EHLE PROJECT TRAINING TOOLKIT: HANDBOOK ppt




EmpoweringHealthLearningforElderly(EHLE)

 2











Handbook



























EmpoweringHealthLearningforElderly(EHLE)

 3


PARTNERS:
RegionedelVenetoULSS16,Padua(Italy),
Uncass–NationalUnionofCommunalCentresforSocialAction(France),
PermanentUniversityoftheUniversityofAlicante(Spain),
EMGOInstitute,VUUniversityMedicalCenter,Amsterdam(TheNetherlands).

Editors: Chiara Petrolito, Claudio Casotto, Concepción Bru, Maria Chiara Corti, Nuria Ruiz, Giel
 Nijpels,
GiorgiodeGobbi,LauraThorogood,LauraWelschen,KristineStempien.

Authorsofthetextsbyareas:CarlosPuerta&AlfonsoSoler(NutritionandGerontology);GiuseppeSergi

& Flavio Varotto (Nutrition); Christian Loison (Nutrition, Physical activities, “Daily Addictions”) Lylian
Vega,JuanTortosa&JuanM.Cortell(PhysicalEducation)andMaurizioSchiavon
&VincenzoMalatesta
(Physical Activity); Alberto Plaza & Antonio Vallés (Psychology); Encarna Gómez & Myriam Cano,
Umberto Gallo & Sandra Scapolo (Pharmacology); Antonio López, Víctor Sarrión & Abel Villaverde,
Claudio Casotto & Laura Bracconeri (Statistical and Graphical Treatment); Caterina Angelini & Cosimo
Guerra (Tobacco Consumption); Stefano Ivis & Maria Assunta Longo
 (Patient Communication); Gilles
Vangrevelynghe (Communication and Emotional health); Anna Galiazzo & Elena Chinellato (Emotional
Health);LauraWelschen&GielNijpels(TheoriesandTools).

Translation:LauraThorogood,VíctorM.PinaMedina&UNCCASStaff.


The European project Empowering Health Learning for the Elderly (EHLE) was cofinanced by the
EuropeanCommissionaspartoftheGrundtvigLifeLongLearningProgramme.

The opinions expressed in this document have not been adopted or approved by the European
CommissionanddonotreflecttheCommission’sofficialposition.
TheEuropeanCommissiondeclinesall
responsibilityfortheusestowhichthepresentdocumentmaybeput.

This work has been released under the license Creative Commons AttributionNoncommercialNo
Derivative Works 2.5. To read a copy of the license visit the
website send a letter to Creative Commons,
171SecondStreet,Suite300,SanFrancisco,California,94105,USA.



EmpoweringHealthLearningforElderly(EHLE)


 4

Presentation
The Veneto Region government and the ULSS (PCT) 16 have taken part in the European
GrundtvigLifelongLearningProgramme.Thisinitiativetakes concreteforminthe MultimediaTraining
ToolkitproducedbytheEHLE (EmpoweringHealth Learninginthe Elderly)Project. TodaytheTraining
Toolkitwillbepassedon
tothecitizensofItaly,Spain,HollandandFrance,thefourEuropeancountries
whohavecollaboratedontheproject.
The institutions involved in the EHLE project are many and varied, from Universities to Local
AssociationstoPCTs.Theyhave workedtogether togive voiceto theirexperiences,gained fromtheir
daily work with elderly people and in social action through which people and communities take
responsibilityfortheirown
health.
TheaimofthisTrainingToolkit,(producedinEnglishaswellasthefourpartnerlanguages),isto
provide uptodate and portable instruments for communication, training and education for health,
primarily for professionals and others who work daily with elderly people. The acquisition of
responsibilityforandunderstanding
ofone’sownhealth,lifestyleandqualityoflife–empowerment
meansthatthosewhoareawareoftheirhealthrisksandwhowishtochangetheirlifestyles,havethe
knowledgeandtoolsmakepositiveandsuccessfulchange.

Thefutureis,asalwaysinthehandsofourcitizensandpatientsandourroleis,morethanever,
togivevoiceandenergytothepersonalresourcesofeveryoneofthem.Ourroleisalsotocontribute
to the global good which we call ‘Health’, with evermore innovative, sustainable and effective
instruments,bothforoursandfuturegenerations.
In the hope that we will be able to continue our partnership with trusted European partners
suchasthosewithwhomwehaveworkedontheEHLEproject,Iwishyouallsuccessinyourwork.



StefanoValdegamberi
RegionalMinisterforSocialPolicy
SocialandHealthPlanning
VoluntaryandNonProfitSectors 
VenetoRegion
FortunatoRao
DirectorGeneral
AziendaULSS16
Padua

Venice,12November2009



EmpoweringHealthLearningforElderly(EHLE)

 5

HowToUsetheHandbook
Index
1. PREFACE 6
2. THEPROJECT 7
3. ACTIVITIES 10
4. CONTEXTOFTHEPERCEPTIONANALYSIS 11
5. THETRAININGCONCEPT 16
a. ConceptualFramework 16
b. MethodologicalTechniques 18
6. TRAININGHEALTHPROFESSIONALS 21
a. CommunicatingwithElderlyPeople 22

b. PersonalRelationshipsandEmotionalHealth 23
c. NutritionandElderlyPeople 28
d. UseofMedicinesinElderlyPeople 30
e. TobaccoconsumptionintheElderly 33
f. PhysicalActivityinElderlyPeople 35
7. TEACHINGELDERLYPEOPLETOLIVEHEALTHYLIFESTYLES 38
a. EmotionalHealth 39
b. NutritionandtheElderly 39
c. UseofMedicinesinElderlyPeople 40
d. SmokingandAlcoholConsumptioninElderlyPeople 40
e. PhysicalActivityinElderlyPeople 41
8. PLANNINGTHECOURSE 42
a. SuggestionsfortheSchedulingoftheCourse 42
b. SuggestionsforTrainersWhoWorkWithGroupsofElderlyPeople 43
9. CONCLUSIONS 45
10. BIBLIOGRAPHY 47




EmpoweringHealthLearningforElderly(EHLE)

 6


1. PREFACE

ThishandbookisaguidetousingtheTrainingPackproducedbytheEHLEProject(Empowering
Health Learning for the Elderly), which was developed between 2008 and 2009 in four European
countries: Italy, Spain, France and the Netherlands.It was developed within the Grundtvig Life Long

LearningprogrammeoftheEuropean
Commission.

