CHAMPS physical activity questionnaire for older adults: outcomes for interventions.

PURPOSE: To evaluate effectively interventions to increase physical activity among older persons, reliable and valid measures of physical activity are required that can also detect the expected types of physical activity changes in this population. This paper describes a self-report physical activity questionnaire for older men and women, developed to evaluate the outcomes of the Community Healthy Activities Model Program for Seniors (CHAMPS), an intervention to increase physical activity. METHODS: The questionnaire assesses weekly frequency and duration of various physical activities typically undertaken by older adults. We estimated caloric expenditure/wk expended in physical activity and created a summary frequency/wk measure. We calculated measures of each of these for: 1) activities of at least moderate intensity (MET value >/= 3.0); and 2) all specified physical activities, including those of light intensity. Six-month stability was estimated on participants not likely to change (assessment-only control group, physically active cohort). Several tests of construct validity were conducted, and sensitivity to change was analyzed based on response to the CHAMPS intervention. RESULTS: The sample (N = 249) comprised underactive persons (N = 173 from the CHAMPS trial) and active persons (N = 76). The sample was aged 65-90 yr (mean = 74, SD = 6); 64% were women, and 9% were minorities. Six-month stability ranged from 0.58 to 0.67, using intraclass correlation coefficients. Nearly all construct validity hypotheses were confirmed, though correlations were modest. All measures were sensitive to change (P < or = 0.01), with small to moderate effect sizes (0.38-0.64). CONCLUSIONS: The CHAMPS measure may be useful for evaluating the effectiveness of programs aimed at increasing levels of physical activity in older adults.

Self-reports of health care utilization compared to provider records.

This study compares self-reports of medical utilization with provider records. As part of a chronic disease self-management intervention study, patients completed self-reports of their last six months of health care utilization. A subgroup of patients was selected from the larger study and their self-reports of utilization were compared to computerized utilization records. Consistent with earlier studies, patients tended to report less physician utilization than was recorded in the computerized provider records. However, they also tended to report slightly more emergency room visits than were reported in the computerized utilization records. There was no association between demographic or health variables and the tendency toward discrepancy between self-report and computerized utilization record reports. However, there was a tendency for the discrepancy to increase as the amount of record utilization increased. Thus, the likelihood of bias caused by differing demographic factors is low, but researchers should take into account that underreporting occurs and is likely to increase as utilization increases.

Effect of a self-management program on patients with chronic disease.

CONTEXT: For patients with chronic disease, there is growing interest in "self-management" programs that emphasize the patients' central role in managing their illness. A recent randomized clinical trial demonstrated the potential of self-management to improve health status and reduce health care utilization in patients with chronic diseases. OBJECTIVE: To evaluate outcomes of a chronic disease self-management program in a real-world" setting. STUDY DESIGN: Before-after cohort study. PATIENTS AND SETTING: Of the 613 patients from various Kaiser Permanente hospitals and clinics recruited for the study, 489 had complete baseline and follow-up data. INTERVENTION: The Chronic Disease Self-Management Program is a 7-week, small-group intervention attended by people with different chronic conditions. It is taught largely by peer instructors from a highly structured manual. The program is based on self-efficacy theory and emphasizes problem solving, decision making, and confidence building. MAIN OUTCOME MEASURES: Health behavior, self-efficacy (confidence in ability to deal with health problems), health status, and health care utilization, assessed at baseline and at 12 months by self-administered questionnaires. RESULTS: At 1 year, participants in the program experienced statistically significant improvements in health behaviors (exercise, cognitive symptom management, and communication with physicians), self-efficacy, and health status (fatigue, shortness of breath, pain, role function, depression, and health distress) and had fewer visits to the emergency department (ED) (0.4 visits in the 6 months prior to baseline, compared with 0.3 in the 6 months prior to follow-up; P = 0.05). There were slightly fewer outpatient visits to physicians and fewer days in hospital, but the differences were not statistically significant. Results were of about the same magnitude as those observed in a previous randomized, controlled trial. Program costs were estimated to be about $200 per participant. CONCLUSIONS: We replicated the results of our previous clinical trial of a chronic disease self-management program in a "real-world" setting. One year after exposure to the program, most patients experienced statistically significant improvements in a variety of health outcomes and had fewer ED visits.

