Evidence-based Guidelines on Health Promotion for Older People: Social determinants, Inequality and Sustainability

National Evaluation Report – Czech Republic Eva Křížová With special acknowledgements to Hana Janečková, Petr Veleta, Lumír Komárek, Věra Kernová, Hana Vaňková, Leona Škaloudová, Věra Tučková

Third Faculty of Medicine, Charles University in Prague, Czech Republic

Co-financed by the European Commission

March 2008

Co-financed by Fund for a Healthy Austria "This project has been funded with support from the European Commission. This report reflects the views only of the author, and the Commission cannot be held responsible for any use which may be made of the information contained therein."

Contents

1 The Evaluated Health Promotion Cases for Older People ................................ 1 1.1

National Selection Procedure .....................................................................................1

1.2

Short presentation of the Three Health Promotion Case for Older People ................2

2 Results of the National Case Studies ................................................................. 4 2.1

2.2

2.3

In-depth Analysis of Case 1: Delicious Life ................................................................4 2.1.1

Structure Evaluation Results....................................................................................... 4

2.1.2

Process Evaluation Results ........................................................................................ 7

2.1.3

Outcome Evaluation Results....................................................................................... 9

In-depth Analysis of Case 2: Reminiscence therapy ................................................12 2.2.1

Structure Evaluation Results..................................................................................... 12

2.2.2

Process Evaluation Results ...................................................................................... 16

2.2.3

Outcome Evaluation Results..................................................................................... 18

In-depth Analysis of Case 3: „Dance therapy”..........................................................23 2.3.1

Structure Evaluation Results..................................................................................... 23

2.3.2

Process Evaluation Results ...................................................................................... 25

2.3.3

Outcome Evaluation Results..................................................................................... 27

3 Conclusions........................................................................................................ 30 3.1

Recommendations for Successful Health Promotion for Older People ....................30

3.2

Specific Recommendations for Project Aims............................................................31

4 References .......................................................................................................... 33 5 Annex .................................................................................................................. 35

1 The Evaluated Health Promotion Cases for Older People For the purpose of case analysis three successful health promoting projects were chosen. Each of them is different so that the diversity of health promotion in elderly can be mirrored. •

“Delicious Life“

•

„Reminiscence Therapy “

•

„Dance Therapy“

1.1 National Selection Procedure The selection procedure resulted from the previous research phases of the project HealthPROelderly. During the first research phase literature items have been collected in order to document the activity of health promotion for elderly at the national level. Thanks to a collaboration with the National Institute of Public Health the access to the database of projects subvented within the National Programme for Health – Health Promotion Projects was guaranteed. The second source of information were the collegial contacts established in the academic sphere which provided the information on projects subsidised by other financing schemes (like e.g. Internal Grant Agency of the Czech Ministry of Health). The collaborating staff has appointed 8 health promoting projects from the database of the National Institute of Public Health and 2 other have been added thanks to collegial contacts because of their remarkable reputation and innovative content. Each of the entire 10 appointed projects was evaluated according the list of inclusion and exclusion criteria and followingly 3 projects with the highest score were selected with respect to diversity. Therefore one project was chosen in order to represent each of the defined categories – evidence-based, innovative and broader project. Since it was recommended by the coordinators of the 3rd phase the main resource base for the case studies were printed documents, application forms, interim and final reports, articles in newspapers and professional journals, authors´powerpoint presentation from scientific conferences and internet information. Further, leaflets, books, calenders, DVD´s, photos, essays, conference powerpoint presentations which have been produced during the period of projects were used as the source of relevant information. Subsequently, principal stakeholders were interviewed (3-2-2). Two interviews were performed out of Prague in the regional and local settings (Liberec and Chrudim).

healthPROelderly – National Report (Czech Republic)

