University of Southern California Dissertations and Theses

Examination of the long-term psychosocial and functioning effects of a healthy living, life management behavior intervention for older adults

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Examination of the long-term psychosocial and functioning effects of a healthy living, life management behavior intervention for older adults

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EXAMINATION!OF!THE!LONG.TERM!PSYCHOSOCIAL!AND!FUNCTIONING!EFFECTS!
OF!A!HEALTHY!LIVING,!LIFE!MANAGEMENT!BEHAVIOR!INTERVENTION!FOR!
OLDER!ADULTS!
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by!
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Nicholas!E.!Pisca!
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________________________________________________________________________!
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A!Dissertation!Presented!to!the!
FACULTY!OF!THE!GRADUATE!SCHOOL!
UNIVERSITY!OF!SOUTHERN!CALIFORNIA!
In!Partial!Fulfillment!of!the!
Requirements!for!the!Degree!
DOCTOR!OF!PHILOSOPHY!
(GERONTOLOGY)!
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December!2015!
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Copyright!2015! ! ! ! ! ! ! !!!!!Nicholas!E.!Pisca!
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Abstract!
Old!age!can!be!accompanied!by!a!set!of!unique!age.related!stressors,!as!well!as!a!
decline!in!mental!and!physical!health.!!Interventions!that!modify!the!daily!activities!
and!habits!of!older!adults!have!become!increasingly!important!in!slowing!the!
decline!in!age.related!health!outcomes.!!However,!there!are!methodological!issues!
that!must!be!considered!when!determining!the!efficacy!of!behavioral!interventions!
with!older!adults,!including!the!sustainability!of!treatment!effects,!controlling!for!
threats!to!internal!validity,!and!identifying!clinically!meaningful!change.!!The!
primary!goal!of!this!dissertation!was!to!study!the!sustainability!of!positive!effects!
using!non.experimental!data!from!Well!Elderly!2!(WE2),!a!two.year!occupational!
therapy!intervention!that!focused!on!modifying!healthy!behaviors!and!activities!in!
older!adults.!!The!aim!of!Chapter!1!was!to!examine!the!extent!to!which!WE2.based!
positive!treatment!effects!were!sustained!at!post.intervention!follow.ups!of!6.!and!
12.months.!!Results!from!Chapter!1!indicated!that!key!study!outcomes!(depression,!
life!satisfaction,!mental!health,!and!physical!health)!were!significant!at!post.test,!
with!the!largest!post.test!effect!size!occurring!in!depression.!!Subsequently,!
depression!was!significantly!sustained!at!the!6.month!follow.up,!such!that!78.6%!of!
the!post.test!treatment!effects!were!maintained.!!However,!results!evidenced!that!
by!the!12.month!follow.up!there!were!no!statistically!significant!maintenance!of!
treatment!effects!among!any!of!the!study!outcomes.!!As!a!side!analysis!in!Chapter!1,!
the!sustainability!of!selected!relationships!that!indicated!a!larger!effect!size!in!the!
main!analysis!was!tested.!!The!results!supported!the!notion!that!such!larger!effects!
are!associated!with!greater!sustainability.!!Chapter!2!sought!to!identify!older!adults!
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in!the!WE2!study!who!had!clinically!meaningful!positive!improvement!in!study!
outcomes.!!Results!indicated!that!approximately!one.third!of!participants!had!
clinically!meaningful!improvement!in!the!area!of!depression!at!post.test.!!Chapter!3!
aimed!to!determine!if!clinically!meaningful!positive!change!in!depression!
experienced!by!participants!in!the!WE2!study!was!sustained!at!6.!and!12.months!
post.intervention.!!Results!from!Chapter!3!indicated!that!60.5%!of!those!who!
experienced!clinically!meaningful!pre.!to!post.test!change!in!depression!maintained!
clinically!meaningful!gains!at!the!6.month!follow.up,!and!46.7%!of!participants!
maintained!this!change!1–year!post!intervention.!!Insight!gained!from!this!
dissertation!provides!a!method!of!dealing!with!threats!to!the!ability!to!infer!
sustainable!effects!using!non.experimental!data.!!Additionally,!this!work!supports!
the!notion!that!sustainability!is!greater!for!stronger!in!comparison!to!weaker!
intervention!effects!(i.e.,!smaller!vs.!larger!effect!sizes).!!The!overall!results!of!this!
dissertation!are!important!because!knowledge!of!the!studied!issues!can!assist!
researchers!and!practitioners!in!(a)!improving!interventions!so!as!to!sustain!
clinically!meaningful!health!effects,!and!(b)!identifying!methodological!
enhancements!in!attempting!to!document!sustainable!effects!based!on!non.
experimental!data.!!!
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For!Kimberly!and!Oliver.!!Before!you!entered!my!life,!I!used!to!wonder!what!I!might!
accomplish;!now!I!want!to!be!the!best!husband!and!father!I!can!be.
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Acknowledgments!
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I!would!like!to!express!my!deepest!appreciation!to!my!committee!chair!
Professor!Eileen!Crimmins,!who!has!the!attitude!and!the!substance!of!a!genius;!she!
continually!and!convincingly!conveyed!a!spirit!of!support!and!rigor!in!regard!to!
research!and!scholarship,!and!an!excitement!in!regard!to!mentoring.!!I!have!been!
privileged!to!work!under!her!aegis,!and!without!her!guidance!and!support!this!
dissertation!would!not!have!been!actualized.!
I!would!also!like!to!thank!other!members!of!my!committee,!Professor!
Florence!Clark,!Professor!Mike!Carlson,!and!Professor!Aaron!Hagedorn.!!Dr.!Clark’s!
ground.breaking!work!in!the!field!of!Occupational!Science,!and!specifically!her!Well!
Elderly!Study!inspired!me!to!study!the!importance!of!the!lasting!effects!of!lifestyle!
on!aging.!!The!resources!she!provided!quite!literally!made!my!work!possible.!
I!am!truly!indebted!to!Dr.!Carlson’s!countless!hours!of!shaping!me!into!a!
scientist.!!He!demonstrated!and!passed!on!to!me!a!process!for!me!to!model,!and!he!
instilled!in!me!a!higher!respect!for!my!work.!!His!graciousness!and!flexibility!in!our!
time!together!can!only!be!repaid!to!future!mentees!that!I!might!have!the!privilege!to!
guide.!!!!!!!
Dr.!Hagedorn!saw!me!as!a!scholar!well!before!I!did!and!even!when!I!resisted.!!
His!persistence!for!me!to!stay!the!course!even!when!the!turbulent!waters!of!life!
redirected!me!can!never!be!repaid.!!!
In!addition,!I!would!like!to!thank!the!USC!Davis!School!of!Gerontology!and!
the!many!individuals!that!helped!me!navigate!the!transformation!from!graduate!
student!to!professional.!!
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I!would!also!like!to!thank!the!National!Science!Foundation!and!the!USC!
Graduate!School!for!their!financial!support!granted!through!a!predoctoral!
fellowship.!
Last,!I!need!to!thank!my!wife,!Dr.!Kimberly!Kisler.!!Through!death!and!
through!life!we!continue!to!hold!each!other’s!hands.!
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TABLE!OF!CONTENTS!
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INTRODUCTION.!........................................................................................................................!1!
Specific!Aims.!.................................................................................................................!7!
References.!.....................................................................................................................!9!
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CHAPTER!1:!THE!DURABILITY!OF!BEHAVIORAL!CHANGE!AFTER!TREATMENT:!THE!
LONG.TERM!FOLLOW.UP!OF!A!LIFE!MANAGEMENT!BEHAVIORAL!INTERVENTION!
FOR!HEALTHY!OLDER!ADULTS!...........................................................................................!15!
Method!..........................................................................................................................!20!
Results!...........................................................................................................................!27!
Discussion!....................................................................................................................!31!
References!....................................................................................................................!38!
Tables!............................................................................................................................!45!
Figures!..........................................................................................................................!50!
Appendix!1A.1.4:!Therapist!Ethnic!Concordance!Analyses!..............................!51!
Appendix!1B:!Unadjusted!Effect!Sizes!....................................................................!53!
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CHAPTER!2:!IDENTIFYING!CLINICALLY!MEANINGFUL!CHANGE!IN!DEPRESSION,!
LIFE!SATISFACTION,!MENTAL!HEALTH,!AND!PHYSICAL!HEALTH!AMONG!OLDER!
ADULTS!WHO!HAVE!PARTICIPATED!IN!A!LIFESTYLE!INTERVENTION!.....................!54!
Method!..........................................................................................................................!58!
Results!...........................................................................................................................!67!
Discussion!....................................................................................................................!69!
References!....................................................................................................................!73!
Tables!............................................................................................................................!81!
Figures!..........................................................................................................................!87!
Appendix!2A.1.2:!Mean!Absolute!Deviation!Rationale!and!Formula!..............!91!
Appendix!2B.1.4:!Regression!to!Mean!Time!Reverse!Analyses!Plots!.............!92!
Appendix!2C.1.3:!Measurement!Invariance!of!CES.D!.........................................!96!
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CHAPTER!3:!PREDICTORS!OF!SUSTAINED!CLINICALLY!MEANINGFUL!CHANGE!IN!
DEPRESSION!OVER!TIME!AMONG!OLDER!ADULTS!WHO!HAVE!PARTICIPATED!IN!A!
BEHAVIORAL!INTERVENTION!.............................................................................................!99!
Method!.......................................................................................................................!103!
Results!........................................................................................................................!106!
Discussion!.................................................................................................................!109!
References!.................................................................................................................!112!
Tables!.........................................................................................................................!118!
Figures!.......................................................................................................................!123!
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CONCLUSION!.........................................................................................................................!124!
Future!Directions!.....................................................................................................!127!
Summary!...................................................................................................................!128!
References!.................................................................................................................!130!
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INTRODUCTION
Unique!sets!of!stressors!(e.g.,!co.morbidities,!financial!limitations,!and!
decreased!independence)!along!with!declines!in!mental!or!physical!health!often!
accompany!old!age!(Low!&!Molzahn,!2007;!National!Institutes!of!Health,!2007).!!As!
the!aging!population!sharply!increases,!the!healthcare!system!will!continually!face!a!
greater!demand!for!health.related!resources!(Medicare!Payment!Advisory!
Commission,!2014,!2009)!and!a!need!for!viable!solutions!to!reduce!the!expected!
healthcare!burden!(Jin,!Simpkins,!Ji,!Leis,!&!Stambler,!2015).!
!!Over!the!past!two!decades,!investigators!have!studied!the!link!between!
activity!participation!and!aging!outcomes!in!older!adults!(King!et!al.,!2000;!King!&!
Guralnik,!2010;!Marcus!et!al.,!2006).!!Specifically,!the!type!of!participation!that!
researchers!have!examined!includes!leisure!pursuits!(Zingmark,!Fisher,!Rocklov,!&!
Nilsson,!2014;!Verghese!et!al.,!2003),!social!engagement!(Dahan.Oliel,!Gelinas,!&!
Mazer,!2008;!Ginsberg,!Hammerman.Rozenberg,!Cohen,!&!Stessman,!1999;!Mendes!
de!Leon,!Glass,!&!Berkman,!2003),!recreation!(Greenfield!&!Marks,!2007),!religious!
activity!(Strawbridge,!Cohen,!&!Shema,!2000),!and!volunteer!opportunities!(Musick!
&!Wilson,!2003).!!Commonly!it!is!observed!that!elders’!involvement!in!such!
activities!is!associated!with!reductions!or!even!reverses!in!negative!age.related!
outcomes!in!mental,!physical,!or!cognitive!functioning!(Hamer,!Bates,!&!Mishra,!
2011,!Liao!et!al.,!2011;!McGuire,!Strine,!Okoro,!Ahluwalia,!&!Ford,!2007).!!Consistent!
with!this!research,!interventions!that!target!activity!and!lifestyle!change!also!have!
been!shown!to!improve!older!adults’!psychosocial!health!and!quality!of!life!(for!
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review,!see!Riekert,!Ockene,!&!Pbert,!2013;!United!States!Department!of!Health!and!
Human!Services![USDHHS],!2008).!!!
Despite!the!positive!outcomes!of!such!interventions,!several!important!issues!
still!require!clarification.!!First,!due!to!a!dearth!of!longitudinal!data,!it!is!unclear!
whether!the!positive!outcomes!reported!in!previous!studies!have!meaningful!long.
term!effects!that!last!beyond!a!few!months!post.intervention!(Foxx,!2013;!Kazdin!&!
Kendall,!1998).!!Although!it!is!a!useful!and!accepted!practice!to!examine!change!
immediately!after!the!conclusion!of!an!intervention,!improved!outcomes,!
particularly!in!the!case!of!psychosocial!and!physical!health,!require!maintenance!
over!time!if!intervention.related!effects!are!to!be!maximized.!!In!addition,!long.term!
positive!gains!tracked!for!longer!terms,!such!as!one!year!or!more,!are!more!reliable!
in!demonstrating!intervention!effectiveness!and!durability!than!their!short.term!
counterparts.!!For!example,!when!examining!older!adults,!changes!that!are!tracked!
over!longer.term!follow.ups!are!more!likely!to!provide!insight!on!whether!or!not!
effects!are!lasting!and!meaningful!in!the!lives!of!elders.!!Thus,!it!is!crucial!to!
document!the!extent!to!which!improvements!are!sustained!over!the!long.term!at!
follow.up!intervals!post.intervention.!!!
Second,!although!experimental!tests!of!post.intervention!maintenance!exist!
(e.g.,!Alp,!Kanat,!&!Yurtkuran,!2007;!Clark!et!al.,!2001;!Eklund,!Sonn,!&!Dahin.
Ivanoff,!2004),!useful!information!regarding!long.term!intervention!effects!can!also!
come!from!non.experimental!data,!such!as!pre.post!comparisons!(e.g.,!Bartels!et!al.,!
2004;!Gitlin!et!at.,!2008;!Hibbard,!Greene,!&!Tusler,!2009).!!However,!limitations!
inherent!in!non.experimental!methods!need!to!be!acknowledged!(or!recognized)!in!
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order!to!avoid!drawing!inaccurate!conclusions!about!intervention!effectiveness.!!
Among!these!limitations!are!threats!to!internal!validity!such!as!regression!to!the!
mean!(RTM),!maturation,!and!experimental!mortality!(Campbell!&!Stanley,!1963).!!
For!example,!RTM!is!a!common!phenomenon!in!which!scores!that!are!
extreme!on!an!initial!measurement!tend!to!be!closer!to!the!mean!of!the!underlying!
distribution!on!subsequent!assessments.!!Likewise,!scores!that!are!extreme!on!the!
second!measurement!tend!to!have!been!closer!to!the!mean!on!the!first!
measurement!(Campbell!&!Stanley,!1963;!Campbell!&!Kenny,!1999).!!Therefore,!in!
any!case!in!which!individuals!are!selected!on!the!basis!of!extreme!pre.test!scores,!
those!scores!will!more!likely!be!less!extreme!at!post.test.!!RTM!can!lead!to!spurious!
inferences!in!pre.to.post!assessments!of!intervention!efficacy.!!
Unfortunately,.researchers.who.use.non3experimental.data.to.document.
sustainable.change.due.to.activity.interventions.rarely.address.threats.to.internal.
validity,.and.no.commonly.accepted.methodology.to.achieve.this.purpose.exists.!!For!
example,!in!a!pre.post!longitudinal!study!of!the!efficacy!of!a!chronic!disease!self.
management!intervention!involving!831!older!adults,!Lorig!and!colleagues!(2001)!
found!a!statistically!significant!reduction!in!health!distress!and!considerable!
improvement!in!self.efficacy!at!both!1.!and!2.year!follow!ups.!!However,!the!study!
lacked!a!control!group,!and!the!authors!did!not!account!for!RTM!or!maturation.!!
More!recently,!Arbesman!and!Mosley!(2012)!conducted!a!systematic!review!of!28!
occupational.!and!activity.based!health!interventions!for!older!adults.!!Of!four!of!the!
studies!reviewed!that!did!not!contain!a!randomized!control!group,!none!employed!
analyses!to!control!for!RTM,!maturation,!or!experimental!mortality.!!Without!taking!
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into!consideration!such!threats!to!internal!validity,!these!studies!failed!to!ensure!
accuracy!in!the!assessment!of!intervention!effectiveness.!
A!third!issue!that!requires!clarification!is!that!researchers!have!failed!to!
examine!whether!older!adults!who!participate!in!lifestyle!interventions!experience!
clinically!meaningful!change.!!Clinically!meaningful!change!in!a!health.related!
measure!is!an!alteration!in!a!variable!that!corresponds!to!the!smallest!change!in!
status!that!healthcare!professionals!consider!important!(Eisen,!Ranganathan,!Seal,!&!
Spiro,!2007).!!Although!the!health!of!older!adults!varies!considerably,!scant!research!
has!been!conducted!on!whether!healthier!groups!of!elders!benefit!in!a!clinically!
meaningful!way!from!activity.based!interventions.!!Research!that!identifies!subsets!
of!older!adults!who!are!benefitting!from!interventions!in!a!clinically!meaningful!way!
would!make!an!important!contribution!to!the!literature.!
Fourth,!personal!characteristics!(e.g.,!age,!race/ethnicity,!gender,!education,!
language,!marital!status)!can!affect!the!degree!to!which!an!intervention’s!effects!are!
sustainable!or!can!affect!the!intervention’s!capacity!to!bring!about!clinically!
significant!change.!!In!this!regard,!demographic!characteristics!such!as!being!
married!(Gennuso,!Gangnon,!Matthews,!Thraen.Borowski,!Colbert,!2013),!and!
speaking!English!(Viruell.Fuentes,!Morenoff,!Williams,!&!House,!2011)!may!
contribute!to!maximizing!the!benefits!gained!from!interventions!as!well.!
In!summary,!there!are!four!major!issues!that!need!to!be!addressed!when!
determining!the!efficacy!of!interventions!designed!to!improve!aging!outcomes!in!
older!adults.!!First,!longitudinal!follow.up!assessments!are!necessary!to!document!
whether!or!not!treatment!effects!are!sustainable!in!the!long.term.!!Second,!
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researchers!using!non.experimental!data!to!examine!effect!sustainability!must!
incorporate!methodology!that!controls!for!threats!to!internal!validity!in!order!to!
arrive!at!valid!conclusions!about!change!at!post.intervention!and!over!time.!!Third,!
researchers!should!ideally!identify!groups!that!experience!greater!clinically!
meaningful!change.!!And!fourth,!given!the!complexity!of!many!interventions,!it!may!
be!unreasonable!for!researchers!to!expect!effectiveness!to!be!equal!across!all!
groups;!therefore,!it!is!important!to!identify!which!groups!have!larger!effect!sizes!
and!conduct!tests!to!determine!whether!larger!effects!equate!to!more!sustainability.!!
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Purpose!of!Dissertation !
! The!objective!of!this!dissertation!is!to!address!the!four!aforementioned!
issues!using!data!from!the!University!of!Southern!California!(USC)!Well!Elderly!2!
(WE2)!Study.!!WE2!was!a!randomized!controlled!trial!(RCT)!testing!the!
effectiveness!of!a!6.month!occupational!therapy!lifestyle!intervention!aimed!at!
improving!psychosocial!health!and!enhancing!quality!of!life!by!enabling!older!adults!
to!implement!healthy!habits!into!their!daily!routines!(Clark!et!al.,!2012).!!Building!
on!its!successful!predecessor—the!Well!Elderly!1!Study!(WE1;!Clark!et!al.,!1997),!
WE2!replicated!the!WE1!results!using!a!larger!and!more!representative!sample!of!
community.dwelling!older!adults.!!In!addition,!the!WE2!study!design!contained!a!
crossover!feature!in!which!all!participants!received!the!intervention!during!either!
the!first!or!the!second!6.month!phase!of!their!study!participation,!thereby!making!it!
possible!to!combine!both!groups!into!one!larger,!non.experimental!sample!to!assess!
effectiveness!and!sustainability!(as!a!result!of!6.!and!12.month!follow.up!testing).!!
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Although!the!WE2!study’s!total!sample!consisted!of!440!participants,!the!present!
study!only!includes!those!subjects!with!both!pre.!and!post.intervention!data!(N!=!
