Lifestyle Redesign
Publications

This chapter presents findings from a study analyzing occupational therapy intervention outcomes to elucidate the relationship between lifestyle changes and pressure ulcer development. The complexities of lifestyle and behavior changes contributed to different patterns which impacted the development and progression of pressure ulcers. The four identified patterns included positive pressure ulcer changes accompanied by positive lifestyle and behavior changes, negative or no pressure ulcer changes accompanied by positive lifestyle and behavior changes, positive pressure ulcer changes accompanied by minor or no lifestyle or behavior changes, and negative or no pressure ulcer changes accompanied by minor or no lifestyle changes. Community-based occupational therapy practice provides an opportunity to comprehensively address important lifestyle factors impacting pressure ulcer development.

Keywords. occupational therapy, lifestyle, behavior, pressure ulcer, community-based practice

Occupational therapy (OT) has the potential to mitigate against the health risks associated with older adulthood but traditionally has been applied only after catastrophic health events. The Well Elderly study included a randomized controlled trial comparing preventive OT services to non-professionally led social activity and a non-treatment control condition in 361 independent-living, multiethnic older adults (60+ years old). Physical, social, and mental health outcomes were measured at baseline, 9 months (intervention end), and 15 months. Results showed significant benefits for the OT group in overall health, functional status, and life satisfaction compared with both control conditions. The social activity control group did not differ significantly in outcomes compared with the non-treatment control. This study provides support for preventive OT service provision to promote the health and well-being of independent-living older adults, above and beyond mere participation in group-based social activities.

Keywords. occupational therapy, older adult, independent living, Well Elderly, health promotion, well-being, function, social activity, life satisfaction

Telehealth delivery of Lifestyle Redesign®, an occupational therapy intervention framework addressing health and quality of life among people with chronic conditions, is understudied. The objective of this study was to evaluate the effectiveness, satisfaction, and engagement of telehealth Lifestyle Redesign for young adults with diabetes. Using process data from two randomized controlled trials, we compared in-person and telehealth intervention effects. Among telehealth clients, effectiveness was assessed using pre-post changes in occupational performance, occupational satisfaction, and health management; a survey captured telehealth satisfaction. Attendance and engagement in in-person versus telehealth therapy were compared. Preliminary results indicate telehealth clients had significant increases in occupational performance, occupational satisfaction, and health management (all p < .02), and high levels of telehealth satisfaction. Intervention engagement (p = .59) and attendance (p = .42) were similar across treatment modalities. Telehealth delivery of Lifestyle Redesign occupational therapy is feasible and potentially efficacious, and continued advocacy is needed to ensure access to occupational therapy through telehealth.

Importance. Fibromyalgia is a complex chronic pain condition for which effective nonpharmacological treatment interventions are lacking. Objective: To explore the effects of an occupational therapy intervention for fibromyalgia on client-reported outcomes of pain interference, self-efficacy, mood, and function.

Design. Retrospective cohort study using a chart review method.

Setting. Outpatient clinic.

Participants. Twenty-one adults with fibromyalgia (M age = 54 yr).

Intervention. A 10-wk occupational therapy group intervention using a Lifestyle Redesign® (LRD) approach.

Outcomes and Measures. The Brief Pain Inventory, Pain Self-Efficacy Scale, Beck Depression Inventory (BDI), and the Fibromyalgia Impact Questionnaire (FIQ) or the Revised Fibromyalgia Impact Questionnaire were administered at the first and last sessions of the program.

Results. Between 2015 and 2018, 37 clients entered the program, and 21 completed it. Changes in group averages exceeded the minimal clinically important difference for the BDI and the FIQ. Eighty-one percent of clients who completed the program had a clinically significant improvement on one or more of the outcome measures.

Conclusions and Relevance. The findings demonstrate the potential benefit of occupational therapy as a complementary approach to pharmacological treatment for people with fibromyalgia. Preliminary evidence suggests that a 10-wk occupational therapy group intervention using an LRD approach may reduce symptoms of depression and decrease the impact on daily function for people with fibromyalgia.

Keywords. fibromyalgia, pain, clients, personal satisfaction, self efficacy, life style, depressive disorders

Importance. Lifestyle Redesign® originated as a preventive occupational therapy intervention for healthy older adults, and it was found to be both effective and cost effective in the Well Elderly Studies initiated in the 1990s. Building on that empirical foundation, the scope of Lifestyle Redesign has been greatly expanded as a general intervention framework addressing prevention and chronic condition management in a wide range of populations, settings, and conditions. Yet until now, its full scope, defining characteristics, and supporting evidence have not been clearly and succinctly described, limiting its potential reach and impact.

Objective. To outline the definition and key characteristics of Lifestyle Redesign, provide a scoping review of its evidence base and future directions for research, describe its current applications, and make recommendations for its use in clinical practice.

Evidence Review. We searched PubMed and CINAHL, tables of contents of 10 occupational therapy journals, and citations in two seminal Lifestyle Redesign publications to identify articles published in 1997–2020 that described quantitative outcomes (for n ≥ 20) of interventions meeting the defining characteristics of Lifestyle Redesign.

Findings. Our scoping review yielded 12 publications providing supportive evidence for Lifestyle Redesign’s positive impact on a range of health and well-being outcomes among both well populations and those with chronic conditions.

Conclusions and Relevance. Lifestyle Redesign has the potential to meet a growing need in clinical and community settings for health care services that address prevention, health promotion, and chronic disease management.

Keywords. clients, health, life style, personal satisfaction

This article proposes that ‘meliorism’—a philosophical belief in people’s abilities to improve lived experience through engaged problem-solving—is a useful concept to describe and orient occupational science research, given the challenges of our time. This proposal derives from an intensive period of discussion through occupational science seminars, strategic planning sessions, and other activities at the University of Southern California’s Mrs. T. H. Chan Division of Occupational Science and Occupational Therapy, including preparations for the 26th Occupational Science Symposium in 2019. While many disciplines and professions express a melioristic intent, we believe that occupational science and occupational therapy exemplify a particular understanding of meliorism, given the view of occupation that they share, as: 1) engaged activity that has meaning and purpose; and 2) a powerful tool that builds consciousness and practices that can promote desired change. We suggest that occupational scientists’ aim to develop impactful research manifests these conceptual foundations. Further, we argue that a commitment to meliorism requires concerted efforts to mobilize knowledge by intentionally planning for stakeholder engagement and societal impact across all phases of research. We suggest that active knowledge mobilization will enhance the knowledge base of occupational science and help to realize its meliorist potential in both research and practice contexts.

Keywords. Occupational science; Knowledge mobilization; Meliorism; History of academic disciplines; Pragmatism

Importance. Rural-dwelling Latinos are an underresourced population in need of accessible and effective wellness programs.

Objective. To evaluate patients’ long-term health-related outcomes after lifestyle intervention.

Design. An uncontrolled pilot trial assessing change in health from pretreatment to long-term follow-up (12 mo after intervention completion, no contact) and from posttreatment to long-term follow-up.

Setting. Rural, community-based primary care.

Participants. Latino and Hispanic safety-net primary care patients, ages 50 to 64 yr.

Intervention. A culturally tailored, 4-mo lifestyle intervention co-led by occupational therapy practitioners and Latino community health workers that features telehealth and in-home sessions covering topics such as healthy eating and navigating health care.

Outcomes and Measures. Self-reported and physiological outcomes: symptom–well-being (primary), stress, sleep disturbance, social satisfaction, physical activity, patient activation, blood pressure, and weight. Exit interviews addressed health experiences and intervention impact on participants’ lives.

Results. Participants (N = 27) demonstrated clinically significant pretreatment to long-term follow-up benefits in all symptom–well-being dimensions (Cohen’s d ≥ 0.8, p ≤ .004), with additional gains from posttreatment to long-term follow-up (d ≥ 0.4, p ≤ .05). Significant improvements from pre- to posttreatment in systolic blood pressure, stress, and social role and activity satisfaction were maintained at long-term follow-up. No changes were observed in weight, physical activity, or diastolic blood pressure. Participants described the intervention’s sustained positive effect on their wellness.

Conclusions and Relevance. A lifestyle intervention led by occupational therapy practitioners and community health workers in a primary care context has potential to achieve long-term health benefits in rural-dwelling, late-midlife Latinos.

What This Article Adds. This study reveals that rural, late-midlife Latinos showed long-lasting improvements in psychological and physical health after finishing a program that helped them make healthy lifestyle choices. This finding supports the unique contribution of occupational therapy in primary care settings.

