Part I. Community Guide Update and Rationale for Intervention
| Author & Year | Intervention Setting, Description, and Comparison Group(s) | Study Population Description and Sample Size | Effect Measure (Variables) | Results including Test Statistics and Significance | Follow-up Time |
| Gitlin et al., 2013 | The multi-faceted home-based BTB (Beat the Blues) intervention was led by social worker. The BTB intervention took place at a senior center and in the homes of participants over 8 months. The treatment group received the BTB treatment, which was tailored specifically to older African Americans. The control “wait-list” group did not receive BTB intervention until month 4. | The participants in this study were all African Americans adults aged 55+ with symptoms of depression. n=182 (89 assigned intervention; 93 assigned to control wait-list group) | Measures included participant self-reported depression levels at 4 months (initial outcome). At the 4 to 8 month, outcome measures include understanding the course of depression and identifying anxiety, function, and ultimately remission. | At 4 months, 43.8% (n=39) of the BTB group were in remission in comparison to the control wait-list group (26.9% n=25). Participants in the BTB group also showed reduced depressive symptoms -2.9 (95% CI, -4.6 to -1.2).
At 8 months, the control group showed similar benefits to the adjusted BTB group. Minimal changes occurred relative to the initial 4 months period. |
Follow up occurred after 4 months for the BTB treatment and after 8 months for the BTB and control group |
| Markle-Reid et al., 2014 | A preliminary one group, pre- test/post-test nurse-led multi faceted intervention with a duration of 6 months. The RN was charged to detect manage, and reduce the severity of depression symptoms. All participants were offered monthly visits for six months in coordination with usual home care. | The participants in this study were adults aged 70+ receiving long-stay home heath care and newly referred to the Community Care Access Centre. (n=142; 98 completed 6 month intervention; 87 completed 12 month intervention) | The measure of outcome for this study was the change in the expression of depressive symptoms from baseline to six month, measured by the CES-D (Centre for Epidemiological Studies in Depression). The CES-D is a 20 item scale, scores ranging from 1-60. | The baseline CES-D score was 17.7; statistical significance was found in the decrease of CES-D scores post intervention (-3.22, CI -5.35 to -1.08, p=).008) at the 1 year follow up. | 12 months |
| Bruce et al., 2015 | The Depression CAREPATH intervention was designated to 6 home health care agencies with patients aged 65+ who tested positive for depression. Participants were interviewed at home and via phone. The nurses were randomly assigned to an intervention (Depression CAREPATH) or to enhanced usual care (control) . | The nurses selected were associated with 1 of the 6 home health care agencies, an n=178 (100 assigned to intervention; 78 assigned to control group) n=306 (number of clients whom consented to participate in the study) | The severity of depressive symptoms were the main outcomes of this study. It was measured by using all assessments in the Hamilton Scale for Depression (HAM-D).A score of 10 more high was identified as significant depression. | Overall, the intervention had no effect (P=.13 for intervention x time interaction) The HAM-D scores for intervention and control did not differ at 3 or 6 months (10.5 vs 11.4, p=.26 & 9.3 vs 10.5, P=.12) but did reach significance at 12 months (8.7 vs 10.6, P=.05). For participants with a HAM-D score of 10 or more, the intervention proved effective (P=0.02) with lower scores at all months of the trial (14.1 vs 16.1, P=.04; 12.0 vs 14.7, P=.02; 11.8 vs 15.7, P=.005, respectively) | Follow up occurred after 3, 6, and 12 months |
The Community Preventive Services Task Force currently recommends home-based depression care management for older adults. Their recommendation is based off of a systematic review that was conducted in February 2008 based on 3 studies. All of the studies reviewed by the Community Preventative Services Task Force has a response rate range from 27-43% and a 36% remission rate and due to the randomized nature of the interventions, they can all be applied to the general public with reference to communities, home health care, and gender/race and ethnicity. (Community Preventative Task Force, 2008)
- Justify your recommendation. Identify whether there were any changes to the recommendations. For example, did you change one of the recommendations from “insufficient evidence” to “recommended”? Explain why or why not based on the evidence. (12 points)
Based on the 3 articles that I reviewed since the Task Force’s recommendation in 2008, I would also recommend home-based depression care management for older adults.
The decision to recommend the home-based depression care management intervention is due to the consistency of the results found in the studies I reviewed in comparison to the systematic review conducted by the Task Force. In the Gitlin et al., (2013) study, 43.8% of the participants who received the BTB intervention were in remission, which falls slightly above the range identified in the systematic review done by the Task Force. Although the increase in remission is slight, it is still significant in supporting the recommendation for home-based depression care management interventions. This study also focused on African-Americans, given validity to the ability for the intervention to be applied to specific ethic/racial groups.
