthcare agencies Implementation Notes Program was originally designed for Spanish- speaking Mexican Americans, so it is not appropriate to deliver it for non-Spanish speakers or other Hispanic groups at this time. This program has also been piloted as a six month intervention. However, the long-term efficacy of the twelve month program is greater than the shorter version, hence its inclusion. Toolkit – Page 99 Back ToC Starr County Border Health Initiative Extended version of the program (12 months) Project Cost Information Duration 48 weeks Program Characteristics Sessions 26 Participants 10 Personnel Costs Title Not available Diabetes Salary % Time Offering Cost $13,760 Fringe Rate % $ Item Description Computer for downloading glucometer data TV/DVD combo unit Videotapes Unit Cost Quantity Total $1,500 $400 $5 1 1 7 $1,500 $400 $35 Expendable Equipment/Supplies Item Description Glucometers Glucometer strips - 25 strips per person per week for 12 months for 13 people Pedometers Snacks for each session Consultants Unit Cost Quantity Total $25 $1 13 3900 $325 $,3900 $25 $25 20 26 Description $0 Total $0 Non-Expendable Equipment Cost/Person $1,376 $500 $650 $1,935 $5,375 $6,450 Cost Nurses. Provide intervention sessions @ $50/hour for 52 hours Dietitians. Provide nutrition aspects of intervention sessions @ $50/hour for 52 hours Community health workers. Set-up, reminder calls, food preparation, transportation $2,600 $2,600 $,1250 Other Costs Description $ Cost Lab work to measure outcomes. $Not available Toolkit – Page 100 Back ToC Staff Requirements A Matter of Balance/Volunteer Lay Leader Model Certification Master Trainers attend a training and teach coaches (volunteers or paid staff), who then teach the classes None required Falls Education Program Fidelity Quality Assurance • Master Trainers (MTs) provide an 8-hour training session to coaches • Coaches are observed by MTs for one of the four first sessions • Coaches are paired with more experienced coaches, mentored by MTs Space Maintenance Resources Space for chairs set up in a circle for 8-12 participants Funding • Area Agencies on Aging • Department of Health • Private grants Equipment • DVD player • 2 DVD's (provided by the program) Sustainability There is an ongoing search for partnerships with this program Implementation Notes Sessions 1 & 3 can also be held in a room for 14 with a TV and DVD player Toolkit – Page 101 Back ToC A Matter of Balance/Volunteer Lay Leader Model Project Cost Information Duration 4 weeks Program Characteristics Sessions 8 Participants 0 Personnel Costs Title Not available Falls Salary % Time Offering Cost $2,066 Fringe Rate % $ Item Description Not available Unit Cost Quantity $ Item Description Coach manuals Participant workbooks Refreshments for coach training Refreshments for participants Consultants Unit Cost Quantity Total $20 $13 $5 $5 2 12 2 12 $40 $156 $10 $60 Description $0 Total $0 Expendable Equipment/Supplies $0 Total $0 Non-Expendable Equipment Cost/Person $172 $266 $1,500 Cost Master trainer. Program coordinator/Master trainer - training fee includes program DVD and CD that sites can make copies of $1,500 Other Costs Description $300 Cost Staff mileage reimbursement. Materials shipping/postage. Combined cost of $300 Toolkit – Page 102 Back ToC Staff Requirements EnhanceFitness Falls Certification Instructors are required to: • Be certified in American Council on Exercise (ACE) or American College of Sports Medicine (ACSM), a nationally-recognized fitness program, or have a related college degree (exercise science, physiology, or PT) • Obtain current first aid and CPR certification Master Trainer (MT) contacts instructors 1-2 times in the first month MT observes instructor's class on monthly and annual basis Instructor completes a self-assessment form and MTs fill out an instructor review form Instructors attend annual workshops for ongoing assistance and mainetnace of fidelity Space Resources Indoor space for participants to extend arms Maintenance • Experience with teaching older adult group exercise classes • 2 months of experience teaching an EnhanceFitness class Program Fidelity Quality Assurance • • • • Education Funding • Older Americans Act funding through state units on aging and Are Agencies on Aging • CDC Arthritis Program funding through state Department of Health • Local foundations • Private fitness clubs and YMCA's • Periodic grant funding by university investig • • • • • • Equipment Fitness equipment Armless chairs CD player and CDs Stopwatch Cone Tape measure Sustainability • There are 450 EnhanceFitness sites nationwide • Program has partnered with healthcare groups, foundations, Area Agencies on Aging, and community-based organizations Implementation Notes Toolkit – Page 103 Back ToC EnhanceFitness Falls Project Cost Information Duration 24 weeks Program Characteristics Sessions 72 Personnel Costs Participants 21 Offering Cost $26,437 Title Salary % Time Fringe Rate % Total Site coordinator $37,440 .05 Non-Expendable Equipment 0.25 $2,340 Item Description Unit Cost Quantity Total $32 $10 $5 $40 $125 21 1 1 1 1 $672 $10 $5 $40 $125 Soft wrist and ankle weights (including shipping) Stopwatch Tape measure CD player and CD's Storage cart for weights Expendable Equipment/Supplies Item Description Mailing participant intake forms, attendance logs, and fitness checks to EF administrative offices Printing program forms, ie. Participant Intake Forms, Attendance, FitnessChecks as well as training materials such as manuals Unit Cost Quantity Total $125 1 $125 $5 12 Cost/Person $1,259 $2,340 $852 $185 $60 Consultants $17,000 Description Cost Fitness instructor. Teaches EnhanceFitness classes, 3 1-hour classes/week with an additional hour for setting up and taking down class equipment; i.e. weights, chairs. Salary varies by region, $20/hour is salary used herein.. EF trainer of instructors. Given the number of potential sites in NYC, it is recommended that a Trainer be hired to be able to train Instructors as needed; to have a local person to provide technical assistance to Instructors; and to conduct fidelity monitoring. If there isn’yt a local trainer, a trainer would be brought in from another location and additional expenses for travel would be added. $4,000 $13,000 Other Costs Description $6,060 Cost Trainer travel expenses. Airfare ($500), meals ($75), hotel ($320) and travel ($125) per Trainer, two for Trainer and/or Instructor training and one for administrative training. Licensing/Training Fee--Year One only and training could include up to 15 Instructors. 12 hours training of no more than 12 instructors on class protocols, inc. exercises, data collection, and fidelity monitoring; Instructor and Coordinator training manuals, listing on EF website; technical support, and program data entry and reports. This assumes one organization will manage all EF sites. (An additional $1,000/organization is required if necessary. Not included in the costs listed herein) Toolkit – Page 104 $3,060 $3,000 Back ToC Staff Requirements Falls Management Exercise (FaME) Falls Certification Instructors need to obtain: • Level 4 National Vocational Qualifications (NVQ)-level training • Post-Qualifying Endorsed training Status with the Chartered Society of Physiotherapists Education Several educational requirements exist for the various staff members in this program, including Postural Stability Instructors, exercise instructors, leisure managers, physiotherapists, ocuppational therapists, therapy/rehabilitation/support workers, and health managers Program Fidelity Quality Assurance • Two Internal Verifiers ensure fidelity • University of Derby also provides external verification of fidelity Space • • • • • Maintenance Resources Space for 20 participants • • • • Funding National Health Service – United Kingdom Local Council Acute Trusts Funding is not uniform across the UK Equipment Chairs for balance exercises Mats for floorwork Therabands Ankle/free weights Steps Sustainability Funding by Health Trusts and Councils ensures sustainability by requiring the program to meet targets on accident prevention and include older adults in active lifestyles Implementation Notes Toolkit – Page 105 Back ToC Falls Management Exercise (FaME) Falls Project Cost Information is not available Toolkit – Page 106 Back ToC Staff Requirements Stepping On Falls Certification Community Class Leaders are required to: • receive 3-year certification after being trained in the program • conduct at least one Stepping On class yearly • provide evidence of providing classes on an ongoing basis in order to be re-certified after 3 years Education Master Trainers must be healthcare professionals (RN, NP, PA, OT, PT) with knowledge of falls prevention Quality Assurance Program Fidelity •Community Class Leaders are monitored by Master Trainers (MTs), and get re-certified after a refresher course •Agencies implementing the program must: (1) use training materials provided by the program; (2) be given oversight by MTs; (3) provide yearly report to the Wisconsin Partnership for Healthy Aging (WPHA) with listing of leaders, training dates, and number of classes led by each leader • In addition, fidelity monitoring includes: (1) Direct observation; (2) Observe via videotape or Skype; (3) Administer knowledge quizzes at leader training; (4) Review of Participant; and (5) Leader ratings of classes Space Equipment • Display table • Ankle weights for class Resources Space for 12 participants to perform strengthening exercises Funding Maintenance • Centers for Disease Control and Prevention (CDC) • Administration on Aging (AoA) • Wisconsin Department of Health Services Sustainability • Widely disseminated falls program in WI with over 30 sites providing workshops. • Have collaborated with other states to implement the program. • Local and federal funding • Local and national collaborative partnerships for dissemination of Stepping-On Implementation Notes This implementation information has been derived from personal communications with the Wisconsin Partnership for Healthy Aging (WPHA). Toolkit – Page 107 Back ToC Stepping On Falls Project Cost Information Duration Program Characteristics Sessions Participants Offering Cost $5,540 Personnel Costs Title Not available Salary % Time Fringe Rate % $ Item Description Leader manuals for class Display Table Ankle weights for class Unit Cost Quantity Total $95 $200 $7.5 2 1 12 $190 $200 $90 Expendable Equipment/Supplies Item Description Printing handouts exercise manual (including labor) Snacks Consultants Unit Cost Quantity Total $2 15 $30 $10 8 Description $0 Total $0 Non-Expendable Equipment Cost/Person $80 $480 $110 $3,950 Cost Master trainer. Trainees come to Wisconsin - 3 day training for Leaders /4 day training for Master Trainers Leader training = $1,400 per person if sending two or more persons $1000.00 per person Master Trainer training (one additional day added to leader training) = Lead trainer. Peer trainer. Older adult peer co-leader attending with leader Other Costs Description $2,050 $1,400 $500 Cost Licensure. $500/year up to 10 classess; $1,000/year 11-30 classes Toolkit – Page 108 $1,000 $1,000 Back ToC Staff Requirements Strategies and Actions for Independent Living (SAIL) Certification Falls Education Program training Instructors must be qualified health professionals who have worked in home support services for older adults (i.e., PT, OT, RN, MSW) Program Fidelity Quality Assurance Master Trainers attend and mentor new trainers and community health workers Space Maintenance Resources • Most of the program is delivered in homes of older adults • Training space for 20 facilitators, home health professionals, and community health workers Funding • Research grant from Vancouver Foundation of the Medical Services Association and British Columbia Ministry of Health • In-kind funding from British Columbia Health Authorities • Provincial funding from Fraser Health Equipment • Fall surveillance and risk screening tools • Access to Excel spreadsheet • Laptop projector for trainings Sustainability • Since the program is designed to be integrated into existing home care services, it uses existing resources and does not require anything additional besides a realignment of staff time • Steering committee has been set up to address gaps in program delivery and sustainability Implementation Notes While this program can be modified based on client needs, and has been modified for assisted living residences (Promoting Active Living program), it is only designed for home support services for older adults. Fraser Health Authority of British Columbia was unable to provide costs since the program serves as an add-on to existing home care services, whose costs vary by region. Toolkit – Page 109 Back ToC Strategies and Actions for Independent Living (SAIL) Project Cost Information is not available Toolkit – Page 110 Falls Back ToC Staff Requirements Tai Chi: Moving for Better Balance Falls Certification Instructors are required to attend a 1-2 day training by Oregon Research Institute None required Education Program Fidelity Quality Assurance Instructors are observed by Master-level instructors Space Equipment • Chairs • DVD player (optional) • Attendance sheet Maintenance Resources Space for 15 participants Funding Federal – Centers for Disease Control & Prevention Sustainability Program has partnered with local senior service providers (i.e., senior centers, meal sites) is recommended Implementation Notes Program has been adapted for adults who use special equipment, i.e., walkers, wheelchairs. Costs elements that have not been specified in the Cost Sheet include personnel (salary rate unknown) and materials (class size unknown). Toolkit – Page 111 Back ToC Tai Chi: Moving for Better Balance Project Cost Information Duration 12 weeks Program Characteristics Sessions 24 Participants 10 Personnel Costs Title Not available Falls Salary % Time Offering Cost $10,549 Fringe Rate % $ Item Description CD player Unit Cost Quantity Total $25 1 $25 Expendable Equipment/Supplies Item Description User's guide and workbook for instructors User's guide for participants Consultants Unit Cost Quantity Total $15 $8 1 10 $15 $80 Description $0 Total $0 Non-Expendable Equipment Cost/Person $1,055 $25 $95 $10,429 Cost Fuzhong Li. Provides instructor training; cost includes round-trip airfare from Oregon, travel reimbursement, lodgingq Master-level trainer. Instructor @ $35/hour, two 2-hour sessions/week Other Costs Description $3,149 $7,280 Cost Room rental. Costs not available $ Toolkit – Page 112 $0 Back ToC Staff Requirements Health for Your Heart (Salud Por Tu Corazón) Certification Instructors are required to attend a 5-8 day training in Su Corazón Su Vida curriculum delivered by experienced community health workers Heart disease Education Minimum high school education Program Fidelity Quality Assurance Instructors are mentored and observed by experienced community health workers Space Equipment Maintenance Resources Space for 15-20 participants Funding Equipment/materials to measure blood pressure, body mass index, and waist circumference • Federal funding through the National Heart, Lung, and Blood Institute and National Center on Minority Health and Health Disparities of the National Institutes of Health, and Health Resources and Services Administration • Metropolitan Life Sustainability • Fund depletion following program completion has been an ongoing issue. Therefore, community partnerships are essential Implementation Notes Toolkit – Page 113 Back ToC Health for Your Heart (Salud Por Tu Corazón) Project Cost Information Duration 16 weeks Heart disease Program Characteristics Sessions 10 (8 + 2 follow-up) Personnel Costs Participants 100 Offering Cost $64,700 Title Salary % Time Fringe Rate % Total Community health worker Community health worker Project coordinator $25,000 $25,000 $30,000 0.5 0.5 0.5 0.26 0.26 0.26, $15,750 $15,750 $18,900 Non-Expendable Equipment Item Description Not available Unit Cost Quantity $ Item Description Su Corazón Su Vida materials Training materials Incentives for participants Consultants Unit Cost Quantity Total $50 $1,500 $25 100 1 100 $5,000 $1,500 $2,500 Description $50,400 $0 Total $0 Expendable Equipment/Supplies Cost/Person $647 $9,000 $5,000 Cost Promotora trainee. Training for one week - stipend plus travel Other Costs $5,000 Description Cost Room rental $300 Toolkit – Page 114 $300 Back ToC Staff Requirements Project Joy Heart disease Certification Instructors must obtain CPR certification in order to administer the program None required Education Program Fidelity Quality Assurance Instructors are observed by Master Trainers Space Maintenance Resources Indoor meeting room and space for exercises Funding Federal funding through the Centers for Disease Control & Prevention • • • • Equipment Portable scale LCD projector Computer CD/MP3 player and music Sustainability Program has partnered with local churches Implementation Notes Toolkit – Page 115 Back ToC Project Joy Heart disease Project Cost Information Duration 20 weeks Program Characteristics Sessions 20 Personnel Costs Participants 75 Offering Cost $36,215 Title Salary % Time Fringe Rate % Total Health educator - note: rates are based on 1996 estimates Health educator - note: rates are based on 1996 estimates $14,000 1 0.28 $17,920 $14,000 1 0.28 Not available $0 Unit Cost Quantity $ Educational materials (rate for color photocopies) Total $0 Expendable Equipment/Supplies Item Description $35,840 $17,920 Non-Expendable Equipment Item Description Cost/Person $483 Unit Cost Quantity Total $5 75 $375 Consultants $375 $0 Description Cost Not available $ Description Cost Not available $ Other Costs Toolkit – Page 116 $0 ToC REFERENCES ARTHRITIS Arthritis Foundation Exercise Program (AFEP) Boutaugh, M. (2003). Arthritis Foundation community-based physical activity programs: Effectiveness and implementation issues. Arthritis & Rheumatism (Arthritis Care & Research), 49(3), 463–470. Callahan, L.F., Mielenz, T., Freburger, J., Shreffler, J., Hootman, J., Brady, T., Buysse, K., & Schwartz, T. (2008). A randomized controlled trial of the People With Arthritis Can Exercise Program: Symptoms, function, physical activity, and psychosocial outcomes. Arthritis & Rheumatism (Arthritis Care & Research), 59(1), 92–101. Enabling Self-Management and Coping with Arthritic Knee Pain Through Exercise (ESCAPE-knee pain) Hurley, M. V., Walsh, N. E., Mitchell, H. L., Pimm, T. J., Patel, A., Williamson, E., Jones, R. H., Dieppe, P. A., & Reeves, B. C. (2007). Clinical effectiveness of a rehabilitation program integrating exercise, self-management, and active coping strategies for chronic knee pain: A cluster randomized trial. Arthritis & Rheumatism (Arthritis Care & Research), 57(7), 1211– 1219. Hurley, M. V., Walsh, N. E., Mitchell, H. L., Pimm, T. J., Patel, A., Williamson, E., Jones, R. H., Dieppe, P. A., & Reeves, B. C. (2007). Enabling Self-Management and Coping with Arthritic Knee Pain through Exercise (ESCAPE-knee pain). Arthritis & Rheumatism (Arthritis Care & Research), 57(7), 1211-1219. Fit & Strong Hughes, S.L., Seymour, R.B, Campbell, R., Huber, G., Pollak. N., Sharma, L., & Desai, P. (2006). Long-term impact of Fit and Strong! on older adults with osteoarthritis. The Gerontologist, 46(6), 801-814. Hughes, S.L., Seymour, R.B., Campbell, R., Pollak, N., Huber, G., & Sharma, L. (2004). Impact of the Fit and Strong intervention on older adults with osteoarthritis. The Gerontologist, 44(2), 217–228. Seymour, R.B., Hughes, S.L., R.B, Campbell, Huber, G., & Desai, P. (2009). Comparison of two methods of conducting the Fit and Strong! program. Arthritis & Rheumatism (Arthritis Care & Research), 61(7), 876-884. Hop with the Hip Tak, E., Staats, P., Van Hespen, A., & Hopman-Rock, M. (2005). The effects of an exercise program for older adults with osteoarthritis of the hip. Journal of Rheumatology. 32(6), 1106-1113. CANCER Learn Share and Live Program Skinner, C.S., Arfken, C.L., & Waterman, B. (2000). Outcomes of the Learn Share & Live Breast Cancer Education Program for older urban women. American Journal of Public Health, 90(8), 1229-1234. Skinner, C.S., Sykes, R.K., Monsees, B.S., Andriole, D.A., Arfken, C.L., & Fisher, E.B. (1998). Learn, Share, and Live: Breast cancer education for older, urban minority women. Health Education & Behavior, 25(1), 60-78 Screen for Life National Colorectal Cancer Action Campaign Ward, A.J., Kluhsman, B.C., Lengerich, E.J., & Piccinin, A.M. (2006). The impact of cancer coalitions on the dissemination of colorectal cancer materials to community organizations in rural Appalachia. Preventing Chronic Disease Public Health Research, Practice, and Policy, 3(2), 1-13. Tepeyac Project Sauaia, A., Min, S., Lack, D., Apodaca, C., Osuna, D., Stowe, A., McGinnis, G.F., Latts, L.M., & Byers, T. (2007). Church-based breast cancer screening education: Impact of two approaches on Latinas enrolled in public and private health insurance plans. Preventing Chronic Disease Public Health Research, Practice, and Policy, 4(4), 1-10. DEPRESSION Healthy Identifying Depression, Empowering Activities for Seniors (Healthy IDEAS) Quijano, L.M., Stanley, M.A., Petersen N.J., Casado, B.L., Steinberg E.H., Cully J.A., & Wilson, N.L. (2007). Healthy IDEAS: A depression intervention delivered by community-based case managers serving older adults. Journal of Applied Gerontology, 26(2), 139-156. Improving Mood Promoting Access to Collaborative Care Treatment (IMPACT) Arean, P., Hegel, M., Vannoy, S., Fan, M.Y., & Unutzer, J. (2008). Effectiveness of problemsolving therapy for older, primary care patients with depression: Results from the IMPACT project. The Gerontologist, 48(3), 311-323. Hunkeler, E., Katon, W., Tang, L., Williams, Jr., J., Kroenke, K., Lin E., Harpole, L., Arean, P., Levine, S., Grypma, L., Hargreaves, W., & Unutzer, J. (2006). Long-term outcomes from the IMPACT randomized trial for depressed elderly patients in primary care. BMJ, 332: 259263. Unutzer, J., Katon, W., Callahan, C., Williams, Jr., J., Hunkeler, E., Harpole, L., Hoffing, M., Della-Penna, R.D., Hitchcock, N. P., Lin, E., Arean, P., Hegel, M., Tang, L., Belin, T., Oishi, S., & Langston, C. (2002). Collaborative care management of late-life depression in the primary care setting. JAMA, 288(22), 2846-2845. Life Review Therapy Serrano, J.P., Latorre, J.M., Gatz, M., & Montanes, J. (2004). Life review therapy: Using autobiographical retrieval practice for older adults with depressive symptomatology. Psychology and Aging, 19(2), 272-277. Program to Encourage Active, Rewarding Lives for Seniors (PEARLS) Ciechanowski, P., Wagner, E., Schmaling, K., Schwartz S., Williams, B. Diehr., P., Kulzer, J., Gray, S., Collier, C., & LoGerfo, J. (2004). Community-integrated home-based depression treatment in older adults, a randomized controlled trial. JAMA, 291(13), 1569-1577. Psycho geriatric Assessment and Treatment in City Housing (PATCH) Rabins, P.V., Black, B.S., Roca, R., German, P., McGuire, M., Robbins, B., Rye, R., & Brant, L. (2000). Effectiveness of a nurse-based outreach program for identifying and treating psychiatric illness in the elderly. JAMA, 283(21), 2802-2809. DIABETES Diabetes Education & Prevention with a Lifestyle Intervention Offered at the YMCA (DEPLOY) Ackermann, R.T., Finch, E.A., Brizendine, E., Zhou, H., & Marrero, D.G. (2008). Translating the Diabetes Prevention Program into the community: The DEPLOY pilot study. American Journal of Preventive Medicine, 35(4), 357–363. Ackermann, R.T. & Marrero, D.G. (2007). Adapting the Diabetes Prevention Program lifestyle intervention for delivery in the community. The YMCA model. The Diabetes Educator, 33(1), 69-78. Finch, E.A., Kelly, M.S., Marrero, D.G. & Ackermann, R.T. (2009). Training YMCA wellness instructors to deliver an adapted version of the Diabetes Prevention Program lifestyle intervention. The Diabetes Educator, 35(2), 224-232. Diabetes Health Connection Glasgow, R.E., Nelson, C.C., Strycker, L.A. & King, D.K. (2006). Using RE-AIM metrics to evaluate diabetes self-management support interventions. American Journal of Preventive Medicine, 30(1) 67-73. King, D.K., Estabrooks, P.A., Strycker, L.A., Toobert, D.J., Bull, S.S. & Glasgow, R.E. (2006). Outcomes of a multifaceted physical activity regimen as part of a diabetes self-management intervention. Annals of Behavioral Medicine, 31(2), 28–137. Diabetes Prevention Program (DPP) Knowler, W.C., Barrett-Connor, E., Fowler, S.E., Hamman, R.F., Lachin, J.M., Walker, E.A. & Nathan, D.M. (2002). Reduction in the incidence of type 2 diabetes with lifestyle intervention or metformin. New England Journal of Medicine, 346(6), 393-403. The Diabetes Prevention Program Research Group. (1999). The Diabetes Prevention Program: Design and methods for a clinic trial in the prevention of type 2 diabetes. Diabetes Care, 22(44), 623-634. Wylie-Rosett, J., Herman, W.H. & Goldberg, R.B. (2006). Lifestyle intervention to prevent diabetes: Intensive AND cost-effective. Current Opinion in Lipidology Nutrition and Metabolism, 17, 37-44. Group Lifestyle Balance (GLB) Seidel, M. C., Powell, R.O., Zgibor, J.C., Siminerio, L.M., & Piatt, G.A. (2008). Translating the Diabetes Prevention Program into an urban medically underserved community: A nonrandomized prospective intervention study. Diabetes Care, 31(4), 684–689. Healthy ChangesTM by NCOA Elders in Action. (2007). Healthy Changes: A community-based diabetes education and support program. Healthy Changes Replication Report, 1-25. National Council on Aging. (2006). Center for Healthy Aging model health programs for communities. Using the evidence base to promote healthy aging: The Administration on Aging’s evidence-based prevention programs for the elderly initiative. Evidence-Based Health Promotion Series, 3, 1-5. Look After Yourself (LAY) Cooper, H., Booth, K. & Gill, G. (2008). A trial of empowerment-based education in type 2 diabetes—Global rather than glycaemic benefits. Diabetes Research and Clinical Practice, 82, 165-171. Look AHEAD (Action for Health in Diabetes) Ryan, D.H., Espeland, M.A., Foster, G.D., Haffner, S.M., Hubbard, V.S., Johnson, K.C., Kahn, S.E., Knowler, W.C., & Yanovski, S.Z. (2003). Look AHEAD (Action for Health in Diabetes): Design and methods for a clinical trial of weight loss for the prevention of cardiovascular disease in type 2 diabetes. Controlled Clinical Trials, 24, 610–628. The Look AHEAD Research Group. (2007). Reduction in weight and cardiovascular disease risk factors in individuals with type 2 diabetes: One-year results of the Look AHEAD trial. Diabetes Care, 30(6), 1374–1383. New Leaf … Choices for Healthy Living with Diabetes Keyserling, T.C., Ammerman, A.S., Samuel-Hodge, Ingram, A.F., Skelly, A.H., Elasy, T.A., Johnston, L.F., Cole, A.S. & Henríquez-Roldán, C.F. (2000). A diabetes management program for African American women with type 2 diabetes. The Diabetes Educator, 26(5), 796-805. Keyserling, T.C., Samuel-Hodge, C.D., Ammerman, A.S., Ainsworth, B.E., Henríquez-Roldán, C.F., Elasy, T.A., Skelly, A.H., Johnston, L.F., & Bangdiwala, S.I. (2002). A randomized trial of an intervention to improve self-care behaviors of African-American women with type 2 diabetes: Impact on physical activity. Diabetes Care, 25(9), 1576–1583. Seniors Taking Charge of Diabetes! Speer, E.M., Reddy, S., Lommel, T.S., Fischer, J.G., Stephens, H., Park, S. & Johnson, M.A. (2008). Diabetes self-management behaviors and Alc improved following a communitybased intervention in older adults in Georgia senior centers. Journal of Nutrition for the Elderly, 27(1/2), 179-200. Starr County Border Health Initiative Brown, S.A., Garcia, A.A., Kouzekanani , K., & Hanis, G.L. (2002). Culturally competent diabetes self-management education for Mexican Americans: The Starr County Border Health Initiative. Diabetes Care, 25(2), 259–268. FALLS A Matter of Balance/Volunteer Lay Leader Model Tennstedt, S., Howland, J., Lachman, M., Peterson, E., Kasten, L., & Jette, A. (1998). A randomized, controlled trial of a group intervention to reduce fear of falling and associated activity restriction in older adults. Journal of Gerontology: Psychological Sciences, 53B(6), 384-392. van Haastregt, J.C.M., Zijlstra, G.A.R., van Rossum, E., van Eijk, J.T.M, de Witte, L.P., & Kempen, G.I.J.M. (2007). Feasibility of a cognitive behavioral group intervention to reduce fear of falling and associated avoidance of activity in community-living older people: A process evaluation. BMC Health Services Research, 7(156), 1-9. Zijlstra, G.A.R., Tennstedt, S.L., van Haastregt, J.C.M., van Eijk, J.T.M., & Kempen, G.I.J.M. (2006). Reducing fear of falling and avoidance of activity in elderly persons: The development of a Dutch version of an American intervention. Patient Education and Counseling, 62, 220-227. EnhanceFitness Belza, B., Shumway-Cook, A., Phelan, E.A., Williams, B., Snyder, S.J., & LoGerfo, J.P. (2006). The effects of a community-based exercise program on function and health in older adults: The EnhanceFitness Program. Journal of Applied Gerontology, 25(4), 291-306. Wallace, J.I., Buchner, D.M., Grothaus, L., Leveille, S., Tyll., L., LaCroix, A.Z., & Wagner, E.H. (1998). Implementation and effectiveness of a community-based health promotion program of older adults. The Journals of Gerontology: Medical Sciences, 53A(4), M301M306. Falls Management Exercise (FaME) Skelton, D., Dinan, S., Campbell, M., & Rutherford, O. (2005). Tailored group exercise (Falls Management Exercise — FaME) reduces falls in community-dwelling older frequent fallers (an RCT). Age and Ageing, 34(6), 636-639. NoFalls Day, L., Fildes, B., Gordon, I., Fitzharris, M., Flamer H., & & Lord, S. (2002). Randomized factorial trial of falls prevention among older people living in their own homes. BMJ, 325, 16. Step by Step Baker, D.I., Gottschalk, M., & Bianco, L.M. (2007). Step by Step: Integrating evidence-based fall-risk management into senior centers. The Gerontologist, 47(4), 548–554. Stepping On Clemson, L., Cumming., R.G., Kendig, H., Swann, M., Heard, R., & Taylor, K. (2004). The effectiveness of a community-based program for reducing the incidence of falls in the elderly: A randomized trial. JAGS, 52(9), 1487-1494. Strategies and Actions for Independent Living (SAIL) Scott, V.J., Votova, K., & Callagher, E. (2006). Falls prevention training for community health workers:. Strategies and Actions for Independent Living (SAIL). Journal of Gerontological Nursing, 32(10), 48-56. Tai Chi: Moving for Better Balance Li, F., Harmer, P., Fisher, J., McAuley, E., Chaumeton, N., Eckstrom, E., & Wilson, N.L. (2005). Tai chi and fall reductions in older adults: A randomized controlled trial. Journal of Gerontology: Medical Sciences, 60A(2), 187-194. HEART DISEASE Airdie Community Hypertension Awareness and Management Program (A-CHAMP) Jones, C., Simpson, S.H., Mitchell, D., Haggarty, S., Campbell, N., Then, K., Lewanczuk, R.Z., Sebaldt, R.J., Farrell, B., Dolovich, L., Kaczorowski, J., & Chambers, L.W. (2008). Enhancing hypertension awareness and management in the elderly: Lessons learned from the Airdrie Community Hypertension Awareness and Management Program (A-CHAMP). The Canadian Journal of Cardiology, 24(7), 561-567. Eat Better Move More Wellman, N.S., Kamp, B., Kirk-Sanchez, N.J., & Johnson, P.M. (2007). Eat Better & Move More: A community-based program designed to improve diets and increase physical activity among older Americans. American Journal of Public Health, 97(4), 710-717. Health for Your Heart (Salud Por Tu Corazón) Balcázar, H., Alvarado, M., Hollen, M.L., Gonzalez-Cruz, Y., & Pedregón, V. (2005). Evaluation of Salud Para Su Corazón (Health for Your Heart) — National Council of La Raza Promotora Outreach Program. Preventing Chronic Disease Public Health Research, Practice, and Policy, 2(3), 1-9. URL: http://www.cdc.gov/pcd/issues/2005/ Prime Time Sister CirclesTM Gaston, M.H., Porter, G.K. & Thomas, V.G. (2007). Prime Time Sister CirclesTM: Evaluating a gender-specific, culturally relevant health intervention to decrease major risk factors in mid-life African-American women. Journal of the National Medical Association, 99(4), 428438. Project Joy Yanek, L.R., Becker, D.M., Moy, T.F., Gittelsohn, J., & Koffman, D.M. (2001). Project Joy: Faith-based cardiovascular health promotion for African American women. Public Health Reports, 116(S1), 68-81. OBESITY For the evidence-based program references for obesity, please refer to the citations listed above for the following programs: Condition Diabetes Diabetes Heart Disease Diabetes Program Name Diabetes Education & Prevention with a Lifestyle Intervention Offered at the YMCA (DEPLOY) Diabetes Prevention Program (DPP) Eat Better Move More Group Lifestyle Balance (GLB) APPENDICES ToC APPENDIX 1: Evidence-Based Program Logistics Survey ToC EVIDENCE-BASED PROGRAM LOGISTICS SURVEY PROGRAM NAME: RESPONDENT NAME: TITLE: Funding 1. What is the funding source used to implement your program (e.g., local agency, foundation, federal grant)? Resources 2. What types of resources are required for implementing your program? a. Space requirements b. Equipment/material requirements Certification/Educational Background 3a. If appropriate, do trainers need to obtain special certification to implement your program? ** If trainers are not required for your program, SKIP TO QUESTION 4 on next page □ Yes □ No If so, please explain below. 3b. Do trainers need to have specific educational background/experience to implement your program? (i.e., MSW, RN, PT, etc.) □ Yes □ No If so, please specify below. 1 ToC Fidelity 4. Are any specific arrangements made to ensure program fidelity? For instance, do Master Trainers attend program sessions to observe whether the program is implemented per original specifications? □ Yes □ No If so, please explain below. Replicability and Modifications (if any) 5a. Can your program be replicated in any community setting? □ Yes □ No ** If the answer to item 5a (above) was NO: 5b. Are there any suggested modifications that need to be made for community settings to implement your program? □ Yes □ No If so, what would these modifications entail? Sustainability 6. Does your program have any elements used to ensure its sustainability? For example, does your program partner with community-based organizations or healthcare providers/networks to facilitate ongoing or continuous implementation of the program? □ Yes □ No If so, please explain. Finally, would you please provide us with contact information in case we have questions about your responses? Phone: Email: THANK YOU! 2 ToC APPENDIX 2: Evidence-Based Program Cost Sheet ToC Evidence-Based Program Cost Sheet Program Name: Does this budget worksheet describe a/an: Annual program Single offering Program Duration (weeks) Number of Sessions If this is an annual budget, how many offerings/programs are run annually? On average, how many participants take part in each program offering? PERSONNEL For each staff member WORKING DIRECTLY ON THE PROGRAM, list each position, annual salary and percent time devoted to program (FTE). This does not include contracted personnel providinf services for the intervention. Position/Title Annual Salary Percent Time (FTE) Program Salary 1 X "=" $0 2 X "=" $0 3 X "=" $0 4 X "=" $0 5 X "=" $0 6 X "=" $0 SALARY SUB-TOTAL $0 FRINGE BENEFITS For each staff member listed above, please provide the fringe benefit rate used for that position.Please keep in mind that staff at various levels may have different fringe benefit rates. The position/titles and salaries from above will self-populate the table below. Position/Title (Self-Populating) Fringe Benefit Program Salary Program Fringe 1 0 X $0 "=" $0 2 0 X $0 "=" $0 3 0 X $0 "=" $0 4 0 X $0 "=" $0 5 0 X $0 "=" $0 6 0 X $0 "=" $0 FRINGE SUB-TOTAL $0 ToC NON-EXPENDABLE EQUIPMENT List NON-EXPENDABLE items related to the program intervention in the spaces below. NON-EXPENDABLE equipment is usually defined as tangible property having a useful life of 2 or more years. Single, or short-term, use items should be listed under EXPENDABLE ITEMS below. Construction costs are not to be included. Please describe each item fully. Items Unit Cost Quantity 1 X "=" $0 2 X "=" $0 3 X "=" $0 4 X "=" $0 5 X "=" $0 NON-EXP SUB-TOTAL $0 SUPPLIES/EXPENDABLE EQUIPMENT List EXPENDABLE items related to the program intervention by type (training materials, postage, copies, etc.) in the spaces below. EXPENDABLE items are those items consumed during the course of a program. Please describe each item fully. Items Unit Cost Quantity 1 X "=" $0 2 X "=" $0 3 X "=" $0 4 X "=" $0 5 X "=" $0 6 X "=" $0 7 X "=" $0 8 X "=" $0 SUPPLIES SUB-TOTAL $0 ToC CONSULTANTS/CONTRACTUAL For each consultant/contractor provide a description of services provided. If additional costs are included in the consultant's fee (travel, lodging, etc.) please include that in the total cost of that contractor's services. This would also include students or others that are paid but not considered employees. Consultant/Contractor Details of Service Provided Total Cost 1 2 3 4 5 CONSULTANT SUB-TOTAL $0 OTHER COSTS Specify Details of Service Provided Total Cost 1 2 3 4 5 OTHER SUB-TOTAL ORGANIZATIONAL INDIRECT COSTS Specify if indirect rate is a federally negotiated rate and oversite organization (DHHS, etc.) Federal Agency or Source of Indirect Rate Indirect Rate Personnel Fringe Non-Exp Supplies Consult Other TOTAL $0 $0 $0 $0 $0 $0 $0 $0 BROOKDALE DEMONSTRATION INITIATIVE IN HEALTHY URBAN AGING: BRIDGING THE DIVIDE BETWEEN PUBLIC HEALTH & HEALTHY AGING EVIDENCE-BASED TOOLKIT: Condition-Specific Instruments PREPARED FOR: THE COMMISIONER NEW YORK CITY DEPARTMENT FOR THE AGING LILLIAM BARRIOS-PAOLI COMMISSIONER APRIL 2010 FUNDING PROVIDED BY: OFFICE OF THE MAYOR CITY OF NEW YORK MICHAEL R. BLOOMBERG MAYOR CREATED BY: THE BROOKDALE CENTER FOR HEALTHY AGING & LONGEVITY OF HUNTER COLLEGE/ CUNY 2 Arthritis-Specific Instruments •Tab 1 Cancer-Specific Instruments •Tab 2 Depression-Specific Instruments •Tab 3 Diabetes-Specific Instruments •Tab 4 Falls-Specific Instruments •Tab 5 Heart DiseaseSpecific Instruments •Tab 6 Obesity-Specific Instruments •Tab 7 INSTRUMENT GUIDE FOR ARTHRITIS-SPECIFIC PROGRAMS Instruments preceded by an asterisk (*) and bolded are common to a number of conditions and can be found in the Cross-Cutting Instruments Guide Important Note: While rigorous research was conducted to provide readers with all of the instrumentation for implementing the programs outlined in this toolkit, for a limited number of programs, instrumentation was not available for public use. Therefore, interested parties are encouraged to contact selected programs to obtain permission for instruments not included here. Instrument Program • *6-Minute Walk Test • • Arthritis Self-Efficacy Scale English & Spanish versions • Arthritis Foundation Exercise Program (AFEP) Enabling Self-Management and Coping with Arthritic Knee Pain through Exercise (ESCAPE-knee pain) Fit and Strong Fit and Strong * Center for Epidemiologic Studies Depression (CES-D) Scale • * Community Health Activities Model Program for Seniors (CHAMPS) Physical Activity Questionnaire English & Spanish versions, including manual and scoring guide • Fit and Strong • ESCAPE-knee pain EuroQol (EQ-5D) Including user’s guide Gait Speed Test • Groningen Activity Restriction Scale • Geri-AIMS Pain Scale Harris Hip Score (HHS) Including instrument overview Health Assessment Questionnaire (HAQ)-8 English & Spanish versions Helplessness Subscale of the Rheumatology Attitudes Index Hospital Anxiety and Depression Scale (HADS) McMaster Toronto Arthritis Quality of Life Questionnaire (MACTAR) • • • • • • AFEP AFEP Fit and Strong Hop with the Hip Hop with the Hip AFEP AFEP ESCAPE-knee pain ESCAPE-knee pain Instrument *Physical Activity Scale for the Elderly (PASE) Rheumatoid Arthritis Self-Efficacy (RASE) Scale Rheumatology Attitudes Index (RAI) Self-Efficacy for Exercise Adherence Scale Self-Efficacy for Physical Activity (SEPA) Scale Short Portable Mental Status Questionnaire (SPSMQ) Program • • • • • • * Sickness Impact Profile (SIP) • Timed 10-Pound Lifts • Timed 360-Degree Turn • Timed Up and Go Test • Timed Chair Stand Test Visual Analog Scale (VAS) Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) Including instrument overview and scoring guide • • • • • • AFEP AFEP AFEP Fit and Strong AFEP Fit and Strong Hop with the Hip AFEP AFEP AFEP Fit and Strong Hop with the Hip AFEP Hop with the Hip ESCAPE-knee pain Fit and Strong Back ToC Arthritis Self-Efficacy For each of the following questions, please circle the number that corresponds to how certain you are that you can do the following tasks regularly at the present time. Self-Efficacy Pain Scale (may be combined with Other Symptoms Scale) 1. How certain are you that you can decrease your pain quite a bit? ______________________________ very | | | | | | | | | | very uncertain 1 2 3 4 5 6 7 8 9 10 certain 2. How certain are you that you can continue most of your daily activities? ______________________________ very | | | | | | | | | | very uncertain 1 2 3 4 5 6 7 8 9 10 certain 3. How certain are you that you can keep arthritis pain from interfering with your sleep? ______________________________ very | | | | | | | | | | very uncertain 1 2 3 4 5 6 7 8 9 10 certain 4. How certain are you that you can that you can make a small-tomoderate reduction in your arthritis pain by using methods other than taking extra medication? ______________________________ very | | | | | | | | | | very uncertain 1 2 3 4 5 6 7 8 9 10 certain 5. How certain are you that you can make a large reduction in your arthritis pain by using methods other than taking extra medication? ______________________________ very | | | | | | | | | | very uncertain 1 2 3 4 5 6 7 8 9 10 certain Self-Efficacy Function Scale 1. How certain are you that you can walk 100 feet on flat ground in 20 seconds? ______________________________ very | | | | | | | | | | very uncertain 1 2 3 4 5 6 7 8 9 10 certain 2. How certain are you that you can that you can walk 10 steps downstairs in 7 seconds? ______________________________ very | | | | | | | | | | very uncertain 1 2 3 4 5 6 7 8 9 10 certain 3. How certain are you that you can get out of an armless chair quickly, without using your hands for support? ______________________________ very | | | | | | | | | | very uncertain 1 2 3 4 5 6 7 8 9 10 certain 4. How certain are you that you can very ______________________________ | | | | | | | | | | very 1 button and unbutton 3 medium-size buttons in a row in 12 seconds? uncertain 1 2 3 4 5 6 7 8 9 10 certain 5. How certain are you that you can cut 2 bite-size pieces of meat with a knife and fork in 8 seconds? ______________________________ very | | | | | | | | | | very uncertain 1 2 3 4 5 6 7 8 9 10 certain 6. How certain are you that you can turn an outdoor faucet all the way on and all the way off? ______________________________ very | | | | | | | | | | very uncertain 1 2 3 4 5 6 7 8 9 10 certain 7. How certain are you that you can scratch your upper back with both your right and left hands? ______________________________ very | | | | | | | | | | very uncertain 1 2 3 4 5 6 7 8 9 10 certain 8. How certain are you that you can get in and out of the passenger side of a car without assistance from another person and without physical aids? ______________________________ very | | | | | | | | | | very uncertain 1 2 3 4 5 6 7 8 9 10 certain 9. How certain are you that you can put on a long-sleeve front-opening shirt or blouse (without buttoning) in 8 seconds? ______________________________ very | | | | | | | | | | very uncertain 1 2 3 4 5 6 7 8 9 10 certain Self-Efficacy Other Symptoms Scale (may be combined with Pain Scale) 1. How certain are you that you can control your fatigue? ______________________________ very | | | | | | | | | | very uncertain 1 2 3 4 5 6 7 8 9 10 certain 2. How certain are you that you can regulate your activity so as to be active without aggravating your arthritis? ______________________________ very | | | | | | | | | | very uncertain 1 2 3 4 5 6 7 8 9 10 certain 3. How certain are you that you can do something to help yourself feel better if you are feeling blue? ______________________________ very | | | | | | | | | | very uncertain 1 2 3 4 5 6 7 8 9 10 certain 4. As compared with other people with arthritis like yours, how certain are you that you can manage arthritis pain during your daily activities? ______________________________ very | | | | | | | | | | very uncertain 1 2 3 4 5 6 7 8 9 10 certain 5. How certain are you that you can manage your arthritis symptoms so that you can do the things you enjoy doing? ______________________________ very | | | | | | | | | | very uncertain 1 2 3 4 5 6 7 8 9 10 certain 6. How certain are you that you can deal with the frustration of arthritis? ______________________________ very | | | | | | | | | | very uncertain 1 2 3 4 5 6 7 8 9 10 certain 2 Characteristics Mean N=95 (T) N=49 (C) Standard Deviation N=95 (T) N=49 (C) Internal Consistency Reliability N=97 Test-Retest Reliability N=91 2.14 (T) 1.79 (C) .75 .87 7.33 (T) 6.79 (C) 2.02 (T) 2.25 (C) .90 .85 5.56 (T) 4.92 (C) 2.16 (T) 2.06 (C) .87 .90 Scale No. of items Observed Range SE Pain 5 1-10 5.20 (T) 4.82 (C) SE Function 9 1-10 SE Other Symptoms 6 1-10 Source of Psychometric Data Stanford Arthritis Self-Management Study. Psychometrics reported in: Lorig K, Chastain RL, Ung E, Shoor S, & Holman HR: Development and evaluation of a scale to measure self-efficacy in people with arthritis. Arthritis and Rheumatism, 32, 1, 1989, pp. 37-44. Scoring The score for each item is the number circled. If two consecutive numbers are circled, code the lower number (less self-efficacy). If the numbers are not consecutive, do not score the item. The score for the scale is the mean of the items. If more than 25% of the items are missing, do not score the scale. Comments The original response categories for these scales were 10-100, with “moderately certain” place midway between “very uncertain” and “very certain”. We found that subjects tended to circle the phrases rather than the numbers, and there was some confusion about whether “moderate” was truly in the middle for all people, so we dropped “moderately” from the scales. Data above have been adjusted to reflect the 1-10 response categories that we use now. The Self-Efficacy Function Scale should be scored separately, but Self-Efficacy Pain and Self-Efficacy Other Symptoms may be combined. There are 2 ways to format these items. We use the format above, because it takes up less room on the questionnaire. The other is shown on the web page. References Lorig K, Chastain RL, Ung E, Shoor S, & Holman HR: Development and evaluation of a scale to measure self-efficacy in people with arthritis. Arthritis and Rheumatism, 32, 1, 1989, pp. 37-44. 3 Current 8-item scale: 1. How certain are you that you can decrease your pain quite a bit? ______________________________ very | | | | | | | | | | very uncertain 1 2 3 4 5 6 7 8 9 10 certain 2. How certain are you that you can keep your arthritis or fibromyalgia pain from interfering with your sleep? ______________________________ very | | | | | | | | | | very uncertain 1 2 3 4 5 6 7 8 9 10 certain 3. How certain are you that you can keep your arthritis or fibromyalgia pain from interfering with the things you want to do? ______________________________ very | | | | | | | | | | very uncertain 1 2 3 4 5 6 7 8 9 10 certain 4. How certain are you that you can regulate your activity so as to be active without aggravating your arthritis or fibromyalgia? ______________________________ very | | | | | | | | | | very uncertain 1 2 3 4 5 6 7 8 9 10 certain 5. How certain are you that you can keep the fatigue caused by your arthritis or fibromyalgia from interfering with the things you want to do? ______________________________ very | | | | | | | | | | very uncertain 1 2 3 4 5 6 7 8 9 10 certain 6. How certain are you that you can do something to help yourself feel better if you are feeling blue? ______________________________ very | | | | | | | | | | very uncertain 1 2 3 4 5 6 7 8 9 10 certain 7. As compared with other people with arthritis or fibromyalgia like yours, how certain are you that you can manage pain during your daily activities? ______________________________ very | | | | | | | | | | very uncertain 1 2 3 4 5 6 7 8 9 10 certain 8. How certain are you that you can deal with the frustration of arthritis or fibromyalgia? ______________________________ very | | | | | | | | | | very uncertain 1 2 3 4 5 6 7 8 9 10 certain Scoring The score for each item is the number circled. If two consecutive numbers are circled, code the lower number (less self-efficacy). If the numbers are not consecutive, do not score the item. The score for the scale is the mean of the eight items. If more than two items are missing, do not score the scale. Characteristics Tested on 175 subjects with arthritis. No. of items Observed Range Mean Standard Deviation Internal Consistency Reliability Test-Retest Reliability 8 1-10 5.53 2.20 .92 NA 4 Source of Psychometric Data Stanford Arthritis Self-Management Study participants. Unpublished. Comments This is the scale we use in our current studies, as it is much less burdensome for subjects than the original 3 scales with 20 total items. We have not included function items because we also use the HAQ and there is a high correlation between the SE function scale and the HAQ disability scale. There are 2 ways to format these items. We use the format above, because it takes up less room on the questionnaire. The other is shown on the web site (address below). This scale is available in Spanish. References Lorig K, Chastain RL, Ung E, Shoor S, & Holman HR: Development and evaluation of a scale to measure self-efficacy in people with arthritis. Arthritis and Rheumatism, 32, 1, 1989, pp. 37-44 (original scales). This scale is free to use without permission Stanford Patient Education Research Center 1000 Welch Road, Suite 204 Palo Alto CA 94304 (650) 723-7935 (650) 725-9422 Fax [email protected] http://patienteducation.stanford.edu Funded by the National Institute of Nursing Research (NINR) 5 Back ToC Spanish Arthritis Self-Efficacy En las siguientes preguntas nos gustaría saber cómo le afecta el dolor de artritis y qué piensa Ud. de sus habilidades para controlar su artritis. En cada una de las siguientes escalas, por favor marque el número que mejor corresponda a su nivel de seguridad de que puede realizar en este momento las siguientes tareas. 1. ¿Qué tan seguro se siente Ud. de poder reducir bastante su dolor? ______________________________ muy | | | | | | | | | | muy inseguro(a) 1 2 3 4 5 6 7 8 9 10 seguro(a) 2. ¿Qué tan seguro se siente Ud. de poder evitar que el dolor de la artritis interfiera con su sueño? ______________________________ muy | | | | | | | | | | muy inseguro(a) 1 2 3 4 5 6 7 8 9 10 seguro(a) 3. ¿Qué tan seguro se siente Ud. de poder evitar que el dolor de la artritis interfiera con las cosas que quiere hacer? ______________________________ muy | | | | | | | | | | muy inseguro(a) 1 2 3 4 5 6 7 8 9 10 seguro(a) 4. ¿Qué tan seguro se siente Ud. de poder regular su actividad para mantenerse activo sin empeorar (agravar) su artritis? ______________________________ muy | | | | | | | | | | muy inseguro(a) 1 2 3 4 5 6 7 8 9 10 seguro(a) 5. ¿Qué tan seguro se siente Ud. de poder evitar que la fatiga (el cansancio), debido a su artritis, interfiera con las cosas que quiere hacer? ______________________________ muy | | | | | | | | | | muy inseguro(a) 1 2 3 4 5 6 7 8 9 10 seguro(a) 6. ¿Qué tan seguro se siente Ud. de poder ayudarse a sí mismo a sentirse mejor si se siente triste? ______________________________ muy | | | | | | | | | | muy inseguro(a) 1 2 3 4 5 6 7 8 9 10 seguro(a) 7. Comparándose con otras personas con artritis como la suya, ¿qué tan seguro se siente Ud. de poder sobrellevar el dolor de artritis durante sus actividades diarias? ______________________________ muy | | | | | | | | | | muy inseguro(a) 1 2 3 4 5 6 7 8 9 10 seguro(a) 8. ¿Qué tan seguro se siente Ud. de poder sobrellevar la frustración debido a su artritis? ______________________________ muy | | | | | | | | | | muy inseguro(a) 1 2 3 4 5 6 7 8 9 10 seguro(a) Scoring The score for each item is the number circled. If two consecutive numbers are circled, code the lower number (less self-efficacy). If the numbers are not consecutive, do not score the item. The score for the scale is the mean of the eight items. If more than two items are missing, do not score the scale. Characteristics Tested on 272 Spanish-speaking subjects. N=25 for test-retest. No. of items Observed Range Mean Standard Deviation Internal Consistency Reliability Test-Retest Reliability 8 1-10 5.9 2.1 .92 .69 Source of Psychometric Data Stanford Spanish Outcome Measures Study. Results reported in: González V, Stewart A, Ritter P, Lorig K, Translation and validation of arthritis outcome measures into Spanish. Arthritis and Rheumatism, 38(10),1995, pp.1429-1446. Comments There are 2 ways to format these items. We use the format above, because it takes up less room on the questionnaire. The other is shown on the web page. References González V, Stewart A, Ritter P, Lorig K, Translation and validation of arthritis outcome measures into Spanish. Arthritis and Rheumatism, 38(10),1995, pp.1429-1446. This scale is free to use without permission Stanford Patient Education Research Center 1000 Welch Road, Suite 204 Palo Alto CA 94304 (650) 723-7935 (650) 725-9422 Fax [email protected] http://patienteducation.stanford.edu Funded by the National Institute of Nursing Research (NINR) Back ToC Table of contents 1. INTRODUCTION........................................................................................................... 3 EUROQOL GROUP .......................................................................................................... 3 EQ-5D ........................................................................................................................... 4 WHAT IS A HEALTH STATE?.............................................................................................. 7 VERSIONS OF EQ-5D...................................................................................................... 8 2. SCORING THE EQ-5D DESCRIPTIVE SYSTEM ........................................................ 9 3. SCORING THE EQ VAS............................................................................................. 10 4. CONVERTING EQ-5D STATES TO A SINGLE SUMMARY INDEX ......................... 11 5. ORGANISING EQ-5D DATA ...................................................................................... 12 6. PRESENTING EQ-5D RESULTS ............................................................................... 13 HEALTH PROFILES ......................................................................................................... 13 EQ VAS ....................................................................................................................... 15 EQ-5D INDEX ............................................................................................................... 16 7. EQ-5D: FREQUENTLY ASKED QUESTIONS........................................................... 19 8. ADDITIONAL INFORMATION.................................................................................... 