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Chronic diseases may impact older adults’ health outcomes, health care costs, and quality of life. Self-management is expected to encourage individuals to make autonomous decisions, adhere to treatment plans, deal with emotional and social consequences, and provide choices for healthy lifestyle. New eHealth solutions significantly increase the health literacy and empower patients in self-management of chronic conditions.
This study aims to develop a Community-Based e-Health Program (CeHP) for older adults with chronic diseases and conduct a pilot evaluation.
A pilot study with a 2-group pre- and posttest repeated measures design was adopted. Community-dwelling older adults with chronic diseases were recruited from senior activity centers in Singapore. A systematic 3-step process of developing CeHP was coupled with a smart-device application. The development of the CeHP intervention consists of theoretical framework, client-centric participatory action research process, content validity assessment, and pilot testing. Self-reported survey questionnaires and health outcomes were measured before and after the CeHP. The instruments used were the Self-care of Chronic Illness Inventory (SCCII), Healthy Aging Instrument (HAI), Short-Form Health Literacy Scale, 12 Items (HLS-SF 12), Patient Empowerment Scale (PES), and Social Support Questionnaire, 6 items. The following health outcomes were measured: Montreal Cognitive Assessment, Symbol Digit Modalities Test, total cholesterol (TC), high-density lipoproteins, low-density lipoproteins/very-low-density lipoproteins (LDL/VLDL), fasting glucose, glycated hemoglobin (HbA1c), and BMI.
The CeHP consists of health education, monitoring, and an advisory system for older adults to manage their chronic conditions. It is an 8-week intensive program, including face-to-face and eHealth (
The CeHP is feasible, and it engages and empowers community-dwelling older adults to manage their chronic conditions. The rigorous process of program development and pilot evaluation provided valid evidence to expand the CeHP to a larger-scale implementation to encourage self-management, reduce debilitating complications of poorly controlled chronic diseases, promote healthy longevity and social support, and reduce health care costs.
The life expectancy of Singaporeans has increased from 76.1 years in 1990 to 84.8 years in 2017 [
Self-management refers to daily activities that individuals take for themselves and families to stay healthy and to care for long-term illness [
Self-management is expected to make the health care system more patient-centric by shifting responsibilities toward individuals in terms of making autonomous decisions, adhering to treatment plans, and dealing with emotional and social consequences caused by their medical conditions [
Additionally, social support from family, friends, and neighbors serves as a complementary strategy for enhancing an individual’s self-management skills [
The modern health care system leverages on innovation and technologies to empower patients and families in self-care. Compared to conventional approaches to patient education, new eHealth solutions such as mobile health, web-based learning, and telehealth significantly increase patients’ health literacy and empower them in self-management [
In an aging population, it is necessary to shift the health care landscape toward the community to ease the burden of acute hospitals [
This study describes a systematic 3-step process of developing the CeHP, coupled with the use of a smart device application. A pilot study with a 2-group pre- and posttest repeated measures design was adopted.
Subjects were recruited from Community Nurse Posts at two senior activity centers (SACs) within the neighborhood in the east region of Singapore. The strategic location ensures that the nursing service is convenient and accessible for the older adults living in the community. The services consist of health screening, individual and group health coaching, health and geriatric assessment, chronic disease monitoring and education, care referral and coordination, and complex nursing care [
Development of the CeHP consisted of a systematic 3-step process: theoretical framework, a client-centric participatory action research process, content validity assessment and pilot testing.
