The prevalence and negative health effects of chronic diseases are disproportionately high among Hispanics, the largest minority group in the United States. Self-management of chronic conditions by older adults is a public health priority. The objective of this study was to examine 6-week differences in self-efficacy, time spent performing physical activity, and perceived social and role activities limitations for participants in a chronic disease self-management program for Spanish-speaking older adults, Tomando Control de su Salud (TCDS).
Through the Healthy Aging Regional Collaborative, 8 area agencies delivered 82 workshops in 62 locations throughout South Florida. Spanish-speaking participants who attended workshops from October 1, 2008, through December 31, 2010, were aged 55 years or older, had at least 1 chronic condition, and completed baseline and post-test surveys were included in analysis (N = 682). Workshops consisted of six, 2.5-hour sessions offered once per week for 6 weeks. A self-report survey was administered at baseline and again at the end of program instruction. To assess differences in outcomes, a repeated measures general linear model was used, controlling for agency and baseline general health.
All outcomes showed improvement at 6 weeks. Outcomes that improved significantly were self-efficacy to manage disease, perceived social and role activities limitations, time spent walking, and time spent performing other aerobic activities.
Implementation of TCDS significantly improved 4 of 8 health promotion skills and behaviors of Spanish-speaking older adults in South Florida. A community-based implementation of TCDS has the potential to improve health outcomes for a diverse, Spanish-speaking, older adult population.
Hispanic people comprise the largest and fastest growing minority group in the United States (
Because a large percentage of the US population is approaching age 65 and because health care costs continue to rise, self-management of chronic conditions by all older adults is a public health priority (
The Health Foundation of South Florida (HFSF) created the Healthy Aging Regional Collaborative (HARC) to offer evidence-based health promotion programs to the large older adult population in South Florida through community-based agencies. HARC provided a network for local community agencies to reduce start-up costs and other barriers to offering community-based health promotion programs, and to share best practices.
Postulating that chronic disease self-management is a significant issue for the estimated 390,000 older Hispanic adults in South Florida (
The purpose of this study was to examine whether TCDS improved symptom management self-efficacy, perceived social and role activities limitations, and time spent exercising, when implemented by community-based agencies through a large-scale collaborative effort in South Florida. The effort by HARC represented the first large-scale, community-based implementation of TCDS and was an example of Phase 4 translational research, the evaluation of health outcomes in a real-world setting. Since limited information is available on the translation of TCDS to practice settings, we focused on short-term program outcomes to evaluate effectiveness outside controlled trials. We hypothesized that program participants would show significant improvements over baseline scores for measures of self-efficacy, perceived social and role activities limitations, and time spent exercising when measured on the last day of workshop participation.
HFSF requested proposals to participate in HARC. Through a peer-review process, 8 agencies were funded to deliver 82 TCDS workshops, using 82 instructors, at 62 sites throughout Broward and Miami-Dade Counties from October 1, 2008, through December 31, 2010. Two instructors led each class following the order and scripts in the leader's manual. Agencies offering TCDS were 6 community service agencies or health clinics that provide services for older adults, 1 hospital, and 1 county-level elder services department. Workshop sites were churches, nursing homes, community centers, residential community clubhouses, and health clinics. Agencies recruited participants from their client bases and the community through advertising and word of mouth. Program participants were self-selected and generally enrolled in the study before the start of the first workshop. The target population consisted of Spanish-speaking Hispanic adults aged 55 years or older who had at least 1 chronic disease.
Instructors were required to attend a 4-day (20-hour) program-specific training. New instructors were paired with an experienced instructor (
Maintaining fidelity is key to the successful translation of an evidence-based health promotion program (
Six 2.5-hour classes were offered once per week. TCDS uses didactic lectures, role play, brainstorming, written assignments, modeling, and goal setting to teach participants disease management skills, problem-solving techniques, critical thinking, and how to appropriately use available resources (
All participants completed an informed consent, a demographic survey, and a baseline survey before the start of the first session. At the end of the sixth and final session, participants in attendance completed a post-intervention survey. Instructors distributed the written surveys, which participants completed independently. Participants who were unable to read or write were assisted by instructors or agency staff. After the sixth session, agency staff entered TCDS participant data into an online database. The original forms were then sent to an independent evaluation team for data entry verification.
We applied methods previously used to evaluate TCDS (
Self-management behaviors were evaluated pre-intervention and post-intervention by using measures of exercise frequency and level of interference in social and daily activities by chronic disease symptoms. Other pre-intervention and post-intervention measures include a single item used to evaluate the amount of time per week spent performing stretching or strengthening exercises, and 2 items used to assess aerobic activity: time spent walking and time spent performing other aerobic activity. The measures assessing stretching or strengthening and aerobic exercises used a Likert response scale (0 = none, 5= more than 3 hours per week). The 4 items used to measure perceived social and role activities limitations used a Likert response scale (0 = almost totally, 4 = not at all). Participants were asked to rate how much their health interfered with the following: normal social activities with family and friends, hobbies or recreational activities, household chores, errands and shopping. Cronbach's α for this scale was 0.93. An average across all answered items was calculated.
