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Occupation-focused and occupation-based interventions for community-dwelling older people: Intervention effects in relation to facets of occupational engagement and cost effectiveness
Umeå University, Faculty of Medicine, Department of Community Medicine and Rehabilitation, Occupational Therapy.
2015 (English)Doctoral thesis, comprehensive summary (Other academic)
Abstract [en]

Background

 Occupation-focused and occupation-based interventions can potentially promote occupational engagement among community-dwelling older people, but there is limited evidence to identify the most effective and cost-effective interventions. For independent-living older people, there is a lack of evidence to determine if occupation-focused and occupation-based interventions have an effect on their occupational engagement. For older people who need assistance because of bathing disabilities, there is limited evidence of the effects of occupation-focused and occupation-based interventions on their occupational engagement or for reducing or omitting their need for assistance. Finally, there is limited evidence to determine if occupation-focused and occupation-based interventions implemented for community-dwelling older people are cost effective.

Aim

The aim of this thesis was to evaluate the effects and cost effectiveness of occupation-focused and occupation-based interventions for two groups of community-dwelling older people, independent-living, community-dwelling older people and older people with bathing disabilities.

Method

Studies I and II were based on an exploratory randomized controlled trial. One hundred and seventy seven persons, 77–82 years, single living, and without need for home help were randomized to a no-intervention control group or to one of three occupational therapy interventions focused on promoting occupational engagement: an individual intervention, an activity group or a discussion group. In study I, effect sizes for leisure engagement and ability to perform activities of daily living (ADL) tasks were estimated for each intervention in relation to the control group to identify the most effective intervention at 3 and 12 months after baseline. In study II, the effects on quality adjusted life years (QALYs) and the total costs for the intervention, social services provided by the municipality and health care were used evaluate cost-effectiveness.

Study III was a quasi-experimental clinical trial and included 95 persons, 65+, who had applied for municipality-based home help with bathing. For participants in the intervention group, occupational therapists implemented occupation-focused and occupation-based interventions. No occupational therapy intervention was implemented for those in the control group, but they were allocated home help services if judged to need it based on an assessment by a municipality care manager. Evaluations of ADL ability, self-rated health and allocated home help were implemented at baseline and after 15 weeks.

Study IV involved the use of decision-modeling based on a five state Markov model that included levels of dependency in ADLs, place of residency and death. Probabilities for transitions between states in the model, QoL scores and societal costs for each state were derived from previous research. Overall, the model was based on research indicating that more severe levels of dependency reduced QALY scores and increased societal costs. Previous trials have provided evidence that an occupation-focused and occupation-based intervention implemented to reduce bathing disabilities increased the probability of independence of home help. The Markov model was used to evaluate cost-effectiveness over 8 years for an intervention compared to no intervention.

Results

The results of study I indicated that each intervention had a small positive effect on minimizing a decline in leisure engagement and/or ADL, but no intervention was clearly superior. In study II, the results indicated that the interventions delivered in a group format positively affected self-rated health. The discussion group was the most cost-effective intervention. The results of study III indicated that the intervention had no effect on ADL ability or self-rated health. There was, however, a large difference in the allocation of home help at follow up, indicating that the intervention was effective in reducing dependency on home help for bathing. The results of study IV indicated that compared to no intervention, the intervention resulted in a positive accumulation of QALYs and lower costs for every year during the entire 8 year period.

Conclusion

This thesis provides evidence to support the implementation of occupation-focused and occupation-based interventions for independent-living, community-dwelling older people in order to reduce their decline in occupational engagement and improve their self-rated health; the interventions also have the potential to be cost effective. This thesis also provides evidence that an occupation-focused and occupation-based intervention implemented for older people with bathing disabilities was effective in promoting independence from home help for bathing. Finally, an occupation-focused and occupation-based intervention that increased the probability of being independent of home help for bathing had a positive impact on the long term accumulation of QALYs and reduced societal costs and, therefore, can be considered very cost effective.

Place, publisher, year, edition, pages
Umeå: Umeå Universitet , 2015. , 99 p.
Series
Umeå University medical dissertations, ISSN 0346-6612 ; 1699
Keyword [en]
Activities of daily living, Bathing disabilities, Cost effectiveness, Effect size, Health promotion, Occupational therapy, Leisure engagement, Reablement, Self-rated health, Successful aging, QALY
National Category
Occupational Therapy
Identifiers
URN: urn:nbn:se:umu:diva-100064ISBN: 978-91-7601-218-5 (print)OAI: oai:DiVA.org:umu-100064DiVA: diva2:789740
Public defence
2015-03-23, Aulan, Vårdvetarhuset, Umeå, 13:00 (Swedish)
Opponent
Supervisors
Available from: 2015-02-25 Created: 2015-02-20 Last updated: 2015-04-29Bibliographically approved
List of papers
1. Meeting the needs of elderly with bathing disability
Open this publication in new window or tab >>Meeting the needs of elderly with bathing disability
2011 (English)In: Australian Occupational Therapy Journal, ISSN 0045-0766, E-ISSN 1440-1630, Vol. 58, no 3, 164-71 p.Article in journal (Refereed) Published
Abstract [en]

BACKGROUND/AIMS: Difficulties with bathing are frequent among older people and are associated with an increasing need for societal support. As loss of independence has a negative impact on health and wellbeing, it is important to study interventions that can provide the required support for people to be able to remain independent. Occupational therapy interventions can improve clients' abilities enabling them to bathe themselves, thus reducing the need for other, more long-term societal support from, e.g. a home help. In this study, two groups of elderly people with difficulties in bathing were compared; the clients in the intervention group were engaged in occupational therapy.