22 Version 2.0 February 2009 Web: www.euroqol.org Email: [email protected] 1. Introduction This guide has been developed in order to give users basic information on how to use EQ-5D. Topics include administering the instrument, setting up a database for data collected using EQ-5D as well as information about how to present the results. Also included are some frequently asked questions dealing with common issues regarding the use of EQ-5D and a list of currently available EuroQol Group products. EuroQol Group • The EuroQol Group is a network of international multidisciplinary researchers devoted to the measurement of health status. Established in 1987, the EuroQol Group originally consisted of researchers from Europe, but nowadays includes members from North America, Asia, Africa, Australia, and New Zealand. The Group is responsible for the development of EQ-5D, a preference based measure of health status that is now widely used in clinical trials, observational studies and other health surveys. • The EuroQol Group has been holding annual scientific meetings since its inception in 1987. • The EuroQol Group can be justifiably proud of its collective scientific achievements over the last 20 years. Research areas include: valuation, EQ-5D use in clinical studies and in population surveys, experimentation with the EQ-5D descriptive system, computerized applications, interpretation of EQ-5D ratings and the role of EQ-5D in measuring social inequalities in self-reported health. • The EuroQol Group’s website (www.euroqol.org) contains detailed information about EQ-5D, guidance for users, a list of available language versions, EQ-5D references and contact details. 3 EQ-5D EQ-5D is a standardised measure of health status developed by the EuroQol Group in order to provide a simple, generic measure of health for clinical and economic appraisal1. Applicable to a wide range of health conditions and treatments, it provides a simple descriptive profile and a single index value for health status that can be used in the clinical and economic evaluation of health care as well as in population health surveys (Figure 1). EQ-5D is designed for self-completion by respondents and is ideally suited for use in postal surveys, in clinics, and in face-to-face interviews. It is cognitively undemanding, taking only a few minutes to complete. Instructions to respondents are included in the questionnaire. EQ-5D essentially consists of 2 pages - the EQ-5D descriptive system (page 2) and the EQ visual analogue scale (EQ VAS) (page 3). The EQ-5D descriptive system comprises the following 5 dimensions: mobility, self-care, usual activities, pain/discomfort and anxiety/depression. Each dimension has 3 levels: no problems, some problems, severe problems. The respondent is asked to indicate his/her health state by ticking (or placing a cross) in the box against the most appropriate statement in each of the 5 dimensions. This decision results in a 1-digit number expressing the level selected for that dimension. The digits for 5 dimensions can be combined in a 5digit number describing the respondent’s health state. It should be noted that the numerals 1-3 have no arithmetic properties and should not be used as a cardinal score. The EQ VAS records the respondent’s self-rated health on a vertical, visual analogue scale where the endpoints are labelled ‘Best imaginable health state’ and ‘Worst imaginable health state’. This information can be used as a quantitative measure of health outcome as judged by the individual respondents. 1 EuroQol Group. EuroQol-a new facility for the measurement of health-related quality of life. Health Policy 1990;16:199-208 4 Figure 1: EQ-5D (UK English version) By placing a tick in one box in each group below, please indicate which statements best describe your own health state today. Mobility I have no problems in walking about I have some problems in walking about I am confined to bed Self-Care I have no problems with self-care I have some problems washing or dressing myself I am unable to wash or dress myself Usual Activities (e.g. work, study, housework, family or leisure activities) I have no problems with performing my usual activities I have some problems with performing my usual activities I am unable to perform my usual activities Pain/Discomfort I have no pain or discomfort I have moderate pain or discomfort I have extreme pain or discomfort Anxiety/Depression I am not anxious or depressed I am moderately anxious or depressed I am extremely anxious or depressed 5 Best imaginable health state 100 To help people say how good or bad a health state is, we have drawn a scale (rather like a thermometer) on which the best state you can imagine is marked 100 and the worst state you can 9 0 imagine is marked 0. We would like you to indicate on this scale how 8 0 good or bad your own health is today, in your opinion. Please do this by drawing a line from the box below to whichever point on the scale 7 0 indicates how good or bad your health state is today. 6 0 Your own health state today 5 0 4 0 3 0 2 0 1 0 0 Worst imaginable health state 6 What is a health state? Each of the 5 dimensions comprising the EQ-5D descriptive system is divided into 3 levels of perceived problems: Level 1: indicating no problem Level 2: indicating some problems Level 3: indicating extreme problems A unique health state is defined by combining 1 level from each of the 5 dimensions. Anxiety / Depression Pain / Discomfort Mobility Health state Self-Care UsualActivities Activity Usual A total of 243 possible health states is defined in this way. Each state is referred to in terms of a 5 digit code. For example, state 11111 indicates no problems on any of the 5 dimensions, while state 11223 indicates no problems with mobility and self care, some problems with performing usual activities, moderate pain or discomfort and extreme anxiety or depression. Note: Two further states (unconscious and death) are included in the full set of 245 EQ-5D health states, but information on these states is not collected via self-report. 7 Versions of EQ-5D EQ-5D in different languages Currently there are more than 100 translated versions of EQ-5D. If you want to know if there is an EQ-5D version appropriate for your country, please consult the website. All translations/adaptations of EQ-5D are produced using a standardised translation protocol that conforms to internationally recognized guidelines. These guidelines aim to ensure semantic and conceptual equivalence and involve a forward/backward translation process and lay panel assessment. Only the EuroQol Group Executive Office can give permission for a translation to be performed and translations can only be stamped as official if they are performed in cooperation with EuroQol Group reviewers. Alternative modes of administration EQ-5D was primarily designed for self-completion by the patient or respondent. However EQ-5D self-report data can also be collected using the following alternative modes of administration: (i) Face-to-face (ii) Self-completion in the presence of an interviewer (iii) Telephone interview (iv) Interactive Voice Response (IVR) versions (available through a preferred vendor - Perceptive Informatics) (v) Proxy (asking the proxy to rate how he or she, (i.e. the proxy), would rate the subject’s health) 8 2. Scoring the EQ-5D descriptive system The EQ-5D descriptive system should be scored as follows: Levels of perceived problems are coded By placing a tick in one box in each group, please indicate which whic h statements best describe your health today. as follows: 9 Mobility I have no problems in walking about I have some problems in walking about I am confined to bed Self-Care I have no problems with self-care I have some problems washing or dressing myself I am unable to wash or dress myself Level 2 9 is coded as a ‘2’ Level 3 Pain/Discomfort I have no pain or discomfort I have moderate pain or discomfort I have extreme pain or discomfort 9 is coded Anxiety/Depression I am not anxious or depressed I am moderately anxious or depressed I am extremely anxious or depressed Usual Activities (e.g. work, study, housework, family or leisure activities) I have some problems with performing my usual activities II have no usual activities activities have no problems problems with with performing performing my my usual housework, family ormy leisure I(e.g. havework, somestudy, problems with performing usualactivities) activities I am unable to perform my usual activities Level 1 is coded as a ‘1’ as a ‘3’ NB: There should be only one response for each dimension. This example identifies the state 11232. Missing values can be coded as ‘9’. Ambiguous values (e.g. 2 boxes are ticked for a single dimension) should be treated as missing values. 9 3. Scoring the EQ VAS The EQ VAS should be scored as follows: To help people say how good or bad a health state is, we have drawn a scale (rather like a thermometer) on which the best state you can imagine is marked 100 and the worst state you can imagine is marked 0. We would like you to indicate on this scale how good or bad your own health is today, in your opinion. Please do this by drawing a line from the box below to whichever point on the scale indicates how good or bad your health state is today. Your own health state today Best imaginable health state 100 9 0 8 0 7 0 6 0 5 0 4 0 3 0 2 0 8 0 7 0 6 0 8 0 7 0 6 0 1 0 0 Worst imaginable health state For example this response should be coded as 77 Even though the line does not cross the VAS this response can still be scored by drawing a horizontal line from the end point of the response to the VAS. In this example the response should be coded as 77 Missing values should be coded as ‘999’. Ambiguous values (e.g. the line crosses the VAS twice) should be treated as missing values. 10 4. Converting EQ-5D states to a single summary index EQ-5D health states, defined by the EQ-5D descriptive system, may be converted into a single summary index by applying a formula that essentially attaches values (also called weights) to each of the levels in each dimension. The index can be calculated by deducting the appropriate weights from 1, the value for full health (i.e. state 11111). Information in this format is useful, for example, in cost utility analysis. Value sets have been derived for EQ-5D in several countries using the EQ-5D visual analogue scale (EQ-5D VAS) valuation technique or the time trade-off (TTO) valuation technique. The list of currently available value sets with the number of respondents and valuation technique applied is presented in table 1. Most of the EQ5D value sets have been obtained using a representative sample of the general population, thereby ensuring that they represent the societal perspective. For anyone working with EQ-5D data, an essential guide to the Group’s available value sets can be found in: EuroQol Group Monograph series: Volume 2: EQ-5D value sets: inventory, comparative review and user guide, recently published by Springer (see section 8 for more information). Table 1: List of available value sets (references available on the website) Country Belgium Denmark Denmark Europe Finland Germany Germany Japan Netherlands New Zealand Slovenia Spain Spain UK UK US Zimbabwe N Valuation method 722 1686 1332 8709 1634 339 339 621 309 1360 733 300 1000 3395 3395 4048 2440 EQ-5D VAS EQ-5D VAS TTO EQ-5D VAS EQ-5D VAS EQ-5D VAS TTO TTO TTO EQ-5D VAS EQ-5D VAS EQ-5D VAS TTO EQ-5D VAS TTO TTO TTO Documents containing the scoring algorithms, information on the valuation studies, tables of values for all 243 health states and SPSS and SAS syntax files can be ordered from the EuroQol Executive Office ([email protected]). 11 5. Organising EQ-5D data Data collected using EQ-5D can be entered in a database according to the following schema: Variable ID COUNTRY YEAR MOBILITY name patient ID 1=No Variable Problems, description number 2=Some problems, 3=Extreme problems, 9=Missing value Data row 1 Data row 2 1001 1002 Variable STATE name Variable description Data row 1 Data row 2 21221 21111 UK UK EQ_VAS 999= Missing value 80 90 2006 2006 SELFCARE 1=No Problems, 2=Some problems, 3=Extreme problems, 9=Missing value ACTIVITY 1=No Problems, 2=Some problems, 3=Extreme problems, 9=Missing value PAIN 1=No Problems, 2=Some problems, 3=Extreme problems, 9=Missing value ANXIETY 1=No Problems, 2=Some problems, 3=Extreme problems, 9=Missing value 1 1 2 1 2 1 1 1 2 1 SEX 1=male, 2=female, 9=Missing value AGE 999= Missing value 1 2 EDU 1=low, 2=medium, 3=high, 9=Missing value 43 24 METHOD 0=postal, 1=interview, 2=telephone, 9=Missing value 1 2 SOC_ECON 1=employed, 2=retired, ….., 9=Missing value 0 0 NB: The variable names are just examples. However, the variables for the 5 dimensions of the EQ-5D descriptive system should be named 'mobility', 'selfcare', 'activity', 'pain', and 'anxiety'. If they are given different names the syntax codes containing the value sets that are distributed by the EuroQol Group will not work properly. 12 1 4 6. Presenting EQ-5D results Data collected using EQ-5D can be presented in various ways. A basic subdivision can be made according to the structure of the EQ-5D: 1. Presenting results from the descriptive system as a health profile 2. Presenting results of the EQ VAS as a measure of overall self-rated health status 3. Presenting results from the descriptive system as a weighted index However, the way results are presented is partly determined by what message you, as a researcher, wish to convey to your audience. Health profiles One way of presenting data as a health profile is by making a table with the frequency or the proportion of reported problems for each level for each dimension. These tables can be broken down to include the proportions per subgroup, such as age, before vs. after treatment, treatment vs. comparator, etc. Sometimes it is more convenient to dichotomise the EQ-5D levels into 'no problems' (i.e. level 1) and 'problems' (i.e. levels 2 and 3), thereby changing the profile into frequencies of reported problems. This can be the case, for example, in a general population survey where the numbers of reported level 3 problems are very low. Tables 2 and 3 are examples of how to present EQ-5D data in tabulated form. The data for the tables originates from a general population survey in the UK2. 2 Kind P, Dolan P, Gudex C, Williams A. Variations in population health status: results from a United Kingdom national questionnaire survey Bmj 1998;316 (7133): 736-41. 13 Table 2: Proportion of levels 1, 2 and 3 by dimension and by age group EQ-5D DIMENSION Level 1 MOBILITY Level 2 Level 3 Level 1 SELF-CARE Level 2 Level 3 Level 1 USUAL Level 2 ACTIVITIES Level 3 Level 1 PAIN / DISCOMFORT Level 2 Level 3 Level 1 ANXIETY / DEPRESSION Level 2 Level 3 18-29 95.4 4.6 0.0 99.1 0.9 0.0 93.3 6.3 0.4 83.9 15.8 0.3 86.5 12.6 0.9 AGE GROUPS 40-49 50-59 60-69 89.7 78.1 70.7 9.9 21.9 29.3 0.4 0.0 0.0 95.8 94.8 94.3 4.0 5.2 5.5 0.2 0.0 0.2 89.2 78.1 75.3 9.4 18.8 21.6 1.5 3.0 3.1 74.1 56.3 53.8 22.8 38.1 40.6 3.1 5.6 5.6 81.3 72.8 72.0 16.9 24.4 25.1 1.8 2.8 2.9 30-39 92.2 7.6 0.1 98.4 1.5 0.1 91.4 7.9 0.7 80.7 17.7 1.6 82.6 16.4 1.0 70-79 60.2 39.8 0.0 92.6 7.1 0.2 73.7 22.1 4.2 44.0 48.4 7.6 74.7 22.6 2.7 80+ 43.3 56.7 0.0 83.7 15.6 0.7 56.0 38.3 5.7 39.7 49.6 10.6 75.2 24.1 0.7 TOTAL 81.6 18.3 0.1 95.7 4.1 0.1 83.7 14.2 2.1 67.0 29.2 3.8 79.1 19.1 1.8 80+ 61 81 119 23 80 62 56 86 107 35 TOTAL 2770 625 3251 144 2842 553 2275 1120 2684 711 Table 3: Frequency of reported problems by dimension and age group EQ-5D DIMENSION No problems MOBILITY Problems No problems SELF-CARE Problems USUAL No problems ACTIVITIES Problems PAIN / No problems DISCOMFORT Problems ANXIETY / No problems DEPRESSION Problems 18-29 643 31 668 6 629 45 566 108 583 91 30-39 631 53 673 11 625 59 552 132 565 119 AGE GROUPS 40-49 50-59 60-69 489 362 339 56 101 140 522 439 452 23 24 27 486 362 361 59 101 118 404 261 258 141 202 221 443 337 345 102 126 134 70-79 246 162 378 30 301 107 179 229 305 103 In addition to presenting the results in tabulated form, you can also use graphical presentations. Two or 3 dimensional bar charts can be used to summarise the results in 1 graph, (see figure 2). Figure 2 shows the sum of the proportion of reported level 2 and level 3 problems for each of the 5 EQ-5D dimensions for 3 distinct age groups. Older people reported more problems on all dimensions but the effect of age was strongest for mobility and weakest for anxiety/depression. 14 Figure 2: Profile of the population (% reporting problem) 70 60 50 40 18-39 yrs 40-59 yrs 30 60+ yrs 20 10 0 Mobility Self care Usual act Pain/Disc Anx/Depr EQ VAS In order to present all aspects of the EQ VAS data, you should present both a measure of the central tendency and a measure of dispersion. This could be the mean values and the standard deviation or, if the data is skewed, the median values and the 25th and 75th percentiles. An example is presented in table 4. The data for the table originates from a general population survey in the UK3. Table 4: EQ VAS values by age – mean + standard deviation and median + percentiles EQ VAS Mean - Std dev Median - 25th - 75th 18-29 87.0 13.8 90 80 98 30-39 86.2 14.6 90 80 95 AGE GROUPS 40-49 50-59 60-69 85.1 81.3 79.8 15.5 46.8 17.5 90 86 85 80 70 70 95 95 93 70-79 75.3 18.5 80 65 90 80+ 72.5 18.2 75 60 88 TOTAL 82.8 23.1 90 75 95 You can present a graphical representation of the data by using bar charts, line charts, or both (see figure 3). Figure 3 shows the mean EQ VAS ratings reported by 3 Kind P, Dolan P, Gudex C, Williams A. Variations in population health status: results from a United Kingdom national questionnaire survey Bmj 1998;316 (7133): 736-41. 15 men, women and both for 7 distinct age groups. The mean EQ VAS ratings are seen to decrease with increasing age. Also, men of all age groups reported higher EQ VAS ratings than women. Figure 3: Mean population EQ VAS ratings by age group and sex 100 EQ VAS 90 80 Men Women Total 70 60 50 18-29 30-39 40-49 50-59 60-69 70-79 80+ age (yrs) EQ-5D index Information about the EQ-5D index can be presented in much the same way as the EQ VAS data. This means that for the index, you can present both a measure of the central tendency and a measure of dispersion. This could be the mean values and the standard deviation (or standard error). If the data is skewed, the median values and the 25th and 75th percentiles could be presented. Tables 5 and 6 and figures 4 and 5 contain 2 examples of how to present EQ-5D index results. Table 5 and figure 4 present the results from a study where the effect of a treatment on health status is investigated. Table 6 and figure 5 show results for a patient population and 3 subgroups (the tables and figures are based on hypothetical data and for illustration purposes only). 16 Table 5: EQ-5D index values before and after treatment – mean + standard deviation and median + percentiles EQ-5D index Mean - Std error Median - 25th - 75th before treatment 0.59 0.012 0.60 0.50 0.70 after treatment 0.76 0.015 0.70 0.65 0.80 120 110 Figure 4: EQ-5D index values before and after treatment ─ mean values and 95% confidence intervals 1.00 0.90 0.80 0.70 Utility 0.60 N 0.50 0.40 0.30 0.20 0.10 0.00 17 before treatment after treatment Table 6: EQ-5D index values of the total patient population and the 3 subgroups – mean + standard deviation and median + percentiles EQ-5Dindex Mean - Std error Median - 25th - 75th All patients 0.66 0.010 0.55 0.50 0.70 Subgroup 1 0.45 0.013 0.40 0.30 0.50 Subgroup 2 0.55 0.015 0.55 0.50 0.60 Subgroup 3 0.90 0.010 0.95 0.80 1.00 N 300 100 75 125 Figure 5: EQ-5D index values of the total patient population and the 3 subgroups – mean values and 95% confidence intervals 1.00 0.90 0.80 0.70 Utility 0.60 0.50 0.40 0.30 0.20 0.10 0.00 All patients Subgroup 1 18 Subgroup 2 Subgroup 3 7. EQ-5D: Frequently asked questions For what period of time does EQ-5D record health status? Self-reported health status captured by EQ-5D relates to the respondent’s situation at the time of completion. No attempt is made to summarise the recalled health status over the preceding days or weeks, although EQ-5D has been tested in recall mode. An early decision taken by the EuroQol Group determined that health status measurement ought to apply to the respondent’s immediate situation - hence the focus on ‘your own health state today’. General population value sets vs patient population value sets If you want to undertake a utility analysis you will need to use a value set. Generally speaking utility analysis requires a general population-based value set (as opposed to a patient-based set). The rationale behind this is that the values are supposed to reflect the preferences of local taxpayers and potential receivers of healthcare. Additionally, patients tend to rate their health states higher than the general population because of coping etc, often underestimating their need for healthcare. The EQ-5D value sets are therefore based on the values of the general population. Difference between the EQ-5D descriptive system and the EQ VAS The descriptive system can be represented as a health state, e.g. health state 11212 represents a patient who indicates some problems on the usual activities and anxiety/depression dimensions. These health states can be converted to a single index value using (one of) the available EQ-5D value sets. These value sets have been derived using VAS or TTO valuation techniques, and reflect the opinion of the general population. The EQ VAS scores are patient-based and are therefore not representative of the general population. The EQ VAS self-rating records the respondent’s own assessment of their health status. The EQ VAS scores however are anchored on 100 = best imaginable health and 0 = worst imaginable health, whereas the value sets are anchored on 11111 = 1 and dead = 0 and can therefore be used in QALY calculations. 19 Difference between the VAS and TTO techniques The difference between the value sets based on TTO and those based on VAS is that the techniques used for the elicitation of the values on which the models are based differ. In the TTO task, respondents are asked, for example, to imagine they live in a health state (e.g. 22222) for 10 years and then asked to specify the amount of time they are willing to give up to live in full health instead (i.e. 11111). For example, someone might find 8 years in 11111 equivalent to 10 years in 22222. The VAS technique on the other hand, asks people to indicate where, on a vertical thermometer-like scale ranging from best imaginable health to worst imaginable health, they think a health state should be positioned. Multinational clinical trials Information relating to EQ-5D health states gathered in the context of multinational trials may be converted into a single summary index using one of the available EQ5D value sets. There are different options available to do this using appropriate value sets-however the choice depends on the context in which the information will be used by researchers or decision makers. In cases where data from an international trial are to be used to inform decision makers in a specific country, it seems reasonable to expect decision makers to be interested primarily in value sets that reflect the values for EQ-5D health states in that specific country. So for example, if applications for reimbursement of a drug are rolled out from country to country, country-specific value sets should be applied and reported in each pharmaco-economic report. This is no different from the requirement to use country-specific costs. In the absence of a country-specific value set, the researcher should select another set of values for a population that most closely approximates that country. Sometimes however, information about utilities is required to inform researchers or decision makers in an international context. In these instances, 1 value set applied over all EQ-5D health states data is probably more appropriate. The decision about which value set to use will also depend on whether the relevant decision making body in each country specifies any requirements or preferences in regard to the methodology used in different contexts (e.g. TTO, standard gamble (SG), VAS or discrete choice modelling (DCM)). These guidelines are the topic of an international ongoing debate but the EuroQol Group website is planning to provide a summary of health care decision-making bodies internationally, and their stated requirements regarding the valuation of health states. 20 Detailed information regarding the valuation protocols, guidelines on which value set to use and tables of all available value sets has recently been published by Springer in: EuroQol Group Monograph series: Volume 2: EQ-5D value sets: inventory, comparative review and user guide’ (see section 8 for more information). Chapter 4 by Nancy Devlin and David Parkin will be of special interest to researchers pondering the issue of which value set to use. Can I use only the EQ-5D descriptive system or only the EQ VAS? We cannot advise this. EQ-5D is a 2-part instrument so if you only use 1 part you cannot claim to have used EQ-5D in your publications. How long should the EQ VAS be? Officially, for paper versions, the EQ VAS scale should be 20cms. All methodological and developmental work has been carried using this length. To ensure that you print the correct length, make sure your paper size is set at A4 and the box in your printing instructions labelled ‘scale to paper size’ is set at ‘no scaling’. Can I publish our study using EQ-5D? Yes, you are free to publish your results. If you are reproducing the EQ-5D in an appendix we request that you use the sample version of EQ-5D and that the following text is included in the footer: © 1990 EuroQol Group. EQ-5D™ is a trade mark of the EuroQol Group. 21 8. Additional information Key EuroQol Group references 1. The EuroQol Group (1990). EuroQol-a new facility for the measurement of health-related quality of life. Health Policy 16(3):199-208. 2. Brooks R (1996). EuroQol: the current state of play. Health Policy 37(1):53-72. 3. Dolan P (1997). Modeling valuations for EuroQol health states. Med Care 35(11):1095-108. 4. Roset M, Badia X, Mayo NE (1999). Sample size calculations in studies using the EuroQol 5D. Qual Life Res 8(6):539-49. 5. Greiner W, Weijnen T, Nieuwenhuizen M, et al. (2003). A single European currency for EQ-5D health states. Results from a six country study. Eur J Health Econ; 4(3):222-231. 6. Shaw JW, Johnson JA, Coons SJ (2005). US valuation of the EQ-5D health states: development and testing of the D1 valuation model. Med Care; 43(3): 203-220. Referring to the EQ-5D instrument in publications When publishing results obtained with the EQ-5D, the following references can be used: 1. The EuroQol Group (1990). EuroQol-a new facility for the measurement of health-related quality of life. Health Policy 16(3):199-208. 2. Brooks R (1996). EuroQol: the current state of play. Health Policy 37(1):53-72. If you used a value set in your study you can also include a reference to the publication regarding that value set. The appropriate references for the value sets can be found in the EQ-5D Value Sets Monograph and in the value set summary documents that can be ordered from the EuroQol Executive Office. Products available from the EuroQol Executive Office EQ-5D language versions (self-report and alternative modes of self-report) All self-report and alternative modes of self-report versions in different languages must be obtained exclusively from the EuroQol Executive Office. Normally only the language(s) appropriate to the country where the research request originates will be supplied. Licensing fees are determined by the EuroQol Executive Office on the basis of information provided by the user. Whether a fee is appropriate depends upon the type of study, size and/or number of patients/respondents and requested languages. 22 The Measurement and valuation of health status using EQ-5D: A European perspective. Eds Brooks R, Rabin R, de Charro F. Kluwer Acacemic Publishers, 2005 This book reports on the results of the European Union-funded EQ-net project which furthered the development of EQ-5D in the key areas of valuation, application and translation. The book can be obtained from Springer at www.springeronline.com at a cost of €107.95. Measuring self-reported population health: An international perspective based on EQ-5D. Eds Szende A, Williams A. EuroQol Group Monographs Volume 1. SpringMed publishing, 2004. This booklet provides population reference data for a number of different countries and is available on request from the EuroQol Executive Office. EQ-5D concepts and methods: a developmental history. Eds Kind P, Brooks R, Rabin R. Springer, 2005. This book is a collection of papers representing the collective intellectual enterprise of the EuroQol Group and can be obtained from Springer at www.springeronline.com at a cost of € 85.00. EQ-5D value sets: Inventory, comparative review and user guide. Eds. Szende A, Oppe M, Devlin N. EuroQol Group Monographs Volume 2. Springer, 2006. This book provides an essential guide to the use of the EuroQol Group’s value sets for anyone working with EQ-5D data and can be obtained from Springer at www.springeronline.com at a cost of € 49.95. Future developments Since 2002, the EuroQol Group Foundation has provided modest funding for EuroQol Group members to carry out innovative EQ-5D-related research. Since 2004, the Group has been establishing specific task forces to: • Investigate the use of EQ-5D in different disease areas • Develop a 5-level version of EQ-5D • Explore different valuation methodologies for valuing EQ-5D health states 23 • Develop an EQ-5D version for young people and children in different languages • Investigate the use of EQ-5D in population health • Explore the use of electronic versions of EQ-5D in pc and web-based applications as well as palm pilots and (in the future) cell phones. This task force will also investigate the eliciting of values via the computer Please check the EuroQol Group website for up-to-date information on the availability of current and future EuroQol Group products. Contact information: For more information please look at the EuroQol Group website at www.euroqol.org or e-mail us at [email protected] Acknowledgements: Part of this user guide was taken from and is based on the UK user guide that was developed by Professor Paul Kind from York University, UK in 1998. 24 Back ToC GAIT SPEED TEST Equipment needed: • Masking tape or paper tape (4 pieces). • Tape measure (English or metric) • Stopwatch. Setup: • Decide on length of gait test distance, acceleration zone and deceleration zone based on space availability. Be sure to have unobstructed floor space. • Using masking tape or paper tape mark a start line on the floor (line#1). • Measure an acceleration zone of 1 step to 3 meters based on available space and place a piece of tape at this distance on the floor (line#2). • Measure the test distance of 10 ft etc and place a piece of tape on the floor (line#3). • Measure a deceleration zone of 1 step to 3 meters and place a piece of tape at this distance on the floor (line#4). Measuring comfortable gait speed: Start position: Patient/client stands behind the start line. Instructions given: • Ask patient to walk at a comfortable pace from before the start line (line#1) to the end line (line#4). Measurement: • Using a stopwatch, time from when the patient’s leading limb (toe) crosses the test distance line (line #2) until the leading limb crosses the end test distance line (line#3). Be sure patient does not stop at line #3, patient should walk to line #4 to insure deceleration does not occur in the test distance. Calculation: Comfortable gait speed = test distance/time to complete test distance. Measuring fast gait speed: Same as cgs except for the instructions given to the patient. • Ask patient to walk as fast as you safely can from before the start line (line#1) to the end line (line#4). Measurement and calculation are the same as cgs. Back ToC GERI-AIMS PAIN SCALE The following questions concern the amount of pain you are currently experiencing in your hips and/or knees. For each situation, please indicate the amount of pain you recently experienced using the following scale: None, Mild, Moderate, Severe, Extreme. CIRCLE ONE NUMBER ONLY. QUESTION: How much pain do you have? None Mild Moderate Severe Extreme 1 2 3 4 1 2 3 4 0 1 2 3 4 0 1 2 3 4 0 1 2 3 4 14. Walking on a flat surface 0 15. Going up or down stairs 0 16. At night while in bed 17. Sitting or lying 18. Standing upright The following questions concern the amount of joint stiffness (not pain) you are currently experiencing in your hips and/or knees. Stiffness is a sensation of restriction or slowness in the ease with which you move your joints. CIRCLE ONE NUMBER ONLY. None Mild Moderate Severe Extreme 19. How severe is your stiffness after first waking in the morning? 0 1 2 3 4 20. How severe is your stiffness after sitting, lying, or resting later in the day? 0 1 2 3 4 21. During the past month, how often have you had to take medication for your arthritis? Always .............................................................................................1 Very often ........................................................................................2 Fairly often ......................................................................................3 Sometimes ........................................................................................4 Almost never ....................................................................................5 Never ............................................................................................... These questions are about how you feel and how things have been with you during the past month. For each question, please circle one number for each question that comes closest to the way you have been feeling How much time during the past 4 weeks… 22. Did you feel worn out? 0 1 None of A little the time of the time 2 Some of the time 3 A good bit of the time 4 Most of the time 5 All of the time 2 Some of the time 3 A good bit of the time 4 Most of the time 5 All of the time 2 Some of the time 3 A good bit of the time 4 Most of the time 5 All of the time 23. Did you have a lot of energy? 0 1 None of A little the time of the time 24. Did you feel tired? 0 1 None of A little the time of the time 25. Did you have enough energy to do the things you wanted to do? 0 1 None of A little the time of the time 2 Some of the time 3 A good bit of the time 4 Most of the time 5 All of the time 3 A good bit of the time 4 Most of the time 5 All of the time 26. Did you feel full of pep? 0 1 None of A little the time of the time 2 Some of the time Back ToC The Groningen Activity Restriction Scale (GARS) Overview: The Groningen Activity Restriction Scale (GARS) is general disease independent instrument for measuring disability. It can be used to monitor a patient over time and to identify potential interventions. The authors are from the University of Groningen in The Netherlands. Statements about Activities of Daily Living (ADL) - Can you fully independently: (1) dress yourself? (2) get in and out of bed? (3) stand up from sitting in a chair? (4) wash your face and hands? (5) wash and dry your whole body? (6) get on and off the toilet? (7) feed yourself? (8) get around in the house (if necessary with a cane)? (9) go up and down the stairs? (10) walk outdoors (if necessary with a cane)? (11) take care of your feet and toenails? Statements about Instrumental Activities of Daily Living (IADL) - Can you fully independently: (12) prepare breakfast or lunch? (13) prepare dinner? (14) do "light" household activities (for example dusting and tidying up)? (15) do "heavy" household activities (for example mopping cleaning the windows and vacuuming)? (16) wash and iron your clothes? (17) make the beds? (18) do the shopping? Response (based on what the patient is able to do) Points Yes I can do it fully independently without any difficulty 1 Yes I can do it fully independently but with some difficulty 2 Yes I can do it fully independently but with great difficulty 3 No I cannot do it fully independently. I can only do it with someone's help. 4 No I cannot do it at all. I need complete help. 4 where: • The point assignment for needing complete help was originally 5 points but was switched to 4 becaue only a few patients selected this response. There may be an argument to keep it at 5 points. • The response is based on what the patient is able to do rather than what s/he usually does. total score = SUM(points for all 18 items) Interpretation: • minimum score: 18 • maximum score: 72 • The higher the score the greater the disability. References: Suurmeijer TBPM Doeglas DM et al. The Groningen Activity Restriction Scale for measuring disability: Its utility in international comparisons. Am J Public Health. 1994; 84: 1270-1273 (Table 1 page 1271). Back ToC Hip ID: Study Hip: Left Right Examination Date (MM/DD/YY): Subject Initials: |____|____|____| Medical Record Number: Harris Hip Score Interval: / / ______________ Harris Hip Score Pain (check one) None or ignores it (44) Slight, occasional, no compromise in activities (40) Mild pain, no effect on average activities, rarely moderate pain with unusual activity; may take aspirin (30) Moderate Pain, tolerable but makes concession to pain. Some limitation of ordinary activity or work. May require Occasional pain medication stronger than aspirin (20) Marked pain, serious limitation of activities (10) Totally disabled, crippled, pain in bed, bedridden (0) Limp None (11) Slight (8) Moderate (5) Severe (0) Support None (11) Cane for long walks (7) Cane most of time (5) One crutch (3) Two canes (2) Two crutches or not able to walk (0) Distance Walked Unlimited (11) Six blocks (8) Two or three blocks (5) Indoors only (2) Bed and chair only (0) Sitting Comfortably in ordinary chair for one hour (5) On a high chair for 30 minutes (3) Unable to sit comfortably in any chair (0) Enter public transportation Yes (1) No (0) Stairs Normally without using a railing (4) Normally using a railing (2) In any manner (1) Unable to do stairs (0) Put on Shoes and Socks With ease (4) With difficulty (2) Unable (0) Absence of Deformity (All yes = 4; Less than 4 =0) Less than 30° fixed flexion contracture Less than 10° fixed abduction Less than 10° fixed internal rotation in extension Limb length discrepancy less than 3.2 cm Yes Yes Yes Yes Range of Motion (*indicates normal) Flexion (*140°) ________ Abduction (*40°) ________ Adduction (*40°) ________ External Rotation (*40°) ________ Internal Rotation (*40°) ________ Range of Motion Scale 211° - 300° (5) 61° - 100 (2) 161° - 210° (4) 101° - 160° (3) 31° - 60° (1) 0° - 30° (0) Range of Motion Score ____________ Total Harris Hip Score ____________ No No No No Explaining the use of the Harris Hip Questionnaire By Thomas J. Blumenfeld, MD. The old adage, there is no such thing as a stupid question, may at times be sorely tested. I have wondered about this as I have come to the end of asking many of you about how your hip is doing, just prior to the physical exam. Those of you who have had your hip replaced know that, at each follow-up visit, a standard set of questions is asked. You are asked questions such as if you have any hip pain, how far you can walk whether you can put on your own shoes and socks, even if you can use public transportation. To date, no one has asked why we ask these questions, or what their relevance is. The answers to these questions form the basis for the Harris Hip Score (HHS1~ Developed by Dr. William Harris, a prominent orthopaedist in Massachusetts, the HHS is a tool for the evaluation of how a patient is doing after their hip is replaced. Based on a total of 100 points possible, each question is awarded a certain number of points based on how it is answered. Questions are further grouped into categories. The first category is pain. For example, if you have no pain in your hip you get 44 points, slight pain 40 points, down to 0 points for disabling pain. The second category is function. If you have no limp, do not use a walking aid, and can walk more than six blocks, you get 33 points; less if you were to use a cane, or walk only two blocks, etc. The third category, functional activities, consists of questions about how you climb stairs, put on shoes, length of time you can sit in a chair, and if you can use public transportation. Finally, the physical exam results are tabulated, and based on your range of motion, up to 9 points awarded. The score is reported as 90-100 for excellent results, 80-90 being good, 70-79 fair, 60-69 poor, and below 60 a failed result. Using the HHS, results of hip replacements can be compared across the country in an objective fashion. In the clinic, the HHS allows us to rapidly get a feel for how you are doing after surgery. The HHS, being an objective tool, has one shortcoming. The score does not allow for individual differences based on age, health, or other personal issues that may affect the total score. How might this occur? Let us imagine that one of you finds the idea of walking six blocks as appealing as root canal surgery, or you can only walk two blocks because of asthma, not because of your hip. You would only get five out of a possible eleven points. Then let's say that you use a cane for balance when you walk. You would get seven out of a possible eleven points. If you use a railing to go up stairs (and I expect that many of you do for safety alone), you only get two out of the possible 4 points. This would mean that the best HHS you could get would be an 88, which is a good result. You however may feel that because you have no pain and can do what you wish, that you have an excellent result from you hip replacement. We here would agree. The above example highlights a key point, that while the HHS is an objective tool, it must be interpreted by a subjective individual, namely your doctor. While we take some comfort when you have a high score, and tend to be concerned when the score is low, there are many variables that affect the total score. The HHS, without the clinical acumen to use it appropriately, is only a number. In summary, the HHS is a tool that allows us to find out how you are doing after your hip replacement. We keep all of your scores enabling us to follow you along as you and your hip pass the years together. We hope to have many chances to ask questions of you that may at times seem stupid, but are quite important to you and your hip's health and good function. Back ToC Stanford HAQ 8-Item Disability Scale Please check ( ) the one best answer for your abilities. Without ANY difficulty With SOME difficulty With MUCH difficulty UNABLE to do 1. Dress yourself, including tying shoelaces and doing buttons? .......................... R R R R 2. Get in and out of bed? ..................................... R R R R 3. Lift a full cup or glass to your mouth? .............. R R R R 4. Walk outdoors on flat ground? ......................... R R R R 5. Wash and dry your entire body? ...................... R R R R R R R R 7. Turn faucets on and off?................................... R R R R At this moment, are you able to: 6. Bend down to pick up clothing from the floor? 8. Get in and out of a car? .................................... Scoring Score the number circled for each item. If more than one consecutive number is circled for one item, code the higher number (more difficulty). If responses are not consecutive, code as blank. The disability index is the mean of the eight items. If more than 2 items are blank, do not score the index. Characteristics Tested on 611 subjects with chronic disease. No. of items Observed Range Mean Standard Deviation Internal Consistency Reliability Test-Retest Reliability 1 0-1.88 0.384 0.409 .85 NA Source of Psychometric Data Stanford/Garfield Kaiser Chronic Disease Dissemination Study. Psychometrics reported in: Lorig KR, Sobel, DS, Ritter PL, Laurent, D, Hobbs, M. Effect of a self-management program on patients with chronic disease. Effective Clinical Practice, 4, 2001,pp. 256-262. Comments This is a short version of the 22-item disability scale in the Stanford Health Assessment Questionnaire. The 8-item scale was originally developed in Spanish. We have replaced the numbers with check boxes on the print version. It should be noted that the items have been chosen as they represent use of every major joint in the body. While closely related to an ADL scale this is not an ADL scale but rather a disability scale. This scale is available in Spanish. References Lorig KR, Sobel, DS, Ritter PL, Laurent, D, Hobbs, M. Effect of a self-management program on patients with chronic disease. Effective Clinical Practice, 4, 2001,pp. 256-262. This scale is free to use without permission Stanford Patient Education Research Center 1000 Welch Road, Suite 204 Palo Alto CA 94304 (650) 723-7935 (650) 725-9422 Fax [email protected] http://patienteducation.stanford.edu Funded by the National Institute of Nursing Research (NINR) Back ToC Stanford Spanish HAQ 8-Item Disability Scale Por favor marque la respuesta que mejor describa sus habilidades usuales (comunes) durante la semana pasada. Sin ninguna dificultad Con alguna dificultad Con mucha dificultad No puedo hacerlo 1. Vestirse, incluyendo amarrarse los zapatos y abrocharse (abotonarse)? ................ R R R R 2. Acostarse y levantarse de la cama?................. R R R R 3. Levantar hasta su boca una taza o vaso lleno? .................................................... R R R R 4. Caminar al aire libre en terreno plano? ........... R R R R 5. Bañarse y secarse todo el cuerpo? ................. R R R R R R R R 7. Abrir y cerrar las llaves del agua (los grifos)?... R R R R ¿Actualmente puede Ud: 6. Agacharse para recoger ropa del piso? 8. Subir y bajar del auto (carro)? .......................... Scoring Score the number circled for each item. If more than one consecutive number is circled for one item, code the higher number (more difficulty). If responses are not consecutive, code as blank. The disability index is the mean of the eight items. If more than 2 items are blank, do not score the index. Characteristics Tested on 272 Spanish-speaking subjects with arthritis. N=25 for test-retest. No. of items Observed Range Mean Standard Deviation Internal Consistency Reliability Test-Retest Reliability 8 0-3 1.7 .8 .89 .87 Source of Psychometric Data The Stanford Spanish Arthritis Self-Management Study (Programa de Manejo Personal de la Artritis). The psychometrics were done on the original 20-item Spanish scale, resulting in this version. Psychometrics reported in: González V, Stewart A, Ritter P, Lorig K, Translation and validation of arthritis outcome measures into Spanish. Arthritis and Rheumatism, 38(10),1995, pp.1429-1446. Comments This is a modified version of the 20-item Spanish disability scale which we translated and back translated from the Stanford Health Assessment Questionnaire. We have replaced the numbers with check boxes on the print version. It should be noted that the items have been chosen as they represent use of every major joint in the body. While closely related to an ADL scale this is not an ADL scale but rather a disability scale. References González V, Stewart A, Ritter P, Lorig K, Translation and validation of arthritis outcome measures into Spanish. Arthritis and Rheumatism, 38(10),1995, pp.1429-1446. This scale is free to use without permission Stanford Patient Education Research Center 1000 Welch Road, Suite 204 Palo Alto CA 94304 (650) 723-7935 (650) 725-9422 Fax [email protected] http://patienteducation.stanford.edu Funded by the National Institute of Nursing Research (NINR) Back ToC Rheumatology Attitudes Index (RAI) The statements below concern your personal beliefs. Please check the number beside each statement that best describes how you feel. Do not Strongly Disagree agree or Agree disagree disagree a. My condition is controlling my life Strongly agree b. I would feel helpless if I couldn’t rely on other people for help with my condition c. No matter what I do, or how hard I try, I just can’t seem to get relief from my pain d. I am NOT coping effectively with my condition 1 1 1 1 e. It seems as though fate and other factors beyond my control affect my condition 1 2 2 2 2 2 3 3 3 3 3 4 4 4 4 4 5 5 5 5 5 Back ToC Hospital Anxiety and Depression Scale (HADS) Reference: Zigmond and Snaith (1983) Patients are asked to choose one response from the four given for each interview. They should give an immediate response and be dissuaded from thinking too long about their answers. The questions relating to anxiety are marked "A", and to depression "D". The score for each answer is given in the right column. Instruct the patient to answer how it currently describes their feelings. A I feel tense or 'wound up': Most of the time 3 A lot of the time 2 From time to time, occasionally 1 Not at all 0 D I still enjoy the things I used to enjoy: A Definitely as much 0 Not quite so much 1 Only a little 2 Hardly at all 3 I get a sort of frightened feeling as if something awful is about to happen: Very definitely and quite badly 3 Yes, but not too badly 2 A little, but it doesn't worry me 1 Not at all 0 D I can laugh and see the funny side of things: As much as I always could 0 Not quite so much now 1 Definitely not so much now 2 Not at all 3 A Worrying thoughts go through my mind: A great deal of the time 3 A lot of the time 2 From time to time, but not too often 1 Only occasionally 0 D I feel cheerful: Not at all 3 Not often 2 Sometimes 1 Most of the time 0 A I can sit at ease and feel relaxed: Definitely 0 Usually 1 Not Often 2 Not at all 3 D I feel as if I am slowed down: Nearly all the time 3 Very often 2 Sometimes 1 Not at all 0 A I get a sort of frightened feeling like 'butterflies' in the stomach: Not at all 0 Occasionally 1 Quite Often 2 Very Often 3 D I have lost interest in my appearance: Definitely 3 I don't take as much care as I should 2 I may not take quite as much care 1 I take just as much care as ever 0 A I feel restless as I have to be on the move: Very much indeed 3 Quite a lot 2 Not very much 1 Not at all 0 D I look forward with enjoyment to things: As much as I ever did 0 Rather less than I used to 1 Definitely less than I used to 2 Hardly at all 3 A I get sudden feelings of panic: Very often indeed 3 Quite often 2 Not very often 1 Not at all 0 D I can enjoy a good book or radio or TV program: Often 0 Sometimes 1 Not often 2 Very seldom 3 Scoring (add the As = Anxiety. Add the Ds = Depression). The norms below will give you an idea of the level of Anxiety and Depression. 0-7 = Normal 8-10 = Borderline abnormal 11-21 = Abnormal Back ToC MODIFIED MACTAR BASELINE INTERVIEWER NOTE: When the question ends with "…" read the response categories provided, otherwise wait for a spontaneous response form the respondent for all questions. Circle the number of the response. INTERVIEWER START TIME: __________ A.M. P.M. SECTION A: This section contains some question about your general health. 1. Over the last weeks how would you say your overall health has been? Would you say your overall health has been… 1. Very good 2. Pretty good 3. Not too good 2. a. Do you think your arthritis limits your ability to carry out activities you did before you had arthritis? INTERVIEWER NOTE: See Probe 1. No 2. Yes b. Please tell me which activities are affected. ______________________________ [ ] ______________________________ [ ] ______________________________ [ ] ______________________________ [ ] ______________________________ [ ] ______________________________ [ ] ______________________________ [ ] ______________________________ [ ] ______________________________ [ ] ______________________________ [ ] INTERVIEWER NOTE: In order to elicit as comprehensive a list of activities affected by respondent's arthritis as possible, please read each probe to all respondents. Record each new activity in Q 2b and indicate a probed response with a "P" and the probe number. e.g., "P 3" would indicate a response to the leisure activity probe. PROBE: Does your arthritis limit… (1) any (other) activities around the house such as cooking, housework, etc. (2) any activity related to dressing such as doing up buttons, pulling sweater over head, etc. (3) any (other) activities at your work (outside the house)? (4) any (other) leisure activities. Either athletic such as bowling, swimming, golf, etc. or non-athletic such as needlework, woodwork, etc.? (5) any (other) social activities such as visiting, playing cards, going to church, etc.? INTERVIEWER NOTE: To rank the list of activities in order of importance to the respondent follow the steps below. 2. c. Which of these activities would you most like to be able to do without the pain or discomfort of your arthritis? INTERVIEWER NOTE: Please show and read the list to the respondent. Place a "1" in the box next to the selected activity. 2. d. After _______________ (read ACTIVITY "1") which activity would you next most like to be able to do without the pain and discomfort of your arthritis? INTERVIEWER NOTE: Please show and read the list to the respondent again, do not read activity "1". Place a "2" in the box beside the selected activity. 2. e. After _______________ (read ACTIVITY "1" and ACTIVITY "2") which activity would you next like to be able to do without the pain and discomfort of your arthritis? INTERVIEWER NOTE: Please show the list to the respondent. Read the remaining activities, do not read activities "1" and "2". Place a "3" in the box beside the selected activity. Continue in this manner until all the activities have been ranked. 3. a. In general, how satisfying do you find the way you've been spending your life? For example, over the last 2 weeks would you call your life… 1. Completely satisfying 2. Pretty satisfying 3. Not very satisfying GO TO Q 4 b. Is your life not completely satisfying because of your arthritis? 1. No 2. Yes 4. a. How would you say your overall physical functioning has been? For example, over the last 2 weeks would you call your physical function… 1. 2. 3. 4. 5. Good Good to fair Fair Fair to poor Poor GO TO Q 5 b. Is your physical function not as good as it might be because of your arthritis? 2. No 2. Yes 5. a. How would you say your overall social functioning has been over the last 2 weeks?… (such as your ability to work, to have friends, and to get along with you family). Would you call your social function… 1. 2. 3. 4. 5. Good Good to fair Fair Fair to poor Poor GO TO Q 6 b. Is your social function not as good as it might be because of your arthritis? 1. No 2. Yes 6. a. How would you say your overall emotional functioning has been over the last 2 weeks?… (such as your ability to remain in good spirits most of the time, and to be usually happy). Would you call your emotional function… 1. 2. 3. 4. 5. Good Good to fair Fair Fair to poor Poor SKIP PART B b. Is your overall emotional function not as good as it might be because of your arthritis? 1. No 2. Yes MODIFIED MACTAR FOLLOW-UP INTERVIEWER NOTE: When the question ends with "…" read the response categories provided, otherwise wait for a spontaneous response from the respondent for all questions. Circle the number of the response. INTERVIEWER START TIME: __________ A.M. P.M. SECTION A: This section contains some question about your general health. 