Identifying acceptable components for home-based health promotion services for older people with mild frailty: A qualitative study

1 INTRODUCTION

Frailty in later life is associated with greater risk of hospitalisation, functional decline, falls, worsening mobility and death (Clegg, Young, Iliffe, Rikkert, & Rockwood, 2013). However, mild (or pre- or early) frailty, where individuals are between robust and frail is more common and may be present in up to half of all older adults in high-income countries, depending on the definition used, compared to 11% who are frail (Collard, Boter, Schoevers, & Oude Voshaar, 2012).

Over time, this population is more likely to become robust or remain stable than those with frailty (Gill, Gahbauer, Allore, & Han, 2006), suggesting mild frailty could be an important opportunity for promoting health and delaying frailty. Indeed, targeting older people with a lower mortality risk is associated with greater effects on functional status (Stuck, Egger, Hammer, Minder, & Beck, 2002).

Targeting health promotion behaviours—i.e. actions with the potential to protect or enhance physical or mental health, or protect against declines (Steptoe, Gardner, & Wardle, 2010) offers a means of shielding against frailty and related detrimental outcomes. Within UK National Health Service (NHS) policy, there is a focus on targeted prevention and encouraging behaviours supporting health promotion (NHS England, Care Quality Commission, Health Education England, Monitor, Public Health England, Trust Development Authority (TDA), 2014). Additionally, far fewer older people are now receiving social care owing to reductions in public funding which is likely to lead to higher numbers of older people with unmet needs (Iparraguirre, 2017). Despite this, there is a paucity of policies focussing on preventing frailty in those already on a pathway to frailty (Drennan et al., ), with a concurrent lack of services and interventions in this area.

Currently, the few interventions targeted at mild frailty focus mainly upon exercise to increase mobility, occasionally with changes in nutrition, or problem-solving therapy (Brown et al., 2000; Chan et al., 2012; Frost et al., 2017; Tieland et al., 2012), but neglect related issues such as social isolation, low mood, and sensory or cognitive impairment (Lang, Michel, & Zekry, 2009). Interventions which are multidimensional and home-based tend to target either broader or frailer populations, have had mixed success and can lack clarity as to their effective “active ingredients” (Behm et al., 2015; Li, Chen, Li, Wang, & Wu, 2010; Puts et al., 2017; Tappenden, Campbell, Rawdin, Wong, & Kalita, 2012). Stakeholder involvement in intervention development is recommended to maximise the acceptability, relevance and feasibility of frailty interventions (Gwyther et al., 2017) and can produce substantial changes (van Velsen et al., 2015).

Older people's views have been widely canvassed regarding self-care, health promotion and lived experiences of frailty (Birkeland & Natvig, 2009; Lloyd, Kendall, Starr, & Murray, 2016; Lommi, Matarese, Alvaro, Piredda, & De Marinis, 2014; Menichetti & Graffigna, 2016). However, to our knowledge, no study has focussed specifically on community-dwelling populations with mild frailty in the United Kingdom (UK), explored the acceptability of different health promotion behaviours or offered practical recommendations for designing new health promotion services. We therefore aimed to explore: (1) behaviours older people with mild frailty engage in to promote health and barriers/facilitators to engagement and (2) potential components for new home-based health promotion interventions to promote health and well-being in this group.

2 METHODS

We carried out face-to-face, semi-structured qualitative interviews (Silverman, 2006) in participants’ homes with community-dwelling adults aged ≥75 years who were judged to be “vulnerable” (not dependent on others, with symptoms of being ‘slowed up’ or tired that limited activities) or “mildly frail” (more evident slowing, with some assistance needed in instrumental activities of daily living, e.g. finances, heavy housework) on the Rockwood Clinical Frailty Scale (Rockwood et al., 2004). Older adults were recruited through one urban general practice, with a diverse ethnic population (84% White British, 8% Asian/Asian British and 4.5% Black African/Caribbean/British) where approximately one quarter of older people live in deprived households, and one semi-rural general practice, in an area with a majority White British population (97%) and low deprivation levels (Department for Communities and Local Government, 2015; Institute of Public Care, 2017). Almost half of all older people in both areas report being limited a little or a lot by long-term illness (Institute of Public Care, 2017). We sampled for maximum diversity with respect to age, gender, socioeconomic status and ethnicity.

People with a life expectancy of <6 months, housebound or with a dementia diagnosis were excluded. Carers were recruited through interviews with older people where possible; however, many interviewees did not have paid care and their relatives provided general support not personal care. We therefore also recruited carers through snowball sampling at carers’ groups at both sites. Carers were invited to participate in semi-structured interviews or focus groups at their choice. Focus groups were also carried out with community multidisciplinary frailty teams (with representation from primary care and social care) in each area and with urban homecare (domiciliary) workers. Focus groups with teams at their organisation were used as a pragmatic way to access multidisciplinary teams and to facilitate participation and discussion. We contacted the lead of relevant teams in each area and provided recruitment materials prior to the focus group. Consent was sought in person on the day of the focus group. Professionals who could not attend their team's focus group were invited to a second one to ensure a wide variety of experience was sampled.