Measures of confidence across multiple aspects of disease management — managing disease, managing emotions, communicating with a physician, and using mental and physical techniques learned from the program to manage symptoms — were assessed at baseline and post-intervention and used to evaluate self-efficacy using a Cantril ladder response scale (1 = not at all confident, 10 = totally confident). Three items were used to measure self-efficacy to manage disease. These items asked participants to rate self-efficacy to keep health problems, discomfort, and fatigue from interfering with daily activities. To be included in analysis, participants were required to answer all 3 items. Cronbach's α for the scale was 0.94. An average across 3 items was calculated. Single items were used to measure self-efficacy to manage emotions, self-efficacy to communicate with a physician, and self-efficacy to use techniques learned in class.
Measures that describe participant characteristics and attitudes at baseline include information on sex, age, race/ethnicity, income level, highest education level, marital status, disability status, household number, and county of residence in South Florida. A single item taken from the National Health Interview Survey (
Participant data were extracted from an online database; 1,186 participants enrolled in the program. Participants younger than 55 years or missing data on age (n = 160) or those not having completed both a baseline and post-intervention survey (n = 344), were removed from the data set, leaving 682 to be included in analysis. Analysis was performed using SPSS version 17 (SPSS Institute, Inc, Cary, North Carolina). Data were cleaned of outliers and values outside possible response limits. Counts, means, and standard deviations (SDs) were obtained using frequency and descriptive data reports. One-way analysis of variance (ANOVA) was used to determine if outcome differences existed based on demographic characteristics and baseline health status measures. The Bonferonni method was used to determine whether significant differences existed for multiple comparisons. The general linear model was chosen to assess within-subject changes in outcome measures (self-efficacy, health behaviors, and social and role activities) at baseline and 6 weeks, because it is able to control for multiple covariates simultaneously (
From October 1, 2008, through December 31, 2010, 682 participants attended at least 1 session of TCDS and met the inclusion criteria to be included in analysis. No significant differences were observed in demographic and baseline values between participants included and those excluded from analysis.
Average participant age was 76 (
| Characteristic | All Eligible Participants (N = 682) |
|---|---|
|
| 76.4 (8.7) |
|
| 2.0 (1.1) |
|
| |
| Female | 566 (83.0) |
| Male | 107 (15.7) |
|
| |
| Broward | 138 (20.2) |
| Miami-Dade | 533 (78.2) |
|
| |
| Married/partnered | 261 (38.3) |
| Single/not partnered | 407 (59.7) |
|
| |
| Yes | 63 (9.2) |
| No | 274 (40.2) |
|
| |
| <$15,000 | 428 (62.8) |
| ≥$15,000 | 51 (7.5) |
|
| |
| Lives alone | 415 (60.9) |
| Lives with others | 267 (39.1) |
|
| |
| Less than high school | 262 (38.4) |
| High school graduate/GED | 193 (28.3) |
| Some college | 79 (11.6) |
| College graduate | 93 (13.6) |
|
| |
| Self-rated health | 3.2 (0.99) |
| Poor physical health days | 5.8 (9.3) |
| Poor mental health days | 4.7 (9.0) |
| Days where activities were prevented | 3.5 (7.9) |
| Communication with physician | 2.5 (1.5) |
| MD visits | 2.8 (2.5) |
| ER visits | 0.2 (0.8) |
| Times hospitalized | 0.2 (1.0) |
| Days in hospital | 0.5 (3.0) |
| Level of fatigue | 3.1 (3.0) |
| Level shortness of breath | 1.9 (2.7) |
| Level of pain | 3.5 (3.3) |
| Level of frustration | 2.0 (2.7) |
Abbreviations: SD, standard deviation; GED, general educational diploma.
Cells may not add up to the study sample total because surveys were self-report and participants were encouraged, but not required, to answer all questions.
Response scale of 1 = excellent to 5 = poor.
Number of days out of the past 30.
A 3-item scale, which included items asking frequency of preparing a question list, asking questions, and discussing personal problems with a physician. Response scale of 0 = never to 5 = always.
Number of times in the past 6 months.
Response scale of 0 = none to 10 = extreme, using 10 corresponding histograms of different heights and shading intensities.
