Health and illness over time: the trajectory perspective in nursing science.

BACKGROUND: Understanding change in health and illness over time is central to creating and evaluating interventions for individuals, families, and populations. The term health trajectory is a succinct and useful way to describe change in health status over time. OBJECTIVES: The aims of this article were to define the notion of a health trajectory; comment on the usefulness and current status of health trajectory research for nursing science and practice; and identify and illustrate the key elements of theory, design, and statistical models for health trajectory research. APPROACH: Constructs in theory about individual change are summarized, synthesized with characteristics of longitudinal design and statistical models for change, and discussed in light of current and emerging health care priorities and trends in nursing research. RECOMMENDATIONS: Health trajectory research is person focused and congruent with the person-centered emphasis of nursing practice. The contribution of nursing science to the overall effort to improve health will be enhanced when change over time is explicit in nursing theory, longitudinal designs are used, and contemporary statistical approaches for modeling change in health status are incorporated into research plans.

Predictors of long-term exercise adherence in a community-based sample of older women.

BACKGROUND: Few studies have examined long-term exercise adherence in older women. The purpose of this study was to assess predictors of adherence to an intervention involving walking and balance exercises. METHODS: This was a randomized controlled trial with 2-year follow-up. Sedentary women (n = 137) aged > or =70 randomized to the exercise intervention were evaluated in their homes. The exercise prescription included walking 30 minutes per day 5 days per week and completing 11 balance exercises twice per week. The main outcome measure was exercise adherence of the intervention group only. RESULTS: The average number of minutes walked per week was 95.2 (SD 68.8); 17% walked the recommended 150 minutes or greater. The average number of times the balance exercises were done was 1.5 (SD 1.6) per week. Results of regression analysis for walking adherence showed clinical variables accounted for the greatest variance (17%) of all the blocks, and cognitive variables were second highest (12%). The final model explained 19% of the variance in predicting adherence to walking. Results of regression analysis for adherence to balance exercises showed health-related quality of life (HRQOL) variables accounted for the greatest variance (14%), followed by cognitive variables (12%). The final model explained 24% of the variance in predicting adherence to balance exercises. CONCLUSIONS: Adherence to exercise was below recommended goals, although this study demonstrated that sedentary women can adopt and continue regular exercise long term. Predictors of adherence varied with different forms of exercise. Individually tailored exercise interventions may be most amenable to older women.

Circumstances and consequences of falls in community-dwelling older women.

AIMS: To describe the circumstances and consequences of falls reported by community-dwelling older women. METHODS: This prospective study collected data for approximately 2 years for women aged>or=70 years at risk for falling who were enrolled in the Fall Evaluation and Prevention Program. RESULTS: Participants (263) completed a median of 24 months of follow-up. A total of 143 participants reported 341 falls; 70 reported 1 fall, and 73 reported 2 or more. A majority of falls (62%) occurred in/around the home, primarily during the daytime, and in living rooms or kitchens/dining rooms. Falls frequently occurred while walking, carrying objects, or reaching/leaning. Many falls did not result in injury (53%); however, 31% resulted in minor injuries, 10% in moderate injuries, and 6% in major injuries. Soft tissue injuries were common, and 5% of falls resulted in fractures. Nine falls resulted in hospitalization. CONCLUSIONS: The high rate of injurious falls seen here and the detailed information on activity at the time of the fall emphasize the need to increase awareness of behaviors and the environment to reduce fall risk. Previous studies have identified risk factors for falls, some of which cannot be modified, such as age or gender. In contrast, this study describes the activity at the time of the fall: many falls occur in the home environment, some with modifiable circumstances.

Design of control-group conditions in clinical trials of behavioral interventions.

PURPOSE: To review considerations in the design of placebo (attention) control conditions for community-based clinical trials of health behavior change interventions and to provide practical strategies for the design of control conditions. ORGANIZING CONSTRUCTS: A well-designed control condition is an essential component of a clinical trial to foster the unambiguous interpretation of study findings. METHODS: Pitfalls in the design of control conditions in clinical trials of behavioral interventions are identified and strategies to address them are offered. Types of control conditions that have been used in fall prevention trials are described, along with their strengths and weaknesses. The control condition used in the recent fall evaluation and prevention program (FEPP) was designed to overcome limitations of previous trial designs; it is provided to illustrate how to apply specific design principles. CONCLUSIONS: Pitfalls in the design of behavioral intervention studies may be avoided with the application of sound design principles. The FEPP active control condition can be used as a model in the design of future studies.

Measuring the direct healthcare costs of a fall injury event.