285).!!Because!of!the!WE2!study’s!heterogeneous!sample,!large!groups!of!
demographically!defined!subgroups!could!be!meaningfully!studied!for!modifier!
effects.!!Furthermore,!as!the!WE2!study!was!longitudinal,!effect!sustainability!could!
be!examined!over!a!one.year!period.!!Although!the!intervention.based!experimental!
effect!sizes!tended!to!be!small!for!the!overall!sample!(ranging!from!0.14!to!0.23!for!
significant!effects),!the!initial!evaluation!of!WE2!revealed!that!the!intervention!was!
successful!in!improving!a!variety!of!health.related!outcomes!(Clark!et!al.,!2012).!!
This!dissertation!will!focus!on!the!following!four!outcomes!due!to!their!general!
importance!and!sensitivity!to!the!intervention:!depression,!life!satisfaction,!and!self.
rated!mental!health!and!physical!health.!
The!primary!goal!of!this!dissertation!is!to!study!the!sustainability!of!the!WE2!
intervention’s!positive!effects!using!non.experimental!data.!!In!addition,!this!work!
will!elucidate!various!methodological!issues!that!arise!in!inferring!sustainability!in!
non.experimental!contexts,!and!will!identify!both!clinically!significant!change!and!
its!beneficiaries.!!These!issues!will!be!addressed!via!the!following!three!aims,!which!
respectively!correspond!to!the!dissertation’s!three!chapters:!
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Aim!1.!Verify!the!extent!to!which!WE2Dbased!positive!treatment!effects!on!
depression,!life!satisfaction,!mental!health,!and!physical!health!were!
sustained!at!the!6D!and!12Dmonth!postDintervention!followDups.!!!
Aim3Related.Questions.
1. Were!the!positive!outcomes!of!the!WE2!intervention!sustained!at!the!6.
month!and!12.month!follow.ups?!!Specifically,!were!post.intervention!effects!
sustained!after!adjusting!for!threats!to!internal!validity!such!as!RTM?!!
2. What!percentage!of!change!from!the!pre.!to!post.test!intervention.based!
gains!were!maintained!at!the!6.!and!12.month!follow.ups!after!adjusting!for!
threats!to!internal!validity?!!
3. Was!greater!sustainability!observed!in!instances!where!subgroups!evidenced!
larger!effect!sizes!on!selected!variables?!
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Aim!2.!Identify!which!older!adults!in!the!WE2!study!had!clinically!meaningful!
positive!improvement!in!depression,!life!satisfaction,!mental!health,!and!
physical!health!from!preD!to!postDintervention.!!
Aim3Related.Questions.
1. What!percentage!of!study!participants!demonstrated!clinically!meaningful!
change!from!pre.!to!post.intervention?!!Did!this!percentage!exceed!the!
percentage!of!participants!who!experienced!clinically!meaningful!decline?!
2. What!were!the!socio.demographic!correlates!of!clinically!meaningful!
improvement!in!depression,!life!satisfaction,!mental!health,!and!physical!
health!in!older!adults!from!pre.!to!post.intervention?!
! 8!
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!
Aim!3.!Determine!if !clinically!meaningful!positive!change!in!depression!was!
sustained!at!6D!and!12Dmonths!postDintervention.!
Aim3Related.Questions.
1. Did!participants!with!meaningful!change!in!depression!from!pre.!to!post.
intervention!sustain!this!change!over!6.!and!12.month!follow.ups?!!
2. Were!age,!race/ethnicity,!gender,!language,!marital!status,!or!education!
associated!with!the!maintenance!of!clinically!meaningful!change!over!6.!and!
12.month!follow.up!periods?!
!
This!dissertation!is!potentially!important!because!knowledge!of!the!studied!
issues!can!assist!researchers!and!practitioners!in!(a)!improving!interventions!so!as!
to!sustain!clinically!meaningful!health!effects,!and!(b)!identifying!methodological!
enhancements!in!attempting!to!document!sustainable!effects!based!on!non.
experimental!data.!!First,!insight!gained!from!this!dissertation!will!reveal!whether!
the!WE2!post.intervention!treatment!effects!were!sustainable.!!Second,!it!will!
provide!a!method!of!dealing!with!threats!to!the!ability!to!infer!sustainable!effects!
using!non.experimental!data.!!Third,!it!will!address!questions!about!the!relative!
degree!of!sustainability!of!stronger!versus!weaker!intervention!effects!(i.e.,!larger!
vs.!smaller!effect!sizes).!!Fourth,!this!work!will!also!help!identify!which!participants!
stand!to!benefit!the!most!in!a!sustained!way!from!this!intervention,!and!how!often!
these!obtained!changes!are!clinically!meaningful.!!
! 9!
!
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!
!
15!
CHAPTER 1
THE DURABILITY OF BEHAVIORAL CHANGE AFTER TREATMENT: THE
LONG-TERM FOLLOW-UP OF A LIFE MANAGEMENT BEHAVIORAL
INTERVENTION FOR HEALTHY OLDER ADULTS
Background!
Interventions!that!encourage!participant!engagement!in!an!active!and!
healthy!lifestyle!by!improving!eating!habits!and!performance!of!daily!activities,!as!
well!as!increasing!social!support!and!a!sense!of!autonomy,!mitigate!the!progression!
and!negative!impact!of!age.related!health!declines!among!older!adults!(Hendricks!&!
Hatch,!2009).!!Such!interventions!can!enhance!older!adults’!ability!to!maintain!their!
independence!(Jobe!et!al.,!2001),!greatly!improve!their!overall!well.being!
(Hendricks!&!Hatch,!2009),!increase!their!functional!ability!(Chou,!Hwang,!&!Wu,!
2012),!support!a!high!quality!of!life!(Langlois!et!al.,!2013),!and!reduce!the!incidence!
of!falls!(Steultjens!et!al.,!2004).!!Further,!at!least!one!lifestyle!intervention!for!older!
adults!has!shown!to!reduce!post.intervention!healthcare!costs!by!more!than!half!
(Hay!et!al.,!2002).!!!
The!goal!of!most!lifestyle!interventions!has!been!to!produce!positive!
enduring!change.!!Yet,!research!in!this!area!has!often!been!characterized!by!studies!
that!report!positive!effects!immediately!after!treatment!and!involve!little!to!no!long.
term!follow.up!(Foxx,!2013;!Spiegler,!2015).!!In!other!words,!many!studies!have!
drawn!conclusions!about!the!efficacy!and!effectiveness!of!interventions!based!solely!
on!the!status!of!participants!at!post.treatment!(Foxx,!2013;!Kazdin!&!Kendall,!1998).!
!
!
16!
However,!there!are!several!reasons!for!expecting!that!lifestyle!interventions!
for!older!adults!will!produce!sustainable!effects.!!In!this!regard,!factors!such!as!the!
development!of!self.perpetuating!habits,!increases!in!self.efficacy!which!lead!to!
continuing!motivation!and!effort!to!maintain!healthy!living,!or!ongoing!social!
support!(e.g.,!from!a!helpful!spouse)!should!on!theoretical!grounds!promote!lasting!
intervention!effects!(Bandura,!2004;!Lally,!Van!Jaarsveld,!Potts,!&!Wardle,!2010;!
Seeman,!1996).!!With!the!Well!Elderly!intervention!in!particular,!an!explicit!effort!
was!made!to!anchor!new,!healthful!habits!into!the!fabric!of!daily!activities!that!were!
intrinsically!motivated!and!contextually!feasible!within!the!participant’s!everyday!
life.!!This!was!accomplished!largely!through!individual!sessions!in!which!the!
therapist!worked!with!the!client!to!identify!strategies!for!such!anchoring.!!On!the!
other!hand,!it!is!possible!that!over!time!considerations!such!as!age.related!declines,!
decay!of!memory!or!motivation!for!performing!recommended!behaviors,!or!
environmental!changes!that!disrupt!previously!achieved!healthful!habits!will!
mitigate!against!sustainability.!!Therefore,!if!sustainability!is!in!fact!achieved,!it!
would!be!expected!to!attenuate!to!some!extent!in!the!months!following!the!
conclusion!of!the!intervention.!
The!notion!of!sustainability!has!been!examined!experimentally.!!In!some!
cases!where!researchers!have!examined!intervention!efficacy!beyond!the!post.test!
follow.up,!studies!have!been!limited!to!a!single!follow.up!of!6!months!or!less!
(Dahlin.Ivanoff,!Sonn,!&!Svensson,!2002;!King!et!al.,!2006;!Murphy,!Lyden,!Smith,!
Dong,!&!Koliba,!2010).!!For!example,!King!and!colleagues!(2006)!examined!the!
effectiveness!of!a!multifaceted!physical!activity!intervention!with!335!diabetic!
!
!
17!
participants.!!These!researchers!reported!that,!at!the!2.month!post.intervention!
follow.up,!participants!significantly!improved!on!all!physical!activity!measures!
compared!to!a!control!group.!!However,!the!2.month!post.intervention!follow.up!
was!the!only!additional!assessment!conducted.!!Similarly,!the!Well!Elderly!study!
(WE1;!Clark!et!al.,!1997),!which!involved!an!occupational!therapy!intervention!that!
focused!on!modifying!healthy!behaviors!and!activities!in!older!adults,!included!a!
slightly!later!follow.up!at!6!months!post.intervention.!!This!study!reported!
significant!positive!intervention!effects!immediately!following!post.treatment!on!a!
range!of!outcomes!such!as!role!functioning,!life!satisfaction,!and!self.rated!mental!
and!physical!health.!!In!a!follow.up!study!on!the!maintenance!of!WE1!treatment!
effects,!Clark!and!colleagues!(2001)!reported!that!approximately!90%!of!the!
intervention.based!gains!were!sustained!at!the!6.month!post.intervention!follow.
up,!an!excellent,!experimentally!based!demonstration!of!endurance!of!effect.!!!!
There!are!some!studies!that!have!employed!follow.up!assessments!beyond!6.
months!(Eklund,!Sonn,!&!Dahlin.Ivanoff,!2004;!Holland!et!al.,!2005;!Jerant,!Moore.
Hill,!&!Franks,!2009;!Lorig,!Ritter,!Laurant,!&!Fries,!2004;!Phelan,!Williams,!Penninx,!
LoGerfo,!&!Leveille,!2004;!Rejeski!et!al.,!2003).!!For!example,!in!a!randomized!
controlled!trial,!Lorig,!Ritter,!and!Gonzalez!(2003)!evaluated!the!effectiveness!of!a!6.
week!community.based!program!for!551!Spanish.speaking!older!adults!with!
chronic!disease!(heart!disease,!lung!disease,!or!type!2!diabetes).!!Participants!were!
randomized!into!either!a!peer.led!program!or!a!wait.list!control.!!Researchers!
reported!that!at!the!4.month!post.intervention!follow.up,!those!in!the!peer.led!
group!had!improved!health!behavior,!health!status,!self.efficacy,!and!fewer!
!
!
18!
emergency!room!visits!when!compared!to!the!control!group.!!These!gains!were!also!
maintained!at!1.year!post.intervention.!!Similarly,!a!study!by!Phelan!and!colleagues!
(2004)!evaluated!the!efficacy!of!an!intervention!aimed!at!preventing!and!reducing!
disability!in!activities!of!daily!living!(ADL)!in!community.dwelling!older!adults.!!
After!participants!in!the!treatment!group!developed!and!followed!a!health!action!
plan!with!a!gerontological!nurse!practitioner,!researchers!reported!that!these!
participants!maintained!improvement!in!ADL!function!at!12.months!post.
intervention!when!compared!to!the!non.treatment!control!group.!
Although!some!studies!have!included!follow.up!assessments!at!6!months!or!
beyond,!many!of!these!same!studies!are!wrought!with!significant!limitations!such!as!
small!sample!size!or!a!high!dropout!rate.!!For!example,!Alp,!Kanat,!and!Yurtkuran!
(2007)!examined!the!effects!of!a!self.management!program!for!older!adults!
designed!to!improve!better!health!behavior.!!The!intervention!provided!participants!
with!education!regarding!diet,!living!safely,!exercise,!and!more.!!Results!from!this!
study!found!that!older!adults!maintained!beneficial!effects!in!mental!health,!general!
health!perception,!vitality,!social!function,!and!other!quality!of!life!measures!6!
months!following!the!intervention.!!However,!the!sample!was!relatively!small!and!
was!recruited!from!one!hospital.!!Additionally,!Eklund!and!colleagues!(2004)!
investigated!the!impact!of!a!health!education!program!on!participants’!perception!of!
security!in!performing!daily!activities!in!253!older!adults.!!These!researchers!
concluded!that!those!in!the!treatment!group!who!received!medical!information!and!
instruction!in!self.care,!cleaning,!communication,!orientation!and!mobility,!food!
preparation,!shopping,!and!financial!management!reported!improved!perceived!
!
!
19!
security!compared!to!controls.!!However,!by!the!28.month!follow.up,!only!62!of!the!
original!253!participants!remained!in!the!intervention!group,!thus!indicating!a!
significant!dropout!rate!and!largely!eliminating!the!possibility!of!evaluating!
sustainability!effect.!
In!some!cases,!an!intervention!effect!may!be!statistically!significant,!but!
nonetheless!relatively!small!in!magnitude.!!For!example,!in!the!Well!Elderly!2!data!
set!that!is!analyzed!in!the!current!study,!effect!sizes!at!the!time!of!post.intervention!
for!significant!variables!commonly!ranged!from!.11!to!.18.!!In!such!instances,!the!
health.related!benefits!may!be!somewhat!tenuous!and!therefore!more!easily!
disrupted,!leading!to!reduced!potential!for!sustainability.!!To!shed!light!on!this!issue!
of!the!relationship!between!effect!magnitude!and!sustainability,!it!is!useful!to!
consider!“pockets!of!data”!in!which!larger!effect!was!achieved,!to!test!the!durability!
of!such!larger!effects,!and!to!hypothesize!that!a!greater!percentage!of!post.
intervention!effect!will!be!maintained!in!such!instances.!!This!notion!seems!to!make!
sense!conceptually,!insofar!as!health.related!changes!with!a!firmer!foundation!(i.e.,!
larger!initial!effect!size)!should!in!principle!be!more!resistant!to!decay.!
Despite!growing!evidence!that!behavioral!change!interventions!are!
efficacious!in!the!short.term,!the!aim!of!the!present!study!is!to!add!to!the!literature!
on!whether!treatment!effects!are!sustained!over!time!period!in!a!lifestyle!
intervention!follow.up!study!with!a!culturally!diverse!community.dwelling!sample!
of!older!adults.!!
!
!
!
!
20!
Method!!
Study!Intervention!
This!paper!will!examine!the!persistence!of!effects!of!the!Well!Elderly!2!(WE2)!
study!at!6.!and!12.month!post.intervention!follow.ups.!!The!WE2!study!was!a!
randomized!controlled!trial!(RCT)!that!examined!the!effects!of!a!lifestyle.based!
intervention!designed!to!increase!life!satisfaction!and!reduce!health!decline!among!
racially!and!culturally!diverse!community.dwelling!older!adults!(Clark!et!al.,!2012).!!
WE2!is!an!extension!of!the!Well!Elderly!(WE1)!study,!with!WE1!carried!out!
in!the!mid!1990s!(Clark!et!al.,!1997).!!The!two!studies!differ!in!several!significant!
ways.!!First,!WE2!consisted!of!two!phases:!an!initial!experimental!phase!and!a!
crossover!non.experimental!phase.!!In!WE2,!all!participants!received!the!treatment!
intervention!prior!to!follow.up!assessments;!consequently,!there!is!no!control!group!
to!act!as!a!basis!of!comparison!after!the!fist!six!months.!!Second,!although!the!WE1!
study!consisted!of!an!ethnically!diverse!population!with!47%!Asian!older!adults,!
more!than!one.half!of!the!WE2!study!sample!consisted!of!African!American!(33%)!
and!Hispanic!(26%)!older!adults,!the!groups!most!at!risk!for!health!disparities!in!the!
United!States!(Smedley,!Stith,!&!Nelson,!2003).!!Third,!the!goal!of!the!WE1!study!was!
to!test!intervention!efficacy!in!government!subsidized!housing!for!independent.
living!older!adults,!whereas!the!aim!of!the!WE2!study!focused!on!intervention!
effectiveness!by!examining!a!sample!of!older!adults!that!were!gathered!from!21!
different!sites!throughout!the!greater!Los!Angeles!area,!including!senior!housing!
complexes,!senior!community!centers,!and!retirement!communities.!
!
!
21!
A!slightly!modified!and!shorter!(6.month!rather!than!9.month)!version!of!the!
original!Lifestyle!Redesign
®
!intervention!was!utilized!in!WE2.!!The!WE2!intervention!
consisted!of!weekly!2.hour,!small!group!(8.10!people)!treatment!sessions!delivered!
by!a!trained!occupational!therapist!over!a!6.month!period.!!During!these!sessions,!
participants!were!taught!modules!that!covered!the!following!topics:!1)!Everyday.
Activity.on.Health,!about!the!incorporation!of!physical!and!mental!exercise!into!
everyday!life;!2)!Time.Use.and.Energy.Conservation,!about!how!to!plan!a!healthful!
daily!routine;.3)!Transportation,.about!different!public!transportation!options;!4)!
Safety,!about!the!concerns!that!older!adults!may!have!regarding!safety!in!the!
community!and!how!it!affects!their!lifestyle!choices;.5)!Social.Relationships,!about!
how!relationships!and!changes!in!social!network!(e.g.,!death,!family!members!move,!
disability)!can!occur!with!age;.6)!Cultural.Awareness,!about!the!exploration!of!
diversity!within!the!group!and!within!the!participants’!environment;.7)!Goal.Setting,.
about!developing!attainable!goals!for!increased!health!throughout!the!day;!and.8).
Integrative.Summary,.or!syntheses!of!what!participants!have!learned!from!the!
intervention!modules!and!discussions.!!Taken!together,!these!topics!provided!
information!that!was!used!by!the!participants!and!occupational!therapist!to!
customize!individual!plans!to!help!participants!adapt!to!the!challenges!associated!
with!aging,!life!management,!and!healthy!living.!
! In!addition!to!weekly!small!group!meetings,!each!participant!also!had!the!
opportunity!to!engage!in!up!to!10!hours!of!individual!treatment!with!the!
occupational!therapist.!!However,!only!17%!of!the!older!adults!in!the!study!sample!
participated!in!5!or!more!individual!sessions.!!
!
!
22!
! As!noted!above,!the!WE2!study!contained!a!crossover!design!feature!in!which!
all!participants!were!randomly!scheduled!to!receive!the!intervention!during!either!
the!first!or!the!second!6.month!phase!of!their!study!participation!(Clark!et!al.,!2012;!
see!Table!1.1.).!!In!accordance!with!study!protocol,!participants!were!not!exposed!to!
any!experimental!treatment!when!they!were!not!receiving!the!intervention.!!
Because!every!participant!eventually!received!the!treatment,!the!long.term!effects!
of!the!intervention!cannot!be!compared!against!an!untreated!control!group.!!Study!
participation!included!longitudinal!assessment!of!functioning!at!6.month!intervals:!
pre.test,!post.test,!6.month!follow.up,!and!12.month!follow.up.!!Jackson!and!
colleagues!(2009)!extensively!describe!the!WE2!study!design!details!elsewhere.!
!
Sample!
The!sample!for!the!present!study!consisted!of!285!WE2!study!participants!
(out!of!the!440!originally!enrolled)!who!had!both!pre.intervention!and!post.test!
data.!!The!group!was!made!up!of!men!and!women!aged!60!to!94!years!who!were!
recruited!from!12!senior!residences!and!9!senior!activity!centers!throughout!the!
greater!Los!Angeles!region.!!All!study!participants!were!fluent!in!either!English!or!
Spanish,!and!were!previously!screened!for!cognitive!functioning!(those!with!severe!
cognitive!impairment!were!excluded).!!
For!the!purposes!of!the!present!study,!participants!had!to!attend!at!least!2!
group!sessions!to!be!considered!as!having!had!sufficient!exposure!to!the!
intervention.!!Although!roughly!10%!(n!=!32)!of!the!original!WE2!study!sample!did!
not!complete!a!single!group!session,!the!vast!majority!of!the!sample!(87%)!
!
!
23!
completed!2!or!more!sessions!and!were!subsequently!included!in!the!study!analysis.!!
Statistical!tests!compared!those!with!fewer!than!2!group!sessions!to!those!with!2!or!
more!sessions,!and!results!showed!that!there!were!no!statistically!significant!
differences!in!depression!at!baseline.!!!