METHODS: A quasi-experimental non-equivalent control group design was used, in which participants with reported difficulties in bathing were recruited consecutively from two municipalities. The clients in the intervention group routinely received occupational therapy, whereas clients in the control group received assistance from a home help for bathing. Activities of daily living, quality of life and home-help allocation were assessed at the baseline and after 15 weeks.

RESULTS: Clients in the intervention group received less than three home visits on average, with majority of interventions consisting of graded activity and the use of an encouraging approach. Seventy per cent of the interventions were adaptive. Activities of daily living and quality of life of both groups improved, but the differences of being allocated a home help were significant.

CONCLUSION: Occupational therapy interventions seem beneficial in terms of supporting older people in becoming independent of home help in bathing but the results must be interpreted with caution as there were differences at baseline between the groups.

Place, publisher, year, edition, pages
Wiley-Blackwell, 2011
Keyword
activities of daily living, bathing, home care, quality of life
National Category
Occupational Therapy
Identifiers
urn:nbn:se:umu:diva-81614 (URN)10.1111/j.1440-1630.2010.00904.x (DOI)21599681 (PubMedID)
Available from: 2013-10-18 Created: 2013-10-18 Last updated: 2017-12-06Bibliographically approved
2. Occupation-focused interventions for well older people: an exploratory randomized controlled trial
Open this publication in new window or tab >>Occupation-focused interventions for well older people: an exploratory randomized controlled trial
2014 (English)In: Scandinavian Journal of Occupational Therapy, ISSN 1103-8128, E-ISSN 1651-2014, Vol. 21, no 6, 447-457 p.Article in journal (Refereed) Published
Abstract [en]

Objective: The aim of this exploratory randomised controlled trial (RCT) was to evaluate three different occupation-focused interventions for well older people by estimating effect sizes for leisure engagement and ability in activities of daily living (ADL) and thereby identifying the most effective interventions.

Methods: One hundred and seventy seven persons, 77-82 years old, living alone and without home help, were randomized to a control group (CG), an individual intervention (IG), an activity group (AG), and a one-meeting discussion group (DG). All interventions focused on occupational engagement and how persons can cope with age-related activity restrictions in order to enhance occupational engagement. Data were collected by blinded research assistants at baseline, three, and 12 months. Ordinal outcome data were converted, using Rasch measurement methods, to linear measures of leisure engagement and ADL ability. Standardized between-group effect sizes, Cohen's d, were calculated.

Results: While all groups showed a decline in leisure engagement and ADL over time, the IG and the DG were somewhat effective in minimizing the decline at both three and 12 months. However, the effect sizes were small.

Conclusions: The findings indicate that occupation-focused interventions intended to minimize a decline in leisure engagement and ADL were sufficiently promising to warrant their further research.

Place, publisher, year, edition, pages
Informa Healthcare, 2014
Keyword
leisure engagement, healthy ageing, health promotion, effect size, ADL
National Category
Occupational Therapy
Identifiers
urn:nbn:se:umu:diva-91941 (URN)10.3109/11038128.2014.927919 (DOI)25022428 (PubMedID)
Available from: 2014-08-18 Created: 2014-08-18 Last updated: 2017-12-05Bibliographically approved
3. Occupation-focused health promotion for well older people - a cost-effectiveness analysis
Open this publication in new window or tab >>Occupation-focused health promotion for well older people - a cost-effectiveness analysis
(English)In: Article in journal (Other academic) Submitted
National Category
Occupational Therapy
Identifiers
urn:nbn:se:umu:diva-100059 (URN)
Available from: 2015-02-20 Created: 2015-02-20 Last updated: 2015-04-29Bibliographically approved
4. Cost effectiveness of an intervention focused on reducing bathing disability
Open this publication in new window or tab >>Cost effectiveness of an intervention focused on reducing bathing disability
Show others...
2017 (English)In: European Journal of Ageing, ISSN 1613-9372, E-ISSN 1613-9380, Vol. 14, no 3, 233-241 p.Article in journal (Refereed) Published
Abstract [en]

The onset of bathing disability among older people is critical for a decline in functioning and has implications for both the individuals’ quality of life and societal costs. The aim of this study was to evaluate longterm cost effectiveness of an intervention targeting bathing disability among older people. For hypothetical cohorts of community-dwelling older people with bathing disability, transitions between states of dependency and death were modelled over 8 years including societal costs. A five-state Markov model based on states of dependency was used to evaluate Quality-adjusted life years (QALYs) and costs from a societal perspective. An intervention group was compared with a no intervention control group. The intervention focused on promoting safe and independent performance of bathing-related tasks. The intervention effect, based on previously published trials, was applied in the model as a 1.4 increased probability of recovery during the first year. Over the full follow-up period, the intervention resulted in QALY gains and reduced societal cost. After 8 years, the intervention resulted in 0.052 QALYs gained and reduced societal costs by €2410 per person. In comparison to the intervention cost, the intervention effect was a more important factor for the magnitude of QALY gains and long-term societal costs. The intervention cost had only minor impact on societal costs. The conclusion was that an intervention targeting bathing disability among older people presents a cost-effective use of resources and leads to both QALY gains and reduced societal costs over 8 years.

Keyword
Cost effectiveness, QALY, Occupational therapy intervention, Reablement
National Category
Occupational Therapy Health Care Service and Management, Health Policy and Services and Health Economy
Identifiers
urn:nbn:se:umu:diva-100062 (URN)10.1007/s10433-016-0404-1 (DOI)000409468500003 ()
Note

Orginally published in manuscript form with title: Recovery from bathing disability among older people - modeling long term cost-effectiveness of an occupational therapy intervention

Available from: 2015-02-20 Created: 2015-02-20 Last updated: 2017-09-27Bibliographically approved

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