1. Over the last 2 weeks how would you say your overall health has been? Would you say your overall health has been… 1. Very good 2. Pretty good 3. Not too good b. Have you noticed any change in your arthritis since we talked during the first interview? 1. No 2. Yes GO TO Q 2 c. Has your arthritis improved or got worse? 1. Improved 2. Got worse d. Please describe how your arthritis has changed. ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ e. Compared to how your arthritis was during the 2 weeks before you began taking the new medication, how much better or worse overall has your arthritis been? (Circle one.) -3 -2 -1 0 +1 +2 +3 A great deal worse Moderately worse Slightly worse No change Slightly better Moderately better A great deal better 2. You may remember the first time we talked you said your arthritis limited your ability to carry out some activities. (INTERVIEWER NOTE: For a to j read and insert the activities elicited at baseline). a. Since the first interview have you noticed any change in your ability to… ____________________________________________________________________ 1. No 2. Yes GO TO Q 2b Has this improved or got worse? 1. Improved 2. Got worse b. Have you noticed any change in your ability to… ____________________________________________________________________ 1. No 2. Yes GO TO Q 2c Has this improved or got worse? 1. Improved 2. Got worse c. Since the first interview have you noticed any change in your ability to… ____________________________________________________________________ 1. No 2. Yes GO TO Q 2d Has this improved or got worse? 1. Improved 2. Got worse d. Since the first interview have you noticed any change in your ability to… ____________________________________________________________________ 1. No 2. Yes GO TO Q 2e Has this improved or got worse? 1. Improved 2. Got worse e. Have you noticed any change in your ability to… ____________________________________________________________________ 1. No 2. Yes Has this improved or got worse? 1. Improved 2. Got worse GO TO Q 2f f. Since the first interview have you noticed any change in your ability to… ____________________________________________________________________ 1. No 2. Yes GO TO Q 2g Has this improved or got worse? 1. Improved 2. Got worse g. Have you noticed any change in your ability to… ____________________________________________________________________ 1. No 2. Yes GO TO Q 2h Has this improved or got worse? 1. Improved 2. Got worse h. Since the first interview have you noticed any change in your ability to… ____________________________________________________________________ 1. No 2. Yes GO TO Q 2i Has this improved or got worse? 1. Improved 2. Got worse i. Have you noticed any change in your ability to… ____________________________________________________________________ 1. No 2. Yes GO TO Q 2j Has this improved or got worse? 1. Improved 2. Got worse j. Since the first interview have you noticed any change in your ability to… ____________________________________________________________________ 1. No 2. Yes Has this improved or got worse? 1. Improved 2. Got worse 3. a. In general, how satisfying do you find the way you've been spending your life? For example, over the last 2 weeks would you call your life… 1. Completely satisfying 2. Pretty satisfying 3. Not very satisfying GO TO Q 3c b. Is your life not completely satisfying because of your arthritis? 1. No 2. Yes c. How satisfying do you find the way you are spending your life since we last talked, would you say it has improved, got worse, or not changed? 1. Improved 2. Got worse 3. Not changed 4. a. How would you say your overall physical functioning has been? For example, over the last 2 weeks would you call your physical function… 1. 2. 3. 4. 5. Good Good to fair Fair Fair to poor Poor GO TO Q 4c b. Is your physical function not as good as it might be because of your arthritis? 1. No 2. Yes c. Has your physical function improved, got worse, or not changed since we last talked? 1. Improved 2. Got worse 3. Not changed 5. a. How would you say your overall social functioning has been over the last 2 weeks?… (such as your ability to work, to have friends, and to get along with your family). Would you call your social function… 1. 2. 3. 4. 5. Good Good to fair Fair Fair to poor Poor GO TO Q 5c b. Is your social function not as good as it might be because of your arthritis? 1. No 2. Yes c. Has your social function improved, got worse, or not changed since the first interview? 1. Improved 2. Got worse 3. Not changed 6. a. How would you say your overall emotional functioning has been over the last 2 weeks?… (such as your ability to remain in good spirits most of the time, and to be usually happy). Would you call your emotional function… 1. 2. 3. 4. 5. Good Good to fair Fair Fair to poor Poor GO TO Q 6c b. Is your overall emotional function not as good as it might be because of your arthritis? 1. No 2. Yes c. Has your emotional function improved, got worse, or not changed since we last talked? 1. Improved 2. Got worse 3. Not changed MACTAR SCORING GUIDELINES SUMMARY The Modified Mactar [McMaster (Mac) Toronto Arthritis] Questionnaire was developed from the original Mactar [J Rheumatol 1987;14(3):446-451] and consists of two components: 1. A "priority function questionnaire designed to identify individual disabilities due to arthritis" and their "relative importance to the patient". The patient is asked the following questions, "Please tell me which activities are affected by your arthritis." To ensure the patient realized that we are interested in all activities including mobility, self-care, work and leisure, the interviewer described this "menu" and provided a standardized explanation with examples of what is meant by each of these. The patient is then asked to add any activities in each of these areas not already listed and to be as specific as possible in describing which activities are affected. Following this, the rank order of these activities is elicited using the following wording: "Which of these activities would you most like to be able to do?" Further questions are asked to determine the rank order of the other disabilities mentioned. 2. Four global questions (original questionnaire) eliciting information on physical, social and emotional functions, each scored on a five-point scale. If a less than perfect score is elicited for any of these functions, a further question is asked to determine the association of these difficulties with arthritis, i.e., " Is your physical function not as good as it might be because of arthritis?" For both components, patients are questioned over a two-week period. The modified Mactar takes 5 to 10 minutes to administer, depending on the number of activities in the priority function section. The follow-up or post-treatment section consists of change questions for both the priority function and conventional components. The patient is questioned as follow: "Have you noticed any change in your arthritis since the first interview?"; "Since the first interview, have you noticed any changes in your ability to walk?", etc. If the response is positive, a further question is asked as follows: "Has this improved or gotten worse?". SCORING THE MACTAR Priority Function Section This section does not receive a score at baseline: a direct change score is computed at follow-up. Scoring of the Mactar can be computed using different methods. Weights can be given to the priority problems depending on the rank order of these problems by the patient. It is possible to select the top five problems (if the patient has at least five problems) or the top three problems. If the top five problems are selected, the problem ranked No. 1 will be given a score of 5, the problem ranked No. 2 will be assigned a score of 4, and similarly weights 3, 2, 1 for the problems ranked Nos. 3, 4, 5. The top five problems elicited from and ranked by a hypothetical patient are shown in column 1 of Table 1. In order to avoid problems with negative signs, all change scores will be positive as follows: worse = 1, no change = 2, improved = 3. Walking is ranked No. 1; therefore, it received a weight of 5. TABLE 1 Problems Standing Dressing Walking Driving Socializing Rank by Patient 2 3 1 4 5 Weights 4 3 5 2 1 Worse No Change 2 Improved 3 2 2 3 The score can be computed as follows: Sum of [weight x change score] Denote S5R as score ranked for top 5 problems For example given in table 1 S5R = 5(2) + 4(2) + 3(3) + 2(2) + 1(3) = 34 The maximum possible score for S5R using this weighting is 45. The minimum score is 15. This allows for a change score to vary over 30 between interview 1 and 2. If fewer than 5 problems are identified, it is possible to compute S5R for the smaller set by using dummy problems for the missing ones and scoring them as no change (i.e. 2). Equal weights can also be assigned to the activities in the previous example as outlined in Table 2: TABLE 2 Problems Standing Dressing Walking Driving Socializing Rank by Patient 2 3 1 4 5 Weights 1 1 1 1 1 Worse No Change 2 Improved 3 2 2 3 The score can be computed as follows: S5E = equal scores for top 5 problems Sum of [weight x change score] S5E = 1(2) + 1(3) + 1(2) + 1(2) + 1(3) = 12 The maximum possible score for S5E using the previous example is 15. The minimum score is 5, thus permitting a change score to vary over 10 units between interview 1 and 2. If fewer than 5 problems are identified, it is possible to compute S5E for the smaller set by using dummy problems for the missing ones and scoring them as no change (i.e. 2). Conventional Questions In order to maintain consistency with the priority function component, the scores assigned to the conventional questions must again be reversed. TABLE 3: Scoring Scheme for Baseline Conventional Questions Question Number 1 2a 3a 3b 4a, 5a and 6a 4b, 5b and 6b Response # 1 2 3 1 2 1 2 3 1 2 1 2 3 4 5 1 2 Responses Very good Pretty good Not too good No Yes Completely satisfying Pretty satisfying Not very satisfying No Yes Good Good to fair Fair Fair to poor Poor No Yes Score 3 2 1 1 0 3 2 1 1 0 5 4 3 2 1 1 0 Using these guidelines it is possible to compute a best and worst score for the physical, social and emotional components of the conventional section of the questionnaire at baseline: best possible baseline score = 26; worst possible baseline score = 5 TABLE 4: Scoring Scheme for Post-Treatment Follow-up Questionnaire Question 1a 1b 1c 1e 2a to 2j 3a 3b 3c 4a, 5a and 6a 4b, 5b and 6b 4c, 5c and 6c Response # 1 2 3 1 2 1 2 -3 -2 -1 0 +1 +2 +3 2&1 2&2 1 1 2 3 1 2 1 2 3 1 2 3 4 5 1 2 1 2 3 Responses Very good Pretty good Not too good No Yes Improved Got worse A great deal better Moderately better Slightly better No change Slightly worse Moderately worse A great deal worse Yes and Improved Yes and Got worse No Completely satisfying Pretty satisfying Not very satisfying No Yes Improved Got worse No change Good Good to fair Fair Fair to poor Poor No Yes Improved Got worse No change Score 3 2 1 2 0 3 1 7 6 5 4 3 2 1 3 1 2 3 2 1 1 0 3 1 2 5 4 3 2 1 1 0 3 1 2 Using these guidelines it is possible to compute a best and worst score for the physical, social and emotional components of the conventional section of the questionnaire at posttreatment follow-up: best possible post-treatment score = 47; worst possible post-treatment score = 11 References Tugwell P, Bombardier C, Buchanan WW, Goldsmith C, Grace E & Hanna B. The MACTAR patient preference disability questionnaire – An individualized functional priority approach for assessing improvement in physical disability in clinical trials in rheumatoid arthritis. J Rheumatol 1987;14:446-451. Verhoeven AC Boers M & van der Linden S. Validity of the MACTAR questionnaire as a functional index in a rheumatoid arthritis clinical trial. J Rheumatol 2000;27:2801-9. Clinch JJ, Tugwell P, Wells G & Shea B. An individualized functional priority approach to the assessment of health-related quality of life in rheumatology. J Rheumatol 2001;28:44551. Back ToC Rheumatoid Arthritis Self-Efficacy (RASE) Scale We are interested in finding out what things you believe you could do to help you with your arthritis. We want to know what you think you could do, even if you are not actually doing it at the moment. Please check one column for each question. Do you believe you could do these things to help you with your arthritis? Strongly disagree Disagree Do not agree or disagree Agree Strongly agree a. I believe I could use relaxation techniques to help with pain b. I believe I could think about something else to help with pain d. I believe I could think positively to help with pain e. I believe I could avoid doing things that cause pain g. I believe I could have a hot drink before bed, to improve my sleep h. I believe I could use relaxation before bed, to improve my sleep I believe I could pace myself and take my arthritis into account to help deal with tiredness I believe I could accept fatigue as part of my arthritis I believe I could ask for help to deal with the difficulties of doing everyday tasks m. I believe I could do exercises to deal with the difficulty of doing everyday tasks c. I believe I could use my joints carefully (joint protection) to help with pain f. i. j. I believe I could wind down and relax before going to bed, to improve my sleep k. I believe I could use gadgets to help with mobility, household tasks or personal care l. 1 1 1 1 1 1 1 1 1 1 1 1 1 2 2 2 2 2 2 2 2 2 2 2 2 2 3 3 3 3 3 3 3 3 3 3 3 3 3 4 4 4 4 4 4 4 4 4 4 4 4 4 5 5 5 5 5 5 5 5 5 5 5 5 5 Do you believe you could do these things to help you with your arthritis? Strongly disagree Disagree Do not agree or disagree Agree Strongly agree o. I believe I could educate my family and friends about my arthritis to help with the strains that arthritis can make on relationships p. I believe I could explain to friends and family when I do or do not need help q. I believe I could discuss any problems with my partner or family r. u. I believe I could use relaxation to deal with worries v. I believe I could allocate time for relaxation w. I believe I could use a relaxation tape or instructions to help me relax x. I believe I could use regular exercise 4 4 z. I believe I could manage my medication, knowing how and when to take it aa. I believe I could look out for and avoid side-effects of my medication bb. I believe I could seek help with persistent side effects n. I believe I could plan or prioritize my day to deal with difficulties of doing everyday tasks 1 I believe I could make time for leisure activities, hobbies or socializing s. I believe I could save energy for leisure activities, hobbies or socializing t. I believe I could focus on the positive when I am feeling down 1 1 1 1 1 1 1 1 1 1 y. I believe I could be aware of my limits in exercise 1 1 1 1 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 4 4 4 4 4 4 4 4 4 4 4 4 4 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 Back ToC Rheumatology Attitudes Index (RAI) The statements below concern your personal beliefs. Please check the number beside each statement that best describes how you feel. Do not Strongly Disagree agree or Agree disagree disagree a. My condition is controlling my life b. I would feel helpless if I couldn’t rely on other people for help with my condition c. No matter what I do, or how hard I try, I just can’t seem to get relief from my pain d. I am NOT coping effectively with my condition e. It seems as though fate and other factors beyond my control affect my condition 1 2 1 2 1 1 1 3 3 2 2 2 Strongly agree 4 4 5 3 4 5 3 4 5 3 4 5 5 Back ToC SELF-EFFICACY FOR EXERCISE ADHERENCE We would like to know how confident you are in doing certain activities. We want you to answer based on your current level of ability (how you feel at the present time). For each of the following questions, please circle the number that indicates your confidence that you can do the activities regularly. On a scale of 1 to 10, how confident are you that you can do exercises for flexibility and range of motion 3 to 4 times per week? A few examples of flexibility exercises include stretching exercises, Tai Chi, and yoga. Not at all 1 Confident 2 3 4 5 6 7 8 9 10 Totally confident On a scale of 1 to 10, how confident are you that you can do exercises for muscle strength 3 to 4 times per week? Examples of exercises for muscle strength include using weights, elastic exercise bands, or weight machines. Not at all 1 Confident 2 3 4 5 6 7 8 9 10 Totally confident On a scale of 1-10, how confident are you that you can do exercises such as aerobics, walking, biking or swimming – physical activity that makes your heart beat faster and makes you breathe hard or make you sweat? Not at all 1 Confident 2 3 4 5 6 7 8 9 10 Totally confident On a scale of 1 to 10, how confident are you that you can exercise without causing yourself pain or other symptoms? Not at all 1 Confident 2 3 4 5 6 7 8 9 10 Totally confident Physical activities are activities where you move and increase your heart rate above its resting rate, whether you do them for pleasure, work, or transportation. Examples of physical activity intensity levels: Description of intensity levels Possible examples of light activities for some people may include: Light activities • Your heart beats slightly faster than normal • You can talk and sing • • • Walking leisurely Stretching Vacuuming or light yard work Moderate Activities • Your heart beats faster than normal • You can talk but not sing • • • • • • • Brisk walking Aerobics Class Strength training Swimming Stair machine Jogging or running Tennis, racquetball, pickle ball or badminton Vigorous Activities • Your heart rate increases a lot • You can’t talk, or your talking is broken up by large breaths Does this accurately describe you? I rarely or never do any physical activities…………………………….Yes No I do some light or moderate physical activities, but not every week……………………………………………………….Yes I do some light physical activity every week……….……………........Yes No I do moderate physical activity every week………………….………..Yes No No I do 30 minutes or more per day of moderate physical activity, 5 or more days per week.….…………………………Yes No I do vigorous physical activities every week, but for less than 5 days per week or less than 20 minutes at a time. ………………………………………………………Yes No I do 20 minutes or more per day of vigorous physical activities, 3 or more days per week. ……….Yes No I do activities to increase muscle strength, such as lifting weights or calisthenics, once a week or more. ………………………..Yes No I do activities to improve flexibility, such as stretching or yoga, once a week or more. . ……Yes No Back ToC Self-Efficacy for Physical Activity (SEPA) Scale Physical activity or exercise includes activities such as walking briskly, jogging, bicycling, swimming, or any other activity in which the exertion is at least as intense as these activities. For each item, check the box that indicates how confident you are that you could be physically active in each of the following situations: a. When I am tired Not at all confident Slightly confident Moderately confident Very confident Extremely confident 1 b. When I am in a bad mood 2 1 c. When I feel I don’t have time 2 1 d. When I am on vacation 2 1 e. When it is raining or snowing 2 1 2 1 3 3 3 3 3 4 4 4 4 4 5 5 5 5 5 Back ToC THE SHORT PORTABLE MENTAL STATUS QUESTIONNAIRE (SPMSQ) Question Response Incorrect Responses 1. What are the date, month, and year? 2. What is the day of the week? 3. What is the name of this place? 4. What is your phone number? 5. How old are you? 6. When were you born? 7. Who is the current president? 8. Who was the president before him? 9. What was your mother's maiden name? 10. Can you count backward from 20 by 3's? SCORING:* 0-2 errors: normal mental functioning 3-4 errors: mild cognitive impairment 5-7 errors: moderate cognitive impairment 8 or more errors: severe cognitive impairment *One more error is allowed in the scoring if a patient has had a grade school education or less. *One less error is allowed if the patient has had education beyond the high school level. Source: Pfeiffer, E. (1975). A short portable mental status questionnaire for the assessment of organic brain deficit in elderly patients. Journal of American Geriatrics Society. 23, 433-41. Back ToC Timed 10 Pound Lifts 1. Have the participant stand in front of a table with a basket containing a 10 pound weight. 2. The participant is allowed to use both upper extremities. 3. Instruct the participant using the following script: “On the word “go,” lift up the basket and raise it to chin level, then lower it to your belly button as quickly as you can. At the end, place the basket back on the table. Ready, go.” 4. Begin timing the participant as you say “go” and end timing when the participant has placed the basket back on the table. Record the time below to the nearest hundredth of a second. Also indicate whether the participant had any pain during the test. 5. If the participant was successful with the single lift, have the participant do another single lift. 6. Instruct the participant using the following script: “On the word “go,” lift up the basket and raise it to chin level, then lower it to your belly button as quickly as you can. At the end, place the basket back on the table. Ready, go.” 7. Record the time below to the nearest hundredth of a second and indicate whether the participant had any pain during the test. 8. If the participant was successful with both single 10 pound lifts, then have him/her repeat this 3 times. 9. Instruct the participant using the following script: “On the word “go,” lift up the basket and raise it to chin level, then lower it to your belly button, 3 times, as quickly as you can. At the end, place the basket back on the table. Ready, go.” (Note: It is OK to count as the subject performs the lifts) 10. Begin timing the participant as you say “go” and end timing when the participant has placed the basket back on the table. Record the time below to the nearest hundredth of a second and indicate whether the participant had any pain during the test. TIMED 10 POUND LIFTS TIME INCREASE IN PAIN DURING TEST? Single Lift NO YES Single Lift NO YES Three Lifts NO YES 11. If the participant is unable to complete all three lifts, record the number of lifts completed and the time it took. Back ToC Timed 360° Turn Test 1. This test can be performed with an assistive device. 2. Ask the participant to stand with arms at his/her side and feet comfortably apart and pointed straight ahead. If the participant uses an assistive device, he/she may hold onto the device. 3. Instruct the participant using the following script: “When I say go, I want you to turn to your right at your normal pace making sure to go in a complete circle and making sure you end up with your feet facing straight ahead.” 4. Ask the participant to perform a practice trial. 5. Then instruct the participant using the following script: “ I want you to start when I say go and turn to your right at your normal pace. Ready, go.” 6. The participant’s feet can be together or apart at the end of the turn, but they should both be facing forward. If one or both feet end up greater than 45 degrees rotated to the left or right, redo the trial. 7. Record the time, to the nearest hundredth of a second, it took to complete the turn and indicate whether the participant had any pain during the test. 8. Repeat the test having the participant initiating the turn toward the left. 9. Instruct the participant using the following script: “ I want you to start when I say go and turn to your left at your normal pace. Ready, go.” 10. Have the participant do a second trial to the right and a second trial to the left. Timed 360° Turn Time for Turn (R) Increase in Pain? Increase in Pain? Time for Turn (L) TRIAL 1 NO YES NO YES TRIAL 2 NO YES NO YES Did participant use an assistive device? NO YES Back ToC Timed chair stand test Critical issues No previous international recommendations for standardized protocol exist Exclusion criteria Equipment Stopwatch Armless chair (height: 45 cm) with straight back Procedure Participant should be sitting on the chair with his/her feet on the floor. Participant is asked to rise from the chair without the help of his/her arms. The success is recorded. If successful, the participant can proceed to the next step of chair rises. Participant is asked to sit down again, with feet on the floor. Participant is asked to rise from the chair without the help of his/her arms (arms folded across chest), 10 times. Time to complete 10 rises is recorded. If the person cannot complete 10 rises, the number of completed rises is recorded. Back ToC Timed “Up and Go”* Directions: The timed “Up and Go” test measures, in seconds, the time taken by an individual to stand up from a standard arm chair (approximate seat height of 46 cm, arm height 65 cm), walk a distance of 3 meters (approximately 10 feet), turn, walk back to the chair, and sit down. The subject wears their regular footwear and uses their customary walking aid (none, cane, walker). No physical assistance is given. They start with their back against the chair, their arms resting on the armrests, and their walking aid at hand. They are instructed that, on the word “go” they are to get up and walk at a comfortable and safe pace to a line on the floor 3 meters away, turn, return to the chair and sit down again. The subject walks through the test once before being timed in order to become familiar with the test. Either a stopwatch or a wristwatch with a second hand can be used to time the trial. Instructions to the patient: “When I say ‘go’ I want you to stand up and walk to the line, turn and then walk back to the chair and sit down again. Walk at your normal pace.” Variations: You may have the patient walk at a fast pace to see how quickly they can ambulate. Also you could have them turn to the left and to the right to test any differences. *Podsiadlo D, Richardson S. The timed “up and go”: a test of basic functional mobility for frail elderly persons. JAGS 1991; 39: 142-148. Back ToC Patient Name: ______________________________________________________________ Date: ________________________ Visual Analog Scale (VAS)* No pain Pain as bad as it could possibly be *A 10-cm baseline is recommended for VAS scales. From: Acute Pain Management: Operative or Medical Procedures and Trauma, Clinical Practice Guideline No. 1. AHCPR Publication No. 92-0032; February 1992. Agency for Healthcare Research & Quality, Rockville, MD; pages 116-117. Visual Analog Scale NO PAIN WORST PAIN Directions: Ask the patient to indicate on the line where the pain is in relation to the two extremes. Measure from the left hand side to the mark. From Stratton Hill C. Guidelines for Treatment of Cancer Pain: The Revised Pocket Edition of the Final Report of the Texas Cancer Council's Workgroup on Pain Control in Cancer Patients, 2nd Edition; pages 61-63. Copyright 1997, Texas Cancer Council. Reprinted with permission. www.texascancercouncil.org. A7012-AS-1 Appendix II • Health Status Assessment Instruments in Common Use 385 WESTERN ONTARIO AND McMASTER UNIVERSITIES OSTEOARTHRITIS INDEX (WOMAC)-VA3.0 ToC Courtesy of the originator. Back Source: J Rheumatol 15:1833-1840,1988. Contact Address: Telephone: Fax: Dr. Nicholas Bellamy Division of Rheumatology Victoria Hospital EO. Box 5375 London, Ontario Canada N6A 4G5 519-667-6815 519-667-6687 INSTRUCTIONS TO PATIENTS In Sections A, B, and C questions will be asked in the following format and you should give your answers by putting an "X" on the horizontal line. NOTE: 1. If you put your "X" at the left-hand end of the line, i.e., NO I---~Ir-----------------------i EXTREME PAIN PAIN then you are indicating that you have no pain. 2. If you place your "X" at the right-hand end of the line, i.e., P~~ r----------------------~~--~I ~!JfEME then you are indicating that your pain is extreme. 3. Please Note: a) that the further to the right-hand end you place your "X" the more pain you are experiencing. b) that the further to the left-hand end you place your "X" the less pain you are experiencing. c) Please do not place your "X" outside the end markers. You will be asked to indicate on this type of scale the amount of pain, stiffness, or disability you are experiencing. please remember the further you place your "X" to the right, the more pain, stiffness, or disability you are indicating that you experience. WOMAC Continued 386 Appendix II • Health Status Assessment Instruments in Common Use Section A INSTRUCTIONS TO PATIENTS The following questions concern the amount of pain you are currently experiencing due to arthritis in your hips and/or knees. For each situation please enter the amount of pain recently experienced (please mark your answers with an "X"). QUESTION: How much pain do you have? ~ ____________________________________________________ ~I EXTREME PAIN r---------------------------------------------------------~I EXTREME PAIN ~--------------------------------------------------------~I EXTREME PAIN EXTREME PAIN r---------------------------------------------------------~I EXTREME PAIN Section B INSTRUCTIONS TO PATIENTS The following questions concern the amount of joint stiffness (not pain) you are currently experiencing in your hips and/or knees. Stiffness is a sensation of restriction or slowness in the ease with which you move your joints (please mark your answers with an "X"). 1. How severe is your stiffness after first wakening in the morning? NO EXTREME STIFFNESS STIFFNESS 2. How severe is your stiffness after sitting, lying or resting later in the day? NO I STIFFNESS IEXTREME STIFFNESS WOMAC Continued Appendix II • Health Status Assessment Instruments in Common Use 387 Section C INSTRUCTIONS TO PATIENTS The following questions concern your physical function. By this we mean your ability to move around and to look after yourself. For each of the following activities, please indicate the degree of difficulty you are currently experiencing due to arthritis in your hips and/or knees (please mark your answers with an "X"). QUESTION: What degree of difficulty do you have with: 1. Descending stairs. NO ~~ ____________________________________________________4EXTREME DIFFICULTY DIFFICULTY 2. Ascending stairs. NO r-----------------------------------------------------~ DIFFICUlTY EXTREME DIFFICULTY 3. Rising from sitting. NO ~----------------------------------------------------__4 EXTREME NO r-----------------------------------------------------~ EXTREME DIFFICULTY DIFFICUlTY 4. Standing. DIFFICULTY DIFFICULTY S. Bending to floor. NO DIFFICULTY ~-------------------------------------------------------11 EXTREME DIFFICULTY 6. Walking on flat. r-____________________________________________________--1EXTREME NO DIFFICULTY 7. DIFFICULTY Getting in/out of car. NO r-____________________________________________________ ~EXTREME DIFFICULTY DIFFICULTY 8. Going shopping. NO DIFFICUlTY ~----------------------------------------------------~EXTREME DIFFICULTY 9. Putting on socks/stockings. NO DIFFICULTY r-----------------------------------------------------~ EXTREME DIFFICUlTY 10. Rising from bed. NO DIFFICULTY ~----------------------------------------------------__4 EXTREME DIFFICULTY 11. Taking off socks/stockings. NO r-----------------------------------------------------__4 EXTREME DIFFICULTY DIFFICULTY 12. Lying in bed. NO DIFFICULTY ~----------------------------------------------------__4 EXTREME DIFFICULTY WOMAC Continued 388 Appendix II • Health Status Assessment Instruments in Common Use 13. Getting in/out of bath. NO DIFFICUUY 14. Sitting. NO DIFFICULTY 15. I I I I EXTREME DIFFICULTY Heavy domestic duties. NO DIFFICULTY 17. EXTREME DIFFICULTY Getting on/off toilet. NO DIFFICULTY 16. EXTREME DIFFICULTY EXTREME DIFFICULTY Light domestic duties. NO DIFFICULTY I I EXTREME . DIFFICULTY WOMAC The WOMAC (Western Ontario and McMaster Universities) Index of Osteoarthritis Overview: The WOMAC (Westren Ontario and McMaster Universities) index is used to assess patients with osteoarthritis of the hip or knee using 24 parameters. It can be used to monitor the course of the disease or to determine the effectiveness of anti-rheumatic medications. Pain: (1) walking (2) stair climbing (3) nocturnal (4) rest (5) weight bearing Stiffness: (1) morning stiffness (2) stiffness occurring later in the day Physical function: (1) descending stairs (2) ascending stairs (3) rising from sitting (4) standing (5) bending to floor (6) walking on flat (7) getting in or out of car (8) going shopping (9) putting on socks (10) rising from bed (11) taking off socks (12) lying in bed (13) sitting (14) sitting (15) getting on or off toilet (16) heavy domestic duties (17) light domestic duties While the index was being developed performance of social functions and the status of emotional function were also included. These were not included in the final instrument. Social function: (1) leisure activities (2) community events (3) church attendance (4) with spouse (5) with family (6) with friends (7) with others Emotional function: (1) anxiety (2) irritability (3) frustration (4) depression (5) relaxation (6) insomnia (7) boredom (8) loneliness (9) stress (10) well-being Scoring and Interpretation Response Points none 0 slight 1 moderate 2 severe 3 extreme 4 Alternatively a visual analogue scale (VAS) may be used ranging from 0 to 10. score = = SUM(points for relevant items) average score = = (total score) / (number of items) Interpretation: • minimum total score: 0 • maximum total score: 96 • minimum pain subscore: 0 • maximum pain subscore: 20 • minimum stiffness subscore: 0 • maximum stiffness subscore: 8 • minimum physical function subscore: 0 • maximum physical function subscore: 68 References: Bellamy N Buchanan WW et al. Validation study of WOMAC: A health status instrument for measuring clinically important patient relevant outcomes to antirheumatic drug therapy in patients with osteoarthritis of the hip or knee. J Rheumatol. 1988; 15: 1833-1840. Bellamy N. Pain assessment in osteoarthritis: Experience with the WOMAC osteoarthritis index. Semin Arthritis Rheumatism. 1989; 18 (supplement 2): 14-17. Bellamy N Kean WF et al. Double blind randomized controlled trial of sodium meclofenamate (Meclomen) and diclofenac soidum (Voltaren): Post validation reapplication of the WOMAC osteoarthritis index. J Rheumatol. 1992; 19: 153-159. Hawker G Melfi C et al. Comparison of a generic (SF-36) and a disease specific (WOMAC) instrument in the measurement of outcomes after knee replacement surgery. J Rheumatol. 1995; 22: 1193-1196. Lequesne M. Indices of severity and disease activity for osteoarthritis. Seminars in Arthritis and Rheumatism. 1991; 20 (supplement 2): 48-54. Stucki G Sangha O et al. Comparison of WOMAC (Western Ontario and McMaster Universities) osteoarthritis index and a self-report format of the self-administered Lequesne-Algofunctional index in patients with knee and hip osteoarthritis. Osteoarthritis and Cartilage. 1998; 6: 79-86. ToC INSTRUMENT GUIDE FOR CANCER-SPECIFIC PROGRAMS Please note that there are no instruments for the evidence-based cancer programs included this toolkit. INSTRUMENT GUIDE FOR DEPRESSION-SPECIFIC PROGRAMS Instruments preceded by an asterisk (*) and bolded are common to a number of conditions and can be found in the Cross-Cutting Instruments Guide Important Note: While rigorous research was conducted to provide readers with all of the instrumentation for implementing the programs outlined in this toolkit, for a limited number of programs, instrumentation was not available for public use. Therefore, interested parties are encouraged to contact selected program 1s to obtain permission for instruments not included here. Instrument Brief Psychiatric Rating Scale (BPRS) CAGE Questionnaire * Center for Epidemiologic Studies Depression (CES-D) Scale * Community Health Activities Model Program for Seniors (CHAMPS) Physical Activity Questionnaire English & Spanish versions, including manual and scoring guide Psycho geriatric Assessment and Treatment in City Housing (PATCH) PATCH Life Review Therapy Healthy Identifying Depression Empowering Activities for Seniors (Healthy IDEAS) Life Satisfaction Index A Life Review Therapy Functional Assessment of Cancer Therapy ScaleGeneral (FACT-G1) PEARLS Geriatric Depression Scale-15 (GDS-15) Mini-Mental State Examination (MMSE) Montgomery - Asberg Depression Rating Scale (MADRS) Patient Health Questionnaire (PHQ-9) Sheehan Disability Scale * Short Form-36 Health Survey (SF-36) Including scoring guide 1 Program Healthy IDEAS Healthy IDEAS PATCH PATCH Improving Mood-Promoting Access to Collaborative Treatment (IMPACT) IMPACT Healthy IDEAS Readers interested in using the scoring sheet for the FACT-G instrument may visit http://www.facit.org/. Back ToC Brief Psychiatric Rating Scale (BPRS) Expanded Version (4.0) Introduction This section reproduces an interview schedule, symptom definitions, and specific anchor points for rating symptoms on the BPRS. Clinicians intending to use the BPRS should also consult the detailed guidelines for administration contained in the reference below. Scale Items and Anchor Points Rate items 1-14 on the basis of individual's self-report. Note items 7, 12 and 13 are also rated on the basis of observed behaviour. Items 15-24 are rated on the basis of observed behaviour and speech. 1. Somatic Concern Degree of concern over present bodily health. Rate the degree to which physical health is perceived as a problem by the individual, whether complaints have realistic bases or not. Somatic delusions should be rated in the severe range with or without somatic concern. Note: be sure to assess the degree of impairment due to somatic concerns only and not other symptoms, e.g., depression. In addition, if the individual rates 6 or 7 due to somatic delusions, then you must rate Unusual Thought Content at least 4 or above. 2 Very mild Occasional somatic concerns that tend to be kept to self. 3 Mild Occasional somatic concerns that tend to be voiced to others (e.g., family, doctor). 4 Moderate Frequent expressions of somatic concern or exaggerations of existing ills OR some preoccupation, but no impairment in functioning. Not delusional. 5 Moderately severe Frequent expressions of somatic concern or exaggerations of existing ills OR some preoccupation and moderate impairment of functioning. Not delusional. 6 Severe Preoccupation with somatic complaints with much impairment in functioning OR somatic delusions without acting on them or disclosing to others. 7 Extremely severe Preoccupation with somatic complaints with severe impairment in functioning OR somatic delusions that tend to be acted on or disclosed to others. "Have you been concerned about your physical health?" "Have you had any physical illness or seen a medical doctor lately? (What does your doctor say is wrong? How serious is it?)" "Has anything changed regarding your appearance?" "Has it interfered with your ability to perform your usual activities and/or work?" "Did you ever feel that parts of your body had changed or stopped working?" [If individual reports any somatic concerns/delusions, ask the following]: "How often are you concerned about [use individual's description]?" "Have you expressed any of these concerns to others?" 2. Anxiety Reported apprehension, tension, fear, panic or worry. Rate only the individual's statements - not observed anxiety which is rated under Tension. 2 Very mild Reports some discomfort due to worry OR infrequent worries that occur more than usual for most normal individuals. 3 Mild Worried frequently but can readily turn attention to other things. 4 Moderate Worried most of the time and cannot turn attention to other things easily but no impairment in functioning OR occasional anxiety with autonomic accompaniment but no impairment in functioning. 5 Moderately Severe Frequent, but not daily, periods of anxiety with autonomic accompaniment OR some areas of functioning are disrupted by anxiety or worry. 6 Severe Anxiety with autonomic accompaniment daily but not persisting throughout the day OR many areas of functioning are disrupted by anxiety or constant worry. 7 Extremely Severe Anxiety with autonomic accompaniment persisting throughout the day OR most areas of functioning are disrupted by anxiety or constant worry. "Have you been worried a lot during [mention time frame]? Have you been nervous or apprehensive? (What do you worry about?)" "Are you concerned about anything? How about finances or the future?" "When you are feeling nervous, do your palms sweat or does your heart beat fast (or shortness of breath, trembling, choking)?" [If individual reports anxiety or autonomic accompaniment, ask the following]: "How much of the time have you been [use individual's description]?" "Has it interfered with your ability to perform your usual activities/work?" 3. Depression Include sadness, unhappiness, anhedonia and preoccupation with depressing topics (can't attend to TV or conversations due to depression), hopeless, loss of self-esteem (dissatisfied or disgusted with self or feelings of worthlessness). Do not include vegetative symptoms, e.g., motor retardation, early waking or the amotivation that accompanies the deficit syndrome. 2 Very mild Occasionally feels sad, unhappy or depressed. 3 Mild Frequently feels sad or unhappy but can readily turn attention to other things. 4 Moderate Frequent periods of feeling very sad, unhappy, moderately depressed, but able to function with extra effort. 5 Moderately Severe Frequent, but not daily, periods of deep depression OR some areas of functioning are disrupted by depression. 6 Severe Deeply depressed daily but not persisting throughout the day OR many areas of functioning are disrupted by depression. 7 Extremely Severe Deeply depressed daily OR most areas of functioning are disrupted by depression. "How has your mood been recently? Have you felt depressed (sad, down, unhappy, as if you didn't care)?" "Are you able to switch your attention to more pleasant topics when you want to?" "Do you find that you have lost interest in or get less pleasure from things you used to enjoy, like family, friends, hobbies, watching TV, eating?" [If individual reports feelings of depression, ask the following]: "How long do these feelings last?" "Has it interfered with your ability to perform your usual activities?" 4. Suicidality Expressed desire, intent, or actions to harm or kill self. 2 Very mild Occasional feelings of being tired of living. No overt suicidal thoughts. 3 Mild Occasional suicidal thoughts without intent or specific plan OR he/she feels they would be better off dead. 4 Moderate Suicidal thoughts frequent without intent or plan. 5 Moderately Severe Many fantasies of suicide by various methods. May seriously consider making an attempt with specific time and plan OR impulsive suicide attempt using non-lethal method or in full view of potential saviours. 6 Severe Clearly wants to kill self. Searches for appropriate means and time, OR potentially serious suicide attempt with individual knowledge of possible rescue. 7 Extremely Severe Specific suicidal plan and intent (e.g., "as soon as ________ I will do it by doing X"), OR suicide attempt characterised by plan individual thought was lethal or attempt in secluded environment. "Have you felt that life wasn't worth living? Have you thought about harming or killing yourself? Have you felt tired of living or as though you would be better off dead? Have you ever felt like ending it all?" [If individual reports suicidal ideation, ask the following]: "How often have you thought about [use individual's description]?" "Did you (Do you) have a specific plan?" 5. Guilt Overconcern or remorse for past behaviour. Rate only individual's statements, do not infer guilt feelings from depression, anxiety, or neurotic defences. Note: if the individual rates 6 or 7 due to delusions of guilt, then you must rate Unusual Thought Content at least 4 or above, depending on level of preoccupation and impairment. 2 Very mild Concerned about having failed someone, or at something, but not preoccupied. Can shift thoughts to other matters easily. 3 Mild Concerned about having failed someone, or at something, with some preoccupation. Tends to voice guilt to others. 4 Moderate Disproportionate preoccupation with guilt, having done wrong, injured others by doing or failing to do something, but can readily turn attention to other things. 5 Moderately Severe Preoccupation with guilt, having failed someone or at something, can turn attention to other things, but only with great effort. Not delusional. 6 Severe Delusional guilt OR unreasonable self-reproach very out of proportion to circumstances. Moderate preoccupation present. 7 Extremely Severe Delusional guilt OR unreasonable self-reproach grossly out of proportion to circumstances. Individual is very preoccupied with guilt and is likely to disclose to others or act on delusions. "Is there anything you feel guilty about? Have you been thinking about past problems?" "Do you tend to blame yourself for things that have happened?" "Have you done anything you're still ashamed of?" [If individual reports guilt/remorse/delusions, ask the following]: "How often have you been thinking about [use individual's description]?" "Have you disclosed your feelings of guilt to others?" 6. Hostility Animosity, contempt, belligerence, threats, arguments, tantrums, property destruction, fights, and any other expression of hostile attitudes or actions. Do not infer hostility from neurotic defences, anxiety or somatic complaints. Do not include incidents of appropriate anger or obvious self-defence. 2 Very mild Irritable or grumpy, but not overtly expressed. 3 Mild Argumentative or sarcastic. 4 Moderate Overtly angry on several occasions OR yelled at others excessively. 5 Moderately Severe Has threatened, slammed about or thrown things. 6 Severe Has assaulted others but with no harm likely, e.g., slapped or pushed, OR destroyed property, e.g., knocked over furniture, broken windows. 7 Extremely Severe Has attacked others with definite possibility of harming them or with actual harm, e.g., assault with hammer or weapon. "How have you been getting along with people (family, co-workers, etc.)?" "Have you been irritable or grumpy lately? (How do you show it? Do you keep it to yourself?" "Were you ever so irritable that you would shout at people or start fights or arguments? (Have you found yourself yelling at people you didn't know?)" "Have you hit anyone recently?" 7. Elevated Mood A pervasive, sustained and exaggerated feeling of well-being, cheerfulness, euphoria (implying a pathological mood), optimism that is out of proportion to the circumstances. Do not infer elation from increased activity or from grandiose statements alone. 2 Very mild Seems to be very happy, cheerful without much reason. 3 Mild Some unaccountable feelings of well-being that persist. 4 Moderate Reports excessive or unrealistic feelings of well-being, cheerfulness, confidence or optimism inappropriate to circumstances, some of the time. May frequently joke, smile, be giddy, or overly enthusiastic OR few instances of marked elevated mood with euphoria. 5 Moderately Severe Reports excessive or unrealistic feelings of well-being, confidence or optimism inappropriate to circumstances, much of the time. May describe feeling `on top of the world', `like everything is falling into place', or `better than ever before', OR several instances of marked elevated mood with euphoria. 6 Severe Reports many instances of marked elevated mood with euphoria OR mood definitely elevated almost constantly throughout interview and inappropriate to content. 7 Extremely Severe Individual reports being elated or appears almost intoxicated, laughing, joking, giggling, constantly euphoric, feeling invulnerable, all inappropriate to immediate circumstances. "Have you felt so good or high that other people thought that you were not your normal self?" "Have you been feeling cheerful and `on top of the world' without any reason?" [If individual reports elevated mood/euphoria, ask the following]: "Did it seem like more than just feeling good?" "How long did that last?" 8. Grandiosity Exaggerated self-opinion, self-enhancing conviction of special abilities or powers or identity as someone rich or famous. Rate only individual's statements about himself, not his/her demeanour. Note: if the individual rates 6 or 7 due to grandiose delusions, you must rate Unusual Thought Content at least 4 or above. 2 Very mild Feels great and denies obvious problems, but not unrealistic. 3 Mild Exaggerated self-opinion beyond abilities and training. 4 Moderate Inappropriate boastfulness, e.g., claims to be brilliant, insightful or gifted beyond realistic proportions, but rarely self-discloses or acts on these inflated selfconcepts. Does not claim that grandiose accomplishments have actually occurred. 5 Moderately Severe Same as 4 but often self-discloses and acts on these grandiose ideas. May have doubts about the reality of the grandiose ideas. Not delusional. 6 Severe Delusional - claims to have special powers like ESP, to have millions of dollars, invented new machines, worked at jobs when it is known that he/she was never employed in these capacities, be Jesus Christ, or the Prime Minister. Individual may not be very preoccupied. 7 Extremely Severe Delusional - same as 6 but individual seems very preoccupied and tends to disclose or act on grandiose delusions. "Is there anything special about you? Do you have any special abilities or powers? Have you thought that you might be somebody rich or famous?" [If the individual reports any grandiose ideas/delusions, ask the following]: "How often have you been thinking about [use individuals description]? Have you told anyone about what you have been thinking? Have you acted on any of these ideas?" 9. Suspiciousness Expressed or apparent belief that other persons have acted maliciously or with discriminatory intent. Include persecution by supernatural or other non-human agencies (e.g., the devil). Note: ratings of 3 or above should also be rated under Unusual Thought Content. 2 Very mild Seems on guard. Reluctant to respond to some `personal' questions. Reports being overly self-conscious in public. 3 Mild Describes incidents in which others have harmed or wanted to harm him/her that sound plausible. Individual feels as if others are watching, laughing or criticising him/her in public, but this occurs only occasionally or rarely. Little or no preoccupation. 4 Moderate Says other persons are talking about him/her maliciously, have negative intentions or may harm him/her. Beyond the likelihood of plausibility, but not delusional. Incidents of suspected persecution occur occasionally (less than once per week) with some preoccupation. 5 Moderately Severe Same as 4, but incidents occur frequently, such as more than once per week. Individual is moderately preoccupied with ideas of persecution OR individual reports persecutory delusions expressed with much doubt (e.g., partial delusion). 6 Severe Delusional - speaks of Mafia plots, the FBI or others poisoning his/her food, persecution by supernatural forces. 7 Extremely Severe Same as 6, but the beliefs are bizarre or more preoccupying. Individual tends to disclose or act on persecutory delusions. "Do you ever feel uncomfortable in public? Does it seem as though others are watching you? Are you concerned about anyone's intentions toward you? Is anyone going out of their way to give you a hard time, or trying to hurt you? Do you feel in any danger?" [If individual reports any persecutory ideas/delusions, ask the following]: "How often have you been concerned that [use individual's description]? Have you told anyone about these experiences?" 10. Hallucinations Reports of perceptual experiences in the absence of relevant external stimuli. When rating degree to which functioning is disrupted by hallucinations, include preoccupation with the content and experience of the hallucinations, as well as functioning disrupted by acting out on the hallucinatory content (e.g., engaging in deviant behaviour due to command hallucinations). Include thoughts aloud (`gedenkenlautwerden') or pseudohallucinations (e.g., hears a voice inside head) if a voice quality is present. 2 Very mild While resting or going to sleep, sees visions, smells odours or hears voices, sounds, or whispers in the absence of external stimulation, but no impairment in functioning. 3 Mild While in a clear state of consciousness, hears a voice calling the individual's name, experiences non-verbal auditory hallucinations (e.g., sounds or whispers), formless visual hallucinations or has sensory experiences in the presence of a modalityrelevant stimulus (e.g., visual illusions) infrequently (e.g., 1-2 times per week) and with no functional impairment. 4 Moderate Occasional verbal, visual, gustatory, olfactory or tactile hallucinations with no functional impairment OR non-verbal auditory hallucinations/visual illusions more than infrequently or with impairment. 5 Moderately Severe Experiences daily hallucinations OR some areas of functioning are disrupted by hallucinations. 6 Severe Experiences verbal or visual hallucinations several times a day OR many areas of functioning are disrupted by these hallucinations. 7 Extremely Severe Persistent verbal or visual hallucinations throughout the day OR most areas of functioning are disrupted by these hallucinations. "Do you ever seem to hear your name being called?" "Have you heard any sounds or people talking to you or about you when there has been nobody around? [If hears voices]: "What does the voice/voices say? Did it have a voice quality?" "Do you ever have visions or see things that others do not see? What about smell odours that others do not smell?" [If the individual reports hallucinations, ask the following]: "Have these experiences interfered with your ability to perform your usual activities/work? How do you explain them? How often do they occur?" 11. Unusual thought content Unusual, odd, strange, or bizarre thought content. Rate the degree of unusualness, not the degree of disorganisation of speech. Delusions are patently absurd, clearly false or bizarre ideas that are expressed with full conviction. Consider the individual to have full conviction if he/she has acted as though the delusional belief was true. Ideas of reference/persecution can be differentiated from delusions in that ideas are expressed with much doubt and contain more elements of reality. Include thought insertion, withdrawal and broadcast. Include grandiose, somatic and persecutory delusions even if rated elsewhere. Note: if Somatic Concern, Guilt, Suspiciousness or Grandiosity are rated 6 or 7 due to delusions, then Unusual Thought Content must be rated 4 or above. 2 Very mild Ideas of reference (people may stare or may laugh at him), ideas of persecution (people may mistreat him). Unusual beliefs in psychic powers, spirits, UFOs, or unrealistic beliefs in one's own abilities. Not strongly held. Some doubt. 3 Mild Same as 2, but degree of reality distortion is more severe as indicated by highly unusual ideas or greater conviction. Content may be typical of delusions (even bizarre), but without full conviction. The delusion does not seem to have fully formed, but is considered as one possible explanation for an unusual experience. 