Peer Support to Enhance Social and Emotional Self-Management Following Acquired Brain Injury Rehabilitation: Design of a Pre-post Study With Process Evaluation.

Background: Specialized rehabilitation following acquired brain injury provides intensive multidisciplinary treatment to individuals with complex disabilities for optimizing recovery and supporting a safe transition to the community. Post-specialist rehabilitation, patients and caregivers have reported a need for support. We present the design of an implementation study to evaluate a new self-management support service for individuals with acquired brain injury and their caregivers. Methods: This is a pre-post intervention study with a mixed-method design. The study population comprises individuals aged ≥18 years with acquired brain injury living independently following specialized rehabilitation in the Southern part of the Netherlands. All participants receive a post-rehabilitation support service. The support service consists of several house visits by a peer support volunteer in the first weeks after specialized rehabilitation treatment. The peer support volunteers are trained according to an adapted version of the previously developed Self-Management Support (SMS) program. The SMS program is directed at improving social and emotional self-management. Patient outcomes are assessed by questionnaire pre-, directly post-, and 6 months post-intervention. The primary patient outcome measure is self-efficacy. Secondary outcomes are perceived autonomy, quality of life, and psychological well-being. A process evaluation will be performed to gain insight into barriers and facilitators for the implementation of peer-led SMS by combining both quantitative, questionnaire data and qualitative data derived from focus groups with peer supporters and patients. In a workshop with relevant stakeholders, possibilities for dissemination and sustainability will be explored. Discussion: This paper describes the design of a practice-based study on feasibility, barriers, and facilitators to the implementation of a home-based, peer-led self-management support intervention for patients with acquired brain injury. We will quantitatively and qualitatively evaluate the change in relevant patient outcomes pre- and post-intervention and the barriers and facilitators related to the implementation of the intervention. Following a positive evaluation, the final stage of the study aims to facilitate deployment and utilization of the intervention.

Patients' readiness to receive psychosocial care during nurse-led routine diabetes consultations in primary care: A mixed methods study.

BACKGROUND: Patients with type 2 diabetes mellitus face several emotional and social consequences of their chronic illness in their everyday life. Symptoms of distress and depression are prevalent. For providing psychosocial self-management support, nurses in primary care were trained to identify patients with psychosocial problems during routine medically-shaped diabetes consultations. However, detection rates appeared to be strikingly low. OBJECTIVES: Our study aimed to examine patients' readiness to discuss psychosocial problems with nurses during diabetes consultations. DESIGN: A mixed methods design was used in which qualitative data collection was followed up by quantitative data collection. SETTING: Diabetes care in a regional group of family practices in the south of the Netherlands. PARTICIPANTS: Type 2 diabetes patients with psychosocial problems, determined by a self-administered questionnaire. METHODS: First, in-depth interviews (n=12) were conducted about patients' experiences with routine diabetes consultations and their perspective on a biopsychosocial care approach. Based on a qualitative content analysis, a structured questionnaire was designed to further explore the findings among a larger group of patients. This questionnaire was completed by 205 patients. The questionnaire included 14 items measuring patients' agreement with statements about diabetes care and the role of the nurse to focus on patients' emotional and social functioning. RESULTS: The interviews showed that patients view a diabetes consultation primarily as a biomedical check-up, and do not perceive discussion of psychosocial well-being as an integral part of diabetes management. More than 90% of the sample showed a positive attitude towards current diabetes consultations. Patients' intentions and perceived needs regarding a biopsychosocial care approach of the nurse were variable. Younger patients seemed more open to discussing psychosocial problems with the nurse than patients over 65. Patients' openness to discussing psychosocial problems was not significantly (p<0.05) associated with the nurses being trained in the biopsychosocial self-management approach. CONCLUSION: Patients see primary care nurses primarily as specialists regarding the biomedical management of diabetes. Although patients seemed to support the ideal of integrated care, they did not expect a discussion about psychosocial problems in diabetes consultations. The incorporation of systematic detection of patients with psychosocial problems in diabetes care requires endeavours to make patients acquainted with the new role of the nurse.

Lessons learnt from a cluster-randomised trial evaluating the effectiveness of Self-Management Support (SMS) delivered by practice nurses in routine diabetes care.