The study published by Bruce et al., (2015) focused on the effectiveness of a CAREPATH depression care management in Medicare Home Health. The interesting consideration in this study was the focus on the randomization of the nursing staff, assigning them to the intervention or to the control group. Although a statistical significance was not found until after 12 months of intervention, the necessity of the program is still in line with all the other studies I reviewed for this intervention, being that the majority of them were over at least a 12 month period. Similar in statistical measures was the Markle-Reid et al., (2013) study which was not a randomized trial, however a pre/post test delivered intervention in a home health care agency; their was a significant decrease in CES-D scores post intervention.
None of the previously mentioned studies caused me to increase the recommendation because the findings were directly in line with the findings in the systematic review. The studies aforementioned continues to provide sufficient evidence for home-based depression care management.
Part II. Theoretical Framework/Model
The Theory of Planned Behavior (TPB) identify the relationship amongst behavior, beliefs, attitudes, and intentions, with the assumption that behavioral intentions are the most pivotal in determining behavior (NIH, 2005). TPB is ideal for home-based depression care management because it’s main focus is behavioral intentions. The model focuses on behavioral intention, attitude, subjective norm, and perceived behavioral control-which serve as the key factors in overall behavioral change. In the NIH text (2005) behavioral intention determines behavior while attitude, subjective norms, and perceived behavioral control influence behavioral intention. This theory allows us to see the intention of older adults to address depressive symptoms despite the thoughts of the ones around them. The individual constructs for the TPB in relation to home-based depression care are identified below.
Constructs
Behavioral Intentions: This is considered the most important factor in the TPB theory in relation to behavioral change (NIH, 2005). It is identified as the perceived likelihood of performing behavior. In relation to home-based depression care management, the behavioral intention is adherence to depression-care management and the intention to adhere to program regulations will influence the behaviors following the intervention.
Attitude: This construct identifies the evaluation of the changed behavior at a personal level (NIH, 2005). The attitude is measured by the participant’s opinion on whether the behavior is good, neutral or bad (NIH, 2005). With regards to depression care management, the person’s attitude toward receiving the intervention is directly related to their intention to adhere to the program. For example, a person may view the decrease in depression episodes as good because they can become more social or on the contrary, it can be viewed as bad because people outside of themselves now know that they have a mental condition.
Subjective Norm: This construct refers to the beliefs about key persons opinions, approval or disapproval of the behavior change; this could also serve as a motivation for intervention participants to behave in a manner that is approved by said persons (NIH, 2005). For this particular intervention, participants may be concerned with the thoughts of those they are close to and the stigma associated with admittance of mental illness and having lack of support due to their age. Additionally, because the prevalence of depression in older adults is high and often goes unnoticed, it could also cause older adults to not want to admit they are battling depression due to the negative societal views surrounding it (Gitlen et al., 2013).
Perceived Behavioral Control: This construct refers to the belief that one can exercise, control over performing the behavior (NIH, 2005). The approach this construct takes is identifying if the person involved in the intervention believes that the behavioral outcome is under their control (NIH, 2005). The participants in the home-based depression care management intervention were given the option to participate in the intervention, as identified by the aforementioned evidence listed in Table 1. Therefore, the control of participation was left solely upon the participants.
- Draw a diagram to illustrate your conceptual model, making sure to include an indication of the hypothesized direction of the relation (positive or inverse) between the constructs. You may use plus or minus signs, up and down arrows, or another method as long as it is clear. Do not create a logic model. (16 points)
Home-Based Depression Care Management
Part III. Logic Model, Causal and Intervention Hypotheses, and Intervention Strategies
The target population for the home-based depression care management intervention are older adults aged 65 and older who have tested positive for depressive symptoms, receive home health care, and come from diverse ethnic and cultural backgrounds (Markle-Reid,2014) . One of the studies specifically used older African American adults as a target population, to address the health disparities associated with receiving mental health care in the African American community (Gitlin et al., 2013)
The program setting took place in the respective homes of the participants which involved weekly in-person and over the phone symptom care management, medication management, care coordination, and goal setting (Bruce et al., 2015).
Using older adults as a target population directly coincides with the fact the majority of them are not able to access quality health care as a result of socioeconomic status and the increased likelihood of disabilities that affect mobility in comparison to their younger adult counterpart (Braveman et al., 2011). Although depression is a widely known mental health problem for older adults, the symptoms are still widely unrecognized and undetected in older adults (Gitlin et al., 2013).