At!the!6.!and!12.month!follow.ups,!228!(80%)!and!227!(79%)!of!the!285!
participants!remained!in!the!study,!respectively.!!A!one.tailed!t.test!for!post.test!
outcome!means!revealed!that!there!were!no!statistical!differences!at!baseline!
between!participants!that!remained!in!the!study!and!those!that!dropped!out!on!any!
of!the!study!outcomes.!!Of!those!participants!who!withdrew!from!the!study!after!
post.test!(n!=!57),!reasons!included!personal!illness,!time!commitment!restraints,!
and!scheduling!difficulties!(see!Jackson!et!al.,!2009!for!detailed!information).!!
Additionally,!ethnic!concordance!of!the!therapist!was!tested!as!a!moderator!
and!found!to!be!unrelated!to!each!of!the!four!study!outcomes!(see!Appendix!1A.1.
4.).!!Consequently,!participants!who!had!a!therapist!of!the!same!race/ethnicity!did!
not!evidence!more!positive!change!in!any!of!the!study!outcomes!when!controlling!
for!baseline!levels.!!Additionally,!time!of!year!(i.e.,!summer!vs.!winter)!the!
intervention!was!received!by!participants!was!not!associated!with!any!of!the!four!
study!outcomes.!!!
!
Measures!
This!study!focuses!on!four!outcome!measures:!
Symptoms!of!depression.!!Depressive!symptomatology!was!assessed!using!
the!20.item,!self.report!Center.for.Epidemiologic.Studies.Depression.Scale!(CES.D).!!
!
!
24!
The!CES.D!has!been!found!to!validly!assess!symptoms!of!depression!in!older!adult!
samples!(Foley,!Reed,!Mutran,!&!DeVellis,!2002)!by!tapping!multiple!domains!of!
depressive!symptomology!indicating!depressed!affect,!positive!affect,!
somatic/reduced!activity,!and!interpersonal!relationships.!!Examples!of!items!
include,!“I!felt!depressed,”!and,!“I!felt!sad.”!!Participants!indicate!responses!on!a!4.
point!scale!from!“Rarely/none!of!the!time!(less!than!1!day!per!week)”!to!“Most/all!of!
the!time!(5.7!days!per!week).”!!Total!scores!range!from!0.60,!where!a!higher!score!
indicates!more!symptoms!of!depression.!!
Life!satisfaction.!!The.Life.Satisfaction.Index3Z!(LSI.Z;!Wood,!Wylie,!&!
Schefor,!1969)!was!used!to!assess!general!life!satisfaction.!!The!index!consists!of!13!
items!relevant!to!older!adults!(McDowell!&!Newell,!1996).!!For!example,!some!LSI.Z!
questions!include,!“I!am!just!as!happy!as!when!I!was!younger,”!and,!“These!are!the!
best!years!of!my!life.”!!Participants!indicate!responses!on!a!3.point!scale:!“0”!
equating!to!Unsure;!“1”!equating!to!Disagree;.and!“2”!equating!to!Agree.!!The!item!
responses!are!summed,!and!the!total!scores!range!from!0!to!26,!where!a!higher!
score!indicates!greater!perceived!life!satisfaction.!
HealthDrelated!quality!of!life.!!Norm.based!scores!from!the!RAND!Short.
Form!Health!Survey!Version!2!(SF.36v2)!were!employed!to!measure!participants’!
perceptions!of!their!mental!well.being!and!physical!health!during!the!past!four!
weeks!(Ware,!Kosinski,!&!Dewey,!2000).!!The!SF.36v2!consists!of!36!items,!includes!
eight!scales!(general!and!mental!health,!physical!and!social!functioning,!role!
physical!and!emotional,!bodily!pain,!and!vitality),!and!has!been!validated!with!more!
!
!
25!
objective!measures!(Brazier!et!al.,!1992)!for!use!with!samples!consisting!of!ethnic!
minorities!(Madsen,!2000)!and!older!adults!(Hayes,!Morris,!Wolfe,!&!Morgan,!1995).!!!!
! The!SF.36v2!can!also!generate!two!summary!indices:!the!mental!component!
summary!(MCS)!and!the!physical!component!summary!(PCS).!!The!MCS!is!a!
summary!of!four!subscales!(vitality,!social!functioning,!role!emotional,!and!mental!
health),!as!is!the!PCS!(physical!functioning,!role!physical,!bodily!pain,!and!general!
health).!!Scores!for!scales!were!transformed!to!norm.based!scores!(range!=!0.100)!
using!the!Medical!Outcomes!Study!scoring!system.!!!
! In!the!present!study,!the!author!hypothesizes!that!the!treatment!effects!
gained!from!a!6.month!lifestyle!intervention!leads!to!sustained!long.term!health!
gains!in!the!form!of!reduced!depression,!and!greater!life!satisfaction,!mental!health,!
and!physical!health!among!older!adults!reported!6.!and!12.months!following!an!
intervention.!
!
Statistical!Methods!
To!examine!the!extent!to!which!the!treatment!effects!found!at!the!conclusion!
of!the!intervention!endured!over!time!for!the!set!of!four!measures!(CES.D,!LSI.Z,!SF.
36v2!MCS,!and!SF.36v2!PCS),!Cohen’s.d!effect!size!estimates!were!calculated!(for!
post.test,!6.,!and!12.month!follow.ups)!using!the!change–from–baseline!score!
means!and!standard!deviations!(Cohen,!1988).!!The!effect!size!for!each!follow.up!
assessment!was!then!divided!by!the!post.test!effect!size!mean!to!derive!an!overall!
percentage!reflective!of!the!degree!to!which!the!post.intervention.based!gains!were!
retained!over!the!6.!and!12.month!follow.up!assessments.!!Effect!sizes!have!been!
!
!
26!
previously!interpreted!as!being!small!(≤!.20),!medium!(.20!.!.50),!and!large!(≥!.80),!
where!larger!effect!sizes!indicate!greater!change!(Bartolucci,!Tendera,!&!Howard,!
2011;!Cohen,!1988).!!Also,!to!examine!if!there!was!greater!sustainability!observed!in!
instances!where!subgroups!might!evidence!larger!effect!sizes!on!selected!SF36v2!
variables!and!whether!they!sustained!potential!post.test!effects,!effect!sizes!were!
also!estimated!for!racial/ethnic!subgroups.!!
Additionally,!bivariate!descriptive!analyses!were!conducted!to!describe!the!
relationship!between!outcomes.!!This!primarily!serves!the!function!to!identify!the!
positive!and!negative!associations!among!study!variables.!!
Apart!from!descriptive!analyses!and!effect!size!calculations,!statistical!
comparisons!were!used!to!examine!the!mean!change!from!pre.intervention!of!CES.
D,!LSI.Z,!SF.36v2!MCS,!and!SF.36v2!PCS!across!time.!!One.tailed!statistical!
significance!tests,!conducted!at!the!0.05!α!level,!were!used!to!examine!the!
hypotheses!of!positive!beneficial!treatment!effects.!!This!testing!method!was!chosen!
because:!1)!only!positive!treatment!effects!were!obtained!in!the!original!WE1!study!
(Clark!et!al.,!1997),!and!2)!previous!occupational!theory!links!the!intervention!with!
positive!effects!(see!Clark!et!al.,!2012;!Jackson,!Carlson,!Mandel,!Zemke,!&!Clark,!
1998;!Jackson!et!al.,!2009).!!To!correct!for!the!problem!of!multiple!comparison!
testing,!a!Bonferroni!correction!p.value!of!.0125!(i.e.,!.05/4)!was!used!(Bonferroni,!
1935).!!Additionally,!within!each!assessment!phase,!a!False!Discovery!Rate!(FDR)!
corrected!p!value!cutoff!of!p.<..03!was!chosen!for!the!set!of!outcomes!as!an!Omnibus!
test!to!control!the!expected!proportion!of!incorrectly!rejected!null!hypotheses!(type!
I!errors)!in!a!list!of!rejected!hypotheses!(Shaffer,!1995).!
!
!
27!
Results!
Descrip tive!and!Bivariate!!
Participants!with!missing!observations!from!pre.test!to!post.test!did!not!
differ!from!those!with!complete!data!from!pre.test!to!post.test!on!any!of!the!
outcome!variables!at!pre.test!(e.g.,!CES.D,!LSI.Z,!or!SF.36v2!measures).!!Participants!
with!missing!data!did,!however,!differ!significantly!from!those!with!complete!data!in!
a!few!ways:!a!significantly!lower!proportion!of!participants!with!missing!data!
completed!the!assessment!in!Spanish!(p.=!0.03)!and!on!average,!participants!with!
missing!data!undertook!fewer!individual!intervention!sessions!(p.<..001).!
A!one.tailed!significance!test,!conducted!at!the!0.05!α!level,!was!used!to!
examine!the!potential!effect!from!the!extra!testing!exposure!the!control!group!had!
before!being!combined!with!the!treatment!group!for!all!four!major!study!variables.!!
The!change!for!the!control!group’s!first!pre.intervention!(baseline)!assessment!was!
not!found!to!be!statistically!significantly!different!from!the!second!pre.intervention!
assessment;!this!indicated!that!testing!exposure!did!not!have!a!significant!influence!
on!test!scores.!!!
The!score!distributions!for!the!CES.D,!LSIZ,!and!two!SF.36v2!component!
scales!were!tested!for!normality.!!The!CES.D!was!slightly!positively!skewed,!
indicating!fewer!participants!with!more!depression.!!The!LSI.Z!was!slightly!
negatively!skewed,!showing!that!most!of!the!sample!reported!higher!than!average!
on!the!life!satisfaction!measure.!!As!a!result!of!slight!skewedness!for!the!CES.D!and!
LSIZ!score!distributions,!no!transformation!or!corrections!were!needed!for!the!
purposes!of!analyses.!!Both!the!SF.36v2!MCS!and!SF.36v2!PCS!had!normal!
!
!
28!
distributions!(SF.36v2!MCS!mean!=!47.70;!SF.36v2!PCS!mean!=!40.95).!!However,!
the!scoring!for!the!SF.36v2!uses!norm.based!estimates!that!make!it!possible!to!
interpret!whether!scores!fall!within!typical!expected!ranges!(e.g.,!a!score!of!50!for!
U.S.!population).!!Norm.based!scoring!allows!researchers!to!estimate!scores!in!
standard!units!as!deviations!from!the!average!score,!rather!than!from!the!extreme!
score.!!All!scales!exhibited!normal!kurtosis,!and!all!four!instruments!resulted!in!
either!minimal!or!no!ceiling!or!floor!effects.!
For!the!present!study,!the!mean!age!among!participants!was!75.62!years!(see!
Table!1.2B.).!!Participant!ethnic/racial!groups!included!White!(41%),!Black!(33%),!
and!Hispanic!(26%).!!Over!two.thirds!(71%)!of!the!participants!were!female.!!
Eighty.five!percent!of!participants!were!married.!!Regarding!education,!38%!of!the!
participants!had!some!college,!29%!had!not!completed!high!school,!19%!had!
completed!high!school!only,!and!15%!had!higher!than!a!college!degree.!!Eighty.two!
percent!of!the!sample!spoke!English,!and!those!remaining!(18%)!were!Spanish.
speaking.!!Participants!were!recruited!from!various!sites:!residence.subsidized!
senior!housing!(9%),!senior!center:!multipurpose!(45%),!senior!center:!parks!and!
recreation!(27%),!and!continuous!care!retirement!communities!(19%).!!
! United!States!population!age.matched!norms!on!the!SF.36v2!MCS!scale!and!
SF.36v2!PCS!scale!(National!Survey!of!Functional!Health!Status![NSFHS],!1998)!for!
adults!75!years!of!age!were!chosen!because!of!the!present!sample’s!mean!age!of!
(75.6!years).!!When!comparing!the!normative!age.matched!U.S.!norms!for!the!SF.
36v2!MCS!scale!and!SF.36v2!PCS!scale,!the!mean!scores!at!pre.test!for!both!
outcomes!fall!between!the!25
th!!
and!50
th
!percentiles!of!the!population!norms.!!The!
!
!
29!
mean!pre.test!SF.36v2!MCS!score!in!this!sample!(47.70)!was!slightly!above!the!25
th
!
percentile!for!the!U.S.!population!of!older!adults!(46.37).!!This!sample!scored!40.95!
on!the!SF.36v2!PCS!scale!at!pre.test;!this!valuation!falls!between!the!25
th
!percentile!
(34.60)!and!the!median!(46.06)!of!the!age.matched!population!normative!data.!
Bivariate!analysis!of!outcome!variables!at!pre.test!revealed!that!all!outcome!
variables!were!significantly!related!to!each!other!beyond!the!α!.=!Table!1.3.).!!CES.D!was!negatively!associated!with!all!other!outcome!variables!(rs.=..
.23!to!..75,!p.health!measures!(CES.D,!SF.36v2!MCS);!CES.D!was!most!strongly!related!to!SF.36v2!
MCS!(r!=!3.75,!p.=.<..01).!!!
!
PreDtest!to!PostDtest!Change!and!LongDterm!FollowDup!
Comparison!of!means!revealed!beneficial!statistically!significant!change!from!
pre.test!to!post.test!in!all!outcome!variables!(see!Table!1.4.).!!Pre.test!to!post.test!
mean!change!occurred!in!depression!(p!=..002),!with!the!depression!mean!
decreasing!by!1.32!units.!!Life!satisfaction!mean!change!increased!by!.63!(p.=..008),!
and!there!was!also!positive!change!in!the!two!SF.36v2!composite!scales:!MCS!(1.72,!
p.=!.002),!and!PCS!(1.08,!p!=!.008).!!These!post.test!findings!were!consistent!with!
results!from!the!RCT!component!of!the!study!previously!reported!in!Clark!and!
colleagues!(2012).!!
Results!of!the!6.month!follow.up!tests!showed!significant!mean!change!in!
depression!(p.=..011)!from!pre.test!to!the!6.month!follow.up.!!On!average,!
depression!was!1.26!units!lower!at!6.month!follow.up!relative!to!study!baseline.!!All!
!
!
30!
other!outcomes,!on!the!other!hand,!were!no!longer!significant!at!the!6.month!
follow.up!period.!!Likewise,!analyses!for!mean!change!from!pre.test!to!12.month!
follow.up!revealed!that!no!outcomes!were!significant!(all!p’s!>!.05).!!Despite!the!
non.significant!findings,!all!variables!trended!in!the!direction!of!improvement!for!
both!the!6.!and!12.month!follow.up!phases.!!
Across!the!four!outcomes,!the!average!effect!size!for!mean!change!from!pre.
test!to!post.test!was!.13,!with!a!range!of!.11!to!.14!(see!Figure!1.1.),!indicating!a!
small!effect!size!magnitude.!!The!mean!effect!size!of!this!study!was!somewhat!
smaller!than!the!moderate!mean!effect!size!(.32)!in!the!WE1!study!(Clark!et!al.,!
2001).!!As!shown!in!Table!1.5.,!the!largest!effect!size!of!the!current!study!at!post.test!
occurred!in!depression!(d.=.14,!p!=!.01),!followed!by!life!satisfaction!(d.=!.12,!p.=.01),!
SF.36v2!MCS!(d.=.11,!p.=.01),!and!then!SF.36v2!PCS!(d.=.11,!p!=!.01).!!Though!
smaller,!these!findings!were!consistent!with!the!effect!sizes!reported!in!WE2!at!
post.test!(Clark!et!al.,!2012).!!
At!6.month!follow.up,!approximately!80%!(.79)!of!the!magnitude!of!the!
treatment!effect!on!depression!was!retained!at!the!conclusion!of!the!intervention.!!
However,!the!corresponding!mean!effect!size!of!all!four!outcome!variables!at!the!6.
month!follow.up!assessment!was!.05!(with!a!range!of!.00!to!.11),!demonstrating!
that,!in!a!general!sense,!42%!(.05/.12)!of!the!magnitude!of!the!treatment!effects!
found!at!the!conclusion!of!the!intervention!were!retained!at!the!6.month!follow.up!
(See!Table!1.5.).!!
The!mean!effect!size!for!depression!at!the!12.month!follow.up!was!.03!(with!
a!range!of!!.00!to!.07!across!outcomes),!revealing!that!no!detectable!treatment!effect!
!
!
31!
was!maintained!at!1.year!post.intervention.!!As!described!in!Figure!1.1.,!there!was!a!
continued!downward!trend!among!all!effect!sizes!(except!PCS)!such!that!no!
significant!effect!sizes!were!found!at!the!12.month!follow.up!among!any!of!the!
study!outcomes.!!
There!were!no!notable!pre.test!to!post.test!effects!sizes!found!in!depression,!
life!satisfaction,!mental!health,!or!physical!health!among!specific!racial/ethnic!
subgroups.!!However,!exploratory!analysis!was!conducted!using!other!SF.36v2!
study!variables!not!included!in!the!primary!analysis!revealed!notable!effect!sizes!
and!sustainability!among!certain!subgroups.!!Appendix!1B.!summarizes!the!largest!
effect!sizes!found!among!study!outcomes!at!post.test!and!their!sustainment.!!
Specifically,!this!exploratory!analysis!found!that!Latinos!evidenced!the!largest!effect!
size!(.33)!at!post.test!in!general!health!and!maintained!75%!and!73%!of!this!effect!
at!the!6.month!and!12.month!follow.ups,!respectively.!!African!Americans!had!a!.29!
effect!size!in!vitality!at!post.test!and!maintained!72%!and!38%!of!this!effect!at!the!6.!
and!12.month!follow.ups,!respectively.!!Whites!had!a!.29!effect!in!mental!health,!but!
the!effect!had!vanished!by!the!6.month!follow.up.!
!
Discussion !
A!common!criticism!of!behavioral!interventions!is!that!researchers!rarely!
examine!or!report!the!durability!of!treatment!effects!beyond!post.test,!which!tends!
to!take!place!immediately!after!treatment!cessation!(Foxx,!2013).!!This!omits!the!
question!of!whether!reported!post.intervention!gains!are!truly!durable!over!time.!!!
!
!
32!
As!described!earlier,!the!present!study!consisted!of!participants!who!had!
both!pre.intervention!and!post.intervention!data.!!Although!pre.test!to!post.test!
analysis!was!not!an!aim!of!the!present!study,!post.test!results!from!this!sample!
included!findings!that!were!consistent!with!what!was!previously!reported!in!the!
WE2!study!(Clark!et!al.,!2012).!!Namely,!there!was!statistically!significant!
improvement!in!depression,!life!satisfaction,!mental!health,!and!physical!health!at!
post.test.!
Although!the!present!analysis!of!subgroups!on!depression,!life!satisfaction,!
mental!health,!and!physical!health!did!not!yield!notable!effect!sizes!to!further!
examine!sustainability,!exploratory!analyses!yielded!promising!findings.!!
Specifically,!the!maintenance!of!somewhat!larger!effect!sizes!in!vitality!and!general!
health!were!relatively!well!maintained!in!African!Americans!and!Latinos,!
respectively.!!There!was!a!small!noteworthy!post.test!effect!size!found!in!mental!
health!with!Whites.!!However,!this!effect!dissipated!by!the!6.month!follow.up.!!
Overall,!the!findings!underscored!the!greater!potential!of!sustainability!for!stronger!
initial!effects.!!In!addition,!these!results!highlight!the!possibility!for!varying!patterns!
of!sustainability!among!differing!racial/ethnic!groups.!!It!is!possible,!for!example,!
that!relative!to!non.Hispanic!Whites,!greater!levels!of!familial!social!support!exist!
among!Latinos!and!African!Americans!(Almeida,!Molnar,!Kawachi,!&!Subramanian,!
2009;!Taylor,!Chatters,!Tucker,!&!Lewis,!1990),!and!that!such!support!may!have!
contributed!to!their!increased!sustainability!of!intervention!effects.!!For!example,!
there!is!research!demonstrating!that!social!networks,!such!as!familial!support,!are!
an!important!factor!predicting!long.term!maintenance!of!activities!in!older!adults!
!
!
33!
(Carron,!Hausenblas,!&!Mack,!1996;!Chogahara,!Cousins,!&!Wankel,!1998;!McAuley,!
Jerome,!Elavsky,!Marquez,!&!Ramsey,!2003).!!!!
Furthermore,!the!intervention!effect!on!depressive!symptoms!was!significant!
and!maintained!a!small!positive!effect!at!the!6.month!follow.up.!!Sustainment!of!the!
change!in!depression!at!6.month!follow.up!could!have!been!affected!by!the!fact!that!
the!largest!change!in!effect!size!among!outcomes!occurred!in!depression!at!post.test!
(see!discussion!on!p.!20).!!In!passing,!it!should!be!noted!that!at!6!months!a!
marginally!significant!sustainability!effect!was!observed!for!life!satisfaction!(50%!
retained!relative!to!post.intervention).!!