4 Moderate Delusion present but no preoccupation or functional impairment. May be an encapsulated delusion or a firmly endorsed absurd belief about past delusional circumstances. 5 Moderately Severe Full delusion(s) present with some preoccupation OR some areas of functioning disrupted by delusional thinking. 6 Severe Full delusion(s) present with much preoccupation OR many areas of functioning are disrupted by delusional thinking. 7 Extremely Severe Full delusion(s) present with almost total preoccupation OR most areas of functioning disrupted by delusional thinking. "Have you been receiving any special messages from people or from the way things are arranged around you? Have you seen any references to yourself on TV or in the newspapers?" "Can anyone read your mind?" "Do you have a special relationship with God?" "Is anything like electricity, X-rays, or radio waves affecting you?" "Are thoughts put into your head that are not your own?" "Have you felt that you were under the control of another person or force?" [If individual reports any odd ideas/delusions, ask the following]: "How often do you think about [use individual's description]?" "Have you told anyone about these experiences? How do you explain the things that have been happening [specify]?" Rate items 12-13 on the basis of individual's self-report and observed behaviour. 12. Bizarre behaviour Reports of behaviours which are odd, unusual, or psychotically criminal. Not limited to interview period. Include inappropriate sexual behaviour and inappropriate affect. 2 Very mild Slightly odd or eccentric public behaviour, e.g., occasionally giggles to self, fails to make appropriate eye contact, that does not seem to attract the attention of others OR unusual behaviour conducted in private, e.g., innocuous rituals, that would not attract the attention of others. 3 Mild Noticeably peculiar public behaviour, e.g., inappropriately loud talking, makes inappropriate eye contact, OR private behaviour that occasionally, but not always, attracts the attention of others, e.g., hoards food, conducts unusual rituals, wears gloves indoors. 4 Moderate Clearly bizarre behaviour that attracts or would attract (if done privately) the attention or concern of others, but with no corrective intervention necessary. Behaviour occurs occasionally, e.g., fixated staring into space for several minutes, talks back to voices once, inappropriate giggling/laughter on 1-2 occasions, talking loudly to self. 5 Moderately Severe Clearly bizarre behaviour that attracts or would attract (if done privately) the attention of others or the authorities, e.g., fixated staring in a socially disruptive way, frequent inappropriate giggling/laughter, occasionally responds to voices, or eats non-foods. 6 Severe Bizarre behaviour that attracts attention of others and intervention by authorities, e.g., directing traffic, public nudity, staring into space for long periods, carrying on a conversation with hallucinations, frequent inappropriate giggling/laughter. 7 Extremely Severe Serious crimes committed in a bizarre way that attract the attention of others and the control of authorities, e.g., sets fires and stares at flames OR almost constant bizarre behaviour, e.g., inappropriate giggling/laughter, responds only to hallucinations and cannot be engaged in interaction. "Have you done anything that has attracted the attention of others?" "Have you done anything that could have gotten you into trouble with the police?" "Have you done anything that seemed unusual or disturbing to others?" 13. Self-neglect Hygiene, appearance, or eating behaviour below usual expectations, below socially acceptable standards or life threatening. 2 Very mild Hygiene/appearance slightly below usual community standards, e.g., shirt out of pants, buttons unbuttoned, shoe laces untied, but no social or medical consequences. 3 Mild Hygiene/appearance occasionally below usual community standards, e.g., irregular bathing, clothing is stained, hair uncombed, occasionally skips an important meal. No social or medical consequences. 4 Moderate Hygiene/appearance is noticeably below usual community standards, e.g., fails to bathe or change clothes, clothing very soiled, hair unkempt, needs prompting, noticeable by others OR irregular eating and drinking with minimal medical concerns and consequences. 5 Moderately Severe Several areas of hygiene/appearance are below usual community standards OR poor grooming draws criticism by others and requires regular prompting. Eating or hydration are irregular and poor, causing some medical problems. 6 Severe Many areas of hygiene/appearance are below usual community standards, does not always bathe or change clothes even if prompted. Poor grooming has caused social ostracism at school/residence/work, or required intervention. Eating erratic and poor, may require medical intervention. 7 Extremely Severe Most areas of hygiene/appearance/nutrition are extremely poor and easily noticed as below usual community standards OR hygiene/appearance/nutrition require urgent and immediate medical intervention. "How has your grooming been lately? How often do you change your clothes? How often do you take showers? Has anyone (parents/staff) complained about your grooming or dress? Do you eat regular meals?" 14. Disorientation Does not comprehend situations or communications, such as questions asked during the entire BPRS interview. Confusion regarding person, place, or time. Do not rate if incorrect responses are due to delusions. 2 Very mild Seems muddled or mildly confused 1-2 times during interview. Oriented to person, place and time. 3 Mild Occasionally muddled or mildly confused 3-4 times during interview. Minor inaccuracies in person, place, or time, e.g., date off by more than 2 days, or gives wrong division of hospital or community centre. 4 Moderate Frequently confused during interview. Minor inaccuracies in person, place, or time are noted, as in 3 above. In addition, may have difficulty remembering general information, e.g., name of Prime Minister. 5 Moderately Severe Markedly confused during interview, or to person, place, or time. Significant inaccuracies are noted, e.g., date off by more than one week, or cannot give correct name of hospital. Has difficulty remembering personal information, e.g., where he/she was born or recognising familiar people. 6 Severe Disoriented as to person, place, or time, e.g., cannot give correct month and year. Disoriented in 2 out of 3 spheres. 7 Extremely Severe Grossly disoriented as to person, place, or time, e.g., cannot give name or age. Disoriented in all three spheres. "May I ask you some standard questions we ask everybody?" "How old are you? What is the date [allow 2 days]" "What is this place called? What year were you born? Who is the Prime Minister?" Rate items 15-24 on the basis of observed behaviour and speech. 15 Conceptual disorganisation Degree to which speech is confused, disconnected, vague or disorganised. Rate tangentiality, circumstantiality, sudden topic shifts, incoherence, derailment, blocking, neologisms, and other speech disorders. Do not rate content of speech. 2 Very mild Peculiar use of words or rambling but speech is comprehensible. 3 Mild Speech a bit hard to understand or make sense of due to tangentiality, circumstantiality, or sudden topic shifts. 4 Moderate Speech difficult to understand due to tangentiality, circumstantiality, idiosyncratic speech, or topic shifts on many occasions OR 1-2 instances of incoherent phrases. 5 Moderately Severe Speech difficult to understand due to circumstantiality, tangentiality, neologisms, blocking or topic shifts most of the time, OR 3-5 instances of incoherent phrases. 6 Severe Speech is incomprehensible due to severe impairment most of the time. Many BPRS items cannot be rated by self-report alone. 7 Extremely Severe Speech is incomprehensible throughout interview. 16. Blunted affect Restricted range in emotional expressiveness of face, voice, and gestures. Marked indifference or flatness even when discussing distressing topics. In the case of euphoric or dysphoric individuals, rate Blunted Affect if a flat quality is also clearly present. 2 Very mild Emotional range is slightly subdued or reserved but displays appropriate facial expressions and tone of voice that are within normal limits. 3 Mild Emotional range overall is diminished, subdued or reserved, without many spontaneous and appropriate emotional responses. Voice tone is slightly monotonous. 4 Moderate Emotional range is noticeably diminished, individual doesn't show emotion, smile or react to distressing topics except infrequently. Voice tone is monotonous or there is noticeable decrease in spontaneous movements. Displays of emotion or gestures are usually followed by a return to flattened affect. 5 Moderately Severe Emotional range very diminished, individual doesn't show emotion, smile, or react to distressing topics except minimally, few gestures, facial expression does not change very often. Voice tone is monotonous much of the time. 6 Severe Very little emotional range or expression. Mechanical in speech and gestures most of the time. Unchanging facial expression. Voice tone is monotonous most of the time. 7 Extremely Severe Virtually no emotional range or expressiveness, stiff movements. Voice tone is monotonous all of the time. Use the following probes at end of interview to assess emotional responsivity: "Have you heard any good jokes lately? Would you like to hear a joke?" 17. Emotional withdrawal Deficiency in individual's ability to relate emotionally during interview situation. Use your own feeling as to the presence of an `invisible barrier' between individual and interviewer. Include withdrawal apparently due to psychotic processes. 2 Very mild Lack of emotional involvement shown by occasional failure to make reciprocal comments, appearing preoccupied, or smiling in a stilted manner, but spontaneously engages the interviewer most of the time. 3 Mild Lack of emotional involvement shown by noticeable failure to make reciprocal comments, appearing preoccupied, or lacking in warmth, but responds to interviewer when approached. 4 Moderate Emotional contact not present much of the interview because individual does not elaborate responses, fails to make eye contact, doesn't seem to care if interviewer is listening, or may be preoccupied with psychotic material. 5 Moderately Severe Same as 4 but emotional contact not present most of the interview. 6 Severe Actively avoids emotional participation. Frequently unresponsive or responds with yes/no answers (not solely due to persecutory delusions). Responds with only minimal affect. 7 Extremely Severe Consistently avoids emotional participation. Unresponsive or responds with yes/no answers (not solely due to persecutory delusions). May leave during interview or just not respond at all. 18. Motor retardation Reduction in energy level evidenced by slowed movements and speech, reduced body tone, decreased number of spontaneous body movements. Rate on the basis of observed behaviour of the individual only. Do not rate on the basis of individual's subjective impression of his own energy level. Rate regardless of medication effects. 2 Very mild Slightly slowed or reduced movements or speech compared to most people. 3 Mild Noticeably slowed or reduced movements or speech compared to most people. 4 Moderate Large reduction or slowness in movements or speech. 5 Moderately Severe Seldom moves or speaks spontaneously OR very mechanical or stiff movements 6 Severe Does not move or speak unless prodded or urged. 7 Extremely Severe Frozen, catatonic. 19. Tension Observable physical and motor manifestations of tension, `nervousness' and agitation. Self-reported experiences of tension should be rated under the item on anxiety. Do not rate if restlessness is solely akathisia, but do rate if akathisia is exacerbated by tension. 2 Very mild More fidgety than most but within normal range. A few transient signs of tension, e.g., picking at fingernails, foot wagging, scratching scalp several times or finger tapping. 3 Mild Same as 2, but with more frequent or exaggerated signs of tension. 4 Moderate Many and frequent signs of motor tension with one or more signs sometimes occurring simultaneously, e.g., wagging one's foot while wringing hands together. There are times when no signs of tension are present. 5 Moderately Severe Many and frequent signs of motor tension with one or more signs often occurring sim ultaneously. There are still rare times when no signs of tension are present. 6 Severe Same as 5, but signs of tension are continuous. 7 Extremely Severe Multiple motor manifestations of tension are continuously present, e.g., continuous pacing and hand wringing. 20. Unco-operativeness Resistance and lack of willingness to co-operate with the interview. The uncooperativeness might result from suspiciousness. Rate only unco-operativeness in relation to the interview, not behaviours involving peers and relatives. 2 Very mild Shows non-verbal signs of reluctance, but does not complain or argue. 3 Mild Gripes or tries to avoid complying, but goes ahead without argument. 4 Moderate Verbally resists but eventually complies after questions are rephrased or repeated. 5 Moderately Severe Same as 4, but some information necessary for accurate ratings is withheld. 6 Severe Refuses to co-operate with interview, but remains in interview situation. 7 Extremely Severe Same as 6, with active efforts to escape the interview 21. Excitement Heightened emotional tone or increased emotional reactivity to interviewer or topics being discussed, as evidenced by increased intensity of facial expressions, voice tone, expressive gestures or increase in speech quantity and speed. 2 Very mild Subtle and fleeting or questionable increase in emotional intensity. For example, at times seems keyed-up or overly alert. 3 Mild Subtle but persistent increase in emotional intensity. For example, lively use of gestures and variation in voice tone. 4 Moderate Definite but occasional increase in emotional intensity. For example, reacts to interviewer or topics that are discussed with noticeable emotional intensity. Some pressured speech. 5 Moderately Severe Definite and persistent increase in emotional intensity. For example, reacts to many stimuli, whether relevant or not, with considerable emotional intensity. Frequent pressured speech. 6 Severe Marked increase in emotional intensity. For example, reacts to most stimuli with inappropriate emotional intensity. Has difficulty settling down or staying on task. Often restless, impulsive, or speech is often pressured. 7 Extremely Severe Marked and persistent increase in emotional intensity. Reacts to all stimuli with inappropriate intensity, impulsiveness. Cannot settle down or stay on task. Very restless and impulsive most of the time. Constant pressured speech. 22. Distractibility Degree to which observed sequences of speech and actions are interrupted by stimuli unrelated to the interview. Distractibility is rated when the individual shows a change in the focus of attention as characterised by a pause in speech or a marked shift in gaze. Individual's attention may be drawn to noise in adjoining room, books on a shelf, interviewer's clothing, etc. Do not rate circumstantiality, tangentiality or flight of ideas. Also, do not rate rumination with delusional material. Rate even if the distracting stimulus cannot be identified. 2 Very mild Generally can focus on interviewer's questions with only 1 distraction or inappropriate shift of attention of brief duration. 3 Mild Individual shifts focus of attention to matters unrelated to the interview 2-3 times. 4 Moderate Often responsive to irrelevant stimuli in the room, e.g., averts gaze from the interviewer. 5 Moderately Severe Same as above, but now distractibility clearly interferes with the flow of the interview. 6 Severe Extremely difficult to conduct interview or pursue a topic due to preoccupation with irrelevant stimuli. 7 Extremely Severe Impossible to conduct interview due to preoccupation with irrelevant stimuli. 23. Motor hyperactivity Increase in energy level evidenced in more frequent movement and/or rapid speech. Do not rate if restlessness is due to akathisia. 2 Very mild Some restlessness, difficulty sitting still, lively facial expressions, or somewhat talkative 3 Mild Occasionally very restless, definite increase in motor activity, lively gestures, 1-3 brief instances of pressured speech. 4 Moderate Very restless, fidgety, excessive facial expressions, or non-productive and repetitious motor movements. Much pressured speech, up to one-third of the interview. 5 Moderately Severe Frequently restless, fidgety. Many instances of excessive nonproductive and repetitious motor movements. On the move most of the time. Frequent pressured speech, difficult to interrupt. Rises on 1-2 occasions to pace. 6 Severe Excessive motor activity, restlessness, fidgety, loud tapping, noisy, etc., throughout most of the interview. Speech can only be interrupted with much effort. Rises on 3-4 occasions to pace. 7 Extremely Severe Constant excessive motor activity throughout entire interview, e.g., constant pacing, constant pressured speech with no pauses, individual can only be interrupted briefly and only small amounts of relevant information can be obtained 24. Mannerisms and posturing Unusual and bizarre behaviour, stylised movements or acts, or any postures which are clearly uncomfortable or inappropriate. Exclude obvious manifestations of medication side effects. Do not include nervous mannerisms that are not odd or unusual. 2 Very mild Eccentric or odd mannerisms or activity that ordinary persons would have difficulty explaining, e.g., grimacing, picking. Observed once for a brief period. 3 Mild Same as 2, but occurring on two occasions of brief duration. 4 Moderate Mannerisms or posturing, e.g., stylised movements or acts, rocking, nodding, rubbing, or grimacing, observed on several occasions for brief periods or infrequently but very odd. For example, uncomfortable posture maintained for 5 seconds more than twice. 5 Moderately Severe Same as 4, but occurring often, or several examples of very odd mannerisms or posturing that are idiosyncratic to the individual. 6 Severe Frequent stereotyped behaviour, assumes and maintains uncomfortable or inappropriate postures, intense rocking, smearing, strange rituals or foetal posturing. Individual can interact with people and the environment for brief periods despite these behaviours. 7 Extremely Severe Same as 6, but individual cannot interact with people or the environment due to these behaviours. Back ToC CAGE Questionnaire 1. Have you ever felt you should Cut down on your drinking? _____ Yes _____ No 2. Have people Annoyed you by criticizing your drinking? _____ Yes _____ No 3. Have you ever felt bad or Guilty about your drinking? _____ Yes _____ No 4. Have you ever had a drink first thing in the morning to steady your nerves or to get rid of a hangover (Eye opener)? _____ Yes _____ No ******************************************************************************************** Scoring: Item responses on the CAGE are scored 0 or 1, with a higher score an indication of alcohol problems. A total score of 2 or greater is considered clinically significant. Back ToC Life Satisfaction Index A (LSIA; Adams, 1969) Here are some statements about life in general that people feel different ways about. Read each statement on the list and indicate on the left the number that best describes how you feel about the statement. 1= Agree 2= Disagree 3= Unsure 1. ___ As I get older, things seem better than I thought they would be. 2. ___ I have gotten more of the breaks in life than most of the people that I know. 3. ___ This is the dreariest time of my life. 4. ___ I am just as happy as when I was younger. 5. ___ My life could be happier than it is now. 6. ___ These are the best years of my life 7. ___ Most of the things I do are boring or monotonous. 8. 9. ___ I expect some interesting and some pleasant things to happen to me in the future. ___ The things I do are as interesting to me as they ever were. 10. ___ I feel old and somewhat tired. 11. ___ As I look back on my life, I am fairly well satisfied. 12. ___ I would not change my past life even if I could 13. ___ Compared to other people my age, I make a good appearance. 14. ___ I have made plans for things I’ll be doing in a month or a year from now. 15. ___ When I think back over my life, I didn’t get most of the important things I wanted. 16. ___ Compared to other people, I get down in the dumps too often. 17. ___ I got pretty much what I expected out of life.; 18. ___ In spite of what some people say, the lot of the average man is getting worse, not better. Scoring Guide LSIA Adams (1969) uses Wood’s scoring method (Wood, Wylie, & Sheafor, 1969). Method assigns 2 points fro positive answers, 0 for negative answers, and 1 for “don’t know” answers, provide a range of 0 to 36, with the highest scores indicating the greatest satisfaction. Back ToC Geriatric Depression Scale -15 (GDS-15) Choose the best answer for how you have felt over the past week: 1 Are you basically satisfied with you life? Yes No 2 Have you dropped many of your activities and interests? Yes No 3 Do you feel that your life is empty? Yes No 4 Do you often get bored? Yes No 5 Are you in good sprits most of the time? Yes No 6 Are you afraid that something bad is going to happen to you? Yes No 7 Do you feel happy most of the time? Yes No 8 Do you often feel helpless? Yes No 9 Do you prefer to stay at home, rather than going out and doing new things? Yes No 10 Do you feel you have more problems with memory than most? Yes No 11 Do you think is it wonderful to be alive now? Yes No 12 Do you feel pretty worthless the way you are now? Yes No 13 Do you feel full of energy? Yes No 14 Do you feel that your situation is hopeless? Yes No 15 Do you think that most people are better off than you are? Yes No Answers in bold indicate depression. Although differing sensitivities and specificities have been obtained across studies, for clinical purposes a score >5 bold answers is suggestive of depression and should warrant a follow-up interview. This instrument, and other versions of the GDS in multiple translations, are in the public domain and can be found at: ww.stanford.edu?~yesavage/DGS.html Back ToC FACT-G (Version 4) Below is a list of statements that other people with your illness have said are important. Please circle or mark one number per line to indicate your response as it applies to the past 7 days. PHYSICAL WELL-BEING Not at all A little bit Somewhat Quite a bit Very much GP1 I have a lack of energy ....................................................... 0 1 2 3 4 GP2 I have nausea ...................................................................... 0 1 2 3 4 GP3 Because of my physical condition, I have trouble meeting the needs of my family ......................................... 0 1 2 3 4 GP4 I have pain .......................................................................... 0 1 2 3 4 GP5 I am bothered by side effects of treatment ......................... 0 1 2 3 4 GP6 I feel ill ............................................................................... 0 1 2 3 4 GP7 I am forced to spend time in bed ........................................ 0 1 2 3 4 Not at all A little bit Somewhat Quite a bit Very much SOCIAL/FAMILY WELL-BEING GS1 I feel close to my friends .................................................... 0 1 2 3 4 GS2 I get emotional support from my family ............................ 0 1 2 3 4 GS3 I get support from my friends............................................. 0 1 2 3 4 GS4 My family has accepted my illness .................................... 0 1 2 3 4 GS5 I am satisfied with family communication about my illness.................................................................................. 0 1 2 3 4 I feel close to my partner (or the person who is my main support) .............................................................................. 0 1 2 3 4 0 1 2 3 4 GS6 Q1 Regardless of your current level of sexual activity, please answer the following question. If you prefer not to answer it, please mark this box and go to the next section. GS7 I am satisfied with my sex life ............................................ English (Universal) Copyright 1987, 1997 16 November 2007 Page 1 of 2 FACT-G (Version 4) Please circle or mark one number per line to indicate your response as it applies to the past 7 days. EMOTIONAL WELL-BEING Not at all A little bit Somewhat Quite a bit Very much GE1 I feel sad .............................................................................. 0 1 2 3 4 GE2 I am satisfied with how I am coping with my illness.......... 0 1 2 3 4 GE3 I am losing hope in the fight against my illness.................. 0 1 2 3 4 GE4 I feel nervous....................................................................... 0 1 2 3 4 GE5 I worry about dying ............................................................. 0 1 2 3 4 GE6 I worry that my condition will get worse ............................ 0 1 2 3 4 Not at all A little bit Somewhat Quite a bit Very much FUNCTIONAL WELL-BEING GF1 I am able to work (include work at home) .......................... 0 1 2 3 4 GF2 My work (include work at home) is fulfilling..................... 0 1 2 3 4 GF3 I am able to enjoy life.......................................................... 0 1 2 3 4 GF4 I have accepted my illness................................................... 0 1 2 3 4 GF5 I am sleeping well ............................................................... 0 1 2 3 4 GF6 I am enjoying the things I usually do for fun ...................... 0 1 2 3 4 GF7 I am content with the quality of my life right now.............. 0 1 2 3 4 English (Universal) Copyright 1987, 1997 16 November 2007 Page 2 of 2 Back ToC Mini-Mental State Examination (MMSE) Patient’s Name: Date: Instructions: Ask the questions in the order listed. Score one point for each correct response within each question or activity. Maximum Patient’s Questions Score Score 5 “What is the year? Season? Date? Day of the week? Month?” 5 “Where are we now: State? County? Town/city? Hospital? Floor?” 3 The examiner names three unrelated objects clearly and slowly, then asks the patient to name all three of them. The patient’s response is used for scoring. The examiner repeats them until patient learns all of them, if possible. Number of trials: ___________ 5 “I would like you to count backward from 100 by sevens.” (93, 86, 79, 72, 65, …) Stop after five answers. Alternative: “Spell WORLD backwards.” (D-L-R-O-W) 3 “Earlier I told you the names of three things. Can you tell me what those were?” 2 Show the patient two simple objects, such as a wristwatch and a pencil, and ask the patient to name them. 1 “Repeat the phrase: ‘No ifs, ands, or buts.’” 3 “Take the paper in your right hand, fold it in half, and put it on the floor.” (The examiner gives the patient a piece of blank paper.) 1 “Please read this and do what it says.” (Written instruction is “Close your eyes.”) 1 “Make up and write a sentence about anything.” (This sentence must contain a noun and a verb.) “Please copy this picture.” (The examiner gives the patient a blank piece of paper and asks him/her to draw the symbol below. All 10 angles must be present and two must intersect.) 1 30 TOTAL (Adapted from Rovner & Folstein, 1987) 1 Source: www.medicine.uiowa.edu/igec/tools/cognitive/MMSE.pdf Provided by NHCQF, 0106-410 Instructions for administration and scoring of the MMSE Orientation (10 points): • Ask for the date. Then specifically ask for parts omitted (e.g., "Can you also tell me what season it is?"). One point for each correct answer. • Ask in turn, "Can you tell me the name of this hospital (town, county, etc.)?" One point for each correct answer. Registration (3 points): • Say the names of three unrelated objects clearly and slowly, allowing approximately one second for each. After you have said all three, ask the patient to repeat them. The number of objects the patient names correctly upon the first repetition determines the score (0-3). If the patient does not repeat all three objects the first time, continue saying the names until the patient is able to repeat all three items, up to six trials. Record the number of trials it takes for the patient to learn the words. If the patient does not eventually learn all three, recall cannot be meaningfully tested. • After completing this task, tell the patient, "Try to remember the words, as I will ask for them in a little while." Attention and Calculation (5 points): • Ask the patient to begin with 100 and count backward by sevens. Stop after five subtractions (93, 86, 79, 72, 65). Score the total number of correct answers. • If the patient cannot or will not perform the subtraction task, ask the patient to spell the word "world" backwards. The score is the number of letters in correct order (e.g., dlrow=5, dlorw=3). Recall (3 points): • Ask the patient if he or she can recall the three words you previously asked him or her to remember. Score the total number of correct answers (0-3). Language and Praxis (9 points): • Naming: Show the patient a wrist watch and ask the patient what it is. Repeat with a pencil. Score one point for each correct naming (0-2). • Repetition: Ask the patient to repeat the sentence after you ("No ifs, ands, or buts."). Allow only one trial. Score 0 or 1. • 3-Stage Command: Give the patient a piece of blank paper and say, "Take this paper in your right hand, fold it in half, and put it on the floor." Score one point for each part of the command correctly executed. • Reading: On a blank piece of paper print the sentence, "Close your eyes," in letters large enough for the patient to see clearly. Ask the patient to read the sentence and do what it says. Score one point only if the patient actually closes his or her eyes. This is not a test of memory, so you may prompt the patient to "do what it says" after the patient reads the sentence. • Writing: Give the patient a blank piece of paper and ask him or her to write a sentence for you. Do not dictate a sentence; it should be written spontaneously. The sentence must contain a subject and a verb and make sense. Correct grammar and punctuation are not necessary. • Copying: Show the patient the picture of two intersecting pentagons and ask the patient to copy the figure exactly as it is. All ten angles must be present and two must intersect to score one point. Ignore tremor and rotation. (Folstein, Folstein & McHugh, 1975) 2 Source: www.medicine.uiowa.edu/igec/tools/cognitive/MMSE.pdf Provided by NHCQF, 0106-410 Interpretation of the MMSE Method Score Single Cutoff <24 Abnormal <21 Increased odds of dementia >25 Decreased odds of dementia 21 Abnormal for 8th grade education <23 Abnormal for high school education <24 Abnormal for college education Range Education Severity Interpretation 24-30 No cognitive impairment 18-23 Mild cognitive impairment 0-17 Severe cognitive impairment Sources: • • • • Crum RM, Anthony JC, Bassett SS, Folstein MF. Population-based norms for the mini-mental state examination by age and educational level. JAMA. 1993;269(18):2386-2391. Folstein MF, Folstein SE, McHugh PR. "Mini-mental state": a practical method for grading the cognitive state of patients for the clinician. J Psychiatr Res. 1975;12:189-198. Rovner BW, Folstein MF. Mini-mental state exam in clinical practice. Hosp Pract. 1987;22(1A):99, 103, 106, 110. Tombaugh TN, McIntyre NJ. The mini-mental state examination: a comprehensive review. J Am Geriatr Soc. 1992;40(9):922-935. 3 Source: www.medicine.uiowa.edu/igec/tools/cognitive/MMSE.pdf Provided by NHCQF, 0106-410 Back ToC Montgomery-Åsberg Depression Rating Scale (MADRS) Montgomery-Åsberg Depression Rating Scale (MADRS) Please visit us at www.lundbeck.com/cnsforum 1 Montgomery-Åsberg Depression Rating Scale (MADRS) 1. Apparent sadness Representing despondency, gloom and despair (more than just ordinary transient low spirits), reflected in speech, facial expression, and posture. Rate by depth and inability to brighten up. 0 = No sadness. 2 = Looks dispirited but does brighten up without difficulty. 4 = Appears sad and unhappy most of the time. 6 = Looks miserable all the time. Extremely despondent 2. Reported sadness Representing reports of depressed mood, regardless of whether it is reflected in appearance or not. Includes low spirits, despondency or the feeling of being beyond help and without hope. 0 = Occasional s adness in keeping with the circumstances. 2 = Sad or low but brightens up without difficulty. 4 = Pervasive feelings of sadness or gloominess. The mood is still influenced by external circumstances. 6 = Continuous or unvarying sadness, misery or despondency. Please visit us at www.lundbeck.com/cnsforum 2 Montgomery-Åsberg Depression Rating Scale (MADRS) 3. Inner tension Representing feelings of ill-defined discomfort, edginess, inner turmoil, mental tension mounting to either panic, dread or anguish. Rate according to intensity, frequency, duration a nd the extent of reassurance called for. 0 = Placid. Only fleeting inner tension. 2 = Occasional feelings of edginess and ill-defined discomfort. 4 = Continuous feelings of inner tension or intermittent panic which the patient c an only master with some difficulty. 6 = Unrelenting dread or anguish. Overwhelming panic. 4. Reduced sleep Representing the experience of reduced duration or depth of sleep compared to the subject's own normal pattern when well. 0 = Sleeps as normal. 2 = Slight difficulty dropping off to sleep or slightly reduced, light or fitful sleep. 4 = Moderate stiffness and resistance 6 = Sleep reduced or broken by at least 2 hours. Please visit us at www.lundbeck.com/cnsforum 3 Montgomery-Åsberg Depression Rating Scale (MADRS) 5. Reduced appetite Representing the feeling of a loss of appetite compared with when-well. Rate by loss of desire for food or the need to force oneself to eat. 0 = Normal or increased appetite. 2 = Slightly reduced appetite. 4 = No appetite. Food is tasteless. 6 = Needs persuasion to eat at all. 6. Concentration difficulties Representing difficulties in collecting one's thoughts mounting to an incapacitating lack of concentration. Rate accordin g to intensity, frequency, and degree of incapacity produced. 0 = No difficulties in concentrating. 2 = Occasional difficulties in collecting one's thoughts. 4 = Difficulties in concentrating and sustaining thought which reduced ability to read or hold a conversation. 6 = Unable to read or converse without great difficulty. Please visit us at www.lundbeck.com/cnsforum 4 Montgomery-Åsberg Depression Rating Scale (MADRS) 7. Lassitude Representing difficulty in getting started or slowness in initiating and performing everyday activities. 0 = Hardly any difficulty in getting started. No sluggishness. 2 = Difficulties in starting activities. 4 = Difficulties in starting simple routine activities which are carried out with effort. 6 = Complete lassitude. Unable to do anything without help. 8. Inability to feel Representing the subjective experience of reduced interest in the surroundings, or activities that normally give pleasure. The ability to react with adequate emotion to circumstances or people is reduced. 0 = Normal interest in the surroundings and in other people. 2 = Reduced ability to enjoy usual interests. 4 = Loss of interest in the surroundings. Loss of feelings for friends and acquaintances. 6 = The experience of being emotionally paralysed, inability to feel anger, grief or pleasure and a complete or even painful failure to feel for close relatives and friends. Please visit us at www.lundbeck.com/cnsforum 5 Montgomery-Åsberg Depression Rating Scale (MADRS) 9. Pessimistic thoughts Representing thoughts of guilt, inferiority, self-reproach, sinfulness, remorse and ruin. 0 = No pessimistic thoughts. 2 = Fluctuating ideas of failure, self-reproach or self- depreciation. 4 = Persistent self-accusations, or definite but still rational ideas of guilt or sin. Increasingly pessimistic about the future. 6 = Delusions of ruin, remorse or irredeemable sin. Self- accusations which are absurd and unshakable. 10. Suicidal thoughts Representing the feeling that life is not worth living, that a natural death would be welcome, suicidal thoughts, and preparations for suicide. Suicide attempts should not in themselves influence the rating. 0 = Enjoys life or takes it as it comes. 2 = Weary of life. Only fleeting suicidal thoughts. 4 = Probably better off dead. Suicidal thoughts are common, and suicide is considered as a possible solution, but without specific plans or intenstion. 6 = Explicit plans for suicide when there is an opportunity. Active preparations for suicide. Please visit us at www.lundbeck.com/cnsforum 6 Back ToC PATIENT HEALTH QUESTIONNAIRE (PHQ-9) DATE: NAME: Over the last 2 weeks, how often have you been bothered by any of the following problems? (use "ⁿ" to indicate your answer) More than Nearly half the every day days Not at all Several days 1. Little interest or pleasure in doing things 0 1 2 3 2. Feeling down, depressed, or hopeless 0 1 2 3 3. Trouble falling or staying asleep, or sleeping too much 0 1 2 3 4. Feeling tired or having little energy 0 1 2 3 5. Poor appetite or overeating 0 1 2 3 6. Feeling bad about yourself or that you are a failure or have let yourself or your family down 0 1 2 3 7. Trouble concentrating on things, such as reading the newspaper or watching television 0 1 2 3 8. Moving or speaking so slowly that other people could have noticed. Or the opposite being so figety or restless that you have been moving around a lot more than usual 0 1 2 3 9. Thoughts that you would be better off dead, or of hurting yourself 0 1 2 3 add columns + + (Healthcare professional: For interpretation of TOTAL, TOTAL: please refer to accompanying scoring card). 10. If you checked off any problems, how difficult have these problems made it for you to do your work, take care of things at home, or get along with other people? Not difficult at all Somewhat difficult Very difficult Extremely difficult Copyright © 1999 Pfizer Inc. All rights reserved. Reproduced with permission. PRIME-MD© is a trademark of Pfizer Inc. A2663B 10-04-2005 PHQ-9 Patient Depression Questionnaire For initial diagnosis: 1. Patient completes PHQ-9 Quick Depression Assessment. 2. If there are at least 4 3s in the shaded section (including Questions #1 and #2), consider a depressive disorder. Add score to determine severity. Consider Major Depressive Disorder - if there are at least 5 3s in the shaded section (one of which corresponds to Question #1 or #2) Consider Other Depressive Disorder - if there are 2-4 3s in the shaded section (one of which corresponds to Question #1 or #2) Note: Since the questionnaire relies on patient self-report, all responses should be verified by the clinician, and a definitive diagnosis is made on clinical grounds taking into account how well the patient understood the questionnaire, as well as other relevant information from the patient. Diagnoses of Major Depressive Disorder or Other Depressive Disorder also require impairment of social, occupational, or other important areas of functioning (Question #10) and ruling out normal bereavement, a history of a Manic Episode (Bipolar Disorder), and a physical disorder, medication, or other drug as the biological cause of the depressive symptoms. To monitor severity over time for newly diagnosed patients or patients in current treatment for depression: 1. Patients may complete questionnaires at baseline and at regular intervals (eg, every 2 weeks) at home and bring them in at their next appointment for scoring or they may complete the questionnaire during each scheduled appointment. 2. Add up 3s by column. For every 3: Several days = 1 More than half the days = 2 Nearly every day = 3 3. Add together column scores to get a TOTAL score. 4. Refer to the accompanying PHQ-9 Scoring Box to interpret the TOTAL score. 5. Results may be included in patient files to assist you in setting up a treatment goal, determining degree of response, as well as guiding treatment intervention. Scoring: add up all checked boxes on PHQ-9 For every 3 Not at all = 0; Several days = 1; More than half the days = 2; Nearly every day = 3 Interpretation of Total Score Total Score 1-4 5-9 10-14 15-19 20-27 Depression Severity Minimal depression Mild depression Moderate depression Moderately severe depression Severe depression PHQ9 Copyright © Pfizer Inc. All rights reserved. Reproduced with permission. PRIME-MD ® is a trademark of Pfizer Inc. A2662B 10-04-2005 Back ToC INSTRUMENT GUIDE FOR DIABETES-SPECIFIC PROGRAMS Instruments preceded by an asterisk (*) and bolded are common to a number of conditions and can be found in the Cross-Cutting Instruments Guide Important Note: While rigorous research was conducted to provide readers with all of the instrumentation for implementing the programs outlined in this toolkit, for a limited number of programs, instrumentation was not available for public use. Therefore, interested parties are encouraged to contact selected programs to obtain permission for instruments not included here. Instrument Chronic Illness Resources Survey * Community Health Activities Model Program for Seniors (CHAMPS) Physical Activity Questionnaire English & Spanish versions, including manual and scoring guide Program • Healthy Changes™ • Diabetes Health Connection Diabetes Integration Questionnaire (ATT39) • Look After Yourself (LAY) Diabetes Knowledge (SKILLD) 1 Scale • New Leaf Diabetes Knowledge Questionnaire English & Spanish versions * Fat-Related Diet Habits Questionnaire 2 Measurement of Beliefs of Diabetic Patients English & Spanish versions Modifiable Activity Questionnaire National Health Interview Survey (NHIS) Item on self-rated health Personal Models of Diabetes Questionnaire (Updated 2001 version) Including scoring guide Stanford Patient Education Exercise Behaviors Questionnaire Stanford Patient Education Research Center Self Efficacy for Diabetes Measure Summary of Diabetes Self-Care Activities (SDSCA) • Starr County Border Health Initiative • Diabetes Prevention Program (DPP) • New Leaf • Starr County Border Health Initiative • DPP • Healthy Changes™ • LAY • Healthy Changes™ • Healthy Changes™ • Healthy Changes™ • LAY • New Leaf • Seniors Taking Charge of Diabetes! Please note that we are recommending the SKILLD measure as a substitute measure for the diabetes knowledge measure used in the New Leaf program because that measure is not currently available. 1 2 Please note that we are recommending the Fat-Related Diet Habits Questionnaire as a substitute measure for the DPP and New Leaf Interventions. The measure used by the study authors in those two interventions to assess diet would be overly burdensome to administer. Back ToC Back ToC Diabetes Integration Questionnaire (ATT39) INSTRUCTIONS: This form contains 19 questions to see how you feel about diabetes and its effect on your life. The are no ‘right’ or ‘wrong’ answers because everyone has the right to his or her own views. Please do not spend too long on each question. There are 5 possible answers to choose from: I DISAGREE COMPLETELY (DC) or I DISAGREE (D) or I DON’T KNOW (?) or I AGREE (A) or I AGREE COMPLETELY (AC) For each question, circle the ONE answer that is right for you. Give your first, natural answer as it occurs to you. 1. If I did not have diabetes I think I would be quite a different person 2. I dislike being referred to as ‘A DIABETIC’ 3. Diabetes is the worst thing that has ever happened to me 4. 5. 6. 7. 8. 9. Most people would find it difficult to adjust to having diabetes I often feel embarrased about having diabetes There is not much I seem to be able to do to control my diabetes There is little hope of leadinga normal life with diabetes The proper control of diabetes involves a lot of sacrifice and inconvenience I try not to let people know about my diabetes I disagree completely I disagree I don’t know I agree I agree completely DC D ? A AC DC D ? A AC DC D ? A AC DC D ? A AC DC D ? A AC DC D ? A AC DC D ? A AC DC D ? A AC DC D ? A AC 10. 11. 12. 13. 14. 15. I disagree completely I disagree I don’t know I agree I agree completely DC D ? A AC DC D ? A AC DC D ? A AC Having diabetes over a long period changes the personality DC D ? A AC I often find it difficult to decide whether I feel sick or well DC D ? A AC Diabetes is not really a problem because it can be controlled DC D ? A AC DC D ? A AC DC D ? A AC DC D ? A AC DC D ? A AC Being told you have diabetes is like being sentences to a lifetime of illness My diabeteic diet does not really spoil my social life In general, doctors need to be a lot more sympathetic in their treatment of people with diabetes 16. There is really nothing you can do if you have diabetes 17. There is no-one I feel I can talk to openly about my diabetes 18. I believe I have adjusted well to having diabetes 19. I often think it is unfair that I should have diabetes when other people are so healthy Back ToC Diabetes Knowledge Questionnaire: English & Spanish Errata Garcı́a AA, Villagomez, ET, Brown SA, Kouzekanani K, Hanis CL: The Starr County Diabetes Education Study: development of the Spanish-language diabetes knowledge questionnaire. Diabetes Care 24:16 –21, 2001 In the APPENDIX of the above article, errors appeared that were introduced at the composition stage. The corrected Diabetes Knowledge Questionnaire appears below. APPENDIX—24-Item Diabetes Knowledge Questionnaire and Correct Responses CUESTIONAIRIO DE CONOCIMIENTO DE LA DIABETES DIABETES KNOWLEDGE QUESTIONNAIRE Item # 1. 1. 2. 2. 3. 3. 4. 4. 5. 5. 6. 6. 7. 7. 8. 8. 9. 9. 10. 10. 11. 11. 12. 12. 13. 13. 14. 14. 15. 15. 16. 16. 17. 17. 18. 18. 19. 19. 20. 20. 21. 21. 22. 22. 23. 23. 24. 24. Preguntas Questions Sı́ Yes El comer mucha azúcar y otras comidas dulces es una causa de la diabetes. Eating too much sugar and other sweet foods is a cause of diabetes. La causa común de la diabetes es la falta de insulina efectiva en el cuerpo. The usual cause of diabetes is lack of effective insulin in the body. La diabetes es causada porque los riñones no pueden mantener el azúcar fuera de la orina. Diabetes is caused by failure of the kidneys to keep sugar out of the urine. Los riñones producen la insulina. Kidneys produce insulin. En la diabetes que no se está tratando, la cantidad de azúcar en la sangre usualmente sube. In untreated diabetes, the amount of sugar in the blood usually increases. Si yo soy diabético, mis hijos tendrán más riesgo de ser diabéticos. If I am diabetic, my children have a higher chance of being diabetic. Se puede curar la diabetes. Diabetes can be cured. Un nivel de azúcar de 210 en prueba de sangre hecha en ayunas es muy alto. A fasting blood sugar level of 210 is too high. La mejor manera de checar mi diabetes es haciendo pruebas de orina. The best way to check my diabetes is by testing my urine. El ejercicio regular aumentará la necesidad de insulina u otro medicamento para la diabetes. Regular exercise will increase the need for insulin or other diabetic medication. Hay dos tipos principales de diabetes: tipo 1 (dependiente de insulina) y tipo 2 (no-dependiente de insulina). There are two main types of diabetes: type 1 (insulin-dependent) and type 2 (non-insulin dependent). Una reacción de insulina es causada por mucha comida. An insulin reaction is caused by too much food. La medicina es más importante que la dieta y el ejercicio para controlar mi diabetes. Medication is more important than diet and exercise to control my diabetes. La diabetes frecuentemente causa mala circulación. Diabetes often causes poor circulation. Cortaduras y rasguños cicatrizan más despacio en diabéticos. Cuts and abrasions on diabetics heal more slowly. Los diabéticos deberı́an poner cuidado extra al cortarse las uñas de los dedos de los pies. Diabetics should take extra care when cutting their toenails. Una persona con diabetes deberı́a limpiar una cortadura con yodo y alcohol. A person with diabetes should cleanse a cut with iodine and alcohol. La manera en que preparo mi comida es igual de importante que las comidas que como. The way I prepare my food is as important as the foods I eat. La diabetes puede dañar mis riñones. Diabetes can damage my kidneys. La diabetes puede causar que no sienta en mis manos, dedos y pies. Diabetes can cause loss of feeling in my hands, fingers, and feet. El temblar y sudar son señales de azúcar alta en la sangre. Shaking and sweating are signs of high blood sugar. El orinar seguido y la sed son señales de azúcar baja en la sangre. Frequent urination and thirst are signs of low blood sugar. Los calcetines y las medias elásticas apretadas no son malos para los diabéticos. Tight elastic hose or socks are not bad for diabetics. Una dieta diabética consiste principalmente de comidas especiales. A diabetic diet consists mostly of special foods. √ √ √ √ √ √ √ √ √ √ √ √ √ √ √ √ √ √ √ √ √ √ No No No sé I don’t know √ √ √ √ √ √ √ √ √ √ √ √ √ √ √ √ √ √ √ √ √ √ √ √ √ √ √ ⫽ correct answer 972 DIABETES CARE, VOLUME 24, NUMBER 5, MAY 2001 Errata Phillips LS, Grunberger G, Miller E, Patwardhan R, Rappaport EB, Salzman A, for the Rosiglitazone Clinical Trials Study Group: Once- and twice-daily dosing with rosiglitazone improves glycemic control in patients with type 2 diabetes. Diabetes Care 24:308-315, 2001 The first complete sentence in column 2 on page 309 should state: “LDL cholesterol concentrations were estimated using the Friedewald equation (11) when triglycerides were ⱕ400 mg/dl.” In line 4, “⬎400 mg/dl” was corrected to “ⱕ400 mg/dl.” In lines 12 and 20 in column 1 of Table 2 on page 312, “Baseline triglycerides ⱕ5.17 mmol/l” should state “Baseline triglycerides ⱕ2.26 mmol/l.” The first sentence of paragraph 2 in column 1 on page 312 should state: “In general, the rosiglitazone treatment groups demonstrated small but significant increases in triglyceride levels, with greater increases observed in patients with baseline levels ⱕ2.26 mmol/l (200 mg/dl); however, these changes were not dosage related.” In the same paragraph, the third sentence should state: “In patients with baseline triglyceride levels 2.26 mmol/l, no change was significant in any treatment group (Table 2).” In both sentences, “5.17 mmol/l” was corrected to “2.26 mmol/l.” The third complete sentence of column 3 on page 310 should state: “In comparison with placebo, there were small but statistically significant increases in the rosiglitazone 2 mg b.i.d., 8 mg o.d., and 4 mg b.i.d. treatment groups.” In line 14, the first mention of “4 mg b.i.d.” was corrected to “2 mg b.i.d.” Crook MA, Pickup JC, Lumb PJ, Georgino F, Webb DJ, Fuller JH, The EURODIAB IDDM Complications Study Group: Relationship between plasma sialic acid concentration and microvascular and macrovascular complications in type 1 diabetes: the EURODIAB Complications Study. Diabetes Care 24:316 –322, 2001 The authors of the above article wish to note that Dr. Francesco Giorgino’s name was inadvertently misspelled and that his affiliation should read Istituto di Clinica Medica, Endocrinologia e Malattie Metaboliche, Bari, Italy. DIABETES CARE, VOLUME 24, NUMBER 5, MAY 2001 973 Back ToC Rothman R., Malone R, Bryant B, et al. The Spoken Knowledge in Low-literacy Patients with Diabetes. Diabetes Educator. 2005;31(2):215-224. Back ToC Back ToC Modifiable Activity Questionnaire. Medicine & Science in Sports & Exercise. A Collection of Physical Activity Questionnaires for Health-Related Researc. 29(6) Supplement:73-78, June 1997. 2 Back ToC NHIS Self-Rated Health In general, would you say your health is:............................................