Intervention Method Alignment with Theory Intervention Strategy
| Improve behavioral intention and attitude to adhere to intervention programming | The TPB construct of behavioral intention is the most important construct of TPB. Behavioral intention explores the likelihood that the participant will adhere to the the program as well as have a positive attitude about it. An increase in behavioral intention would include educating the client on depression care management and stress reduction techniques as well as referrals and linkage to resources that could further aid in participant’s intention to participate in the program. | Provide pamphlets on the signs of depression
Referral contact sheets for participants to be able to reach out to local and community resources in-person depression education sessions with trained clinical staff Art/Music/Exercise classes and an explanation as to how these activities can help reduce stress inducing situations. |
| Increase perceived behavioral control | The TPB construct aligns with behavioral activation is perceived behavioral control. The Behavioral Activation portion of the intervention helped participants create goals their own plan of action in order to effectively handle depression symptoms. Allowing the participant to have full control over their plan of action is pivotal in the intervention because it directly affects the intention to adhere to the depression care management program. | Creating short term goals with participant in sessions with clinical staff
Making the community and family members aware of their goals to help hold the participant accountable Advisement on how to create a solid plan of action with trained clinical staff in sessions |
| Inputs/Resources | Activities | Outputs | Short-term Outcomes | Intermediate Outcomes | Long-term Outcomes |
| Funding for depression care management educational pamphlets and other materials; Personnel to include trained clinical staff who are equipped to teach community members and participants; Partnerships with local resources to include medical, mental, and recreational sources where participants can be referred to receive care for priority needs as well as stress reduction activities. The space that the intervention takes place in the home of the participants so there needs to be a dedicated area free of clutter/negative influence. | Care management that focuses on tailoring and identifying unmet needs for the participants that could be hindering them from being successful in depression care management; Referrals and linkage to community resources that will address the participants unmet needs in order to reduce negative environmental influences; Depression Education and Stress Reduction Techniques that teach the participants how to recognize depression symptoms and how to effectively manage stress-inducing situations; Behavioral activation that allow the facilitator and the participant to work together to create goals and a plan of action in order to effectively achieve those goals. | 100 Nurses (or trained Social Workers/ other Clinical staff) who are trained on the intervention (BTB, PEARLS, etc)
Resources information to include pamphlets on depression care management, recognizing symptoms, and stress reduction activities as well as contact information sheets for local/community resources 10 1-hour in home weekly sessions for 3 weeks and bi-weekly sessions for 4 months thereafter. Older adults age 65 and older (at least 200 for initial intervention)
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Attitude: changed attitude would increase behavioral intention of adherence to the program. A positive attitude would make the participant more likely to adhere to program guidelines. Behavioral Intention: Participants will adhere to the intervention methods within the program Subjective Norms: Having the client realize that receiving help for depression is not a bad thing and admittance to having a mental illness does not make them less of an individual Perceived control: Participants understand that they have the power to control their changes in mood by having an understanding of depression symptoms, setting goals and executing a plan of action.
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Decrease on the Hamilton Scale for Depression (HAM-D) scale, ability to cope with stressful situation in a more positive manner | Long-term remission of depressive symptoms and the ability to handle stressful situations without overwhelming feelings of grief and/or loss of control |
Intervention Hypothesis
Care management will lead to improvements in behavioral intention by ensuring that all priority care needs are being met first which would allow the participant to shift their focus to the intervention program.
Referral and linkage will increase positive attitudes and positive subjective norms surrounding depression care management by connecting participant’s to organizations that can help them with physical and mental health care.
Depression Education will help increase the ability for participant’s to identify symptoms of depression and how to manage a depression episode . Stress Reduction techniques will increase behavioral intention and decrease depression episodes by finding positive ways to handle stressful situations. It would also increase there confidence in contradiction to subjective norms that may make them feel like management of a mental illness is not okay.
Behavioral activation will help increase perceived behavioral control in participant’s as well as improve their ability to create a plan of action for themselves after the intervention period.
Causal hypothesis
Attitude improvements surrounding depression care management, a decrease in negative subjective norms, and an increase in perceived behavioral control will aid in decreasing HAM-D scores and increase the likelihood of remission of depressive symptoms. An improvement of the environment in which participant’s are in will also decrease the scores on HAM-D test and help keep depression triggers at bay.