OBJECTIVE: To evaluate the effectiveness of biopsychosocial Self-Management Support (SMS) delivered by practice nurses in routine diabetes care. DESIGN: A pragmatic cluster-randomised controlled trial within a hybrid effectiveness-implementation study design. Practice nurses were cluster-randomised. SETTING: A regional care group in the Netherlands consisting of 77 family practices. The study involved practice nurses (n=40) providing care to approximately 4000 patients with diabetes. PARTICIPANTS: Patients with type 2 diabetes (n=264) selected by a self-administered questionnaire aimed at measuring emotional distress and diabetes-related reduced daily functioning. INTERVENTION: Practice nurses in the intervention arm (n=19) were trained to integrate SMS into their routine consultations. SMS included detection of patients with emotional distress and reduced daily functioning, and supporting them when needed through problem solving and reattribution techniques. Practice nurses in the control arm (n=21) provided usual care. MAIN OUTCOME MEASURES: The primary outcome measure was a dichotomised score on a Visual Analogue Scale that measured the perceived effect of diabetes on daily functioning. Secondary measures included patients' diabetes-related distress, quality of life, autonomy and participation, self-efficacy, self-management and glycaemic control. Outcomes were measured at baseline and at 4-month and 12-month follow-ups. RESULTS: Only 16 of the 117 patients in the intervention arm (14%) who were found eligible by the posted research-driven screening questionnaire were detected by their practice nurses. Extra consultations for the self-management support were delivered to only 11 study participants. In the control arm, 147 patients received usual care. Multilevel analyses showed no significant differences in outcomes between the intervention and control arms. CONCLUSIONS: SMS in its present form was not effective. The research-driven screening to select trial participants appeared to be inconsistent with nurse-led detection in routine practice. Adequate follow-up moments need to be built in to overcome barriers resulting from tension between the implementation and effectiveness parts of hybrid studies. TRIAL REGISTRATION NUMBER: Current Controlled Trials NTR2764.

Development and psychometric properties of the Maastricht Personal Autonomy Questionnaire (MPAQ) in older adults with a chronic physical illness.

PURPOSE: To develop and test the Maastricht Personal Autonomy Questionnaire (MPAQ), an instrument measuring personal autonomy of older adults with a chronic physical illness in accordance with their experience of autonomy. Achievement of personal autonomy is conceptualized as correspondence between the way people's lives are actually arranged and the way people want to arrange their lives. METHODS: A field test was conducted in three waves (n = 412, n = 125 and n = 244) among a random sample of people older than 59 years with either chronic obstructive pulmonary disease or diabetes mellitus. Construct validity, reproducibility and responsiveness were evaluated. RESULTS: The MPAQ entailing 16 items consists of three scales: degree of (personal) autonomy, working on autonomy and dilemmas. Construct validity was largely supported by confirmatory factor analysis and correlations between the MPAQ and other instruments. Intraclass correlation coefficients ranged from 0.61 to 0.80 and SRDsgroup from 0.10 to 0.13. Mean change was larger (0.54) than was SRDgroup (0.11) in patients who had deteriorated, but smaller in patients who had improved (0.07). CONCLUSIONS: The MPAQ has good content and construct validity and moderate reproducibility. Responsiveness is weak, although better for deterioration than for improvement.

Do psychosocial profiles predict self-rated health, morbidity and mortality in late middle-aged and older people?

Considering many psychosocial health risk factors are interrelated, determining psychosocial health risk might benefit from a more person-centered perspective. This paper explores to what extent a psychosocial profile that combines potentially synergistic effects of different psychosocial characteristics, including psychological attributes and functioning, coping styles and social support, predicts self-rated health, morbidity and mortality. Prospective, longitudinal data from 1,912 Dutch participants aged 55-91 years were used to determine distinct psychosocial profiles by means of two-step cluster analysis. The predictive power of these profiles over a 5-year follow-up was calculated with Cox regression models for all-cause mortality and general practitioner-diagnosed somatic morbidity, and logistic regression models for self-rated health. Three distinct psychosocial risk profiles emerged: an adverse, an average and a beneficial profile. These profiles strongly predicted self-rated health but not morbidity or mortality. The health effects of the cluster (profile) model suggest synergism between the psychosocial characteristics. Future research should replicate our findings to further validate the approach.

Cost-effectiveness of an intervention to reduce fear of falling.

