By Y. Marius. University of Pennsylvania.
Three components of the TTM are hypothesised to mediate the behaviour change process: the decisional balance buy generic provera 2.5mg online, self-efﬁcacy and the processes of change cheap provera 2.5mg fast delivery. Decisional balance involves a comparison of the perceived pros and cons of engaging in behaviour. Studies have demonstrated a signiﬁcant rela- tionship between exercise adherence and perceived pros and cons of exercise in patients with CHD (Tirrell and Hart, 1980; Robertson and Keller, 1992; Hellman, 1997). A recent meta-analysis (Marshall and Biddle, 2001) found that the decisional balance is related to the stage of exercise behaviour change as depicted in Figure 8. The pros of exercise increase with advancing stage of change, with the largest increase evident from the precontemplation to the contemplation stage. The perceived cons of change decrease across the stages, with the most pronounced decline occurring from precontemplation to contemplation. Therefore, it seems that increasing perception of the pros and decreasing per- ception of the cons of exercise are important to increase physical activity. Similarly, Hellman (1997) reported a decline in the perceived costs of exercise and an increase in the perceived beneﬁts of exercise, with advancing stage of change in a group of patients who had previously attended in-patient CR. Self-efﬁcacy was integrated into the TTM from Bandura’s Self-Efﬁcacy Theory (Bandura, 1977), and is deﬁned as an individual’s conﬁdence in his or her ability to perform a speciﬁc behaviour. Self-efﬁcacy is an important deter- minant of exercise compliance in cardiac rehabilitation settings (Robertson and Keller, 1992; Vidmar and Rubinson, 1994). Findings from the meta- analysis (Marshall and Biddle, 2001) demonstrated a signiﬁcant relationship between exercise self-efﬁcacy and stage of change, as illustrated in Figure 8. The graph shows that conﬁdence to be active increases with each forward movement in stage of change. Individuals in the precontemplation stage demonstrate the lowest self-efﬁcacy, whereas those in maintenance have the highest self-efﬁcacy. Furthermore, the relationship between exercise self- efﬁcacy and stage of change is non-linear, and self-efﬁcacy seems to be Maintaining Physical Activity 199 Figure 8. Relationship between the stages of change and decisional balance, self- efﬁcacy and processes of change. Processes of Exercise Behaviour Change Process of Change Deﬁnition (adapted from Marcus, et al. Similarly, Hellman (1997) reported that exercise self-efﬁcacy is signiﬁcantly related to stage of exercise behaviour change in CR participants. The processes of change are strategies and techniques that individuals use when changing their exercise behaviour (Marcus, et al. The meta-analysis (Marshall and Biddle, 2001) found that the frequency of using the processes of change varies across the ﬁve stages of change (see Figure 8. The use of experiential and behavioural processes increases with advancement through stages, with the largest increase occurring from pre- contemplation to contemplation and preparation to action. Furthermore, the frequency of using the behavioural processes is more important than that of experiential processes, from the contemplation stage onwards. There is little change in process use from the action to maintenance stages, implying either that maintenance of physical activity does not require further change in expe- riential and behavioural strategies, or that individuals use additional strategies to those proposed by the processes of change. Similarly, an observational study of patients who had previously attended a cardiac rehabilitation programme Maintaining Physical Activity 201 found that the experiential and behavioural processes were used more fre- quently with advancing through the stages of exercise behaviour change (Hellman, 1997). Changes in the stages and processes of change for exercise behaviour from baseline to six months were measured in a longitudinal study of a group of healthy individuals (Marcus, et al. At six months, individuals were categorised into four groups: stable sedentary (remained in either precon- templation or contemplation at both assessments), stable active (remained in preparation, action or maintenance at both assessments), adopters (progres- sion from precontemplation, or contemplation to preparation, action or main- tenance) and relapsers (regression from preparation, action or maintenance to either contemplation or precontemplation). This study found that behav- ioural change process use did not change for individuals in the stable active or stable sedentary categories. However, behavioural change process use was signiﬁcantly greater for individuals who remained active, compared to those who stayed inactive over the study period. Adopters reported a signiﬁcant increase in the use of experiential and behavioural processes, whereas relapses reported a signiﬁcant decline in the use of all behavioural processes and one experiential process (dramatic relief). These ﬁndings suggest that continued use of behavioural strategies may be important to prevent relapse. Further- more, a signiﬁcant decline in dramatic relief among relapses suggests that either belief in the health beneﬁts of physical activity decreases considerably when individuals are no longer physically active, or that inactivity is no longer viewed as an emotional issue. At the beginning of phase II, 43% of participants were in the action and maintenance stages (i. At the end of the programme, 96% of participants were in the action and maintenance stages, and self-reported physical activity had signiﬁcantly increased. Moreover, there were signiﬁcant increases in exercise self-efﬁcacy and the use of behavioural processes, and a signiﬁcant reduction in the per- ceived cons of exercise, with no change in the use of experiential processes or perceived pros of exercise. Three months after programme completion, the proportion of patients in the action and maintenance stages had decreased to 80%, and nearly 50% of participants had reduced their physical activity com- pared to the end of the phase II programme. Individuals who had regressed at the three-month follow-up had signiﬁcantly lower scores for self-efﬁcacy and use of behavioural processes, and they had more negative decisional balance scores at the end of the phase II programme, compared to participants 202 Exercise Leadership in Cardiac Rehabilitation who remained physically active at three months. Thus, maintenance of physi- cal activity after completion of a CR exercise programme appears to be asso- ciated with changes in self-efﬁcacy, decisional balance and behavioural processes. These ﬁndings suggest that interventions based on components of the TTM may promote maintenance of physical activity after CR programme completion. Application of the TTM in the general population Interventions based on the TTM are effective in promoting and maintaining physical activity in the general population (Marcus, et al. Marcus randomised 194 sedentary adults to receive either an individualised, stage-matched intervention or a standard intervention over a six-month period (Marcus, et al. The stage- matched intervention involved providing participants with individualised feedback about their physical activity behaviour and stage-matched self-help manuals that were designed to apply the components of the TTM.