Purpose. Medically underserved adults with spinal cord injury (SCI) remain at high risk of incurring medically serious pressure injuries even after receiving education in prevention techniques. The purpose of this research is to identify circumstances leading to medically serious pressure injury development in medically underserved adults with SCI during a lifestyle-based pressure injury prevention program, and provide recommendations for future rehabilitation approaches and intervention design.

Methods. This study entailed a qualitative secondary case analysis of treatment notes from a randomized controlled trial. Participants were 25 community-dwelling, medically underserved adults with SCI who developed medically serious pressure injuries during the course of the intervention of the RCT.

Results and conclusions. Among the 25 participants, 40 unique medically serious pressure injuries were detected. The six themes related to medically serious pressure injury development were: (1) lack of rudimentary knowledge pertaining to wound care; (2) equipment and supply issues; (3) comorbidities; (4) non-adherence to prescribed bed rest; (5) inactivity; and (6) circumstances beyond the intervention’s reach. Together, these factors may have undermined the effectiveness of the intervention program. Modifications, such as assessing health literacy levels of patients prior to providing care, providing tailored wound care education, and focusing on equipment needs, have potential for altering future rehabilitation programs and improving health outcomes.

Keywords. Spinal cord injuries, pressure injury, lifestyle, intervention, cultural diversity

Research shows that personal and public health are intrinsically intertwined with ecological conditions and that actions that promote environmental sustainability are good prescriptions for health and wellness. I call this awareness and its implications for occupational therapists ‘environmentally-informed occupational therapy’ (EIOT). EIOT is an approach to occupational therapy founded in the growing body of scientific evidence that demonstrates that what is good for the environment is good for human health and well-being. It looks to nature to inform interventions and helps occupational therapists support their clients, students and communities to make lifestyle choices that contribute to their personal health while protecting and ideally enhancing the environment, e.g. while reducing global warming, preserving natural resources, preventing biodiversity loss, and more. Clinical and educational examples of EIOT are described.

Background. Research indicates that the incidence rate and clinical presentation of multiple sclerosis (MS) varies between patients of different ethnic backgrounds. On average, the incidence rate of Hispanic patients with MS tends to be lower than that of non-Hispanic whites, while the average age of first reported MS symptom is earlier in the Hispanic population. Hispanic patients have higher incidence of cervical spinal lesions, mobility impairments, and optic neuritis at first MS-related event. Patients with MS of Hispanic descent may be at a higher risk of disability earlier in the disease process. Due to the identified clinical presentation and disability risks, it is critical to provide rehabilitation services that will support symptom and disease management. Evidence in the MS literature supports behavior and lifestyle interventions as critical components for symptom and disease management, as well as improved quality of life. Lifestyle Redesign is an occupational therapy (OT) approach that focuses on helping patients acquire health-promoting habits and routines to improve overall function, health, and quality of life, as well as to improve self-management of chronic conditions. This methodology involves education, occupational self-analysis, personal exploration, and goal setting interventions, to facilitate reflection and increase motivation for and the enactment of health-promoting behavior changes.

Objectives. Describe the delivery of Lifestyle Redesign to address chronic disease and symptom management in patients with MS within an OT plan of care and provide a descriptive case series with clinical outcomes to demonstrate how this intervention can be applied clinically with Hispanic females with MS.

Methods. The subjects included in this case series participated in an average of 11 OT sessions. All subjects are female, of Hispanic descent, and between the ages of 20 and 45. The Canadian Occupational Performance Measure (COPM), Multiple Sclerosis Quality of Life Inventory (MSQLI), and Health Related Quality of Life Short Form-36 (SF-36) were used at pre- and postintervention.

Results. Clinically significant improvements occurred in the COPM overall performance and satisfaction scores, with patients demonstrating an average 5.3-point increase on performance and an average 7.2-point increase on satisfaction. On average, SF-36 scores improved in 7 subscales including emotional well-being, social functioning, and bodily pain, and MSQLI scores improved in 3 subscales including the MFIS.

Conclusions. This case series supports the use of Lifestyle Redesign to address symptom and chronic disease management in Hispanic females with MS because of the demonstrated benefits in the areas of functional performance and symptom presentation. Additionally, this case series contributes to the broader evidence for the feasibility of Lifestyle Redesign services for neurologic populations.

Keywords. Comprehensive care and MS, Lifestyle interventions, Management of activities of daily living in MS

Importance. Primary health care is rapidly developing as an occupational therapy practice area. Yet, to date, little evidence supports occupational therapy’s feasibility and efficacy in primary care settings.

Objective. To report on the implementation and preliminary clinical outcomes of a Lifestyle Redesign® (LR)–occupational therapy (LR–OT) diabetes management intervention in a primary care clinic.

Design. Patients were randomized to be offered LR–OT or to a no-contact comparison group (data not reported). We assessed implementation outcomes using mixed methods.

Setting. Safety-net primary care clinic.

Participants. Clinic providers and staff; English- or Spanish-speaking clinic patients ages 18–75 yr with diabetes and a current hemoglobin A1c (HbA1c) ≥ 9.0%.

Intervention. Eight 1-hr individual sessions of LR–OT focused on diabetes management.

Outcomes and Measures. Clinical and health behavior outcomes were assessed via electronic medical record (EMR) review and self-report surveys of patients receiving LR–OT at initial evaluation and discharge. We assessed implementation outcomes (acceptability, appropriateness, feasibility, fidelity, efficiency, and timeliness) using patient and staff surveys, interviews, focus groups, and observations.

Results. Seventy-three patients were offered LR–OT: 51 completed one or more sessions, and 38 completed the program. Clinical outcomes among program completers indicate beneficial changes in HbA1c, diabetes self-care, and health status. Implementation challenges included a need for patient and staff education, securing adequate workspace, and establishing a referral process. Factors contributing to implementation success included strong buy-in from clinic leadership, colocation, and shared EMR documentation.

Conclusions and Relevance. LR–OT is a feasible approach to enhancing service delivery and clinical outcomes in primary care.

What This Article Adds. This study provides insight into factors that may create challenges or contribute to the success of implementing occupational therapy services within primary health care settings. In addition, this study provides preliminary evidence of occupational therapy’s effectiveness in improving clinical outcomes among ethnically diverse, low-income patients with diabetes in a safety-net primary care setting.

Older, rural-dwelling Latinos face multiple health disparities. We describe the protocol of a pilot study of a community health worker–occupational therapist-led lifestyle program, ¡Vivir Mi Vida! (¡VMV!), designed for delivery in primary care and adapted for late-midlife, Latino rural-living patients. Using mixed methods, we collected feasibility, acceptability, and preliminary efficacy data on ¡VMV!. Forty 50- to 64-year-old Latinos participated in a 16-week lifestyle intervention led by a community health worker–occupational therapist team. We conducted pre- and post-intervention assessments to evaluate the efficacy of ¡VMV! in improving psychosocial and clinical health outcomes. Focus groups and interviews were held post-intervention with participants and key stakeholders to assess feasibility and acceptability. This is the first trial designed to evaluate a lifestyle intervention that includes collaboration between occupational therapists and community health workers within primary care. The detailed description of methodology promotes research transparency and reproducibility of a community health worker–occupational therapist-led lifestyle intervention.

Background. Pressure injuries negatively impact quality of life and participation for individuals with spinal cord injury (SCI).

Objective. To examine the factors that may protect against the development of medically serious pressure injuries in adults with SCI.

Methods. A qualitative analysis was conducted using treatment notes regarding 50 socioeconomically disadvantaged individuals who did not develop medically serious pressure injuries during a 12-month pressure injury prevention intervention program.

Results. Eight types of potentially protective factors were identified: meaningful activity, motivation to prevent negative health outcomes, stability/resources, equipment, communication and self-advocacy skills, personal traits, physical factors, and behaviors/activities.

Conclusions. Some protective factors (e.g., personal traits) may be inherent to certain individuals and nonmodifiable. However, future interventions for this population may benefit from a focus on acquisition of medical equipment and facilitation of sustainable, health-promoting habits and routines. Substantive policy changes may be necessary to facilitate access to adequate resources, particularly housing and equipment, for socioeconomically disadvantaged individuals with SCI. Further research is needed to understand the complex interplay of risk and protective factors for pressure injuries in adults with SCI, particularly in underserved groups.

Context/Objective. Medically serious pressure injuries (MSPrIs), a common complication of spinal cord injury (SCI), have devastating consequences on health and well-being and are extremely expensive to treat. We aimed to test the efficacy of a lifestyle-based intervention designed to reduce incidence of MSPrIs in adults with SCI.

Design. A randomized controlled trial (RCT), and a separate study wing involving a nonrandomized standard care control group.

Setting. Rancho Los Amigos National Rehabilitation Center, a large facility serving ethnically diverse, low income residents of Los Angeles County.

