Sf36 Analyses Of Safh Courses Jan 09 - Mar 09

An extract from the PCT Health Equity Report (2007- 2009) On SF36 analyses of Healthy Moves and Self-management courses Some findings from the BMed Sci student Project May 2009 titled “AN EVALUATION OF THE IMPACT OF SELF MANAGEMENT COURSES WITHIN TOWER HAMLETS; A) PATIENT/PARTICIPANT ASSESSMENT OF COURSES AND B) PRIMARY CARE CLINICIAN’S KNOWLEDGE OF COURSES”

Funded by the Health Foundation Based in the Clinical Effectiveness Group, Working in partnership with Social action for Health and Tower Hamlets PCT

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Assessing primary care staff understanding of self management groups

In January 2009 a survey of all GP practices was undertaken to explore understanding and current referral levels to both generic SMGs such as the expert patient programme and to disease specific courses such as HAMLET and pulmonary rehabilitation. There was 100/265 (37.7%) response rate, with a response from 31/38 practices. 88% of responders knew about the EPP, and 76 % were aware of the EPP courses based within Tower Hamlets. However 52% were not aware of the referral process to the generic self management courses. Referrals to expert patient programmes

This illustrates the low level of referrals to the expert patient programme initiated by primary care teams Feedback and views on self management courses In general respondents gained more feedback about attendance at disease specific courses, and the perception of these courses was more positive than for the generic EPP. Response Generic Expert Patient Disease Specific Expert Programmes % Patient Programmes % Received Yes 35 56 course No 63 38 feedback Nature of Positive 12 35 feedback Negative 6 4

Mixed

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Social marketing and the referral process to SMGs The following comments are taken from the free text section of the questionnaire, looking at the theme of ‘course referral and proceedures’. They illustrate the current difficulties primary care teams have in understanding the role of the generic courses in the chronic disease management pathway. 2 Course procedure 2.1 Advertising V12: Programs are not well marketed

2.2 Referral M1: Difficult to know who attends as there are no referral forms?

2.3 Follow up R8: Refresher courses are required

R4: I find it difficult to refer patients to EPP due to the lack of details of where and when they are. N3: Need course timetables available

V3: Should be one point of referral for exercise courses

M1: Monitoring system needed

N3: Need a referral process

II1: Must be widely marketed directly at patients

V6: I feel that referring patients to EPP in some ways feels like rejection to the patient. I would prefer if the patient was directly contacted by the organisation. V4: We need to encourage self referrals

V12: Courses are never followed up F5: Need refresher courses

V4: We need visual promotional material and take home photocopies and leaflets V4: Patient has left leaflets about courses in the practice J2: More promotional material around the community to help advertise courses to patients O1: More advertising material is required for patients and doctors

J2: Promote self referrals Y1: enable a standardised referral process where attendance can be monitored

2.4 Education HH12: I would like to attend a session to see for myself how to motivate patients B3: Patients should be receiving education every time they visit the surgery 00: More group education sessions are needed for staff poor training opportunities

00: no code Improved take up of these generic EPP courses will depend on a strong PCT wide focus on publicity, self referral mechanisms and a single point of entry for health professional referral. These comments apply less to the disease specific SMGs, which fall more within the traditional medical model and show more evidence of becoming attached to the disease pathway. (Further details of the survey method and full results available on request from the project team) Analysis of the ‘Healthy Moves’ SMG run by Social Action for Health

The Healthy moves course was developed by SAfH as a hybrid self management/exercise course containing self efficacy elements of the EPP programme, but including more directive sessions on diet and activity, with sessions on common chronic diseases such as diabetes and heart disease. There is an emphasis on doing physical activity during the sessions. The analysis is based on 20 courses, which ran during January to March 2009. •

66% of the participants attending the courses were female

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93% of course participants were Bangladeshi

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Over 85% of course attendees had diabetes

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75% of participants were directly invited to attend the course by SAfH, 13% were recruited by their doctors.