(Circle one) Excellent...............................1 Very good .............................2 Good ....................................3 Fair .......................................4 Poor......................................5 Scoring Score the number circled. If two consecutive numbers are circled, choose the higher number (worse health); if two non-consecutive numbers are circled, do not score. The score is the value of this single item only. A higher score indicates poorer health. Characteristics Tested on 1,129 subjects with chronic disease. N=51 for test-retest. No. of items Observed Range Mean Standard Deviation Internal Consistency Reliability Test-Retest Reliability 1 1-5 3.29 .91 — .92 Source of Psychometric Data Stanford Chronic Disease Self-Management Study. Psychometrics reported in Lorig K, Stewart A, Ritter P, González V, Laurent D, & Lynch J, Outcome Measures for Health Education and other Health Care Interventions. Thousand Oaks CA: Sage Publications, 1996, p.25. Comments This item is used in the National Health Interview Survey. In a number of studies self-rated health has been found to be an excellent predictor of future health. This scale available in Spanish. References Idler EL, & Angel RJ, Self-rated health and mortality in the NHANES-I epidemiologic follow-up study. American Journal of Public Health, 80, 1990, pp.446-452. Schoenfeld DE, Malmrose LC, Blazer DG, Gold DT, & Seeman TE, Self-rated health and mortality in the high-functioning elderly: A closer look at healthy individuals; MacArthur Field Study of Successful Aging. Journal of Gerontology: Medical Sciences, 49, 1994, pp.M109-M115. U.S. Bureau of the Census, National Health Interview Survey. Washington DC: U.S. Dept. of Commerce, 1985. Ware JE Jr, Nelson EC, Sherbourne CD, & Stewart AL, Preliminary tests of a 6-item general health survey: A patient application; in AL Stewart & JE Ware Jr (Eds), Measuring Functioning and WellBeing: The Medical Outcomes Study Approach, Durham NC: Duke University Press, 1992, pp.291-303. Wolinsky FD, & Johnson RJ, Perceived health status and mortality among older men and women. Journal of Gerontology: Social Sciences, 47, 1992, pp.S304-S312. This scale is free to use without permission Stanford Patient Education Research Center 1000 Welch Road, Suite 204 Palo Alto CA 94304 (650) 723-7935 (650) 725-9422 Fax [email protected] http://patienteducation.stanford.edu Funded by the National Institute of Nursing Research (NINR) Back ToC Back ToC Exercise Behaviors During the past week, even if it was not a typical week for you, how much total time (for the entire week) did you spend on each of the following? (Please circle one number for each question.) less than 30 min/wk 30-60 min/wk 1. Stretching or strengthening exercises (range of motion, using weights, etc.) ................0 1 2 3 4 2. Walk for exercise ...............................................0 1 2 3 4 3. Swimming or aquatic exercise ...........................0 1 2 3 4 4. Bicycling (including stationary exercise bikes) ...................................................0 1 2 3 4 5. Other aerobic exercise equipment (Stairmaster, rowing, skiing machine, etc.) ........0 1 2 3 4 1 2 3 4 none 1-3 hrs more than per week 3 hrs/wk 6. Other aerobic exercise Specify_________________________ .............0 Scoring Code each item as the number circled, then covert as follows. If two consecutive numbers are circled, code the lower number (less exercise). If two non-consecutive numbers are circled, do not score the item. For "Other aerobic", try to fit the type of exercise into the existing aerobic categories (i.e., treadmill as "other aerobic equipment”), otherwise leave as "other aerobic" (i.e., "dancing"). However, if exercise that is not aerobic, such as yoga or weight training, do not score as aerobic. Yoga, weight training, tai chi, etc., should be scored as "stretching or strengthening". Each category is converted to the number of minutes below. Time spent in stretching or strengthening is the value for item 1. Time spent in aerobic exercise is the sum of the values for items 2 through 6. None Less than 30 minutes/week 30-60 minutes/week 1-3 hours/week More that 3 hours/week 0 15 45 120 180 Characteristics Stretching/strengthening (minutes/week) tested on 1,127 subjects with chronic disease. N=51 for testretest. No. of items Observed Range Mean Standard Deviation Internal Consistency Reliability Test-Retest Reliability 1 0-180 40.1 54.8 — .56 Aerobic exercise (minutes/week) tested on 1,130 subjects with chronic disease. M=51 for test-retest. No. of items Observed Range Mean Standard Deviation Internal Consistency Reliability Test-Retest Reliability 5 0-540 90.6 90.9 — .72 Source of Psychometric Data Stanford Chronic Disease Self-Management Study. Psychometrics reported in: Lorig K, Stewart A, Ritter P, González V, Laurent D, & Lynch J, Outcome Measures for Health Education and other Health Care Interventions. Thousand Oaks CA: Sage Publications, 1996, pp.25,37-38. Comments We have used this scale to measure both aerobic and a combination of stretching strengthening exercise for many years. This scale available in Spanish. References Lorig K, Stewart A, Ritter P, González V, Laurent D, & Lynch J, Outcome Measures for Health Education and other Health Care Interventions. Thousand Oaks CA: Sage Publications, 1996, pp.25,37-38. This scale is free to use without permission Stanford Patient Education Research Center 1000 Welch Road, Suite 204 Palo Alto CA 94304 (650) 723-7935 (650) 725-9422 Fax [email protected] http://patienteducation.stanford.edu Funded by the National Institute of Nursing Research (NINR) Back ToC Self-Efficacy for Diabetes We would like to know how confident you are in doing certain activities. For each of the following questions, please choose the number that corresponds to your confidence that you can do the tasks regularly at the present time. 1. How confident do you feel that you can eat your meals every 4 to 5 hours every day, including breakfast every day? ______________________________ not at all | | | | | | | | | | totally confident 1 2 3 4 5 6 7 8 9 10 confident 2. How confident do you feel that you can follow your diet when you have to prepare or share food with other people who do not have diabetes? ______________________________ not at all | | | | | | | | | | totally confident 1 2 3 4 5 6 7 8 9 10 confident 3. How confident do you feel that you can choose the appropriate foods to eat when you are hungry (for example, snacks)? ______________________________ not at all | | | | | | | | | | totally confident 1 2 3 4 5 6 7 8 9 10 confident 4. How confident do you feel that you can exercise 15 to 30 minutes, 4 to 5 times a week? ______________________________ not at all | | | | | | | | | | totally confident 1 2 3 4 5 6 7 8 9 10 confident 5. How confident do you feel that you can do something to prevent your blood sugar level from dropping when you exercise? ______________________________ not at all | | | | | | | | | | totally confident 1 2 3 4 5 6 7 8 9 10 confident 6. How confident do you feel that you know what to do when your blood sugar level goes higher or lower than it should be? ______________________________ not at all | | | | | | | | | | totally confident 1 2 3 4 5 6 7 8 9 10 confident 7. How confident do you feel that you can judge when the changes in your illness mean you should visit the doctor? ______________________________ not at all | | | | | | | | | | totally confident 1 2 3 4 5 6 7 8 9 10 confident 8. How confident do you feel that you can control your diabetes so that it does not interfere with the things you want to do? ______________________________ not at all | | | | | | | | | | totally confident 1 2 3 4 5 6 7 8 9 10 confident 1 Scoring The score for each item is the number circled. If two consecutive numbers are circled, code the lower number (less self-efficacy). If the numbers are not consecutive, do not score the item. The score for the scale is the mean of the six items. If more than two items are missing, do not score the scale. Higher number indicates higher self-efficacy. Characteristics Tested on 186 subjects with diabetes. . No. of items Observed Range Mean Standard Deviation Internal Consistency Reliability Test-Retest Reliability 8 1-10 6.87 1.76 .828 NA Source of Psychometric Data Stanford English Diabetes Self-Management study, ongoing. Comments This 8-item scale was originally developed and tested in Spanish for the Diabetes Self-Management study. For internet studies, we add radio buttons below each number. There is another way that we use to format these items, which takes up less space on a questionnaire, shown also in the PDF document. This scale is available in Spanish. References Unpublished. This scale is free to use without permission Stanford Patient Education Research Center 1000 Welch Road, Suite 204 Palo Alto CA 94304 (650) 723-7935 (650) 725-9422 Fax [email protected] http://patienteducation.stanford.edu Funded by the National Institute of Nursing Research (NINR) 2 Back ToC INSTRUMENT GUIDE FOR FALLS-SPECIFIC PROGRAMS Instruments preceded by an asterisk (*) and bolded are common to a number of conditions and can be found in the Cross-Cutting Instruments Guide Important Note: While rigorous research was conducted to provide readers with all of the instrumentation for implementing the programs outlined in this toolkit, for a limited number of programs, instrumentation was not available for public use. Therefore, interested parties are encouraged to contact selected programs to obtain permission for instruments not included here. Instrument Program *6-Minute Walk Test • Berg Balance Scale • Dynamic Gait Index • Functional Reach test • *Physical Activity Scale for the Elderly (PASE) • * Center for Epidemiologic Studies-Depression (CES-D) Scale Falls Efficacy Scale Modified Falls Efficacy Scale (MFES) Short Form-12 Health Survey (SF-12) Short Form-20 Health Survey (SF-20) * Short Form-36 Health Survey (SF-36) Including scoring guide * Sickness Impact Profile (SIP) Survey of Activities and Fear of Falling in the Elderly (SAFFE) Timed Chair Stand Test Timed Up and Go test • • • • • • • • • • • • • EnhanceFitness Tai Chi: Moving for Better Balance EnhanceFitness Tai Chi: Moving for Better Balance A Matter of Balance/Volunteer Lay-Leader Model Tai Chi: Moving for Better Balance Stepping On Stepping On EnhanceFitness Tai Chi: Moving for Better Balance A Matter of Balance/Volunteer Lay-Leader Model EnhanceFitness Stepping On A Matter of Balance/Volunteer Lay-Leader Model Tai Chi: Moving for Better Balance EnhanceFitness Stepping On Tai Chi: Moving for Better Balance Back ToC Berg Balance Scale Description: 14-item scale designed to measure balance of the older adult in a clinical setting. Equipment needed: Ruler 2 standard chairs (one with arm rests, one without) Footstool or step Stopwatch or wristwatch 15 ft walkway Completion: Time: 15-20 minutes Scoring: A five-point ordinal scale, ranging from 0-4. “0” indicates the lowest level of function and “4” the highest level of function. Total Score = 28 Interpretation: 41-56 = low fall risk 21-40 = medium fall risk 0 –20 = high fall risk < 36 fall risk close to 100% Berg Balance Scale Name: __________________________________ Date: ___________________ Location: ________________________________ Rater: ___________________ ITEM DESCRIPTION SCORE (0-4) 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14. ________ ________ ________ ________ ________ ________ ________ ________ ________ ________ ________ ________ ________ ________ Sitting to standing Standing unsupported Sitting unsupported Standing to sitting Transfers Standing with eyes closed Standing with feet together Reaching forward with outstretched arm Retrieving object from floor Turning to look behind Turning 360 degrees Placing alternate foot on stool Standing with one foot in front Standing on one foot Total ________ GENERAL INSTRUCTIONS Please document each task and/or give instructions as written. When scoring, please record the lowest response category that applies for each item. In most items, the subject is asked to maintain a given position for a specific time. Progressively more points are deducted if the time or distance requirements are note met, if the subject’s performance warrants supervision, or if the subject touches an external support or receives assistance from the examiner. Subject should understand that they must maintain their balance while attempting the tasks. The choices of which leg to stand on or how far to reach are left to the subject. Poor judgment will adversely influence the performance and the scoring. Equipment required for testing is a stopwatch or watch with a second hand, and a ruler or other indicator of 2, 5, and 10 inches. Chairs used during testing should be a reasonable height. Either a step or a stool of average step height may be used for item # 12. Berg Balance Scale 1. SITTING TO STANDING INSTRUCTIONS: Please stand up. Try not to use your hand for support. ( )4 able to stand without using hands and stabilize independently ( )3 able to stand independently using hands ( )2 able to stand using hands after several tries ( )1 needs minimal aid to stand or stabilize ( )0 needs moderate or maximal assist to stand 2. STANDING UNSUPPORTED INSTRUCTIONS: Please stand for two minutes without holding on. ( )4 able to stand safely for 2 minutes ( )3 able to stand 2 minutes with supervision ( )2 able to stand 30 seconds unsupported ( )1 needs several tries to stand 30 seconds unsupported ( )0 unable to stand 30 seconds unsupported If a subject is able to stand 2 minutes unsupported, score full points for sitting unsupported. Proceed to item #4. 3. SITTING WITH BACK UNSUPPORTED BUT FEET SUPPORTED ON FLOOR OR ON A STOOL INSTRUCTIONS: Please sit with arms folded for 2 minutes. ( )4 able to sit safely and securely for 2 minutes ( )3 able to sit 2 minutes under supervision ( )2 able to able to sit 30 seconds ( )1 able to sit 10 seconds ( )0 unable to sit without support 10 seconds 4. STANDING TO SITTING INSTRUCTIONS: Please sit down. ( )4 sits safely with minimal use of hands ( )3 controls descent by using hands ( )2 uses back of legs against chair to control descent ( )1 sits independently but has uncontrolled descent ( )0 needs assist to sit 5. TRANSFERS INSTRUCTIONS: Arrange chair(s) for pivot transfer. Ask subject to transfer one way toward a seat with armrests and one way toward a seat without armrests. You may use two chairs (one with and one without armrests) or a bed and a chair. ( )4 able to transfer safely with minor use of hands ( )3 able to transfer safely definite need of hands ( )2 able to transfer with verbal cuing and/or supervision ( )1 needs one person to assist ( )0 needs two people to assist or supervise to be safe 6. STANDING UNSUPPORTED WITH EYES CLOSED INSTRUCTIONS: Please close your eyes and stand still for 10 seconds. ( )4 able to stand 10 seconds safely ( )3 able to stand 10 seconds with supervision ( )2 able to stand 3 seconds ( )1 unable to keep eyes closed 3 seconds but stays safely ( )0 needs help to keep from falling 7. STANDING UNSUPPORTED WITH FEET TOGETHER INSTRUCTIONS: Place your feet together and stand without holding on. ( )4 able to place feet together independently and stand 1 minute safely ( )3 able to place feet together independently and stand 1 minute with supervision ( )2 able to place feet together independently but unable to hold for 30 seconds ( )1 needs help to attain position but able to stand 15 seconds feet together ( )0 needs help to attain position and unable to hold for 15 seconds Berg Balance Scale continued….. 8. REACHING FORWARD WITH OUTSTRETCHED ARM WHILE STANDING INSTRUCTIONS: Lift arm to 90 degrees. Stretch out your fingers and reach forward as far as you can. (Examiner places a ruler at the end of fingertips when arm is at 90 degrees. Fingers should not touch the ruler while reaching forward. The recorded measure is the distance forward that the fingers reach while the subject is in the most forward lean position. When possible, ask subject to use both arms when reaching to avoid rotation of the trunk.) ( )4 can reach forward confidently 25 cm (10 inches) ( )3 can reach forward 12 cm (5 inches) ( )2 can reach forward 5 cm (2 inches) ( )1 reaches forward but needs supervision ( )0 loses balance while trying/requires external support 9. PICK UP OBJECT FROM THE FLOOR FROM A STANDING POSITION INSTRUCTIONS: Pick up the shoe/slipper, which is place in front of your feet. ( )4 able to pick up slipper safely and easily ( )3 able to pick up slipper but needs supervision ( )2 unable to pick up but reaches 2-5 cm(1-2 inches) from slipper and keeps balance independently ( )1 unable to pick up and needs supervision while trying ( )0 unable to try/needs assist to keep from losing balance or falling TURNING TO LOOK BEHIND OVER LEFT AND RIGHT SHOULDERS WHILE STANDING INSTRUCTIONS: Turn to look directly behind you over toward the left shoulder. Repeat to the right. Examiner may pick an object to look at directly behind the subject to encourage a better twist turn. ( )4 looks behind from both sides and weight shifts well ( )3 looks behind one side only other side shows less weight shift ( )2 turns sideways only but maintains balance ( )1 needs supervision when turning ( )0 needs assist to keep from losing balance or falling 10. 11. TURN 360 DEGREES INSTRUCTIONS: Turn completely around in a full circle. Pause. Then turn a full circle in the other direction. ( )4 able to turn 360 degrees safely in 4 seconds or less ( )3 able to turn 360 degrees safely one side only 4 seconds or less ( )2 able to turn 360 degrees safely but slowly ( )1 needs close supervision or verbal cuing ( )0 needs assistance while turning 12. PLACE ALTERNATE FOOT ON STEP OR STOOL WHILE STANDING UNSUPPORTED INSTRUCTIONS: Place each foot alternately on the step/stool. Continue until each foot has touch the step/stool four times. ( )4 able to stand independently and safely and complete 8 steps in 20 seconds ( )3 able to stand independently and complete 8 steps in > 20 seconds ( )2 able to complete 4 steps without aid with supervision ( )1 able to complete > 2 steps needs minimal assist ( )0 needs assistance to keep from falling/unable to try 13. STANDING UNSUPPORTED ONE FOOT IN FRONT INSTRUCTIONS: (DEMONSTRATE TO SUBJECT) Place one foot directly in front of the other. If you feel that you cannot place your foot directly in front, try to step far enough ahead that the heel of your forward foot is ahead of the toes of the other foot. (To score 3 points, the length of the step should exceed the length of the other foot and the width of the stance should approximate the subject’s normal stride width.) ( )4 able to place foot tandem independently and hold 30 seconds ( )3 able to foot ahead independently and hold 30 seconds ( )2 able to take small step independently and hold 30 seconds ( )1 needs help to step but can hold 15 seconds ( )0 loses balance while stepping or standing 14. STANDING ON ONE LEG INSTRUCTIONS: Stand on one leg as long as you can without holding on. ( )4 able to lift leg independently and hold > 10 seconds ( )3 able to lift leg independently and hold 5-10 seconds ( )2 able to lift leg independently and hold ≥ 3 seconds ( )1 tries to lift leg unable to hold 3 seconds but remains standing independently. ( )0 unable to try of needs assist to prevent fall ( ) TOTAL SCORE (Maximum = 56) Back ToC Dynamic Gait Index* Description: Developed to assess the likelihood of falling in older adults. This scale was designed to test eight facets of gait. Equipment needed: Box (Shoebox) Cones (2) Stairs Completion: Time: 15 minutes Scoring: A four-point ordinal scale, ranging from 0-3. “0” indicates the lowest level of function and “3” the highest level of function. Total Score = 24 Interpretation: < 19 = predictive of falls in the elderly > 22 = safe ambulators *Shumway-Cook A, Woollacott M. Motor Control Theory and Applications, Williams and Wilkins Baltimore, 1995: 323-324 Dynamic Gait Index 1. Gait level surface _____ Instructions: Walk at your normal speed from here to the next mark (20’) Grading: Mark the lowest category that applies. (3) Normal: Walks 20’, no assistive devices, good sped, no evidence for imbalance, normal gait pattern (2) Mild Impairment: Walks 20’, uses assistive devices, slower speed, mild gait deviations. (1) Moderate Impairment: Walks 20’, slow speed, abnormal gait pattern, evidence for imbalance. (0) Severe Impairment: Cannot walk 20’ without assistance, severe gait deviations or imbalance. 2. Change in gait speed _____ Instructions: Begin walking at your normal pace (for 5’), when I tell you “go,” walk as fast as you can (for 5’). When I tell you “slow,” walk as slowly as you can (for 5’). Grading: Mark the lowest category that applies. (3) Normal: Able to smoothly change walking speed without loss of balance or gait deviation. Shows a significant difference in walking speeds between normal, fast and slow speeds. (2) Mild Impairment: Is able to change speed but demonstrates mild gait deviations, or not gait deviations but unable to achieve a significant change in velocity, or uses an assistive device. (1) Moderate Impairment: Makes only minor adjustments to walking speed, or accomplishes a change in speed with significant gait deviations, or changes speed but has significant gait deviations, or changes speed but loses balance but is able to recover and continue walking. (0) Severe Impairment: Cannot change speeds, or loses balance and has to reach for wall or be caught. 3. Gait with horizontal head turns _____ Instructions: Begin walking at your normal pace. When I tell you to “look right,” keep walking straight, but turn your head to the right. Keep looking to the right until I tell you, “look left,” then keep walking straight and turn your head to the left. Keep your head to the left until I tell you “look straight,“ then keep walking straight, but return your head to the center. Grading: Mark the lowest category that applies. (3) Normal: Performs head turns smoothly with no change in gait. (2) Mild Impairment: Performs head turns smoothly with slight change in gait velocity, i.e., minor disruption to smooth gait path or uses walking aid. (1) Moderate Impairment: Performs head turns with moderate change in gait velocity, slows down, staggers but recovers, can continue to walk. (0) Severe Impairment: Performs task with severe disruption of gait, i.e., staggers outside 15” path, loses balance, stops, reaches for wall. 4. Gait with vertical head turns _____ Instructions: Begin walking at your normal pace. When I tell you to “look up,” keep walking straight, but tip your head up. Keep looking up until I tell you, “look down,” then keep walking straight and tip your head down. Keep your head down until I tell you “look straight,“ then keep walking straight, but return your head to the center. Grading: Mark the lowest category that applies. (3) Normal: Performs head turns smoothly with no change in gait. (2) Mild Impairment: Performs head turns smoothly with slight change in gait velocity, i.e., minor disruption to smooth gait path or uses walking aid. (1) Moderate Impairment: Performs head turns with moderate change in gait velocity, slows down, staggers but recovers, can continue to walk. (0) Severe Impairment: Performs task with severe disruption of gait, i.e., staggers outside 15” path, loses balance, stops, reaches for wall. Dynamic Gait Index continued…. 5. Gait and pivot turn _____ Instructions: Begin walking at your normal pace. When I tell you, “turn and stop,” turn as quickly as you can to face the opposite direction and stop. Grading: Mark the lowest category that applies. (3) Normal: Pivot turns safely within 3 seconds and stops quickly with no loss of balance. (2) Mild Impairment: Pivot turns safely in > 3 seconds and stops with no loss of balance. (1) Moderate Impairment: Turns slowly, requires verbal cueing, requires several small steps to catch balance following turn and stop. (0) Severe Impairment: Cannot turn safely, requires assistance to turn and stop. 6. Step over obstacle ____ Instructions: Begin walking at your normal speed. When you come to the shoebox, step over it, not around it, and keep walking. Grading: Mark the lowest category that applies. (3) Normal: Is able to step over the box without changing gait speed, no evidence of imbalance. (2)Mild Impairment: Is able to step over box, but must slow down and adjust steps to clear box safely. (1) Moderate Impairment: Is able to step over box but must stop, then step over. May require verbal cueing. (0) Severe Impairment: Cannot perform without assistance. 7. Step around obstacles _____ Instructions: Begin walking at normal speed. When you come to the first cone (about 6’ away), walk around the right side of it. When you come to the second cone (6’ past first cone), walk around it to the left. Grading: Mark the lowest category that applies. (3)Normal: Is able to walk around cones safely without changing gait speed; no evidence of imbalance. (2) Mild Impairment: Is able to step around both cones, but must slow down and adjust steps to clear cones. (1) Moderate Impairment: Is able to clear cones but must significantly slow, speed to accomplish task, or requires verbal cueing. (0) Severe Impairment: Unable to clear cones, walks into one or both cones, or requires physical assistance. 8. Steps _____ Instructions: Walk up these stairs as you would at home, i.e., using the railing if necessary. At the top, turn around and walk down. Grading: Mark the lowest category that applies. (3) Normal: Alternating feet, no rail. (2) Mild Impairment: Alternating feet, must use rail. (1) Moderate Impairment: Two feet to a stair, must use rail. (0) Severe Impairment: Cannot do safely. TOTAL SCORE: ______ Back ToC Falls Efficacy Scale Name_________________________________ Date__________________________________ On a scale from 1 to 10, with 1 being very confident and 10 being not confident at all, how confident are you that you do the following activities without falling? Activity Score 1 very confident 10 not confident at all Take a bath or shower Reach into cabinets or closets Walk around the house Prepare meals not requiring carrying heavy or hot objects Get in and out of bed Answer the door or telephone Get in and out of a chair Getting dressed and undressed Personal grooming (i.e. washing your face) Getting on and off of the toilet Total Score A total score of greater than 70 indicates that the person has a fear of falling Source: Tinetti, M., Richman, D., Powell, L. (1990). Falls Efficacy as a Measure of Fear of Falling. Journal of Gerontology. 45;239 Back ToC Functional Reach Test The Functional Reach Test is a single item test developed as a quick screen for balance problems in older adults. Interpretation: A score of 6 or less indicates a significant increased risk for falls. A score between 6-10 inches indicates a moderate risk for falls. Age related norms for the functional reach test: Age 20-40yrs 41-69yrs 70-87 Men (in inches) 16.7 ± 1.9 14.9 ± 2.2 13.2 ± 1.6 Women (in inches) 14.6 ± 2.2 13.8 ± 2.2 10.5 ± 3.5 Requirements: The patient must be able to stand independently for at least 30 seconds without support, and be able to flex the shoulder to at least 90 degrees. Equipment and Set up: A yard stick is attached to a wall at about shoulder height. The patient is positioned in front of this so that upon flexing the shoulder to 90 degrees, an initial reading on the yard stick can be taken. The examiner takes a position 5-10 feet away from the patient, viewing the patient from the side. Instructions: Position the patient close to the wall so that they may reach forward along the length of the yardstick. The patient is instructed stand with feet shoulder distance apart then make a fist and raise the arm up so that it's parallel to the floor. At this time the examiner takes an initial reading on the yard stick, usually spotting the knuckle of the third metacarpal. The patient is instructed to reach forward along the yardstick without moving the feet. Any reaching strategy is allowed but the hand should remain in a fist. The therapist takes a reading on the yardstick of the farthest reach attained by the patient without taking a step. The initial reading is subtracted from the final to obtain the functional reach score. References: Duncan, PW, Weiner DK, Chadler J, Studenske S. Functional reach: A new clinical measure of balance. J Gerontol. 1990; 45:M192. Duncan, PW, et al: Functional reach: Predictive validity in a sample of elderly male veterans. J Gerontol. 1992; 47:M93. Mann, GC, et al: Functional reach and single leg stance in patients with peripheral vestibular disorders. J Vestib Res. 1996; 6:343. Weiner, DK, et al: Does functional reach improve with rehabilitation. Arch Phys Med Rehab. 1993; 74:796. This and other balance tests can be found at AROM.COM ~ the web address for physical therapy www.arom.com Back ToC Modified Falls Efficacy Scale* Administration: The Modified Falls Efficacy Scale (mFES) can be self-administered or administered via personal or telephone interview. Larger typeset should be used for self-administration, while an enlarged version of the rating scale on an index card will facilitate in-person interviews. Regardless of method of administration, each respondent should be queried concerning their understanding of instructions, and probed regarding difficulty answering specific items. Instructions to Participants: Subjects are asked, “How confident/sure are you that you do each of the activities without falling?” Instructions for Scoring: The mFES scale is a visual analog scale in which items are scored from 0 to 10, with 0 meaning “not confident/not sure at all,” 5 being “fairly confident/fairly sure,” and 10 being “completely confident/completely sure.” Total the ratings (possible range = 0 – 140) and divide by 14 to get each subject’s mFES score. Scores of < 8 indicate fear of falling, 8 or greater indicate lack of fear. *Hill KD, Schwarz JA, Kalogeropolous AJ, Gibson, SJ. Fear of Falling Revisited. Arch Phys Med Rehabil. 1996;77:1025-1029. -1- Modified Falls Efficacy Scale* Instructions: For each statement circle the level of confidence expressed, using the code below. 0= No confidence at all to 10 = Extreme confidence How confident are you that you can... 1. Get dressed and undressed 0 1 2 3 4 5 6 7 8 9 10 2. Prepare a simple meal 0 1 2 3 4 5 6 7 8 9 10 3. Take a bath or a shower 0 1 2 3 4 5 6 7 8 9 10 4. Get in/out of a chair 0 1 2 3 4 5 6 7 8 9 10 5. Get in/out of bed 0 1 2 3 4 5 6 7 8 9 10 6. Answer the door or telephone 0 1 2 3 4 5 6 7 8 9 10 7. Walk around the inside of your house 0 1 2 3 4 5 6 7 8 9 10 8. Reach into cabinets or closets 0 1 2 3 4 5 6 7 8 9 10 9. Light housekeeping 0 1 2 3 4 5 6 7 8 9 10 10. Simple shopping 0 1 2 3 4 5 6 7 8 9 10 11. Using public transportation 0 1 2 3 4 5 6 7 8 9 10 12. Crossing roads 0 1 2 3 4 5 6 7 8 9 10 13. Light gardening or hanging out the washing 0 1 2 3 4 5 6 7 8 9 10 14. Using front or rear steps at home 0 1 2 3 4 5 6 7 8 9 10 …..without falling? Score = Total _____/14 = ______ *Modified from Hill KD, Schwarz JA, Kalogeropolous AJ, Gibson, SJ. Fear of Falling Revisited. Arch Phys Med Rehabil. 1996;77:1025-1029 -2- Back ToC SF-12 1. In general, would you say your health is… Excellent. . . . . . . . . . . . .. .. .. . . . . . . . 1 Very Good . . . . . .. .. . . . . . . . . . . . . .. . 2 Good . . . . . .. . . . . . . .. . . . . . . .. . . . . 3 Fair . . . . . . .. . . .. . .. .. . . . . . . . . . . . . 4 Poor . . . . .. . . .. . .. . . .. . . . . . .. . . . . . 5 2. The following questions are about activities you might do during a typical day. Does your health now limit you in these activities? If so, how much? Yes, limited a lot Yes, limited a little No, not limited at all 1 1 2 2 3 3 a. Moderate activities, such as moving a table, pushing a vacuum cleaner, bowling, or playing golf? b. Climbing several flights of stairs? 3. During the past 4 weeks, how much of the time have you had any of the following problems with your work or other daily activities as a result of your physical health? a. Accomplished less than you would like? b. Were limited in the kind of work or other daily activities? All of the time Most of the time Some of the time A little of the time None of the time 1 2 3 4 5 1 2 3 4 5 4. During the past 4 weeks, how much of the time have you had any of the following problems with your work or other daily activities as a result of any emotional problems (such as depressed or anxious)? a. Accomplished less than you would like? b. Were limited in the kind of work or other daily activities? All of the time Most of the time Some of the time A little of the time None of the time 1 2 3 4 5 1 2 3 4 5 5. During the past 4 weeks, how did pain interfere with your normal work (including both work outside the home and housework)? 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. 6. How much of the time during the past 4 weeks… a. Have you felt calm and peaceful? b. Did you have a lot of energy? c. Have you felt downhearted and depressed? All of the time 1 1 Most of the time 2 2 A good bit of the time 3 3 1 2 3 Some of the Time 4 4 A little of the time 5 5 None of the time 6 6 4 5 6 7. During the past 4 weeks, how much of the time has your physical health or emptional problems interfered with your social activities (like visiting friends, relatives, etc.)? 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 Back ToC SF-20 1. In general, would you say your health is… Excellent. . . . . . . . . . . . .. .. .. . . . . . . . 1 Very Good . . . . . .. .. . . . . . . . . . . . . .. . 2 Good . . . . . .. . . . . . . .. . . . . . . .. . . . . 3 Fair . . . . . . .. . . .. . .. .. . . . . . . . . . . . . 4 Poor . . . . .. . . .. . .. . . .. . . . . . .. . . . . . 5 2. For how long (if at all) has your health limited you in each of the following activities? a. The kinds or amounts of vigorous activities you can do, like lifting heavy objects, running, or participating in strenuous sports? b. The kinds or amounts of moderate activities, like moving a table, carrying groceries, or bowling? c. Walking uphill or climbing a few flights of stairs? d. Bending, lifting or stooping? e. Walking one block? f. Eating, dressing, bathing or using the toilet? Limited for more than 3 months Limited for 3 months or less Not limited at all 1 2 3 1 2 3 1 1 1 2 2 2 3 3 3 1 2 3 3. How much bodily pain have you had during the past 4 weeks? Would you say… None . . . . . . . . . . . . . . . . . . . . . . . 1 Very mild,. . . . . . . . . . . . . . . . . . .2 Mild,. . . . . . . . . . . . . . . . . . . . . . . .3 Moderate . . . . . . . . . . . . . . . . . . . .4 Severe, or. . . . . . . . . . . . . . . . . . . .5 Very severe?. . . . . . . . .. . . . . . . . .6 4. Does your health keep you from working at a job, doing work around the house, or going to school? YES, for more than 3 months . . . . 1 YES, for 3 months or less . . . . . . 2 NO. . . . . . . . . . . . . . . . . . . . . . . . .3 5. Have you been unable to do certain kinds or amounts of work, housework, or schoolwork because of your health? YES, for more than 3 months . . . . 1 YES, for 3 months or less . . . . . . 2 NO. . . . . . . . . . . . . . . . . . . . . . . . .3 For each of the following questions, please give the one answer that comes closest to the way you have been feeling during the past month. 9. How much of the time during the past month… All of the time Most of the time A good bit of the time 1 2 3 4 5 6 1 2 3 4 5 6 1 2 3 4 5 6 1 1 2 2 3 3 4 4 5 5 6 6 1 2 3 4 5 6 a. Has your health limited your social activities, like visiting friends or close relatives? b. Have you been a very nervous person? c. Have you felt calm and peaceful? d. Have you felt downhearted and blue? e. Have you been a happy person? f. Have you felt so down in the dumps that nothing could cheer you up? Some of the Time A little of the time None of the time 11. How true or false is each of the following statements for you? a. b. c. d. I am somewhat ill I am as healthy as anybody I know My health is excellent I have been feeling bad lately Definitely True 1 1 1 1 Mostly True 2 2 2 2 Mostly False 4 4 4 4 Definitely False 5 5 5 5 Back ToC Survey of Activities and Fear of Falling in the Elderly (SAFFE) 1) Do you currently… a. Go to the store? b. Prepare simple meals? c. Take a tub bath? d. Get out of bed? e. Take a walk for exercise? f. Go out when it is slippery? g. Visit a friend or relative? h. Reach for something over your head? i. Go to a place with crowds? j. Walk several blocks outside? k. Bend down to get something? IF RESPONDENT ANSWERED “YES” TO ANY OF THE ABOVE (a THRU k), FOLLOW UP WITH: 2) When you _____, how worried are you that you might fall? 3) Do you not _____ because you are _____ that you might fall? 4) Are there other reasons why you do not _____? 5) What are the reasons that you do not_____? 6) Compared to 5 years ago, would you say that you are ______? Back ToC Timed chair stand test Critical issues No previous international recommendations for standardized protocol exist Exclusion criteria Equipment Stopwatch Armless chair (height: 45 cm) with straight back Procedure Participant should be sitting on the chair with his/her feet on the floor. Participant is asked to rise from the chair without the help of his/her arms. The success is recorded. If successful, the participant can proceed to the next step of chair rises. Participant is asked to sit down again, with feet on the floor. Participant is asked to rise from the chair without the help of his/her arms (arms folded across chest), 10 times. Time to complete 10 rises is recorded. If the person cannot complete 10 rises, the number of completed rises is recorded. Back ToC Timed “Up and Go”* Directions: The timed “Up and Go” test measures, in seconds, the time taken by an individual to stand up from a standard arm chair (approximate seat height of 46 cm, arm height 65 cm), walk a distance of 3 meters (approximately 10 feet), turn, walk back to the chair, and sit down. The subject wears their regular footwear and uses their customary walking aid (none, cane, walker). No physical assistance is given. They start with their back against the chair, their arms resting on the armrests, and their walking aid at hand. They are instructed that, on the word “go” they are to get up and walk at a comfortable and safe pace to a line on the floor 3 meters away, turn, return to the chair and sit down again. The subject walks through the test once before being timed in order to become familiar with the test. Either a stopwatch or a wristwatch with a second hand can be used to time the trial. Instructions to the patient: “When I say ‘go’ I want you to stand up and walk to the line, turn and then walk back to the chair and sit down again. Walk at your normal pace.” Variations: You may have the patient walk at a fast pace to see how quickly they can ambulate. Also you could have them turn to the left and to the right to test any differences. *Podsiadlo D, Richardson S. The timed “up and go”: a test of basic functional mobility for frail elderly persons. JAGS 1991; 39: 142-148. INSTRUMENT GUIDE FOR HEART DISEASE-SPECIFIC PROGRAMS Instruments preceded by an asterisk (*) and bolded are common to a number of conditions and can be found in the Cross-Cutting Instruments Guide Important Note: While rigorous research was conducted to provide readers with all of the instrumentation for implementing the programs outlined in this toolkit, for a limited number of programs, instrumentation was not available for public use. Therefore, interested parties are encouraged to contact selected programs to obtain permission for instruments not included here. Instrument Program Congregate Meals Survey * Fat-Related Diet Habits Questionnaire • Eat Better Move More Modified Baecke Questionnaire For Older Adults • Eat Better Move More Nutritional Screening Initiative (NSI) Checklist Yale Physical Activity Survey Including response cards • Project Joy • Eat Better Move More • Project Joy Back ToC POMP 5 CONGREGATE MEALS EXTENDED CORE SURVEY (PHONE VERSION: April 19, 2004) I would like to ask you some questions about the nutrition program that you receive. 1. During a typical week, how many days do you eat at the [NAME OF NUTRITION SITE]? Enter # of days per week in this space. 2. |___| Please tell me how many meals you eat every day, including meals provided at a nutrition site? 1 meal………………………………………………………... 2 meals………………………………………………………. 3 meals………………………………………………………. More than 3 meals……………………………………….…. Other……………………………………….….……………... [Please describe______________________________] 3. 1 2 3 4 5 Think about the meal you get at the [NAME OF NUTRITION SITE] compared to all the other food you usually eat each day. Please tell me whether the meal you get from the nutrition program is: Less than 1/3 of the food you usually eat each day………………...… About 1/3 of the food you usually eat each day………………………. About 1/2 of the food you usually eat each day……………………..... More than 1/2 of the food you usually eat each day…………………… 4. 1 2 3 4 Now think about the days when you don’t have a meal at the [NAME OF NUTRITION SITE]. Do you eat: About the same amount of food?…………………………… 1 More food?…………………………………………………..… 2 Less food?………………………………………………….…. 3 For Office Use: Agency:________________________________________ State:_______________ Client ID:_______________________________________ Date:_______________ 1 Self Administered Telephone Other 5. Let’s talk about the period of time about a month before you started the nutrition program. I am going to read a number of ways you may have gotten your meals during that time. Please tell me whether this was true most of the time, sometimes, or almost never. □ CHECK THIS BOX, IF RESPONDENT DOES NOT REMEMBER. a. [READ EACH STATEMENT & REPEAT RESPONSES AS NEEDED] I cooked for myself. b. Family or friends provided me with meals. 1 2 3 c. I ate at restaurants. 1 2 3 d. I ate meals that were easy to fix like sandwiches, microwavable meals, or soups. 1 2 3 e. I ate meals that were ready to eat right out of the package. 1 2 3 f. I skipped meals or ate less food. 1 2 3 g. I saved food from other meals. 1 2 3 h. Other, please explain _______________________________________________ 2 Most of the time 1 Sometimes 2 Almost never 3 6. 7. Now I’m going to read some things that many people do for meals on the days when the [NAME OF NUTRITION SITE] is not open, such as on weekends or holidays. Please tell me whether this was true for you most of the time, sometimes, or almost never. Most of the time 1 Sometimes 2 Almost never 3 a. Family or friends provide me with meals. b. I eat meals that are easy to fix like sandwiches, microwavable meals, or soups. 1 2 3 c. I eat meals that are ready to eat right out of the package. 1 2 3 d. I use the emergency packs they provide (Emergency packs are for days when delivery is cancelled because of inclement weather.) 1 2 3 e. I skip meals or eat less food. 1 2 3 f. I save food from other meals. 1 2 3 g. Other, please explain ______________________________________________ Do you always have enough money or food stamps to buy the food you need? Yes……………………………………………………………. No…………………………………………………………….. 1 2 Please answer the following questions by circling the response that best represents the amount and type of food you usually eat. 8. How many servings of fruit do you usually eat every day? (1 serving = 1 piece; 1/2 cup chopped, cooked, or canned fruit; or 3/4 cup of juice) 0 servings………………………………………………….… 1 serving…………………………………………………….. 2 servings………………………………………………….… 3 or more servings………………………………………….. 9. 1 2 3 4 When you eat the congregate meals, do you usually eat the fruit that is provided? Yes……………………………………………………………. No…………………………………………………………….. 3 1 2 10. How many servings of potatoes do you usually eat each day? (1 serving = 1 small baked potato; 1/2 c mashed or boiled; 10 french fries; 1/2 c hashed browns) 0 servings……………………………………………………. 1 serving…………………………………………………..… 2 servings……………………………………………………. 3 or more servings………………………………………….. 11. When you eat the congregate meals, do you usually eat the potatoes that are provided? Yes……………………………………………………………. No…………………………………………………………….. 12. 1 2 How many servings of bread, cereal, rice, pasta, noodles, and tortillas do you usually eat every day? (1 serving = 1 piece bread or tortilla; or 1/2 cup cereal, rice, pasta, noodles) 0 servings……………………………………………………. 1 – 2 servings……………………………………………….. 3 – 5 servings……………………………………………….. 6 or more servings………………………………………….. 15. 1 2 3 4 Other than potatoes, when you eat the congregate meals, do you usually eat the vegetables that are provided? Yes……………………………………………………………. No…………………………………………………………….. 14. 1 2 Other than potatoes, how many servings of vegetables do you usually eat every day? (1 serving = 1 cup raw salad greens; 1/2 cup cooked or chopped raw vegetables; or 3/4 cup juice) 0 servings……………………………………………………. 1 serving……………………………………………………... 2 servings……………………………………………………. 3 or more servings………………………………………….. 13. 1 2 3 4 1 2 3 4 When you eat the congregate meals, do you usually eat the bread, cereal, rice, pasta, noodles, or tortillas that are provided? Yes……………………………………………………………. No…………………………………………………………….. 4 1 2 16. How many servings of milk, cheese, yogurt, and calcium rich soy products do you usually eat every day? (1 serving = 1 cup milk or yogurt; or 1 piece or slice of cheese) 0 servings………………………………………………….… 1 serving……………………………………………………... 2 servings……………………………………………………. 3 or more servings………………………………………….. 17. When you eat the congregate meals, do you usually eat the milk, cheese, yogurt, or calcium rich soy products that are provided? Yes…………………………………………………………… No…………………………………………………………….. 18. 1 2 How many servings of nuts, soy products, and beans (such as baked beans, pintos, kidney beans, lima beans soybeans, or black-eyed peas) do you usually eat every day? (1 serving = 1-2 cups of beans or tofu; 4-6 tablespoons of peanut butter; and 1/2-1cup of nuts) 0 servings……………………………………………………. 1 serving…………………………………………………..… 2 servings………………………………………………….… 3 or more servings………………………………………….. 21. 1 2 3 4 When you eat the congregate meals, do you usually eat the meat, chicken, fish, or eggs that are provided? Yes…………………………………………………………… No…………………………………………………………….. 20. 1 2 How many servings of meat, chicken, fish, and eggs do you usually eat every day? (1 serving = 1 small piece, such as a small chicken breast, hamburger patty, or fish fillet; or 2-3 eggs) 0 servings………………………………………………….… 1 serving…………………………………………………….. 2 servings………………………………………………….… 3 or more servings………………………………………….. 19. 1 2 3 4 1 2 3 4 When you eat the congregate meals, do you usually eat the nuts, soy products, or beans if they are provided? Yes………………………………………………………….… No……………………………………………………………... 5 1 2 22. Think about all the water or other non-alcoholic fluids you usually drink. How many glasses do you usually drink per day? 0 servings…………………………………………………….. 1 – 4 glasses………………………………………………… 5 – 7 glasses………………………………………………… 8 or more glasses…………………………………………… 23. 1 2 3 4 I’m going to read some statements about the nutrition program. Please choose one of the following options: yes, definitely; yes, I think so; I’m not sure; no, I don’t think so; or no, definitely not. As a result of the nutrition program..... Yes Yes, I [READ EACH STATEMENT & REPEAT definitely think so RESPONSES AS NEEDED] a. I eat a healthier variety of food. 1 2 No, I’m not No, I don’t definitely not sure think so 3 4 5 Not applicable -1 b. I am better able to follow the special diet that is prescribed by my doctor or dietitian. 1 2 3 4 5 -1 c. I eat less salt (sodium). 1 2 3 4 5 -1 d. I eat less high fat foods. 1 2 3 4 5 -1 e. I can achieve or maintain a healthy weight. 1 2 3 4 5 -1 f. I believe my health has improved and I feel better. 1 2 3 4 5 -1 g. I am less hungry throughout the day. 1 2 3 4 5 -1 h. I can continue to live in my own home. 1 2 3 4 5 -1 6 24. Now I want you to think of all the nutrition education information you have received through the nutrition program. I am going to read some statements about the nutrition education information and I want you to choose one of the following options: yes, definitely; yes, I think so; I’m not sure; no, I don’t think so; or no, definitely not. [IF THE RESPONDENT HAS NOT PARTICIPATED IN ANY NUTRITION EDUCATION AT THE SITE, CIRCLE NOT APPLICABLE.] As a result of the nutrition education information I received… [READ EACH STATEMENT & REPEAT RESPONSES AS NEEDED] a. I make healthier food choices. b. I handle or store food more safely. c. I have shortened the time I let cooked food stay outside the refrigerator. d. I know what to eat for my health conditions. 25. Yes definitely 1 Yes, I think so 2 I’m not sure 3 No, I don’t think so 4 No, definitely not 5 Not applicable -1 1 2 3 4 5 -1 1 2 3 4 5 -1 1 2 3 4 5 -1 Would you recommend this program to your friends, neighbors, and relatives? Yes………………………………………... No…………………………………………. Not Sure………………………………….. 7 1 2 3 26. Now I’m going to read a list of services that may be offered through the nutrition program. Please tell me which of these you have received. Yes 1 No 2 b. Legal Help 1 2 c. Nutrition Counseling 1 2 d. Transportation 1 2 e. Help with shopping 1 2 f. Help with personal care 1 2 g. Help with housekeeping 1 2 h. Help with cooking 1 2 Help getting benefits like food stamps and other public assistance 1 2 Help paying for prescription drugs 1 2 k. None 1 2 l. 1 2 a. Case Management i. j. 27. Other (Describe) ______________________________________ Have your social opportunities increased since you became involved with the nutrition program at [NAME OF NUTRITION SITE]? Yes………………………………………... No…………………………………………. 28. 1 2 How would you rate nutrition program overall? Would you say…. Excellent……………………………………………. Very Good ………………………………………… Good………………………………………………… Fair, or……………………………………………… Poor…………………………………………………. 8 1 2 3 4 5 29. In general, would you say your health is excellent, very good, good, fair, or poor? Excellent……………………………………………. Very Good ………………………………………… Good………………………………………………… Fair, or……………………………………………… Poor…………………………………………………. 30. 1 2 3 4 5 Do you have any suggestions that would make the nutrition program better? [RECORD SUGGESTIONS VERBATIM] 9 Back ToC Modified Baecke Questionnaire For Older Adults 1. How many flights of stairs do you walk up per day? One flight is 10 steps. a. I never walk stairs b. 1-5 c. 6-10 d. More than 10 2. If you go somewhere in your hometown, what kind of transportation do you use? a. I never go out b. Car c. Public transportation d. Bicycle e. Walking 3. If you go out for shopping, what kind of transportation do you use? a. I never go out b. Car c. Public transportation d. Bicycle e. Walking Back ToC Determine Your Nutritional Health The Warning Signs of poor nutritional health are often overlooked. Use this checklist to find out if you or someone you know is at nutritional risk. Read the statements below. Add up the numbers in the "YES" column for those that apply for you. YES I have an illness or condition that made me change the kind and / or amount of food I eat. 2 I eat fewer than 2 meals per day. 3 I eat few fruits or vegetables, or milk products. 2 I have 3 or more drinks of beer, liquor or wine almost every day. 2 I have tooth or mouth problems that make it hard for me to eat. 2 I don't always have enough money to buy the food I need. 4 I eat alone most of the time. 1 I take 2 or more different prescribed or over-the-counter drugs a day. 1 Without wanting to, I have lost or gained 10 pounds in the last 6 months. 2 I am not always physically able to shop, cook and / or feed myself. 2 Total Total your Nutritional Score: If it’s- 0-2 GOOD! Recheck your nutritional score in 6 months 3-5 You are at Moderate nutritional risk. See what can be done to improve your eating habits and lifestyle. Your office on aging, senior nutrition program, senior citizens center or health department can help. Check your score again in 3 months 6 or more You are at high nutritional risk Bring this checklist the next time you see your doctor, dietitian or other qualified health or social service professional. Talk to them about any problems you may have. Ask for help to improve your nutritional health. Remember that Warning Signs suggest risk, but do not represent a diagnosis of any condition. Turn to the page to learn more about the Warning Signs of poor nutritional health. The Nutrition Checklist is based on the Warning Signs described below. Use the word DETERMINE to remind you of the Warning Signs. Any disease, illness or chronic condition which causes you to change the way you eat, or makes it hard for you to eat, puts your nutritional health at risk. Four out of five adults have chronic diseases that are affected by diet. Confusion or memory loss that keeps getting worse is estimated to affect one out of five or more older adults. This can make it hard to remember what, when or if you've eaten. Feeling sad or depressed, which happens to about one in eight older adults, can cause big changes in appetite, digestion, energy level, weight and well-being. Eating too little and eating too much both lead to poor health. Eating the same foods day after day or not eating fruits and vegetables, and milk products daily will also cause poor nutritional health. One in five adults skip meals daily. Only 13% of adults eat the minimum amount of fruits and vegetables needed. One in four older adults drink too much alcohol. Many health problems become worse if you drink more than one or two alcoholic beverages per day. A healthy mouth, teeth and gums are needed to eat. Missing, loose, or rotten teeth or dentures which don't fit well or cause mouth sores make it hard to eat. As many as 40% of older Americans have incomes of less than $6,000 per year. Having less -- or chosing to spend less -- than $25-30 per week for food makes it very hard to get the foods you need to stay healthy. One-third of all older people live alone. Being with people daily has a positive effect on morale, well-being and eating. Many older Americans must take medicines for health problems. Almost half of older Americans take multiple medicines daily. Growing old may change the way we respond to drugs. The more medicines you take, the greater the chance for side effects such as increased or decreased appetite, change in taste, constipation, weakness, drowsiness, diarrhea, nausea, and others. Vitamins or minerals when taken in large doses act like drugs and can cause harm. Alert your doctor to everything you take. Losing or gaining a lot of weight when you are not trying to do so is an important warning sign that must not be ignored. Being overweight also increases your chance of poor health. Although most older people are able to eat, one of every five have trouble walking, shopping, buying and cooking food, especially as they get older. Most older people lead full and productive lives. But as age increases, risk of frailty and health problems increase. Checking your nutritional health regularly makes good sense. ——————— Reprinted with permission from the Nutrition Screening Initiative, a project of the American Academy of Family Physicians, the American Dietetic Association and the National Council on the Aging, Inc., and funded in part by a grant from Ross Products Division, Abbott Laboratories. APPENDIX 100 PRIOR AUTHORIZATION REQUEST, DMA-80 Instructions Community Care Services Program NUTRITIONAL SCREENING INITIATIVE (NSI) NUTRITIONAL HEALTH CHECKLIST Purpose: The purpose of the NSI Checklist is to identify individuals who are at high risk of nutritional problems or who have poor nutritional status. Who Completes/ When Completed: The care coordinator completes the NSI in CHAT at initial assessment and reassessments. Should the client’s condition or situation change, the care coordinator, completes the NSI, as needed, between reassessments. NOTE: Referral sources include but are not limited to physicians, dietitians or other health professionals, social services, oral health, mental health, nutrition education, support or counseling services. Instructions: For each of the ten statements, read and circle the appropriate number in the “Yes” column which describes each client/ client representative response. Total the numbers circled to identify the client’s nutritional score. Based on the total score, make the appropriate referrals, if indicated, as suggested in the reference - Nutrition Interventions Manual for Professionals Caring for Older Americans Executive Summary 1992. Document all activity relative to the NSI checklist referral, such as follow-up and outcome results. Complete the NSI checklist as needed. Distribution: A copy is filed in the client’s case record along with documentation regarding any deviation from normal, specific instructions or referral information. MT 2008-1 07/07 Appendix 100 page 118 Back ToC 1 YALE PHYSICAL ACTIVITY SURVEY FOR OLDER ADULTS Interviewer: Please hand the subject the list of activities (Card #1) while reading the following statement. Here is a list of common types of physical activities. Please tell me which of them you did during a typical week in the last month. Our interest is learning about the types of physical activity that are a part of your regular work and leisure routines. For each activity you do, please tell me how much time (hours) you spend doing this activity during a typical week. Work Time (Hrs/wk) Shopping Intensity Code (Kcal/min) 3.5 Laundry (time loading, unloading, hanging, folding; consider 1 load takes 15 minutes) 3.0 Light housework: tidying, dusting, sweeping, collecting trash in home; polishing, indoor gardening; ironing 3.0 Heavy housework: vacuuming, mopping; scrubbing floors and walls; moving furniture, boxes, or garbage cans 4.5 Food preparation (10+ minutes in duration): chopping, stirring moving about to get food items, pans 2.5 Food service (10+ minutes in duration): setting table; carrying food; serving food 2.5 Dish washing (10+ minutes in duration): clearing table; washing/drying dishes, putting dishes away 2.5 Light home repair: small appliance repair; light home maintenance 3.0 Heavy home repair: painting, carpentry, washing/polishing car 5.5 Other: 2 Time (Hrs/wk) Intensity Code (Kcal/min) Yardwork Gardening: planting, weeding, digging, hoeing 4.5 Lawn mowing (walking only) 4.5 Clearing walks/driveway: sweeping, shoveling, raking 5.0 Other: Caretaking Older or disabled person (lifting, pushing wheelchair) 5.5 Childcare (lifting, carrying, pushing stroller) 4.0 Exercise Brisk walking (10+ minutes in duration) 6.0 Pool exercises, stretching, yoga 3.0 Vigorous calisthenics, aerobics 6.0 Cycling, exercycle 6.0 Swimming (laps only) 6.0 Other: Recreational Activities Leisurely walking (10+ minutes in duration) 3.5 Dancing (moderate/fast): line, ballroom, tap, square 5.5 Bowling, Bocci ball 3.0 Golf (walking to each hole only) 5.0 Racquet sports: tennis, racquet ball 7.0 Other: 3 Interviewer: (Please read the following to the subject) I would now like to ask you about certain types of activities that you have done during the past month. I will ask you about how much vigorous activity, leisurely walking, sitting, standing, and some other things that you usually do. 1. About how many times during the month did you participate in vigorous activities that lasted at least 10 minutes and caused large increases in breathing, heart rate, or leg fatigue or caused you to perspire? (Hand subject Card #2.) SCORE: 0 = Not at all (go to Question 3) 1 = 1 - 3 times per month 2 = 1 - 2 times per week 3 = 3 - 4 times per week 4 = 5+ times per week 7 = refused 8 = don’t know FREQUENCY SCORE = 2. About how long do you do this vigorous activity(ies) each time? (Hand subject Card #3.) SCORE: 0 = Not applicable 1 = 10 - 30 minutes 2 = 31 - 60 minutes 3 = 60+ minutes 7 = refused 8 = don’t know DURATION SCORE = VIGOROUS ACTIVITY INDEX SCORE: FREQUENCY SCORE * DURATION SCORE * 5 = (Responses 7 or 8 are scored as missing) 4 3. Think about the walks you have taken during the past month. About how many times per month did you walk for at least 10 minutes or more without stopping which was not strenuous enough to cause large increases in breathing, heart rate, or leg fatigure or cause you to perspire? (Hand subject Card #2.) SCORE: 0 = Not at all (go to Question 5) 1 = 1 - 3 times per month 2 = 1 - 2 times per week 3 = 3 - 4 times per week 4 = 5+ times per week 7 = refused 8 = don’t know FREQUENCY SCORE = 4. #3.) When you did this walking, for how many minutes did you do it? (Hand subject Card SCORE: 0 = Not applicable 1 = 10 - 30 minutes 2 = 31 - 60 minutes 3 = 60+ minutes 7 = refused 8 = don’t know DURATION SCORE = LEISURELY WALKING INDEX SCORE: FREQUENCY SCORE * DURATION SCORE * 4 = (Responses 7 or 8 are scored as missing) 5. About how many hours a day do you spend moving around on your feet while doing things? Please report only the time that you are actually moving. (Hand subject Card #4.) SCORE: 0 = Not at all 1 = less than 1 hour per day 2 = 1 to less than 3 hours per day 3 = 3 to less than 5 hours per day 4 = 5 to less than 7 hours per day 5 = 7+ hours per day 7 = refused 8 = don’t know MOVING SCORE = MOVING INDEX SCORE = MOVING SCORE * 3 = (Responses 7 or 8 are scored as missing) 6. Think about how much time you spend standing or moving around on your feet on an average day during the past month. About how many hours per day do you stand? (Hand subject Card #4.) 