Participants. Adults with SCI, with history of one or more MSPrIs over the past 5 years: N=166 for RCT component, N=66 in nonrandomized control group.

Interventions. The Pressure Ulcer Prevention Program, a 12-month lifestyle-based treatment administered by healthcare professionals, largely via in-home visits and phone contacts.

Outcome Measures. Blinded assessments of annualized MSPrI incidence rates at 12 and 24 months, based on: skin checks, quarterly phone interviews with participants, and review of medical charts and billing records. Secondary outcomes included number of surgeries and various quality-of-life measures.

Results. Annualized MSPrI rates did not differ significantly between study groups. At 12 months, rates were .56 for intervention recipients, .48 for randomized controls, and .65 for nonrandomized controls. At follow-up, rates were .44 and .39 respectively for randomized intervention and control participants.

Conclusions. Evidence for intervention efficacy was inconclusive. The intractable nature of MSPrI threat in high-risk SCI populations, and lack of statistical power, may have contributed to this inability to detect an effect.

Trial Registration. ClinicalTrials.gov NCT01999816.

IMPORTANCE: A recent reanalysis of data from the Well Elderly (WE) 2 study purportedly indicated that the intervention did not achieve clinically meaningful or statistically significant effects; this article addresses these criticisms.

OBJECTIVE: To contextualize the WE 2 study as targeting a nonclinical population and demonstrate that the intervention produced substantively important, statistically significant effects.

DESIGN: Secondary analysis of WE 2 intervention-based pre–post change scores.

SETTING: The original trial occurred primarily in senior centers and senior housing facilities in greater Los Angeles.

PARTICIPANTS: Independent-living older adults (N = 324) who were assessed before and after intervention.

INTERVENTION: The WE intervention, a version of the Lifestyle Redesign® (LR) approach, was administered by occupational therapists over 6 mo by means of group and individual sessions.

OUTCOMES AND MEASURES: The 36-item Short Form Health Survey, the Life Satisfaction Index–Z, and the Center for Epidemiologic Studies Depression Scale.

RESULTS: The WE intervention was associated with statistically significant improvement on 10 of 12 outcome variables that were examined.

CONCLUSIONS AND RELEVANCE: Because the WE intervention was hypothesized to reduce age-related decline and followed a population-oriented approach, the expectation that average results would be clinically meaningful was inappropriate. The intervention produced positive effects across a wide array of outcome domains. In settings in which clinical meaningfulness is an appropriate index of intervention outcomes, evidence suggests that LR produces effects that are clinically meaningful. As an evidence-based intervention, LR should be considered useful both in population-oriented contexts and in addressing discrete health conditions.

WHAT THIS ARTICLE ADDS: Valid analyses demonstrate that the positive experimental effects of the WE 2 study are, in fact, genuine and cost-effective, and LR in clinically oriented contexts has produced statistically significant, clinically meaningful results. Clearly and accurately representing the evidence base of occupational therapy in prevention and chronic care is of critical importance to advance the field as a whole.

Aim. The aim of this study was to determine the feasibility and efficacy of a culturally tailored lifestyle intervention, ¡Vivir Mi Vida! (Live My Life!). This intervention was designed to improve the health and well-being of high risk late middle-aged Latino adults and to be implemented in a rural primary care system.

Background. Rural-dwelling Latino adults experience higher rates of chronic disease compared with their urban counterparts, a disparity exacerbated by limited access to healthcare services. Very few lifestyle interventions exist that are both culturally sensitive and compatible for delivery within a non-metropolitan primary care context.

Methods. Participants were 37 Latino, Spanish-speaking adults aged 50–64-years-old, recruited from a rural health clinic in the Antelope Valley of California. ¡Vivir Mi Vida! was delivered by a community health worker-occupational therapy team over a 16-week period. Subjective health, lifestyle factors, and cardiometabolic measures were collected pre- and post-intervention. Follow-up interviews and focus groups were held to collect information related to the subjective experiences of key stakeholders and participants.

Findings. Participants demonstrated improvements in systolic blood pressure, sodium and saturated fat intake, and numerous patient-centered outcomes ranging from increased well-being to reduced stress. Although participants were extremely satisfied with the program, stakeholders identified a number of implementation challenges. The findings suggest that a tailored lifestyle intervention led by community health workers and occupational therapists is feasible to implement in a primary care setting and can improve health outcomes in rural-dwelling, late middle-aged Latinos.

Objective. To assess the efficacy of a manualized occupational therapy (OT) intervention (Resilient, Empowered, Active Living with Diabetes [REAL Diabetes]) to improve glycemic control and psychosocial well-being among ethnically diverse young adults with low socioeconomic status (SES) who have type 1 or type 2 diabetes.

Research Design and Methods. Eighty-one young adults (age 22.6 ± 3.5 years; hemoglobin A_1c [HbA_1c] = 10.8%/95 mmol/mol ± 1.9%/20.8 mmol/mol) were randomly assigned to the REAL Diabetes intervention group (IG) or an attention control group (CG) over 6 months. IG participants received biweekly sessions guided by a manual composed of seven content modules; CG participants received standardized educational materials and biweekly phone calls. Blinded assessors collected data at baseline and 6 months. The primary outcome was HbA_1c; secondary outcomes included diabetes self-care, diabetes-related quality of life (QOL), diabetes distress, depressive symptoms, and life satisfaction. Change scores were analyzed using Wilcoxon rank sum tests.

Results. Intent-to-treat analyses showed that IG participants showed significant improvement in HbA_1c (-0.57%/6.2 mmol/mol vs. +0.36%/3.9 mmol/mol, P = 0.01), diabetes-related QOL (+0.7 vs. +0.15, P = 0.04), and habit strength for checking blood glucose (+3.9 vs. +1.7, P = 0.05) as compared with CG participants. There was no statistically significant effect modification by sex, ethnicity, diabetes type, recruitment site, or SES. No study-related serious adverse events were reported.

Conclusions. The REAL Diabetes intervention improved blood glucose control and diabetes-related QOL among a typically hard-to-reach population, thus providing evidence that a structured OT intervention may be beneficial in improving both clinical and psychosocial outcomes among individuals with diabetes.

Purpose of the Study. This study investigated the mechanisms of change underlying an activity-based lifestyle intervention, an occupational therapy program aimed at promoting healthy habits, and routines in older adults. We examined two activity-relevant factors as potential mediators linking the intervention to reduced symptoms of depression: activity frequency and global perceptions of activity significance. Social connections and perceived control were assessed to understand how activity-related factors relate to reduced symptoms of depression.

Design and Methods. The sample consisted of 460 multiethnic community-dwelling older adults aged 60-95 years. Participants were randomly assigned to a 6-month lifestyle redesign intervention (n = 232) or a no-treatment control (n = 228) condition. After the 6-month period, 360 individuals completed post-testing. Latent change score models were used to represent changes from baseline over the experimental interval. Structural equation models were applied to examine the indirect effects of the intervention on reduced depressive symptoms.

Results. The results demonstrated significant indirect effects from intervention receipt to decreased depressive symptoms via increased activity frequency and activity significance. Higher activity frequency was linked to fewer depressive symptoms via heightened social connections, whereas increased activity significance was associated with fewer depressive symptoms via enhanced perceived control.

Implications. The results support basic principles of occupational therapy by highlighting important mediating roles of activity frequency and activity significance in reducing depressive symptoms. Understanding of these change mechanisms can help optimize activity-centered interventions to reduce depressive symptoms.

Objective. We investigated the feasibility and acceptability of an occupational therapy intervention targeting diabetes management for underserved young adults.

Method. Eight participants completed the intervention and a battery of assessments at baseline and after the intervention. At completion, the participants and occupational therapist were interviewed about their experiences with the study. Four categories of assessment questions were used to guide the study: process, resource, management, and scientific.

Results. Successes included recruitment; fulfillment of tasks by staff and partnering clinics; adequate space, financial support, and equipment; and meaningfulness of the intervention for participants. Challenges included scheduling participants for the intervention and follow-up focus groups and providing client centeredness and flexibility while reducing burden on the intervener.

Conclusion. This feasibility study allowed us to make necessary revisions to our study protocol before implementing a larger pilot study.

Purpose. The purpose of this study was to evaluate relationships between behavioral and psychosocial constructs, A1C, and diabetes-dependent quality of life (DQoL) among low-socioeconomic status, ethnically diverse young adults with diabetes.

Methods. Using baseline data of 81 participants in the Resilient, Empowered, Active Living (REAL) randomized controlled trial, behavioral, cognitive, affective, and experiential variables were correlated with A1C and DQoL while adjusting for demographic characteristics, and these relationships were examined for potential effect modification.