Thehandbookisaimedatallthoseinthehealthandsocialfieldswho,duringtheirwork,come
intocontactandinteractwitholderpeopleinordertopromotetheirgoodhealthandsocialwellbeing.

Amongthesewethereforeincludedoctors,pharmacists,rehabilitationtherapists,dieticiansand
nutritionists, psychologists, social
 workers andhealth and social careworkers.We would notexclude
volunteers,workersinnonprofitorganisations,ortrainersinvolvedintheformalandinformaltraining
ofadultsandtheelderly.

ThesearethepeopletowhomthisTrainingPackisdedicated.TheTrainingPackisdesignedto
be a
flexible multimedia instrument in the communication of health and lifestyle messages within a
process oflifelonglearning, capitalising on ourinnateability to learn throughout life indifferent ways
andwithdifferent effects.Educationis apowerfulroute tosocial promotion,anindispensable toolin
thepromotionofhealthandquality
oflife,thevalueofwhichhasbeenconfirmedbymanystudies.

Inthehope ofhaving createda toolthatwillbeuseful toall thosementioned above,wewish
everyonethebestofsuccesswiththeircontinuingwork.

Wewouldlike to thankall theProject Partners for
 theircontribution.TheVenetoRegion and
theULSS(PCT)6ofPadua(Italy),theNationalUnionofCommunalCentresforSocialAction(France),the
Permanent University of the University of Alicante (Spain), and the EMGO Institute, VU University
MedicalCenterAmsterdam(theNetherlands).

We also thank the European commission, DG

Culture, for cofinancing the project within the
GrundtvigLifeLongLearningProgramme.

Weinviteyoutovisittheprojectwebsite
www.ehleproject.eu
whereitispossibletodownload
alltheprojectmaterials.





EmpoweringHealthLearningforElderly(EHLE)

 7
Fig.1:Proportionofcitizensaged65yearsinEU

Source:EuropeanHealthForAllDatabase,
WHO/Europe,variousyears(19972004)
2. THEPROJECT

THEGRUNDTVIGPROGRAMME:It’snevertoolatetolearn 

Demographic changes in Europe, where
today the over65s make up 16.9% of the
population (Fig. 1) and will make up over 30% by
2025, represent a challenge for all European
countries and require evermore urgent
implementation
of ‘active ageing’ policies, aimed

atthelivesofcitizensbeforeandafterretirement.

The European Commission identified the
priority of the Grundtvig Programme as the
creation of new educational opportunities for
adults and elderly people at risk of social
marginalisationduetotheirearlyexitfromformal
educationandtraining.

Advantages of investment in adult
education include greater chances of more
professionalemploymentandageneralincreasein
social benefits in terms of better health and
individualwellbeing.Researchcarriedoutonolder
elderlypeople hasshown thatthose whoare involvedin learningactivities enjoybetter health,with a
consequentreductioninhealthspending.
It’snevertoolatetolearn:infact,thebetterableoneistolearn,thebetterone’squalityoflife
generally.More and better job opportunities reduced spending on unemployment benefits, better
health,andsoon.

Learning for healthy lifestyles is a key factor
to promote health and quality of life of elderly
people.Itisessentialtohelpelderlypeoplemakebetterchoicesintermsofnutritionandlifestyle,and
in communicating clear and simple messages to help keep them in good health. According to World
Health Organisation data, 50%of disabilities in European
 countries could be avoidedwith appropriate
preventionmeasures.





EmpoweringHealthLearningforElderly(EHLE)

 8

THEEHLEPROJECT:Whichactivitieswewanttocarryout 

Financed as partof the Grundtvig Life Long LearningProgramme of the EuropeanCommunity,
the European EHLE ProjectEmpowering Health Learning for the Elderly – comes from the close
collaboration of four European countries (Italy, France, Spain and the
 Netherlands).In particular the
projectaimsto:
• Improvethetrainingofthosewhoworkwithelderlypeople,
• CreateaninnovativetrainingmodelvalidacrossEurope,
• Promotediffusionthroughtheproductionanddistributionoflearningmaterials
• Promotetheexchangeofknowledgeandexperienceinordertoachieve
resultsvalidacrossthefield
oflifelonglearningforelderlypeople.


RESULTS:Whatwewanttoachieve…

The aim of the project is to develop a standardised training concept for the four Partner
countries and the eventual creation of a training toolbox.This should be available for all health and
social care workers and professionals in order to help them communicate directly with older people.
Thisisthereforeadualtrainingtoolboxbasedaroundfivekeythematicareas:foodandnutrition,useof
medicines, physical activity, life habits (smoking, use of alcohol, and other risk factors) and emotional
health.

As

partoftheprojectactivitiesatrainingsessionwaspreparedwhichtrainsparticipantsto:
• Empowerelderlypeopletomakeinformedchoicesintheareasofhealthandlifestyle.
• Developandcommunicateclearsimplemessagesaboutfoodandhealthylifestyles.