OBJECTIVES: The aim of this study was to assess whether a multicomponent cognitive behavioral group intervention is preferable to usual care in terms of (healthcare) costs and effects on fear of falling and activity avoidance. METHODS: This economic evaluation was embedded in a randomized controlled trial among 540 community-living adults in the Netherlands, aged 70 years and older who reported fear of falling and fear-induced activity avoidance. The participants allocated to the intervention group received a multicomponent cognitive behavioral group intervention consisting of eight weekly sessions and a booster session. The sessions were aimed at instilling realistic views of falls, reducing fall risk, and increasing activity and safe behavior. Participants in the control group received usual care. Cost outcome measures were healthcare costs, and patient and family costs. Clinical outcomes were fear of falling and activity avoidance. All outcomes were assessed at baseline and at 2, 8, and 14 months by means of registration forms, self-administered questionnaires, and interviews by telephone. RESULTS: Participants were randomly allocated to intervention (n = 280) and control groups (n = 260). Costs for the intervention program were on average €276 per person. Total costs per person were comparable (€4,925 in intervention group and €4,828 in control group). Furthermore, favorable effects of the program were observed for fear of falling and activity avoidance. CONCLUSIONS: This study showed that the intervention program is preferable to usual care in terms of costs and effects. The program had comparable costs and significantly reduced fear of falling and associated activity avoidance among older community-living persons.

Integrating nurse-led Self-Management Support (SMS) in routine primary care: design of a hybrid effectiveness-implementation study among type 2 diabetes patients with problems of daily functioning and emotional distress: a study protocol.

BACKGROUND: Psychosocial problems are more prevalent among patients with chronic diseases than among the general population. They may lead to a downward spiral of poor adherence, deterioration of the condition and decline in daily functioning. In addition to medical management, systematic attention to emotional and role management tasks during routine chronic care seems mandatory. We intend to integrate an existing nurse-led minimal psychological intervention to support patients' self-management, which appeared to be effective and cost-effective, in routine care by primary care nurses, so we adjusted it to fit the host setting. The resulting Self-Management Support (SMS) programme involves early detection of patients with emotional distress and problems of daily functioning, as well as self-management support through problem solving and reattribution techniques. Strategies to embed SMS in daily practice include training and booster sessions for practice nurses as well as organisational and financial arrangements. This study aims to simultaneously evaluate the implementation process and effects of SMS in routine care, using a hybrid effectiveness-implementation design. METHODS/DESIGN: Registration data, questionnaires and interviews will be used to explore the facilitators, barriers and costs regarding successful implementation of SMS. The effects of SMS will be evaluated in a pragmatic cluster-randomised controlled trial with a baseline measurement and follow-up measurements after 4 and 12 months. The population will consist of 46 practice nurses and their type 2 diabetes patients (N = 460; 10 per practice nurse). The practice nurses will be randomly assigned to the intervention or control group. Practice nurses of the intervention group will receive SMS training. Patients for the intervention and control groups will be recruited by a researcher-led self-administered screening procedure to decide which patients of those scheduled for routine consultation are likely to be detected by the practice nurses as eligible for the self-management support. Primary outcome measure is patients' daily functioning. Secondary measures include emotional well-being, participation, autonomy and control over the disease. DISCUSSION: Our hybrid study design is complicated by the detection method used by the practice nurses. This method is an implementation issue in itself that has consequences for the realisation and power of the effect evaluation. TRIAL REGISTRATION: Current Controlled Trials, NTR2764.

Unhealthy lifestyles do not mediate the relationship between socioeconomic status and incident depressive symptoms: the Health ABC study.