Another!explanation!for!sustainment!in!depression!at!the!6.month!follow.up!
is!that!the!intervention!included!modules!that!were!primarily!psychosocial!in!
nature.!!Specifically,!the!intervention!aimed!to!teach!participants!topics!that!were!
more!amenable!to!depression!change.!!For!example,!learning!the!importance!of!
social!relationships!and!safety!in!the!community!may!have!positively!influenced!
participants’!reported!levels!of!interpersonal!relationships,!which!is!a!domain!of!
depressive!symptomology.!!
Despite!the!sustainment!of!reduced!depression!at!the!6.month!follow.up,!
post.intervention!treatment!effects!in!life!satisfaction,!mental!health,!and!physical!
health!were!not!sustained!past!the!post.test!follow.up,!and!none!of!the!study!
outcomes,!including!depression,!were!sustained!at!the!12.month!follow.up.!!
Vanishing!effects!can!result!from!factors!that!are!not!amenable!to!maintenance.!!For!
example,!self.reported!physical!health!gains!reported!at!post.intervention!may!not!
be!sustainable!in!vulnerable!populations!such!as!older!adults!with!poor!health.!!
!
!
34!
Participants’!social!resources!may!also!play!a!role!in!potential!fading!effects.!!For!
example,!many!older!adult!participants!may!not!have!adequate!supportive!social!
networks!in!place—networks!that!offer!the!emotional!and!instrumental!support!
needed!to!sustain!post.intervention!gains!over!time.!!Furthermore,!the!regularly!
assigned!meetings!held!during!the!intervention!periods!may!not!reflect!the!natural!
environment!in!which!elders!receive!social!support!and!consequently!could!have!
contributed!to!the!vanishing!treatment!effect!over!time!upon!study!completion.!!A!
study!by!Oka,!King,!and!Young!(1994)!examining!sources!of!social!support!as!
predictors!of!exercise!adherence!in!older!adults!reported!that!the!type!as!well!as!the!
amount!of!social!support!preferred!by!older!adults!(e.g.,!family!and!friends!vs.!those!
formed!in!the!intervention!group)!may!differ!depending!on!the!phase!of!the!physical!
activity!intervention!(e.g.,!initial!adoption!during!intervention!or!maintenance!post.
intervention).!!Therefore,!social!support!formed!in!the!context!of!the!intervention!
may!dissipate!after!the!conclusion!of!the!intervention,!and!the!type!of!social!support!
needed!to!maintain!these!changes!may!not!be!the!same.!
!! Although!the!results!of!this!study!add!to!the!literature!on!the!sustainability!of!
behavioral!intervention!outcomes!in!healthy!older!adults,!the!study!had!some!
limitations.!!Even!though!the!findings!indicated!that!the!WE2!intervention!improved!
all!study!outcome!scores!from!pre.test!to!post.test,!and!significantly!reduced!
depression!from!pre.test!to!the!6.month!follow.up,!insofar!as!it!is!impossible!to!
discount!all!potential!threats!to!internal!validity!on!pre.test!to!post.test!designs!
examining!non.experimental!data!(Campbell!&!Stanley,!1963;!Shadish,!Cook,!&!
Campbell,!2002)!it!would!be!a!mistake!to!infer!causality!in!accounting!for!the!
!
!
35!
significant!follow.up!effect!without!addressing!internal!threats!to!validity.!!Campbell!
and!Stanely!(1963)!outline!that!one.group!pre.test!to!post.test!designs!have!
potential!sources!of!invalidity!specifically!with!mortality,!maturation,.testing,!history,.
and!instrumentation.!!Experimental!mortality!refers!to!the!effects!of!sample!attrition!
in!affecting!study!outcomes.!!In!the!present!case,!among!the!285!elders!who!
completed!the!intervention,!228!were!tested!at!6.month!follow.up!and!227!at!12.
month!follow.up.!!Thus,!given!an!approximately!20%!attrition!rate!the!possibility!
exists!that!those!who!dropped!out!of!the!study!experienced!worse!outcomes!
following!the!intervention,!and!that!these!less!favorable!outcomes!went!
unreported—thereby!biasing!the!results!in!favor!of!sustainability.!!A!second!
plausible!hypothesis!for!a!change!in!an!outcome!that!might!be!due!to!development!
and!not!the!treatment!is!maturation..!For!example,!participants!in!the!study!may!
have!experienced!natural!changes!such!as!becoming!wiser!or!growing!older,!leading!
to!more!positive!outcomes!that!may!have!been!falsely!attributed!to!the!intervention.!!
However,!in!the!present!study,!which!involved!older!adults,!maturation!is!likely!to!
have!been!associated!with!declines!in!health,!thus!producing!bias!against!any!
sustainability!effect.!!Further,!although!the!effects!of!maturation!cannot!be!fully!
controlled!with!non.experimental!data,!selecting!participants!that!are!
approximately!of!the!same!age!group!(e.g.,!older!adults)!helps!to!minimize!the!
influence!of!maturation!(Shaddish!et!al.,!2002).!!Third,!there!was!a!threat!due!to!
repeated!testing.!!Exposure!to!an!assessment!can!affect!scores!on!subsequent!tests!
that!may!be!falsely!attributed!to!a!treatment!effect.!!As!reported,!this!testing!threat!
was!unlikely!to!play!a!major!role!because!no!such!effect!was!found!for!repeated!
!
!
36!
assessments!of!the!control!group!between!baseline!and!pre.testing.!!Fourth,!history,!
or!the!threat!of!specific!outside!events!occurring!between!measurements!have!the!
potential!to!confound!the!treatment!variable.!!Field!research,!such!as!the!methods!
outlined!for!the!present!study,!do!not!allow!for!experimental!isolation!controlling!
for!participants’!exposure!to!potentially!influencing!outside!events.!!Although!
completely!controlling!for!all!influencing!events!that!may!have!occurred!between!
the!beginning!and!completion!of!study!participation!is!not!possible,!the!plausibility!
and!extent!of!history.can!be!reduced!by!having!a!relatively!short!time.lapse!between!
assessments!(i.e.,!6!months).!!Thus,!there!seems!to!be!no!clear!reason!to!suspect!a!
biasing!role!for!history!in!the!current!study.!!Last,!instrumentation!was!not!a!threat!
in!the!current!study!because!instrumentation!was!consistent!throughout!the!various!
assessment!periods!and!was!not!modified.!!Additionally,!it!is!reasonable!to!assume!
that!measurement!units!or!scales!had!constant!meaning!over!the!age!range!of!this!
sample!(60!and!over).!!Although!the!task!of!individually!assessing!the!plausibility!of!
threats!to!internal!validity!in!a!context.specific!manner!is!labor!intensive!and!
potentially!unclear,!this!study!identified!the!specific!threats!to!internal!validity,!and!
ruled!them!out!in!a!context.specific!way.!!!!
Although!the!current!finding!of!sustainability!in!different!contexts!(e.g.,!for!
depression!as!well!as!for!larger!initial!effects)!is!encouraging,!the!results!are!
consistent!with!other!research!investigations!that!reveal!a!pattern!of!progressive!
decay!leading!to!near.zero!effects!at!12!or!more!months!post.intervention.!!Because!
health!benefits!are!valuable!roughly!in!proportion!to!their!extent!of!continuation!
(e.g.,!effects!lasting!for!five!years!are!arguably!five!times!more!valuable!than!the!
!
!
37!
same!effects!experienced!for!a!single!year!only),!it!is!useful!to!implement,!when!
feasible,!intervention!strategies!that!promote!more!sustainable!outcomes.!!Three!
such!strategies!correspond!to!(1)!use!of!longer!interventions,!perhaps!lasting!over!a!
several!year!period,!(2)!provision!of!booster!sessions,!in!which!an!intervention!is!
tapered,!but!still!continues!over!a!several!year!period,!and!(3)!inclusion!of!
caregivers!or!relatives!as!co.interveners!as!a!mean!of!promoting!a!socially!
connected!network!of!continuing!support!to!the!elder!recipients.!!Future!research!is!
required!to!test!the!viability!and!cost.effectiveness!of!these!and!other!alternatives.!
Although!this!study!focused!on!statistically!significant!improvements!in!
outcomes!such!as!depression,!a!key!additional!issue!pertains!to!clinically.significant!
change.!!Future!analyses!that!examine!and!identify!which!participants!improve!and!
sustain!improvement!at!clinically!significant!levels!can!help!inform!researchers!of!
the!mechanisms!that!help!create!and!sustain!long.lasting!healthy!lifestyle!change.!!
With!these!mechanisms!in!mind,!researchers!can!design!interventions!that!result!in!
lasting,!beneficial!outcomes.!!Chapter!2!of!this!dissertation!addresses!this!question.!!
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38!
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Phelan,!E.!A.,!Williams,!B.,!Penninx,!B.!W.,!LoGerfo,!J.!P.,!&!Leveille,!S.!G.!(2004).!
Activities!of!daily!living!function!and!disability!in!older!adults!in!a!
randomized!trial!of!the!health!enhancement!program.!Journals.of.
Gerontology,.Series.A:.Biological.Sciences.and.Medical.Sciences,.59,!838.843.!
Rejeski,!W.!J.,!Brawley,!L.!R.,!Ambrosius,!W.!T.,!Brubaker,!P.!H.,!Focht,!B.!C.,!Foy,!C.!G.,!
&!Fox,!L.!D.!(2003).!Older!adults!with!chronic!disease:!Benefits!of!group.
mediated!counseling!in!the!promotion!of!physically!active!lifestyles.!Health.
Psychology,.22,!414.423.!
Seeman,!T.!E.!(1996).!Social!ties!and!health:!The!benefits!of!social!integration.!Annals.
of.Epidemiology,!6(5),!442.451.!
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44!
Shadish,!W.!R.,!Cook,!T.!D.,!&!Campbell,!D.!T.!(2002).!Experimental.and.quasi3
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Mifflin.!
Shaffer,!J.!P.!(1995).!Multiple!hypothesis!testing.!Annual.Review.of.Psychology,!46(1),!
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Smedley,!B.!D.,!Stith,!A.!Y.,!&!Nelson,!A.!R.!(Eds.)!(2003).!Unequal.treatment:.
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National!Academies!Press.!
Spiegler,!M.!(2015).!Contemporary.behavior.therapy.(6
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!ed.).!Belmont,!CA:!Cengage!
Learning/Wadsworth.!
Steultjens,!E.!M.,!Dekker,!J.,!Bouter,!L.!M.,!Jellema,!S.,!Bakker,!B.!B.,!&!Ende,!V.!(2004).!!
Occupational!therapy!for!community!dwelling!elderly!people:!A!systematic!
review.!!Age.and.Ageing,.33,.453.460.!
Taylor,!R.!J.,!Chatters,!L.!M.,!Tucker,!M.!B.,!&!Lewis,!E.!(1990).!Developments!in!
research!on!Black!families:!A!decade!review.!Journal.of.Marriage.and.the.
Family,!52(4),!993.1014.!
Ware,!J.!E.,!Kosinski,!M.,!&!Dewey,!J.!E.!(2000).!How.to.score.version.two.of.the.SF336.
health.survey.!Lincoln,!RI:!QualityMetric!Incorporated.!
Wood,!V.!M.,!Wylie,!M.!L.,!&!Schefor,!B.!(1969).!An!analysis!of!a!short!self.report!
measure!of!life!satisfaction:!Correlation!with!rater!judgments.!Journal.of.
Gerontology,.24,.465.46.!
!
!
45!
Table!1.1.! !
!
Overview.of.design.for.the.Well.Elderly.2.Study.
! ! ! ! ! ! ! ! ! ! ! ! ! ! !
!
!
Data!
collection!
(months)!
0! 2! 4! 6! 8! 10! 12! 14! 16! 18! 20! 22! 24!
Condition! ! ! ! ! ! ! ! ! ! ! ! ! ! !
! ! ! ! ! ! ! ! ! ! ! ! ! ! !
Treatment!!! ! X
a!
!TX!
X! ! ! X! ! ! X! ! ! !
! ! ! ! ! ! ! ! ! ! ! ! ! ! !
Control! ! X! ! X!
TX!
X! ! ! X! ! ! X!
Note.!!This!is!per!participant.!!X
a!!
=!Data!Collection.!TX!=!Treatment.!!!
! ! ! ! ! ! ! ! ! ! ! ! ! ! !
!
!
!
46!
Table!1.2A.!
!
Study.outcome.mean.and.standard.deviation.for.all.time.points.(N!=!285)!
.
. Pre.test! Post.test! 6.month!
Follow.up.
12.month!
Follow.up!
Outcome! M!(SD)! M!(SD). M!(SD). M!(SD).
!!!!!CES.D! 13.32!(10.06)! 12.00!(9.39)! 12.06!(9.95)! 13.44!(10.44)!
.....LSI.Z! 17.33!(5.38)! 17.96!(5.13)! 17.44!(4.88)! 17.24!(5.66)!
.....MCS! 47.70!(12.08)! 49.42!(10.28)! 48.54!(10.70)! 47.91!(11.10)!
.....PCS! 40.95!(10.09)! 42.03!(10.31)! 40.81!(10.13)! 40.90!(10.01)!
Note.!!Pre.test!=!pre.intervention;!post.test!=!post.intervention.!
!
Table!1.2B.!
!
Demographic.and.outcome.variables.at.baseline.(N!=!285).
!
Characteristic! N.(%)! ! !
Age!mean!(SD)! 75.62!(7.09)! ! !
Race! ! ! !
White! (41%)! ! !
Black! !(33%)! ! !
Hispanic! !(26%)! ! !
Gender! ! ! !
!!!!!Female! 205!(71%)! ! !
!!!!!Male! 84!(29%)! ! !
Marital!Status! ! ! !
!!!!!Married! 141!(85%)! ! !
!!!!!Single! 25!(15%)! ! !
Education! ! ! !
!!!!!No!High!School! 48!(29%)! ! !
!!!!!High!School! 31!(19%)! ! !
!!!!!Some!College! 63!(38%)! ! !
!!!!!College!+! 24!(15%)! ! !
Language! ! ! !
!!!!!English! 237!(82%)! ! !
!!!!!Spanish! 52!(18%)! ! !
Recruitment!Site! ! ! !
!!!!!Residence.subsidized!senior! 26!(9%)! ! !
!!!!!Senior!center:!multi.purpose! 131!(45%)! ! !
!!!!!Senior!center:!parks!and!rec! 78!(27%)! ! !
!!!!!Continuous!care!retirement!!!
community!
54!(19%)! ! !
!
!
!
47!
Table!1.3.!
!
Pearson.correlation.coefficients.between.outcome.variables.at.pre3test.(N.=!285)!
Correlation!coefficients!
! CES.D! LSI.Z! MCS! PCS!
1.!CES.D! —!! ! ! ! ! ! !
2.!LSI.Z! ..59*! —! ! ! ! ! !
3.!MCS! ..75*! .55*! —! ! ! ! !
4.!PCS! ..23*! .28*! .19*! —! ! ! !
Note...CES.D!=!Center!for!Epidemiologic!Studies!Depression!Scale;!LSI.Z!=!Life!Satisfaction!
Index.Z;!MCS!=!SF.36v2!Mental!Component!Summary;!PCS!=!SF.36v2!Physical!Component!
Scale!
*!=.p.!
!
!
!
!
!
!
!
!
!
!
!
!
!
!
!
!
48!
Table!1.4.!
Results.of.one3tailed.t3tests.for.mean.change.in.outcome.relative.to.pre3test.
Outcome!Variable!!
!
!
Pre.test!!
!
M!(SD)!
Subsequent!
Test!
M!(SD)!
Mean!!
Difference!!
[90%!CI]!
p.value!
!
!
Pre.test!to!Post.test!(N.=!285)!
! ! ! ! !
CES.D!! 13.32!(10.06)! 12.00!(9.39)! .1.32![.2.14,!..50]! .002*!
LSI.Z!! 17.33!(5.38)! 17.96!(5.13)! !0.63![.20,!1.10]!! .008*!
SF.36v2!MCS!! 47.70!(12.08)! 49.42!(10.28)! !1.72![.73,!2.71]! .002*!
SF.36v2!PCS! 40.95!(10.09)! 42.03!(10.31)! !1.08![.35,!1.81]! .008*!
! ! ! ! !
Pre.test!to!6.month!Follow.up!(N.=!228)!
! ! ! ! !
CES.D!!! 13.32!(10.73)! 12.06!(9.45)! .1.26![.2.17,!..36]! .011*!
LSI.Z!!! 17.34!(5.35)! 17.44!(4.88)! !0.10![..38,!.57]! .366!
SF.36v2!MCS! 47.64!(12.08)! 48.54!(10.70)! !0.90![..20,!2.00]! .089!
SF.36v2!PCS! 40.51!(10.08)! 40.81!(10.13)! !0.30![..48,!1.08]! .263!
! ! ! ! !
Pre.test!to!12.month!Follow.up!(N.=!227)!
! ! ! ! !
CES.D! 13.62!(10.94)! 13.44!(10.44)! .0.18![.1.14,!.78]! .381!
LSI.Z! 17.17!(5.43)! 17.24!(5.66)! !0.07![..44,!.58]! .408!
SF.36!MCS! 47.37!(12.19)! 47.91!(11.10)! !0.54![..76,!1.84]! .247!
SF.36!PCS! 40.76!(10.09)! 40.90!(10.01)! !0.14![..78,!1.06]! .401!
! ! ! !! !
Note...CES.D!=!Center!for!Epidemiologic!Studies!Depression!Scale;!LSI.Z!=!Life!
Satisfaction!Index.Z;!SF.!36v2!MCS!=!Mental!Component!Summary;!SF.36v2!PCS!=!
Physical!Component!Summary.!A!Bonferroni!correction!α!value!of!.0125!was!chosen!
and!used!to!address!the!problem!of!multiple!comparison!testing.!!Additionally,!
within!each!assessment!phase,!a!False!Discovery!Rate!(FDR)!corrected!p.value!
cutoff!of!alpha.<..03!was!applied!for!the!set!of!outcomes!as!an!Omnibus!test!to!
control!the!expected!proportion!of!incorrectly!rejected!null!hypotheses!(type!I!
errors)!in!a!list!of!rejected!hypotheses.!!!
!
!
!
!
!
!
!
!
!
!
!
49!
Table!1.5.!
!
Effect.sizes.by.post3test,.63,.and.123month.follow3up.relative.to.pre3test.!
Comparison!
Pre.test!to!
Post.test!
.
d!
Pre.test!to!
6.month!
Follow.up!
d.(%!retained)!
Pre.test!to!
12.month!
Follow.up!
d.(%!retained)!
Outcome!
!!CES.D! .14! .11!(78.6%)! .03!(21.4%)!
!!LSI.Z! .12! .06!(50.0%)! .03!(25.0%)!
!!MCS! .11! .02!(18.2%)! .00!(0.0%)!
!!PCS! .11! .00!(0.0%)! .01!(0.7%)!
Note...d!=!Cohen’s!effect!size!(M2.M1/SD).!!The!effect!size!was!calculated!using!
the!pooled!SD.!!CES.D!=!Center!for!Epidemiologic!Studies!Depression!Scale;!LSI.Z!
=!Life!Satisfaction!Index.Z;!MCS!=!SF.36v2!Mental!Component!Scale;!PCS!=!SF.
36v2!Physical!Component!Scale.!CES.D!effect!sizes!were!reverse.scored!so!effect!
sizes!were!positive.!!!
!
!
!
!
50!
!
Figure 1.1. CES-D = Center for Epidemiologic Studies Depression Scale; LSI-Z = Life Satisfaction
Index-Z; MCS = SF-36v2 Mental Component Summary score; PCS = SF-36v2 Physical Component
Summary score.
!
0.00
0.02
0.04
0.06
0.08
0.10
0.12
0.14
0.16
Post-test Effect
Size
6-month Effect
Size
12-month Effect
Size
Effect Size
Effect Sizes Relative to Pre-test
CES.D!
LSI.Z!
MCS!
PCS!
!
!
51!
!
!
! !
!
!
!
!
!
!
!
!
!
!
!
!
!
!
!
!
!
!
!
!
!
!
Appendix!1A.1.!
!
Therapist.Concordance.as.a.moderator.predicting.CES.D!change!from!pre.test!to!
post.test!by.linear.regression!!
! ! B!(SE)!
Intercept! ! 4.63!(0.72)!
Pre.test!CES.D! ! 0.55!(0.04)!
Therapist!
Concordance!
! !!!!!!!!!!!!!!!!!!!!!!!!!!.2.63!(1.24)!!!!!!!!p.=!0.83.