1

1.2 Short presentation of the Three Health Promotion Case for Older People “Delicious Life“, 2003-2005, National Institute of Public Health, chief coordinator doc. MUDr. Lumír Komárek, CSc. Among the projects gathered in the database of the National Institute of Public Health “Delicious Life” (2003-2005) was highly valued and received the best reputatiton as well as it already has been involved in the international database of good practice EuroHealthNet at the moment of our search. It is a project which intentionally involves a European and global dimension, because it introduces the knowledge and cooking skills of the main world cuisines to the Czech public and emphasises their healthy elements. The consequence is an enrichment of the Czech cooking stereotypes, knowledge of new types of food and cooking procedures (olive oil, fishes, sea fruits, exotic fruits etc.). The focus was laid on the social and joyful athmosphere of collective cooking and degustation in small groups instead of lecturing and theoretical health education to large auditory. Tasting and sensual experience in a friendly group were prior to mentoring and stressing the healthy or unhealthy elements. Not only seniors were the target group but also public health experts were educated and stimulated in agenda setting and networking in health promotion in elderly. In some facilities the project continues to run with the use of approved methodics but with own resources which documents an effective sustainability of the project. A following project with the title "Pharmacy on your plate" (Lékárna na talíři) which is managed by MUDr. Kernová, National Institute of Public Health, further elaborates the recommended nutrition guidelines for elderly and pays a special attention to specific alimentation needs in selected chronic diseases (e.g. diabetes). The project was implemented in seniors homes with domiciliary (social) services for its inhabitants and partially in minor extent also for external visitors. „Reminiscence Therapy”, 2005-2007 (original title: Effect of reminiscence therapy on health status and quality of life in inhabitants of residential homes“), Internal Grant Agency of Health Ministry of the CR, Gerontocentrum Praha, chief coordinator PhDr. Hana Janečková, PhD. This project represents a health promoting activity which adresses a broader theme. It focuses not only on mental health and social participation but it influences also somatic status and quality of life. Moreover it has a crucial impact on intergenerational mutuality and improvement of personal relations between staff and residents in residential homes. The project is based on the theory of reminiscence (R.Butler) and its application in elderly residents of institutions. Narrations in small groups, life stories, objects of memories, creating "historical rooms" in residential homes helps enrich the social activities of patients, who are stereotypically considered by staff as passive, less communicative and less collaborative. It enhances also self-esteem, the mutual respect of the residents, deepens reciprocal healthPROelderly – National Report (Czech Republic)

2

understanding and enhances intergenerational relationships. Even when the main focus is laid on reminiscing (verbal activity) and on mental health, the fact that it takes place in small groups affects the way how people pay attention to their look, dress and general outfit. This new attention paid to appearance, coiffure and overall visage increases subsequently the motivation to social participation which can very likely lead to somatic improvements and/or subjective well-being. Financial and organisational demands of the project are low. Only a training course of reminiscence therapists and a room for reminiscence were required before a reminiscence group can be created and launched. The activities were highly valued by the residents as well as by staff. The project included the scientific measurement of health and psychological effects of reminiscing and systematically collected and analysed the relevant data. “Dance Therapy”, 2005-2007, (original title: „Effect of dance therapy on health status and quality of life in inhabitants of residential homes“), Internal Grant Agency of Health Ministry of the CR, Gerontocentrum Praha, chief coordinator mgr. Petr Veleta The project on dance therapy for inhabitants of residential homes belongs to innovative projects which are based rather on creativity and artistic perception of life. Dance movement is hence not perceived as a source of an artistic impression neither as a means of aesthetic enjoyment. It serves rather as an elementary instrument how internal emotions can be visualised by body movement and how vital force and human existence can be non-verbally expressed. The project has been successfully running in different places and facilities of the Czech Republic in the course of several last years even without a long-term financial subvention by official grant programmes. The engagement of its founder Petr Veleta who is a former professional dancer and who personally participated in dance lessons and later on started the education of dance therapists has contributed essentially to the prosperity of the project. Even when the idea of dance lessons was the inspiration from Great Britain Petr Veleta has substantially modified the programme on the basis of his own experience and with respect to the Czech reality. The project which is mentioned in this database has focused on scientific evaluation and measurement of health effects of dance therapy on general health status, quality of life and well-being of elderly residents of social care institutions (pensioners homes). The project aims at inclusion of invisible population (residents with Alzheimer disease). The preliminary findings document a positive impact of dance therapy on general health status and subjectively perceived quality of life.

healthPROelderly – National Report (Czech Republic)