THETARGETGROUP:Whowearetryingtoreach…

To empower elderly peopleEHLE intendstowork primarily through professionals (GPs, nurses
and pharmacists)but also through healthand socialcare workers andvolunteerswho work dailywith
elderly people.These are the intended recipients of the multiprofessional training toolkit which the
projectaimstocreate.




EmpoweringHealthLearningforElderly(EHLE)

 9

THEPARTNERSHIP:EHLEProjectPartners 

The project involves four European countries: France, Italy, The Netherlands and Spain,
representedby:
X VenetoRegionalGovernmentULSS(PCT)16,Padua(Italy);
X NationalUnionofCommunalCentresforSocialActionUNCCAS,Paris(France);
X PermanentUniversityoftheUniversityofAlicante,Alicante(Spain);
X EMGOInstitute,VUUniversityMedicalCenterAmsterdam,Amsterdam(theNetherlands).





EmpoweringHealthLearningforElderly(EHLE)

 10
3. ACTIVITIES


PERCEPTIONANALYSIS–ThiswasthefirstactivityoftheProjectandwascarriedoutbythefour
European countries involved.It reveals sociodemographic and health characteristics through a
questionnaireadministeredto1200subjects:patientsaged65andoverinDistrict1ofULSS(PCT)
16in
the Veneto, students aged 55 or over at the University of Alicante in Spain, the over 65s who receive
social care from UNCCAS in France and, in the Netherlands, elderly people who were already
participatinginalongitudinalstudyoftheVUUniversityofAmsterdam.

TRAININGCONCEPT–
BasedontheresultsobtainedfromthePerceptionAnalysis, theSpanish
and Dutch partners created a training system designed to provide new knowledge and skills, both
technical and communicative, to those who work with the elderly.These skills will allow such health
and social workers to better guide and interact
with elderly people, giving them the tools to make
responsiblenutritionalandlifestylechoices.

PILOT TRAINING – The EHLE Training System was then tested in Italy and France in four pilot
training courses (two per country).The general objective of the course was to
promote effective
methodologiesforcommunicatinghealthmessagestoelderlypeople.Morespecifically, bytheendof
the course participants knew the relevant scientific evidence regarding health promotion in elderly
peopleand wereable toemploy themost appropriatemethod ofcommunicationinordertopromote
healthinthetargetgroup.


TRAININGTOOLBOX–Allthescientific,methodologicalandcommunicative
materialdeveloped
duringthecourseoftheprojectandrefinedduringthePilotTrainingmakepartoftheTrainingToolbox.
ThisTrainingToolboxisdesignedtogiveconcreteandpracticalsupporttothosewhoworkorvolunteer
withelderlypeople.




EmpoweringHealthLearningforElderly(EHLE)

 11
Fig.2:Agedistributionofintervieweesacrossfourcountries.

4. CONTEXTOFTHEPERCEPTIONANALYSIS

The
PerceptionAnalysisofownhealthandwellbeingwascarriedouton1,200peopleofover55
yearsold.The
questionnaireadministeredincludedquestionstodrawoutsocialanddemographicdata
as well as data on lifestyle including alcohol consumption, use of medicines, dietary habits, smoking,
physicalactivityandthesubjects’perceptionoftheirownemotionalwellbeing.

There is great diversity of
characteristics of the subjects surveyed
in the four countries.
Age distribution
and the level of education vary
enormously and these are reflected in

all the variables examined.These
differences aredueto thefactthat the
surveyed populations are structurally
different: students at the Permanent
University of Alicante in Spain, patients
fromaparticulardistrictfortheVeneto
in Italy,
 participants in a longitudinal
study for the University of Amsterdam
in the Netherlands and users of social
servicesforUNCASSinFrance.

Looking at age it is notable that
intheNetherlandstheagerange5564representsalmost70%ofthetotal,andover85’s0%.France,in
contrast,
sees5564yearoldsat17%and‘theolderelderly’at21%(Fig.2).

LevelsofeducationaremuchhigherintheSpanishsample(about43%ofthosesurveyedhavea
degree), medium in the Netherlands and low in France and Italy, where not more than 10% have a
degree.

Anotherfactorthatinfluenceslifestyleistheplaceofresidenceofthosesurveyed.InSpainand
theNetherlandsabout80%ofthosesurveyedcomefromrelativelylargetowns (>50,000inhabitants),
and only 34% from villages and rural areas.In France almost 25% of thosesurveyedcomefromless

denselypopulatedruralareas.



EmpoweringHealthLearningforElderly(EHLE)


 12
Fig.3:Smokinghabitsbycountryofresidence.

Fig. 4: Alcohol consumption stratified by
frequencyandcountryofresidence.

Fig. 5: Frequency of physical activity
stratifiedbycountry.

In general the subjects sleep for 68
hours a night (although about half do not
consider their sleep satisfactory).Most do not
smoke or have given up smoking, although Italy
stands out with a higher percentage of active
smokers (18%, Figure 3). Alcohol is consumed
withdifferingfrequencyacro s
thefou countries
(Fig. 4).Different answers were given when
physical activity was measured in terms of the
dailylevelofactivity(Fig.5).
s
r




























EmpoweringHealthLearningforElderly(EHLE)

 13
Fig.6:Satisfactionwithone’sowndietbycountry.

The perception of one’s own
physical health is, overall, good (60%
positive or very positive and only 5% in
decline, see Fig. 6), a factor probably
influenced by the fact that those

interviewed come from selected
segmentsofthepopulation:studentsata
universityforolderpeopleandthosewho
refer themselves to a health centre.In
fact, among those interviewed only 5%
have difficulty in their Basic Daily
Activities (BDA), a very low proportion
compared the general population at the
ameage.s

Those interviewed are satisfied with their diet and provide the following responses to the
questiononhow
satisfiedtheyconsider mselves tobewiththeirowndiet:the 
• Mostofthosesurveyedeatthreemealsaday;
• Eatatleastoneportionoffruitandvegetablesadayand
• Eatmeatorfishtwiceorthreetimesaweek.
Therearealso‘unexpected’statistics,for
examplethat14%eatcoldmealsonadailybasisand23%eat
puddingeveryday.