Results. The data indicate that depressive symptoms and satisfaction with daily activities are associated with both A1C and DQoL, while diabetes knowledge and participation in daily activities are associated with neither A1C nor DQoL. Two constructs, diabetes distress and life satisfaction, were associated with DQoL and were unrelated to A1C, while 2 constructs, self-monitoring of blood glucose and medication adherence, were associated with A1C but unrelated to DQoL. These relationships were largely unchanged by adjusting for demographic characteristics, while numerous effect modifications were found.

Conclusion. The data suggest that when tailoring interventions, depressive symptoms and satisfaction with daily activities may be particularly fruitful intervention targets, as they represent modifiable risk factors that are associated with both A1C and DQoL.

Objective. Our objective was to determine the efficacy of a Lifestyle Redesign® intervention for people living with chronic pain on quality of life (QOL), function, self-efficacy, and pain levels.

Method. Clinical outcomes were collected from 45 patients who completed an individual outpatient Lifestyle Redesign occupational therapy program for chronic pain as part of their usual plan of medical care. Outcome measures included the Canadian Occupational Performance Measure, the 36-Item Short-Form Survey, the Brief Pain Inventory, and the Pain Self-Efficacy Questionnaire. We analyzed scores using paired-samples t tests.

Results. Significant changes were observed in occupational performance and satisfaction scores, physical and social functioning, role limitations due to physical and emotional problems, energy and fatigue, general health, and pain self-efficacy.

Conclusion. Lifestyle Redesign interventions, when integrated into a patient's medical plan of care, can improve patient functioning, self-efficacy, and QOL.

Overview. This paper describes the study protocol used to evaluate the Resilient, Empowered, Active Living with Diabetes (REAL Diabetes) intervention and reports on baseline characteristics of recruited participants. REAL Diabetes is an activity-based intervention designed to address the needs of young adults diagnosed with type 1 (T1D) or type 2 diabetes (T2D) from low socioeconomic status or racial/ethnic minority backgrounds. The REAL intervention incorporates tailored delivery of seven content modules addressing various dimensions of health and well-being as they relate to diabetes, delivered by a licensed occupational therapist.

Methods. In this pilot randomized controlled trial, participants are assigned to the REAL Diabetes intervention or an attention control condition. The study's primary recruitment strategies included in-person recruitment at diabetes clinics, mass mailings to clinic patients, and social media advertising. Data collection includes baseline and 6-month assessments of primary outcomes, secondary outcomes, and hypothesized mediators of intervention effects, as well as ongoing process evaluation assessment to ensure study protocol adherence and intervention fidelity.

Results. At baseline, participants (n=81) were 51% female, 78% Latino, and on average 22.6years old with an average HbA1c of 10.8%. A majority of participants (61.7%) demonstrated clinically significant diabetes distress and 27.2% reported symptoms consistent with major depressive disorder. Compared to participants with T1D, participants with T2D had lower diabetes-related self-efficacy and problem-solving skills. Compared to participants recruited at clinics, participants recruited through other strategies had greater diabetes knowledge but weaker medication adherence.

Discussion. Participants in the REAL study demonstrate clinically significant medical and psychosocial needs.

Background. Multiple sclerosis (MS) can affect an individual’s ability to perform daily activities due to functional difficulties. Occupational therapy (OT) helps people to participate in these activities of daily life to improve health and independence across the lifespan. Lifestyle Redesign® (LRD) is the process of acquiring health-promoting habits and routines to improve overall function, health, and quality of life. The LRD technique has been shown to slow declines associated with typical aging, and improve overall health, functioning, and life satisfaction.

Objectives. To apply the LRD technique to a community-based population with MS for quality improvement purposes.

Methods. This community-based program is a 12-week course in which OT students deliver group and individual LRD interventions once per week for participants living with MS. The National Multiple Sclerosis Society recruits the participants, who also receive physical therapy (PT) for the duration of the program. The LRD technique uses didactic presentation, occupational self-analysis, and hands-on activity-based learning to address topics such as fatigue management, bowel and bladder function, stress management, adaptive equipment, self-advocacy, and sexual function. Outcome measures utilized pre- and post-program were the Canadian Occupational Performance Measure (COPM) and Modified Fatigue Impact Scale (MFIS). Paired-samples t tests were used to determine significant changes pre- and post-program.

Results. COPM Performance score mean increased by 1.77 points (P < .0001, df = 94), and COPM Satisfaction score increased by 2.71 points (P < .0001, df = 94). On average, participants improved their perceived participation and overall satisfaction in self-identified areas of function and lifestyle difficulty. MFIS Physical Subscale mean decreased by 4.07 points (P < .0001, df = 41), Cognitive Subscale mean decreased by 4.26 points (P = .0002, df = 41), and Psychosocial Subscale mean decreased by 0.94 points (P = .0057, df = 41). Total MFIS Score revealed a mean decrease of 9.24 points (P < .0001, df = 41). On average, participants felt that the impact of fatigue on various areas of functioning was lessened by the end of the program.

Conclusions. This quality improvement study suggests that LRD can be an effective OT intervention for people living with MS to improve their function, health, and quality of life. More controlled research is needed to further investigate effects of LRD without confounding factors (eg, PT) in MS care.

Keywords. Comprehensive care and MS, Lifestyle and behavioral modification in MS, Management of activities of daily living in MS

Objective. To describe sleeping behaviors and trends over time among an ethnically diverse group of community-living older adults.

Method. A descriptive secondary data analysis of a subsample (n = 217) from the Lifestyle Redesign randomized controlled trial was done to explore baseline napping and sleeping patterns as well as 6-mo changes in these outcomes.

Results. At baseline, the average time sleeping was 8.2 hr daily (standard deviation = 1.7). Among all participants, 29% reported daytime napping at baseline, of which 36% no longer napped at follow-up. Among participants who stopped napping, those who received an occupation-based intervention (n = 98) replaced napping time with nighttime sleep, and those not receiving an intervention (n = 119) experienced a net loss of total sleep (p < .05).

Conclusion. Among participants who stopped napping, the occupation-based intervention may be related to enhanced sleep. More research examining the role of occupation-based interventions in improving sleep is warranted.

Reorganized, expanded, and updated, this new edition of the award-winning Lifestyle Redesign gives practical guidance in this preventative occupational therapy program for independent-living older adults. The work integrates the concept of the USC's landmark Well Elderly Studies, which determined that preventive occupational therapy greatly enhances the health and quality of life of independent-living older adults.

Twelve modules, including those on longevity, stress, home safety and navigating health care, illustrate how to incorporate the program into practice. Includes a flash drive with program handouts.

Latino adults between ages 50 and 60 yr are at high risk for developing chronic conditions that can lead to early disability. We conducted a qualitative pilot study with 11 Latinos in this demographic group to develop a foundational schema for the design of health promotion programs that could be implemented by occupational therapy practitioners in primary care settings for this population. One-on-one interviews addressing routines and activities, health management, and health care utilization were conducted, audiotaped, and transcribed. Results of a content analysis of the qualitative data revealed the following six domains of most concern: Weight Management; Disease Management; Mental Health and Well-Being; Personal Finances; Family, Friends, and Community; and Stress Management. A typology of perceived health-actualizing strategies was derived for each domain. This schema can be used by occupational therapy practitioners to inform the development of health-promotion lifestyle interventions designed specifically for late-middle-aged Latinos.

This article reports on the development of a manualized occupational therapy intervention for diabetes management. An initial theoretical framework and core content areas for a Stage 1 intervention manual were developed based on an in-depth needs assessment and review of existing literature. After evaluation by a panel of experts and completion of a feasibility study, the intervention was revised into a Stage 2 manual in preparation for a randomized study evaluating the intervention's efficacy. In developing the initial manual, we delineated core theoretical principles to allow for flexible application and tailoring of the intervention's content areas. Expert panel feedback and feasibility study results led to changes to the intervention structure and content as we developed the Stage 2 manual. Through describing this process, we illustrate the dynamic evolution of intervention manuals, which undergo revisions due to both theoretical and practical considerations at each stage of the research-to-clinical practice pipeline.

Simulation results are reported on methods that allow both within group and between group heteroscedasticity when testing the hypothesis that independent groups have identical regression parameters. The methods are based on a combination of extant techniques, but their finite-sample properties have not been studied. Included are results on the impact of removing all leverage points or just bad leverage points. The method used to identify leverage points can be important and can improve control over the Type I error probability. Results are illustrated using data from the Well Elderly II study.