Note.!!Dependent!variable!is!CES.D!post.test.!!!
Appendix!1A.2.!
!
Therapist.Concordance.as.a.moderator.predicting.LSI.Z!change!from!pre.test!to!
post.test!by.linear.regression!!
! ! B!(SE)!
Intercept! ! !!!!!!!!!!!!!!!!!!!!!!!!7.45!(0.75)!
Pre.test!CES.D! ! !!!!!!!!!!!!!!!!!!!!!!!!0.63!(0.04)!
Therapist!
Concordance!
! !!!!!!!!!!!!!!!!!!!!!!.1.18!(0.65)!!!!!!!!!!!!!!p.=!0.07!
Note.!!Dependent!variable!is!LSIZ.Z!post.test.!!!
!
!
52!
!
!
!
!
!
!
!
!
!
!
!
!
Appendix!1A.3.!
!
Therapist.Concordance.as.a.moderator.predicting.SF.36v2!MCS!change!from!pre.
test!to!post.test!by.linear.regression!!
! ! B!(SE)!
Intercept! ! !!!!!!!!!!!!!!!!!!!!!!!!!!22.54!(2.12)!
Pre.test!CES.D! ! !0.57!(0.04)!
Therapist!
Concordance!
! !!!!!!!!!!!!!!!!!!!!!!!!!.0.55!(1.39)!!!!!!!!!!p!=!0.67!
Note.!!Dependent!variable!is!!SF.36v2!MCS!post.test.!!!
Appendix!1A.4.!
!
Therapist.Concordance.as.a.moderator.predicting.SF.36v2!PCS!change!from!pre.
test!to!post.test!by.linear.regression!!
! ! B!(SE)!
Intercept! ! 11.64!(1.72)!
Pre.test!CES.D! ! !!!!!!!!!!!!!!!!!!!!!!!!!!!!!0.61!(0.04)!
Therapist!
Concordance!
! !!!!!!!!!!!!!!!!!!!!!!!!!!.1.72!(1.56)!!!!!!!!!!p.=!0.14!
Note.!!Dependent!variable!is!SF.36v2!PCS!post.test.!!!
!
!
53!
Appendix!1B.!
!
Unadjusted*effect*sizes*by*post3test,*63,*and*123month*follow3up*relative*to*pre3test*!
Comparison!
Pre5test!to!
Post5test!
d!
Pre5test!to!
65month!Follow5up!
d!
Pre5test!to!
125month!Follow5up!
d*
Subgroup!(Outcome)!
!!African!Americans!(Vitality)! .29! .21! .11!
!!Latinos!(General!Health)! .33! .25! .24!
!!Whites!(Mental!Health)! .29! .03! 5.11!
Note.*d!=!Cohen’s!effect!size!(M25M1/SD).!!The!effect!size!was!calculated!using!the!pooled!SD.!!Vitality!=!SF536v2!Vitality!Scale;!
General!Health!Scale!=!SF536v2!General!Health!Scale;!Mental!Health!=!SF536v2!Mental!Health!Scale.!
! 54!
CHAPTER 2
IDENTIFYING CLINICALLY MEANINGFUL CHANGE IN DEPRESSION,
LIFE SATISFACTION, AND MENTAL AND PHYSICAL HEALTH AMONG
OLDER ADULTS WHO HAVE PARTICIPATED IN A LIFESTYLE
INTERVENTION
Background+
Observing!and!tracking!clinically!meaningful!impact!on!health!outcomes!such!
as!depression,!life!satisfaction,!mental!health,!and!physical!health!among!older!
adults!is!critically!important!to!intervention!studies.!!Such!feedback,!which!goes!
beyond!examination!of!group?based!mean!intervention!effects,!can!address!
clinically!relevant!information!that!would!otherwise!be!overlooked,!provide!
valuable!data!that!bear!on!treatment!efficacy,!and!ultimately!guide!treatment!
planning!and!research!hypotheses!for!future!studies.!!In!this!regard,!researchers!
have!cautioned!that!the!importance!of!statistically!significant!change!has!limited!
value!in!determining!whether!treatment!effects!are!impactful!in!the!lives!of!older!
adults.!!Failing!to!examine!the!clinical!significance!of!health!outcomes!goes!against!
the!purpose!of!these!interventions,!which!is!to!induce!meaningful!lifestyle!changes!
in!this!potentially!vulnerable!population.!!In!contrast,!placing!importance!on!
identifying!clinically!significant!change!emphasizes!the!applied!value!of!the!change!
in!real?life!settings!in!individual!lives!and!reveals!whether!statistically!significant!
changes!are!actually!clinically!meaningful!as!well!(Kazdin,!1999).!!!
!
! ! !
!
55!
The!concept!of!identifying!clinically!meaningful!change!has!been!studied!for!
more!than!three!decades!(e.g.,!Campbell,!2005;!Jacobson,!Follette!&!Revenstorf,!
1984;!Jacobson!&!Truax,!1991;!Peterson,!2008).!!More!recently,!however,!studies!
have!examined!clinically!significant!change!due!to!intervention.!!For!example,!Shultz!
and!colleagues!(2002)!reviewed!a!broad!range!of!intervention!studies!that!reported!
dementia!caregiver!outcomes.!!They!found!that,!while!a!majority!of!studies!reported!
statistically!significant!outcomes,!only!a!small!proportion!of!these!studies!actually!
reported!on!clinically!meaningful!change!(Shultz!et!al.,!2002).!!Given!the!important!
role!clinically!meaningful!change!plays!in!determining!the!effectiveness!of!a!given!
intervention,!there!is!a!necessity!to!examine!it!beyond!mean!differences!across!
groups.!
A!growing!number!of!intervention!studies!from!fields!such!as!caregiving!
(Gaugler,!Mittelman,!Hepburn,!&!Newcomer,!2010;!for!a!review!of!literature!see!
Shabbir!&!Sanders,!2014)!and!clinical!medicine!(Barret,!Brown,!Mundt,!&!Brown,!
2005;!Katona!et!al.,!2005)!incorporate!clinically!significant!change!criteria!into!their!
analyses,!but!to!the!best!of!this!author’s!knowledge!there!have!been!no!studies!that!
have!examined!clinically!meaningful!change!in!lifestyle!interventions!designed!
specifically!for!older!adults.!!Of!the!intervention!studies!designed!to!address!the!
needs!of!this!population,!the!majority!strive!to!enhance!mental!and!physical!health,!
daily!functioning,!and!life!satisfaction!because!aging!is!often!associated!with!
downward!trends!in!these!areas.!!In!turn,!such!declines!may!reduce!overall!activity!
and!engagement!with!the!environment,!thereby!increasing!the!potential!for!poorer!
quality!of!life!(Blazer,!2003;!Fiske,!Wetherell,!&!Gatz,!2008)!and!depression.!!!
! ! !
!
56!
However,!examining!clinically!meaningful!change!in!these!commonly!studied!
outcomes!can!help!researchers!determine!if!lifestyle!intervention!treatment!effects!
are!impactful!in!elders’!lives.!!
Depression!is!important!to!understanding!older!adults’!lifestyle!and!activity!
patterns!because,!within!this!population,!this!condition!is!generally!associated!with!
a!number!of!negative!consequences!and!risk!factors!such!as!anxiety!(Hettema,!Kuhn,!
Prescott,!&!Kendler,!2006),!sleep!disorders!(Cole!&!Dendukuri,!2003),!and!physical!
disability!(Blazer,!2003;!Demura!&!Sato,!2003).!!When!the!severity!of!depression!is!
reduced,!however,!it!can!have!positive!implications!for!older!adults’!overall!health!
(Walker,!Ludman,!&!Russo,!1998)!and!social!role!functioning!(Schmid!et!al.,!2012).!!
In!a!review!on!depression!in!older!adults,!Fiske!and!colleagues!(2008)!concluded!
that!among!the!biological,!psychological,!and!social!risks!associated!with!depression,!
diminished!daily!activity!is!the!greatest!consequence.!!For!this!reason,!activity?based!
interventions!often!pinpoint!depression!as!an!important!focus!of!change.!!For!
instance,!Clark!and!colleagues!(2012)!utilized!a!depression!symptoms!measure,!
among!others,!and!examined!change!in!depression!as!an!outcome!measure!to!
provide!evidence!of!the!effectiveness!of!an!activity?based!intervention!in!improving!
the!psychosocial!well?being!in!older!adults.!!They!found!that!depressive!symptoms!
were!in!fact!significantly!reduced.!!
Like!depression,!life!satisfaction!has!been!used!as!a!health?related!quality!of!
life!outcome!measure!in!a!number!of!studies!(Adams,!Liebbrandt,!&!Moon,!2011;!
Nimrod,!2008;!War,!Butcher,!&!Robertson,!2004).!!Life!satisfaction!is!the!subjective!
cognitive!assessment!of!how!a!person!feels!about!his!or!her!life!as!a!whole!(Diener,!
! ! !
!
57!
1994).!!In!a!review!article,!high!life!satisfaction!was!cited!as!one!of!the!most!
important!components!of!successful!aging!(Phelan!&!Larson,!2002).!!This!finding!
was!further!validated!in!a!study!that!found!a!correlation!between!high!life!
satisfaction!and!self?defined!successful!aging!among!a!sample!of!community?
dwelling!adults!aged!60!or!more!years!(Montross!et!al.,!2006).!!Further,!perceived!
life!satisfaction!has!been!linked!to!a!number!of!physical!and!mental!health!outcomes!
(Strine,!Chapman,!Balluz,!Moriarty,!&!Mokdad,!2008).!!For!instance,!in!a!sample!of!
older!adults,!life!satisfaction!was!found!to!predict!longevity!and!psychiatric!
morbidity;!those!with!greater!life!dissatisfaction!showed!evidence!of!higher!rates!of!
disease,!injury,!and!mortality!(Koivumaa?Honkanen!et!al.,!2000).!
In!addition!to!depression!and!life!satisfaction,!the!more!general!constructs!of!
mental!and!physical!health!are!also!crucial!to!successful!aging.!!Having!sound!mental!
and!physical!health!is!a!springboard!to!the!ability!to!participate!fully!in!life!and!
experience!satisfying!relationships.!!Currently,!information!is!unavailable!on!the!
ability!of!lifestyle!interventions!for!elders!to!stimulate!clinically!meaningful!change!
on!these!two!broader!constructs.!!!
The!present!study!examines!clinically!meaningful!change!from!pre?test!to!
post?test!in!depression,!life!satisfaction,!mental!health,!and!physical!health!in!a!
sample!of!ethnically!diverse,!community?dwelling!older!adults!aged!60!years!or!
older!who!took!part!in!a!6?month!lifestyle!activity?based!intervention.!!Specifically,!
the!aims!of!this!study!included!examining!clinically!significant!positive!change!that!
occurred!post?intervention!by:!a)!identifying!participants!who!responded!to!the!
intervention!by!manifesting!clinically!significant!positive!change;!b)!assessing!
! ! !
!
58!
whether!clinically!significant!change!was!more!likely!to!be!positive!than!negative!in!
direction;!and!c)!examining!the!socio?demographic!characteristics!of!those!who!
evidenced!such!change.!
!
Method+
Sample+
+ The!present!research!is!based!on!data!from!the!University!of!Southern!
California!Well!Elderly!2!(WE2)!study!(Clark!at!al.,!2012).!!WE2!was!a!NIH?funded!
randomized!controlled!trial!of!the!effectiveness!of!an!activity?based!intervention!
aimed!at!mitigating!age?related!decline!among!ethnically!diverse,!community?
dwelling,!older!adults!aged!60!years!or!more.!!Of!the!440!total!participants,!285!
completed!data!for!both!pre?!and!post?test!and!are!included!in!the!analyses!reported!
below.!!
+
Study!Intervention+
The!WE2!study!intervention!consisted!of!weekly!2?hour,!small!group!(8?10!
people)!treatment!sessions!delivered!by!a!trained!occupational!therapist!over!a!6?
month!period.!!Groups!typically!had!members!that!were!recruited!from!the!same!
recruitment!site.!!During!these!sessions,!participants!were!taught!modules!that!
covered!the!following!topics:!1)!Everyday/Activity/on/Health,!about!the!incorporation!
of!physical!and!mental!exercise!into!everyday!life;!2)!Time/Use/and/Energy/
Conservation,!about!how!to!plan!a!healthful!daily!routine;/3)!Transportation,/about!
different!public!transportation!options;!4)!Safety,!about!the!concerns!that!older!
! ! !
!
59!
adults!have!regarding!safety!in!the!community!and!how!it!affects!their!lifestyle!
choices;/5)!Social/Relationships,!about!how!satisfying!relationships!and!changes!in!
social!network!(e.g.,!death,!family!members!move,!disability)!can!be!enacted!in!old!
age;/6)!Cultural/Awareness,!about!the!exploration!of!diversity!within!the!therapy!
group!and!within!the!participants’!environment;/7)!Goal/Setting,!about/developing!
attainable!goals!for!increased!health!throughout!the!day;!and/8)/Integrative/
Summary,/or!a!syntheses!of!what!participants!learned!from!the!intervention!
modules!and!discussions.!!Taken!together,!these!topics!provided!information!that!
was!used!by!the!participants!and!occupational!therapist!to!customize!individual!
plans!to!help!participants!adapt!to!the!challenges!associated!with!aging,!life!
management,!and!healthy!living.!!Group!sessions!were!delivered!at!each!respective!
recruitment!site.!!Regular!monthly!meetings!were!scheduled!in!the!community!to!
facilitate!direct!experience!with!intervention!topics!such!as!the!use!of!public!
transportation.!!In!addition,!each!participant!also!had!the!opportunity!to!engage!in!
up!to!10!hours!of!individual!treatment,!typically!in!the!participant’s!home!or!at!the!
treatment!site,!with!the!occupational!therapist.+
+
Measures+
Depressive+symptoms!were!measured!using!the!Center/for/Epidemiologic/
Studies/Depression/Scale!(CES?D).!!This!scale!is!comprised!of!a!20?item,!self?report!
questionnaire!designed!to!measure!current!levels!of!depressive!symptomology!
through!the!following!domains:!depressed!affect,!positive!affect,!somatic/reduced!
activity,!and!interpersonal!relationships.!!For!each!item,!participants!indicate!
! ! !
!
60!
symptom!frequency!based!on!a!four?point!scale!ranging!from!“Rarely/None!of!the!
Time!(less!than!1!day!per!week)”!to!“Most/All!of!the!Time!(5?7!days!per!week).”!!
Total!scores!range!from!0?60,!with!a!higher!score!indicating!a!more!frequent!
occurrence!of!depression!symptoms.!!!
The!CES?D!validly!measures!self?reported!depressive!symptomology!in!the!
general!population!(McDowell!&!Newell,!1996;!Wada!et!al.,!2007)!and!in!older!
adults!(Callahan!&!Wolinsky,!1994;!Cole,!Kawachi,!Maller,!&!Berkman,!2000;!
Davidson,!Feldman,!&!Crawford,!1994;!Hertzog,!Van!Alstine,!Usala,!Hultsch,!&!Dixon,!
1990;!Murrell,!Himmelfarb,!&!Wright,!1983).!!In!a!large!community!sample!of!adults!
55!years!or!older,!Murrell!and!colleagues!(1983)!found!an!internal!consistency!
reliability!alpha!of!.89.!!Similarly,!Radloff!(1977)!found!an!internal!consistency!
reliability!alpha!range!from!.85!to!.91,!and!a!test?retest!reliability!range!from!.45!to!
.70.!!More!recently,!researchers!have!reported!an!internal!consistency!alpha!over!
.90!in!chronic!spinal!cord!injury!patients!(Miller,!Anton,!&!Townson,!2008).!!
Previous!research!has!also!demonstrated!good!validity!with!other!instruments!such!
as!the!SF?36!Mental!Health!(r!=!.76;!Miller!et!al.,!2008).!+
Life+satisfaction.++The!Life/Satisfaction/Index/Z!(LSI?Z)!demonstrates!
consistent!psychometric!properties.!!The!scale’s!internal!reliability!ranges!from!.70!
to!.82!(Dobson,!Powers,!Keith,!&!Goudy,!1979;!Okun!&!Stock,!1984),!and!test?retest!
reliability!spans!from!.80!to!.90!(McDowell!&!Newell,!1996).!!Studies!have!shown!
that!the!LSI?Z!discriminates!between!community?dwelling!older!adults!and!those!in!
psychiatric!inpatient!units!(Himmelfarb!&!Murrell,!1983)!as!well!as!between!
persons!with!and!without!self?ascribed!handicaps!(Stock!&!Okun,!1982).!!
! ! !
!
61!
Additionally,!the!LSI?Z’s!moderate!to!high!correlations!with!similar!scales!
substantiates!its!convergent!validity!with!older!adults.!!The!LSI?Z!has!been!found!to!
have!moderate!positive!correlations!with!other!instruments!related!to!happiness,!
morale,!and!life?satisfaction!assessments!(Okun!&!Stock,!1987),!as!well!as!significant!
positive!associations!with!subjective!health!and!activity!frequency!(e.g.,!Hillerås,!
Jorm,!Herlitz,!&!Winblad,!2001).!!!
Health>related+quality+of+life.++Norm?based!scores!from!the!RAND!Short?
Form!Health!Survey!Version!2!(SF?36v2)!were!employed!to!measure!participants’!
perceptions!of!their!mental!well?being!and!physical!health!during!the!past!four!
weeks!(Ware,!Kosinski,!&!Dewey,!&!Gandek,!2000).!!The!SF?36v2!consists!of!36!
items,!includes!eight!scales!(general!and!mental!health,!physical!and!social!
functioning,!physical!and!emotional!role!functioning,!bodily!pain,!and!vitality),!and!
has!been!validated!with!more!objective!measures!(Brazier!et!al.,!1992)!for!use!with!
ethnic!minority!(Madsen,!2000)!and!older!adults!(Hayes,!Morris,!Wolfe,!&!Morgan,!
1995).!!!!
! The!SF?36v2!can!also!generate!two!summary!indices:!the!mental!component!
summary!(MCS)!and!the!physical!component!summary!(PCS).!!The!MCS!is!a!
summary!of!four!subscales!(vitality,!social!functioning,!role!emotional,!and!mental!
health),!while!the!PCS!is!also!generated!by!four!subscales!(physical!functioning,!role!
physical,!bodily!pain,!and!general!health).!!Scores!for!scales!were!transformed!to!
norm?based!scores!(range!=!0?100)!using!the!Medical!Outcomes!Study!scoring!
system.!!!
!
! ! !
!
62!
In!addition!to!depression,!life!satisfaction,!mental!health,!and!physical!health,!
socio?demographic!measures!such!as!age,!race/ethnicity,!gender,!and!education!
were!included!as!predictors!of!clinically!significant!change!among!study!
participants.!
!
Analytical+Approach+
Clinically+Meaningful+Change+in+CES>D,+LSI>Z,+SF>36v2+MCS,+and+SF>36v2+
PCS+
Cutoffs!found!in!the!literature!were!used!to!define!clinically!meaningful!
change!in!depression,!life!satisfaction,!mental!health,!and!physical!health.!!Previous!
research!on!clinically!meaningful!change!in!depression!indicates!that!reliable!
change!in!CES?D!has!been!operationalized!by!value!alterations!that!exceed!5!points!
(Wassertheil?Smoller!et!al.,!1996).!!In!the!current!sample,!a!5?point!change!in!
depression!was!also!half!of!the!pooled!pre?and!post?test!standard!deviation!(SD/=/
10.0)—a!criterion!that,!more!generally,!has!been!suggested!for!defining!clinically!
meaningful!change!across!measures!(Norman,!Sloan,!&!Wyrwich,!2003).!!In!a!
systematic!review!of!38!studies!that!computed!the!minimally!important!difference!
(MID)!for!health?related!quality!of!life!instruments,!all!but!six!studies!utilized!MID!
estimates!that!were!close!to!one!half!of!a!SD!(Norman!et!al.,!2003).!!In!the!present!
study,!precautions!were!taken!to!account!for!the!influence!of!outliers!in!the!sample,!
which!have!the!potential!to!influence!the!SD.!!Therefore,!in!addition!to!using!the!SD/
to!compute!a!change!value,!the!Median!Absolute!Deviation!(M|D|)!was!computed!
(Appendix!2A.1.).!!As!the!mean!and!SD!are!sensitive!to!outliers,!computing!the!M|D|!
! ! !
!
63!
is!an!effective!alternative!and!more!robust!measure!of!dispersion!(Leys,!Ley,!Klein,!