3

2 Results of the National Case Studies 2.1 In-depth Analysis of Case 1: Delicious Life 2.1.1 Structure Evaluation Results 1. Target group Delicious Life was designed for inhabitants of homes with domiciliary services at the age 65+, although the age limit was not strictly defined (in Liberec e.g. the age varied from 57 to 86 with the average 75 years). Inhabitants of those homes are independently living in their own individual or marital households. The home is equipped with certain special services for elderly people and provides further supply of services like flat cleaning, supply of warm meals, help in personal hygiene etc. Those homes are usually administered by Local or Regional Centres of Social Help and Services or by institutions with similar missions (Centre of Health and Social Care). At the beginning of the pilot phase the category of lifestyle was inquired by a questionnaire both in potential future participants and in those who would not participate. During the implementation phase seniors were invited to contribute by their own recipes or in some places seniors have participated directly in preparation of the food. In one institution seniors have prepared food decoration which was placed in the workshop rooms. Voice of older people was monitored not only in the preparation period but also during the implementation phase. The project did not address specific subgroups of elderly and was not gender or condition specific. It was directed at seniors generally. 2. Theoretical foundation Even when there is no absolute consensus in the nutrition theory there are commonly shared and accepted recommendations most usually represented by the WHO nutrition recommendations. Also, the so called food pyramid served as an instrument of healthy food assessments for elderly. Apart from theory, long-term practice of the staff and experts has contributed to a working consensus within this project which aimed at improvement of nutrition in elderly. In the documents also a concept of “gastrotherapy” has been mentioned which expresses the influential role which food and nutrition have on our somatic and mental health. While unhealthy food can make people sick, healthy nutrition can enhance their recovery and improve at least their quality of life providing new joyful experiences and impressions. The focus was laid on maximal use of creativity, activization and pleasure during the everyday preparation of meals and on innovation and diversity thanks to stressing some typical products of world cuisine (olive oil, seafood etc.). As a side effect, not only a gastronomic but also a cultural experience was reached possibly enhancing healthPROelderly – National Report (Czech Republic)

4

the process of Europeanisation at the moment of accession of the Czech Republic to European Union in 2004. 3. Health determinants Life style was the central category in which two basic behavioural components were stressed – nutrition and physical movement. The project addressed them both even when nutrition was emphasised more strictly whereas physical warm-ups created an introductory opening of each cooking and tasting sessions. However, health education was conceived not in the traditional theoretical way but the emphasis was laid on a direct involvement of participants in the process of preparation new meals and their tasting within a group in a friendly atmosphere. Hence, social participation and empowerment were certainly addressing mental health as a further health determinant. At the beginning, 935 persons (who did not participate later in the project) were interviewed about health-related lifestyle, among them 206 males and 729 females. 21% of the sample considered nutrition as a very essential part of their lives, 28% as very important, and 39% as important. Only 11% of respondents believed that food (meals) were less important or unimportant part of their lives. 73% of respondents assessed food as the essential or important health determinant. 89% of them try to follow healthy nutrition and 72% do some physical exercise. 45% do physical exercise daily, 20% several times a week. The most frequent physical activity was walking and gardening. 4. Settings The project was implemented in particular housing and service facilities for elderly. There were three types of settings. First was represented by residential homes with social (domiciliary) services in 3 regions of the CR, the second by pensioners homes in 2 regions of the CR and one was the Day Care Centre of Charita (Caritas) in 1 region. The difference lies in the type of housing and the scope of services. While in the residential homes with domiciliary (social) services the clients live in their independent households located in one facility and can use the supply of client-centred services, the life in pensioners homes is subordinated to the institutional order and rules. People can choose from single or double or shared rooms, however they are fully served with catering and other health and social care and do not have their individual households. Charita (Caritas) Day Care Centre is an example of an out-patient facility which provides care and assistance in satisfying daily needs like personal hygiene, food etc., however in the evening clients return back home. Concerning geographical selection regions and local addresses were chosen on the basis of collegial networks and previous collaboration which existed hitherto.

healthPROelderly – National Report (Czech Republic)