Prevalence and correlates of physician recommendations to exercise among older adults.

BACKGROUND: This study explored the prevalence of and factors associated with physician suggestions to exercise in a sample of older adults. METHODS: We conducted telephone interviews of a random sample of members of two Medicare health maintenance organizations (HMOs) in Northern California. Participants were 893 community-dwelling older adults of whom 63% were women, 52% were married, and 12% were in a minority group. Mean years of education was 14.8 +/- (2.6) and mean years of age was 74.9 +/- (6.5). The associations between patient self-reports of ever receiving physician recommendations to exercise and the following categories of variables were assessed: demographics, health-related quality of life, medical conditions, health/risk behaviors, and health knowledge/interest/satisfaction. RESULTS: The prevalence of older adults in this study ever receiving a physician suggestion to exercise was 48.2%. In a multivariate logistic regression model, being younger, sedentary, and having a higher body mass index were independently (p < or = .05) and positively associated with increased reports of having ever received a physician's advice to exercise. Those who were precontemplators (not thinking about changing physical activity behavior), and those who reported greater frequency of endurance exercise were less likely to report receiving a physician recommendation to exercise (p < or = .05). CONCLUSIONS: Although physician advice appeared to be targeted to subgroups that could benefit, physician advice on exercise could be particularly increased for patients over 75 years of age, those currently not thinking about an increase in physical activity, and those currently active patients who may benefit from ongoing physician advice to promote maintenance.

Parenting styles, adolescents' attributions, and educational outcomes in nine heterogeneous high schools.

This article examined the contemporaneous and predictive relations between parenting styles, adolescents' attributions, and 4 educational outcomes. Data were collected from adolescents attending 6 high schools in California and 3 high schools in Wisconsin during the 1987-1988 and 1988-1989 school years. The results of path analyses partially confirmed the central hypotheses. Adolescents who perceived their parents as being nonauthoritative were more likely than their peers to attribute achievement outcomes to external causes or to low ability. Furthermore, the higher the proportion of dysfunctional attributions made for academic successes and failures, the lower the levels of classroom engagement and homework 1 year later. Although adolescents' attributional style provided a bridge between parenting style and 2 educational outcomes, it did not fully explain the impact of parenting on those outcomes. Additional analyses within gender and ethnic subgroups reinforced the overall pattern of findings observed within the entire sample.

Evaluation of CHAMPS, a physical activity promotion program for older adults.

We evaluated physical activity changes resulting from a six-month public health model intervention that encouraged seniors (N = 89) 62-91 years of age (mean = 76) living in two low-income congregate housing facilities to increase their physical activity by participating in existing community-based physical activity classes and programs of their choice. The program was offered to everyone regardless of their health problems. Enrollees were encouraged to adopt activities tailored to their preferences, physical abilities, health status, income, and transportation resources. Using a comparison-group design, the intervention group was more active for all comparison months of the intervention period (p values < .05). The intervention also was associated with improvements in self-esteem (p < .05), though not with an array of other measures of health-related quality-of-life. Those who adopted and maintained a new physical activity over the six-month intervention period experienced improvements in anxiety, depression, and overall psychological well-being relative to those who did not. The intervention was subsequently replicated through a senior center (N = 22). A much larger proportion of the senior center sample adopted and maintained a new activity for six months (68%) compared to the congregate facilities sample (35%), which may have been due to differences in recruitment methods and sample characteristics in the two settings. An intervention promoting increased physical activity through the use of existing community resources may help increase physical activity in older adults.

Factors associated with enrollment of older adults into a physical activity promotion program.