Topic guides were developed from reviews of the existing literature and refined iteratively as the study progressed (see Table 1 for topic guide content). Interviews and focus groups lasted approximately 1 hr and were conducted by four research team members (AJ, AL, KK, KW) with experience of qualitative research and backgrounds in psychology, academic general practice and ageing research. Interviews and focus groups were conducted between December 2014 and July 2015. They were audio-recorded with consent (one older person declined but agreed for detailed interview notes to be taken), transcribed verbatim and brief field-notes were taken. We continued recruiting older adults and their carers until no new major themes emerged and the sample was sufficiently diverse.

We thematically analysed (Braun & Clarke, 2006) the data in NVivo 11 (QSR International Pty Ltd., 2015), led by RY. Transcripts were read independently by KK, AL, KW, RF and CA and each developed a thematic framework, which was amalgamated into a single initial coding framework through discussion. RY coded the transcripts according to the framework with minor revisions as needed. Themes and interpretations were discussed and agreed within the group.

This study was approved by the NHS Camden and King's Cross Research Ethics Committee (ref 14/LO/1698). All participants were provided with an information sheet explaining the study and were given the opportunity to ask questions prior to seeking consent. They were informed they could withdraw at any time, and capacity was assumed (as required by the Mental Capacity Act 2005) unless otherwise indicated. All participants provided informed consent to participate.

3 FINDINGS

We interviewed 14 older adults with mild frailty, 12 family carers and 27 community health and social care professionals (Tables 2 and 3). As noted, we recruited a diverse sample of older adults according to gender, age and socioeconomic status; however, there was limited ethnic diversity as the majority of people were White British. All older people were experiencing some frailty symptoms to be eligible for the study, although older people's health problems varied. Some were very limited in mobility due to their physical health, while others had reduced energy and were finding activities more difficult but could get out and about independently. Two carers were recruited through the older person with mild frailty interviewed; the remainder were recruited from local carers’ groups. Most carers (n = 9) were female. We sampled a range of partner-carers, family carers and one paid carer of people with frailty and dementia across each area. Within our health and social care professional focus groups, we sampled a range of primary care (e.g. GPs, nurses) and social care (e.g. social workers, care services managers) professionals, as well as homecare workers.

The following four themes emerged: behaviours to promote health and well-being, barriers and facilitators to health promotion behaviours, content of a health promotion service for people with mild frailty, and delivery of a health promotion service for older people with mild frailty.

4 DISCUSSION

Older people with mild frailty carry out a variety of lifestyle behaviours to promote health and well-being, and health, social support and transport are important facilitators for engaging in these. Stakeholders have a consensus view that new services for mild frailty should be personalised and focus on maintaining independence. In addition to addressing topics of socialising and mobility, it should cover a broad range of domains and facilitate individuals to carry out activities and behaviours that could improve their well-being through providing information and signposting, emotional and practical support, and boosting motivation. Stakeholders prefer a non-specialist trained worker to provide this low-level support, ideally over a sustained period of time.

Frail and robust older adults across a range of countries report a range of health promotion priorities, behaviour and activities (e.g. shopping, gardening, crosswords) and internal processes (e.g. accepting decline and interdependency) to maintain positive well-being (Birkeland & Natvig, 2009; Boggatz & Meinhart, 2016; D'Avanzo et al., 2017; Holm & Severinsson, 2013; Lloyd et al., 2016; Lommi et al., 2014; Menichetti & Graffigna, 2016; Nicholson, Meyer, Flatley, Holman, & Lowton, 2012; Warmoth et al., 2016). Our study showed that people with mild frailty, whose needs have not previously been explored, engage in similar health promotion activities and have similar motivational barriers. However, we also highlighted a wider range of external factors affecting health behaviours (such as knowledge, transport and social capital), which new services could have a potential role in addressing.

In contrast to previous interventions targeted at mild frailty, which have mainly focussed upon group exercise for mobility (Frost et al., 2017; Puts et al., 2017), our qualitative study suggests that stakeholders value personalised interventions addressing a broad range of domains. Inclusion of personalised planning and tailored goal setting within self-management interventions for older people has been associated with a greater impact upon activities of daily living (van het Bolscher-Niehuis, den Ouden, de Vocht, & Francke, 2016), while one qualitative meta-synthesis emphasised the need to focus interventions upon building on older people's own resources and context (D'Avanzo et al., 2017). Increasing motivation may be an important component and services may benefit from explicit content focussed on behaviour change to initiate or capitalise on health behaviours already undertaken by mildly frail older adults.