5

5. Involvement of stakeholders National Institute of Public Health was the coordinator of the project and it collaborated with as many as 14 regional and local partners in 11 cities. Centres of social help and social services or Centres of health and social care, eventually Pensioners Homes or Day Care Centre were the institutions which implemented the project in their settings. In some case they were assisted e.g. by Regional hygiene stations. Depending on concrete needs and conditions local catering schools and local sponsors helped carry out the activities by provision of services (cooking), food (Meinl supermarket) or finances. 6. Goals The project aimed to improve nutrition and physical activity of elderly in residential homes and also from independent households, to offer a new gastronomy experience and enhance diversity in healthy cooking, to provide healthy food without stressing its healthy qualities but rather due to gustatory perception in a friendly environment. Empowerment and social participation were considered be important supporting factors and those goals were expected to be reached by involving seniors as suppliers of healthy recipes and by direct inclusion of some of them in the cooking teams. Apart from food and nutrition an emphasis was laid on regular and ageappropriate physical exercise, hence a short warm-up was the necessary opening moment of each cooking and tasting workshop.

http://www.eurohealthnet.eu, 2004.

7. Management structure and budgetary arrangements In 2003 a pilot project was launched which financed total activities within it, so that both the activity of the coordinating centre and those of regional and local collaborating partners were covered. In 2004 the project was continuously carried on according to its established methodology which was completed during the pilot phase. Material expenses were billed to the coordinating centre (National Institute of Public Health) or were reimbursed by him retrospectively. The collaborating partners have spent their expenses accordingly the approved budget items. In 2005 the state subvention was reduced and ultimately provided only to the coordinating centre (National Institute of Public Health), while the regional or local collaborating partners were responsible to raise their own resource in order to continue the activities within the project. Usually, a user´s fee, municipal resources and/or sponsorship were applied in order to sustain the project. Since the central subvention granted by healthPROelderly – National Report (Czech Republic)

6

National Programme on Health was reduced in 2005 the collaborating partners became financially independent on the coordinating centre. In the following years material expenses must have been financed from regional and local resources. Labour of lecturers and other staff was usually involved in the regular fulltime job or was performed voluntarily without financial reward.

2.1.2 Process Evaluation Results 8. Involvement and activation of the target groups At the beginning a small group of potential participants was selected by the staff. This group looked into the first session and on the basis of this introductory experience trust was built up between the project managers and users. First participants were very satisfied with the session and they spread out their positive impression among the other inhabitants of the facility which led to an enormous increase in demand of participants so that even waiting lists have emerged as the means of how the surplus in demand was solved. Later, external visitors received the opportunity to participate so far there was a free place in the group. 9. Implementation of the theoretical foundation The project combined diverse strategies and was carried out on the basis of a commonly shared screenplay which served as a “recommended methodical procedure”. First, within the project a follow-up series of “Delicious Wednesdays” was prepared in each of the participating facilities. Delicious Wednesdays were considered be the central activity and were conceived as a workshop, where food of selected world cuisines was prepared, evaluated from the view of nutrition expertise, tasted by participants and evaluated by them from the gustatory point of view. Participants were invited to bring their own healthy recipes, to try presented meals at home or to prepare some food decorations. However, with respect to psychological traits of higher age no dramatic changes in nutrition were presented as necessary, rather minor realistic modifications of present habits and eating stereotypes were recommended. Further, practical advice was given to participants how to replace inaccessible or extremely expensive components of selected cuisines with similar Czech products. In the beginning of each workshop a short physical warm-up took place and a short theoretical assessment of healthy potential and unhealthy risks of the presented cuisine were summarised. 10. Addressing of health determinants Nutrition and physical movement were addressed by new knowledge and skills which made seniors familiar with some European or Asian cuisines. Short lectures took place preceding the main item of the programme which was cooking and tasting healthPROelderly – National Report (Czech Republic)

7

new dishes and products. In each session a short physical warm up was hold in order to remember the beneficence of regular physical activity also at higher age. 11. Accessibility of the setting The setting was accessible for its inmates and also external visitors from the neighbourhood could come without any geographical barriers. 12. Involvement and activation of people/organisations/NGOs It was not a goal of the project to activate non-governmental associations, however thanks to articles and interviews which were publicized in media local NGO´s raised their interest in the project and have overtaken its certain elements in their activities (like tasting of healthy food on particular occasions). 13. Strategies and methods Physical activity, workshop on cooking and tasting of selected world cuisines, theoretical lecture, evaluation.