Keywords. Analysis of covariance; HC4 estimator; Heteroscedasticity; Johansen’s method; Robust estimators; Well Elderly II study

Motivated by a situation encountered in the Well Elderly 2 study, the paper considers the problem of robust multiple comparisons based on K independent tests associated with 2K independent groups. A simple strategy is to use an extension of Dunnett’s T3 procedure, which is designed to control the probability of one or more Type I errors. However, this method and related techniques fail to take into account the overall pattern of p-values when making decisions about which hypotheses should be rejected. The paper suggests a multiple comparison procedure that does take the overall pattern into account and then describes general situations where this alternative approach makes a practical difference in terms of both power and the probability of one or more Type I errors. For reasons summarized in the paper, the focus is on 20% trimmed means, but in principle the method considered here is relevant to any situation where the Type I error probability of the individual tests can be controlled reasonably well.

Pressure ulcers (PrUs) are a major burden to patients with spinal cord injury (SCI), affecting their psychological, physical, and social well-being. Lifestyle choices are thought to contribute to the risk of developing PrUs. This article focuses on the interaction between lifestyle choices and the development of PrUs in community settings among participants in the University of Southern California-Rancho Los Amigos National Rehabilitation Center Pressure Ulcer Prevention Study (PUPS II), a randomized controlled trial of a lifestyle intervention for adults with SCI. We conducted a secondary cross-case analysis of treatment notes of 47 PUPS II participants and identified four patterns relating PrU development to lifestyle changes: positive PrU changes (e.g., healing PrUs) with positive lifestyle changes, negative or no PrU changes with positive lifestyle changes, positive PrU changes with minor lifestyle changes, and negative or no PrU changes with no lifestyle changes. We present case studies exemplifying each pattern.

Background/Aim. Engagement in desired occupations can promote health and wellbeing in older adults. Assessments of engagement often measure frequency, amount or importance of specific activities. This study aimed to develop a scale to measure older adults' evaluation of the extent to which their everyday activities are contributing to their health and wellness.

Methods. Eighteen items, each scored with a seven-point rating scale, were initially developed by content experts, covering perceptions of how daily activities contribute to physical and mental health, as well as satisfaction and activity participation in the last six months. Rasch analysis methods were used to refine the scale using the pencil and paper responses of 460 community-living older adults.

Results. Initial Rasch analysis indicated three unlabelled rating scale categories were seldom used, reducing measurement precision. Five items were conceptually different by misfit statistics and principal component analysis. Subsequently, those items were removed and the number of rating scale steps reduced to 4. The remaining 13-item, 4-step scale, termed the Activity Significance Personal Evaluation (ASPEn), formed a unidimensional hierarchy with good fit statistics and targeting. Person separation reliability (2.7) and internal consistency (.91) indicated the tool is appropriate for individual person measurement. Relative validity indicated equivalence between Rasch measures and total raw scores.

Conclusions. ASPEn is a brief, easily administered assessment of older adults' perception of the contribution of everyday activities to personal health and wellness. ASPEn may facilitate occupational therapy practice by enabling clinicians to assess change in meaning of an older adult's activity over time.

The paper deals with three approaches to comparing the regression lines corresponding to two dependent groups when using a robust estimator. The focus is on the Theil–Sen estimator with some comments about alternative estimators that might be used. The first approach is to test the global hypothesis that the two groups have equal intercepts and slopes in a manner that allows a heteroscedastic error term. The second approach is to test the hypothesis of equal intercepts, ignoring the slopes, and testing the hypothesis of equal slopes, ignoring the intercepts. The third approach is to test the hypothesis that the regression lines differ at a specified design point. This last goal corresponds to the classic Johnson and Neyman method when dealing with independent groups and when using the ordinary least squares regression estimator. Based on extant studies, there are guesses about how to proceed in a manner that will provide reasonably accurate control over the Type I error probability: Use some type of percentile bootstrap method. (Methods that assume the regression estimator is asymptotically normal were not considered for reasons reviewed in the paper.) But there are no simulation results providing some sense of how well they perform when dealing with a relatively small sample size. Data from the Well Elderly II study are used to illustrate that the choice between the ordinary least squares estimator and the Theil–Sen estimator can make a practical difference.

Keywords. Analysis of covariance; Bootstrap methods; Well Elderly II study

Background. Cortisol and dehydroepiandrosterone (DHEA) are considered to be valuable markers of the hypothalamus-pituitary-adrenal (HPA) axis, while salivary alpha-amylase (sAA) reflects the autonomic nervous system. Past studies have found certain diurnal patterns among these biomarkers, with some studies reporting results that differ from others. Also, some past studies have found an association among these three biomarkers while other studies have not. This study investigates these patterns and associations in older adults by taking advantage of modern statistical methods for dealing with non-normality, outliers and curvature. Basic characteristics of the data are reported as well, which are relevant to understanding the nature of any patterns and associations.

Methods. Boxplots were used to check on the skewness and presence of outliers, including the impact of using simple transformations for dealing with non-normality. Diurnal patterns were investigated using recent advances aimed at comparing medians. When studying associations, the initial step was to check for curvature using a non-parametric regression estimator. Based on the resulting fit, a robust regression estimator was used that is designed to deal with skewed distributions and outliers.

Results. Boxplots indicated highly skewed distributions with outliers. Simple transformations (such as taking logs) did not deal with this issue in an effective manner. Consequently, diurnal patterns were investigated using medians and found to be consistent with some previous studies but not others. A positive association between awakening cortisol levels and DHEA was found when DHEA is relatively low; otherwise no association was found. The nature of the association between cortisol and DHEA was found to change during the course of the day. Upon awakening, cortisol was found to have no association with sAA when DHEA levels are relatively low, but otherwise there is a negative association. DHEA was found to have a positive association with sAA upon awakening. Shortly after awakening and for the remainder of the day, no association was found between DHEA and sAA ignoring cortisol. For DHEA and cortisol (taken as the independent variables) versus sAA (the dependent variable), again an association is found only upon awakening.

The purpose of this study was to document predictors of long-term retention among minority participants in the Well Elderly 2 Study, a randomized controlled trial of a lifestyle intervention for community-dwelling older adults. The primary sample included 149 African American and 92 Hispanic men and women aged 60 to 95 years, recruited at senior activity centers and senior residences. Chi-square and logistic regression procedures were undertaken to examine study-based, psychosocial and health-related predictors of retention at 18 months following study entry. For both African Americans and Hispanics, intervention adherence was the strongest predictor. Retention was also related to high active coping and average (vs. high or low) levels of activity participation among African Americans and high social network strength among Hispanics. The results suggest that improved knowledge of the predictors of retention among minority elders can spawn new retention strategies that can be applied at individual, subgroup, and sample-wide levels.

Advances in salivary bioscience enable the widespread integration of biological measures into the behavioral and social sciences. While theoretical integration has progressed, much less attention has focused on analytical strategies and tactics. The statistical literature warns that common methods for comparing groups and studying associations can have relatively poor power compared to more modern robust techniques. Here we illustrate, in secondary data analyses using the USC Well Elderly II study (n=460, age 60-95, 66% female), that modern robust methods make a substantial difference when analyzing relations between salivary analyte and behavioral data. Analyses that deal with the diurnal pattern of cortisol and the association of the cortisol awakening response with depressive symptoms and physical well-being are reported. Non-significant results become significant when using improved methods for dealing with skewed distributions and outliers. Analytical strategies and tactics that employ modern robust methods have the potential to reduce the probability of both Type I and Type II errors in studies that compare salivary analytes between groups, across time, or examine associations with salivary analyte levels.

Background. Randomized trials of complex, non-pharmacologic interventions implemented in home and community settings, such as the University of Southern California (USC)-Rancho Los Amigos National Rehabilitation Center (RLANRC) Pressure Ulcer Prevention Study (PUPS), present unique challenges with respect to (1) participant recruitment and retention, (2) intervention delivery and fidelity, (3) randomization and assessment, and (4) potential inadvertent treatment effects.

Purpose. We describe the methods employed to address the challenges confronted in implementing PUPS. In this randomized controlled trial, we are assessing the efficacy of a complex, preventive intervention in reducing the incidence of, and costs associated with, the development of medically serious pressure ulcers in people with spinal cord injury.

Methods. Individuals with spinal cord injury recruited from RLANRC were assigned to either a 12-month preventive intervention group or a standard care control group. The primary outcome is the incidence of serious pressure ulcers with secondary endpoints including ulcer-related surgeries, medical treatment costs, and quality of life. These outcomes are assessed at 12 and 24 months after randomization. Additionally, we are studying the mediating mechanisms that account for intervention outcomes.