Consumption of medicines is the section in which the results differ most widely and in which
themostdifferentsituationsemergeineachcountry.Aboutaquarterofthetotalconsumedmedicines
arenot
prescribedbythedoctor(selfprescribedorasrecommendedbyfriendsorrelatives).Only50%
ofthosesurveyedbelievethatamedicineboughtinapharmacywithoutprescriptioncouldbedamaging
andabout20%donotbelievethisispossible.

Notable differences in the quantity and type of medicines consumed
appear across the four
European countries surveyed (Fig. 7). The French groupthe oldest and with the lowest level of

educationresultsasthegroupwhichconsumesmostmedicines(mostfrequentlypainkillers,antihigh
blood pressure drugs and sleeping pills). The Dutch group, the youngest, consumes noticeably fewer
medicines,whilethe
groupsfromItalyandSpainshowverysimilarconsumptioninquantitative terms.
It can be hypothesised that these differences in consumption can also be attributed to differences in
accessibilityandeaseofprescriptionofthesedrugsinthedifferentcountriesandnotonlytopopulation
characteristics.




EmpoweringHealthLearningforElderly(EHLE)

 14

Fig.7:Percentageconsumptionofmedicines,bytypeofmedicineandbycountry.



The perception of one’s own mnemonic and cognitive abilities is very different across the
countries but most clearly across the different age groups.Overall subjects mentioned that they had
difficulty in remembering the correct words for things, remembering names of people or where they
had put things, but only rarely
 noted that they forgot to pass on important messages or were
disorientedoutsidethehome.Theoldestsubjectmentionedthesesymptomsmostfrequently.
3.12and3.10pointsrespectively)whiletheItaliansandtheFrenchreport
anaverageof2.75
and2.76.
reallydoexistbetweenthedifferentpopulationsoriftheyaretheresultofdifferent
subject roups.

 populations with significant and

Inordertoevaluatetheperceptionofone’sownemotionalwellbeingascalewascreated,able
to summarise responses to all the questions in this area.This
scale measures emotional wellbeing
cumulatively(forexample,feelingoneselfuseful,fulloflife,desiretolearn,andmeetingfrequentlywith
friendsandfamily).OnaveragetheDutchandtheSpanishreportthehighestlevelsemotionalwellbeing
(aratingof

These differences, from which it appears that the Dutch and Spanish enjoy greater wellbeing
compared to the Italians and French, can be explained in part by the different characteristics of age,
social status and health across the different groups, and not only by geographical
or cultural factors.
Deeper analysis, eliminating the effects of these potential confounders, could demonstrate whether
thesedifferences
g

In summary,for all fourcountries someimportant determinants foremotional wellbeing were
revealed.Indicatorsof
adherence to goodlifestylesinclude: intensity ofphysical activity, satisfaction
withone’sdiet,andperceivedqualityofphysicalhealth.Thecorrelationbetweenhealthylifestylesand
a better level of emotional health can be traced across all four



EmpoweringHealthLearningforElderly(EHLE)

 15
Fig.8:Correlationbetweenaverageemotionalhea scoresandthelevelofsatisfactionwithone’sdiet


lth
increasingeffectasthevariablebeingtracedincreases(eg.inFig.8).

rcountriesdespitedifferentstarting
levelsperhapspromptedbygeographicalandculturaldifferences.
people’ personalandemotionalwellbeing,whethertheyliveinItaly,France,TheNetherlandsorSpain.


















Inconclusion,eveninthevarietyofthepopulationssurveyed,fromthedataobtainedemerges
animportanthealthmessageforadultsandelderlypeople.Adheringtoahealthylifestyleisassociated
withameasurableandconsistent
emotionalwellbeingacrossallfou

Ourwork,topromoteinitiativesdesignedtoimprovethelifestylesandhabitsofelderlypeople,

isthereforefully supportedbythe datacollectedfromourelderly citizens.Aswewill see,adopting a
healthy lifestyle is effective not only in reducing the risk of adverse events but also in augmenting
s



EmpoweringHealthLearningforElderly(EHLE)

 16
5. THETRAININGCONCEPT

a. ConceptualFramework

The goal of the EHLE project is to empower elderly people to make informed choices in the areas of
health and lifestyle and to develop and communicate clear simple messages about food and healthy
lifestyles.Thisgoalisbasedonthe
“patientempowermentapproach”:toenablethepatient(orinthis
project elderly people) to use their own internal resources and abilities in order to manage their own
health.

The Patient Empowerment Approach became well known in the 1990s and has been defined as an
interventiondesignedto“helpthepatient
todiscoverandemployhis/herownabilitiesinordertotake
controloftheirownhealth”.Thisapproachcomesoutoftheideathat,althoughdoctors,nurses,health
workersandcaregiversareexpertsincures,theindividualiscertainlytheexpertontheirownlifeand
should therefore be given
 first decisionmaking responsibility.As a result the provision of healthcare
becomescollaborationbetweenthepersonandthehealthworker.Thelatter’straditionalroleofexpert
advisorislessinevidence.