Chemoprevention of breast cancer in the orectal cancer by colonoscopic polypectomy discount provera 5mg online. Prevention of stroke raloxifene on risk of breast cancer in postmenopausal by antihypertensive drug treatment in older persons women: results from the MORE randomized trial order 5 mg provera mastercard. Flood AB, Wennberg JE, Nease RF, Fowler FJ, Ding J, Joint National Committee on Dection, Evaluation, and Hynes LM. From the Health Care Financing Administra- ing tests for preventing coronary heart disease in adults. Accuracy of the Cholesterol Education Program (NCEP) Expert Panel on Papanicolaou test in screening for and follow-up of cervi- Detection, Evaluation, and Treatment of High Blood cal cytologic abnormalities: a systematic review. Prevention consensus statement from the National Stroke Associa- of type 2 diabetes mellitus by changes in lifestyle among tion. Department of Health and Human Services, Diabetes generalizability of randomized trials. Type by antihypertensive drug treatment in older persons with 2 diabetes: causes, complications, and new screening isolated systolic hypertension. Update: Preventive medicine and screening Prevention, Detection, Evaluation, and Treatment of High in older adults. Identiﬁcation healthy postmenopausal women: principal results from the and fracture outcomes of undiagnosed low bone mineral Women’s Health Initiative randomized controlled trial. Osteoporosis prevention, diagnosis, and Estrogen/Progestin Replacement Study Follow-up (HERS therapy. Writing Group for the Women’s Health Initiative Investi- screening in older persons. Reuben Geriatric assessment refers to an overall evaluation of the Psychometric Attributes of Instruments health status of the elderly patient. The well-being of any person is the result of the interactions among a number As there are a wide variety of assessment instruments, it of factors, only some of which are medical. In the geri- is important for practitioners to chose those that have atric population, these various factors may have become been appropriately evaluated for validity, reliability, and, impaired at different rates. The ultimate goal of these evaluations is to Validity improve or maintain function. Frequently, assessment instruments are used to evalu- Validity is the extent to which an assessment instrument ate the various components of patients’ lives that con- accurately measures the quality it is intended to measure. These components, or Usually, validity is the relationship between an instru- domains, include cognitive function, affective disorders, ment’s performance and a "gold standard," another sensory impairment, functional status, nutrition, mobility, instrument, or a future event. Sensitivity is the extent to which a test is able to ment itself can take many forms: it can be a structured 1 detect persons with a disorder. Speciﬁcity is the extent interview, a self-reported questionnaire, a physical or to which those with a negative test result do not have a mental task, or a blood test. The results from an individual upon disease prevalence in the population being exam- patient assessment can be used to establish a baseline for ined. However, they are frequently combined with preva- future comparisons, form diagnoses, monitor the course lence rates to estimate positive and negative predictive of treatment, provide prognostic information, and screen values. This last application is the most mize sensitivity at the expense of speciﬁcity to capture as common use for instruments that are employed in the many patients with the condition as possible. This chapter provides an overview of geriatric assess- Reliability ment instruments. We begin by brieﬂy describing some of the basic psychometric attributes that should guide the Reliability is the ability of a test to arrive at the same use of any instrument. Interrater end with a review, arranged by functional domain, of reliability refers to the degree of similarity between some useful instruments. The emphasis is on those instru- two scores obtained by two simultaneous observers. A list of some suggested scores obtained serially by the same observer over a time instruments appears in Table 17. Domain Instrument Sensitivity Speciﬁcity Time (min) Cutpoint Comments Cognition Dementia MMSE7 79%–100%a 46%–100% 9 <24b Widely studied and accepted Timed time and 94%–100% 37%–46% <2 <3 s for time and Sensitive and quick change test20 <10 s for change Delirium CAM23 94%–100% 90%–95% <5 Sensitive and easy to apply Affective GDS 5 question 97% 85% 1 2 Rapid screen disorders form33 Visual Snellen chart4 Gold standard Gold standard 2 Inability to read Universally used impairment at 20/40 line Hearing Whispered voice4,40 80%–90% 70%–89% 0. Responsiveness refers to an instrument’s ability to detect This criterion does not mean, however, that they must clinically signiﬁcant changes over time, even if these 2 be administered by the primary clinicians. Tests demonstrating a high sensitivity utilities of administering various instruments in clinical to small changes may have an increased rate of false settings by nonphysician ofﬁce staff are reasonably positives. Furthermore, patients can are likely to be responsive, the two terms are not complete self-administered surveys at home. Self-administered Strengths and Weaknesses questionnaires, although efﬁcient and inexpensive, may of Instruments introduce elements of underreporting or overreporting because of lack of motivation or denial of dysfunction. Assessment instruments are simply tools to begin an Furthermore, elderly patients may require or request evaluation process. It is easy to overestimate their value assistance from family members when completing the and make their application an end unto itself. The crucial questionnaire, thus introducing the biases of a second step in the use of assessment instruments is the inter- reporter; this may be especially true for those with cog- pretation of their ﬁndings. However, even trained interviewers based on positive or negative results is one of the most can introduce their own biases during the information- 5 important duties of the clinician. The choice of which assessment instrument to use is Another element to consider is the contrast between based on a careful consideration of its relative strengths measures of capacity and those of performance.
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