14. Changes during the project In 2005 which was the last year of the 3-year project the central financial subvention form the National Programme for Health – Health Promoting Projects was cut and the collaborating partners had to gain their own resources in order to cover their expenses. However, this fact did not lead to a collapse of the network. Only in 1 collaborating centre due to changes in staff the continuation of project was stopped. A person has left who was responsible for management and the new staff did not want to overtake her responsibility. In general terms, overall problems were considered be only minor by the interviewed persons and easily overcome thanks to personal engagement of involved staff and external lecturers.

healthPROelderly – National Report (Czech Republic)

8

2.1.3 Outcome Evaluation Results 15. Kind of evaluation and results. Evaluation methods The project elaborated both the process and the outcomes evaluation. In the frame of process evaluation questionnaires inquired the eating stereotypes and the health-related lifestyle behaviour. Concerning outcomes evaluation the focus was on changes in lifestyle behaviour which occurred after the project was terminated. 16. Outcomes concerning cost-effectiveness Project leaders have provided us with the information on the 3-year budget in CZK, however these data do not allow an in-depth analysis of cost-effectiveness for lacking benchmarks. Also, only with difficulties the overall resources of the coordinating centre and regional collaborators can be clearly separated from the project-related budget. 17. Effects on health (physical, mental, social health) It was not possible to measure direct health effects on participants because irregular workshops on nutrition and physical activity is not likely to influence directly and in a measurable way the health status of elderly. Changes were expected rather in behaviour than in the somatic health status. The final survey documents that almost one half of participants (46%) changed their food habits (48% of females and 34% of males) and 39% changed their physical activities (41% of females, 30% of males). Almost all participants (95%) appreciated the friendly atmosphere of the workshops.

http://www.eurohealthnet.eu, 2004

18. Sustainable effects In some partner institutions new recipes and physical warm-ups were incorporated into the weekly menu and daily programme. The project contributed both to the improvement of individual boarding which people prepare for themselves in their independent households and to improvement of the institutional catering which is provided as a domiciliary service by the Centres of social help and social services (or similarly by the Centre of health and social care). The daily menu was enlarged with one salad and elements of the world cuisine may be found in the daily offer. The enrichment of the daily menu was stimulated by the goals and values of the project “Delicious Life”. healthPROelderly – National Report (Czech Republic)

9

http://www.eurohealthnet.eu, 2004

19. Transferable effects The common methodical procedure involved 4 general categories of cuisines namely the Mediterranean, Central-European, Asian and Other Cuisine. Within each category the concrete local organiser could have addressed a cuisine of their choiceAustrian or German or Czech within Central European, Japanese, Indonesian, Thai or Chinese within Asian, Greek, Italian or Spanish in the category of Mediterranean cuisine, Vegetarian and other special nutrition approaches within the Other diet. The guidelines provided both commonly shared instructions and free space enough for local variations according local needs and resources. The screenplay of “Delicious Wednesdays” which involved a series of successive health promoting activities was the basis of the encounters. First a physical warm-up was introduced and then a preparation of selected example of world cuisine took place accompanied with a short lecture on its traditionally healthy elements or risks. Then collective tasting and evaluation of the food followed. Further, seniors were asked to bring their own healthy recipes and participate directly in the food preparation and in the collection of healthy recipes which was published as one of the outcomes (calendar “The Taste of Replenished Age”).

http://www.eurohealthnet.eu, 2004

20. Public recognition, awards The project did not receive an award, but it was involved as an example of good practice in the international database of health promoting projects which was collected within EuroHealthNet (see references). The project was also repeatedly healthPROelderly – National Report (Czech Republic)

10

posted in mass media (e.g. Komárek et al 2005) and succeeded in reaching a great attention of general public and public health experts.