This article investigates the extent to which a proactive two-phased recruitment approach resulted in recruitment of a representative sample of older adults from two lower income congregate housing facilities into a physical activity promotion program. Enrollees were similar to nonenrollees with respect to education, gender, marital status, race/ethnicity, self-rated health, physical functioning, psychological distress, exercise frequency, level of social contact, having a confidant, use of alcohol, and smoking status. However, enrollees were younger, more likely to speak English as a primary language, less likely to be completely sedentary, and more likely to be overweight. Overall, 21% of the target population were recruited into the program. Recruitment strategies such as those used in this study appeared to enable enrollment of a reasonably representative sample of a small well-defined population.

Translation and validation of arthritis outcome measures into Spanish.

OBJECTIVE: To produce Spanish versions of common arthritis outcome measures: the Health Assessment Questionnaire (HAQ) Disability Scale, the Center for Epidemiologic Studies Depression Scale (CES-D), the Medical Outcomes Study (MOS) Pain Severity Scale, the Arthritis Self-Efficacy Scale for Pain and Other Symptoms (with the addition of 2 new items), the Visual Analogue Pain Scale, the MOS Self-Rated Health Item, and a Physical Activities Scale that would be usable by most Hispanics living in the US. We tested these translated measures for reliability and, where appropriate, validity. METHODS: Instruments were translated and back translated by bilingual persons from 5 different countries of origin. Translators met to resolve variations in translation. The instruments were then administered to Hispanic arthritis patients in 6 geographic locations (5 in the United States and 1 in Latin America). All instruments underwent standard psychometric testing. As appropriate, the sample was stratified by level of acculturation, nation of origin, and geographic location. RESULTS: The translated instruments, with slight modification, met acceptable levels of reliability and validity. They are understood and easily usable by diverse Spanish-speaking populations. CONCLUSION: The availability of these translated outcome measures should enable investigators to include monolingual Spanish-speakers into their studies, and should facilitate study of cross-cultural differences with respect to these specific outcomes.

Does smoking cessation improve health-related quality-of-life?

This article examines whether smokers who enrolled in a community-based smoking cessation program and were successful in quitting for a six-month period had better health-related quality-of-life at six months relative to those who relapsed. An observational, longitudinal design was used; the sample included 350 participants 18-65 years of age. Health-related quality-of-life was measured using a broad array of indicators of physical and mental health. Six-month outcomes were compared between successful quitters and relapsers using analysis of covariance. Those who quit for six months had better psychological well-being, cognitivefunctioning, energy/fatigue, sleep adequacy, selfesteem, sense of mastery, and worse role functioning at six months than those who continued to smoke (p values > .05). No differences were observed in physical and social functioning, pain, or current health perceptions. There were no significant differences at enrollment in health-relatedquality-of-life between those who quit subsequently and those who relapsed, thus quality-of-life measures did not predict smoking status. We conclude that smokers who quit can possibly anticipate improvements in a range of mental health outcomes within six months, which could become an additional incentive to quit. Subsequent smoking cessation studies should include health-related quality-of-life measures to determine the generalizability of these findings.

Standardized percentile curves of body-mass index for children and adolescents.

Weight-for-height indexes are often used in the clinical assessment of obesity in children and adolescents. The direct measurement of adiposity, using hydrostatic weighing and other techniques, is not feasible in studies involving young children or with large numbers of older subjects. Ratios of weight relative to height, such as the body-mass index (weight/height), may be used as indirect measures of obesity and correlate with more direct measures of adiposity. Using data from the First National Health and Nutrition Examination Study, 1971 to 1974, standardized percentile curves of body-mass index for white children and adolescents were developed. These curves may be used to monitor the body-mass index of white children and adolescents longitudinally and for comparing an individual with others of the same sex and age.

The relation of parenting style to adolescent school performance.

This article develops and tests a reformation of Baumrind's typology of authoritarian, permissive, and authoritative parenting styles in the context of adolescent school performance. Using a large and diverse sample of San Francisco Bay Area high school students (N = 7,836), we found that both authoritarian and permissive parenting styles were negatively associated with grades, and authoritative parenting was positively associated with grades. Parenting styles generally showed the expected relation to grades across gender, age, parental education, ethnic, and family structure categories. Authoritarian parenting tended to have a stronger association with grades than did the other 2 parenting styles, except among Hispanic males. The full typology best predicted grades among white students. Pure authoritative families (high on authoritative but not high on the other 2 indices) had the highest mean grades, while inconsistent families that combine authoritarian parenting with other parenting styles had the lowest grades.