Previous qualitative studies of experiences of preventative home visit (health promotion) services for people aged 80+ or with long-term conditions suggest that they are valued for providing an accessible contact and psychosocial support through good communication skills (Behm, Ivanoff, & Zidén, 2013; Williams, Smith, Chapman, & Oliver, 2011). This aligns with our findings, which further suggest that health promotion services are more likely to be acceptable if delivered by a non-specialist support worker rather than a clinician. Delivering interventions for older people over a sustained time period is supported by one meta-analysis which found that multiple follow-up appointments are more effective than a single visit for preventing nursing home admissions and functional decline (Stuck et al., 2002).

Within the UK's current climate of austerity, the NHS emphasises partnerships with the voluntary or third sector in providing supportive services (NHS England, Care Quality Commission, Health Education England, Monitor, Public Health England, Trust Development Authority (TDA), 2014), e.g. in some areas Age UK is commissioned to provide Care Navigation services (advice and signposting for different subjects) to older people. Currently, there is an absence of policies directed at groups on a pathway to becoming frail, which may reduce support for frailty prevention services compared to those with a specific policy agenda (Drennan et al., ). However, frailty prevention services fit within the existing NHS focus on targeted prevention and encouraging healthy behaviours (NHS England, Care Quality Commission, Health Education England, Monitor, Public Health England, Trust Development Authority (TDA), 2014) and our present study shows that these kind of services would be feasible and acceptable to older people.

Currently, a number of similar models of broader health promotion services exist, which substantially overlap in content:

The content and delivery suggested by stakeholders in our study do not currently fit precisely within the remit of these existing models, although there may be some overlap, such as signposting and psychosocial support (Manderson, McMurray, Piraino, & Stolee, 2012; Tøien et al., 2015). These services are typically broad—few focus on the specific needs of people with mild frailty and encourage changes in health behaviours over a sustained time period, a key feature suggested by stakeholders. However, as specific professional skills were considered inappropriate for low-level support in health promotion in mild frailty (providing staff were adequately trained and supported), a non-professional role such as a “lifestyle advisor” or “health trainer” role may be the most suitable for service providers. Studies suggest that this type of role is generally acceptable, effective and cost-effective for chronic disease management, smoking and changing health behaviours and acceptable to the public and health professionals (Carr et al., 2011; Gardner, Cane, Rumsey, & Michie, 2012).

A recognised advantage to this kind of model is the potential ability to reach marginalised communities and create improved links for accessing health and social care (Carr et al., 2011). Given the higher rates of multimorbidity in more socioeconomically deprived areas (Barnett et al., 2012) and poorer self-rated health in black and minority ethnic groups (Evandrou, Falkingham, Feng, & Vlachantoni, 2016), this may represent an important opportunity to promote health. Although it was difficult to include people with a variety of ethnicities in this study despite our attempts to sample widely, engaging older minority ethnic groups in health promotion research is recognised as a challenge (Liljas et al., 2017). However, 5 out of 14 of our older people received pension credits (indicating low income) and only three received private pensions, indicating that our attempts to sample across a range of socioeconomic status were successful, and suggesting that home-based health promotion services may be acceptable to more deprived populations.

Strengths of our qualitative study include the wide range of key stakeholders relevant to new mild frailty services that were consulted. We captured a variety of health experiences across urban and semi-rural locations and sampled older adults varied according to age, gender and socioeconomic status. The analysis involved a wide range of team members with diverse experiences. We have outlined a number of practical recommendations for new services.

However, our study has a number of limitations. Due to our recruitment methods, we could not document characteristics of non-responders. Despite our attempts to sample widely and in areas with a more diverse population, our sample had limited ethnic diversity and so tailoring services to different cultural needs received limited discussion. Previous work suggests services may receive better uptake if providing information in a range of languages (Manthorpe et al., 2009). Member checking was not used as these findings led into further stakeholder discussion panels to design a new service. The discussion around service domains and characteristics was limited by some older people's difficulties in discussing a hypothetical new service. The professionals we recruited were working with frailer people and so could only draw upon more limited professional experience of a mildly frail population, though they had high consensus and provided insights into the fit between new and existing frailty services.

5 CONCLUSION

In the views of stakeholders, health promotion services for older people with mild frailty have the potential to address currently unmet needs and appear to be acceptable to stakeholders. They should be tailored to individuals and encourage behaviour change, with a particular focus on socialising, exercises to improve mobility and maintaining independence. Desirable components of a health promotion services were information with signposting to relevant local services, encouragement and low-level practical and emotional support provided over a sustained time period by a skilled communicator. This role may be similar to that of a UK “health trainer” or “lifestyle advisor,” but would need to be tailored to the specific needs of those with mild frailty. Future research needs to address those key components identified by older people as important and explore carer involvement and tailoring to different cultural needs. Rigorous evaluations of new initiatives for mild frailty are needed to provide additional data on the content, feasibility and acceptability of such interventions and their active components in practice.

CONFLICT OF INTEREST

The authors declare no conflicts of interest.