SMART Outcome Objectives
Goal 1: Improve attitude surrounding receiving depression care-management
Objective 1: At 4 month follow up, 25% increase from base line in positive attitude towards receiving depression care management as identified by self-report
Objective 2: At 8 month follow up, 45% increase from 4 month follow up in positive attitude towards receiving depression care management as identified by self-report
Objective 3: At 12 month follow up, 65% increase from 8 month follow up in positive attitude towards receiving depression care management as identified by self-report
Goal 2: Combat negative subjective norms surrounding depression care management
Objective 1: By month 8, at least 50% of participants overall will be able to comfortably speak about their depression with family and close friends without feelings of guilt or judgement, as indicated by self report.
Objective 2: After 12 month follow up, the usage of referrals and linkage and depression education will help decrease the fear of admittance of depression care management by 75% overall.
Goal 3: Increase participant’s level of perceived control
Objective 1: By month 4 follow up, 30% of individual participants will have successfully completed the goals they created for themselves and have improved HAM-D scores surrounding control.
Objective 2: By month 8 follow up, 60% of individual participants will have successfully implemented goals they created for themselves and have improved HAM-D scores surrounding control.
Objective 3: By month 12 follow up, 90% of individual participants will have successfully implemented goals they created for themselves and have improved HAM-D scores surrounding control.
Part IV. Evaluation Design and Measures
| Stakeholder | Role in Intervention | Evaluation Questions from Stakeholder | Effect on Stakeholder of a Successful Program | Effect on Stakeholder of an Unsuccessful Program |
| Older Adults | Participants in the program | How will my participation in this program affect my ability to manage my depression at home? How will I be equipped to identify stressful situations? | Decrease in depression symptoms and negative reactions to stressful situations. Increased knowledge on how to identify the onset of depression and stress reduction techniques. | No change in depression symptoms and the inability to correctly identify the onset of depression and either an increase or no change in HAM-D scores. |
| Educators (Nurses, Social Workers, other essential clinical staff) | Implement Program | What is our role in the program?
How we will we obtain appropriate referrals to offer to participants? How will we relay the importance of the program to participants? What will the benefit for participants of this program?
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Increase in effective teaching methods/models
Increase in comfortability in hosting the program and increase in knowledge about the importance of the implementation Willingness to follow up with participants to ensure success |
The inability to confidently disseminate information to participants and unwilling to comply with program FU and future interventions |
| Coordinators (Program Researchers) | Implement program | Are the methods in this program feasible?
What results to we expect from this implementation? How will we determine the program’s effectiveness? |
Increase funding sources and the an increased will to continue further research and increase improvements for the program | Motivation to revamp the program to make it better
Reconsider the resources needed to make an effective program
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| Community Members (Neighbors, Neighborhood resources, and Family) | Support of the program | Will this program help better members of this community?
Is this program fiscal and timely? How will this program affect the relationship with my loved one? Will it be positive or negative?
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Older adults can seek support from the surrounding community and their families and the community and family members will be able to assist participants with stress reduction activities and depression education | No support from the community or family due to stigma’s surrounding depression
Waste of community/family members time and funds
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- Provide the outcome evaluation design(s) name and the scientific notation (Xs and Os). Name the major threats to internal validity for your evaluation, briefly describe why they are a threat, and discuss how your study design or other methods (e.g., incentives) will attenuate these threats. (20 points)
Evaluation Design: Cluster Randomized Effectiveness Trial
This study used a multiple treatment randomized experimental design that implemented a pretest-posttest for all groups and one intervention group.
R O1 X O2 O3 O4 (Intervention Group)
R O1 X O2 O3 O4 (Control Group)
[O1=pre test, O2- post-test after 3 months, 03= post-test after 6 months, O4=post-test after 12 months]
Group randomization will be conducted by randomizing nurse care teams to participants who have depression symptoms indicated by HAM-D scales. Individual treatment groups will receive the following interventions:
Intervention Group: Home-Based Depression Care Management CAREPATH treatment
Control Group: Enhanced usual care
Pre-Test for HAM-D scores will be administered on the first day of the intervention to both groups. The Post-Test will be administered at 3, 6, and 12 months post intervention. The control group will complete the post-tests at the same time as the intervention group. The test assesses: adjusted HAM-D and self-reports. It will also assess a change in attitude towards depression care management, perceived behavioral control, and behavioral activation.
Threats to Validity
Randomization with the use of a control group should provide similar threats to validity such that threats would be significantly diminished in this evaluation. Having a marker such as the pre-test allows us to be able to compare preliminary information to the results post intervention. However, even in light of limited threats to the study, possible threats to internal validity would include mortality and attrition and testing.