5 SCORE: 0 = Not at all 1 = less than 1 hour per day 2 = 1 to less than 3 hours per day 3 = 3 to less than 5 hours per day 4 = 5 to less than 7 hours per day 5 = 7+ hours per day 7 = refused 8 = don’t know STANDING SCORE = STANDING INDEX SCORE = STANDING SCORE * 2 = (Responses 7 or 8 are scored as missing) 7. About how many hours did you spend sitting on an average day during the past month (Hand the subject card #5) SCORE: 0 = Not at all 1 = less than 3 hours 2 = 3 hours to less than 6 hours 3 = 6 hours to less than 8 hours 4 = 8+ hours 7 = refused 8 = don’t know SITTING SCORE = SITTING INDEX SCORE = SITTING SCORE * 1 = (Responses 7 or 8 are scored as missing) 8. About how many flights of stairs do you climb up each day? (let 10 steps = 1 flight.) 9. Please compare the amount of physical activity that you do during other seasons of the year with the amount of activity you just reported for a typical week in the past month. For example, in the summer, do you do more or less activity than what you reported doing in the past month? (Interviewer: Please circle the appropriate score for each season.) Spring Summer Fall Winter Lot more 1.30 1.30 1.30 1.30 Little more 1.15 1.15 1.15 1.15 Same 1.00 1.00 1.00 1.00 Little less 0.85 0.85 0.85 0.85 Lot less 0.70 0.70 0.70 0.70 SEASONAL ADJUSTMENT SCORE = SUM OVER ALL SEASONS/4 = Don’t know . . . . YALE PHYSICAL ACTIVITY SURVEY CARD #1 WEEKLY PHYSICAL ACTIVITIES Work Shopping (e.g., grocery, clothes) Laundry Light Housework: tidying, dusting, sweeping, collecting garbage in home, polishing, indoor gardening, ironing Heavy Housework: vacuuming, mopping, scrubbing floors and walls, moving furniture, moving boxes or garbage cans Food Preparation (10+ minutes): chopping, stirring, moving around to get food items, pots or pans Food Service (10+ minutes): setting table, carrying food, serving food Dish Washing (10+ minutes): clearing table, washing and drying dishes, putting dishes away Light Home Repair: small appliance repair, light household maintenance and repair tasks Heavy Home Repair: painting, washing and polishing car, carpentry Other: Card #1, page 2 Yardwork Gardening: pruning, planting, weeding, hoeing, digging Lawn Mowing (walking only) Clearing Walks and Driveway: raking, shoveling, sweeping Other: Caretaking Older or Disabled Person: lifting, pushing wheelchair Childcare: lifting, pushing stroller Exercise Brisk walking for exercise (10+ min) causes large increases in heart rate, breathing or leg fatigue Stretching exercises, yoga, pool exercise Vigorous calisthenics, aerobics: causes large increases in heart rate, breathing or leg fatigue Cycling, exercycle Lap swimming Other: Card #1, page 3 Recreational Activities Leisurely walking (10+ minutes) Hiking Dancing (moderate/fast) line dancing, ballroom, square, tap Bowling, Boccie Ball Golf (walking to each hole only) Racquet Sports: Other: tennis, racquetball YALE PHYSICAL ACTIVITY SURVEY CARD #2 Not at all 1 - 3 times per month 1 - 2 times per week 3 - 4 times per week 5 or more times per week Don't know YALE PHYSICAL ACTIVITY SURVEY CARD #3 10 - 30 minutes 31 - 60 minutes 60 or more minutes Don't know YALE PHYSICAL ACTIVITY SURVEY CARD #4 Not at all Less than 1 hour per day 1 to less than 3 hours per day 3 to less than 5 hours per day 5 to less than 7 hours per day 7 or more hours per day Don't know YALE PHYSICAL ACTIVITY SURVEY CARD #5 Not at all Less than 3 hours per day 3 hours to less than 6 hours per day 6 hours to less than 8 hours per day 8 or more hours per day Don't know INSTRUMENT GUIDE FOR OBESITY-SPECIFIC PROGRAMS You may consult the Instrument Guides for the specific instrumentation related to the evidence-based programs below that would be appropriate for older adults with obesity. Condition Program Name • Diabetes Education & Prevention with a Lifestyle Intervention Offered at the YMCA (DEPLOY) Diabetes • Diabetes Prevention Program (DPP) • Eat Better Move More Diabetes • Group Lifestyle Balance (GLB) Diabetes Heart Disease BROOKDALE DEMONSTRATION INITIATIVE IN HEALTHY URBAN AGING: BRIDGING THE DIVIDE BETWEEN PUBLIC HEALTH & HEALTHY AGING EVIDENCE-BASED TOOLKIT: Cross-Cutting Instruments PREPARED FOR: THE COMMISIONER NEW YORK CITY DEPARTMENT FOR THE AGING LILLIAM BARRIOS-PAOLI COMMISSIONER APRIL 2010 FUNDING PROVIDED BY: OFFICE OF THE MAYOR CITY OF NEW YORK MICHAEL R. BLOOMBERG MAYOR CREATED BY: THE BROOKDALE CENTER FOR HEALTHY AGING & LONGEVITY OF HUNTER COLLEGE/ CUNY 3 6 Minute Walk Test •Tab 1 CES-D Scale •Tab 2 CHAMPS - English and Spanish with manuals •Tab 3 Fat Related Diet Habits Questionnaire •Tab 4 PASE •Tab 5 SF-36 and scoring guide •Tab 6 Sickness Impact Profile •Tab 7 CROSS-CUTTING INSTRUMENTS GUIDE Instrument 6-Minute Walk Test Center for Epidemiologic Studies-Depression (CES-D) Scale Community Health Activities Model Program for Seniors (CHAMPS) Activity Questionnaire English & Spanish versions, including manual and scoring guide Fat-Related Diet Habits Questionnaire Physical Activity Scale for the Elderly (PASE) Short Form-36 Health Survey (SF-36) Including scoring guide Sickness Impact Profile (SIP) Condition • Arthritis • Falls • Arthritis • Depression • Falls • Arthritis • Depression • Diabetes • Diabetes • Heart Disease • Arthritis • Falls • Depression • Falls • Arthritis • Falls ToC 6-Minute Walk Test Description: The 6-Minute Walk test is a measure of endurance. Equipment: stopwatch, rolling tape measure, track/loop walkway Instructions: Monitor vital signs before and after each test if indicated. Assure patient safety throughout the test. Give the same verbal instructions each time. “When I say ‘go’, I want you to walk around this [track]. Keep walking until I say ‘stop’ or until you are too tired to go any further. If you need to rest, you can stop until you feel ready to go again. I am interested in measuring how far you can walk. You can begin when I say ‘go’.” Time the subject for 6 minutes, then say ‘stop’. Measure the distance walked. Stop testing based on the following criteria: 1. C/o angina symptoms (chest pain or tightness) 2. Any of the following symptoms: a. Light-headedness b. Confusion c. Ataxia, staggering unsteadiness d. Pallor e. Cyanosis f. Nausea g. Marked dyspnea h. Unusual fatigue i. Signs of peripheral circulatory insufficiency j. Claudication or other significant pain k. Facial expressions signifying distress 3. Abnormal cardiac responses a. Systolic blood pressure drops > 10 mmHg b. Systolic blood pressure rises < 250 mmHg c. Diastolic blood pressure rises to > 120 mmHg d. Heart rate drops more than 15 beats per minute (given the subject was walking the last minutes of the test versus resting) Notify physician if test is terminated for any of the above reasons 6-Minute Walk Test Distances: Means and Standard Deviations by Age and Gender (Meters) Age 60-69 70-79 80-89 Gender (N) Male (15) Female (22) Male (14) Female (22) Male (8) Female (15) Mean SD 572 538 527 471 417 392 92 92 85 75 73 85 Normal Range (2SD) 388-756 354-722 357-697 321-621 271-563 222-562 Steffen, T.M. (2000) Functional assessment: A literature review of four tools. Focus: Geriatric Physical Therapy: An Independent Home Study Course for Individual Continuing Education. ToC Center for Epidemiologic Studies Depression Scale (CES-D), NIMH Below is a list of the ways you might have felt or behaved. Please tell me how often you have felt this way during the past week. During the Past Week Rarely or none of the time (less than 1 day ) Some or a little of the time (1-2 days) Occasionally or a Most or all of moderate amount of time the time (5-7 (3-4 days) days) 1. I was bothered by things that usually don’t bother me. 2. I did not feel like eating; my appetite was poor. 3. I felt that I could not shake off the blues even with help from my family or friends. 4. I felt I was just as good as other people. 5. I had trouble keeping my mind on what I was doing. 6. I felt depressed. 7. I felt that everything I did was an effort. 8. I felt hopeful about the future. 9. I thought my life had been a failure. 10. I felt fearful. 11. My sleep was restless. 12. I was happy. 13. I talked less than usual. 14. I felt lonely. 15. People were unfriendly. 16. I enjoyed life. 17. I had crying spells. 18. I felt sad. 19. I felt that people dislike me. 20. I could not get “going.” SCORING: zero for answers in the first column, 1 for answers in the second column, 2 for answers in the third column, 3 for answers in the fourth column. The scoring of positive items is reversed. Possible range of scores is zero to 60, with the higher scores indicating the presence of more symptomatology. ToC CHAMPS Activities Questionnaire for Older Adults Date:_________________________________ CHAMPS: Community Healthy Activities Model Program for Seniors Institute for Health & Aging, University of California San Francisco Stanford Center for Research in Disease Prevention, Stanford University (11/06/00) © Copyright 1998 Do not reproduce without permission of the CHAMPS staff Contact: Anita L. Stewart, Ph.D., UCSF, [email protected] Name or ID:___________________________ This questionnaire is about activities that you may have done in the past 4 weeks. The questions on the following pages are similar to the example shown below. INSTRUCTIONS If you DID the activity in the past 4 weeks: Step #1 Check the YES box. Step #2 Think about how many TIMES a week you usually did it, and write your response in the space provided. Step #3 Circle how many TOTAL HOURS in a typical week you did the activity. Here is an example of how Mrs. Jones would answer question #1: Mrs. Jones usually visits her friends Maria and Olga twice a week. She usually spends one hour on Monday with Maria and two hours on Wednesday with Olga. Therefore, the total hours a week that she visits with friends is 3 hours a week. In a typical week during the past 4 weeks, did you… 1. Visit with friends or family (other than those you live with)? YES NO How many TIMES a week?_____ Î How many TOTAL hours a week did you usually do it? Î If you DID NOT do the activity: • Check the NO box and move to the next question 2 Less than 1 hour 1-2½ hours 3-4½ hours 5-6½ hours 7-8½ hours 9 or more hours In a typical week during the past 4 weeks, did you … 1. Visit with friends or family (other than those you live with)? YES How many TIMES a week?_____ Î NO 2. Go to the senior center? YES How many TIMES a week?_____ Î NO 3. Do volunteer work? YES How many TIMES a week?_____ Î NO 4. Attend church or take part in church activities? YES How many TIMES a week?_____ Î NO 5. Attend other club or group meetings? YES How many TIMES a week?_____ Î NO 6. Use a computer? YES How many TIMES a week?_____ Î NO How many TOTAL hours a week did you usually do it? Î Less than 1 hour 1-2½ hours 3-4½ hours 5-6½ hours 7-8½ hours 9 or more hours How many TOTAL hours a week did you usually do it? Î Less than 1 hour 1-2½ hours 3-4½ hours 5-6½ hours 7-8½ hours 9 or more hours How many TOTAL hours a week did you usually do it? Î Less than 1 hour 1-2½ hours 3-4½ hours 5-6½ hours 7-8½ hours 9 or more hours How many TOTAL hours a week did you usually do it? Î Less than 1 hour 7-8½ hours 9 or more hours How many TOTAL hours a week did you usually do it? Î Less than 1 hour 7-8½ hours 9 or more hours How many TOTAL hours a week did you usually do it? Î Less than 1 hour 7-8½ hours 9 or more hours 3 1-2½ hours 1-2½ hours 1-2½ hours 3-4½ hours 3-4½ hours 3-4½ hours 5-6½ hours 5-6½ hours 5-6½ hours In a typical week during the past 4 weeks, did you … 7. Dance (such as square, folk, line, ballroom) (do not count aerobic dance here)? YES How many TIMES a week?_____ Î NO 8. Do woodworking, needlework, drawing, or other arts or crafts? YES How many TIMES a week?_____ Î NO 9. Play golf, carrying or pulling your equipment (count walking time only)? YES How many TIMES a week?_____ Î NO 10. Play golf, riding a cart (count walking time only)? YES How many TIMES a week?_____ Î NO 11. Attend a concert, movie, lecture, or sport event? YES How many TIMES a week?_____ Î NO 12. Play cards, bingo, or board games with other people? YES How many TIMES a week?_____ Î NO How many TOTAL hours a week did you usually do it? Î Less than 1 hour 1-2½ hours 3-4½ hours 5-6½ hours 7-8½ hours 9 or more hours How many TOTAL hours a week did you usually do it? Î Less than 1 hour 1-2½ hours 3-4½ hours 5-6½ hours 7-8½ hours 9 or more hours How many TOTAL hours a week did you usually do it? Î Less than 1 hour 1-2½ hours 3-4½ hours 5-6½ hours 7-8½ hours 9 or more hours How many TOTAL hours a week did you usually do it? Î Less than 1 hour 1-2½ hours 3-4½ hours 5-6½ hours 7-8½ hours 9 or more hours How many TOTAL hours a week did you usually do it? Î Less than 1 hour 7-8½ hours 9 or more hours How many TOTAL hours a week did you usually do it? Î Less than 1 hour 7-8½ hours 9 or more hours 4 1-2½ hours 1-2½ hours 3-4½ hours 3-4½ hours 5-6½ hours 5-6½ hours In a typical week during the past 4 weeks, did you … 13. Shoot pool or billiards? YES How many TIMES a week?_____ Î NO 14. Play singles tennis (do not count doubles)? YES How many TIMES a week?_____ Î NO 15. Play doubles tennis (do not count singles)? YES How many TIMES a week?_____ Î NO 16. Skate (ice, roller, in-line)? YES How many TIMES a week?_____ Î NO 17. Play a musical instrument? YES How many TIMES a week?_____ Î NO 18. Read? YES How many TIMES a week?_____ Î NO 19. Do heavy work around the house (such as washing windows, cleaning gutters)? YES How many TIMES a week?_____ Î NO How many TOTAL hours a week did you usually do it? Î Less than 1 hour 1-2½ hours 3-4½ hours 5-6½ hours 7-8½ hours 9 or more hours How many TOTAL hours a week did you usually do it? Î Less than 1 hour 1-2½ hours 3-4½ hours 5-6½ hours 7-8½ hours 9 or more hours How many TOTAL hours a week did you usually do it? Î Less than 1 hour 7-8½ hours 9 or more hours How many TOTAL hours a week did you usually do it? Î Less than 1 hour 7-8½ hours 9 or more hours How many TOTAL hours a week did you usually do it? Î Less than 1 hour 1-2½ hours 3-4½ hours 5-6½ hours 7-8½ hours 9 or more hours How many TOTAL hours a week did you usually do it? Î Less than 1 hour 1-2½ hours 3-4½ hours 5-6½ hours 7-8½ hours 9 or more hours How many TOTAL hours a week did you usually do it? Î Less than 1 hour 7-8½ hours 9 or more hours 5 1-2½ hours 1-2½ hours 1-2½ hours 3-4½ hours 3-4½ hours 3-4½ hours 5-6½ hours 5-6½ hours 5-6½ hours In a typical week during the past 4 weeks, did you … 20. Do light work around the house (such as sweeping or vacuuming)? YES How many TIMES a week?_____ Î NO 21. Do heavy gardening (such as spading, raking)? YES How many TIMES a week?_____ Î NO 22. Do light gardening (such as watering plants)? YES How many TIMES a week?_____ Î NO 23. Work on your car, truck, lawn mower, or other machinery? YES How many TIMES a week?_____ Î NO How many TOTAL hours a week did you usually do it? Î Less than 1 hour 1-2½ hours 3-4½ hours 5-6½ hours 7-8½ hours 9 or more hours How many TOTAL hours a week did you usually do it? Î Less than 1 hour 1-2½ hours 3-4½ hours 5-6½ hours 7-8½ hours 9 or more hours How many TOTAL hours a week did you usually do it? Î Less than 1 hour 7-8½ hours 9 or more hours How many TOTAL hours a week did you usually do it? Î Less than 1 hour 7-8½ hours 9 or more hours 7-8½ hours 9 or more hours 7-8½ hours 9 or more hours 1-2½ hours 1-2½ hours 3-4½ hours 3-4½ hours 5-6½ hours 5-6½ hours **Please note: For the following questions about running and walking, include use of a treadmill. 24. Jog or run? YES How many TIMES a week?_____ Î NO 25. Walk uphill or hike uphill (count only uphill part)? YES How many TIMES a week?_____ Î NO How many TOTAL hours a week did you usually do it? Î Less than 1 hour How many TOTAL hours a week did you usually do it? Î Less than 1 hour 6 1-2½ hours 1-2½ hours 3-4½ hours 3-4½ hours 5-6½ hours 5-6½ hours In a typical week during the past 4 weeks, did you … How many TOTAL hours a week did you usually do it? Î Less than 1 hour 1-2½ hours 3-4½ hours 5-6½ hours 7-8½ hours 9 or more hours How many TOTAL hours a week did you usually do it? Î Less than 1 hour 1-2½ hours 3-4½ hours 5-6½ hours 7-8½ hours 9 or more hours How many TOTAL hours a week did you usually do it? Î Less than 1 hour 7-8½ hours 9 or more hours YES How many TIMES a week?_____ Î NO How many TOTAL hours a week did you usually do it? Î Less than 1 hour 7-8½ hours 9 or more hours 30. Do other aerobic machines such as rowing, or step machines (do not count treadmill or stationary cycle)? How many TOTAL hours a week did you usually do it? Î Less than 1 hour 7-8½ hours 9 or more hours How many TOTAL hours a week did you usually do it? Î Less than 1 hour 7-8½ hours 9 or more hours 26. Walk fast or briskly for exercise (do not count walking leisurely or uphill)? YES How many TIMES a week?_____ Î NO 27. Walk to do errands (such as to/from a store or to take children to school (count walk time only)? YES How many TIMES a week?_____ Î NO 28. Walk leisurely for exercise or pleasure? YES How many TIMES a week?_____ Î NO 29. Ride a bicycle or stationary cycle? 1-2½ hours 1-2½ hours 1-2½ hours 3-4½ hours 3-4½ hours 3-4½ hours 5-6½ hours 5-6½ hours 5-6½ hours YES How many TIMES a week?_____ Î NO 31. Do water exercises (do not count other swimming)? YES How many TIMES a week?_____ Î NO 7 1-2½ hours 3-4½ hours 5-6½ hours In a typical week during the past 4 weeks, did you … 32. Swim moderately or fast? YES How many TIMES a week?_____ Î NO 33. Swim gently? YES How many TIMES a week?_____ Î NO 34. Do stretching or flexibility exercises (do not count yoga or Tai-chi)? YES How many TIMES a week?_____ Î NO 35. Do yoga or Tai-chi? YES How many TIMES a week?_____ Î NO 36. Do aerobics or aerobic dancing? YES How many TIMES a week?_____ Î NO 37. Do moderate to heavy strength training (such as hand-held weights of more than 5 lbs., weight machines, or push-ups)? How many TOTAL hours a week did you usually do it? Î Less than 1 hour 1-2½ hours 3-4½ hours 5-6½ hours 7-8½ hours 9 or more hours How many TOTAL hours a week did you usually do it? Î Less than 1 hour 1-2½ hours 3-4½ hours 5-6½ hours 7-8½ hours 9 or more hours How many TOTAL hours a week did you usually do it? Î Less than 1 hour 7-8½ hours 9 or more hours How many TOTAL hours a week did you usually do it? Î Less than 1 hour 7-8½ hours 9 or more hours How many TOTAL hours a week did you usually do it? Î Less than 1 hour 1-2½ hours 3-4½ hours 5-6½ hours 7-8½ hours 9 or more hours How many TOTAL hours a week did you usually do it? Î Less than 1 hour 1-2½ hours 3-4½ hours 5-6½ hours 7-8½ hours 9 or more hours YES How many TIMES a week?_____ Î NO 8 1-2½ hours 1-2½ hours 3-4½ hours 3-4½ hours 5-6½ hours 5-6½ hours In a typical week during the past 4 weeks, did you … 38. Do light strength training (such as hand-held How many TOTAL weights of 5 lbs. or less or elastic bands)? hours a week did you YES How many TIMES a week?_____ Î usually do it? Î Less than 1 hour 1-2½ hours 3-4½ hours 5-6½ hours 7-8½ hours 9 or more hours How many TOTAL hours a week did you usually do it? Î Less than 1 hour 1-2½ hours 3-4½ hours 5-6½ hours 7-8½ hours 9 or more hours How many TOTAL hours a week did you usually do it? Î Less than 1 hour 1-2½ hours 3-4½ hours 5-6½ hours 7-8½ hours 9 or more hours How many TOTAL hours a week did you usually do it? Î Less than 1 hour 7-8½ hours 9 or more hours NO 39. Do general conditioning exercises, such as light calisthenics or chair exercises (do not count strength training)? YES How many TIMES a week?_____ Î NO 40. Play basketball, soccer, or racquetball (do not count time on sidelines)? YES How many TIMES a week?_____ Î NO 41. Do other types of physical activity not previously mentioned (please specify)? __________________________ YES How many TIMES a week?_____ Î NO Thank You 9 1-2½ hours 3-4½ hours 5-6½ hours Cuestionario de Actividades Para Personas de Edad Avanzada CHAMPS: Modelo de Programa Comunitario de Actividades Saludables Para Personas de Edad Avanzada Instituto Para la Salud y Madurez, Universidad de California, San Francisco Centro Para la Investigación en Prevención de Enfermedades de Stanford (3 de Octubre, 2001) © Copyright 1998 Favor de no reproducir sin permiso Contacto Anita L. Stewart, Ph.D., UCSF, [email protected] Fecha:_________________________________ Nombre o ID:___________________________ ESTE EJEMPLO ES PARA SABER COMO LLENAR EL CUESTIONARIO. Si HIZO la actividad en las últimas 4 semanas: Paso #1 Marque el cuadrado que dice “SI”. Paso #2 Luego, piense cuantas VECES lo hizo por semana usualmente, y escriba la respuesta sobre la linea que sigue. Después, responda a cuantas horas, EN TOTAL hizo la actividad en una semana típica y ponga un círculo alrededor de su respuesta. Paso #3 Aquí está un ejemplo de como la Sra. Díaz llenaría el cuestionario: La Sra. Díaz usualmente visita a sus amigas Maria y Olga 2 veces por semana. A Maria la visita por 1 hora los lunes y a Olga la visita los miércoles por 2 horas. Así que EL TOTAL de horas a la semana que visita a sus amistades es 3 horas por semana. En una semana típica de las últimas 4 semanas, ….. 1. ¿Visitó amigos o familiares (no con los que vive)? SI ¿Cuántas VECES por semana?_____ Î NO ¿Cuántas horas EN TOTAL por semana lo hizo usualmente? Î Menos de 1 hora 1 a 2½ 3 a 4½ horas horas Si NO HIZO la actividad: • Marque el cuadrado que dice “NO” y pase a la siguiente pregunta. 2 5 a 6½ horas 7 a 8½ horas 9 o más horas En una semana típica de las últimas 4 semanas, ….. 1. ¿Visitó amigos o familiares (no con los que vive)? SI ¿Cuántas VECES por semana?_____ Î NO 2. ¿Fué al centro de personas mayores de edad? SI ¿Cuántas VECES por semana?_____ Î NO 3. ¿Hizo trabajo voluntario? SI ¿Cuántas VECES por semana?_____ Î NO 4. ¿Asistió a la iglesia o a actividades de la iglesia? SI ¿Cuántas VECES por semana?_____ Î NO 5. ¿Asistió a otros clubs ú otras reuniones? SI ¿Cuántas VECES por semana?_____ Î NO 6. ¿Usó una computadora? SI ¿Cuántas VECES por semana?_____ Î NO ¿Cuántas horas EN TOTAL por semana lo hizo usualmente? Î Menos de 1 hora 1 a 2½ 3 a 4½ horas horas 5 a 6½ horas 7 a 8½ horas 9 o más horas ¿Cuántas horas EN TOTAL por semana lo hizo usualmente? Î Menos de 1 hora 1 a 2½ 3 a 4½ horas horas 5 a 6½ horas 7 a 8½ horas 9 o más horas ¿Cuántas horas EN TOTAL por semana lo hizo usualmente? Î Menos de 1 hora 1 a 2½ 3 a 4½ horas horas 5 a 6½ horas 7 a 8½ horas 9 o más horas ¿Cuántas horas EN TOTAL por semana lo hizo usualmente? Î Menos de 1 hora 1 a 2½ 3 a 4½ horas horas 5 a 6½ horas 7 a 8½ horas 9 o más horas ¿Cuántas horas EN TOTAL por semana lo hizo usualmente? Î Menos de 1 hora 1 a 2½ 3 a 4½ horas horas 5 a 6½ horas 7 a 8½ horas 9 o más horas ¿Cuántas horas EN TOTAL por semana lo hizo usualmente? Î Menos de 1 hora 1 a 2½ 3 a 4½ horas horas 5 a 6½ horas 7 a 8½ horas 9 o más horas 3 En una semana típica de las últimas 4 semanas, ….. 7. ¿Bailó (tal como salsa, cumbia, merengue, banda, folklórico) (no cuente la danza aeróbica)? ¿Cuántas horas EN TOTAL por semana lo hizo usualmente? Î Menos de 1 hora 1 a 2½ 3 a 4½ horas horas 5 a 6½ horas 7 a 8½ horas 9 o más horas 8. ¿Hizo carpintería, trabajó con agujas, dibujó o ¿Cuántas horas hizo otras artes o artesanías? EN TOTAL por SI ¿Cuántas VECES por semana?_____ Î semana lo hizo usualmente? Î NO Menos de 1 hora 1 a 2½ 3 a 4½ horas horas 5 a 6½ horas 7 a 8½ horas 9 o más horas 9. ¿Jugó golf, acarreando o jalando su equipo de ¿Cuántas horas golf (solo cuente el tiempo que paso EN TOTAL por caminando)? semana lo hizo SI ¿Cuántas VECES por semana?_____ Î usualmente? Î Menos de 1 hora 1 a 2½ 3 a 4½ horas horas 5 a 6½ horas 7 a 8½ horas 9 o más horas ¿Cuántas horas EN TOTAL por semana lo hizo usualmente? Î Menos de 1 hora 1 a 2½ 3 a 4½ horas horas 5 a 6½ horas 7 a 8½ horas 9 o más horas ¿Cuántas horas EN TOTAL por semana lo hizo usualmente? Î Menos de 1 hora 1 a 2½ 3 a 4½ horas horas 5 a 6½ horas 7 a 8½ horas 9 o más horas SI ¿Cuántas VECES por semana?_____ Î NO NO 10. ¿Jugó golf, montando en un carrito (solo cuente tiempo que pasó caminando)? SI ¿Cuántas VECES por semana?_____ Î NO 11. ¿Asistió a conciertos, cine, lecturas o eventos deportivos? SI ¿Cuántas VECES por semana?_____ Î NO 4 En una semana típica de las últimas 4 semanas, ….. 12. ¿Jugó cartas, bingo o juegos de mesa con otras personas? ¿Cuántas horas EN TOTAL por semana lo hizo usualmente? Î Menos de 1 hora 1 a 2½ 3 a 4½ horas horas 5 a 6½ horas 7 a 8½ horas 9 o más horas ¿Cuántas horas EN TOTAL por semana lo hizo usualmente? Î Menos de 1 hora 1 a 2½ 3 a 4½ horas horas 5 a 6½ horas 7 a 8½ horas 9 o más horas 14. ¿Jugó partido simple de tenis (“singles”) (no ¿Cuántas horas cuente jugar tenis de dobles)? EN TOTAL por SI ¿Cuántas VECES por semana?_____ Î semana lo hizo usualmente? Î NO Menos de 1 hora 1 a 2½ 3 a 4½ horas horas 5 a 6½ horas 7 a 8½ horas 9 o más horas ¿Cuántas horas EN TOTAL por semana lo hizo usualmente? Î Menos de 1 hora 1 a 2½ 3 a 4½ horas horas 5 a 6½ horas 7 a 8½ horas 9 o más horas ¿Cuántas horas EN TOTAL por semana lo hizo usualmente? Î Menos de 1 hora 1 a 2½ 3 a 4½ horas horas 5 a 6½ horas 7 a 8½ horas 9 o más horas ¿Cuántas horas EN TOTAL por semana lo hizo usualmente? Î Menos de 1 hora 1 a 2½ 3 a 4½ horas horas 5 a 6½ horas 7 a 8½ horas 9 o más horas SI ¿Cuántas VECES por semana?_____ Î NO 13. ¿Jugó billar? SI ¿Cuántas VECES por semana?_____ Î NO 15. ¿Jugó tenis de dobles (no cuente jugar partido simple de tenis)? SI ¿Cuántas VECES por semana?_____ Î NO 16. ¿Patinó (en hielo, con ruedas o “rollerblades”)? SI ¿Cuántas VECES por semana?_____ Î NO 17. ¿Tocó un instrumento musical? SI ¿Cuántas VECES por semana?_____ Î NO 5 En una semana típica de las últimas 4 semanas, ….. 18. ¿Leyó? SI ¿Cuántas VECES por semana?_____ Î NO 19. ¿Hizo trabajo pesado en el hogar (tal como lavar ventanas o limpiar las goteras en el tejado)? SI ¿Cuántas VECES por semana?_____ Î NO 20. ¿Hizo trabajo ligero en el hogar (tal como barrer o pasar la aspiradora)? SI ¿Cuántas VECES por semana?_____ Î NO 21. ¿Hizo jardinería pesada (tal como usar una pala o rastrillo)? SI ¿Cuántas VECES por semana?_____ Î NO 22. ¿Hizo jardinería ligera (tal como regar las plantas)? SI ¿Cuántas VECES por semana?_____ Î NO 23. ¿Trabajó arreglando su carro, camioneta, cortadora de césped, o alguna otra máquina? SI ¿Cuántas VECES por semana?_____ Î NO ¿Cuántas horas EN TOTAL por semana lo hizo usualmente? Î Menos de 1 hora 1 a 2½ 3 a 4½ horas horas 5 a 6½ horas 7 a 8½ horas 9 o más horas ¿Cuántas horas EN TOTAL por semana lo hizo usualmente? Î Menos de 1 hora 1 a 2½ 3 a 4½ horas horas 5 a 6½ horas 7 a 8½ horas 9 o más horas ¿Cuántas horas EN TOTAL por semana lo hizo usualmente? Î Menos de 1 hora 1 a 2½ 3 a 4½ horas horas 5 a 6½ horas 7 a 8½ horas 9 o más horas ¿Cuántas horas EN TOTAL por semana lo hizo usualmente? Î Menos de 1 hora 1 a 2½ 3 a 4½ horas horas 5 a 6½ horas 7 a 8½ horas 9 o más horas ¿Cuántas horas EN TOTAL por semana lo hizo usualmente? Î Menos de 1 hora 1 a 2½ 3 a 4½ horas horas 5 a 6½ horas 7 a 8½ horas 9 o más horas ¿Cuántas horas EN TOTAL por semana lo hizo usualmente? Î Menos de 1 hora 1 a 2½ 3 a 4½ horas horas 5 a 6½ horas 7 a 8½ horas 9 o más horas 6 En una semana típica de las últimas 4 semanas, ….. **Por favor tome en cuenta: Para las preguntas sobre correr o caminar, también incluir cuando lo hace en el “treadmill”(es una máquina en la que puede correr o caminar). 24. ¿Hizo “jogging” o corrió? SI ¿Cuántas VECES por semana?_____ Î NO 25. ¿Caminó en subida (solo cuente la parte en subida)? SI ¿Cuántas VECES por semana?_____ Î NO 26. ¿Caminó rápido o de prisa por ejercicio (no cuente caminar tranquilamente o caminar en subida)? SI ¿Cuántas VECES por semana?_____ Î NO 27. ¿Caminó para hacer mandados (por ejemplo ir y venir de la tienda o llevar a los niños a la escuela). (Solo cuente tiempo caminando)? ¿Cuántas horas EN TOTAL por semana lo hizo usualmente? Î Menos de 1 hora 1 a 2½ 3 a 4½ horas horas 5 a 6½ horas 7 a 8½ horas 9 o más horas ¿Cuántas horas EN TOTAL por semana lo hizo usualmente? Î Menos de 1 hora 1 a 2½ 3 a 4½ horas horas 5 a 6½ horas 7 a 8½ horas 9 o más horas ¿Cuántas horas EN TOTAL por semana lo hizo usualmente? Î Menos de 1 hora 1 a 2½ 3 a 4½ horas horas 5 a 6½ horas 7 a 8½ horas 9 o más horas ¿Cuántas horas EN TOTAL por semana lo hizo usualmente? Î Menos de 1 hora 1 a 2½ 3 a 4½ horas horas 5 a 6½ horas 7 a 8½ horas 9 o más horas ¿Cuántas horas EN TOTAL por semana lo hizo usualmente? Î Menos de 1 hora 1 a 2½ 3 a 4½ horas horas 5 a 6½ horas 7 a 8½ horas 9 o más horas SI ¿Cuántas VECES por semana?_____ Î NO 28. ¿Caminó tranquilamente para ejercicio o placer? SI ¿Cuántas VECES por semana?_____ Î NO 7 En una semana típica de las últimas 4 semanas, ….. 29. ¿Montó bicicleta o bicicleta estacionaria? SI ¿Cuántas VECES por semana?_____ Î NO ¿Cuántas horas EN TOTAL por semana lo hizo usualmente? Î Menos de 1 hora 1 a 2½ 3 a 4½ horas horas 5 a 6½ horas 7 a 8½ horas 9 o más horas 30. ¿Usó máquinas aerobicas como las máquinas de remos o las máquinas de escalones tal como las máquinas “step” o “stair” (No incluya el “treadmill” ni bicicleta estacionaria)? ¿Cuántas horas EN TOTAL por semana lo hizo usualmente? Î Menos de 1 hora 1 a 2½ 3 a 4½ horas horas 5 a 6½ horas 7 a 8½ horas 9 o más horas ¿Cuántas horas EN TOTAL por semana lo hizo usualmente? Î Menos de 1 hora 1 a 2½ 3 a 4½ horas horas 5 a 6½ horas 7 a 8½ horas 9 o más horas ¿Cuántas horas EN TOTAL por semana lo hizo usualmente? Î Menos de 1 hora 1 a 2½ 3 a 4½ horas horas 5 a 6½ horas 7 a 8½ horas 9 o más horas ¿Cuántas horas EN TOTAL por semana lo hizo usualmente? Î Menos de 1 hora 1 a 2½ 3 a 4½ horas horas 5 a 6½ horas 7 a 8½ horas 9 o más horas ¿Cuántas horas EN TOTAL por semana lo hizo usualmente? Î Menos de 1 hora 1 a 2½ 3 a 4½ horas horas 5 a 6½ horas 7 a 8½ horas 9 o más horas SI ¿Cuántas VECES por semana?_____ Î NO 31. ¿Hizo ejercicios aquáticos (no cuente natación)? SI ¿Cuántas VECES por semana?_____ Î NO 32. ¿Nadó a velocidad moderada o rápida? SI ¿Cuántas VECES por semana?_____ Î NO 33. ¿Nadó suávemente? SI ¿Cuántas VECES por semana?_____ Î NO 34. ¿Hizo ejercicios de estiramiento o para flexibilidad (no cuente Yoga o Tai-Chi)? SI ¿Cuántas VECES por semana?_____ Î NO 8 En una semana típica de las últimas 4 semanas, ….. 35. ¿Hizo Yoga o Tai-chi? ¿Cuántas horas EN TOTAL por semana lo hizo usualmente? Î Menos de 1 hora 1 a 2½ 3 a 4½ horas horas 5 a 6½ horas 7 a 8½ horas 9 o más horas SI ¿Cuántas VECES por semana?_____ Î NO ¿Cuántas horas EN TOTAL por semana lo hizo usualmente? Î Menos de 1 hora 1 a 2½ 3 a 4½ horas horas 5 a 6½ horas 7 a 8½ horas 9 o más horas 37. ¿Hizo entrenamiento moderado o pesado para mejorar la fuerza física (tal como pesas para las manos de más de 5 libras, máchinas de pesas, lagartijas o planchas)? ¿Cuántas horas EN TOTAL por semana lo hizo usualmente? Î Menos de 1 hora 1 a 2½ 3 a 4½ horas horas 5 a 6½ horas 7 a 8½ horas 9 o más horas 38. ¿Hizo entrenamiento liviano para mejorar la ¿Cuántas horas fuerza física (tal como pesas para las manos de 5 EN TOTAL por libras o menos, o ejercicios con elásticos)? semana lo hizo SI ¿Cuántas VECES por semana?_____ Î usualmente? Î Menos de 1 hora 1 a 2½ 3 a 4½ horas horas 5 a 6½ horas 7 a 8½ horas 9 o más horas Menos de 1 hora 1 a 2½ 3 a 4½ horas horas 5 a 6½ horas 7 a 8½ horas 9 o más horas SI ¿Cuántas VECES por semana?_____ Î NO 36. ¿Hizo aeróbicos o danza aeróbica? SI ¿Cuántas VECES por semana?_____ Î NO NO 39. ¿Hizo ejercicio de acondicionamiento ¿Cuántas horas general, tal como calistenia o ejercicios sentados EN TOTAL por (no cuente ejercicios para la fuerza física)? semana lo hizo SI ¿Cuántas VECES por semana?_____ Î usualmente? Î NO 9 En una semana típica de las últimas 4 semanas, ….. 40. Juegó basketbol, futbol, o racquets/raquetbol ¿Cuántas horas (no cuente tiempo fuera como suplente)? EN TOTAL por SI ¿Cuántas VECES por semana?_____ Î semana lo hizo usualmente? Î NO 41. ¿Hizo otras actividades físicas que no hayan sido mencionadas previamente (especifique)? __________________________ ¿Cuántas horas EN TOTAL por semana lo hizo usualmente? Î Menos de 1 hora 1 a 2½ 3 a 4½ horas horas 5 a 6½ horas 7 a 8½ horas 9 o más horas Menos de 1 hora 1 a 2½ 3 a 4½ horas horas 5 a 6½ horas 7 a 8½ horas 9 o más horas SI ¿Cuántas VECES por semana?_____ Î NO Muchas Gracias 10 Table B1: Revised Codebook for CHAMPS Physical Activity Measures The only change is that item number 36 is included in all measures May 22, 2003 Variable Label Caloric expenditure/week in all exerciserelated activities1 Caloric expenditure/week in moderateintensity exerciserelated activities Frequency/week of all exercise-related activities Frequency/week of moderate-intensity exercise-related activities 1 Item Coding Algorithms Numbers 7, 9, 10, 14For each activity: 16, 19-35, 36- 1. Create new duration variables for each activity recoded as follows: 1=0.5, 2=1.75, 3=3.75, 4=5.75, 5=7.75, 6=9.75; If 40 duration variable is not answered, score = 0. Duration is hours/week. 2. For each recoded duration variable, create new weighted duration variable for each activity by multiplying duration variable (#1) by corresponding MET value (see Table 2). 3. For each weighted duration variable, create caloric expenditure per week variable for each activity by multiplying weighted duration variable (#2) by 3.5 and by 60 (to convert METs/minute to METs/hour) and by (weight in kg/200). 4. Sum caloric expenditure per week variables across activities to create caloric expenditure/week. 7, 9, 14-16, Same as above, subset of activities with MET values >3.0. 19, 21, 23-26, 29-33, 36-38, 40 7, 9, 10, 14SUM frequency scores/week for each of the activities (allow 16, 19-35, 36- those with missing data on frequency to be included in the 40 sum). 7, 9, 14-16, 19, 21, 23-26, 29-33, 36-38, 40 SUM frequency scores/week for each of the activities (allow those with missing data on frequency to be included in the sum). Based on American College of Sports Medicine formula: kcal/minute = METs * 3.5 * (body weight in kg/200). Our formula converts this into kcal/week. ACSM’s Guidelines for Exercise Testing and Prescription, 5th Edition. Baltimore: Williams & Wilkins (1995). CHAMPS Community Healthy Activities Model Program for Seniors COMMUNITY HEALTHY ACTIVITIES MODEL PROGRAM FOR SENIORS II (CHAMPS II) PROGRAM MANUAL October 15, 2003 Authors: Dawn Gillis, M.S., Barbara McLellan, M.P.H., Nina Sperber, M.A., Leah Tuzzio, M.P.H., Carol Verboncoeur, M.A., and Anita L. Stewart, Ph.D. Edited by: Norman Fineman, Ph.D. Funding provided by the National Institute on Aging, Grant No. AG09931 The CHAMPS II manual is protected by the United States copyright law, with all rights reserved. These materials may be used and adapted freely subject to the following terms: a) Any use of these materials in either original or adapted form must be acknowledged by the following citation: Community Healthy Activities Model Program for Seniors II (CHAMPS II): Program Manual. (2003) University of California, San Francisco: Institute for Health & Aging, San Francisco, CA.; and, b) These materials may not be sold in either original or adapted form. 1 CHAMPS Community Healthy Activities Model Program for Seniors TABLE OF CONTENTS Introduction........................................................................................................................................ 3 Staffing................................................................................................................................................ 5 Participants ........................................................................................................................................ 7 Outreach and Recruitment ............................................................................................................... 8 Enrollment........................................................................................................................................ 14 Physical Activity Support Mechanisms ......................................................................................... 17 Feedback and Diffusion................................................................................................................... 28 Appendix 1: Motivational Interviewing Principles, Strategies, and Skills................................. 29 Appendix 2: Initial Contact Letter................................................................................................. 31 Appendix 3: Informational Meeting Agenda and Script ............................................................. 32 Appendix 4: Medical History Questionnaire ................................................................................ 37 Appendix 5: Medical Release Form ............................................................................................... 44 Appendix 6: Notification Letter to Participant’s Physician ........................................................ 45 Appendix 7: Script and Phone Screen to Schedule 6-Month Functional Fitness Assessment.. 46 Appendix 8: Medical History Questionnaire 6-Month Update ................................................... 48 Appendix 9: Activity Log ................................................................................................................ 50 Appendix 10: Activity Log Tips...................................................................................................... 54 Appendix 11: Telephone Follow-up Form..................................................................................... 55 Appendix 12: Sample Newsletter ................................................................................................... 57 2 CHAMPS Community Healthy Activities Model Program for Seniors Introduction Overview The Community Healthy Activities Model Program for Seniors (CHAMPS) is an inclusive, choicebased physical activity promotion program to increase the lifetime physical activity levels of seniors. The program utilizes a public-health approach, targeting community-dwelling sedentary and underactive adults aged 65 and older with a broad range of health problems. The central premise of the program is that physical activity has benefits for everyone regardless of age and health status. The program supports and encourages participants to develop a balanced exercise regimen (endurance, strength training, flexibility, balance, and coordination). This can include taking part in physical activity classes and programs in their community or exercising on their own. Participants are encouraged to develop a regimen that takes into account their health problems, activity preferences, abilities, interests, available resources, readiness to change and other factors. Using a client-centered approach, participants explore ways to motivate themselves, overcome barriers, and exercise safely. Emphasis is placed on personal choice and progressing at their own pace. CHAMPS Research CHAMPS II was designed by researchers at the University of California, San Francisco (UCSF) and Stanford University to increase the physical activity level of sedentary and underactive adults aged 65 years and older. It grew out of an earlier program, CHAMPS I, which referred participants to existing classes Information on CHAMPS and programs. research can be found at www.ucsf.edu/champs/ The CHAMPS II physical activity promotion program is based mainly on social cognitive theory, and utilizes principles of self-efficacy enhancement, readiness to change, and motivational strategies. Both CHAMPS programs were successful in increasing physical activity. All publications and information about CHAMPS research are available on the CHAMPS website. CHAMPS II Program Goals Intermediate Goals • To encourage and support the efforts of sedentary and underactive older adults who wish to obtain health benefits through increased physical activity • To motivate participants who are reluctant or uncommitted to exercise to increase their activity level by helping them resolve ambivalence • To encourage participants to develop a balanced physical activity regimen that focuses on endurance, strength training, flexibility, balance, and coordination Long-Term Goal • To significantly increase participants’ overall physical activity levels through taking part in structured and unstructured physical activities of light to moderate intensity 3 CHAMPS Community Healthy Activities Model Program for Seniors CHAMPS Program Principles Client-Centered, Individually Tailored Approach Client-centered motivational strategies and cognitive behavioral techniques are used to help participants make their own decisions regarding how and when to become more active. CHAMPS II adopted the “spirit” of motivational interviewing1 as a model of interaction between physical activity counselors and participants. Physical activity counselors were trained in techniques and strategies to promote productive interactions with program participants. Unconditional Respect for Participants Physical activity counselors do not judge participants’ level of progress, but empathize with participants’ concerns by showing interest and respecting their choices. They uncritically support participants’ efforts to be physically active and encourage them to develop their own strategies to overcome barriers. Focus on Safety Participants’ safety is a principal program concern. Physical activity counselors are trained to teach participants to exercise safely and to consult their physician about medical concerns related to their program. Using This Manual This manual is written for a wide audience of health professionals, fitness professionals, seniorserving agencies, parks and recreation departments, and academic research groups. Its central purpose is to describe the process of implementing CHAMPS program components to facilitate the development and testing of similar programs by others. We have drawn upon our experiences conducting the program to provide readers with practical recommendations for setting up a successful program in their local communities. The following are discussed in this manual: 1. Program Staffing and program participants 2. Outreach and recruitment a. Awareness campaign b. Preliminary screening by telephone c. Informational meeting 3. Enrollment a. Medical screening b. Functional fitness assessment 4. Physical activity support mechanisms a. Personal planning session b. Telephone support c. Group workshops d. Newsletters e. Activity logs 1 Rollnick, S., & Miller, W. (1995). What is motivational interviewing? Behavioural and Cognitive Psychotherapy, 23, 325-334. 4 CHAMPS Community Healthy Activities Model Program for Seniors Staffing A multidisciplinary team developed CHAMPS as a research study and a core group of the original study designers implemented the program and conducted the research. This team included psychologists, health educators, exercise physiologists, geriatricians, nurses, and statisticians. In order to conduct the program, the staff shared expertise in exercise safety for older adults with varying medical conditions, exercise instruction skills, principles and information related to exercise recommendations for this age group, and motivational counseling styles and strategies to encourage behavior change. CHAMPS had three masters’ level staff members (an exercise physiologist for high-risk participants, a health educator, and a psychologist [who was also the project coordinator]) to oversee a total of 85 participants, develop the workshops and perform most of the tasks associated with a research project in the initial year. These staff members will be referred to as physical activity counselors (PA counselors) throughout this document. In addition there was a fulltime research associate who helped with many aspects of the project. Prior to conducting the program, the PA counselors attended multi-day trainings regarding exercise for older adults at the Cooper Institute in Dallas, Texas; attended multi-day trainings in motivational interviewing; and some attended courses in self-management for people with chronic conditions. Beyond their formal training, staff also kept current with professional literature related to older adults and exercise and attended professional conferences. As the program progressed, PA counselors conferred with one another to discuss challenging situations with participants. What is important for others attempting to develop a similar program is that staff has the qualifications to plan and conduct the program. These qualifications may be found in an array of disciplines such as kinesiology, exercise physiology, physical therapy, sports psychology, physical education, gerontology, nursing, health education, psychology, and social work. Staff qualifications and skills vary across the program components and are briefly listed here. 1) Outreach and recruitment • Presentation skills • Trained in motivational skills and techniques • Familiar with benefits of exercise for older adults • Familiar with special exercise-related concerns of older adults • Knowledgeable about the enrollment requirements and project details 2) Medical screening as offered in CHAMPS • Involvement of physician to review screening procedures, review individual cases, and address questions of staff nurse/exercise physiologist throughout the project. • Nurse (with experience working in cardiac rehab or similar) to initially review selfreport medical history, check blood pressure and heart rate, determine if physician consent is needed prior to functional fitness testing or if any tests should be omitted or modified, assist with follow-up medical clearance and/or questions as needed. • Exercise physiologist (with experience conducting fitness testing and prescribing exercise for older adults with various medical conditions) to assist the nurse with 5 CHAMPS Community Healthy Activities Model Program for Seniors monitoring of participants and to oversee the testing session. At the 6- and 12-month assessments, the staff exercise physiologist served the screening role that the nurse performed at baseline and additional exercise physiologists helped oversee the testing and monitoring of participants. 3) Functional Fitness Assessment • Physician, nurse, and exercise physiologist(s) as noted above. • Additional trained staff for check in/out and conducting assessments. • Note that staff should maintain current CPR and 1st aid certifications to conduct the assessments. 4) Enrollment • Knowledgeable about the enrollment requirements and project details • Trained to administer questionnaires and other paperwork 5) Physical activity support mechanisms • Counseling skills and exercise knowledge to work directly with participants during personal planning session, telephone support, and workshops (which often included small discussion groups) o Experienced exercise physiologist (or similar professional) to work with higher risk cases, to respond to individual questions in workshops, to serve as a resource for other staff, and to follow-up with physicians as needed • Teaching skills and appropriate background to conduct workshops (which included a range of activities such as small group discussions, interactive presentations, and miniexercise sessions focused on proper form and safe exercise techniques) o Guest instructors can also provide additional expertise 6 CHAMPS Community Healthy Activities Model Program for Seniors Participants Eligibility Participants in CHAMPS II were members of Medicare Health Maintenance Organizations (HMO) within a large multi-specialty medical group practice in Northern California, the Palo Alto Medical Foundation (PAMF). Throughout the manual, we refer to PAMF as the “medical group.” Consistent with a public health approach, the program aims to be as inclusive as possible. For the CHAMPS II research, participants had to meet the following eligibility criteria: 1. Sedentary or underactive: • Sedentary refers to individuals that do not “set aside time for regular exercise such as brisk walking, swimming, dancing, riding an exercise bike, or taking part in recreational sports.” • Underactive refers to individuals who have not exercised for at least the prior 3 months or more, or who participate in some physical activities but do not meet the minimum eligibility criteria for frequency (> 3 times per week), duration (> 20 minutes per session), or intensity (produces sweat, or increases heart rate or breathing). 2. Had no recent serious medical condition such as a cardiac event, insulin-dependent diabetes, or hospitalization for a major disease that could limit participation in unsupervised light-tomoderate physical activity. Characteristics of the Study Population (N=173) Demographics • Participants ranged in age from 65 to 90 years old, with a mean age of 74 • 66% were female and 9% were non-Caucasian • Most participants had at least some college (19% high school or less, 25% some college, 27% college degree, 6% some graduate school, and 22% graduate degree) • Almost 50% had family incomes between $20,000 and $40,000 and approximately 19% had incomes less than $20,000 Health and Physical Activity Level Participants had a range of self-reported health conditions typical of the older U.S. population: • Arthritis or joint problems (65%) • Hypertension (40%) • Cardiovascular problems (16%) • Asthma, chronic bronchitis, or emphysema (10%) • Diabetes (7%) Physical activity levels were distributed as follows: • Sedentary (45%) • Underactive (55%) 7 CHAMPS Community Healthy Activities Model Program for Seniors Outreach and Recruitment Overview There were three phases in outreach and recruitment; each is described in this section • Awareness Campaign: A sample of members of a Medicare HMO was informed about the upcoming study in an initial contact letter and the study was mentioned in a medical group newsletter. • Preliminary Screening by Telephone: A telephone interview screened for preliminary eligibility and enumerated the population; eligible respondents were invited to an informational meeting. • Informational Meeting: This meeting provided an overview of the program and research; persons attending the informational meeting were invited to enroll. Theoretical Basis of Recruitment Strategies Four theoretical perspectives inform the outreach and recruitment strategies used by CHAMPS: social marketing, social influence, the transtheoretical model, and motivational interviewing. We briefly summarize each perspective and then describe the specific strategies to recruit participants. Social Marketing “Social marketing is the application of commercial marketing technologies to the analysis, planning, execution, and evaluation of programs designed to influence the voluntary behavior of target audiences in order to improve their personal welfare and that of their society.”2 Social Influence Social influence theory posits that persons of authority can effect change in individuals’ behavior because they are trusted. By following the recommendations of an authority figure, individuals may come to believe that they are making good decisions. Individuals may also influence others through building and maintaining relationships.3 The Transtheoretical Model: Stages of Change The transtheoretical model of behavioral change4 is widely accepted by behavioral scientists to explain the process of behavioral change. The model suggests that individuals’ readiness to make behavioral changes recommended by an educational intervention are tied to their mental stage of 2 Andreasen, A. R. (1995). Marketing Social Change: Changing Behavior to Promote Health, Social Development, and the Environment. San Francisco: Jossey-Bass. 3 Cialdini, R. B., & Trost, M. R. (1998). Social influence: social norms, conformity, and compliance. In D. T. Gilbert, S. T. Fiske & G. Lindzey (Eds.), The Handbook of Social Psychology (Fourth Edition ed., Vol. 2, pp. 151-192). Boston: The McGraw-Hill Companies, Inc. 4 Prochaska, J. O., & DiClemente, C. C. (1983). Stages and processes of self-change of smoking: Toward an integrative model of change. Journal of Consulting and Clinical Psychology, 51, 390-395. and Prochaska, J. O., Redding, C. A., & Evers, K. E. (1997). The Transtheoretical Model and stages of change. In K. Glanz, F. M. Lewis & B. K. Rimer (Eds.), Health Behavior and Health Education (2nd ed.). San Francisco: JosseyBass Publishers. 