BACKGROUND: The relationship between low socioeconomic status (SES) and depressive symptoms is well described, also in older persons. Although studies have found associations between low SES and unhealthy lifestyle factors, and between unhealthy lifestyle factors and depressive symptoms, not much is known about unhealthy lifestyles as a potential explanation of socioeconomic differences in depressive symptoms in older persons. METHODS: To study the independent pathways between SES (education, income, perceived income, and financial assets), lifestyle factors (smoking, alcohol use, body mass index, and physical activity), and incident depressive symptoms (Center for Epidemiologic Studies-Depression [CES-D 10] and reported use of antidepressant medication), we used 9 years of follow-up data (1997-2007) from 2,694 American black and white participants aged 70-79 years from the Health, Aging, and Body Composition (Health ABC) study. At baseline, 12.1% of the study population showed prevalent depressive symptoms, use of antidepressant medication, or treatment of depression in the 5 years prior to baseline. These persons were excluded from the analyses. RESULTS: Over a period of 9 years time, 860 participants (31.9%) developed depressive symptoms. Adjusted hazard ratios for incident depressive symptoms were higher in participants from lower SES groups compared with the highest SES group. The strongest relationships were found for black men. Although unhealthy lifestyle factors were consistently associated with low SES, they were weakly related to incident depressive symptoms. Lifestyle factors did not significantly reduce hazard ratios for depressive symptoms by SES. CONCLUSION: In generally healthy persons aged 70-79 years, lifestyle factors do not explain the relationship between SES and depressive symptoms.

Continuous versus intermittent data collection of health care utilization.

BACKGROUND: In economic evaluations, participants have to report their health care utilization continuously during follow-up. To unburden participants, researchers often collect data intermittently (i.e., in at least 3 months a year). However, comparability of intermittent v. continuous data collection is unknown. Therefore, this study aimed to compare costs estimated with intermittent data collection of health care utilization with those based on continuous data collection. METHODS: We used continuous health care utilization data from a trial with 12 months of follow-up and simulated several intermittent data collection patterns. Then 3 imputation techniques--individual mean (IM), last observation carried forward (LOCF) and next observation carried backward (NOCB)--were used to estimate total annual costs. Estimated annual costs were compared with observed annual costs from continuous data collection both in the original sample and in 1000 bootstrap samples. RESULTS: Analyses showed that intermittent data collection using cost diaries may offer good estimates of the actual total annual health expenditures. However, estimations of groups of costs differ between data collection patterns and imputation methods. The best estimations of annual total costs and groups of costs were obtained by random cohort data collection, using 3 random cohorts, ensuring that at least a third of the participants were measuring costs each month, combined with IM imputation. Intermittent data collection of health expenditures carries a small risk of missing infrequent expensive events. CONCLUSIONS: Continuous cost data collection remains the first choice. However, if intermittent measurement is chosen, we recommend calculating annual costs from intermittent data collection in random cohorts, combined with IM imputation.

Effectiveness of a minimal psychological intervention to reduce mild to moderate depression and chronic fatigue in a working population: the design of a randomized controlled trial.

BACKGROUND: In a working population, common mental complaints like depressed mood and chronic fatigue are highly prevalent and often result in further deterioration of mental health and consequently absence from work. In a large occupational health setting, we will evaluate the (cost-) effectiveness of a Minimal Psychological Intervention (MPI), in reducing symptoms of depression and chronic fatigue in a working population. The MPI is also evaluated regarding its appreciation by worker, nurse, and occupational health physician (process evaluation). The tailor-made intervention is administered by nurses, who are trained in the principles of cognitive behavioural therapy and self-management. METHODS/DESIGN: The presented WoPaCoM study (Work Participation of Workers with Common Mental complaints) is a two-armed randomized controlled trial, comparing MPI with usual care. A total number of 124 workers suffering from (chronic) mental fatigue or mild to moderate depression will be included. A stratified and block randomization will be applied, stratifying by customer organisation, income, and gender, using a block size of four. It will include a baseline measurement and subsequently follow up measurements after 4, 6 and 12 months. The primary outcome measures are symptoms of either fatigue (using the Checklist Individual Strength) and/or depression (using the Beck Depression Inventory) and secondary outcome measures include sickness absence, self efficacy, costs and quality of life. Analysis will include both univariate and multivariate techniques and data will be analysed according to the intention to treat principle. DISCUSSION: Patient recruitment in an occupational setting proves to be complicated and time consuming. Shift work for instance proved to be an obstacle for making appointments for consultation with the nurse. Furthermore, economic developments might have created job insecurity which negatively influenced participation in the study, with workers being anxious to be detected as having psychological problems. Additionally, long-term follow-up in a working population is time-consuming and continuously engages occupational health staff and administrative personnel to control the process of data gathering. However, if the intervention proves to be effective, occupational medicine will have a manageable option for treatment of workers who are at risk of loss of productivity or sickness absence. TRIAL REGISTRATION: Nederlands Trialregister NTR3162.