Results. PUPS has been successfully implemented, including recruitment of the target sample size of 170 participants, assurance of the integrity of intervention protocol delivery with an average 90% treatment adherence rate, and enactment of the assessment plan. However, implementation has been replete with challenges. To meet recruitment goals, we instituted a five-pronged approach customized for an underserved, ethnically diverse population. In intervention delivery, we increased staff time to overcome economic and cultural barriers to retention and adherence. To ensure treatment fidelity and replicability, we monitored intervention protocol delivery in accordance with a rigorous plan. Finally, we have overcome unanticipated assessment and design concerns related to (1) determining pressure ulcer incidence/severity, (2) randomization imbalance, and (3) inadvertent potential control group contamination.

Limitations. We have addressed the most daunting challenges encountered in the recruitment, assessment, and intervention phases of PUPS. Some challenges and solutions may not apply to trials conducted in other settings.

Conclusions. Overcoming challenges has required a multifaceted approach incorporating individualization, flexibility, and persistence, as well as the ability to implement needed mid-course corrections.

The most common strategy for comparing two independent groups is in terms of some measure of location intended to reflect the typical observation. However, it can be informative and important to compare the lower and upper quantiles as well, but when there are tied values, extant techniques suffer from practical concerns reviewed in the paper. For the special case where the goal is to compare the medians, a slight generalization of the percentile bootstrap method performs well in terms of controlling Type I errors when there are tied values [Wilcox RR. Comparing medians. Comput. Statist. Data Anal. 2006;51:1934–1943]. But our results indicate that when the goal is to compare the quartiles, or quantiles close to zero or one, this approach is highly unsatisfactory when the quantiles are estimated using a single order statistic or a weighted average of two order statistics. The main result in this paper is that when using the Harrell–Davis estimator, which uses all of the order statistics to estimate a quantile, control over the Type I error probability can be achieved in simulations, even when there are tied values, provided the sample sizes are not too small. It is demonstrated that this method can also have substantially higher power than the distribution free method derived by Doksum and Sievers [Plotting with confidence: graphical comparisons of two populations. Biometrika 1976;63:421–434]. Data from two studies are used to illustrate the practical advantages of the method studied here.

This paper describes two new methods for comparing two independent, discrete distributions, when the sample space is small, using an extension of the Storer-Kim method for comparing independent binomials. These methods are relevant, for example, when comparing groups based on a Likert scale, which was the motivation for the paper. In essence, the goal is to test the hypothesis that the cell probabilities associated with two independent multinomial distributions are equal. Both a global test and a multiple comparison procedure are proposed. The small-sample properties of both methods are compared to four other techniques via simulations: Cliff's generalization of the Wilcoxon-Mann-Whitney test that effectively deals with heteroscedasticity and tied values, Yuen's test based on trimmed means, Welch's test and Student's t test. For the simulations, data were generated from beta-binomial distributions. Both symmetric and skewed distributions were used. The sample space consisted of the integers 0(1)4 or 0(1)10. For the global test that is proposed, when testing at the 0.05 level, simulation estimates of the actual Type I error probability ranged between 0.043 and 0.059. For the new multiple comparison procedure, the estimated family wise error rate ranged between 0.031 and 0.054 for the sample space 0(1)4. But for 0(1)10, the estimates dropped as low as 0.016 in some situations. Given the goal of comparing means, Student's t is well known to have practical problems when distributions differ. Similar problems are found here among the situations considered. No single method dominates in terms of power, as would be expected, because different methods are sensitive to different features of the distributions being compared. But in general, one of the new methods tends to have relatively good power based on both simulations and experience with data from actual studies. If, however, there is explicit interest in comparing means, rather than comparing the cell probabilities, Welch's test was found to perform well. The new methods are illustrated using data from the Well-Elderly Study where the goal is to compare groups in terms of depression and the strategies used for dealing with stress.

Keywords. Multinomial distribution; Likert scales; Storer-Kim method; Hochberg's method; Yuen's method; Welch's Test; Student's Test; Well Elderly Study; Stress; Depression; Metodology.

It is well known that when using the ordinary least squares regression estimator, outliers among the dependent variable can result in relatively poor power. Many robust regression estimators have been derived that address this problem, but the bulk of the results assume that the dependent variable is continuous. It is demonstrated that when there are tied values, several robust regression estimators can perform poorly in terms of controlling the Type I error probability, even with a large sample size. The presence of tied values does not necessarily mean that they perform poorly, but there is the issue of whether there is a robust estimator that performs reasonably well in situations where other estimators do not. The main result is that a modification of the Theil–Sen estimator achieves this goal. Results on the small-sample efficiency of the modified Theil–Sen estimator are reported as well. Data from the Well Elderly 2 Study, which motivated this study, are used to illustrate that the modified Theil–Sen estimator can make a practical difference.

The authors obtained older adults’ self-rated judgments about the quality of their activity engagement considered as a whole (global activity evaluation) and, using cross-sectional survey data, tested the ability of such judgments to predict well-being. Participants were 460 community-dwelling older adults who responded to (1) global activity evaluations, (2) activity participation frequency scales, and (3) indices of life satisfaction, depression, and physical and mental health-related quality of life. Regression analyses indicated that global activity evaluations had a stronger relationship to psychosocial outcome indices than did participation frequency ratings, although both measurement approaches were associated with statistically significant predictions. However, global evaluations and participation frequency ratings were approximately equal in their ability to predict physical health-related quality of life. These relationships were fairly consistent across ethnic groups. Overall, the results suggest that ideally the two strategies for assessing activity should be incorporated in future research on activity and occupational therapy practice.

Randomized controlled trials (RCTs) are considered the criterion standard in research design for establishing treatment efficacy. However, the rigorous and highly controlled conditions of RCTs can be difficult to attain when conducting research among individuals living with a confluence of disability, low socioeconomic status, and being a member of a racial/ethnic minority group, who may be more likely to have unstable life circumstances. Research on effective interventions for these groups is urgently needed, because evidence regarding approaches to reduce health disparities and improve health outcomes is lacking. In this methodologic article, we discuss the challenges and lessons learned in implementing the Lifestyle Redesign for Pressure Ulcer Prevention in Spinal Cord Injury study among a highly disadvantaged population. These issues are discussed in terms of strategies to enhance recruitment, retention, and intervention relevance to the target population. Recommendations for researchers seeking to conduct RCTs among socioeconomically disadvantaged, ethnically diverse populations are provided.

Objectives. Recently, there have been major advances in statistical techniques for assessing central tendency and measures of association. The practical utility of modern methods has been documented extensively in the statistics literature, but they remain underused and relatively unknown in clinical trials. Our objective was to address this issue.

Study Design and Purpose. The first purpose was to review common problems associated with standard methodologies (low power, lack of control over type I errors, and incorrect assessments of the strength of the association). The second purpose was to summarize some modern methods that can be used to circumvent such problems. The third purpose was to illustrate the practical utility of modern robust methods using data from the Well Elderly 2 randomized controlled trial.

Results. In multiple instances, robust methods uncovered differences among groups and associations among variables that were not detected by classic techniques. In particular, the results demonstrated that details of the nature and strength of the association were sometimes overlooked when using ordinary least squares regression and Pearson correlation.

Conclusion. Modern robust methods can make a practical difference in detecting and describing differences between groups and associations between variables. Such procedures should be applied more frequently when analyzing trial-based data.

Psychological studies in general, and psychobiological studies in particular, routinely use a collection of classic statistical techniques aimed at comparing groups or studying associations. A fundamental issue is whether violating the basic assumptions underlying these methods, namely normality and homoscedasticity, can result in relatively poor power or miss important features of the data that have practical significance. In the statistics literature, hundreds of papers make it clear that under general conditions the answer is yes and that routinely used strategies for dealing with violations of assumptions can be unsatisfactory. Moreover, a vast array of new and improved techniques is now available for dealing with violations of assumptions, including more flexible methods for dealing with curvature. The paper reviews the major insights regarding standard methods, explains why some seemingly reasonable methods for dealing with violations of assumptions are technically unsound, and then outlines methods that are technically correct. It then illustrates the practical importance of modern methods using data from the Well Elderly II study.

Background. Older people are at risk for health decline and loss of independence. Lifestyle interventions offer potential for reducing such negative outcomes. The aim of this study was to determine the effectiveness and cost-effectiveness of a preventive lifestyle-based occupational therapy intervention, administered in a variety of community-based sites, in improving mental and physical well-being and cognitive functioning in ethnically diverse older people.

Methods. A randomised controlled trial was conducted comparing an occupational therapy intervention and a no-treatment control condition over a 6-month experimental phase. Participants included 460 men and women aged 60-95 years (mean age 74.9±7.7 years; 53% < $12,000 annual income) recruited from 21 sites in the greater Los Angeles metropolitan area.