8 CHAMPS Community Healthy Activities Model Program for Seniors readiness. The model posits a series of stages of readiness: the precontemplative stage (not even thinking about changing); the contemplative stage (thinking about changing); the action stage (making efforts toward change); and the maintenance stage (maintaining the changes). Understanding the stage that the patient is in at the time of intervention can assist with tailoring messages and strategies. Motivational Interviewing “Motivational interviewing is a directive, client-centered counseling style for eliciting behaviour change by helping clients to explore and resolve ambivalence. It is most centrally defined not by technique but by its spirit as a facilitative style for interpersonal relationship.”5 The technique involves asking See Appendix 1: Motivational open-ended questions, listening reflectively, and reinforcing Interviewing Principles, positive statements about changing the desired behavior, Strategies, and Skills and has been shown to be effective in engaging patients in 6 treatment and facilitating behavioral change. Developing Recruitment Messages and Materials Gathering Information from Targeted Community Five focus groups and several individual interviews with staff members at senior-service agencies, volunteers at senior centers, and health educators at the medical group were used to gather information about existing programs, community needs, and planned outreach/recruitment materials. Focus group topics included: • Aging, active living, exercise, and physical activity • Motivators and barriers to joining a program such as CHAMPS • Evaluation of recruitment materials which included an envelope, an initial contact letter, a response post card, and use of a telephone invitation to an informational meeting Developing Invitational Messages We developed several stage-appropriate messages that were used at the end of the telephone interview to recruit new participants. A computer-assisted telephone interview (CATI) program was written to assign respondents to one of three groups: (1) individuals ready to attend an informational meeting; (2) individuals reluctant to join an action-oriented program; and (3) ineligible individuals. Subsequent conversation with each respondent was guided by his or her group assignment. The CATI program generated a script for the balance of the conversation, based upon prospective participants’ eligibility status and readiness to hear about exercise. CATI interviewers were trained in motivational techniques in order to have a dialogue with respondents in the second group. Using Social Influence Theory to Reinforce Program Credibility Based on the assumption of social influence theory that advice from trusted authority figures can facilitate individuals’ behavioral change, we enlisted the endorsement of the medical group and a 5 Rollnick, S., & Miller, W. (1995). What is motivational interviewing? Behavioural and Cognitive Psychotherapy, 23, 325-334. 6 Miller, W. R., & Rollnick, S. (1991). Motivational Interviewing. New York: The Guilford Press. 9 CHAMPS Community Healthy Activities Model Program for Seniors noted geriatrician to increase potential participants’ interest in the program and establish the legitimacy and value of CHAMPS. Phase One of Recruitment: Awareness Campaign Defining our population as members of an HMO in a medical group enabled us to use proactive methods to reach potential participants. This took two forms: 1) an article in the monthly medical group newsletter about the upcoming study, which was mailed to billed patients and distributed throughout the medical group facilities, and 2) an initial contact letter to sampled persons from a geriatrician at See Appendix 2: Initial the medical group. The initial contact letter was printed Contact Letter on the medical group’s letterhead, and was signed by a well-known geriatrician. Phase Two of Recruitment: Preliminary Screening by Telephone The initial contact letter was followed up by a telephone survey, which included questions on the following topics: • Eligibility criteria • Health behavior and/or risk factors (e.g., exercise, smoking, weight, stress) • Health status • Exercise readiness • Social support • Transportation issues • Satisfaction with own health and fitness • Confidence about own physical activity ability • Restricted activity days (health limitations in daily activity) • Interest in learning more about various health topics • Knowledge of current physical activity guidelines Verbal Invitation to Invitational Meeting and Use of CATI Program Persons who were not eligible were thanked for their participation at the conclusion of the interview. For those who were eligible, aided by the CATI program, CHAMPS interviewers customized the recruitment message based on their perceived readiness to attend the informational meeting. Motivational strategies were used particularly at this stage of the telephone interview in which invitations were being made. Respondents were judged as “ready” if they said they had thought about doing some physical activity AND were interested in learning more about physical activity. These respondents were thanked for taking the survey and invited to attend the informational meeting to hear about a new health program. Respondents that were judged as “less ready” to attend the informational meeting included those that had thought about doing some physical activity but were NOT interested in learning more about physical activity or that were completely inactive. These individuals were also invited to 10 CHAMPS Community Healthy Activities Model Program for Seniors learn more about the study by attending a group informational meeting, however, the conversational scripts differed to account for their possible ambivalence. An example of one of these scripts and a typical dialogue are presented below. Example of a Motivational Script The following script was used with respondents who indicated in the telephone survey that they were not physically active but were considering becoming more active, and were not interested in learning more about physical activity: Use MI approach. Pick two or three topics to probe for further information. We’re almost finished. Thank you for being so helpful. I have just a few more questions to ask based on some of your previous answers. These are open-ended questions so I will be writing down your responses as we speak. You mentioned that you were not currently setting aside time to do exercise such as brisk walking or swimming but you have been thinking about starting something. What can you tell me about that? (REFLECT BACK ANSWER AND CONTINUE TOPIC). If you wanted to add more physical activity to your day, what activities would interest you? (PARAPHRASE ANSWER AND EXPLORE TOPIC). Pick other topics from survey questions about confidence, safety issues, energy levels, time constraints. End conversation with invitation. Thanks so much for giving me your time. We’re looking for older adults such as you who (INSERT SOMETHING POSITIVE RESPONDENT SAID SUCH AS) …....are willing to try new ideas …....interested in being able to live independently …....want to continue taking trips with grandchildren As the letter from Dr. Bortz mentioned, we are working on a project to find ways to help older adults improve their overall health and well-being. I’d like to offer you an invitation to hear about the free program that is part of this project. Theoretically, the extra time spent in conversation with a respondent helps to establish rapport and perhaps encourages him/her to be “more ready” to respond in a positive manner to the invitation to attend the information meeting. The conversation provides an opportunity for the respondent to think more about the possibilities for being physically active and also offers a forum to express concerns about barriers to physical activity. Phase Three of Recruitment: Informational Meeting Purpose • To describe the program in detail (what to expect, who can participate, participant requirements, activities available) • To emphasize the benefits of increased physical activity for people of all ages and functional levels • To emphasize the individualized nature of the program • To motivate potential participants to enroll in the program 11 See Appendix 3: Informational Meeting Agenda and Script CHAMPS Community Healthy Activities Model Program for Seniors Group informational meetings were held at the auditorium of the medical group over a 5-month period. Attendance at the meetings ranged from 14 to 42 prospective participants. Motivational Speaker and Message The motivational speaker, Dr. Walter M. Bortz, II was well-known at the medical group as a geriatrician and is the author of several books on aging.7 His message emphasized these points: • There is a link between exercise and physical functioning • The aging process is affected by lifestyle choices • Many health conditions are associated with aging - muscle weakness, joint stiffness, and shortness of breath – but are in part caused by disuse of the associated muscle, joint or cardiovascular system • There is no time to waste. Anyone at any age can benefit from starting to exercise • Participation in CHAMPS II will help answer some scientific questions. • Participation in CHAMPS II may help maintain or improve one’s ability to function as independently as possible Slide Show A slide show was presented of older adults participating in various physical activities. The central messages of the slide show were • Almost everyone can enjoy exercise; • Expensive exercise clothes are not necessary; • A wide variety of activities is available; and • Exercise can be done alone or in a group. The slide show also informed potential participants about the research study design, including what the study hoped to accomplish, the scientific importance of a randomized design, and enrollment requirements, including the time commitment for data collection. Recruitment Mechanisms It was emphasized that individuals did not have to be ready to increase their physical activity to join the program. “This is an individually tailored program. We will work with you to help you accomplish what you want to accomplish. We’d like you to enroll in the program whether or not you are ready to increase your levels of physical activity.” Attendees indicated their interest in joining CHAMPS II by responding “yes,” “no,” or “maybe” on a response card placed on each seat. Those who responded “yes” were asked to sign-up for the study and schedule an enrollment appointment. Participants who said “yes” but did not sign up were called to schedule an appointment. 7 Bortz, W. M. (1996). Dare to Be 100: 99 Steps to a Long, Healthy Life: Fireside. Bortz, W. M., & Tennant, R. (2001). Living Longer for Dummies. New York: John Wiley & Sons. 12 CHAMPS Community Healthy Activities Model Program for Seniors Telephone interviewers trained in motivational interviewing skills called attendees that answered “maybe” on the response card. These interviewers worked with See Appendix 1: Motivational potential participants to explore their hesitation to exercise, Interviewing Principles, help resolve their ambivalence about exercising, and overcome Strategies, and Skills barriers to joining the study. Enrollment Folders Staff handed out (or mailed) folders with the needed enrollment forms to each attendee who wished to enroll in the program. Staff asked attendees to complete the forms on their own and bring them to the enrollment appointment, at which time staff members would assist them with any problems they encountered with the forms. The forms included: • Information about the study • An informed consent form • A medical history and a baseline questionnaire • A physician contact form that gave permission for project staff to notify each patient’s primary care physician about the patient’s participation in the project Participant Reactions to Informational Meetings Program enrollees rated the informational meeting as “very helpful,” and stated that it encouraged them to start and “stick with” their individual physical activity regimens. During focus groups at the conclusion of the intervention, participants (especially men) noted that this meeting was an important motivating factor for joining CHAMPS.8 8 Gillis, D. E., Grossman, M. D., McLellan, B. Y., King, A. K., & Stewart, A. L. (2002). Participant's evaluations of program components of a physical activity promotion program for senior (CHAMPS II). Journal of Aging and Physical Activity, 3, 336-353. 13 CHAMPS Community Healthy Activities Model Program for Seniors Enrollment Enrollment into the CHAMPS II program consisted of attending an enrollment session, completing medical screening and a baseline assessment, and receiving a functional fitness assessment. The portions of this enrollment that are relevant to the program itself (versus the research aspects) include the medical screening and the functional fitness assessment. These are each described in this section. Medical Screening Purpose • To allow the nurse (at baseline) and exercise physiologist (at 6 and 12 months) to review and discuss with participants the self-reported medical history form, and to measure their blood pressure and heart rate • To determine if participants may proceed with the functional fitness assessment or if followup with their physician is needed prior to the functional fitness assessment • To determine if any of the functional fitness assessments need to be modified or omitted because of medical concerns about the participants • To determine if participants need additional assistance or monitoring during the assessments • To inform participants’ physical activity counselor about conditions that could affect the guidance they provide • To exclude participants who should not initiate an unsupervised light-to-moderate intensity physical activity program because of medical problems that had not been identified on the enumeration survey Self-Reported Medical History The medical screening process includes a questionnaire that allows participants to self-report their medical history. The questionnaire is more detailed than the brief enumeration medical screening and functions as a baseline health evaluation for the See Appendix 4: Medical History study. This information also helps to appropriately match Questionnaire participants and PA counselors. Notifying the Participant’s Physician Because CHAMPS II was conducted in a medical group setting, it was appropriate to ask participants for the names of their primary care medical doctors. CHAMPS staff members obtained participants’ written consent to contact their doctors. For participants with no serious, unstable medical problems (such as angina that had not been discussed with his/her physician, uncontrolled hypertension, presence of a pace maker), letters were sent to their primary care physicians notifying physicians of their patient’s participation in the study and asking them to contact the program staff if they had See Appendix 5: Medical Release any concerns or questions. The letters were hand delivered Form and Appendix 6, Notification to the physicians’ offices although certified mail could Letter to Participant’s Physician have been used to ensure delivery. 14 CHAMPS Community Healthy Activities Model Program for Seniors For those with more serious medical problems such as angina with exertion, the participant was asked to discuss the condition and with his/her physician. These individuals typically needed medical clearance from his/her physician prior to enrollment into the project. Individual cases were discussed by the geriatrician (medical director of the project), staff nurse, and staff exercise physiologist. The procedures varied slightly depending on where in the screening process it was determined that clearance was needed. The study physician, nurse, and/or exercise physiologist assisted with this process until medical clearance was obtained. Medical Screening at Subsequent Functional Fitness Assessment For the 6- and 12-month assessments, participants See Appendix 7: Script and Phone Screen to completed a brief telephone screen asking about Schedule 6-Month Functional Fitness changes in their medical history in the prior months Assessment to determine if the nurse or exercise physiologist should discuss these changes before scheduling an assessment. Participants also completed a medical history update that the exercise physiologist See Appendix 8: Medical History reviewed at the functional fitness assessment. The staff Questionnaire 6-Month Update physician and nurse were contacted as needed for questions or follow-up. Functional Fitness Assessment Purposes • To assess participants’ functional fitness through simple performance-based tests of functioning, including measures of balance, upper and lower body strength, low back/hamstring flexibility, and cardio respiratory endurance • To measure changes in fitness over time using repeated tests at 6 and 12 months • To provide feedback to participants Specific Functional Fitness Tests We used a battery of functional fitness tests developed by Guralnik et al.9 which included the standing static balance test, the eight-feet time to walk test, and chair stands, as well as three other tests. 1) Standing static balance test.9 The test requires participants to stand for ten seconds with their feet: side-by-side, semi tandem, and tandem. Note that participants only progress to the next stance if they are able to accomplish the ten seconds in the current stance. 2) Eight-feet time to walk test.9 This test measures participants’ time to walk eight feet at their usual pace. A walking aid may be used. The test is performed twice. 3) Chair stands.9 This test assesses lower body muscular strength and endurance. Participants stand up from a chair with their arms crossed at their chest and then return to a seated position. Testers note if participants need to use their hands or a walking aid to push off the chair. Participants are asked to perform the task as quickly as possible. The test measures the time to complete five repetitions. 9 Guralnik, J. M., Branch, L. G., Cummings, S. R., & Curb, J. D. (1989). Physical performance measures in aging research. Journal of Gerontology, 44, M141-146. 15 CHAMPS Community Healthy Activities Model Program for Seniors 4) Lift and reach test. This test assesses upper body muscular strength and endurance. While seated, a participant lifts a weighted box onto a 13’’ shelf as many times as possible in one minute. The standard weight used is 20 pounds for men (which may be reduced to 10, 5, or 2.5 pounds), and 10 pounds for women (which may be reduced to 5 or 2.5 pounds). The test measures the number of times a participant lifts the weight in one minute. 5) Sit and reach test. This test assesses lower back and hamstring flexibility. Participants sit on the floor (or on a table if it is difficult for them to get down or up from the floor). They extend both legs forward, bending their knees slightly and placing their feet against the back of a sit and reach box that includes a measuring stick. Participants then gently reach forward with two hands (one on top of the other), flexing their torso as far as possible without incurring discomfort. The test measures the distance of the fingertips from the feet, indicated by the measuring stick. 6) Six-minute walk. This test assesses cardiorespiratory endurance. Participants are encouraged to cover as much distance as possible at a pace at which they do not incur shortness of breath. A walking aid may be used. The test measures the distance covered in 6 minutes. NOTE: Rikli and Jones published a battery of functional fitness tests for older adults called the “Senior Fitness Test,”10 which we recommend using because testing results may be compared to national norms for age and gender. The Testing Process • Participants signed up for the functional fitness assessment at the informational meeting or at the time of a follow-up phone call • Test administrators were trained by an exercise physiologist • The assessment was held in the auditorium of the medical group and was conducted using a “station” formation which participants completed all of the tests in a specified sequence, beginning with the medical screening • The functional fitness assessment results were discussed at the participants’ personal planning session • All test results during the program period (baseline, six, and 12 months) were discussed at the end of the one-year program. NOTE: During the functional fitness assessment, staff members reviewed the completed physical activity questionnaires and other paperwork with participants. Participants received a physical See section on Physical Activity Support Mechanism: Activity Logs activity log (and tip sheet) to be completed prior to the personal planning session. 10 Rikli, R. E., & Jones, C. J. (2001). Senior Fitness Testing Manual. Champaign, Illinois: Human Kinetics. 16 CHAMPS Community Healthy Activities Model Program for Seniors Physical Activity Support Mechanisms Introduction This section presents details about the five mechanisms we used to support participants in their efforts to increase physical activity: • Personal planning session • Telephone support • Group workshops • Newsletters • Activity logs As noted above, CHAMPS is a client-centered, self-management program. A PA counselor is assigned to each participant and bears responsibility for the long-term interaction between the participant and the program, but participants make personal choices about their physical activities and goals. The support mechanisms are designed to encourage participants to find personally meaningful goals and to provide motivation, encouragement, and reinforcement for successful changes in activity, no matter how slow the progress. Participants are only required to attend the personal planning session, to receive telephone calls, and to complete activity logs (for two weeks of every month). PA counselors strongly encourage participants to attend the initial workshops that cover exercise safety and getting started; other workshops are optional based on their interest. Physical Activity Support Mechanism: Personal Planning Session Purpose • To enroll and randomize participants into intervention and wait-list control group. • To discuss participants’ needs, concerns, and preferences based on their readiness to increase their level of physical activity • To establish a relationship between the physical activity counselors and participants • To motivate participants to attend the first workshop and to discuss details of the program • To individualize initial plans based on discussion of participants’ needs, concerns, and preferences • To set an initial short-term goal for participants based on their readiness to increase their level of physical activity • To briefly review two exercise booklets that are given to participants Program Folders for Counselors Participants were assigned to specific PA counselors based on their medical needs and schedules. Participants with complicated medical histories (conditions other than controlled hypertension or arthritis) were assigned to the exercise physiologist for activity support. 17 CHAMPS Community Healthy Activities Model Program for Seniors Program folders were assembled for all participants, which helped the PA counselors provide personal support to each participant. Each folder included participants’: • Screening and demographic information • Photo • Completed physical activity questionnaire • Functional fitness assessment results • Baseline activity log • Signed informed consent • Physician contact information Preparing for the Personal Planning Session Prior to each session, PA counselors reviewed and summarized participants’ completed medical history questionnaires and the results of the functional fitness assessments. Counselors also determined participants’ contraindications to exercise, discussed concerns with the staff nurse and exercise physiologist, and selected appropriate handouts for participants. Resources available to PA counselors included: a nursing drug guide and exercise guidelines for individuals with various diseases, handouts and materials in a portable file folder brought by the counselor to the session, a private space with a table, two chairs, and enough room to demonstrate stretching exercises. NOTE: Another good resource for program staff is ACSM’s Exercise Management for Persons with Chronic Diseases and Disabilities, Second Edition11 Planning Session Agenda The planning session focused on the following topics: 1) Defining roles and responsibilities. Each PA counselor and participant discussed a partnership agreement which described each of their roles and responsibilities. These included maintaining monthly telephone contact, keeping activity logs, and completing 6- and 12-month assessments (questionnaires and functional fitness testing). 2) Review timeline. PA counselors scheduled the first telephone appointment, distributed a flyer for the first workshop, and reviewed the commitment to the program including completion of a 12-month assessment. 3) Review functional fitness assessment results. PA counselors explained the individual variability of testing results, i.e., the time to complete the chair stands could vary if they were feeling better on one day versus another day. They also explored participants’ feelings about the tests and whether there were any areas of physical functioning they were interested in focusing on during their program. 11 ACSM's exercise management for persons with chronic diseases and disabilities (2nd ed.) Champaign, Illinois: Human Kinetics (2003). 18 CHAMPS Community Healthy Activities Model Program for Seniors 4) Review completed activity logs. PA counselors reviewed and discussed with participants the activity logs that they completed for two weeks prior See Appendix 9, Activity Log, and to the appointment. They also reviewed the work effort Appendix 10, Activity Log Tips scale and activity log tip sheet again. 5) Discuss the physical activity plan. The PA counselor and participant discussed many factors as they worked together to develop a reasonable plan to increase (or to at least think about increasing) the participant’s physical activity. Depending on the PA counselor’s background and the individual’s needs, the counselor served as a resource and helped provide information for the participant to determine his/her own plan. At times, PA counselors recommended additional follow-up with the staff exercise physiologist or personal physician. 6) Readiness to change and preferences for different activities. Depending on participants’ readiness to change, PA counselors discussed participants’ interests, barriers, and options. When participants were not ready to start a new physical activity, PA counselors asked questions about participants’ barriers and discussed with them the pros and cons of changing their current level of physical activity. Participants were encouraged to come up with their own reasons for possibly increasing activity sometime in the near future. When discussing preferences for exercise, PA counselors always discussed safety issues around those exercises. • Home- versus class-based options for exercise. PA counselors had lists of community sites that offered physical activity classes for seniors. Both class-based and home-based possibilities were explored; they discussed factors such as preference for group versus individual options, location, costs, schedules, and safety concerns. • Goal setting. If participants seemed ready to begin a new activity, PA counselors discussed current guidelines for endurance, strength, flexibility, and balance. They also discussed an appropriate, step-by-step way to increase physical activity (start light, slowly increase). Participants were asked to think about the overall goal that they wanted to reach by the end of the year and about the small steps they would take to reach that goal. • Education around exercise and safety. PA counselors distributed and reviewed two exercise booklets: Exercise and Your Heart: A Guide to Physical Activity (American Heart Association 1993) and Pep Up Your Life (American Association of Retired Persons 1994). • When it was appropriate, staff members also provided handouts including tips developed by the staff nurse on topics such as exercising safely and taking precautions with certain chronic conditions. • PA counselors explained the importance of moderation, demonstrated the “talk test,” showed some modifications of exercises in one of the books, and discussed the “perceived exertion scale.”12 • PA counselors reviewed a Behavioral Contract designed to help participants come up with a self-selected goal for the following week. • Self-monitoring. Participants were asked to fill out activity logs for at least two weeks out of each month. The forms were designed to provide information to PA counselors for use in telephone support and to function as a feedback mechanism for participants. Staff members 12 Borg, G. A. V. (1982). Psychophysical bases of perceived exertion. Medicine and Science in Sports and Exercise, 14, 377-381. 19 CHAMPS Community Healthy Activities Model Program for Seniors mailed to participants each month the logs, a stamped, addressed return envelope, and a newsletter. At the end of the session, PA counselors scheduled a follow-up telephone appointment. They also encouraged participants to sign up for the first workshop about exercise basics, including safety. NOTE: The materials given to participants were the most relevant and economical available at the time. These materials were given to provide some "self-help” in a written format. Currently, we recommend having the participants obtain the free book: Exercise: A Guide from the National Institute on Aging13 which is available in English and Spanish. A Recommendation for Future Programs The CHAMPS PA counselors recommend that future programs include a follow-up session with high-risk participants and with those not ready to begin exercising. Because the initial session covers so much material, a follow-up session to review key safety issues or concerns, practice more of the self-monitoring skills, and address more thoroughly any special needs for higher risk individuals might be useful. For those not ready to begin exercising, additional one-on-one sessions would have allowed more time to work on behavioral strategies to help participants transition to a point of readiness. Physical Activity Support Mechanism: Telephone Support Purpose • To provide support, motivation, and follow-up for all participants • To acknowledge participants’ readiness to change and adopt appropriate strategies • To help participants take the steps to reach their goals • To develop strategies to overcome barriers • To discuss with participants changes in their medical condition and how these changes can affect physical activity planning Details Telephone calling also utilized techniques of “motivational interviewing.” As mentioned earlier, this is an approach that acknowledges a person’s readiness to change, is nonjudgmental, and encourages participants to make their own choices regarding the next steps in their physical activity planning and the strategies they use for overcoming barriers. Generally, participants reported that telephone support is an effective strategy for encouraging the development of a regular physical activity program. To accommodate busy schedules, we noted participants’ preferred times for receiving phone calls in each participant’s folder during the planning session. Sometimes participants were called after business hours. In some cases, phone appointments were scheduled in advance. Prior to calling, PA counselors reviewed participants’ activity logs, notes from their personal planning session (including medical concerns), and notes from previous telephone calls. 13 Available from http://www.nia.nih.gov/exercisebook/ 20 CHAMPS Community Healthy Activities Model Program for Seniors Structure of Telephone-Based Motivational Support Sessions Telephone calls followed a general outline, which changed as participants neared the end of the one-year program to focus on relapse prevention and ways to continue being physically active after the program support ended. See Appendix 11, Telephone Follow-up Form PA counselors began phone calls with open-ended questions about participants’ physical activity program and overall health and wellbeing. They listened reflectively to participants’ comments, probed for information about why their individual activity plan may or may not be working for them, and provided positive reinforcement for accomplishments. Other Topics Discussed by PA counselors Medical Concerns. PA counselors queried participants about any changes in their medical conditions and about signs and symptoms of exercise intolerance such as new or increased pain related to exercise. (NOTE: Participants brought up a wide range of medical concerns from increased joint pain with strengthening exercises to chest pain with walking). Depending on the PA counselor’s background some situations included: • Participant should talk to a physician regarding his/her medical concerns. • Staff exercise physiologist could discuss some questions/concerns regarding a participant’s exercise program. For instance, if a participant felt that certain exercises aggravated his/her arthritis, they could discuss the situation such as the type of arthritis, what exercises the person was doing, and potential modifications that could be tried or whether certain exercises should be avoided (such as during a flare-up of rheumatoid arthritis). • At times, staff could obtain permission from those with medical concerns related to their exercise program to have the exercise physiologist, nurse, and/or geriatrician work with a participant’s physician for additional recommendations. Goals, Barriers, and Motivation. PA counselors discussed participants’ recent physical activity based on their returned activity logs. Additionally, they discussed barriers to participants’ activity program and ways to overcome them. Participants were encouraged to problem solve and come up with their own strategies to overcome barriers. When participants were unable to solve their activity problems, PA counselors asked permission to offer solutions that “worked for others,” and then offered participants a menu of options. Other topics included: • Strategies to resume activity after a medical or personal interruption • Goal-setting for the following month • Arrangements for follow-up phone calls and workshop attendance NOTE: Participants discussed a wide variety of situations with PA counselors. Illness, surgery, and deaths of friends or family members were both major barriers and sometimes major motivators to exercising. Frequency of Phone Calls Event Initial telephone call Months 1-3 Months 4-12 Frequency One time, 1-2 weeks after personal planning session Every two weeks Monthly 21 CHAMPS Community Healthy Activities Model Program for Seniors Physical Activity Support Mechanism: Group Workshops Purpose • To teach the basics of exercise safety • To provide information about health and wellness topics using a step-by-step approach, practical experience, and examples of others in the group (modeling) • To have participants try different types of physical activities under supervision, with staff making appropriate corrections and suggestions • To have participants practice self-management techniques for overcoming barriers • To build self-efficacy and provide group support Format We conducted 10 monthly workshops formatted as small groups. The workshops provided participants with information about and practical tips on how to do various exercises and how to safely increase physical activity level. The workshops also provided participants with opportunities to exchange ideas with each other. NOTE: Although the workshops were optional, we strongly encouraged participants to attend the initial workshops. Specific Workshop Topics & Descriptions of Demonstrations We present here a brief summary of each of the 10 workshops. Workshop #1: EXERCISE BASICS Goal: To teach basics rules of exercising safely Content 1. Normal responses to exercise and signs and symptoms of doing “too much” exercise 2. Contraindicated movements 3. Introduction to the different types of exercises (endurance, strength, flexibility, and balance) and their benefits Practical Lessons Using Demonstrations and Practice 1. How to use the rating of perceived effort scale (RPE) and talk test 2. How to do seated/ standing, marching, and arm movements for warm up, cardiorespiratory fitness, and cool down 3. Flexibility exercises Note: Participants met in small groups to discuss overcoming barriers and setting goals. 22 CHAMPS Community Healthy Activities Model Program for Seniors Workshop #2: STRENGTH AND POSTURE Goal: To educate participants about building strength and improving posture Content Practical Lessons Using Demonstrations and Practice 1. 2. 3. 4. 5. How to identify personal motivators Problem solving Importance of posture Benefits of strength training Current recommendations for strength training 6. Key safety issues 1. Proper posture for sitting, standing, lifting, and carrying objects 2. Strengthening exercises using resistance bands and/or dumbbells 3. Stretching exercises (review from workshop #1) Note: Participants met in small groups to identify personal motivators and practice problem solving. Workshop #3: WALKING AND HEART RATE CLINIC Goal: To practice walking at a safe rate and have fun outdoors. (This workshop was held at a local sports track) Content Practical Lessons Using Demonstrations and Practice 1. How to measure heart rate and calculate target heart rate 2. The influence of medications, pacemakers, etc. on heart rate 3. Walking safely (environmental hazards, footwear, etc.) 1. How to use the rating of perceived effort scale (RPE) and talk test 2. How to measure and calculate heart rate 3. How to properly warm-up and stretch 4. Walking on the track for cardio-respiratory fitness 5. Cool down and post-exercise stretches Workshop #4: FITNESS FAIR Goal: To introduce participants to a wide range of community physical activity classes for older adults Content Practical Lessons Using Demonstrations and Practice 1. Benefits of participating in fitness classes in the community 2. Finding the right class with concerns for cost, location, intensity level, schedule, and format 3. Classes represented included: gentle aerobics, water aerobics, general conditioning, yoga 1. Several class leaders invited class members to perform typical exercises to demonstrate the nature of the class. 2. CHAMPS participants were invited to try some of the exercises 23 CHAMPS Community Healthy Activities Model Program for Seniors Workshop #5: IMPROVING BALANCE & PREVENTING FALLS Goal: To educate participants about exercises that promote balance and coordination and increase awareness of other factors associated with fall prevention Content Practical Lessons Using Demonstrations and Practice 1. Body mechanics related to balance and fall prevention 2. Facts on falling 3. A Tai chi guest instructor discussed the benefits of tai chi. 4. Staff presented a slide show on factors related to falls 1. 2. 3. 4. 5. 6. Lower body strength exercises Feet/ankle range of motion exercises Balance and coordination exercises What to do if you fall Tai chi movements How to get safely down to and up from the floor Workshop #6: FINDING TIME & MOTIVATION FOR PHYSICAL ACTIVITY Goal: To help participants evaluate how to fit appropriate physical activity into their daily lives Content Practical Lessons Using Demonstrations and Practice 1. Reframing and considering other points of view to overcoming common barriers 2. Various “tools” to motivate oneself to maintain or increase physical activity 1. 24 hour personal time study of sedentary and active behavior 2. Participants considered other points of view for overcoming common barriers 3. Participants made a physical activity contract for the next week 4. Participants practiced stretching exercises during “stretch break” Workshop #7: MAINTAINING/ACHIEVING HEALTHY DIET & BODY WEIGHT Goal: to educate participants on healthy approaches to weight management Content Practical Lessons 1. Healthy approaches to losing, gaining, and maintaining body weight 2. Relationship between diet, exercise, and weight control 3. Nutritional needs of older adults 4. Reading food labels 1. A game comparing food labels 2. A group discussion to identify two personal eating modifications that would lead to a healthier diet 24 CHAMPS Community Healthy Activities Model Program for Seniors Workshop #8: MANAGING YOUR STRESS RESPONSE Goal: to help participants identify and manage their responses to stressors Content Practical Lessons 1. Physical responses to stress 2. Methods to modify the stress response 1. 10 minute stretch break 2. Relaxation exercises 3. Note: Participants met in small groups so that they could discuss their personal stressors based on homework assignments. Workshop #9: EXERCISE OPTIONS & PROGRESSION Goal: to help participants develop strategies for incorporating regular physical activity into their daily lives and progressing toward individual goals. Content Practical Lessons 1. Ways to adapt exercise routines to meet personal needs and to keep exercise safe including proper body mechanics and effort level 2. Relationship of person’s current exercise program vs. optimal program for reaching personal goals 3. Ways to progress and to continue developing exercise program 1. Identify correct and incorrect exercise techniques including body alignment in an assortment of exercise videos 2. Follow and adapt for oneself the exercises shown in various exercise videos 3. Try some basic folk dancing steps (guest instructor) Workshop #10: YEAR 1 UPDATE & REVIEW OF PERFORMANCE SCORES Goal: to discuss individual results and present aggregate findings at the end of the program year. Content Practical Lessons 1. A review of Year 1 CHAMPS program and options for Year 2 2. Interpretation of individual data summaries from baseline, 6-month, and 1-year functional fitness assessments 3. Research findings that were presented at various conferences in a poster format 1. Reviewed functional fitness assessment summaries in relation to their own physical activity regimen 25 CHAMPS Community Healthy Activities Model Program for Seniors Physical Activity Support Mechanism: Monthly Newsletters Purpose • To provide participants with the latest information about physical activity • To reinforce information provided during workshops • To remind participants of workshop dates and topics, upcoming program events, and/or related presentations at the medical group • To keep participants interested in the program and their own physical activity and help them feel part of an organized program • To motivate participants with stories of individual participants’ successes and challenges Details The newsletters were sent out by mail each month with the activity log. This monthly mailing provided regular contact with the participants. Staff members often added brief hand-written notes to the newsletter. In addition to the above, the newsletters’ content included myth busters and tips of the month about exercise and health. We endeavored to make the newsletter understandable to participants with a range of reading levels. To this end, the format included pictures, logos, cartoons, large print and plain font styles, and also was See Appendix 12: Sample Newsletter printed with high contrast (black text on very light colored paper) and limited to two sides of one page. Physical Activity Support Mechanism: Activity Logs Purpose • To enable participants to self-monitor their physical activities • To help participants set personal goals • To facilitate PA counselors’ telephone support discussions with participants about their goals and their progress in achieving their goals Details Participants recorded their physical activities in logs during one 2-week period each month. The initial (baseline) log was completed prior to the personal planning session. During the planning session, PA counselors reviewed the first log for accuracy. During the year, logs were mailed to participants each month along with the newsletter, See Appendix 9, Activity Log, and workshop announcements, and a cover letter with Appendix 10, Activity Log Tips personal notes. Use of Activity Logs by PA Counselors • Activity logs were used during telephone support calls to compare participants’ current and past levels of activity and to discuss with participants their success in meeting their goals for that time period. 26 CHAMPS Community Healthy Activities Model Program for Seniors • Prior to mailing the blank logs, PA counselors usually wrote motivational notes on the logs of participants who were difficult to reach by phone or who seemed to need some additional support. Challenges of Using Activity Logs PA counselors found that it was often difficult for participants to quantify the amount of physical activity they performed. For example, many participants reported that they were “busy” all day and regarded as “physical” some sedentary activities such as “driving the car to the supermarket.” Also, a few participants did not fill out the logs and/or did not return them in a timely manner. In these cases the information was collected by phone. NOTE: Although some participants felt that completing activity logs was a burdensome task, others reported that the logs provided motivation to stay active.14 14 Gillis, D. E., Grossman, M. D., McLellan, B. Y., King, A. K., & Stewart, A. L. (2002). Participant's evaluations of program components of a physical activity promotion program for seniors (CHAMPS II). Journal of Aging and Physical Activity, 3, 336-353. 27 CHAMPS Community Healthy Activities Model Program for Seniors Feedback and Diffusion Participant Feedback We asked participants for input on various aspects of the program after they completed the CHAMPS II program. Eighty participants completed a survey to rate how helpful different components of the program (such as activity logs, newsletters, and the informational meeting) were for starting or maintaining their physical activity program. In addition, 20 participants took part in a focus group in which they were asked about the most and least useful aspects of the program. Overall, survey participants rated as most helpful staff members’ personal attention, encouragement and telephone calls, the informational meeting, and the personal physical activity planning session. Focus group participants also rated personal attention by staff members as one of the program’s most helpful features. The aspects of personal attention that seemed most helpful to participants were one-on-one contact with and positive feedback and verbal support from staff members, as well as staff members’ nonjudgmental approach. For details, see Gillis, Grossman, McLellan, King and Stewart.15. Subsequent Program Given the success of CHAMPS II, the researchers obtained a grant from The California Endowment to diffuse the program by working with three different community sites in and around San Francisco, California. The goal of this diffusion research is to adapt and implement the CHAMPS II program to meet the needs and resources of individuals and diverse communities. Please see our web site at www.ucsf.edu/champs/ for more information. 15 Gillis, D. E., Grossman, M. D., McLellan, B. Y., King, A. K., & Stewart, A. L. (2002). Participant's evaluations of program components of a physical activity promotion program for seniors (CHAMPS II). Journal of Aging and Physical Activity, 3, 336-353. 28 CHAMPS Community Healthy Activities Model Program for Seniors Appendix 1: Motivational Interviewing Principles, Strategies, and Skills Motivational interviewing is a directive, client-centered counseling style for eliciting behaviour change by helping clients to explore and resolve ambivalence. It is most centrally defined not by technique but by its spirit as a facilitative style for interpersonal relationship (Rollnick & Miller, 1995). CHAMPS II adopted the “spirit” of motivational interviewing as the primary style behind the interpersonal relationships between program staff and program participants. Staff members were trained in the techniques and strategies that are used to promote productive interactions with program participants, with “a focus on exploring and resolving ambivalence, which is a key obstacle to change.” (Rollnick & Miller, 1995) How is the “spirit” of motivational interviewing used to encourage behavior change such as increased physical activity? Paraphrasing from Rollnick and Miller’s 1995 article, the key points are: 1. Staff help participants identify their own values and goals to evoke motivation to change. 2. It is the participant’s responsibility to articulate the costs and benefits of taking on new activities or changing behaviors. The staff task is to facilitate discussion of both sides of the dilemma and guide participant toward a resolution of the ambivalence, hopefully in a positive direction. 3. Direct persuasion, advice giving, argumentation, and aggressive confrontation are avoided as methods to encourage change. While there is a place for advice-giving when a participant asks for suggestions, motivational interviewing is based on an eliciting style. 4. Staff must be very attentive and responsive to participant’s motivational signals in order to support but not push for change. If a participant makes comments that imply resistance, that may be a sign that a staff member has assumed greater participant readiness to make a change than is the reality. 5. The relationship between staff and participant is a partnership, with the staff respecting each participant’s freedom to make choices, regardless of the consequences. The only caveat occurs when a participant reports excessive physical activity that could be unsafe due to medical and physical circumstances, such as pre-existing cardiac conditions. In such an instance, the participant is strongly advised to make changes to ensure safety. Behaviors that are characteristic of the motivational interview style can be learned and skills will develop with practice. The most important techniques include: 1. Reflective listening to understand what a participant is trying to communicate. 2. Expressing support and acceptance. 3. Eliciting and selectively reinforcing any mention of positive change from the participant. 4. Checking on the participant’s readiness to make changes, making sure not to get ahead of the participant or make assumptions about readiness, willingness, and ability to make changes. 5. Encouraging self-determination and problem-solving. “You’re probably the best judge of what will work for you.” “What do you think about this situation?” CHAMPS staff when discussing physical activity behavior with participants used open-ended questions, affirmations, reflective listening, and summaries, recalled with the acronym “OARS”. These techniques are taught in many communication courses and are useful tools for all types of interpersonal interactions. • • For more information on motivational interviewing, refer to: www.motivationalinterview.org Rollnick, S. and Miller, W. R. (1995). What Is Motivational Interviewing? Behavioural and Cognitive Psychotherapy, 23, 325-334. 29 CHAMPS Community Healthy Activities Model Program for Seniors • • Or read one of William R. Miller and Stephen Rollnick’s books on the subject: Miller, W. R. & Rollnick, S. (1991). Motivational Interviewing: Preparing People to Change Addictive Behavior. New York: The Guilford Press. Miller, W. R.. & Rollnick, S. (2002). Motivational Interviewing: Preparing People for Change (2nd ed.). New York: The Guilford Press. 30 CHAMPS Community Healthy Activities Model Program for Seniors Appendix 2: Initial Contact Letter Date Name Address Dear: As a member of the [name of sponsoring medical group or agency], you have the opportunity to participate in an exciting new program and research study. You have been randomly selected to take part in the first phase of the study, a short telephone interview about the health and health practices of adults 65 years of age and older. This health survey is being conducted by researchers at [name of institution and sponsoring agency]. You may have read about it in a recent issue of [medical group newsletter]. A copy of the article is enclosed. In a few weeks, you will be called by an interviewer who will invite you to complete a 15 minute survey over the telephone. If you decide to complete the interview you will be making a valuable scientific contribution. Your participation in this survey will increase our understanding of the health practices and needs of older adults. In addition, the interview will help determine if you are eligible for the second phase of the project, a new program that may help you improve your health. The program is free and is especially designed to meet the needs of older adults. I am very enthusiastic about this program and I encourage you to take part in the short survey. However, please note that your participation in the telephone interview is voluntary. You may refuse to continue with the phone call at any time. I hope you will choose to take part in this important project. Sincerely, [Name of physician or other well-known person in community] Encl. 31 CHAMPS Community Healthy Activities Model Program for Seniors Appendix 3: Informational Meeting Agenda and Script I. II. III. IV. V. Introduction A. Welcome • Introductions of project staff • General information (such as refreshments and location of restrooms) B. Purpose of Meeting • by completing the telephone survey, you have already made an important contribution (thank you!) • next hour, who we are and what the CHAMPS program is about • make informed decision about whether or not to take part in this program • when making decision about CHAMPS you will fall into 1 of 3 categories: YES -- sign me up now NO -- this program is not for me MAYBE -- I need to think about this some more • at end of meeting we will ask you to complete a card and turn it in, the info you provide will be beneficial • draw for door prize C. Sequence of Meeting To start off our meeting... • -- who and what is CHAMPS -- health benefits of physical activity • -- slide show on what we mean by physical activity • -- specifics of the CHAMPS program • -- importance of physical activity • Complete response forms/door prize • Signup for functional fitness assessment • Throughout please stop and ask us questions or clarify meaning • Any questions? CHAMPS: General Aims and Scientific Importance Health Benefits of Physical Activity (brief talk) What is Physical Activity (slide show) CHAMPS: Specifics of the Program We’ve given you a lot of information on the benefits of physical activity and now I’d like to tell you more about the specifics of the CHAMPS program. You may be asking yourself, “What will I learn if I take part in CHAMPS?” 