Healthy Moves course content Week Week 1

Week 2 Week 3

Week 4

Week 5 Week 6

Week 7

Healthy Moves course topic Introduction to Healthy Moves and meeting the group Know about the broad aspect of health Understand the Healthy Moves approach and experienced body listening/basic awareness Learn about the skeletal and muscular system Map through movement and be aware of various organs Activity plan Understand the importance of physical activity Developing ideas of how to be physically active Problem solving Activity plan Plan lifestyle changes Problem solving Gain knowledge of five food groups, design eat well plate, understand food labels Considering your own diet Feedback on activity plans Understanding the digestive system Awareness of cultural influences on diet and the consequences Improving diet without changing cultural food Understand the anatomy of the heart, relationship of coronary heart disease and diet and physical exercise Understand the relationship between diabetes and physical activity Importance of physical activity Explore what stress is and how it effects health Relaxation through breathing techniques and body awareness Physiological impact of stress on the body Or Session related to diabetes

Week 8

Review and feedback Taking learning forward to everyday life, making a pledge and chart plan

The course analysis is based on data from the SF-36, which is a standard instrument used to assess quality of life and changes in scores following interventions. The SF-36 has 8 scales, which are combined to make up two summary measures, physical health and mental health. Each scale has between 2-10 items, scales are scored 0-100; individuals with higher scores relate to greater levels of health and function

SF 36 Item no 3a,b,c,d, e,f,g,h,i,j

Scale Physical function

Description

Measurement of physical performance from vigorous activities to bathing and dressing 4a,b,c,d Role physical Measurement of any difficulties with daily activities or health problems which restrict working capacity 7,8 Bodily pain Measurement of pain magnitude and interference 1,11a,b,c General health Measurement of individual’s ,d perceived health status from poor to excellent 9a,e,g,i Vitality Measurement of energy levels 6,10 Social functioning Measurement of health status effects on normal social activities 5a,b,c Role emotional Measures effect of emotional problems on daily activities and work 9b,c,d,f, Mental health Measures degree of nervousness, h depression and happiness levels

Summary measure Physical health Overall measure of physical limitations in self care, social and role activities, accounting for pain, disability and energy levels

Mental health Overall measure of mental wellbeing encompassing psychological and emotional affects on daily activities

Data for analysis was collected from 284 participants as follows: •

166 completed sets of data (completed pre and post SF36 forms)

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Missing data: 118 participants without complete data sets (info from pre and post SF36 form) 35/284 missing pre course SF36 data and 83/284 missing post SF36 data.

The initial analysis was designed to explore whether there was a significant change in SF-36 summary scores pre and post course The Null Hypothesis being: There is no change in SF-36 Summary scores pre and post course Box plot of pre and post course SF-36 scores in the physical and mental health domain.

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SF-36 Score 40 60

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Physical & Mental Health Domain Summary Scores

pcs mcs

PCS = Pre Physical component score score MCS = Pre Mental component score score

pcsPost mcsPost

PCSPost = Post Physical component MCSPost = Post Mental component

The null hypothesis for the physical health domain can be rejected. The paired ttest shows there is statistically significant difference between the pre and post physical summary score. p=0.00 (CI -20.01 -11.73) The null hypothesis for the mental health domain can be rejected. The paired ttest shows there is statistically significant difference between the pre and post mental summary score. p=0.00 (CI -22.07 - 13.05) Comparison of the generic EPP courses with the healthy moves courses based on the SF-36 physical and mental health summary scores. This analysis is based on 5 of each course type, with 118 attendees. Overall, all domains making up the physical and mental health component of the SF-36 demonstrated an improvement at post course intervention. However, Healthy Moves exercise courses showed greatest improvements at increasing overall SF 36 score.

Using multiple regression analysis to adjust for age group, baseline score, existing health problems and gender, there was a significant difference in the physical health summary score between the two course types. Averege difference in score -11.3 (95% CI -19.7, -2.8) p = 0.010 The non-parametric Mann-Whitney test was used to assess whether there is a difference in mental health summary scores between the two course types (as the assumptions for linear regression were not met by the data). The Healthy Moves Course shows greatest change in score. The Mann-Whitney test shows there is a significant relationship between overall change in pre/post mental health scores and course type Prob > |z| = 0.0356. This does not adjust for other factors.