Results. Intervention participants, relative to untreated controls, showed more favourable change scores on indices of bodily pain, vitality, social functioning, mental health, composite mental functioning, life satisfaction and depressive symptomatology (ps < 0.05). The intervention group had a significantly greater increment in quality-adjusted life years (p < 0.02), which was achieved cost-effectively (US $41,218/UK £24,868 per unit). No intervention effect was found for cognitive functioning outcome measures.

Conclusions. A lifestyle-oriented occupational therapy intervention has beneficial effects for ethnically diverse older people recruited from a wide array of community settings. Because the intervention is cost-effective and is applicable on a wide-scale basis, it has the potential to help reduce health decline and promote well-being in older people.

The manualization of a complex occupational therapy intervention is a crucial step in ensuring treatment fidelity for both clinical application and research purposes. Toward the latter end, intervention manuals are essential for ensuring trustworthiness and replicability of randomized controlled trials that aim to provide evidence of the effectiveness of occupational therapy. In this article, we review the literature on the process of intervention manualization. We then illustrate the prescribed steps through our experience in implementing the University of Southern California/Rancho Los Amigos National Rehabilitation Center's collaborative Pressure Ulcer Prevention Project. In this research program, qualitative research provided the initial foundation for manualization of a multifaceted occupational therapy intervention designed to reduce the incidence of medically serious pressure ulcers in adults with spinal cord injury.

Objective. In this study, we analyzed self-reported computer use, demographic variables, psychosocial variables, and health and well-being variables collected from 460 ethnically diverse, community-dwelling elders to investigate the relationship computer use has with demographics, well-being, and other key psychosocial variables in older adults.

Background. Although younger elders with more education, those who employ active coping strategies, or those who are low in anxiety levels are thought to use computers at higher rates than do others, previous research has produced mixed or inconclusive results regarding ethnic, gender, and psychological factors or has concentrated on computer-specific psychological factors only (e.g., computer anxiety). Few such studies have employed large sample sizes or have focused on ethnically diverse populations of community-dwelling elders.

Method. With a large number of overlapping predictors, zero-order analysis alone is poorly equipped to identify variables that are independently associated with computer use. Accordingly, both zero-order and stepwise logistic regression analyses were conducted to determine the correlates of two types of computer use: e-mail and general computer use.

Results. Results indicate that younger age, greater level of education, non-Hispanic ethnicity, behaviorally active coping style, general physical health, and role-related emotional health each independently predicted computer usage.

Conclusion. Study findings highlight differences in computer usage, especially in regard to Hispanic ethnicity and specific health and well-being factors.

Application. Potential applications of this research include future intervention studies, individualized computer-based activity programming, or customizable software and user interface design for older adults responsive to a variety of personal characteristics and capabilities.

Reverse-scored items on assessment scales increase cognitive processing demands and may therefore lead to measurement problems for older adult respondents. In this study, the objective was to examine possible psychometric inadequacies of reverse-scored items on the Center for Epidemiologic Studies Depression Scale (CES-D) when used to assess ethnically diverse older adults. Using baseline data from a gerontologic clinical trial (n = 460), we tested the hypotheses that the reversed items on the CES-D (a) are less reliable than nonreversed items, (b) disproportionately lead to intraindividually atypical responses that are psychometrically problematic, and (c) evidence improved measurement properties when an imputation procedure based on the scale mean is used to replace atypical responses. In general, the results supported the hypotheses. Relative to nonreversed CES-D items, the 4 reversed items were less internally consistent, were associated with lower item-scale correlations, and were more often answered atypically at an intraindividual level. Further, the atypical responses were negatively correlated with responses to psychometrically sound nonreversed items that had similar content. The use of imputation to replace atypical responses enhanced the predictive validity of the set of reverse-scored items. Among older adult respondents, reverse-scored items are associated with measurement difficulties. It is recommended that appropriate correction procedures such as item readministration or statistical imputation be applied to reduce the difficulties.

Objective. The objectives of the study were to sensitize practitioners working with individuals with spinal cord injury (SCI) to the complex life circumstances that are implicated in the development of pressure ulcers (PrUs) and to document the ways that interventions can be adapted to target individual needs.

Methods. This study was a content analysis of weekly fidelity/quality control meetings that were undertaken as part of a lifestyle intervention for PrU prevention in community-dwelling adults with SCI.

Results. Four types of lifestyle-relevant challenges to ulcer prevention were identified: risk-elevating life circumstances, communication difficulties, equipment problems, and individual personality issues. Intervention flexibility was achieved by changing the order of treatment modules, altering the intervention content or delivery approach, or going beyond the stipulated content.

Conclusion. Attention to recurrent types of individual needs, along with explicit strategies for tailoring interventions published in a manual, has the potential to enhance PrU prevention efforts for adults with SCI.

Approximately 23.6 million people in the United States are living with diabetes, a disease that is a leading cause of disabling conditions including blindness, kidney failure, amputations, heart disease, and stroke. Although these complications of diabetes can be delayed or prevented through intensive diabetes self-management (DSM), maintaining control of the disease can be burdensome and negatively impact quality of life. Occupational therapy has a largely untapped potential to assist individuals who struggle with managing diabetes in the context of everyday life, yet there is little discussion of DSM in the occupational therapy literature. The author conducts a systematic review of the existing occupational therapy literature on diabetes, examines the current state of DSM interventions, and discusses a potential role for occupational therapy using programs such as Lifestyle Redesign®.

The Meaningful Activity Participation Assessment (MAPA), a recently developed 28-item tool designed to measure the meaningfulness of activity, was tested in a sample of 154 older adults. The MAPA evidenced a sufficient level of internal consistency and test-retest reliability and correlated as theoretically predicted with the Life Satisfaction Index-Z, the Satisfaction with Life Scale, the Engagement in Meaningful Activities Survey, the Purpose in Life Test, the Center for Epidemiologic Studies Depression Inventory and the Rand SF-36v2 Health Survey subscales. Zero-order correlations consistently demonstrated meaningful relationships between the MAPA and scales of psychosocial well-being and health-related quality of life. Results from multiple regression analyses further substantiated these findings, as greater meaningful activity participation was associated with better psychological well-being and health-related quality of life. The MAPA appears to be a reliable and valid measure of meaningful activity, incorporating both subjective and objective indicators of activity engagement.

Background. Community-dwelling older adults are at risk for declines in physical health, cognition, and psychosocial well-being. However, their enactment of active and health-promoting lifestyles can reduce such declines.

Purpose. The purpose of this article is to describe the USC Well Elderly II study, a randomized clinical trial designed to test the effectiveness of a healthy lifestyle program for elders, and document how various methodological challenges were addressed during the course of the trial.

Methods. In the study, 460 ethnically diverse elders recruited from a variety of sites in the urban Los Angeles area were enrolled in a randomized experiment involving a crossover design component. Within either the first or second 6-month phase of their study involvement, each elder received a lifestyle intervention designed to improve a variety of aging outcomes. At 4-5 time points over an 18-24 month interval, the research participants were assessed on measures of healthy activity, coping, social support, perceived control, stress-related biomarkers, perceived physical health, psychosocial well-being, and cognitive functioning to test the effectiveness of the intervention and document the process mechanisms responsible for its effects.

Results. The study protocol was successfully implemented, including the enrollment of study sites, the recruitment of 460 older adults, administration of the intervention, adherence to the plan for assessment, and establishment of a large computerized data base.

Limitations. Methodological challenges were encountered in the areas of site recruitment, participant recruitment, testing, and intervention delivery.

Conclusions. The completion of clinical trials involving elders from numerous local sites requires careful oversight and anticipation of threats to the study design that stem from: (a) social situations that are particular to specific study sites; and (b) physical, functional, and social challenges pertaining to the elder population.

Objectives. To evaluate the cost-effectiveness of a 9-month preventive occupational therapy (OT) program in the Well-Elderly Study: a randomized trial in independent-living older adults that found significant health, function, and quality of life benefits attributable to preventive OT.

Design. A randomized trial.

Setting. Two government-subsidized apartment complexes.

Participants. One hundred sixty-three culturally diverse volunteers aged 60 and older.

Intervention. An OT group, a social activity group (active control), and a nontreatment group (passive control).

Measurements. Use of healthcare services was determined by telephone interview during and after the treatment phase. A conversion algorithm was applied to the RAND 36-item Short Form Health Survey to derive a preference-based health-related quality of life index, quality-adjusted life years (QALYs), and the incremental cost-effectiveness ratio for preventive OT relative to the combined control group.