http://www.eurohealthnet.eu, 2004

21. Consumers satisfaction Questionnaire surveys were conducted both in participants and nonparticipants. They mapped the consumer satisfaction and changes in lifestyle and health-related behaviour in participants and those who received the recipes books. 94% of participants (N=312, 61 males, 251 females) have wished the project to be continued. 80% of respondents were familiar with the recipe book “The Taste of Replenished Age” and considered it as a very useful tool. More than 55% did like the food which was prepared during “Delicious Wednesdays”. Between 72% and 90% of participants evaluated the particular parts of the project (nutrition, physical movement, lifestyle) positively. 22. Empowerment of older people Older people were invited to participate directly in the project by influencing the structure and content. They could have commented the programme structure which was subsequently modified according to their notes. They were also stimulated to bring their own recipes which were published after a revision by nutritionists in a Calendar of healthy recipes.

healthPROelderly – National Report (Czech Republic)

11

2.2 In-depth Analysis of Case 2: Reminiscence therapy 2.2.1 Structure Evaluation Results 1. Target group The project addressed seniors who live permanently in a residential type of social care institution which is called “pensioners home”. This type of housing represents a full board accommodation. Residents do not live in their independent households but usually share the rooms and are provided with food and other social services. The project generally focused on population 60+, but the minimum age was not strictly restricted, hence in the total group the age varied from 59 to 102 years, while in the intervention group the age varied from 59 to 94 years with the average 81.6, 81.7 eventually. 102 residents who participated in a series of 8 reminiscence sessions in 12 pensioners homes were the intervened group, while 101 residents of the same institutions represented the control group, i.e. they did not participate in the reminiscence groups during the research project. In the intervened group the proportion of people with tertiary education was 18.7 %, while in the control group it was slightly higher (21.8 %). This proportion seems to be representative to the population of Prague city or it even may be higher owing to the high age group of participants. No condition-specific selection of participants was made which led to a mix of seniors in different mental and somatic state both in intervened and in control groups. ¾ of participants in both groups were females (75 and 77%). The wards were comparable as for the nursing care needs of the clients, their health status and level of personal dependence. 2. Theoretical foundation The term reminiscence was introduced by R. Butler (1963) as “life review” connected with remembering of pleasant and unpleasant events and accompanied by strong emotions. The method was usually reserved only for trained professional therapists. Naomi Feil (1996) used reminiscence for validation of disoriented patients. According to Erikson (Erikson 1998), remembering enables life assessment and balancing of life. Systematic reminiscence work was developed by Pam Schweitzer (1998). She emphasised the value of narratives, life books, reminiscence groups and other methods of reminiscence therapy for health promotion (Schweitzer 2002, 2006). There are regular International Reminiscence and Life Review Conferences (2007 in San Francisco). In 16 countries of Europe there exists a European Reminiscence Network which was established by Pam Schweitzer since 1993. The Czech researcher Hana Janečková who represented the Czech Alzheimer Society participated in this European Reminiscence Network. In her own project she further evolves the above-mentioned theoretical presumptions and anticipates not only improvement of individual health in the holistic view but also a change for a better in social interactions among inmates/residents and between inmates and staff. She also healthPROelderly – National Report (Czech Republic)

12

believes that this type of activity if incorporated in the institutional structures might help attain the statutory standards of quality of care in social services (required by the Law on Social Service since 2007) thanks to life stories and memories which provide persons with their unique identity. Janečková accepts Wood´s definition of reminiscing (Woods et al. 1992) which is “a vocal or silent recall of events in a person´s life, either alone, or with a person or group of people”. 3. Health determinants Mental health and social participation were the central categories which were addressed by this project. By the means of re-establishing the personal identity thanks to narrating and sharing the memories the empowerment of previously anonymous inmates in their self-esteem but also in their social relations in the group and with the staff were expected. Similarly, a better social integration and cohesion might be reached. Figure 1: Intervened and control group by MMSE score

60% 50% 40% 30% 20% 10% 0%

Control N=102 Intervened N=99

0-14

15-24 25-26 27-30

Source: From the final report of the project elaborated by Hana Janečková

Any score over 27 (out of 30) is effectively normal1, hence according to the research team 44% of the entire sample (both intervened and control groups) did not have any cognitive impairment whereas 16% were assessed as borderline group (2526 points). Almost one third (31%) was in the category mild and moderate dementia

1

The original Folstein´s scale suggested max 30 points,