Socioeconomic factors from midlife predict mobility limitation and depressed mood three decades later; findings from the AGES-Reykjavik Study.

BACKGROUND: Taking into account our rapidly ageing population, older people are of particular interest in studying health inequalities. Most studies of older persons only include measures of current socioeconomic status (SES) and do not take into account data from earlier stages of life. In addition, only classic SES measures are used, while alternative measures, such as car ownership and house ownership, might equally well predict health. The present study aims to examine the effect of midlife socioeconomic factors on mobility limitation and depressed mood three decades later. METHODS: Data were from 4,809 men and women aged 33-65 years who participated in the Reykjavik Study (1967-1992) and who were re-examined in old age in the Age, Gene/Environment Susceptibility (AGES) -Reykjavik Study (2002-2006). RESULTS: Education and occupation predicted mobility limitation and depressed mood. Independently, home and car ownership and the availability of housing features predicted mobility limitation. Shortages of food in childhood and lack of a car in midlife predicted depressed mood. CONCLUSION: Socioeconomic factors from midlife and from childhood affect mobility limitation and depressed mood in old age. Prevention of health problems in old age should begin as early as midlife.

The ideal of biopsychosocial chronic care: how to make it real? A qualitative study among Dutch stakeholders.

BACKGROUND: Chronically ill patients often experience psychosocial problems in everyday life. A biopsychosocial approach is considered to be essential in chronic care. In Dutch primary health care the current biomedically oriented clinical practice may conflict with the biopsychosocial approach. This study is aimed to explore the views of Dutch stakeholders on achieving a biopsychosocial approach to the care of patients with chronic diseases. METHODS: In a qualitative explorative study design, we held semi-structured interviews with stakeholders, face-to-face or by telephone. Data were analysed using content analysis. Thirty representatives of Dutch patients with chronic illnesses, primary care professionals, policy makers, health inspectorate, health insurers, educational institutes and researchers were interviewed. RESULTS: Stakeholders were aware that a systematic biopsychosocial care approach is lacking in current practice. Opportunities for effective change are multidimensional. Achieving a biopsychosocial approach to care relates to active patient participation, the training of professionals, high-quality guidelines, protocols and tools, integrated primary care, research and financial issues. CONCLUSIONS: Although the principles and importance of the biopsychosocial model have been recognized, the provision of care that starts from the medical, emotional or social needs of individual patients does not fit in easily with the current Dutch health care system. All parties involved need to make a commitment to realize the ideal of biopsychosocial chronic care. Together they need to equip health professionals with skills to understand patients' multifaceted needs and to reward integrated biopsychosocial care. Patients need to be empowered to be active partners in their own care.

The effectiveness of a minimal psychological intervention on self-management beliefs and behaviors in depressed chronically ill elderly persons: a randomized trial.

BACKGROUND: Chronically ill patients often develop symptoms of depression. They run the risk of sliding into a downward spiral because of the interaction between depression and chronic illness. A minimal psychological intervention (MPI) has been developed to break through the spiral by applying principles of self-management and cognitive behavioral therapy. This study examines the effects of the MPI on self-efficacy, anxiety, daily functioning and social participation. METHODS: A randomized controlled trial compared the MPI with usual care in 361 primary care patients. Nurses visited patients at home over a period of three months. Patients were aged 60 years and older, had minor depression or mild to moderate major depression and either type 2 diabetes mellitus (DM) or chronic obstructive pulmonary disease (COPD). Outcomes were measured at baseline and at one week, three months, and nine months after the intervention period. RESULTS: At nine months after treatment, the MPI was associated with less anxiety (mean difference 2.5; 95% CI 0.7-4.2) and better self efficacy skills (mean difference 1.8; 95% CI 3.4-0.2), daily functioning (mean difference 1.7; 95% CI 0.6-2.7), and social participation (mean difference 1.3; 95% CI 0.4-2.2). Effect sizes for these outcomes were small to medium (0.29-0.40). Differences were primarily due to a stabilization of outcomes in the intervention group and deterioration in the control group. No major differences were observed between DM and COPD patients. CONCLUSIONS: The intervention appears to be reasonably effective in improving care for chronically ill elderly people. We recommend further evaluation of the MPI, including emphasis on detection and watchful waiting.