Growth curves and adult height estimation for adolescents.

Using data from the large number of adolescents studied in cycle III of the National Health Examination Survey, we utilized a sexual maturity index to develop a set of growth curves that reduce the distortion caused by commingling height data from adolescents maturing at different rates. We also created a set of correction tables to be used with these curves to permit the calculation of an adjusted height percentile that compensates for the effects of the differing rates of pubertal maturation. These adjusted height percentiles should remain more constant throughout puberty than height percentiles obtained from traditional growth curves; they may thus be used to estimate final adult height with only data obtained during routine physical examinations, by assuming that subjects maintain their adjusted height percentile through adolescence to adulthood. Height predictions made in this manner compare favorably with predictions made using two clinically tested algorithms.

Growth and intellectual development.

Data from the National Health Examination Survey (cycles II and III) provided a representative sample of 13,887 US youths (6 to 17 years of age) with which to examine the relationship between height (normalized for age and sex) and measures of intellectual development (Wechsler Intelligence Scale for Children) and academic achievement (Wide Range Achievement Test). Additionally, 2,177 subjects were studied first in cycle II and 2 to 5 years later in cycle III, forming a well-selected longitudinal study group in which to examine any association between linear growth and change in IQ scores. Wechsler Intelligence Scale for Children and Wide Range Achievement Test scores were significantly correlated with height in both cycle II and cycle III. However, no significant association between change in relative height and change in IQ scores could be detected in the longitudinal group. These data suggest that therapies designed to increase height are unlikely to alter measures of intellectual development or academic achievement.

Single parents, extended households, and the control of adolescents.

This paper uses a representative national sample of adolescents to study the interrelationships among family structure, patterns of family decision making, and deviant behavior among adolescents. Mother-only households are shown to be associated with particular patterns of family decision making and adolescent deviance, even when family income and parental education are controlled. In contrast to adolescents in households with 2 natural parents, youth in mother-only households are perceived as more likely to make decisions without direct parental input and more likely to exhibit deviant behavior. The presence of an additional adult in a mother-only household, especially for males, is associated with increased parental control and a reduction in various forms of adolescent deviance. Finally, patterns of family decision making and family structure both make independent contributions to adolescent deviance, and the impact of family structure on deviance of adolescent males is hardly affected by controlling for patterns of family decision making.

The effects of pubertal timing on body image, school behavior, and deviance.

Variation in the timing of pubertal maturation may result in behavioral differences among early, mid-, and late maturers. Using data from the National Health Examination Survey, a national probability sample of children and youth aged 12-17, we investigated the relationships between maturational timing and body image, school behavior, and deviance. In terms of body image, the early maturing boys were the group most satisfied with height and weight. The early maturing girls were most dissatisfied with weight, with 69% wishing to be thinner. This great dissatisfaction with weight reported by early maturing girls is probably not an affect of early maturation, but a concomitant of maturation in general. The majority of girls became dissatisfied with their weight as they matured, and females from the higher social groups were more likely to want to be thinner than females from lower groups. Thus, a normal developmental process is being viewed negatively by females and positively by males. Male early maturers more often had deviant behavior, but there were no consistent findings for girls. There was no effect of maturational timing on teacher reports of school absence, adjustment, popularity, need for discipline, or grade repetition.

Sexual maturation, social class, and the desire to be thin among adolescent females.

Veblen's 1899 hypothesis that associated a female desire for thinness with the higher social classes was tested with data from a representative national sample of adolescents, 12 to 17 years of age, in the National Health Examination Survey. Controlling for the actual level of fatness, adolescent females in higher social classes wanted to be thinner more often than those in lower classes. The greater female desire for thinness was not the product of health information nor of sex differences in the level of fatness. The thinner the female, the greater the impact of social class on the desire for thinness. During puberty, adolescent females negatively evaluated the body fat associated with normal sexual development.