A systemic scoping review identified the focus of the theoretical approaches was behavior change in most of the self-management programs (SMPs). The most frequently used theory was the social cognitive theory, where the participants’ self-efficacy increased as a result of the SMPs, and evidence showed that the associated behavior change could affect various health outcomes [
The individual’s self-management is interactive and influences a variety of health outcomes, especially for individuals living with chronic conditions. In our study, the following outcomes in relation to the factors are measured: (1) health outcomes: cognitive function (Montreal Cognitive Assessment [MoCA], Symbol Digit Modalities Test [SDMT]), lipid profile (total cholesterol [TC], high-density lipoprotein [HDL] cholesterol, and low-density lipoprotein [LDL]/very-low-density lipoprotein [VLDL] cholesterol), glycemic profile (fasting glucose and glycated hemoglobin [HbA1c]), and BMI; (2) individual outcomes: sociodemographics, self-care capabilities (Self-care of Chronic Illness Inventory [SCCII]), health literacy (Short-Form Health Literacy Scale, 12 Items [HLS-SF12]), empowerment (Patient Empowerment scale [PES]); (3) family outcomes: lifestyle (Healthy Aging Instrument [HAI]); and (4) environmental outcomes: social networks and support (Social Support Questionnaire, 6 items [SSQ6]) (
Self-management framework. HAI: Healthy Aging Instrument, HbA1c: glycated hemoglobin, HDL: high-density lipoprotein, HLS-SF 12: Short-Form Health Literacy Scale, 12 Items, LDL: low-density lipoprotein, MoCA: Montreal cognitive assessment, PES: Patient Empowerment Scale, SCCII: Self-care of Chronic Illness Inventory, SDMT: symbol digit modalities test, SES: socioeconomic status, SSQ6: Social Support Questionnaire, 6 items. [
CeHP was developed to promote older adults’ self-management capabilities with their chronic conditions. CeHP was designed through a 3-stage iterative, client-centric, participatory action research process [
A comprehensive search and evaluation of existing eHealth interventions were carried out. Evaluation from the evidence-based literatures provided a fundamental understanding of the current interventions. A systematic review examined community-based SMPs for older adults with chronic conditions and evidenced that SMPs involved fostering skills to improve problem-solving, health behavior, and disease management [
We have conducted a meta-analysis on the technology-based interventions on diabetes, and the results indicate that technology-based psychosocial interventions had significant effects on diabetes distress, self-efficacy, and HbA1c levels in adults with type 2 diabetes mellitus (T2DM) [
Our researchers conducted focus groups with older adults to explore their needs regarding eHealth. Three focus group discussions were conducted, and the thematic analysis was carried out. Three major themes emerged from the analysis: (1) personal approach in living with chronic diseases (older adults applied positive thinking and accepted the needs to change their habits and follow the instructions of health care professionals); (2) navigating health-related information (older adults obtained health information from health care professionals, health talks from reputable organizations, experiences of friends or family, internet resources, talk shows in the media, and web-based videos); and (3) decision-making on sieving credible eHealth information (older adults often experienced online health resources are overwhelming and confusing, they either turn to health care professionals for advice or use own experience and knowledge to judge the reliability and credibility of the web-based health resources). Details of the qualitative study will be published in a subsequent paper. In addition, our recent scoping review also highlighted the concerns of older adults on the barriers of web-based interventions, such as the lack of access and proficiency in technology, or the lack of interest in the use of digital technologies [
With inputs from the literature and focus groups, the researchers developed the preliminary contents of the CeHP. Based on client-centric design suggestions, the following principles guided the development of the CeHP: (1) the intervention must be designed for older adults, (2) the content must be related to the specific health knowledge deficits that were identified during focus group and literature evaluations, and (3) the content needs to be delivered in a brief and skimmable format to fit the attention span and cognitive capabilities of the older adults. The details of the contents are presented in the Results section.
Formative evaluation took the form of multimodal usability testing [
A committee of experts was formed to evaluate the content validity of the CeHP, including 2 nurse clinicians, 2 physicians, a dietician, a physiotherapist, and a pharmacist, specifically on the clinical relevance and quality of the contents. They rated the contents from 1 (not relevant/appropriate/comprehensive) to 4 (very relevant/appropriate/comprehensive). Content experts were required to provide feedback if they had rated any learning point 2 and below on any of the aspects.