BACKGROUND: Falls are a leading cause of injury in older adults. Obtaining cost data for a randomized controlled trial aimed at preventing falls was problematic, and an approach was needed to obtain these data on a relatively small sample of women who used healthcare services. APPROACH: The study population was 272 community-dwelling women aged 70 and over who were participants in a fall prevention trial. Fall incident reports and billing records were used to obtain costs associated with outpatient visits, emergency department visits, acute care hospitalizations, nursing home stays, home healthcare visits, rehabilitation visits, and ambulance use. Average time and costs for obtaining fall-related healthcare cost data also were estimated. RESULTS: The mean age of those with falls requiring healthcare utilization was 78.9 years (SD = 5.1 years). Billing records were obtained for 47 of 55 injurious falls (85%). Costs ranged from $63 to $85,984, with a mean cost of $6,606 and a median cost of $658 per fall-related injurious event. The average time it took to collect the data was just over 5 hr per fall, with an estimated data collection cost of $170 per fall. DISCUSSION: The mean cost of falls was higher than seen in other studies, although methods differ. Collecting cost data related to a specific fall injury event directly from study participants was feasible, practical, and relatively inexpensive. Direct costs of injurious falls are greater than have been estimated in previous studies.

Exercise behavior in older adults: a test of the transtheoretical model.

The transtheoretical model (TTM) was developed as a guide for understanding behavior change. Little attention has been given, however, to the appropriateness of the TTM for explaining the adoption of exercise behavior in older adults. The purposes of this study were to determine the reliability of the TTM instruments and validate TTM predictions in 86 community-dwelling older adults (mean age 75.1 +/- 7.0 years, 87% women) who were participants in a 16-week walking program. TTM construct scales--self-efficacy, decisional balance (pros and cons), and processes of change (behavioral and cognitive)--were generally reliable (all>.78). Behavioral processes of change increased from baseline to follow-up, but pros, cons, and cognitive processes did not change among participants who became regular exercisers. Stage of change did not predict exercise adoption, but baseline self-efficacy predicted walking behavior. These results lend partial support to the TTM in predicting exercise behavior.

Does the Transtheoretical Model (TTM) explain exercise behavior in a community-based sample of older women?

OBJECTIVE: To determine whether patterns of exercise adoption by older women would conform to the Transtheoretical Model (TTM) of behavior change. METHODS: Participants were randomized into an exercise group (walk 30 minutes per day, 5 days per week, plus balance exercises twice per week) or attention control (health education on topics other than exercise). The intervention was conducted over 28 weeks with 1-year follow-up. RESULTS: Participants included 272 sedentary women aged 70 and above. Exercise adoption was higher in the intervention group (83% vs. 17% among controls). After 1 year, 60% of the intervention group was in action or maintenance, compared to 16% of the control group. Self-efficacy following the intervention predicted long-term exercise adherence. DISCUSSION: Few studies have addressed longitudinal analysis of the TTM for exercise adoption. Most constructs from the TTM were useful in explaining exercise adoption in older sedentary women.

Reporting violence to a health care employer: a cross-sectional study.

The purpose of this cross-sectional study was to identify individual and employment characteristics associated with reporting workplace violence to an employer and to assess the relationship between reporting and characteristics of the violent event. Current and former employees of a Midwest health care organization responded to a specially designed mailed questionnaire. The researchers also used secondary data from the employer. Of those who experienced physical and non-physical violence at work, 57% and 40%, respectively, reported the events to their employer. Most reports were oral (86%). Women experienced more adverse symptoms, and reported violence more often than men did. Multivariate analyses by type of reporting (to supervisors or human resources personnel) were conducted for non-physical violence. Reporting work-related violence among health care workers was low and most reports were oral. Reporting varied by gender of the victim, the perpetrator, and the level of violence experienced.

Work-related violence policy: a process evaluation.

This study describes one employer's approach to evaluating employees' knowledge of a violence prevention policy and experience with work-related physical and non-physical violence. A cross-sectional design was used to collect data from a random sample of current and former employees of a Midwest health care organization via a specially designed mailed questionnaire and the employer's internal database. While 7% of employees reported experiencing physical violence in the workplace, almost half of all employees had experienced non-physical violence. Most employees were aware of the organization's violence policy; however, few reported violence or used organizational resources (e.g., employee health) following the violence. Employees experienced symptoms and productivity losses in association with both types of violence. Process evaluations are an effective means of evaluating whether violence policies are used as intended and can provide organizations with considerable information to make effective programmatic changes.

Use of time studies for determining intervention costs.

BACKGROUND: Cost-effectiveness analyses are increasingly recommended to evaluate the effectiveness of health interventions. Determining the costs associated with delivery of a particular intervention is essential in conducting a cost-effectiveness analysis. Yet, there are few guidelines available to assist investigators in how to assess intervention costs associated with the personnel portion of an intervention. OBJECTIVES: To describe the use of time studies in calculating the program costs of personnel for use in future cost-effectiveness analysis of health interventions. METHODS: The literature on calculating intervention costs for use in cost-effectiveness analyses is reviewed. The process for conducting a time study for determining personnel costs in delivering an intervention and a step-by-step example from a time study are used to illustrate how personnel costs associated with delivery of the intervention can be separated from those costs associated with implementation of research procedures in the determination of research costs. CONCLUSIONS: Time studies provide a good estimate of part of the cost of implementing an intervention that is often difficult to determine-personnel time. The design of the time study should consider intervention components, staff involvement, and the time period for data collection.