Thereareseveralstrategiesto increasepatient empowerment.Inthisprojectwebelieve thatwe can
empowerelderlypeople
in3steps:1)bycommunicatingtherisksconnectedtoparticularbehaviours,2)
by motivating them to change and 3) by teaching them how to set SMART (Specific, Measurable,
Achievable,RelevantandTimed)goalsonhowtochangetheirlifestyle.Thesetoolswillbeexplainedin
furtherdetailbelow.

But
why dowethink thatwecan helpelderlypeopleto adoptahealthy lifestylebymeansofapplying
these three steps?The answer can be found in our theoretical framework.The use of a conceptual
frameworkisimportantinprojectsandstudiesthatwouldliketopromotehealthylifestyles
forseveral
reasons.Firstly,a frameworkhelpsto designtheconceptoftheprojectin thesense thattheyhelpto
considerwhichelementsshouldbeincludedintheprojectandwhy.Secondly,itprovidesagoodbase
foranevaluationoftheintervention’sefficiency,methodologyandpracticalimplementation.Thirdly,it

allows others to carry out and improve the same intervention in order to use it in their own specific
context.

Ourtheoreticalframeworkisbasedonthreetheories:TheTheoryofPlannedBehaviour(TPB),theself
regulationtheoryandthesocialnetworktheory.

1) The Theory of Planned Behaviour (TPB)
 helps us to understand how energy balancerelated
behaviourismediatedbycognitiveconstruct.AccordingtoTPB,humanactionisguidedbythreekinds
ofconsiderations:a)behaviouralbeliefs:beliefsaboutthelikelyconsequencesofthebehaviourandthe
evaluation of these consequences; b) normative beliefs: beliefs about the normative
expectations of
others and the motivation to comply with these expectations; c) control beliefs: beliefs about the
presence of factors that may facilitate, or may impede the performance of the behaviour, and the




EmpoweringHealthLearningforElderly(EHLE)

 17
perceived power of these factors. These beliefs can lead, respectively, to a favourable or an
unfavourable attitude towards a certain behaviour, perceived social pressure, and perceived
behaviouralcontrol,andincombinationtheydeterminebehaviouralintention.Finally,givenasufficient
degree of actual control over their own behaviour, people are
expected to carry out their intentions
whentheopportunityarises.

2) SelfRegulation Model: this theory was elaborated by Leventhal and colleagues and suggests that
individualswill usestrategiesthat arebasedonanunderstandingof theirillnessand newexperiences.
Thetheorydelineatesfivecoredimensionsofillnessrepresentation
(people’sperceptionsofandbeliefs
aboutanillness):
• Identificationofthedisease
• Cause
• Timeline
• Consequences
• Controllabilityintermsofpreventionandcure.

The theory hypothesizes that illness representations are important mediating links between health
threatsandpeople’sreactionstothem.Theprocessisadynamicone
thatchangesinresponsetoshifts
inpatients'perceptions:throughexperienceandfeedbackmechanisms,perceptionscanbeinfluenced.
Interventions that are able to successfully incorporate shortterm concrete feedback and tie these to
action plans are more successful than those where feedback is either greatly delayed or nonexistent.

Thismodel
differsfromothertheoriesinitsemphasisontheroleofemotionincopingwithillness.The
modellinkspeople’sperceptionofadiseasewithselfmanagementbehaviours.

3)SocialNetworkTheoryviewssocialrelationshipsintermsofnodesandties.Nodesaretheindividual
actorswithinthenetworks,andties
aretherelationshipsbetweentheactors.Therecanbemanykinds
of ties between the nodes.According to social network theory the attributes of individuals are less
importantthantheirrelationshipsand tieswithotheractorswithinthenetwork.Withinthisapproach
individualbehavioursareconsideredtodependon the
surroundingnetworkinwhich theseindividuals
areembedded.Thereforethefocusoftheanalysesisnottheindividualactorandhisorherattributes
butthe networkpattern,i.e.itssize, structureanditscomposition.Furthermore,members ofasocial
network control andsanction each other’s behaviour.Indensenetworks of
 strongties,the members
controleach othermorethan inopenor sparselyconnectednetworksconsistingofweakerties,partly
becauseinnetworksofstrongertiesmoresanctionpossibilitiesexist.

The firsttwotheories describe theimportance of empowering peopletoadopt a healthy lifestyle.By
providing accessible information on
health risks, patients are likely to change their perceptions,
according to Leventhal’s selfregulation model.As a result, people will change their attitude towards
behaviour change, which is embedded in the Theory of Planned Behaviour.Finally, people might
becomemoremotivatedtochangetheirlifestyleinwayswhichwillreducethe
riskofdevelopingsevere
diseases.Finally, social network theory highlights the importance of paying attention to the social
networkthattheelderlypersonispartof(thenetworkoffriendships,socialandfamilialrelationships).




EmpoweringHealthLearningforElderly(EHLE)

 18

b. MethodologicalTechniques

ThemethodologicalbaseoftheEHLEprojectistheBehaviourChange

approachaccordingtowhichitis
possible to induceapatient to change his orherdangerous or unhealthybehaviourbyintervening on
threelevels:

1. COMMUNICATIONOFRISKSconnectedtolifestyle(increaseorimprovethepatient’sunderstanding
oftheproblem)
2. MOTIVATIONtochange;
3. GOAL SETTING: DEFINITION OF SMART
 OBJECTIVES (Specific, Measurable, Achievable, Relevant,
Timebased).Forexample“walkthreetimesaweekforthirtyminutes”.Onebeginswithshortterm
objectivesandmovesontolongertermobjectives.