Convenience sampling was used. Recruitment was carried out through word of mouth and recruitment poster at 2 SACs. The inclusion criteria were as follows: (1) age ≥55 years; (2) being able to understand and communicate in either English or Chinese (Mandarin); (3) being able to give consent to participate; (4) living within the community setting; (5) being diagnosed with at least one of these chronic conditions (hypertension, hyperlipidemia, or diabetes mellitus); and (6) being able to commit to the 8-week CeHP. The exclusion criteria are as follows: (1) having severe cognitive impairment; (2) having severe psychiatric disorders; (3) having severe vision impairment; and (4) having severe hearing impairment. Participants in the intervention group were recruited from SAC 1, and they completed the CeHP regimen. Participants in the control group were recruited from SAC 2, and they continued with their usual recreational programs. Recruitment was carried out at 2 SACs at different physical locations to minimize contamination between the two groups.
The questionnaires were administered at two time points: baseline and post intervention. Two trained researchers conducted face-to-face sessions. The questionnaires were conducted in the participants’ preferred language, either English or Chinese (in the participant’s preferred dialect). Each session lasted 45-60 minutes. Each participant was given a cash reimbursement after completing questionnaires and providing blood samples. A maximum of 9 mL of blood in ethylenediaminetetraacetic acid (EDTA) blood tubes was collected from every participant at each time point. The responses were recorded using the web-based e-Survey platform approved by the university. Sociodemographic and clinical data such as age, gender, ethnicity, marital status, employment status, education, housing type, morbidities, alcohol intake, smoking status, and physical activity were recorded. Clinical data such as TC, HDL, LDL/VLDL, fasting glucose, HbA1c, and BMI were also measured before and after the intervention.
The SCCII [
The MoCA is a screening instrument to detect mild cognitive impairment [
Upon collection of blood samples, the EDTA tubes were centrifuged at 1500
Descriptive statistics, including mean (SD) and percentages, were used to summarize the demographic information and outcomes at baseline and post intervention. A paired samples
Ethical approval was obtained from the university’s institutional review board (H-20-028) and the hospital’s Centralised Institutional Review Board (Ref 2020/2051). Researchers explained the purpose of the study to potential participants. Informed consent was obtained from the participant prior to data collection. The participants were reassured that participation in the study was voluntary, and withdrawal from the study would not result in any negative consequences. Confidentiality and anonymity were maintained as no identifiers were recorded in the questionnaires.
The CeHP consists of health education, monitoring function, and an alert and advisory system for older adults to manage their chronic conditions (
Conceptual outline of the Community-Based e-Health Program.
Care4Senior App - Main Screen.
Care4Senior App - Health Library.
During the intervention, the research team conducted weekly face-to-face training and evaluated the participant’s competency in using the
The content validity index (CVI) was calculated, and only when both item-CVI and scale-CVI values were above 0.8, the content of the program would then be considered valid [
Among all screened and invited participants, a total of 15 participants enrolled in the pilot study. However, owing to drop-outs, 8 participants in the intervention (CeHP) group and 4 in the control group completed both baseline and postintervention assessments.
Flowchart of participant recruitment for the Community-Based e-Health Program (CeHP).
Demographic and clinical characteristics of participants in pilot evaluation.