Racial differences in mortality in older adults: factors beyond socioeconomic status.

BACKGROUND: Little is known about the simultaneous effect of socioeconomic status (SES), psychosocial, and health-related factors on race differences in mortality in older adults. PURPOSE: This study examined the association between race and mortality and the role of SES, health insurance, psychosocial factors, behavioral factors, and health-related factors in explaining these differences. METHODS: Data consisted of 2,938 adults participating in the Health, Aging and Body Composition study. Mortality was assessed over 8 years. RESULTS: SES differences accounted for 60% of the racial differences in all-cause mortality; behavioral factors and self-rated health further reduced the disparity. The racial differences in coronary heart disease mortality were completely explained by SES. Health insurance and behavioral factors accounted for some, but not all, of the race differences in cancer mortality. CONCLUSIONS: Race-related risk factors for mortality may differ by the underlying cause of mortality.

Good friends, high income or resilience? What matters most for elderly patients?

BACKGROUND: Chronically ill patients need to adapt to their impaired life condition. Social (e.g. social support), material (e.g. income) and personal (e.g. mastery) resources are needed to cope with this challenge. It is, however, less clear whether these factors also contribute to 'relatively successful functioning' and whether these effects are disease specific or generic across chronic diseases. METHODS: Baseline data from 361 Dutch men and women aged≥60 years who were mildly depressed and diagnosed with type 2 diabetes or chronic obstructive pulmonary disease (COPD) were used. These persons participated in the 'Depression in Elderly with Long-Term Afflictions' (DELTA) study. Logistic regression analyses were used to study the independent association of social support, income and mastery (independent variables) with physical, mental and social functioning (dependent variables). RESULTS: A high level of mastery is significantly associated with physical, mental and social functioning in the total study population, as well as in subgroups of patients with COPD or diabetes. This relationship remained significant after controlling for confounding factors such as gender, age, educational level and the other remaining resources. In diabetes patients, high levels of social support and income also contributed significantly to successful social functioning. CONCLUSION: Our findings suggest that rather than having good friends and a high income, having a high level of mastery (resilience) might best help chronically ill patients in coping with and adapting to their often co-morbid condition. Further longitudinal research is necessary to unravel the long-term effects of mastery, income and social support on 'relatively successful functioning' in chronically ill patients.

Material vs. psychosocial explanations of old-age educational differences in physical and mental functioning.

BACKGROUND: Taking into account our rapidly ageing population, older people are of particular interest in studying health inequalities. The aim of the present study is to examine the relation between socio-economic status and health-related functioning in older people and to find out how material factors (e.g. the lack of basic goods) and psychosocial factors (e.g. low self-efficacy) compare regarding the explanation of these socio-economic differences. METHODS: Data came from 5061 Dutch men and women aged ≥ 55 years who participated in the longitudinal Study on Medical Information and Lifestyles Eindhoven (SMILE) study. Baseline data were collected between November 2002 and May 2004 and respondents were followed until May 2009 (follow-up range: 0-5 years). Multilevel analyses were used to study the association between educational level and longitudinal changes in physical and mental functioning (i.e. two subscales of the SF-36) and to study the relative contribution of material and psychosocial factors to this relation. RESULTS: Low educational level was associated with poor initial physical and mental functioning. However, no further widening of these gradients was found during follow-up. Material factors reduced the initial educational differences by an average of 29%, whereas psychosocial factors, mastery and self-efficacy in particular, reduced these differences by an average of 60%. CONCLUSION: More than material factors, psychosocial factors, mastery and self-efficacy in particular, explained a large part of the educational differences in physical and mental functioning in older people. Further research is recommended to explore the amenability to change of characteristics that hamper people from taking control over their lives.

Disparities by education level in outcomes of a self-management intervention: the DELTA trial in The Netherlands.

OBJECTIVE: The study examined whether education level was associated with benefits derived from a self-management intervention. Because such interventions increase one's sense of control, it was hypothesized that persons with less education, who generally have a diminished sense of control, would derive greater benefit. METHODS: A randomized trial was conducted with 361 patients aged 60 and older with type 2 diabetes or chronic obstructive pulmonary disease and mild to moderate depression. The intervention provided individualized contacts (two to ten) with nurses who taught participants to take control of their disease. RESULTS: Positive effects on depression, health-related quality of life, feelings of mastery, and self-efficacy were confined to patients with more education; those with only a primary education did not benefit. CONCLUSIONS: Only more highly educated patients profited from a cognitive-behavioral approach to self-management. Patients with chronic conditions who have less education may derive greater benefits if environmental adversities or lower cognitive abilities are taken into account.