The following is a description of some methodological techniques which can be used to help elderly
peopletochange
theirbehaviour.Allthetechniquesdescribedcanbeadoptedseparately,butareeven
moreeffectiveifusedaspartofathreephaseintervention:CommunicationofRisk,Motivation,Goal
setting.

i.
CommunicationofRisk

It has been demonstrated that people underestimate the risk of developing serious

complications.Furthermore, the health professional’s explanation of the risks is often ineffective,
because these risks are often presented in terms of the percentage of people who will develop such
complications.As a result of this poor communication, people are
 not encouraged to change their
lifestyles.This idea is already central in Leventhal’s selfregulation model (1997), based on the
hypothesisthatapatient’sknowledgeofforexample,diabetesanditstreatment,candeterminehisor
her healthmanagement behaviour.Understanding the evolution, cause, consequence and exact
identity of a
disease increases one’s ability to control it.To this end it is important to use effective
methodsofrisk communication,for exampleusing visualrepresentations ratherthan writtenstatistics
andscientific data.Itisalso importanttofocuson thebenefitsofchangingbehaviourratherthan the
negativeconsequencesofnot
doingso(lossofhealth/yearsoflife).

ii. TheMotivationalInterview

The motivational interview (MI) is a brief counselling session designed to increase motivation
and to explore and resolve any ambiguities.In recent years motivational interviews have been an
important technique used in behaviour interventions.The four guiding principles of
 motivational
interviews are: express empathy, discover discrepancies, challenge resistance and support self
sufficiency. Expressing empathy consists of providing subjects with a respectful and accepting
atmosphere.Thetechniqueused iscalled ‘reflectivelistening’, generallyconsidered thefoundation of
motivationalinterviewsandrecommendedforthewholecounsellingprocess.



EmpoweringHealthLearningforElderly(EHLE)

 19


ThesecondprincipleofMIistohighlightthegapbetweentheperson’scurrentconvictionsand
behaviourandtheirwiderambitions.Whenthepatientrecognisesthesediscrepanciestheyoftenfeela
certaindiscontentwhichmakesitmorelikelythattheywillchange.Differencesarediscoveredthrough
theexplorationof
thevaluesofthepersonandofhowthesevaluesandbehaviourfeedintotheirideal
lifestyle.

The third principle, working on resistance, is based on the idea that a direct challenge to a
person’s resistance to change is counterproductive because it generally renders them defensive and
more resistantto
change.The idea is toinviteconsideration of a newpointof view, nottoimpose it
fromabove.

The person’s self sufficiency and trust in their ability to change a particular behaviour even in
difficultcircumstances mustbothbesupportedwherepossibleastheseareamongthebestpredictors
of
 positive treatment results. The person can be supported by emphasising past successes (positive
reinforcement) presenting examples of other people’s success (remodelling) and expressing the
convictionthatthepersoncanchange.

iii.
Goalsetting:ProblemSolvingTreatment


ProblemSolvingTreatment(PST)istheconstructionofaseriesofpracticalactivitiestodealwith
problems.The technique was originally described by D'Zurilla and Godfried, then developed and
perfectedbyD'ZurillaandNezu.PSTcanbedefinedastheautocognitivebehaviouralprocessthrough
which a person seeks effective
solutions adapted to their specific situation.PST has been shown

effectivewithpatientswithdepression,butispotentiallyusefulinthetreatmentofanyillnessinwhich
thepersondealswithmultipleissuesintheirdailylifeandisunsureofhowtodealwiththem.

Forexample,peoplewithcomplex
medicalconditionscanfindPSThelpful,astheyneedtodeal
withmanycomplexproblems.Suchpatientstypicallymustbecarefulwiththeirdiet,lifestyle,physical
activity and medicinetaking in order to regulate their condition.Psychological problems are also
commoninthesepatients.PSTcanhelptoaugmentpatient
capacitytoresolvepsychologicalproblems
in a structured way, increase their faith that they will be able to deal problems in the future and
thereforeimprovetheirselfmanagementoftheircondition.


PSTcanbeconsideredasaseriesofsteps:
1. Explanationoftheinterventionanditsrationale
2.
Definitionandunpackingoftheproblem
3. Selectionofachievableobjectivesforproblemsolving(SMART)
4. Creationofvariouspossiblesolutions
5. Theevaluationandchoiceofsolution
6. Puttingthepreferredsolutionintoaction



EmpoweringHealthLearningforElderly(EHLE)

 20
7. Evaluationofresults

AnExampleofProblemSolvingTreatment

To help diabetic patients to change their lifestyle, Dutch nutritionists and nurses have used a
questionnaire which outlines the phases of PST: risk communication, motivation, definition of
objectives.Thepatientswereabletoadoptthistechniquetodefinetheirownobjectives.

1. DEFINITION OF THE PROBLEM: What is the problem? For example smoking, excessive weight, low
levelsofphysicalactivityandsoon.
2. DEFINITION
OF ACHIEVABLE OBJECTIVES: For example “I would like to manage more physical
activity:atleast30minutesofphysicalactivity(measurableobjective)everyday(timebased)”.
3. BRAINSTORMING: Whatare thepossible solutions?Go tothe gym,cycle tothe supermarketorto
work,gorunningwithafriendand
soon.
4. EVALUATION OF SOLUTIONS: What are the advantages and disadvantages of each solution? Seek
the best solution: going to the gym is expensive, cycling to the supermarket is possible but not
realisticbecausetheshoppingistoobulky,goingtoworkismanageablebutnotwhenitrains,and

runningwithafrienddependsonthefriendetc.
5. IMPLEMENT THE SOLUTION: The patient goes home and tries to reach their chosen objective or
“takehomemessage”.
6. EVALUATETHERESULT:Hastheresultbeenobtained?Ifthechosenobjectivesarediscoveredtobe
toodifficulttoachieve,it
ispossibletoredefinethem?Ifinsteaditwastooeasy,theeffortcanbe
increased,forexamplebyaddinganextraactivity(e.g.runningwithafriend).