Variables | Community-Based e-health Program group (n=8) | Control group (n=4) | |||||||||||||
Age (years), mean (SD) | 74.4 (6.22) | 69.75 (8.34) | .38 | ||||||||||||
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.48 | ||||||||||||||
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Male | 1 (12.5) | 2 (50) |
|
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|
Female | 7 (87.5) | 2 (50) |
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.71 | ||||||||||||||
|
Chinese | 8 (100) | 3 (75) |
|
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Malay | 0 | 1 (25) |
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.22 | ||||||||||||||
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Single, separated, or divorced | 3 (37.5) | 0 |
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Married | 1 (12.5) | 2 (50) |
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Widowed | 4 (50) | 2 (50) |
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>.99 | ||||||||||||||
|
None or primary education | 6 (75) | 3 (75) |
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|||||||||||
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Secondary school and above | 2 (25) | 1 (25) |
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>.99 | ||||||||||||||
|
Working | 1 (12.5) | 0 |
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Not working or retired | 7 (87.5) | 4 (100) |
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.15 | ||||||||||||||
|
HDBb studio apartment | 3 (37.5) | 4 (100) |
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HDB 3-room apartment and above | 5 (62.5) | 0 |
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.28 | ||||||||||||||
|
Alone | 4 (50) | 0 |
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With others | 4 (50) | 4 (100) |
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.71 | ||||||||||||||
|
>3 times per week | 8 (100) | 3 (75) |
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Never | 0 | 1 (25) |
|
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Current smoker, n (%) | 0 (0) | 1 (25) | .71 | ||||||||||||
Regular drinker, n (%) | 0 (0) | 1 (25) | .71 | ||||||||||||
Hypertension, n (%) | 6 (75) | 4 (100) | .78 | ||||||||||||
Hyperlipidemia, n (%) | 7 (87.5) | 3 (75) | >.99 | ||||||||||||
Type 2 diabetes, n (%) | 3 (37.5) | 4 (100) | .15 |
aAge was compared using the Student
bHDB: Housing and Development Board.
Mean scores of study outcomes.
Measures | Community-Based e-Health Program group (n=8), mean (SD) | Control group (n=4), mean (SD) | ||||||
Baseline | Post intervention | Baseline | Post intervention | |||||
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Maintenance | 85.94 (10.83) | 93.36 (4.85) | .09 | 83.59 (4.69) | 87.5 (14.66) | .56 | ||
Monitoring | 67.29 (24.53) | 70.0 (13.09) | .81 | 52.92 (13.77) | 63.5 (16.56) | .28 | ||
Management | 54.0 (10.47) | 61 (8.21) | .13 | 60 (10.83) | 54 (12.44) | .18 | ||
Confidence | 87.81 (9.95) | 87.5 (10.69) | .95 | 83.13 (10.08) | 78.75 (12.67) | .37 | ||
Healthy Aging Instrument | 147.63 (17.07) | 149.75 (6.82) | .68 | 136.25 (23.26) | 148.25 (15.59) | .10 | ||
Patient Empowerment Scale | 40.63 (3.38) | 43.75 (8.31) | .29 | 39.50 (2.08) | 47.25 (7.54) | .08 | ||
Social Support Questionnaire, 6 items satisfaction total score | 29.63 (4.44) | 28.75 (4.56) | .61 | 27.75 (5.68) | 28.25 (4.79) | .70 | ||
Health Literacy Survey Short Form (HLS-SF12) Index | 30.56 (3.32) | 30.38 (4.03) | .78 | 29.51 (6.35) | 26.39 (6.0) | .06 | ||
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Montreal cognitive assessment total score | 25.13 (3.40) | 23.13 (4.36) | .20 | 19.75 (3.30) | 20.0 (5.72) | .87 | ||
Symbol digit modalities test score | 27.5 (9.68) | 26.0 (14.25) | .56 | 18.75 (2.99) | 19.75 (3.59) | .51 | ||
BMI | 25.19 (3.76) | 24.78 (4.06) | .35 | 25.36 (3.48) | .20 | .68 | ||
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Fasting glucose (mg/dL) | 90.77 (28.32) | 84.12 (13.47) | .26 | 110.54 (24.95) | 124.88 (71.36) | .58 | ||
Glycated hemoglobin (%) | 6.49 (0.84) | 6.31 (0.60) | .11 | 8.13 (0.49) | 7.18 (0.63) | .07 | ||
Total cholesterol (mg/dL) | 115.30 (7.76) | 114.99 (4.76) | .94 | 110.29 (8.12) | 111.53 (9.14) | .68 | ||
High-density lipoprotein cholesterol (mg/dL) | 35.36 (10.46) | 31.38 (7.41) | .29 | 31.20 (5.83) | 32.21 (4.52) | .80 | ||
Low-density lipoprotein/very-low-density lipoprotein cholesterol (mg/dL) | 103.91 (10.49) | 99.10 (16.24) | .25 | 93.69 (12.55) | 88.86 (17.35) | .28 |
a
This paper illustrates a systematic 3-step process of developing a community-based health education program coupled with the use of a smart-device application. Development of the intervention consists of a theoretical framework, a client-centric participatory action research process, and psychometric testing. The rigorous process ensured the validity of the intervention, and explicitly reporting the detailed description of the intervention could facilitate replication of the intervention in the future.