Mortality/Attrition
This is an inevitable threat to any study designs that implores more than one group. If more older adults drop out than stay in, changes would not be associated with the intervention more so than the individuals who dropped out. Additionally, due to older age, mortality is a major concern. For adults who pass away before all of the post-test follow ups, it could have a negative impact on the results of the study.
Testing
When using a pre and post test design, we run the risk of creating a bias with participants in the intervention. Because a pre-test is presented to them, they may be more likely to rank their answers in a different manner due to their knowledge of the nature of the study therefore decreasing the validity of the ranking measures.
14. You are putting together a survey to answer these outcome evaluation questions. Use the table to describe the variables you will measure and how. Be sure to include information on the validity and reliability of the instruments. You may see reliability reported as test-retest reliability or internal consistency (AKA: Cronbach’s alpha). Validity may be reported as face or content validity or construct validity (e.g., factor loadings). (20 points)
| Short-term or Intermediate Outcome Variable | Scale, Questionnaire, Assessment Method | Brief Description of Instrument | Example item (for surveys, scales, or questionnaires) | Reliability and/or Validity Description |
| Attitude, Perceived Control
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Attitude Toward Self (ATS) Instrument (Carver et al., 1988)
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ATS was designed to identify vulnerability towards depression. The vulnerabilities tested for includes; holding overly high standards, tendency to be self-critical and the tendency to generalize from a single failure. It identifies what attitudes people can control versus what they feel they can’t and how it affects the behaviors they exhibit. | “When I don’t do as well as I had hoped to, I often get upset with myself.”
“I get angry with myself if my efforts don’t lead to the results I wanted.” “I set higher goals for myself than other people do.” “Compared to other people, I expect a lot from myself” “When it comes to setting standards for my behavior, I aim higher than most people.”
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ATS correlates with attitude and perceived control by asking questions that would provoke the participant to recognize a change in attitude and perceived control or realize that they have experienced no change at all. |
| Behavioral Intention, Social Norms | Theory of Planned Behavior Questionnaire (Ajzen, 2013) | Although there is not an official questionnaire for the theory of planned behavior, one was created as a template to identify the questions that could be asked that pertain to the constructs of TPB. The questionnaire is in Likert scale format | “Most people who are important to me would support me receiving depression care management”
“I intend to receive treatment for depression” |
The validity and reliability of this questionnaire is questionable because it is not one that is solidified across the board. Furthermore, the details of the questionnaire can be left up to the discretion of the researcher so their is no guaranteed consistency. |
Part V. Process Evaluation and Data Collection Forms
- Provide the following data collection forms for monitoring the program process. More than one form may be submitted for a given category, but all forms must be clearly labeled. (18 points)
Enrollment and Recruitment
Attrition and Fidelity of Program
Attrition
Each participant will be given a form to fill out on the initial day of the intervention, at the 4 months follow up, the 8 month follow up, and the 12 month follow up.
Beat the Blues (BTB) Depression Care Management Program
Contact Information
Name: ________________ DOB:__________
Follow-up Session (check 1) : ___ 4 months ___8 months ______12 months
Name of Home Health Care Agency: _____________________
Permanent Address: ______________________________
_____________________________________________
Best Method of Contact (circle one) phone email postal mail
Phone: home: ____________ cell:______________
Do you anticipate moving or no longer receiving aid from your current home health agency? (Circle) yes no
If yes, why? __________________________________________________________________________________________
Are you receiving Hospice care? (circle) yes no
Fidelity of Program
References
Bruce, M. L. et al., (2015). Clincial Effectiveness of Integrating Depression Care Management Into Medicare Home Health: The Depression CAREPATH Randomized Trial. JAMA Intern Med, 175(1), 55-64.
Carver, C. S. (2013). Attitude Towards Self (ATS) Measurement Instrument Database for the Social. Retrieved from www.midss.ie
Gitlin, L. et al., (2013). A Home-Based Intervention to Reduce Depressive Symptoms and Improve Quality of Life in Older African Americans. Annals of Internal Medicine, 159(4), 243-252.
Markle-Reid, M., McAiney, C., Forbes, D., Thabane, L., Gibson, M., Browne, G., Hoch, J., Pierce, T., & Busing, B. (2014). An interprofessional nurse-led mental promotion intervention for older home care clients with depressive symptoms. BMC Geriatrics, 14(62), 1471-2318.
National Cancer Institute. (2005). Theory at a Glance. Retrieved from file:///Users/imanibyers/Downloads/TheoryAtAGlance%20(4).pdf