EmpoweringHealthLearningforElderly(EHLE)

 21

6. TRAININGHEALTHPROFESSIONALS


The Target Audience: is ideally between 3035 workers or professionals from
differentprofessionalareas.

TheStructureisgivenbythethreekeyphasesofProblemSolvingTreatment:
1. RISKCOMMUNICATION(ofrisksofunhealthylifestyles)
2. MOTIVATION(tochangebehaviour)
3. GOALSETTING(creatingSMART
objectives)

Equipment: Acomputer, projectorand speakers, multimediaresources,stationery,
andenoughspacetoallowforbothtraditionallecturesandworkinmultidisciplinarygroups
andpracticalactivities.

OtherSupportMaterials:
X PowerPointpresentations
X Relevantmodulevideos
X Brochures(Leaflets)
X HealthDiaryorothersupport
X Bibliography

Organisation
ofEachModule:
Eachmodulelastsatotalof1hourapprox.,dividedintotwoseparatesections:atheoreticallecture(30
minutes approx.) and  multidisciplinary group activity (30 minutes approx.).The presentation of the
contentandexercisesisasfollows:

• Introduction(5mins)

• Baseconcepts(5
mins)
• Content:
− Therisksandtheadvantagesofreducingthem(5mins)
− Basicstrengtheningmessages(5mins)
− Objectivesandtechniquesforchange(5mins)
− Video(2mins)
• PracticalActivitywithroleplaysorexercises(20mins)
• Debate,checkingandconclusionsingroupsorinplenary(10mins)





EmpoweringHealthLearningforElderly(EHLE)

 22
a. CommunicatingwithElderlyPeople

Objectives–Elucidatethecommunicativestrategieswhichfacilitatecommunicationwithelderlypeople
andmakeitmoreefficient.

Tool–PowerPointPresentation
“COMMUNICATIONWITHELDERLYPEOPLE”

TheoreticalContent:

To educate an elderly person abouthealthit is necessary to understand the difficulties of this
type of communication: a limited attention span and understanding of technical language, limited
consultation time, the presence of prejudices or preexisting knowledge which are difficult to change,

littlemotivationtochange
–ortheopposite,i.e.overlyhighexpectationsofwhattheprofessionalcan
do,etc.

Theelderlypersonwhostandsinfrontofthehealthorsocialworkerisnotacleanslatebuthas
prejudices,convictions,information,habitsandmemorieswithwhichheorsheinterpretsandfiltersthe
messagessenttohimorher.Inordertocommunicatesuccessfullywithanelderlypersonitisnecessary
toconsidersomespecificstrategies.

Language must be adapted to the person listening, but not necessarily simplified.If it is
necessarytouse technicallanguage, remember touse itin context andalways
toask: “Haveyou ever
heardofthis?Doyouknowwhatitmeans?”

Whencommunicatingwithanelderlypersonitisnecessarytoconsiderthateverythingyousay
willhaveaneffectontheirfamily,whocanbeahelporahindranceinachievingtheobjectivesset.

The winning attitude is that of professional knowledgeable communication, avoiding
spontaneous (in the sense of automatic) responses.If you can imagine a video camera which shows
your interaction with the elderly person, we can see that ‘spontaneous’ communication takes for
granted that the person we are talking to has understood.
This assumption opens the way for
misunderstandings, insinuation, misinterpretation and a general decline in the standard of
communication.

Professionalknowledgeablecommunicationischaracterisedbythepresenceofclearachievable
objectives.

In transmitting information one must take into account the ‘baggage’ of an elderly person,
including limited concentration, and giving information

 which is acceptable, comprehensible,
achievable, concrete and which is transformable into action.Giving too much information risks
promptingakindof‘deafness’which,paradoxically,reinforcestheoriginalnegativeidea.



EmpoweringHealthLearningforElderly(EHLE)

 23
Tobreakdownthewallwhichoftenseparatesthehealthorsocialprofessionalfromthepatient
it isnecessaryto begin by asking what the elderly patient thinks –this sends astrongsignal that the
professionalisinterestedinthepersonandinhisorherpriorinformation.

Make best use of time taking care over the opening communication, facilitating the elderly
person’snarrativewith structuredquestionswhich allow abetterunderstanding ofthe patient’s point
ofviewandpriorknowledge,thusavoidingpointlessrepetition.

“DyingHappy”Onepossibleteachingsupportforthecommunicationmoduleisthesimulation
of a consultation between a GP and a 65 yearold patient who is a smoker, overweight, and with
dyslipidemiaandafamilyhistoryofheartdisease.ShegoestotheGPforacheckup,bringingherlatest
testresultsinwhichitisclearthathercholesterollevelsareevenhigherthanbefore.