The prevalence of chronic diseases is increasing among the older population. Hypertension, hyperlipidemia, and T2DM are the most common chronic conditions among community-dwelling older adults. The progression of diseases and impact on quality of life can be tapered off by active treatment and self-management. By promoting health literacy and awareness of community health resources, it is feasible to reduce debilitating complications of poorly controlled chronic conditions and subsequent hospitalization, which contributes to the burden of the health care system [
The results from the pilot test revealed that the CeHP was feasible and potentially effective in improving self-management capabilities of older adults. The pilot test demonstrated improvements in fasting glucose, HbA1c, TC, LDL/VLDL, BMI, SCCII indices, HAI scores, although these changes were not significant, which could be due to a small sample size. eHealth interventions have gained popularity among older adults in the recent years. Research has shown that daily monitoring via eHealth interventions increased older adults’ confidence, control, awareness in managing their conditions, prompted more communication with their doctors, and using monitoring records to review their medications [
The results of the pilot test showed improvements in the PES score, albeit not significant. Research has shown that eHealth interventions improved older adults’ self-efficacy for health-decision making and patient-provider communication [
With the high attendance rate (86% in average), high overall satisfaction toward the App (75%), and positive user feedback (
It is noteworthy that many older adults are not technologically savvy despite the rapid increase in internet-based users among the older adult population [
A systematic review reported that eHealth programs provide support and feedback for a healthy lifestyle and highlighted the evidence on the facilitating factors and barriers [
The larger-scale intervention after this pilot evaluation will be compared against a control group in a randomized controlled trial. Owing to low education level in older adults (75% with primary school of below in the pilot trial), we anticipate barriers for these older adults to use technological devices. This will be countered by having face-to-face sessions to teach the older adults in using the
As a pilot evaluation, this phase of the study was carried out to assess its feasibility and refine its structure and operations. The results of the pilot test may be biased owing to the small sample size and the predisposition of the participants being already health conscious. The 8-week duration may also be too short to elicit significant changes in health behaviors that improve health outcomes.
A large proportion of older adults are living with multiple chronic diseases, and thus managing their health in the community is a major public health concern. The CeHP engaged and empowered older adults living in the community to manage their chronic conditions. The rigorous process of program development and pilot evaluation provided valid evidence to extend CeHP to a subsequent larger-scale trial to encourage self-management, reduce debilitating complications of poorly controlled chronic diseases, promote healthy longevity and social support, and reduce health care costs. In the future, eHealth interventions can tap on the resources from volunteers in the community to provide support to the older adults.
Face-to-face seminar attendance rates and participants’ ratings regarding app design and user-friendliness.
Community-based e-Health Program
ethylenediaminetetraacetic acid
Healthy Aging Instrument
glycated hemoglobin
high-density lipoprotein
Short-Form Health Literacy Scale, 12 Items
low-density lipoprotein
Montreal Cognitive Assessment
Patient Empowerment Scale
senior activity center
Self-care of Chronic Illness Inventory
Symbol Digit Modalities Test
self-management program
Social Support Questionnaire, 6 items
type 2 diabetes mellitus
total cholesterol
very-low-density lipoprotein
This research is funded by National University of Singapore Start Up Grant (NUHSRO/2019/081/Startup/06). The research team would like to thank staff and participants from Evergreen Circle Senior Activity Centre and Lions Befrienders Senior Activity Centre for their support in the study. We also thank the nurses from Changi General Hospital Community Nursing Department who assisted with the program. We would like to thank Ms Loh Le Xuan, who assisted with the data collection, and Ms Ho Lip Chuen, who assisted with laboratory assays.
None declared.