Treating depression in diabetes patients: does a nurse-administered minimal psychological intervention affect diabetes-specific quality of life and glycaemic control? A randomized controlled trial.

AIMS: The aim of this study was to examine whether a nurse-administered minimal psychological intervention for depressive symptoms improves diabetes-specific quality of life and glycaemic control in older persons with diabetes. BACKGROUND: Depression is common among persons with diabetes and may have a negative impact on diabetes. Interventions aimed at reducing depressive symptoms may positively influence diabetes-specific quality of life as well. METHODS: A pragmatic, randomized controlled trial was carried out comparing the intervention with usual care among 208 Dutch primary care patients of ≥60 years with type 2 diabetes and co-occurring minor to moderate depression. Data on symptom distress and emotional distress were collected during 2003-2006, and haemoglobin A1c levels were obtained from general practices. Data were analysed using mixed model, repeated measures ANCOVAS. Hba1c was collected retrospectively from general practices between December 2006-February 2007. In July 2007 we retrieved some additional HbA1c data from the medical records of the university hospital. RESULTS: Only in higher-educated persons did the intervention have statistically significant effect on both emotional distress and symptom distress (DSC-R total score at 9 months P=0.001; PAID, 9 months P=0.03). Furthermore, we found an effect on symptom distress in men (9 months P=0.01), and on emotional distress in persons with a shorter diabetes duration (<7 years) (9 months P=0.04). A significant trend over time for haemoglobin A1c was found in favour of the intervention, with a statistically significant difference between groups after 9 months (P=0.02). CONCLUSION: The nurse-administered intervention had limited effects on diabetes-specific quality of life. As only certain subgroups benefited, ways of increasing effectiveness in other groups should be explored. The potentially beneficial effect on glycaemic control is encouraging and needs further research because of small numbers in the analysis.

Mediating effects of psychosocial factors on concerns about falling and daily activity in a multicomponent cognitive behavioral group intervention.

OBJECTIVES: Concerns about falling, or fear of falling, is highly common in old age and has adverse consequences. The development and understanding of interventions to reduce concerns about falling are therefore relevant. This study explored the mediating effects of psychosocial factors on trajectories of concerns about falling and daily activity in a multicomponent cognitive behavioral group intervention. METHOD: The study sample comprised 540 community-dwelling adults aged 70 years or older, with concerns about falling and associated activity avoidance, who participated in a randomized controlled trial evaluating this intervention. Control beliefs, self-efficacy beliefs, outcome expectations, and social interactions, as potential mediators, and concerns about falling and daily activity, as outcome variables, were assessed at baseline, and at two, eight, and 14 months. Data were analyzed with mixed-effects regression models. RESULTS: Small to moderate statistically significant effects of the intervention on the potential mediators were found at nearly all follow-up assessments. Separate psychosocial factors showed modest mediating effects on the outcomes. When all mediators were taken into account simultaneously, 44-76% of the association between the intervention and the outcomes was explained. CONCLUSION: This study showed that the multicomponent cognitive behavioral intervention improved control beliefs, self-efficacy, outcome expectations, and social interactions. These variables mediated the association between the intervention and concerns about falling or daily activity in community-dwelling older adults. This knowledge may facilitate further improvement and development of interventions to reduce concerns about falling and to increase daily activity.

Better health reports when the grass is greener on your side of the fence?: a cross-sectional study in older persons.

OBJECTIVE: To study whether the luxury goods make older people feel in better health and whether this association is similar in higher and lower social classes. METHODS: SMILE consists of a Dutch general population consisting of 2.637 men and women aged 60 years and older in 2007. The SF-36 was used to measure health-related functioning. RESULTS: In the lower social class, having many luxury goods was related to feeling in better physical (OR 2.06, 95% CI 1.39-3.07) and mental health (OR 1.79, 95% CI 1.21-2.64), but not in the higher social class. CONCLUSIONS: There might be a health benefit of keeping up appearances, snobbism, and "conspicuous consumption" in older people from lower social classes.