Transcriptoftheconsultation:

GP:
I’mafraidyourcholesterolisevenhigherthanthelasttimeIsawyou:didn’tIrecommendyoutake
statins?
PATIENT
:Butyouknowtheymakemefeelill.
GP:

Well,areyoutryingtofollowthedietthen?
PATIENT:
(irritated)Sorry,butwhatdiet?
GP
: We’vespoken about it manytimes:you needtoreduceyour intake of animal fats,use oil andnot
butter…
PATIENT
:But… youknow Icook, I’machef.Myrestaurantistheonenearthe church.Onceyou even
came…Irememberitwelland…youordered…yes,youorderedfriedsoleandyourwifeorderedbattered
fishandthenIthinkyoubothhadthetiramisu.
GP
:Well,youknowyourrestaurantisfamousforitsbatteredfish…onceinawhile…Butlet’scomeback
toyou.Youdon’tdoanyexercise,yousmoke,youhaveapoordiet…
PATIENT:Doctor, mybrotherJohn, yourememberhimright,he wasskinny,tookallthemedicinesYOU
doctorsprescribedhim,didn’teatanotherfriedthingoranothersliceofsausagefromthemomentYOU
doctorstoldhimnottoandhedied,threeyearsago,at45.AndI…I’mnotgoingtoenduplikehim.
IfIhavetodieatleastI’lldiehappy.
Instructionsforgroupwork:
Comment:Thepatienthasyouincheckmate.
Question:Howwouldyoureactatthispoint?
Comeupwithpossibleanswers…

b. PersonalRelationshipsandEmotionalHealth

Objectives
• Getting to know
 the impact of emotions on health as well as the importance of emotional
regulation.
• Identifyingthebasicemotionalphenomena(emotions,feelingsandstatesofmind).




EmpoweringHealthLearningforElderly(EHLE)

 24
• Perceivingemotionalhealthaspartofalifestylethatcanbedevelopedthroughthe knowledge
andpracticeofcopingstrategies.

Tools–PowerPointPresentation
“PERSONALRELATIONSHIPSANDEMOTIONALHEALTH”

TheoreticalContent:

Whataretherisks?
Itisimportanttoknowhowtohelpanelderlypersonexpressthemselves.Thisisbecausethey
often suffer from hidden or underlying depression which makes it difficult for them to express
themselvesortoverbalisetheirproblems;someevenfeelashamed.For
thisreasonthehealthorsocial
professional needs to seek a point of contact which helps them to talk, for example using ‘neutral’
framing questions (about their family, children, etc): these questions seem neutral but are in fact a
useful way to arrive at the desired information.The relationship between the
 elderly person, their
family, and social and health professionals is a fundamental part of any successful strategy.We also
need torememberthat resistance tochangeis a physiologicalaspect ofbeing human (eachone ofus
determines a successful strategy for managing our dailylivesand is reluctant to
change this) and that
thisresistance,anditsattendantnegativeeffects,arestrongerinanelderlyperson.

HowtoMotivateBehaviourChange


Asuccessfulapproachisempowermentoriented,designedtogivethepersonpoweroverhisor
herownlife.Thehealthorsocial professionalneeds tofollowthefollowing
stepsto change:1) know
andunderstandtheproblemandlocateresourcesfordealingwithit;2)help thepersontochangethe
relevant behaviour and to live with the consequences of that change; 3) reinforce and emphasise
successandtheexperiencegainedand4)givethepersonknowledge.Communication
withtheelderly
person is neither confession nor a consolation but a professional communication which uses specific
objectivesandresources.ThepatientprofessionaldialogueshouldfollowthepatternofQuestion(from
the professional), Answer (from the patient), Strategic Paraphrasing that summarises the answer
receivedandchecksunderstanding(fromtheprofessional).

Itisalsoimportanttoaskquestionsintherightwayinordertoensurethattheelderlypatient
isabletounderstandtheinformationgiventothemandtobecomeknowledgeableaboutthechangeto
beeffected.Forthisreasonitisnecessarytofindapointofcontactandthusencouragethepatientto
talk,using‘neutralframingquestionswiththeillusionofanalternative’,forexample:“Doyoueatthree
mealsa dayordoyousometimesskip meals?”insteadof “Areyoueating?”.Thefirstquestionseems
neutralbutisawayofgettingatthedesired
information.Iftheelderlypersonisstillunabletorespond
clearly,beginagain,askingthequestioninsimplertermsinordertodiscovertheirsymptoms.

Thenextstepistofindpositiveexceptionstotheproblempresented,andthesearetobefound
using the elderly person’s own resources (e.g.
“Are there times when this doesn’t happen to you?”).



EmpoweringHealthLearningforElderly(EHLE)

 25

Theaimistoprescribeasolutionthatmimicsthepositiveexceptionsandtoinvitetheelderlypersonto
returnandrecounttheirexperiences–thusmaintainingmotivation,promotingdialogue,andsoon.

Paraphrasing allows one to simplify the conversation, checking that both parties have
understood and helping to
map the problem.Avoid asking more questions after listening to the first
replies,asitisimportanttosynthesisewhatyouhaveheardusingthesametermsasweregiventoyou
bytheelderly person(thusminimising resistancetochangeas thepatientwill feelthat thesolutionis
theirs).
Don’tforgettoaddthekeyphrase“PleasecorrectmeifI’mwrong”,toencouragedialogueand
toensurethatthepatientfeelslistenedto–andthatyouhaveunderstoodcorrectly.

The reflective technique isat the heart of the process ofinformingan elderly person: to help
the
patientdiscovertheirownstrategiesandsolutionsusingtheirownlanguage,persuadingthemusing
their own arguments.The intervention must be adapted to the person and to their resources, thus
involvingthemandguidingthemtothediscoveryoftheirownsolution.

Whatobjectivestoset

Framing questions and
paraphrases are selfcorrecting: the therapist does not come with
preconceptions and ready made solutions but adapts his or her own vision to that expressed by the
elderlypersonbylookingattheproblemfromhisorherperspective.Thisistheapproachknownasthe
‘locusofinternalcontrol’,where
controlislocatedwiththepersonandisthusempowermentoriented–
the person is pushed to understand the problems as internal in order to resolve these problems with
solutionswhicharealsointernal.