Bernard,!&!Licata,!2013).!!The!M|D|!for!the!CES?D!change,!10.32,!was!similar!to!the!
already!computed!SD!of!10.00.!!Therefore,!half!of!the!M|D|!(5.16)!was!used!in!the!
current!study!as!a!statistically!computed!change!value!to!detect!clinically!significant!
change!in!CES?D!from!pre?test!to!post?test.!!Using!this!standard,!participants!were!
categorized!into!three!groups:!those!who!(1)!improved,!(2)!experienced!no!clinically!
meaningful!change,!or!(3)!worsened.!!!
Although!past!research!reports!a!3?!to!5?point!change!as!clinically!significant!
on!the!Short!Form?20!(SF?20;!Stewart,!Hays,!&!Ware,!1988),!this!value!has!not!yet!
been!substantiated!with!the!SF?36v2.!!Wyrwich!and!colleagues!(2003),!however,!
reported!the!recommendations!of!an!expert!panel!of!North!American!physicians!
familiar!with!the!SF?36v2;!this!panel!identified!detectable!clinically!important!
change!as!ranging!from!5!to!12.5,!and!concluded!that!these!changes!were!
symmetrical!(i.e.,!that!the!positive!and!negative!change!would!be!the!same!
magnitude).!!Later,!Wyrwich,!Tierney,!Babu,!Kroenke,!and!Wolinksy!(2005)!
investigated!clinically!significant!change!using!SF?36v2!subscales!such!as!the!
composite!MCS!and!PCS,!and!demonstrated!that!a!change!of!5!to!12.5!points!in!
either!a!positive!or!negative!direction!is!strongly!associated!with!altered!risk!of!
heart!health?related!problems!(Wyrwich!et!al.,!2005).!!For!the!present!study,!half!of!
the!pooled!pre?test!and!post?test!SD!for!the!MCS!and!PCS!was!5.09!and!5.43,!
respectively.!!After!applying!M|D|!statistical!computation!for!the!MCS!and!PCS,!
change!scores!of!4.74!and!4.41,!respectively,!were!derived!and!used!as!the!
definitional!criteria!for!clinically!significant!change!(Appendix!2A.2.).!!!
! ! !
!
64!
Presently,!no!literature!on!clinically!significant!change!for!the!LSI?Z!has!been!
found.!!For!this!reason,!clinically!significant!change!was!determined!by!applying!the!
.5!SD!criterion!as!identified!above!(e.g.,!Norman!et!al.,!2003),!and!further!comparing!
it!to!the!M|D|,!which!led!to!a!change!value!of!2.53!(Appendix!2A.2.).!!!
In!addition!to!computing!a!clinically!significant!change!score!for!each!
measure,!comparing!it!to!a!half!standard!deviation,!and!computing!the!M|D|,!extra!
precaution!was!undertaken!to!account!for!the!potential!for!regression!artifacts.!!
Regression!artifacts,!or!regression!to!the!mean!(RTM),!refers!to!the!phenomenon!in!
which!if!an!outcome’s!first!measurement!score!is!extremely!high!or!low,!subsequent!
scores!tend!to!be!less!extreme,!gravitating!toward!the!sample!average.!!Conversely,!
if!an!outcome!score!is!extreme!on!its!second!measurement,!it!will!tend!to!have!been!
closer!to!the!mean!on!its!first!measurement!(Campbell!&!Stanley,!1963;!Campbell!&!
Kenny,!1999;!Shadish,!Cook,!&!Campbell,!2002).!!Campbell!and!Stanely!(1963)!
describe!how,!because!of!RTM,!selection!of!groups!based!on!their!extreme!scores!
can!mislead!researchers.!!In!the!present!study,!groups!were!selected!based!on!
change!scores!and!were!not!based!directly!on!extreme!pre?!or!post?intervention!
scores,!thereby!diminishing!the!potential!for!RTM!effects.!!!
Furthermore,!in!the!present!study!precautions!were!taken!to!employ!
methods!outlined!in!previous!research!to!identify!the!extent!of!RTM!by!using!time?
reversed!analyses!(Appendix!2B.1?4.).!!In!time?reversed!analyses,!one!can!see!that!
the!same!pattern!of!RTM!exists!in!both!directions.!!In!this!sample,!extreme!scores!at!
pre?test!are,!on!average,!closer!to!the!mean!at!post?test,!and!vice!versa!(extreme!
scores!at!post?test!are!closer!to!the!mean!at!pre?test).!!This!pattern!was!evident!in!
! ! !
!
65!
each!of!the!four!outcome!variables!(See!Appendix!2B.1?4.).!!!However,!the!pre?test!to!
post?test!correlations!(r)!for!each!respective!outcome!ranged!from!r/=!.62!to!.74.!!
The!CES?D!had!the!lowest!pre?test!to!post?test!association!(r/=!.62),!and!the!PCS!had!
the!highest!(r/=.74).!!This!indicated!that!RTM!was!responsible!for!approximately!
26%!to!38%!of!the!change!from!pre?test!to!post?test.!!Campbell!and!Kenny!(1999)!
outlined!a!formula!using!the!correlation!and!the!common!mean!to!determine!the!
degree!of!regression!toward!the!mean.!!Applying!this!formula!in!the!present!study,!
the!pre?test!post?test!mean!(or!common!mean!of!the!sample)!for!depression!is!
12.66,!and!the!correlation!between!pre?test!and!post?test!scores!is!.62.!!The!
expected!percent!of!regression!toward!the!mean!(PRM)!is!PRM!=!100(1?r)!=!100(1?
.62)!=!38%.!!If!a!participant!scored!15!at!pre?test!(i.e.,!2.34!points!above!the!mean),!
with!.62!pre?test!post?test!correlation,!we!can!expect!regression!down!towards!the!
mean!in!the!amount!of!38%!(2.34!points)!=!0.89!points.!!Likewise,!using!the!same!
steps,!if!a!participant!had!a!pre?test!score!of!10!(i.e.,!2.66!points!below!the!mean),!
his!or!her!post?test!score!would!be!estimated!to!go!up!towards!the!mean!by!1.01!
points.!!These!are!relatively!small!regression!artifacts,!but!large!enough!to!produce!
spuriously!significant!results!without!correction.!!Therefore,!the!present!study!
computed!an!adjustment!to!control!for!baseline!levels!of!each!measure.!!
To!control!for!RTM,!an!adjustment!was!calculated!by!computing!the!residuals!
for!each!outcome.!!Residuals!were!generated!by!linear!regression,!thus!allowing!
control!for!baseline!levels!of!each!outcome.!!For!example,!when!applying!the!change!
criteria!established!above!that!occurs!in!CES?D!from!pre?test!to!post?test,!
participants!that!have!a!difference!of!5.16!from!pre?test!to!post?test!would!have!
! ! !
!
66!
clinically!meaningful!change!regardless!of!where!their!baseline!levels!occurred!(i.e.,!
from!a!score!of!30!to!25!or!from!12!to!7).!!When!applying!an!adjustment!and!
controlling!for!baseline!scores!with!residuals,!however,!the!criteria!for!clinically!
meaningful!change!adjusts!by!becoming!more!stringent!at!both!high!and!low!
extremes.!!
After!identifying!minimally!important!differences!that!signify!clinically!
significant!change,!chi?square!tests!were!conducted!for!each!outcome!to!statistically!
compare!the!proportions!of!participants!who!had!meaningful!improvement!to!those!
who!had!meaningful!deterioration.!!!
! Further!analyses!were!conducted!to!examine!the!measurement!invariance!of!
the!CES?D!among!White,!Black,!and!Hispanic!elders!in!the!study.!!This!was!done!to!
test!the!assumption!that!the!CES?D!measures!the!same!construct!across!race!and!
ethnicity!in!this!sample,!and!that!analyses!that!combine!groups!are!valid.!!The!
“other”!category!was!not!analyzed!due!to!small!sample!size!(n/=!27).!!These!
analyses,!which!are!reported!in!Appendices!2C.1?3,!revealed!that!both!the!CES?D!
factor!structure!and!CES?D!measure!mean!levels!have!similar!factor!structures!and!
that!there!is!no!justification!for!further!racial/ethnic!group!adjustment.!!Other!
outcome!measures!were!not!tested!for!measurement!invariance!as!they!are!one?
factor!measurements!with!a!total!score!designed!to!be!used!on!all!populations.!!All!
analyses!were!conducted!using!SAS!9.2!(SAS!Institute,!Inc.,!Cary,!NC,!2008).!
!
!
!
! ! !
!
67!
Results!
Descriptive+and+Bivariate+Analyses+
+ Of!the!285!older!adults!in!the!current!sample,!38%!were!White,!31%!were!
Black,!23%!were!Hispanic,!and!10%!identified!as!other!or!unspecified!(see!Table!
2.1.).!!The!average!age!of!participants!was!75.0±!SD!years.!!Over!70%!of!the!sample!
consisted!of!females.!!Of!the!participants,!28%!did!not!finish!high!school,!21%!had!a!
high!school!degree,!35%!had!some!college!education,!and!15%!had!a!college!degree!
or!higher.!
! At!the!post?test!assessment,!89!(31%)!participants!had!clinically!meaningful!
improvement!in!depression,!148!(52%)!had!no!change,!and!48!(17%)!had!worsened!
(see!Table!2.2.).!!As!described!in!Figure!2.1.,!the!largest!cluster!of!participants!had!
depression!scores!below!20!for!both!pre?!and!post?tests.!!However,!the!largest!
cluster!of!participants!in!the!improvement!group!started!with!a!score!above!the!
clinical!cutoff!of!16!at!pre?test.!!This!score!subsequently!decreased!on!average!to!
near!10.!!By!comparison,!most!of!the!participants!in!the!no!change!group!clustered!
well!below!the!clinical!cutoff!point.!!Those!whose!symptoms!worsened!seemed!to!
mostly!cluster!above!the!clinical!cutoff!point,!with!the!remaining!having!
substantially!worsened!by!more!than!double!their!pre?test!score.!
! Regarding!life!satisfaction,!85!(30%)!participants!evidenced!meaningful!
positive!change,!160!(56%)!had!no!change,!and!40!(14%)!worsened!(see!Table!2.2.).!!
As!described!in!Figure!2.2.,!the!largest!cluster!of!participants!had!life!satisfaction!
scores!above!15!for!pre?test,!and!either!remained!or!improved!by!post?test.!!!
! ! !
!
68!
! On!the!SF?36v2!MCS,!83!(29%)!of!the!participants!experienced!clinically!
meaningful!positive!change,!160!(56%)!had!no!clinical!change,!and!42!(15%)!
worsened!(see!Figure!2.3.).!!!
! Table!2.2.!summarizes!the!results!for!chi?square!tests,!which!revealed!there!
was!a!higher!proportion!of!participants!in!the!improvement!groups!compared!to!the!
worsen!groups!in!depression!(p/health!(p/On!the!SF?36v2!PCS,!54!(19%)!had!clinically!meaningful!positive!change,!183!
(64%)!did!not!evidence!clinically!meaningful!change,!and!48!(17%)!worsened!(see!
Figure!2.4.).!!The!proportion!of!participants!in!the!improvement!group!versus!the!
worsen!group!was!not!statistically!significant!for!physical!health!(p/=!.55).!
As!shown!in!Table!2.3.,!the!CES?D!improvement!group!and!no!change!group!
were!found!to!be!statistically!different!from!each!other!on!age!(p/=!.04)—namely,!
the!improvement!group!was!significantly!younger!by!roughly!two!years!on!average!
(73.54!years).!!There!was!a!marginally!significant!difference!between!the!
improvement!group!and!the!worsen!group!(p/=!.09)!with!the!improvement!group!
being,!on!average,!younger!(73.54)!compared!to!the!worsen!group!(75.86).!!!
With!regard!to!education,!those!in!the!improve!group!had!significantly!higher!
proportions!of!more!educated!older!adults!relative!to!both!the!no!change!(p/=!.03)!
and!the!worsen!group!(p!=!.004).!!There!were!statistically!significant!differences!in!
race/ethnicity!(p/=!.003),!such!that!being!Hispanic!was!associated!with!worsening.!!
Likewise!use!of!the!Spanish!language!was!also!associated!with!the!worsen!group!(p!
! ! !
!
69!
with!CES?D!change!groups.!
! As!shown!in!Table!2.4.,!only!two!marginally!significant!results!were!found!
when!comparing!change!groups!on!life!satisfaction.!!Lower!education!was,!on!
average,!associated!with!the!worsen!group!(p/=!.08),!as!was!use!of!the!Spanish!
language!(p/=!.06).!!
Table!2.5.!summarizes!the!corresponding!results!for!mental!health.!!There!
were!two!statistically!significant!findings.!!Compared!to!the!no!change!group,!a!
higher!proportion!of!participants!reported!having!a!college!degree!or!more!in!the!
improvement!group!(p!=!.01).!!The!only!other!statistically!significant!finding!had!to!
do!with!language:!Spanish!language!was!associated!with!the!worsen!group!when!
compared!to!the!improvement!group!(p!=!.01).!
! When!comparing!predictors!of!clinical!change!in!physical!health,!the!only!
statistically!significant!finding!was!in!language!between!the!improvement!and!no!
change!groups,!with!Spanish!speakers,!relative!to!English!speakers,!more!likely!to!
improve!than!show!no!change!(p!=!.002).!!The!no!change!group!had!a!higher!
proportion!of!English!speakers!(see!Table!2.6.).!
!
Discussion+
! Findings!from!the!present!study!indicate!that!valuable!information!is!
acquired!when!one!examines!clinically!meaningful!change!criteria!to!track!
symptoms!of!depression!and!other!health?related!quality!of!life!outcomes!in!older!
adults!during!a!life!management!behavior!intervention.!!When!clinically!meaningful!
! ! !
!
70!
change!was!examined,!it!was!found!that!approximately!31%,!30%,!and!29%!of!
evaluable!study!participants!experienced!clinically!significant!improvements!in!
depression,!life!satisfaction,!and!mental!health,!respectively.!!Moreover,!in!each!case!
these!percentages!exceeded!the!percentages!of!individuals!who!worsened,!with!p?
values!all!below!.001!(and!also!below!the!corresponding!mean?based!p?values!
obtained!for!effectiveness).!!Because!of!the!psychosocial!nature!of!the!intervention,!
the!lack!of!similar!positive!findings!for!the!proportion!of!individuals!with!clinically!
meaningful!improvement!in!physical!health!was!not!surprising.!!
The!aforementioned!study!findings!also!demonstrate!that!in!interventions!
where!only!small!mean!changes!in!depression!and!other!health!quality!of!life!
variables!are!observed,!it!is!possible!that!a!significant!portion!of!participants!
actually!experience!beneficial!change!in!these!outcomes!in!clinically!meaningful!
ways.!!This!finding!implies!that!great!variability!occurs!in!response!to!lifestyle!
interventions!which,!in!turn,!suggests!that,!if!researchers!direct!their!attention!to!
subgroups!that!experience!clinically!important!change!and!the!factors!associated!
with!such!change,!then!they!might!find!that!some!participants!benefit!to!such!an!
extent!that!their!clinical!diagnoses!have!actually!been!altered.!!For!example,!within!
the!present!study,!98!(34.4%)!older!adults!were!beyond!the!cutoff!level!for!clinical!
depression!pre?test.!!Although!close!to!two?thirds!of!the!sample!(198)!did!not!have!
depression,!among!those!in!the!improvement!group!with!clinical!depression!at!pre?
test,!26!(88.7%)!evidenced!positive!clinical!diagnosis!change!(i.e.,!clinically!
depressed!to!non?clinically!depressed)!thereby!providing!solid!evidence!for!the!
interventions!ability!to!alter!diagnostic!status.!!!
! ! !
!
71!
! A!benefit!of!examining!clinically!significant!change!in!outcomes!is!that!it!can!
be!easily!applied!to!behavioral!interventions!that!track!change!by!using!only!self?
report!scales.!!More!recently,!there!have!been!more!robust!methods!of!analyzing!
change!that!have!been!proposed!such!as!structural!equation!modeling!(SEM;!
McArdle!&!Prescott,!2010;!McArdle!&!Prindle,!2008).!!Although!these!methods!have!
the!potential!to!examine!latent!change!scores!as!the!basis!of!the!sequential!
influences!of!one!indicator!on!another!over!time,!examining!clinically!significant!
change!requires!little!statistical!expertise.!
! Statistically!significant!predictors!of!clinically!meaningful!change!in!one!or!
more!analyses!involving!depression!or!life!satisfaction!included!age!(younger!vs.!
older),!education!(college),!and!language!(English?speaking).!!A!general!pattern!
surrounding!these!results!is!that!improvers!tended!to!be!those!who!were!more!
advantaged.!!It!is!possible!that!such!individuals!were!better!able!to!understand!
therapeutic!recommendations,!or!perhaps!had!more!resources!to!build!upon!in!
attempting!to!enact!personally!relevant!plans!for!instilling!healthy!habits!into!their!
lives.!!If!general,!this!observation!of!more!frequent!clinically!relevant!improvement!
among!more!advantaged!individuals!suggests!the!need!to!uncover!new!strategies!
for!reaching!those!who!are!more!at!risk!or!who!have!fewer!resources!at!hand.!
! Furthermore,!it!is!important!to!note!that!the!rate!of!clinically!significant!
change!in!the!current!study!is!lower!than!the!rates!of!decreased!depression!
reported!in!past!activity!intervention!studies!aimed!at!older!adults!(see!review!by!
Blake,!Mo,!Malik,!&!Thomas,!2009).!!This!discrepancy!can!be!accounted!for!by!the!
fact!that!certain!variables!distinguish!the!current!study!from!past!investigations.!!
! ! !
!
72!
First,!the!present!study!was!not!designed!to!specifically!treat!depression.!!Although!
the!intervention!was!psychosocial!in!nature,!it!was!designed!to!increase!health?
promoting!activity!and!quality!of!life!in!community?dwelling!older!adults.!!Although!
improved!activity!may!contribute!to!minimizing!depression,!it!may!be!unreasonable!
to!expect!to!find!large!decreases!in!depression!in!this!sample!of!older,!healthier!
adults.!!Second,!the!average!depression!scores!among!all!participants!were!lower!
than!commonly!used!depression!cutoffs.!!Additionally,!mental!and!physical!health!
composite!score!means!in!this!sample!were!close!to!the!U.S.!age?matched!normative!
means.!!This!reveals!that!the!sample!was!relatively!healthy!to!begin!with,!thereby!
leaving!less!room!for!improvement.!
! Given!these!findings,!it!is!imperative!that!future!studies!continue!to!explore!
the!application!of!clinically!meaningful!change!criteria!to!differences!in!depression!
and!other!health?related!quality!of!life!indicators!to!identify!subgroups!that!may!be!
particularly!responsive!to!intervention!treatments.!!This,!in!turn,!will!enable!
researchers!to!better!understand!factors!that!may!modify!treatment!effects!on!
depression!and!examine!potential!predictors!of!outcome!trajectories!over!time.!
! ! !
!
73!
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!
! ! !
!
81!
Table!2.1.!
!
Demographic/and/outcome/variables/of/complete/sample/at/pre\test!(N!=!285)/
Characteristic! N/(%)!
Age!mean!(SD)! 74.98!(7.82)!
Race! !
White! 108!(38%)!
Black! 84!(30%)!
Hispanic! 66!(23%)!
Other! 27!(10%)!
Gender! !
!!!!!Female! 200!(70%)!
!!!!!Male! 85!(30%)!
Marital!Status! !
!!!!!Married! 231!(81%)!
!!!!!Single! 54!(19%)!
Education! !
!!!!!No!High!School! 79!(28%)!
!!!!!High!School! 61!(21%)!
!!!!!Some!College! 101!(35%)!
!!!!!College!+! 44!(15%)!
Language! !
!!!!!English! 238!(84%)!
!!!!!Spanish! 47!(17%)!
!
! ! !
!
82!
Table!2.2.!
!
Change'groups'for'CES-D,!LSI-Z,!SF-36v2!MCS,!and'SF-36v2!PCS!(N'=!285)!
! CES-D! Chi-square!
test
†
!
LSI-Z! Chi-square!
test
†
!
SF-36v2!MCS! Chi-square!
test
†
!
SF-36v2!PCS! Chi-square!
test
†
!
! N!(%)! ' N!(%)! ' N!(%)! ' N!(%)! '
!!!!No!Change! 148!(52%)! ! 160!(56%)! ! 160!(56%)! ! 183!(64%)! !
!!!!Improvement! 89!(31%)*! x
2
= 12.27!
p < .001!
85!(30%)*! x
2
= 16.20!
p < .001!