Results. Costs for the 9-month OT program averaged $548 per subject. Postintervention healthcare costs were lower for the OT group ($967) than for the active control group ($1,726), the passive control group ($3,334), or a combination of the control groups ($2,593). The quality of life index showed a 4.5% QALY differential (OT vs combined control), p < .001. The cost per QALY estimates for the OT group was $10,666 (95% confidence interval = $6,747–$25,430). For the passive and active control groups, the corresponding costs per QALY were $13,784 and $7,820, respectively.

Conclusion. In this study, preventive OT demonstrated cost-effectiveness in conjunction with a trend toward decreased medical expenditures.

The Well Elderly Study was a randomized trial in independent-living older adults that found significant health, function, and quality of life benefits attributable to a 9-month program in preventive occupational therapy (OT). All participants completing the trial were followed for an additional 6 months without further intervention and then reevaluated using the same battery of instruments. Long-term benefit attributable to preventive OT was found for the quality of interaction scale of the Functional Status Questionnaire and for six of eight scales on the RAND SF-36: physical functioning, role functioning, vitality, social functioning, role emotional, and general mental health (p < .05). Approximately 90% of the therapeutic gain observed following OT treatment was retained in follow-up. The finding of a sustained effect for preventive OT is of great public health relevance given the looming health care cost crisis associated with our nation's expanding elderly population.

The practice of occupational therapy for elders is becoming more challenging. This article presents Lifestyle Redesign, an intervention model that promotes quality of life in well elders. Studies will be discussed that demonstrate the long-term efficacy of this treatment and that support the use of occupation-based occupational therapy for independent living. The key concepts of the program and process of delivery will be addressed. Finally, the necessity for cultural sensitivity on a global level will be discussed as it relates to designing similar programs for other cultures.

Keywords. cultural sensitivity; lifestyle redesign; independent living; well-elders

As the percentage of older adults of diverse ethnicities increases in the United States, the call for culturally sensitive health care service strategies that target the special needs of older people grows. The present report describes methods used to adapt a health care program so that it would better meet the needs of a group of well, older Mandarin-speaking Chinese residents of Los Angeles. The specific qualitative research procedures that we used to adapt the treatment program are described, along with the particular adaptations that emerged. Additionally, outcomes from a randomized pilot experiment are presented that are consistent with the notion that the adapted program was effective in reducing health-related declines among older Mandarin-speaking men and women. The overall outcome of this project is in agreement with other reports in the health care literature that address the importance of providing culturally sensitive health care service for elders.

Objectives. To evaluate the psychometric properties of a Chinese translation of the 36-item Short Form Health Survey (SF-36) in the Well Elderly Study—a randomized clinical trial designed to evaluate the effectiveness of preventive occupational therapy services specifically tailored for multiethnic, independent-living, older adults.

Methods. Translation and back-translation procedures were used to obtain appropriate meanings for the SF-36 survey questions and to ensure face, functional, and conceptual equivalence.

Results. Statistical analyses demonstrated satisfactory reliability and validity, with the results generally similar to those reported for older Anglo adults.

Discussion. As the percentage of older adults of diverse ethnicity increases, the need for health care research and service strategies that can effectively include multiple ethnicities becomes paramount. The results of this study suggest that a Chinese-translated SF-36 can be used to assess multiple dimensions of health in a Mandarin-speaking population of older adults.

Given that the longevity revolution has already arrived and will continue to flourish in the upcoming decades, Western societies are confronted with the urgent challenge of promoting the goal of successful ageing for untold millions of citizens. With regard to this goal, current thinking points to the optimistic conclusion that potentially controllable lifestyle factors play a crucial role in enabling people to experience health and satisfying lives well into older adulthood. In this paper, the importance of occupation as providing a fundamental, personally relevant context for the enactment of sustainable lifestyle choices that foster successful ageing is described. This stress on the significance of occupation is supported by the successful outcome of an experimental test of a preventive occupational therapy intervention designed to promote health and psychosocial well-being in community dwelling elders. Based on the theory and research that is discussed, a practically oriented synthetic overview is provided of the conditions conducive to successful ageing.

This article describes an innovative preventive occupational therapy intervention for well older adults, the Well Elderly Treatment Program. In a previously reported large-scale randomized effectiveness study, this intervention was found to be highly successful in enhancing the physical and mental health, occupational functioning, and life satisfaction of multicultural, community-dwelling elders. In this article, the philosophical background, manner of development, topical content, methods of program delivery, and mechanisms underlying the program's positive effects are discussed, along with implications for occupational therapy practice. The treatment was based on application of occupational science theory and research and emphasized the therapeutic process of lifestyle redesign in enabling the participants to actively and strategically select an individualized pattern of personally satisfying and health-promoting occupations. The wide-ranging effectiveness of the program supports the occupational therapy profession's emphasis on occupation in affecting health and positions practitioners to extend their services to the realm of preventive interventions.

Context. Preventive health programs may mitigate against the health risks of older adulthood.

Objective. To evaluate the effectiveness of preventive occupational therapy (OT) services specifically tailored for multiethnic, independent-living older adults.

Design. A randomized controlled trial.

Setting. Two government subsidized apartment complexes for independent-living older adults.

Subjects. A total of 361 culturally diverse volunteers aged 60 years or older.

Intervention. An OT group, a social activity control group, and a nontreatment control group. The period of treatment was 9 months.

Main Outcome Measures. A battery of self-administered questionnaires designed to measure physical and social function, self-rated health, life satisfaction, and depressive symptoms.

Results. Benefit attributable to OT treatment was found for the quality of interaction scale on the Functional Status Questionnaire (P=.03), Life Satisfaction Index-Z (P=.03), Medical Outcomes Study Health Perception Survey (P=.05), and for 7 of 8 scales on the RAND 36-Item Health Status Survey, Short Form: bodily pain (P=.03), physical functioning (P=.008), role limitations attributable to health problems (P=.02), vitality (P=.004), social functioning (P=.05), role limitations attributable to emotional problems (P=.05), and general mental health (P=.02).

Conclusions. Significant benefits for the OT preventive treatment group were found across various health, function, and quality-of-life domains. Because the control groups tended to decline over the study interval, our results suggest that preventive health programs based on OT may mitigate against the health risks of older adulthood.

Older adults are at increased risk for a variety of physical and functional limitations that threaten their ability to lead independent and fulfilling lives. Consequently, they stand to benefit from personalized strategies of adaptation that enable them to achieve successful outcomes in their daily activities and desired goals. In the current investigation, a qualitative descriptive methodology was used to document the perceived life domain of importance and associated strategies of adaptation of 29 residents of Angelus Plaza, a federally subsidized apartment complex in downtown Los Angeles for low-income, well older adults. On the basis of interview data, 10 life domains were identified, and within each domain, a typology of adaptive strategies was derived. The domains were activities of daily living (ADL), adaptation to a multicultural environment, free time usage, grave illness and death–spirituality, health maintenance, mobility maintenance, personal finances, personal safety, psychological well-being and happiness, and relationships with others. Although the typology should not be generalized to a geriatric population, therapists may wish to refer to it to gain a sense of the extent to which certain adaptive strategies may be applicable to the lives of particular older adults to whom they deliver services. The teaching of these adaptive strategies could then be incorporated into an individualized treatment plan.

The typology also provides a broad picture of the kinds of adaptive strategies used by the older adults as a way of coping and adapting to their setting. Although some of the domains do not differ from those typically addressed in occupational therapy textbooks on geriatric care (e.g., ADL, health maintenance), others seem uniquely tailored to the specifics of the Angelus Plaza context (e.g., personal safety). Finally, certain domains emerged that may be highly relevant to older adults in most settings but are not typically the focus of occupational therapy programs (e.g., grave illness and death–spirituality, relationships with others). The emergence of these domains from our data suggests that therapists may wish to consider them more in treatment if they are convinced that they possess local relevance.

This lecture presents an example of research in the genre of interpretive occupational science and demonstrates how occupational science can inform clinical practice. The innovative qualitative methodology used blended elements of the anthropological tradition of life history ethnography, ethnomethodology, the naturalistic methods used by Mattingly and Schön to study practice, and especially narrative analysis as described by Polkinghorne. The bulk of the paper is presented in the form of a narrative analysis that provides an account of a stroke survivor's personal struggle for recovery, a story that emerged from transcription, coding, and analysis of transcripts from approximately 20 hours of interview time. First, this narrative analysis provides an example of how the occupational science framework can evoke a particular kind of storytelling in which childhood occupation can be related to adult character. Storytelling of this kind is later shown to be therapeutic for the stroke survivor. Next, the narrative illustrates how rehabilitation can be experienced by the survivor as a rite of passage in which a person is moved to disability status and then abandoned. Finally, a picture is given of how occupational story making and occupational storytelling embedded in real life can nurture the human spirit to act and can become the core of clinical practice.