32 CHAMPS Community Healthy Activities Model Program for Seniors Slide 1: What Will I Learn? • Physical activity can be fun • How to: Exercise safely Motivate yourself Overcome barriers Set goals Maintain independence As discussed earlier, CHAMPS is... Slide 2: Personalized Physical Activity Program • You choose the activity • You decide if home or class based • We will help you get started • We will help you modify your program (if necessary) • We will help you maintain your program In this program we will work with you at your own pace. You will start slowly... So that your program is safe... Slide 3: CHAMPS Program Start slowly, progress gradually • Safe • Comfortable • Enjoyable 33 CHAMPS Community Healthy Activities Model Program for Seniors The main features of the CHAMPS program include: Slide 4: Main Features of Program • Personal counseling: This includes working one-onone with your physical activity counselor to plan your program. • Telephone follow-up: You receive this from your physical activity counselor, who will check in to make sure everything is ok with your program and answer any questions you may have. • Group workshops: Our staff will conduct these monthly on specific topics of interest such as exercise safety, proper nutrition, and stress management. • Latest information: We will also keep you up to date on key research related to physical activity and older adults. So those are the main features of the CHAMPS program. Now, I’d like to take you through the program step-by-step. After hearing us speak today, if you decide you want to take part in CHAMPS the next step would be to sign up for a functional fitness assessment. When you sign up for this meeting we will give you some materials to complete beforehand. These include: an informed consent, medical history, and an activities questionnaire. At the meeting you will also participate in some simple physical measures. (Demonstrate) These are simple measures of your physical abilities such as how many times you can sit and stand in 1 minute, how long it takes you to walk a short distance, and how far you can walk in 6 minutes. Slide 5: Sequence of Events • • • ⇒ ⇒ ⇒ ⇒ Telephone Survey (already completed) Informational Meeting Functional Fitness Assessment informed consent medical history questionnaire physical measures 34 CHAMPS Community Healthy Activities Model Program for Seniors After the Functional Fitness Assessment is the Personal Planning Session where you will meet oneon-one with your physical activity counselor. During this meeting you will be randomly assigned to either the intervention group or a wait-list control group. [Note: meeting facilitator discusses methods and purpose of randomization, including differences between groups and benefits to participants.] Questions? OK, lets move on. Who can participate in the CHAMPS Program? Slide 6: Who Can Participate Member of HMO • Participating in little or no physical activity or Just started physical activity • Planning to stay in the South Bay • Willing to be randomized OK, so if you decide to take part in CHAMPS, this is what you can expect from our staff: Slide 7: What to Expect from CHAMPS Staff? • Personalized physical activity program (we will work with you to design a personalized....) • Personal attention from our trained staff • Latest information (we will provide the latest information on physical activity for older adults and the health benefits of regular exercise) • Special workshops • Confidentiality • Feedback 35 CHAMPS Community Healthy Activities Model Program for Seniors Since CHAMPS is a partnership between our staff and you, this is what we will expect from you: Slide 8: What to Expect from You? • Minimum 1 year commitment • Take part in all assessments • Provide feedback VI. Motivational Speaker VII. Invitation to fill out response card and sign up for next step. VIII. Thank you for attending 36 CHAMPS Community Healthy Activities Model Program for Seniors Appendix 5: Medical Release Form As a courtesy to your primary care physician, we would like to inform him/her about your participation in CHAMPS. If this is agreeable to you, please provide his/her name and sign below: Primary Care Physician’s Name: ______________________________________ _____________________________________Date: ________/________/______ Signature month day year 44 CHAMPS Community Healthy Activities Model Program for Seniors Appendix 6: Notification Letter to Participant’s Physician Name Address Date Dear Dr. [name]: Your patient, [patient name], has taken the initiative to improve her health by enrolling in the Community Healthy Activities Model Program for Seniors (CHAMPS). CHAMPS is a research project funded by [funding source] and is being conducted at [clinic or agency name] by [project director name and institution]. In addition, [physician name] of [clinic] is the medical director of the study. Attached is a summary sheet explaining the CHAMPS program. One of my roles in the CHAMPS project is to serve as a liaison between the [clinic or agency name] physicians and the CHAMPS staff. . As an exercise physiologist, I will provide physical activity counseling for many of the participants, especially those with chronic medical conditions. In preparation for this program, your patient has completed a medical history form which has been reviewed by our staff nurse and [physician name]. If you have any medical concerns about this person's participation in the study, please call me at [clinic or agency name] (325-6185) or at the CHAMPS main office (323-0601) prior to [date of your patient's enrollment meeting]. Thank you for your assistance in this endeavor. Should you have any questions, please do not hesitate to contact me or the CHAMPS staff. Sincerely, Name Title 45 CHAMPS Community Healthy Activities Model Program for Seniors Appendix 7: Script and Phone Screen to Schedule 6-Month Functional Fitness Assessment CHAMPS Community Healthy Activities Model Program for Seniors SCRIPT TO SCHEDULE 6-MONTH ASSESSMENT *Need participants name, address, phone number, & enrollment appointment book *Make notes on telephone contact sheet , This is from CHAMPS. I am calling to set up an appointment for Hello your six-month assessment. This assessment will consist of questionnaires and physical functioning tests just like those you completed when you joined the study. You will receive $10 for completing the questionnaires and tests. Before we schedule a time, I need to ask you a brief set of questions to check if your medical condition has changed since you enrolled in the study. This should only take a couple of minutes. Is this a good time? If YES-- Continue with PHONE SCREENING FOR 6-MONTH ASSESSMENT If NOT convenient time--Schedule time to call back If REFUSE- Thank them for their time, hang up and alert project director After completion of screening questions: If YES to any of the screening questions, inform them that the exercise physiologist will be calling them to discuss the information in greater detail before scheduling. If NO to ALL screening questions, schedule for testing: Thanks for answering those questions. It seems like it would be O.K. for you to come in for the physical functioning tests. Would you like to get your calendar to set up a time to come to the clinic? If YES -- continue with script If NO -- set up time to call back Testing will be conducted at the same location at the PAMF auditorium above Urgent Care. Your appointment should last approximately one hour. I will send you two questionnaires to complete one to two days before your appointment. Please bring the completed questionnaires with you to your . If you appointment. Do you have any questions? I would like to verify that your address is have any questions between now and your appointment, you may contact me at the CHAMPS office at 3230601. Thank you very much for your time. 46 CHAMPS Community Healthy Activities Model Program for Seniors QM6 ID Date Interviewer's Initials CHAMPS Community Healthy Activities Model Program for Seniors PHONE SCREENING FOR 6-MONTH ASSESSMENT Instructions: Please answer yes or no to the following questions. Your responses will be regarded as strictly confidential. 1. Are you currently recovering from any injury or surgery? YES NO 2. Have you been diagnosed with any new medical condition in the past 6 months such as high blood pressure or diabetes? YES NO 3. Have you been diagnosed with any heart beat irregularities, heart condition, or stroke in the past 6 months? YES NO 4. Have you been diagnosed with congestive heart failure in the past 6 months? YES NO 5. Have you experienced any chest pain in the past 6 months? YES NO 6. Have you experienced any loss of consciousness in the past 6 months? YES NO 7. Has your doctor restricted your physical activity in the past 6 months? YES NO 8. Have you been hospitalized in the past 6 months? YES NO **If YES to any of the above questions, inform them that that staff exercise physiologist or nurse will be calling them to discuss the information in greater detail before scheduling **If NO to all questions, schedule for testing using SCRIPT TO SCHEDULE 6-MONTH ASSESSMENT Interviewer's Comments: 47 CHAMPS Community Healthy Activities Model Program for Seniors Appendix 10: Activity Log Tips The following is a list of tips to help you fill out the activity logs effectively so that we obtain the research information needed. A. Monday – Date: ____/____/____ B. Class Activity#1: ____________________________ Activity#2: ____________________________ Activity#3: ____________________________ Comments: N N N Y Y Y C. Time (min.) _______ _______ _______ D. Effort _______ _______ _______ A) Activity: • Specify exact activity (e.g. walking, stretching, stationary bike). Please do not write in just the word “exercise”. • Even though these activities may be tiring do not record the following: Shopping / Errands Work Meditation / Stress management Driving • Do record walking to and from the grocery store, work, or to lunch if it is clearly stated and does not include time spent shopping, working, or eating lunch. • Physical therapy: ♦ Only record the times when you are doing the actual exercises by yourself. ♦ Do not record the physical therapy sessions with your physical therapist. • Do not group unrelated activities together such as gardening and housework, write as two separate activities since we need to code each activity separately. • Do group similar activities together such as vacuuming and cleaning windows as housework. If you are unclear then state the activities separately. B) Class: • Please remember to circle Y=yes or N=no for whether the activity is a class you are taking or not. Exercising to a video or TV program is not considered a class. C) Time: • Remember to fill in the amount of time in minutes doing a particular activity. ♦ Avoid writing in all day. • Estimate the time to the best of your ability. D) Work Effort Remember to: • Use scale • Estimate work effort for overall activity instead of giving ranges. 54 CHAMPS Community Healthy Activities Model Program for Seniors Appendix 11: Telephone Follow-up Form CHAMPS Telephone Follow-Up – 1st Contact Name: ____________________ Counselor: ________________ Best Time: ________________ Id#: _________________ Date: ____/____/____ Phone #: _____________ Time start: ___________ Introduction How are you doing? (reflective listening) How is your physical activity program doing? (reflective listening) What changes in your health have you noticed during the last ______ weeks? (reflective listening) Pain Do you have any pain associated with exercise? YES NO When do you have this pain? Where is the pain located? Can you describe the pain? How severe is the pain (1 = mild, 5 = moderate; 10 = severe) How long have you had the pain? Does the pain prevent you from doing your exercise? YES Have you sought medical treatment for your pain? YES NO If YES, for how long? NO If YES, what? Goals, Barriers & Motivation What goals have you set for yourself this week? (reflective listening) -- Discuss Contract Do you foresee any obstacles for the next 2 weeks that may make exercise difficult? YES If YES, what is the obstacle? Will it prevent you from exercising? YES NO If YES, for how long? NO Have you thought about how to alter, adapt, avoid this obstacle to maintain your exercise program? If currently NOT exercising: When was the last time you exercised? 55 CHAMPS Community Healthy Activities Model Program for Seniors What has prevented you from exercising? What is your confidence in your ability to restart a regular exercise program? 0 to 100% _________ Do you have any ideas to help you start your exercise program? Do you feel an additional phone call would be helpful 1 to 2 days after you restart your program? Is there anything else you would like to discuss with me at this time? 56 CHAMPS Newsletter Community Healthy Activities Model Program for Seniors March 1998 Vol. 2/ No. 12 CHAMPS Workshop Dates Workshop #9: Exercise Options and Progression Rain or shine, come join us on: Wednesday, March 18th from 2:30 to 4:00 PM • Try some new moves with a local folk dance instructor. • Review safety issues and critique exercise videos available at the public library. • Determine if your current physical activity program is optimal for reaching your goals. • Identify ways to increase strength, endurance, flexibility and balance. Please call by: Tuesday, March 17th to sign-up. Just a reminder... Workshop #10 is the last workshop in our series. At this workshop we will provide you with your individual physical evaluation scores. Workshop #10 will be held several times throughout the next few months. Sign up will occur once your 24-Month Evaluation is complete. If you have any questions about this workshop, please contact your exercise counselor at the CHAMPS office. Clinic Lectures The clinic’s Education Department is offering the following lecture: March 11th: Now Where Did I Put My Keys? 2:30 to 4:30 PM This lecture will take place in the auditorium. To register call: (xxx)xxx-xxxx. CHAMPS Headliner Group A participants may recognize the name of our headliner – Participant Name. He was highlighted two years ago for his enthusiasm and dedication to staying fit so that he could keep playing golf. Now, at a young age of 92, this participant has once again motivated and impressed us all. This fall, he had a tough time with pneumonia. The rains were also making it difficult to get out there and golf. One day he noticed that his watch band was slipping around on his wrist. He said, “ I knew I must be getting weak all over and I needed to do something about it.” This participant took action and signed up for a Foothill College exercise class - the first exercise class of his life! Now he is using exercise machines for upper and lower body strengthening, plus using the treadmill and stationary bike 3 to 4 times per week. After a workout last week, he still had the energy to go hit a bucket of balls. He’ll be ready for golf this season and rumor has it that he’ll be showing off some new strong, rippling muscles! CHAMPS Myth-Buster of the Month True or False? If you haven’t been able to fit more physical activity into your life by now, it’s never going to happen. See back page for answer 401 Burgess Drive, Suite 405, Menlo Park, CA (650) 323-0601 Tip of the Month: The Surgeon General’s Recommendations for Physical Activity Experts agree that for better health, physical activity should be performed regularly. While this is old news for CHAMPS participants, we thought we’d share the recommendations from Physical Activity and Health, A Report of the Surgeon General, 1996. * You’re never too old to exercise. * People of all ages should include a minimum of 30 minutes of moderate intensity exercise on most, if not all, days of the week. * Greater health benefits can be obtained by taking part in physical activity of more vigorous intensity or of longer duration (as long as medical concerns are addressed). * Supplement endurance activities with strength-developing exercises at least 2 times a week. Strengthening exercises help to improve musculoskeletal health, maintain indepen-dence in performing the activities of daily life, and reduce the risk of falling. How can you reach these goals? The Surgeon General’s report suggests you start with what you are currently doing and slowly add activity to each of your days. In Aesop’s classic fable, it’s the tortoise that wins the race; our CHAMPS workshops have emphasized this same “slow but steady” approach to reaching your fitness goals. Limit your progression to 10% a week. For example, if you now walk 20 minutes a day, try 22 minutes a day next week. There are four approaches to increasing your activity: 1) Add new activities (one at a time) to balance your fitness program. Try dance, tai chi, check out a community class, go walking with the Sierra Club. The opportunities are endless! 2) Increase the frequency of the activity you are currently doing. Moderate level (work effort from 11 to 13) endurance, flexibility and balance activities can be done every day of the week. Strength activities are usually recommended 2-3 times a week (more often is “O.K.” if the intensity is light). 3) Increase the intensity (work effort) of the activity. For instance, try walking slightly faster. Check with your physician before progressing to a vigorous effort (work effort 14 and above). 4) Increase the duration of the activity. For example, swim an extra lap or gently hold a stretch a few more seconds. If you have any questions about increasing your activity, give us a call at the CHAMPS office. Say “Cheese” for Research! We need photos or slides of you, your family, or friends involved in vigorous physical activities such as tennis, basket-ball, skiing, hiking, cycling or military exercises to help illustrate one of our staff’s research paper on lifetime physical activity. She will present this paper at the annual meeting of the Society of Behavioral Medicine. Your old photos from the 1920’s through the 1970’s would be especially welcome. Please call the CHAMPS office at 323-0601 as soon as possible. She will make a copy of your photo and return the original. CHAMPS Myth-Buster of the Month False! Research has shown that the amount of progress people make as they follow health promotion programs such as CHAMPS is directly related to how ready they were to make a change at the start of the program. If you felt uncertain about becoming physically active when you joined CHAMPS, it might take you a long time to make beneficial changes. HOWEVER, don’t give up! Research also has shown a considerable “delayed effect” for health promotion programs. In other words, when you’re ready, you’ll be able to fit in more activity. Read the CHAMPS Headliner for an example of this! ToC Fat-Related Diet Habits Questionnaire I. Interviewer Administered Format Please consider your food choices over the past MONTH In the past month… 1. Usually Often Sometimes Rarely or Never REF 1 2 3 4 ref How often did you remove the skin? (READ 1 – 4) 1 2 3 4 ref Did you eat red meat such as beef, pork or lamb? 1 YES When you ate red meat 2 NO 2a. How often did you trim all 3 NA/REF the visible fat? (READ RESPONSES IF NECESSARY) 1 2 3 4 ref 1 2 3 4 ref 1 2 3 4 ref 1 2 3 4 ref Did you eat spaghetti or noodles? 1 YES When you ate spaghetti or noodles 2 NO 6a. Were they plain, or with a red 3 NA/REF or tomato sauce without meat? 1 2 3 4 ref Did you eat cooked vegetables? 1 YES When you ate cooked vegetables 2 NO 7a. How often did you add butter, 3 NA/REF margarine or other fat? 1 2 3 4 ref 1 2 3 4 ref Did you eat chicken? 1 YES 2 NO 3 NA/REF When you ate chicken 1a. How often was it fried? (READ 1 – 4) 1b. 2. 3. 4. 5. 6. 7. Did you eat ground meat? 1 YES When you ate ground meat 2 NO 3a. How often was it extra lean? 3 NA/REF Did you eat fish? 1 YES 2 NO 3 NA/REF When you ate fish 4a. How often was it fried? Did you have at least one vegetarian dinner or main meal – that is, without meat, fish, eggs or cheese? 1 YES 5a. How often did you have a 2 NO vegetarian dinner? 3 NA/REF 7b. How often were they fried? 1 In the past month… 8. 9. 10. 11. 12. 13. 14. Usually Often Rarely or Never REF Did you eat potatoes? 1 YES When you ate potatoes 2 NO 8a. How often were they fried, like 3 NA/REF French fries or hash browns? Sometimes 1 2 3 4 ref Did you eat baked or boiled potatoes? 1 YES When you ate baked or boiled 2 NO potatoes 3 NA/REF 9a. How often did you eat them without any butter, margarine or sour cream? 1 2 3 4 ref Did you eat green salads? 1 YES When you ate green salads 2 NO 10a. How often did you use no 3 NA/REF dressing? 1 2 3 4 ref 10b. How often did you use low-fat or non-fat dressing? 1 2 3 4 ref Did you eat bread, rolls or muffins? 1 YES When you ate bread, rolls or muffins 2 NO 11a. How often did you eat them 3 NA/REF without butter or margarine? 1 2 3 4 ref Did you drink milk or use milk on cereal? 1 YES When you had milk 2 NO 12a. How often was it 1% or nonfat 3 NA/REF milk? 1 2 3 4 ref Did you eat cheese, including on sandwiches or in cooking? 1 YES When you ate cheese 2 NO 13a. How often was it specially-made 3 NA/REF low-fat cheese?? 1 2 3 4 ref 1 2 3 4 ref Did you eat dessert? 1 YES When you ate dessert 2 NO 14a. How often did you eat only 3 NA/REF fruit? 2 In the past month… 15. 16. 17. 18. 19. 20. 21. 22. Usually Often Rarely or Never REF Did you eat home-baked cookies, cakes or pies? 1 YES When you ate home-baked cookies, 2 NO cakes or pies 3 NA/REF 15a. How often were they made with less butter, margarine or oil than the recipe called for? Sometimes 1 2 3 4 ref Did you eat frozen desserts like ice cream or sherbet? 1 YES When you ate frozen desserts 2 NO 16a. How often did you choose 3 NA/REF frozen yogurt, sherbet or low-fat or non-fat ice cream? 1 2 3 4 ref Did you eat snacks between meals? 1 YES When you ate snacks between meals 2 NO 17a. How often did you eat raw 3 NA/REF vegetables or fresh fruit? 1 2 3 4 ref Did you sauté or pan fry any foods? 1 YES When you sautéed or pan fried foods 2 NO 18a. How often did you use Pam® or 3 NA/REF other non-stick spray instead of oil, margarine or butter? 1 2 3 4 ref Did you use mayonnaise or mayonnaise-type spread? 1 YES When you used mayonnaise or 2 NO mayonnaise type spread 3 NA/REF 19a. How often did you choose lowfat or nonfat types? 1 2 3 4 ref Did you eat breakfast? 1 YES When you ate breakfast 2 NO 20a. How often did you have fresh 3 NA/REF fruit? 1 2 3 4 ref Did you eat lunch? 1 YES When you ate lunch 2 NO 21a. How often did you have one or 3 NA/REF more vegetables, not including potatoes or salad? 1 2 3 4 ref At dinner (or your main meal), how often did you have two or more vegetables, not including potatoes or salad? 1 2 3 4 ref 3 Fat-Related Diet Habits Questionnaire II. Example of Self-Administered Format 4 Fat-Related Diet Habits Questionnaire Eating Pattern Score Sheet QUESTION RESPONSE Factor 1 (Substitution) 10b 12a 13a 15a 16a 18a 19a _______ _______ _______ _______ _______ _______ _______ Total _______ + number answered = Factor 1 score _____ 1b 2a 3a _______ _______ _______ Total _______ + number answered = Factor 2 score _____ 1 a* 4 a* 7b* 8 a* _______ _______ _______ _______ Total _______ + number answered = Factor 3 score _____ 5a 14a 17a _______ _______ _______ Total _______ + number answered = Factor 4 score _____ 6a 7 a* 9a 10a 11a _______ _______ _______ _______ _______ Total _______ + number answered = Factor 5 score _____ Factor 2 (Modify meat) Factor 3 (Avoid frying) Factor 4 (Replacement) Factor 5 (Avoid fat) ∑ Factors ___________ = _____________ 5 *Reverse order scoring (done as follows: 1=4, 2=3, 3=2, 4=1). For example, a recorded score of 1 will be noted as a 4 on this score sheet, a 2 will be scored as a 3, and so on. Items 14, 17, 20, 21, and 22 are used for vegetable-related dietary patterns. See: Satia JA, et al, Nutrition, 18: 247-54, 2002, for more information. Summary score 5 References: 1. Kristal AR, Shattuck AL, and Henry HJ. Patterns of dietary behavior associated with selecting diets low in fat: reliability and validity of a behavioral approach to dietary assessment. J Am Diet Assoc 1990;90:214-20. 2. Kristal AR, White E, Shattuck AL, et al. Long-term maintenance of a low-fat diet: durability of fat-related dietary habits in the Women's Health Trial. J Am Diet Assoc 1992;92:553-9. 3. Kristal AR, Beresford SA, and Lazovich D. Assessing change in diet-intervention research. Am J Clin Nutr 1994;59:185S-9S. 4. Glasgow R, Perry JD, Toobert DJ, and Hollis JF. Brief assessments of dietary behavior in field settings. Addict Behav 1996;21:239-47. 5. Shannon J, Kristal AR, Curry SJ, and Beresford SA. Application of a behavioral approach to measuring dietary change: the fat- and fiber-related diet behavior questionnaire. Cancer Epidemiol Biomarkers Prev 1997;6:355-61. 6. Kristal AR, Shattuck AL, and Patterson RE. Differences in fat-related dietary patterns between black, Hispanic, and white women: Results from the Women's Health Trial Feasibility Study in Minority Populations. Public Health Nutr 1999;2:273-6. 7. Kristal AR, Curry SJ, Shattuck AL, Feng Z, and Li S. A randomized trial of a tailored, selfhelp dietary intervention: The Puget Sound Eating Patterns Study. Prev Med 2000;31:380-9. 6 ToC ToC SF-36 QUESTIONNAIRE Name:____________________ Ref. Dr:___________________ ID#: _______________ Date: _______ Age: _______ Gender: M / F Please answer the 36 questions of the Health Survey completely, honestly, and without interruptions. GENERAL HEALTH: In general, would you say your health is: Excellent Very Good Good Fair Poor Compared to one year ago, how would you rate your health in general now? Much better now than one year ago Somewhat better now than one year ago About the same Somewhat worse now than one year ago Much worse than one year ago LIMITATIONS OF ACTIVITIES: 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? Vigorous activities, such as running, lifting heavy objects, participating in strenuous sports. Yes, Limited a lot Yes, Limited a Little No, Not Limited at all Moderate activities, such as moving a table, pushing a vacuum cleaner, bowling, or playing golf Yes, Limited a Lot Yes, Limited a Little No, Not Limited at all Lifting or carrying groceries Yes, Limited a Lot Yes, Limited a Little No, Not Limited at all Climbing several flights of stairs Yes, Limited a Lot Yes, Limited a Little No, Not Limited at all Climbing one flight of stairs Yes, Limited a Lot Yes, Limited a Little No, Not Limited at all Bending, kneeling, or stooping Yes, Limited a Lot Yes, Limited a Little No, Not Limited at all Walking more than a mile Yes, Limited a Lot Yes, Limited a Little No, Not Limited at all Walking several blocks Yes, Limited a Lot Yes, Limited a Little No, Not Limited at all Walking one block Yes, Limited a Lot Yes, Limited a Little No, Not Limited at all Bathing or dressing yourself Yes, Limited a Lot Yes, Limited a Little No, Not Limited at all PHYSICAL HEALTH PROBLEMS: 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? Cut down the amount of time you spent on work or other activities Yes No Accomplished less than you would like Yes No Were limited in the kind of work or other activities Yes No Had difficulty performing the work or other activities (for example, it took extra effort) Yes No EMOTIONAL HEALTH PROBLEMS: 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)? Cut down the amount of time you spent on work or other activities Yes No Accomplished less than you would like Yes No Didn't do work or other activities as carefully as usual Yes No SOCIAL ACTIVITIES: Emotional problems interfered with your normal social activities with family, friends, neighbors, or groups? Not at all Slightly Moderately Severe Very Severe PAIN: How much bodily pain have you had during the past 4 weeks? None Very Mild Mild Moderate Severe Very Severe During the past 4 weeks, how much did pain interfere with your normal work (including both work outside the home and housework)? Not at all A little bit Moderately Quite a bit Extremely ENERGY AND EMOTIONS: These questions are about how you feel and how things have been with you during the last 4 weeks. For each question, please give the answer that comes closest to the way you have been feeling. Did you feel full of pep? All of the time Most of the time A good Bit of the Time Some of the time A little bit of the time None of the Time Have you been a very nervous person? All of the time Most of the time A good Bit of the Time Some of the time A little bit of the time None of the Time Have you felt so down in the dumps that nothing could cheer you up? All of the time Most of the time A good Bit of the Time Some of the time A little bit of the time None of the Time Have you felt calm and peaceful? All of the time Most of the time A good Bit of the Time Some of the time A little bit of the time None of the Time Did you have a lot of energy? All of the time Most of the time A good Bit of the Time Some of the time A little bit of the time None of the Time Have you felt downhearted and blue? All of the time Most of the time A good Bit of the Time Some of the time A little bit of the time None of the Time Did you feel worn out? All of the time Most of the time A good Bit of the Time Some of the time A little bit of the time None of the Time Have you been a happy person? All of the time Most of the time A good Bit of the Time Some of the time A little bit of the time None of the Time Did you feel tired? All of the time Most of the time A good Bit of the Time Some of the time A little bit of the time None of the Time SOCIAL ACTIVITIES: 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.)? All of the time Most of the time Some of the time A little bit of the time None of the Time GENERAL HEALTH: How true or false is each of the following statements for you? I seem to get sick a little easier than other people Definitely true Mostly true Don't know Mostly false Definitely false I am as healthy as anybody I know Definitely true Mostly true Don't know Mostly false Definitely false I expect my health to get worse Definitely true Mostly true Don't know Mostly false Definitely false My health is excellent Definitely true Don't know Mostly false Definitely false Mostly true ToC Sickness n o ti a z y i r p o o C uth w a Profile e t i ou v Re with e s u t o n o D Impact tm Copyright © The Johns Hopkins University 1977 All Rights Reserved SIP - 10030 SD I - 03564 SD II - 03657 THE FOLLOWING INSTRUCTIONS ARE FOR THE INTERVIEWER-ADMINISTERED QUESTIONNAIRE INSTRUCTIONS TO BE READ TO THE RESPONDENT Before beginning the questionnaire, I am going to read you the instructions. You have certain activities that you do in carrying on your life. Sometimes you do all of these activities. Other times, because of your state of health, you don't do these activities in the usual way: you may cut some out; you may do some for shorter lengths of time; you may do some in different ways. These changes in your activities might be recent or longstanding. We are interested in learning about any changes that describe you today and are related to your state of health. n o ti a z y i r p o o C uth w a e t i ou v Re with e s u t o n o D I will be reading statements that people have told us describe them when they are not completely well. Whether or not you consider yourself sick, there may be some statements that will stand out because they describe you today and are related to your state of health. As I read the questionnaire, think of yourself today. I will pause briefly after each statement. When you hear one that does describe you and is related to health please tell me and I will check it. Let me give you an example. I might read the statement "I am not driving my car." If this statement is related to your health and describes you today, you should tell me. Also, if you have not been driving for some time because of your health, and are still not driving today, you should respond to this statement. If you are in the hospital today, you are here because of your state of health, and you are not doing a number of the things you usually do. For instance, if driving is usual for you, then you are not driving today because you are in the hospital, and you should respond to this statement. On the other hand, if you never drive or are not driving today because your car is being repaired, the statement, "I am not driving my car" is not related to your health and you should not respond to it. If you simply are driving less, or are driving shorter distances, and feel that the statement only partially describes you, please do not respond to it. I am now going to begin the questionnaire. Please tell me if you want me to slow down, repeat a statement, or stop so that you can think about one. Also let me know any time you would like to review the instructions. Remember we are interested in the recent or longstanding changes in your activities that are related to your health. © The Johns Hopkins University, 1977. All Rights Reserved i THE FOLLOWING INSTRUCTIONS ARE FOR THE SELF-ADMINISTERED QUESTIONNAIRE PLEASE READ THE ENTIRE INTRODUCTION BEFORE YOU READ THE QUESTIONNAIRE. IT IS VERY IMPORTANT THAT EVERYONE TAKING THE QUESTIONNAIRE FOLLOWS THE SAME INSTRUCTIONS. You have certain activities that you do in carrying on your life. Sometimes you do all of these activities. Other times, because of your state of health, you don't do these activities in the usual way: you may cut some out; you may do some for shorter lengths of time; you may do some in different ways. These changes in your activities might be recent or longstanding. We are interested in learning about any changes that describe you today and are related to your state of health. n o ti a z y i r p o o C uth w a e t i ou v Re with e s u t o n o D The questionnaire booklet lists statements that people have told us describe them when they are not completely well. Whether or not you consider yourself sick, there may be some statements that will stand out because they describe you today and are related to your state of health. As you read the questionnaire, think of yourself today. When you read a statement that you are sure describes you and is related to your health, place a check on the line to the right of the statement. For example: I am not driving my car (031) If you have not been driving for some time because of your health, and are still not driving today, you should respond to this statement. On the other hand, if you never drive or are not driving today because your car is being repaired, the statement, "I am not driving my car" is not related to your health and you should not check it. If you simply are driving less, or are driving shorter distances, and feel that the statement only partially describes you, do not check it. In all of these cases you would leave the line to the right of the statement blank. For example: I am not driving my car (031) Remember that we want you to check this statement only if you are sure it describes you today and is related to your state of health. © The Johns Hopkins University, 1977. All Rights Reserved i Read the introduction to each group of statements and then consider the statements in the order listed. While some of the statements may not apply to you, we ask that you please read all of them. Check those that describe you as you go along. Some of the statements will differ only in a few words, so please read each one carefully. While you may go back and change a response, your first answer is usually the best. Please do not read ahead in the booklet Once you have started the questionnaire, it is very important that you complete it within one day (24 hours). If you find it hard to keep your mind on the statements, take a short break and then continue. When you have read all of the statements on a page, put a check in the BOX in the lower right-hand corner. If you have any questions, please refer back to these instructions. Please do not discuss the statements with anyone, including family members, while doing the questionnaire. n o ti a z y i r p o o C uth w a e t i ou v Re with e s u t o n o D Now turn to the questionnaire booklet and read the statements. Remember we are interested in the recent or longstanding changes in your activities that are related to your health. © The Johns Hopkins University, 1977. All Rights Reserved ii (SR-0499) PLEASE RESPOND TO (CHECK) ONLY THOSE STATEMENTS THAT YOU ARE SURE DESCRIBE YOU TODAY AND ARE RELATED TO YOUR STATE OF HEALTH. _________________________________________________________________________________ 1. I spend much of the day lying down in order to rest _____ (083) 2. I sit during much of the day _____ (049) 3. I am sleeping or dozing most of the time - day and night _____ (104) a z y i r p o o C uth w a e t i ou v Re with e s u t o n o D n o ti 4. I lie down more often during the day in order to rest _____ (058) 5. I sit around half-asleep _____ (084) 6. I sleep less at night, for example, wake up too early, don't fall asleep for a long time, awaken frequently _____ (061) I sleep or nap more during the day _____ (060) 7. CHECK HERE WHEN YOU HAVE READ ALL STATEMENTS ON THIS PAGE © The Johns Hopkins University, 1977. All Rights Reserved 1 (EB-0705) PLEASE RESPOND TO (CHECK) ONLY THOSE STATEMENTS THAT YOU ARE SURE DESCRIBE YOU TODAY AND ARE RELATED TO YOUR STATE OF HEALTH. _________________________________________________________________________________ I say how bad or useless I am, for example, that I am a burden on others _____ (087) 2. I laugh or cry suddenly _____ (068) 3. I often moan and groan in pain or discomfort _____ (069) a z y i r p o o C uth w a e t i ou v Re with e s u t o n o D n o ti 4. I have attempted suicide _____ (132) 5. I act nervous or restless _____ (046) 6. I keep rubbing or holding areas of my body that hurt or are uncomfortable _____ (062) I act irritable and impatient with myself, for example, talk badly about myself, swear at myself, blame myself for things that happen _____ (078) 8. I talk about the future in a hopeless way _____ (089) 9. I get sudden frights _____ (074) 7. CHECK HERE WHEN YOU HAVE READ ALL STATEMENTS ON THIS PAGE © The Johns Hopkins University, 1977. All Rights Reserved 2 (BCM-2003) PLEASE RESPOND TO (CHECK) ONLY THOSE STATEMENTS THAT YOU ARE SURE DESCRIBE YOU TODAY AND ARE RELATED TO YOUR STATE OF HEALTH. _________________________________________________________________________________ 1. I make difficult moves with help, for example, getting into or out of cars, bathtubs _____ (084) I do not move into or out of bed or chair by myself but am moved by a person or mechanical aid _____ (121) 3. I stand only for short periods of time _____ (072) 4. I do not maintain balance _____ (098) 5. I move my hands or fingers with some limitation or difficulty _____ (064) 6. I stand up only with someone's help _____ (100) 7. I kneel, stoop, or bend down only by holding on to something _____ (064) 8. I am in a restricted position all the time _____ (125) 9. I am very clumsy in body movements _____ (058) 10. I get in and out of bed or chairs by grasping something for support or using a cane or walker _____ (082) 11. I stay lying down most of the time _____ (113) 12. I change position frequently _____ (030) 13. I hold on to something to move myself around in bed _____ (086) 2. a z y i r p o o C uth w a e t i ou v Re with e s u t o n o D n o ti (Continued on next page) © The Johns Hopkins University, 1977. All Rights Reserved 3 (Continued from previous page) 14. I do not bathe myself completely, for example, require assistance with bathing _____ (089) I do not bathe myself at all, but am bathed by someone else _____ (115) 16. I use bedpan with assistance _____ (114) 17. I have trouble getting shoes, socks, or stockings on _____ (057) 18. I do not have control of my bladder _____ (124) 15. a z y i r p o o C uth w a e t i ou v Re with e s u t o n o D n o ti 19. I do not fasten my clothing, for example, require assistance with buttons, zippers, shoelaces _____ (074) 20. I spend most of the time partly undressed or in pajamas _____ (074) 21. I do not have control of my bowels _____ (128) 22. I dress myself, but do so very slowly _____ (043) 23. I get dressed only with someone's help _____ (088) CHECK HERE WHEN YOU HAVE READ ALL STATEMENTS ON THIS PAGE © The Johns Hopkins University, 1977. All Rights Reserved 4 (HM-0668) THIS GROUP OF STATEMENTS HAS TO DO WITH ANY WORK YOU USUALLY DO IN CARING FOR YOUR HOME OR YARD. CONSIDERING JUST THOSE THINGS THAT YOU DO, PLEASE RESPOND TO (CHECK) ONLY THOSE STATEMENTS THAT YOU ARE SURE DESCRIBE YOU TODAY AND ARE RELATED TO YOUR STATE OF HEALTH _________________________________________________________________________________ 1. I do work around the house only for short periods of time or rest often _____ (054) I am doing less of the regular daily work around the house than I would usually do _____ (044) I am not doing any of the regular daily work around the house that I would usually do _____ (086) I am not doing any of the maintenance or repair work that I would usually do in my home or yard _____ (062) I am not doing any of the shopping that I would usually do _____ (071) I am not doing any of the house cleaning that I would usually do _____ (077) I have difficulty doing handwork, for example, turning faucets, using kitchen gadgets, sewing, carpentry _____ (069) I am not doing any of the clothes washing that I would usually do _____ (077) 9. I am not doing heavy work around the house _____ (044) 10. I have given up taking care of personal or household business affairs, for example, paying bills, banking, working on budget _____ (084) 2. 3. a z y i r p o o C uth w a e t i ou v Re with e s u t o n o D n o ti 4. 5. 6. 7. 8. CHECK HERE WHEN YOU HAVE READ ALL STATEMENTS ON THIS PAGE © The Johns Hopkins University, 1977. All Rights Reserved 5 (M-0719) PLEASE RESPOND TO (CHECK) ONLY THOSE STATEMENTS THAT YOU ARE SURE DESCRIBE YOU TODAY AND ARE RELATED TO YOUR STATE OF HEALTH. _________________________________________________________________________________ 1. I am getting around only within one building _____ (086) 2. I stay within one room _____ (106) 3. I am staying in bed more _____ (081) 4. I am staying in bed most of the time _____ (109) 5. I am not now using public transportation _____ (041) 6. I stay home most of the time _____ (066) 7. I am only going to places with restrooms nearby _____ (056) 8. I am not going into town _____ (048) 9. I stay away from home only for brief periods of time _____ (054) 10. I do not get around in the dark or in unlit places without someone's help _____ (072) a z y i r p o o C uth w a e t i ou v Re with e s u t o n o D n o ti CHECK HERE WHEN YOU HAVE READ ALL STATEMENTS ON THIS PAGE © The Johns Hopkins University, 1977. All Rights Reserved 6 (SI-1450) PLEASE RESPOND TO (CHECK) ONLY THOSE STATEMENTS THAT YOU ARE SURE DESCRIBE YOU TODAY AND ARE RELATED TO YOUR STATE OF HEALTH. _________________________________________________________________________________ 1. I am going out less to visit people _____ (044) 2. I am not going out to visit people at all _____ (101) 3. I show less interest in other people's problems, for example, don't listen when they tell me about their problems, don't offer to help _____ (067) I often act irritable toward those around me, for example, snap at people, give sharp answers, criticize easily _____ (084) 5. I show less affection _____ (052) 6. I am doing fewer social activities with groups of people _____ (036) 7. I am cutting down the length of visits with friends _____ (043) 8. I am avoiding social visits from others _____ (080) 9. _____ (051) I often express concern over what might be happening to my health _____ (052) 11. I talk less with those around me _____ (056) 12. I make many demands, for example, insist that people do things for me, tell them how to do things _____ (088) I stay alone much of the time _____ (086) 4. a z y i r p o o C uth w a e t i ou v Re with e s u t o n o D n o ti 10. 13. My sexual activity is decreased (Continued on next page) © The Johns Hopkins University, 1977. All Rights Reserved 7 (Continued from previous page) 14. I act disagreeable to family members, for example, I act spiteful, I am stubborn _____ (088) I have frequent outbursts of anger at family members, for example, strike at them, scream, throw things at them _____ (119) I isolate myself as much as I can from the rest of the family _____ (102) 17. I am paying less attention to the children _____ (064) 18. I refuse contact with family members, for example, turn away from them _____ (115) I am not doing the things I usually do to take care of my children or family _____ (079) I am not joking with family members as I usually do _____ (043) 15. 16. a z y i r p o o C uth w a e t i ou v Re with e s u t o n o D n o ti 19. 20. CHECK HERE WHEN YOU HAVE READ ALL STATEMENTS ON THIS PAGE © The Johns Hopkins University, 1977. All Rights Reserved 8 (A-0842) PLEASE RESPOND TO (CHECK) ONLY THOSE STATEMENTS THAT YOU ARE SURE DESCRIBE YOU TODAY AND ARE RELATED TO YOUR STATE OF HEALTH. _________________________________________________________________________________ 1. I walk shorter distances or stop to rest often _____ (048) 2. I do not walk up or down hills _____ (056) 3. I use stairs only with mechanical support, for example, handrail, cane, crutches _____ (067) I walk up or down stairs only with assistance from someone else _____ (076) 5. I get around in a wheelchair _____ (096) 6. I do not walk at all _____ (105) 7. I walk by myself but with some difficulty, for example, limp, wobble, stumble, have stiff leg _____ (055) 8. I walk only with help from someone _____ (088) 9. I go up and down stairs more slowly, for example, one step at a time, stop often _____ (054) 10. I do not use stairs at all _____ (083) 11. I get around only by using a walker, crutches, cane, walls, or furniture _____ (079) I walk more slowly _____ (035) 4. a z y i r p o o C uth w a e t i ou v Re with e s u t o n o D n o ti 12. CHECK HERE WHEN YOU HAVE READ ALL STATEMENTS ON THIS PAGE © The Johns Hopkins University, 1977. All Rights Reserved 9 (AB-0777) PLEASE RESPOND TO (CHECK) ONLY THOSE STATEMENTS THAT YOU ARE SURE DESCRIBE YOU TODAY AND ARE RELATED TO YOUR STATE OF HEALTH. _________________________________________________________________________________ 1. I am confused and start several actions at a time _____ (090) 2. I have more minor accidents, for example, drop things, trip and fall, bump into things _____ (075) 3. I react slowly to things that are said or done _____ (059) 4. I do not finish things I start _____ (067) a z y i r p o o C uth w a e t i ou v Re with e s u t o n o D n o ti 5. I have difficulty reasoning and solving problems, for example, making plans, making decisions, learning new things _____ (084) I sometimes behave as if I were confused or disoriented in place or time, for example, where I am, who is around, directions, what day it is _____ (113) I forget a lot, for example, things that happened recently, where I put things, appointments _____ (078) 8. I do not keep my attention on any activity for long _____ (067) 9. I make more mistakes than usual _____ (064) 10. I have difficulty doing activities involving concentration and thinking _____ (080) 6. 7. CHECK HERE WHEN YOU HAVE READ ALL STATEMENTS ON THIS PAGE © The Johns Hopkins University, 1977. All Rights Reserved 10 (C-0725) PLEASE RESPOND TO (CHECK) ONLY THOSE STATEMENTS THAT YOU ARE SURE DESCRIBE YOU TODAY AND ARE RELATED TO YOUR STATE OF HEALTH. _________________________________________________________________________________ 1. I am having trouble writing or typing _____ (070) 2. I communicate mostly by gestures, for example, moving head, pointing, sign language _____ (102) My speech is understood only by a few people who know me well _____ (093) I often lose control of my voice when I talk, for example, my voice gets louder or softer, trembles, changes unexpectedly _____ (083) 5. I don't write except to sign my name _____ (083) 6. I carry on a conversation only when very close to the other person or looking at him _____ (067) I have difficulty speaking, for example, get stuck, stutter, stammer, slur my words _____ (076) 8. I am understood with difficulty _____ (087) 9. I do not speak clearly when I am under stress _____ (064) 3. 4. a z y i r p o o C uth w a e t i ou v Re with e s u t o n o D n o ti 7. CHECK HERE WHEN YOU HAVE READ ALL STATEMENTS ON THIS PAGE © The Johns Hopkins University, 1977. All Rights Reserved 11 THE NEXT GROUP OF STATEMENTS HAS TO DO WITH ANY WORK YOU USUALLY DO OTHER THAN MANAGING YOUR HOME. BY THIS WE MEAN ANYTHING THAT YOU REGARD AS WORK THAT YOU DO ON A REGULAR BASIS. DO YOU USUALLY DO WORK OTHER THAN MANAGING YOUR HOME? _____ _____ YES NO a z y i r p o o C uth w a e t i ou v Re with e s u t o n o D n o ti IF YOU ANSWERED YES, GO ON TO THE NEXT PAGE. IF YOU ANSWERED NO: ARE YOU RETIRED? IF YOU ARE RETIRED, WAS YOUR RETIREMENT RELATED TO YOUR HEALTH? IF YOU ARE NOT RETIRED, BUT ARE NOT WORKING, IS THIS RELATED TO YOUR HEALTH? NOW SKIP THE NEXT PAGE. © The Johns Hopkins University, 1977. All Rights Reserved 12 _____ YES _____ NO _____ YES _____ NO _____ YES _____ NO (W-0515) IF YOU ARE NOT WORKING AND IT IS NOT BECAUSE OF YOUR HEALTH, PLEASE SKIP THIS PAGE. NOW CONSIDER THE WORK YOU DO AND RESPOND TO (CHECK) ONLY THOSE STATEMENTS THAT YOU ARE SURE DESCRIBE YOU TODAY AND ARE RELATED TO YOUR STATE OF HEALTH. (IF TODAY IS A SATURDAY OR SUNDAY OR SOME OTHER DAY THAT YOU WOULD USUALLY HAVE OFF, PLEASE RESPOND AS IF TODAY WERE A WORKING DAY.) _________________________________________________________________________________ ir za y o p o C uth w a e t i ou v Re with e s u t o n o D 1. I am not working at all _____ (IF YOU CHECKED THIS STATEMENT, SKIP TO THE NEXT PAGE.) (361) 2. I am doing part of my job at home _____ (037) 3. I am not accomplishing as much as usual at work _____ (055) 4. I often act irritable toward my work associates, for example, snap at them, give sharp answers, criticize easily _____ (080) 5. I am working shorter hours _____ (043) 6. I am doing only light work _____ (050) 7. I work only for short periods of time or take frequent rests _____ (061) I am working at my usual job but with some changes, for example, using different tools or special aids, trading some tasks with other workers _____ (034) I do not do my job as carefully and accurately as usual _____ 8. 9. CHECK HERE WHEN YOU HAVE READ ALL STATEMENTS ON THIS PAGE © The Johns Hopkins University, 1977. All Rights Reserved 13 n o ti ( 062) (RP-0422) THIS GROUP OF STATEMENTS HAS TO DO WITH ACTIVITIES YOU USUALLY DO IN YOUR FREE TIME. THESE ACTIVITIES ARE THINGS THAT YOU MIGHT DO FOR RELAXATION, TO PASS THE TIME, OR FOR ENTERTAINMENT. PLEASE RESPOND TO (CHECK) ONLY THOSE STATEMENTS THAT YOU ARE SURE DESCRIBE YOU TODAY AND ARE RELATED TO YOUR STATE OF HEALTH. _________________________________________________________________________________ 1. I do my hobbies and recreation for shorter periods of time _____ (039) 2. I am going out for entertainment less often _____ (036) 3. I am cutting down on some of my usual inactive recreation and pastimes, for example, watching TV, playing cards, reading _____ (059) I am not doing any of my usual inactive recreation and pastimes, for example, watching TV, playing cards, reading _____ (084) I am doing more inactive pastimes in place of my other usual activities _____ (051) 6. I am doing fewer community activities _____ (033) 7. I am cutting down on some of my usual physical recreation or activities _____ (043) I am not doing any of my usual physical recreation or activities _____ (077) a z y i r p o o C uth w a e t i ou v Re with e s u t o n o D n o ti 4. 5. 8. CHECK HERE WHEN YOU HAVE READ ALL STATEMENTS ON THIS PAGE © The Johns Hopkins University, 1977. All Rights Reserved 14 (E-0705) PLEASE RESPOND TO (CHECK) ONLY THOSE STATEMENTS THAT YOU ARE SURE DESCRIBE YOU TODAY AND ARE RELATED TO YOUR STATE OF HEALTH. _________________________________________________________________________________ 1. I am eating much less than usual _____ (037) 2. I feed myself but only by using specially prepared food or utensils _____ (077) I am eating special or different food, for example, soft food, bland diet, low-salt, low-fat, low-sugar _____ (043) 4. I eat no food at all but am taking fluids _____ (104) 5. I just pick or nibble at my food _____ (059) 6. I am drinking less fluids _____ (036) 7. I feed myself with help from someone else _____ (099) 8. I do not feed myself at all, but must be fed _____ (117) 9. I am eating no food at all, nutrition is taken through tubes or intravenous fluids _____ (133) 3. a z y i r p o o C uth w a e t i ou v Re with e s u t o n o D n o ti CHECK HERE WHEN YOU HAVE READ ALL STATEMENTS ON THIS PAGE © The Johns Hopkins University, 1977. All Rights Reserved 15 NOW, PLEASE REVIEW THE QUESTIONNAIRE TO BE CERTAIN YOU HAVE FILLED OUT ALL THE INFORMATION. LOOK OVER THE BOXES ON EACH PAGE TO MAKE SURE EACH ONE IS CHECKED SHOWING THAT YOU HAVE READ ALL OF THE STATEMENTS. IF YOU FIND A n o ti BOX WITHOUT A CHECK, THEN READ THE STATEMENTS ON THAT a z y i r p o o C uth w a e t i ou v Re with e s u t o n o D PAGE. © The Johns Hopkins University, 1977. All Rights Reserved 16 CALCULATION OF CATEGORY SCORES, DIMENSION SCORES, AND OVERALL SIP SCORE The score for each category is calculated by adding the scale values for each item checked within the category and dividing by the maximum possible dysfunction score for the category. This figure is then multiplied by 100 to obtain the category score. n o ti Two dimension scores may be calculated. The physical dimension score is obtained by adding the scale values for each item checked within categories BCM, M, and A, dividing by the maximum possible dysfunction score for these categories, and then multiplying by 100; the psychosocial dimension score is obtained by adding the scale values for each item checked within categories EB, SI, AB, and C, dividing by the maximum possible dysfunction score for these categories, and then multiplying by 100. The scores for the remaining categories are always calculated individually. a z y i r p o o C uth w a e t i ou v Re with e s u t o n o D The overall score for the SIP is calculated by adding the scale values for each item checked across all categories and dividing by the maximum possible dysfunction score for the SIP. This figure is then multiplied by 100 to obtain the SIP overall score. In the SIP booklet the scale values are coded to one decimal as follows: 1. Following the checking line for each item, the item number and scale value are shown, e.g., 070-083 indicates item 70 has a scale value of 8.3. 2. Following each category code in the upper right-hand corner of the page, the total possible scale value for the category is shown, e.g., SR-0499 indicates a total possible scale value of 49.9 for category SR. 3. On the title page of the booklet in the lower right-hand corner appears SD I-03564 and SD II-03657. These indicate a total possible scale value of 356.4 for the physical scoring dimension, and total scale value of 365.7 for the psychosocial scoring dimension. These are the denominators for calculating the respective dimension scores. 4. Also on the title page of the booklet in the lower right-hand corner appears SIP-10030 indicating a total possible scale value of 1003.0 for the entire SIP. This is the denominator for calculating the overall SIP score. Please note that there are two special considerations in scoring Category W - Work: © The Johns Hopkins University, 1977. All Rights Reserved 17 (1) When a subject answers YES to either, "If you are retired, was your retirement related to your health?" or "If you are not retired, but are not working, is this related to your health?", he is instructed to skip Category W - Work. However, in editing the questionnaire prior to coding or scoring, for subjects who answered YES to either of these questions, item 100 should be checked. (2) Item 100, the first item, has been coded 100-361, indicating an unusually high scale value. The scale value for this item has been statistically adjusted to take into account the fact that when item 100 is checked no other item in category W can be checked. n o ti a z y i r p o o C uth w a e t i ou v Re with e s u t o n o D © The Johns Hopkins University, 1977. All Rights Reserved 18