83!(29%)*! x
2
= 13.49!
p < .001!
54!(19%)! x
2
= 0.35!
p = .55! !!!!Worsen! 48!(17%)! 40!(14%)! 42!(15%)! 48!(17%)!
†
Chi-square!test!is!for!the!difference!between!ratio!of!Improve/Worsen!at!post-test!status.!
Note:!!*!=!p'! ! !
!
83!
Table!2.3.!
Demographic'and'outcome'variables'at'pre9test'stratified'by'CES9D'Improvement,'Worsen,'and'No'Change'groups'(N'='285)'
! Improve!
(n'=!89)!
No!Change!
(n'='148)!
p! ! Improve!
(n'=!89)!
Worsen!
(n'=!48)!
p!
Characteristic! ! N'(%)! N'(%)! ! ! N'(%)! N'(%)! !
Age!mean!(SD)! ! 73.54!
(7.26)!
75.50!
(8.18)!
.04*! ! 73.54!
(7.26)!
75.86!
(7.50)!
.09!
Race! ! ! ! .75! ! ! ! .003**!
White! ! 35!(44%)! 58!(39%)! ! ! 35!(44%)! 11!(23%)! !
Black! ! 25!(28%)! 48!(32%)! ! ! 25!(28%)! 11!(23%)! !
Hispanic! ! 15!(17%)! 29!(20%)! ! ! 15!(17%)! 22!(46%)! !
Other! ! !!!!10(11%)! 13!(9%)! ! ! !!!!10(11%)! 4!(8%)! !
Gender! ! ! ! .11! ! ! ! .12!
!!!!!Female! ! 56!(63%)! 108!(73%)! ! ! 56!(63%)! 36!(75%)! !
!!!!!Male! ! 33!(37%)! 40!(27%)! ! ! 33!(37%)! 12!(25%)! !
Marital!Status! ! ! ! .31! ! ! ! .21!
!!!!!Married! ! 68!(76%)! 122!(82%)! ! ! 68!(76%)! 41!(85%)! !
!!!!!Single! ! 21!(24%)! 26!(18%)! ! ! 21!(24%)! 7(15%)! !
Education! ! ! ! .03*! ! ! ! .004**!
!!!!!No!High!School! ! 16!(18%)! 41!(28%)! ! ! 16!(18%)! 22!(46%)! !
!!!!!High!School! ! 15!(17%)! 37!(25%)! ! ! 15!(17%)! 9!(19%)! !
!!!!!Some!College! ! 37!(42%)! 51!(35%)! ! ! 37!(42%)! 13!(27%)! !
!!!!!College!+! ! 21!(24%)! 19!(13%)! ! ! 21!(24%)! 4!(8%)! !
Language! ! ! ! .74! ! ! ! .000***!
!!!!!English! ! 80!(90%)! 131!(89%)! ! ! 80!(90%)! 27!(56%)! !
!!!!!Spanish! ! 9!(10%)! 17!(11%)! ! ! 9!(10%)! 21!(43%)! !
Note.!!One-tailed!Independent!Sample!t-test!was!conducted!for!continuous!variables.!!Chi-square!test!was!used!for!categorical!variables.!!
*!='p'! ! !
!
84!
Table!2.4.!
Demographic'and'outcome'variables'at'pre9test'stratified'by!LSI-Z'Improvement,'Worsen,'and'No'Change!groups'(N!=!285)!
! Improve!
(n'=!85)!
No!Change!
(n'=!160)!
p! ! Improve!
(n'=!85)!
Worsen!
(n'=!40)!
p!
Characteristic! ! N'(%)! N'(%)! ! ! N'(%)! N'(%)! !
Age!mean!(SD)! ! 74.49!
(7.87)!
75.84!
(7.65)!
.20! ! 74.49!
(7.87)!
75.84!
(7.65)!
.21!
Race! ! ! ! .77! ! ! ! .49!
White! ! 31!(37%)! 66!(41%)! ! ! 31!(37%)! 11!(28%)! !
Black! ! 25!(29%)! 48!(30%)! ! ! 25!(29%)! 11!(28%)! !
Hispanic! ! 19!(22%)! 33!(21%)! ! ! 19!(22%)! 14!(35%)! !
Other! ! !10!(12%)! 13!(8%)! ! ! !10!(12%)! 4!(10%)! !
Gender! ! ! ! .56! ! ! ! .11!
!!!!!Female! ! 63!(74%)! 113!(71%)! ! ! 63!(74%)! 24!(60%)! !
!!!!!Male! ! 22!(26%)! 47!(29%)! ! ! 22!(26%)! 16!(40%)! !
Marital!Status! ! ! ! .45! ! ! ! .27!
!!!!!Married! ! 65!(77%)! 132!(83%)! ! ! 65!(77%)! 34!(85%)! !
!!!!!Single! ! !20!(23%)! !28!(17%)! ! ! !20!(23%)! !6!(15%)! !
Education! ! ! ! .45! ! ! !
.08
†
!
!!!!!No!High!School! ! 21!(25%)! 40!(25%)! ! ! 21!(25%)! 18!(45%)! !
!!!!!High!School! ! 15!(18%)! 37!(23%)! ! ! 15!(18%)! 9!(23%)! !
!!!!!Some!College! ! 32!(38%)! 60!(38%)! ! ! 32!(38%)! 9!(23%)! !
!!!!!College!+! ! 17!(20%)! 23!(14%)! ! ! 17!(20%)! 4!(10%)! !
Language! ! ! ! .74! ! ! !
.06
†
!
!!!!!English! ! 72!(85%)! 138!(86%)! ! ! 72!(85%)! 28!(70%)! !
!!!!!Spanish! ! 13!(15%)! !22!(14%)! ! ! 13!(15%)! 12!(30%)! !
Note.!!Independent!Sample!t-test!was!conducted!for!continuous!variables.!!Chi-square!test!was!used!for!categorical!variables.!!
†
=!! ! !
!
85!
Table!2.5.!
Demographic'and'outcome'variables'at'pre9test'stratified'by!SF-36v2!MCS'Improvement,!Worsen,!and!No!Change!groups'(N!=!285)!
! Improve!
(n'=!83)!
No!Change!
(n'='160)!
p! ! Improve!
(n'=!83)!
Worsen!
(n'=!42)!
p!
Characteristic! ! N'(%)! N'(%)! ! ! N'(%)! N'(%)! !
Age!mean!(SD)! ! 75.07!
(7.79)!
72.58!
(7.94)!
.95! ! 75.07!
(7.79)!
75.14!
(8.10)!
.55!
Race! ! ! ! .89! ! ! ! .15!
White! ! 35!(42%)! 63!(39%)! ! ! 35!(42%)! 10!(24%)! !
Black! ! 24!(29%)! 48!(30%)! ! ! 24!(29%)! 12!(29%)! !
Hispanic! ! 18!(22%)! 33!(21%)! ! ! 18!(22%)! 15!(36%)! !
Other! ! !6!(7%)! 16!(10%)! ! ! !6!(7%)! 5!(12%)! !
Gender! ! ! ! .49! ! ! ! .25!
!!!!!Female! ! 55!(66%)! 113!(71%)! ! ! 55!(66%)! 32!(76%)! !
!!!!!Male! ! 28!(34%)! 47!(29%)! ! ! 28!(34%)! 10!(24%)! !
Marital!Status! ! ! ! .92! ! ! ! .98!
!!!!!Married! ! 67!(81%)! 130!(81%)! ! ! 67!(81%)! 34!(81%)! !
!!!!!Single! ! !16!(19%)! !30!(19%)! ! ! !16!(19%)! 8!(19%)! !
Education! ! ! ! .01*! ! ! ! .53!
!!!!!No!High!School! ! 23!(28%)! !42!(26%)! ! ! 23!(28%)! 14!(33%)! !
!!!!!High!School! ! 13!(16%)! 38!(24%)! ! ! 13!(16%)! 10!(24%)! !
!!!!!Some!College! ! 27!(33%)! 64!(40%)! ! ! 27!(33%)! 10!(24%)! !
!!!!!College!+! ! 20!(24%)! 16!(10%)! ! ! 20!(24%)! !8!(19%)! !
Language! ! ! ! .92! ! ! ! .01*!
!!!!!English! ! 72!(87%)! 138!(86%)! ! ! 72!(87%)! 28!(67%)! !
!!!!!Spanish! ! 11!(13%)! !22!(14%)! ! ! 11!(13%)! 14!(33%)! !
Note.!!Independent!Sample!t-test!was!conducted!for!continuous!variables.!!Chi-square!test!was!used!for!categorical!variables.!!
*!='p'! ! !
!
86!
Table!2.6.!
Demographic'and'outcome'variables'at'pre9test'stratified'by!SF-36v2!PCS'Improvement,!Worsen,!and!No!Change!groups'(N!=!285)!
! Improve!
(n'=!54)!
No!Change!
(n'=!183)!
p! ! Improve!
(n'=!54)!
Worsen!
(n'=!48)!
p!
Characteristic! ! N'(%)! N'(%)! ! ! N'(%)! N'(%)! !
Age!mean!(SD)! ! 74.56!
(8.30)!
75.33!
(7.56)!
.52! ! 74.56!
(8.30)!
74.12!
(8.29)!
.79!
Race! ! ! ! .32! ! ! ! .96!
White! ! 18!(33%)! 72!(39%)! ! ! 18!(33%)! 18!(38%)! !
Black! ! 15!(28%)! 56!(30%)! ! ! 15!(28%)! 13!(27%)! !
Hispanic! ! 17!(32%)! 36!(20%)! ! ! 17!(32%)! 13!(27%)! !
Other! ! !4!(7%)! 19!(11%)! ! ! !4!(7%)! 4!(8%)! !
Gender! ! ! ! .12! ! ! ! .87!
!!!!!Female! ! 34!(63%)! 135!(74%)! ! ! 34!(63%)! 31!(65%)! !
!!!!!Male! ! 20!(37%)! 48!(26%)! ! ! 20!(37%)! 17!(35%)! !
Marital!Status! ! ! ! .62! ! ! ! .32!
!!!!!Married! ! 42!(78%)! 148!(81%)! ! ! 42!(78%)! 41!(85%)! !
!!!!!Single! ! !12!(22%)! !35!(19%)! ! ! !12!(22%)! 7!(15%)! !
Education! ! ! ! .13! ! ! ! .67!
!!!!!No!High!School! ! 21!(39%)! 44!(24%)! ! ! 21!(39%)! 14!(29%)! !
!!!!!High!School! ! 10!(19%)! 40!(22%)! ! ! 10!(19%)! 11!(23%)! !
!!!!!Some!College! ! 16!(30%)! 71!(39%)! ! ! 16!(30%)! 14!(29%)! !
!!!!!College!+! ! 7!(13%)! 28!(15%)! ! ! 7!(13%)! !9!(19%)! !
Language! ! ! ! .002*! ! ! ! .20!
!!!!!English! ! 38!(70%)! 143!(85%)! ! ! 38!(70%)! 39!(81%)! !
!!!!!Spanish! ! 16!(30%)! !26!(15%)! ! ! 16!(30%)! 9!(19%)! !
Note.!!Independent!Sample!t-test!was!conducted!for!continuous!variables.!!Chi-square!test!was!used!for!categorical!variables.!!
*!='p'! ! !
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87!
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88!
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89!
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90!
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91!
Appendix!2A.1.!
The!median!absolute!deviation,!or!M|D|,!has!been!used!as!a!well!established!
and!effective!measure!of!variation!that!is!more!tolerant!of!extreme!values.!!This!is!
the!mean!average!of!the!absolute!differences!between!each!of!the!scores!and!the!
overall!mean!(Gorard,!2014).!!The!median!absolute!deviation!can!be!calculated!by!
subtracting!each!value!in!a!data!set!from!the!median.!!Doing!this!gives!the!deviation!
of!each!score!from!the!overall!median.!!Then,!divide!the!sum!of!all!the!deviations!by!
number!of!observation!to!calculate!the!median!absolute!deviation.!!The!formula:!
M|D|!=!median
i
!(|X
i
!–!median
j
!(X
j
)|!
!
!
!
Appendix!2A.2.!
Table)of)pre.test)and)post.test)pooled)SD)and)mean)absolute)deviation)for)outcome)variables)
!
! Pooled!SD!
!
SD/2! M|D|! M|D|/2! !
Outcome! ! ! ! ! !
!!!!!CESRD! 10.00! !!!!!!!5.00! 10.32! !!!!!!!!5.16! !
!!!!!LSIRZ! 5.36! !!!!!!!2.68! 5.06! 2.53! !
SFR36v2!MCS! 10.18! !!!!!!!5.09! !!!!!!!!9.48! !!!!!!!!4.74! !
SFR36v2!PCS! 10.86! !!!!!!!5.43! !!!!!!!!8.83! !!!!!!!!4.41! !
!
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Appendix!2B.1.!
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Appendix!2B.2.!
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Appendix!2B.3.!
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Appendix!2B.4.!
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! 96!
Appendix!2C.1.!
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Four&factor!standardized!solution!for!the!CES1D!items.!
! White! ! Black! ! Latino! !
Factor!1:!Depressed!Affect! ! ! ! ! ! !
!!!3!!!Blues! .71! ! .67! ! .73! !
!!!6!!!Depressed! .81! ! .80! ! .80! !
!!!9!!!Failure! .63! ! .77! ! .65! !
!!!10!!!Fearful! .73! ! .79! ! .74! !
!!!14!!!Lonely! .77! ! .70! ! .72! !
!!!17!!!Crying! .62! ! .54! ! .64! !
!!!18!!!Sad! .82! ! .77! ! .68! !
Factor!2:!Positive!Affect! ! ! ! ! ! !
!!!!R_4!!!Just!as!good! .34! ! .43! ! .14! ns! !
!!!!R_8!!!Hopeful! .53! ! .38! ! 1.07!ns! !
!!!!R_12!!!I!was!happy! .86! ! .84! ! .63! !
!!!!R_16!!!I!enjoyed!life! .84! ! .71! ! .61! !
Factor!3:!Somatic/Reduced!Activity! ! ! ! ! ! !
!!!1!!!Bothered! .63! ! .46! ! .73! !
!!!2!!!Appetite!! .55! ! .49! ! .58! !
!!!5!!!Mind! .61! ! .69! ! .57! !
!!!7!!!Everything!is!an!effort! .75! ! .69! ! .62! !
!!!11!!! Sleep! .50! ! .64! ! .46! !
!!!13!!!Talked!less! .54! ! .34! ! .43! !
!!!20!!!I!could!not!get!going! .68! ! .65! ! .68! !
Factor!4:!Interpersonal!relationships! ! ! ! ! ! !
!!!15!!!People!were!unfriendly! .52! ! .69! ! .56! !
!!!19!!!People!disliked!me! 1.03! ! .87! ! .73! !
Note:!ns!=!not!significant!(>!.05).!!Otherwise,!all!other!factor!loadings!are!statistically!significant!(R_16!are!reversed!scored!items.!!
!
!
97!
Appendix!2C.2.!
!
!
Summary!of!test!for!Crosscultural!Invariance!of!the!CES1D!models!
!
! ! !
! CFI! TLI! RMSEA! SRMR! ΔCFI! ! ! !
Model! ! ! ! ! ! ! ! !
Model!1:!Configural+Model!(number!of!factors!invariant)! .914! .900! .060! .060! 1! ! ! !
! ! ! ! ! ! ! ! !
Model!2:!Measurement+Model!(Model!1!with!pattern!of!factor!
loadings!invariant)!
.906! .898! .060! .081! .008! ! ! !
! ! ! ! ! ! ! ! !
Model!3:!Factor+Correlations!(Model!1!with!pattern!of!factor!
loading!invariant!and!factor!variance!and!covariance!invariant)!
.900! .893! .062! .099! .014! ! ! !
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! 98!
Appendix!2C.3.!
!
Latent&factor&correlations&for&the&CES1D&factor&constrained&model&(Model!3)&
!
! 1! 2! 3! 4!
! White! Black! Latino! White! Black! Latino! White! Black! Latino! White! Black! Latino!
1.!Depressed!Affect! —" —" —" 1.61! 1.61! 1.71! .91! .95! .98! .73! .65! .80!
! ! ! ! ! ! ! ! ! ! ! ! !
2.!Positive!Affect! ! ! ! —" —" —" 1.52! 1.52! 1.59! 1.42! 1.34! 1.49!
! ! ! ! ! ! ! ! ! ! ! ! !
3.!Somatic/Reduced!
Activity!
! ! ! ! ! ! —" —" —" .67! .58! .74!
! ! ! ! ! ! ! " " " " " "
4.!Interpersonal!
Relationships!
! ! ! ! ! ! " " " —" —" —"
Note:!All!factor!correlations!!
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99!
CHAPTER 3
PREDICTORS OF SUSTAINED CLINICALLY MEANINGFUL CHANGE IN
DEPRESSION OVER TIME AMONG OLDER ADULTS WHO HAVE
PARTICIPATED IN A BEHAVIORAL INTERVENTION
Background+
Depression!is!one!of!the!most!prevalent!mental!health!conditions!among!
older!adults!and!often!serves!as!a!barrier!to!living!a!more!active!and!fulfilling!life!
(Fiske,!Wetherell,!&!Gatz,!2008).!!For!instance,!nearly!20%!of!older!adults!aged!over!
65!years!in!the!United!States!have!experienced!depression!in!late!life!(Geriatric!
Mental!Health!Foundation,!2008).!!Clinically!significant!depressive!symptoms!have!
been!found!in!as!much!as!15%!of!communityO living!older!adults!(Blazer,!2003).!!
Previous!studies!have!demonstrated!an!association!between!depressive!symptoms!
in!late!life!and!negative!health!outcomes!such!as!increased!cognitive!impairment!
(Schweitzer,!Tuckwell,!O’Brien,!&!Ames,!2002),!physical!disability!(Blazer,!2003;!
Demura!&!Sato,!2003),!diabetes!(De!Jonge,!Roy,!Saz,!Marcos,!&!Lobo,!2006),!and!risk!
of!cardiovascular!mortality!(Win!et!al.,!2011).!!!
At!the!same!time,!research!has!also!found!that!an!active!lifestyle!reduces!
depression!(van!Gool!et!al.,!2007;!National!Academy!on!an!Aging!Society,!2006)!and!
enhances!other!important!mental!health!aging!outcomes!such!as!vitality!(Solberg,!
Hopkins,!Ommundsen,!&!Halvari,!2012),!life!satisfaction!(Menec,!2003;!Nimrod,!
2007;!Ware,!Butcher,!&!Robertson,!2004),!and!cognitive!functioning!(Wang,!Karp,!
Winblad,!&!Fratiglioni,!2002;!Weuve!et!al.,!2004;!Yaffe,!Barnes,!Nevitt,!Lui,!&!
!
!
!
!
100!
Covinsky,!2001).!!Accordingly,!depression!among!older!adults!can!be!attenuated!by!
participation!in!daily!activities!that!promote!a!healthy!lifestyle.!!For!instance,!the!
results!of!a!prospective!study!that!followed!1,947!communityOdwelling!older!adults!
aged!50O94!years!for!more!than!5!years!indicated!that!greater!physical!activity—a!
key!component!of!an!active!lifestyle—was!protective!against!depression,!even!when!
controlling!for!powerful!confounds!such!as!disability!(Strawbridge,!Deleger,!
Roberts,!&!Caplan,!2002).!!Another!study!that!examined!the!effects!of!a!24Oweek!
resistance!training!intervention!in!older!adults!reported!a!connection!between!
training!and!improvements!in!total!mood!scores!(McLafferty,!Wetzstein,!&!Hunter,!
2004).!!Social!and!leisure!activities!have!also!been!shown!to!mitigate!depression!
(see!Hendrie!et!al.,!2006!for!a!review).!!In!one!study!of!5,294!older!adults,!
researchers!found!that!getting!together,!talking!with!others,!eating!out,!or!
volunteering!was!associated!with!lower!depression!at!baseline!and!decreased!
depression!over!time!(Hong,!Hasche,!&!Bowland,!2009).!!Janke,!Davey,!and!Kleiber!
(2006)!examined!data!gathered!prospectively!on!1,991!older!adults!from!the!
Americans’+Changing+Lives!study!(House,!2003)!and!discovered!that!engagement!in!
physical!leisure!(e.g.,!yard!work,!gardening),!formal!leisure!(e.g.,!attending!clubs,!
religious!services),!and!informal!leisure!(e.g.,!getting!together!or!talking!on!the!
phone!with!friends,!relatives)!predicted!reduced!depression!over!an!eightOyear!
period.!!In!addition,!in!a!crossOsectional!study,!Werngren-Elgström,!Brandt,!and!