There were significant improvements at 6 weeks (post-test) in 4 of the 8 health behavior measures (
| Outcome | n | Score at Baseline | Score at 6 Weeks | Change in Score |
|
|---|---|---|---|---|---|
|
| |||||
| Mean (SD) | |||||
| Self-efficacy to manage disease | 664 | 6.75 (2.66) | 8.05 (2.16) | 1.30 (2.94) | .006 |
| Self-efficacy to manage emotions | 637 | 6.66 (2.88) | 8.11 (2.40) | 1.45 (3.30) | .16 |
| Self-efficacy to use mental and physical techniques to manage symptoms | 641 | 6.02 (3.27) | 8.21 (2.25) | 2.19 (3.64) | .79 |
| Self-efficacy to communicate with physician | 643 | 7.90 (2.60) | 8.73 (2.12) | 0.83 (2.81) | .48 |
| Social/role activities limitations | 655 | 3.15 (1.05) | 3.20 (1.08) | 0.05 (1.28) | .001 |
| Time spent stretching | 639 | 1.08 (1.20) | 1.77 (1.29) | 0.69 (1.54) | .06 |
| Time spent walking | 599 | 1.43 (1.35) | 1.98 (1.36) | 0.55 (1.40) | .02 |
| Time spent performing other aerobic activity | 575 | 0.43 (0.95) | 0.88 (1.33) | 0.45 (1.39) | .005 |
Abbreviation: SD, standard deviation.
Cells may not add up to the study sample total because surveys were self-report and participants were encouraged, but not required, to answer all questions.
Response scale of 1= not at all confident to 10 = totally confident.
Response scale of 0 = almost totally to 4 = not at all.
Response scale of 0 = none to 5 = more than 3 h/week.
Sessions observed for fidelity monitoring lasted an average of 1 hour and 46 minutes and had an average of 9 attendees. Results of fidelity monitoring found a high adherence rate for program content and delivery in the 10 (12%) workshops observed. No deviations from scripted content and delivery methods were observed. The most often identified fidelity issue (50%) was the presence of distractions during class; many workshops were conducted in common areas, and disruptions were the result of site clients or personnel passing through the classroom or making noise.
The objective of this study was to test the hypothesis that significant improvements at 6 weeks would be observed for measures of self-efficacy, health behavior, and perceived social and role activities limitations. Four of the measured outcomes showed significant differences from baseline to 6 weeks post-intervention. These measures were self-efficacy to manage symptoms, time spent walking, time spent performing other aerobic activity, and perceived social and role activities limitations.
Our results for participant self-efficacy to manage symptoms support 2 studies evaluating differences between baseline and 4 and 12 months (
We evaluated the effectiveness of TCDS when implemented at the community level, by community agencies. Previous self-management studies have shown that similar health behavior changes, when sustained, continue to affect health positively and reduce use of health care services (
Our study had limitations. Because some participants were recruited from nursing homes, adult day care centers, and sites having a standing history of clients, such as activity centers or health care clinics, the sample may not be representative of the general population. Because participants were self-selected, bias may have been introduced to both the sample and the results, based on the participants’ ability and eagerness to learn. The self-administration of surveys could introduce report and recall biases, because responses were not verified. Inherent with self-reporting and implementation in a community setting, many fields had missing data; it was not possible to contact participants to complete the missing fields. Results may have been influenced by other factors during the 6 weeks over which the workshop was offered, such as visits to health care providers. The study design did not allow for identification of the effectiveness of individual program components.
Our study also had several strengths. By using an evidence-based program with validated measures, we are confident that the link between program participation and outcomes is a causal one. Use of existing validated measures allowed us to ensure that we were measuring the concepts we set out to measure. Despite potential sample bias previously mentioned, the diversity among the agencies delivering TCDS and participants increased the generalizability of results, because study implementation resembles what can be expected of future community-based translations. Agencies offering TCDS benefited from being members of HARC, because it covered program licensing costs, coordinated instructor trainings, advertised workshop offerings, and led monthly conference calls to discuss implementation concerns faced by the agencies. Sustainability plans indicate that agencies will adopt TCDS fully and seek continued funding on their own.
Because Hispanics are disproportionately affected by incidence of chronic diseases, efforts should be made to decrease the disparities in prevalence and severity. Findings from this study show that evidence-based health promotion programs targeting older Hispanics with 1 or more chronic conditions increase participants’ ability to control important elements of disease management. Participants improved across all measures, and some improvements were significant. Because some measures did not improve significantly, program adaptation specific to the culture and needs of the Hispanic subgroups of South Florida may be warranted. Research studies involving Hispanic populations found significantly different outcomes based on subgroup (eg, Cuban, Mexican, Chilean) (
This evaluation was funded as part of the Healthy Aging Regional Collaborative by the Health Foundation of South Florida. The authors extend their appreciation to the member agencies that comprise the Healthy Aging Regional Collaborative. We also thank Anamica Batra for her role in data management.
The opinions expressed by authors contributing to this journal do not necessarily reflect the opinions of the U.S. Department of Health and Human Services, the Public Health Service, the Centers for Disease Control and Prevention, or the authors' affiliated institutions.