Iwarsson!(2006)!found!that!domestic!activities!and!housework!can!also!potentially!
reduce!or!protect!against!depression!in!older!adults.!!!
!
!
!
!
101!
Conversely,!studies!have!also!confirmed!that!a!lack!of!activity!can!negatively!
affect!health!outcomes.!!For!instance,!physical!inactivity!has!been!linked!to!
increased!depression!(Chen,!Stevinson,!Ku,!Chang,!&!Chu,!2012).!!Likewise,!research!
has!shown!that!role!changes!due!to!a!life!event!in!old!age!(e.g.,!death!of!a!loved!one,!
moving)!that!subsequently!limit!or!prevent!an!active!lifestyle!are!related!to!
depression!(Janke,!Nimrod,!&!Kleiber,!2008a,!2008b).!!More!specifically,!a!study!
using!data!from!the!Americans+Changing+Lives+Study+revealed!a!connection!between!
depressive!symptoms!and!reductions!in!social!activities!among!older!adults!who!
had!been!widowed!(Janke!et!al.,!2008a,!2008b).!
+ Fortunately,!various!lifestyle!behaviors!that!have!been!linked!to!depression!
in!older!adults!are!modifiable!through!activityObased!interventions.!!For!example,!
Wallace!and!colleagues!(1998)!discovered!that!older!adults!who!were!given!a!6O
month!healthOpromoting!and!activityObased!intervention!focusing!on!exercise,!
nutrition!counseling,!and!home!safety!experienced!reduced!depression!compared!to!
a!control!group.!!Similarly,!the!Well!Elderly!2!study!(WE2;!Clark!et!al.,!2012)—a!
randomizedOcontrolled!trial!(RCT)—of!a!lifestyle!intervention!with!440!communityO
dwelling!older!adults!found!reductions!in!depression!and!physical!pain!as!well!as!
increases!in!life!satisfaction,!mental!health,!and!social!functioning!among!treated!
participants!compared!to!controls.!!WE2!incorporated!many!of!the!concepts!
described!earlier!(see!Chapter!1)!into!a!preventative!occupational!therapy!program!
designed!to!reduce!depression!and!associated!negative!mental!and!physical!health!
outcomes.!!Although!previous!studies!had!linked!specific!activities!to!health!
!
!
!
!
102!
outcomes,!the!WE2!intervention!was!unique!in!that!it!was!designed!to!modify!the!
lifestyle!of!older!adults!and!link!everyday!activity!to!health!and!wellObeing.!!
Yet,!not!everyone!exposed!to!interventions!aimed!at!enhancing!a!healthy!
lifestyle!will!benefit!or!change!at!the!same!rate,!if!at!all.!!Many!of!the!reported!
findings!from!lifestyle!interventions!indicate!meanOlevel!gains!for!the!entire!group;!
however,!little!attention!is!given!to!determine!whether!these!gains!are!clinically!
meaningful.!!In!fact,!a!gap!exists!in!the!activityObased!literature!on!the!extent!to!
which!clinically!meaningful!change!is!induced!and!whether!it!is!maintained!over!
time.!!!
! Furthermore,!little!research!has!been!conducted!to!examine!predictors!of!
sustained!clinically!meaningful!change!among!older!adults!who!have!received!a!
lifestyle!intervention.!!To!address!these!gaps,!the!current!study!will!examine!the!
relationship!between!age,!race/ethnicity,!gender,!language,!and!education!on!
clinically!meaningful!depression!change!over!time!within!a!diverse,!longitudinal!
sample!of!communityOdwelling!older!adults!who!participated!in!a!lifestyle!activityO
based!intervention.!!Clinically!meaningful!change!in!depression!was!chosen!as!the!
target!outcome!because!lowered!depression!was!found!to!be!statistically!sustained!
sixOmonths!postOintervention!(previously!reported!in!Chapter!1)!when!group!means!
were!examined.!!!
The!theoretical!rationale!for!the!sustainability!of!depression!improvement!
resulting!from!the!WE2!intervention!is!based!on!a!couple!of!factors.!!First,!the!
conceptual!rationale!for!the!intervention!is!based!on!previous!findings!suggesting!
that!adults’!activity!and!lifestyle!patterns!are!modifiable!on!a!relatively!longstanding!
!
!
!
!
103!
basis!and!predict!aging!outcomes!(Clark!et!al.,!1997;!Clark!et!al.,!2012).!!Second,!the!
chief!therapeutic!aim!of!the!intervention!is!to!achieve!a!careful!understanding!of!
each!elder’s!personalized!pattern!of!attributes,!values,!goals,!and!inO context!life!
circumstances!and!then!work!to!design!an!individually!relevant!plan!for!
implementing!sustainable!healthful!behaviors!(Clark!et!al.,!2001).!!Accordingly,!
activity!that!is!personally!meaningful!and!contextually!anchored!within!older!adults’!
everyday!lives!has!the!greatest!capability!to!improve!healthO related!outcomes!and!
lead!to!sustainable!change.!!Therefore,!it!is!hypothesized!that!a!high!proportion!of!
participants!who!had!clinically!meaningful!change!will!sustain!these!gains!and!be!
significantly!better!off!at!the!6O month!and!12O month!followO up!assessments!
following!intervention!receipt.!
!
Method+
Participants+
+ Data!for!the!present!research!were!obtained!from!the!data!bank!of!the!Well!
Elderly!2!(WE2)!study!(Clark!et!al.,!2012).!!WE2!contained!a!crossover!design!
feature!in!which!all!participants!received!the!intervention!during!either!the!first!or!
the!second!6O month!phase!of!their!study!participation.!!The!total!sample!consisted!
of!440!participants.!!Of!the!440!participants,!the!present!study!only!included!those!
with!both!preO !and!postO intervention!data!(N+=!285).!!The!WE2!study!was!
longitudinal!and!involved!two!followO up!periods:!one!at!6O months!postO intervention!
and!another!at!12O months!postO intervention,!thereby!allowing!for!examination!of!
sustainability!of!effects!over!a!oneO year!period.!!Of!the!285!participants!who!had!
!
!
!
!
104!
data!both!at!the!preOtest!and!postOtest,!246!had!preOtest!and!6Omonth!followOup!
data,!and!242!had!preOtest!and!12Omonth!followOup!data.+
+
Measures+
Symptoms+of+depression.++Depressive!symptomatology!was!measured!using!
the!Center+for+Epidemiologic+Studies+Depression+Scale!(CESOD).!!This!scale!is!
comprised!of!a!20Oitem,!selfOreport!questionnaire!designed!to!measure!current!
levels!of!depressive!symptomology!through!the!following!domains:!depressed!affect,!
positive!affect,!somatic/reduced!activity,!and!interpersonal!relationships.!!For!each!
item,!participants!indicate!symptom!frequency!based!on!a!fourOpoint!scale!ranging!
from!“Rarely/None!of!the!Time!(less!than!1!day!per!week)”!to!“Most/All!of!the!Time!
(5O7!days!per!week).”!!Total!scores!range!from!0O60,!with!higher!scores!indicating!a!
more!frequent!occurrence!of!depressive!symptoms.!!!
The!CESOD!validly!measures!selfOreported!depressive!symptomology!in!the!
general!population!(McDowell!&!Newell,!1996;!Wada!et!al.,!2007)!and!in!older!
adults!(Callahan!&!Wolinsky,!1994;!Cole,!Kawachi,!Maller,!&!Berkman,!2000;!
Davidson,!Feldman,!&!Crawford,!1994;!Hertzog,!Van!Alstine,!Usala,!Hultsch,!&!Dixon,!
1990;!Murrell,!Himmelfarb,!&!Wright,!1983).!!In!a!large!community!sample!of!adults!
55!years!or!older,!Murrell!and!colleagues!(1983)!found!an!internal!consistency!
reliability!alpha!of!.89.!!Similarly,!Radloff!(1977)!determined!an!internal!consistency!
reliability!range!in!alpha!from!.85!to!.91!and!a!testOretest!reliability!range!from!.45!
to!.70.!!More!recently,!researchers!have!reported!an!internal!consistency!alpha!over!
.90!in!chronic!spinal!cord!injury!patients!(Miller,!Anton,!&!Townson,!2008).!!
!
!
!
!
105!
Previous!research!has!also!demonstrated!anticipated!correlations!with!other!
instruments!such!as!the!SFO36v2!Mental!Health!(r!=!.76;!Miller!et!al.,!2008).!
To!examine!if!socioOdemographic!variables!predict!the!maintenance!of!!
clinically!significant!change,!age,!gender,!education,!race,!marital!status,!and!
language!were!examined.!!The!inclusion!of!these!covariates!also!served!to!take!
advantage!of!the!large!heterogeneous!WE2!Study!sample.!!!
!
Analytical+Approach+
Tracking+clinically+meaningful+change+in+depression+over+time.++
Previously!identified!values!were!used!to!define!clinically!meaningful!change!in!
depression!over!time.!!Reliable!change!in!CESOD!was!operationalized!by!value!
alterations!that!exceeded!5.16!points!in!M|D|!(see!Chapter!2).!!Using!this!standard,!
participants!were!categorized!into!three!groups:!those!who!(1)!improved,!(2)!
experienced!no!meaningful!change,!and!(3)!worsened.!!For!this!sample,!a!5.16Opoint!
change!in!depression!is!also!approximately!oneOhalf!of!the!pooled!preOand!postOtest!
standard!deviation!(SD+=!10.07).!!Use!of!a!half!standard!deviation!change!has!been!
commonly!suggested!as!a!definition!of!clinically!meaningful!change!(e.g.,!Norman,!
Sloan,!&!Wyrwich,!2003).!!In!a!systematic!review!of!38!studies!that!computed!the!
minimally!important!difference!(MID)!for!healthOrelated!quality!of!life!instruments,!
all!but!six!studies!included!MID!estimates!that!were!close!to!oneOhalf!of!one!SD!
(Norman!et!al.,!2003).!!This!is!described!in!more!detail!in!Chapter!2,!Analytical!
Approach,!Clinically!Meaningful!Change!in!CESOD.+
!
!
!
!
106!
ChiOsquare!tests!were!used!to!compare!clinical!change!group!proportions!
(improved,!remained!unchanged,!worsened)!by!preO!to!postOintervention!status!at!
the!6O!and!12Omonth!followOups.!!Additional!analyses!were!conducted!to!identify!
participants!in!the!improvement!group!who!evidenced!positive!clinical!depression!
diagnosis!(i.e.,!CESOD!≥!16)!change!by!the!6O!or!12O!month!time!point.!!More!
specifically,!this!was!done!to!examine!participants!in!the!improvement!group!who!
evidenced!additional!beneficial!change!by!changing!their!category!membership!
from!clinically!depressed!to!nonOclinically!depressed!and!maintaining!this!gain!
throughout!the!followOup!periods.!!!
To!test!for!the!effects!of!demographic!variables!on!predicting!whether!
participants!in!the!improvement!group!maintained!gains!over!time,!logistic!
regression!was!employed.!!Furthermore,!to!help!offset!the!potential!for!type!I!error,!
this!study!employed!an!alpha!level!of!.01.!!All!statistical!analyses!was!conducted!
using!SPSS!version!22!(IBM!Corp.,!2013).!!!
!
Results!
Descriptive+and+Bivariate+Correlations+
Participants!consisted!of!those!that!at!postOintervention!had!meaningful!
improvement!(n!=!76),!experienced!no!meaningful!change!(n!=!128),!or!worsened!(n!
=!42).!!Demographic!breakdowns!stratified!by!clinical!improvement!groups!are!
displayed!in!Table!3.1.!!
!
!
!
!
!
107!
+ As!depicted!in!Figure!3.1.,!the!mean!score!at!preOtest!was!13.76!for!the!
improvement!group,!12.09!for!the!noOchange!group,!and!16.40!for!the!worsen!
group.!!Despite!the!decrease!in!the!improvement!group’s!score,!when!compared!to!
the!no!change!group,!the!improvement!group!mean!scores!increased!over!the!6O
month!followOup!(7.96)!and!12Omonth!followOup!(10.57).!!A!different!trend!with!the!
worsen!group!occurredOnamely,!it!declined!in!depression!from!postOtest!(25.27)!to!
the!6Omonth!followOup!(19.67)!and!then!increased!again!by!the!12Omonth!followOup!
(20.90).!!In!the!improvement!group!trajectory!trend,!the!largest!decrease!occurred!
by!postOtest.!!Although!there!was!a!slow!increase!from!postOtest!through!the!12O
month!followOup,!the!depression!score!for!the!improvement!group!remained!
statistically!significantly!lower!than!scores!reported!at!preOtest.!!
! As!Table!3.2.!depicts!from!preOtest!to!the!6Omonth!followOup,!the!
improvement!group!had!a!significant!overall!decrease!of!6.57!(p+depression.!!The!depression!score!substantially!declined!by!3.69!(p+preOtest!to!the!12Omonth!followOup,!thereby!suggesting!that!the!improvement!group,!
on!average,!maintained!some!beneficial!treatment!effects!over!the!two!followOup!
periods.!!Marginally!significant!findings!arose!with!the!worsen!group;!from!preOtest!
to!the!6Omonth!followOup,!this!group!manifested!a!considerable!increase!of!3.45!(p!=!
.022)!in!depression.!!From!preOtest!to!the!12Omonth!followOup,!the!worsen!group!
experienced!an!increase!in!depressive!symptoms!by!4.11!(p!=!.033).!!In!other!words,!
participants!who!had!clinically!significant!deterioration!from!preOtest!to!postOtest!
did!not!improve!at!either!the!6Omonth!or!12Omonth!followOups!(see!Table!3.2.).!!
!
!
!
!
108!
After!computing!a!Bonferroni!correction!for!multiple!hypotheses!(Bonferroni,!
1935),!these!results!were!only!marginally!significant.!
Table!3.3.!summarizes!the!findings!of!the!chiOsquare!test!of!differences!in!
ratio!of!clinical!change!groups!(i.e.,!improvement!group!vs.!worsen!group)!at!6O!and!
12Omonth!followOups.!!Results!reveal!that!compared!to!the!worsen!group,!the!
improvement!group!maintained!a!significantly!higher!percentage!of!participants!at!
both!the!6Omonth!(p!! Table!3.4.!describes!the!participants!in!the!improvement!group!(i.e.,!with!a!
more!than!5.16!change)!who!additionally!evidenced!positive!clinical!depression!
diagnosis!change!by!time!point.!!At!preOtest!there!were!30!participants!in!the!
improvement!group!that!reported!having!depression!(i.e.,!CESOD!≥!16).!!At!postOtest,!
87%!(26)!of!these!individuals!had!evidenced!enough!improvement!to!take!them!out!
of!depression!levels!on!top!of!making!clinically!significant!improvement.!!By!the!6O
month!followOup,!61.5%!(16)!maintained!these!gains,!and!34.6%!(9)!had!maintained!
these!changes!1Oyear!postOintervention.!
! In!the!subgroup!analyses!to!identify!predictors!of!clinically!significant!
improvement!maintenance!(see!Table!3.5.),!the!only!significant!predication!was!
male!vs.!female!with!females!being!more!likely!to!sustain!clinically!significant!
improvement!at!12!months.!
!
!
!
!
!
!
!
!
109!
Discussion!
! The!present!study!contributes!to!the!understanding!of!clinically!meaningful!
depression!change!and!maintenance!following!a!lifestyle!intervention!among!older!
adults!in!several!important!ways.!!First,!this!study!went!beyond!the!common!
practice!of!examining!only!preOtest!to!postOtest!meanOlevel!gains!by!tracking!
clinically!meaningful!change!from!postOtest!to!12Omonths!postOintervention.!!
Interestingly,!evidence!was!found!for!an!intervention!effect!on!clinically!significant!
reductions!in!depression!at!12Omonth!followOup,!a!period!longer!than!what!was!
obtained!for!mean!positive!changes.!!Second,!this!study!provides!insight!into!the!
maintenance!pattern!of!those!who!make!clinically!important!change.!!Namely,!this!
study!demonstrates!that!there!are!considerably!more!older!adults!in!a!lifestyle!
psychosocial!intervention!who!evidence!clinical!improvement!than!those!that!have!
clinical!deterioration.!!Third,!this!study!also!enriches!understanding!of!older!adult!
participants!who!enter!lifestyle!intervention!studies!and!have!clinical!levels!of!
depression.!!For!the!current!study!sample,!among!those!in!the!improvement!group!
who!entered!the!study!with!clinical!levels!of!depressive!symptoms,!the!vast!majority!
of!participants!evidenced!important!improvement!and!maintained!this!
improvement.!!Last,!the!results!of!logistic!regression!analysis!indicated!that!females!
were!more!likely!than!males!to!maintain!clinically!significant!change!in!depression!
at!one!year.!!This!finding!should!be!interpreted!cautiously,!however,!given!the!
number!of!predictors!that!were!assessed.!
Further!research!is!needed!to!determine!if!the!effects!of!aging!potentially!
outweigh!certain!demographic!characteristics!such!as!race/ethnicity.!!!
!
!
!
!
110!
Limitations!!
! This!study!lacked!a!control!group!against!which!to!compare!findings!over!the!
two!followOup!periods.!!Therefore,!although!statistically!significant!findings!
associated!with!depression!change!over!the!followOup!times!surfaced,!this!study!
cannot!definitively!establish!that!the!intervention!contributed!to!a!sustained!
decrease!in!depression!symptoms.!!As!a!result,!alternate!explanations!for!the!
sustained!intervention!effect!on!depression!cannot!be!ruled!out.!!For!example,!
threats!to!internal!validity!such!as!testing!effects!and!regression!to!the!mean!(RTM)!
may!have!played!a!role.!!In!the!present!study,!RTM!may!perhaps!be!the!most!likely!
plausible!rival!hypothesis.!!However,!this!study!took!extra!precaution!to!minimize!
potential!effects.!!For!instance,!robust!methods!where!employed!to!first!identify!the!
extent!of!RTM.!!Next,!statistical!adjustments!that!minimized!RTM!effects!(i.e.,!
residual!adjustmentsOsee!Chapter!2)!were!applied!to!account!for!baseline!levels!of!
each!outcome.!!Although!nonOexperimental!data!may!never!completely!account!for!
all!alternate!hypotheses,!these!methods!reasonably!minimized!the!extent!that!RTM!
could!have!influenced!the!study!results.!!!
It!should!also!be!emphasized!that!regression!to!the!mean!from!preO
intervention!to!postOintervention!was!not!expected!to!continue!in!the!same!fashion!
for!followOup!periods.!!Previous!researchers!have!discussed!that!in!most!situations!it!
is!not!the!case!that!regression!to!the!mean!extends!beyond!the!twoOoccasion!
framework!and!that!any!artifacts!will!likely!be!less!potent!(Nesselroade,!Stigler,!&!
Baltes,!1980).!!Furthermore,!because!the!present!study!used!change!scores!and!
!
!
!
!
111!
computed!residual!corrections!for!baseline!scores,!no!additional!RTM!beyond!the!
postOintervention!was!expected.!!!
The!potential!for!testing!effects!was!addressed!through!analyses!that!were!
conducted!in!Chapter!1!to!see!the!extent!repeated!testing!had!on!controls!who!had!
not!received!the!intervention.!!Results!indicated!that!there!was!no!significant!
difference!between!those!participants!who!has!an!additional!exposure!to!the!test!
versus!those!who!did!not.!!!!
The!fact!that!this!study!sample!is!not!nationally!representative!is!another!
limitation.!!As!stated!earlier,!this!study!represented!communityOdwelling!older!
adults!from!greater!Los!Angeles,!a!large!urban!area!with!warm!weather!yearOround.!!
Among!other!things,!the!milder!climate!may!have!influenced!older!adults’!lifestyle!
and!wellObeing.!!As!other!areas!throughout!the!United!States!experience!vastly!
different!climates!during!the!year,!particularly!climates!known!to!induce!
depression,!similar!studies!that!include!participants!living!in!rural!or!colder!
climates!must!be!conducted!to!ensure!that!results!generalize!to!other!populations.!!
!
Conclusion+
! This!study!of!older!adults!who!participated!in!a!lifestyle!intervention!
enriches!our!understanding!of!depression!change!over!time!by!demonstrating!that!a!
significant!number!of!those!who!make!clinical!meaningful!improvement!maintain!
these!gains!12!months!following!the!intervention.!!Likewise,!this!study!also!
provided!some!insight!about!older!adults!who!had!clinical!levels!of!depression!and!
how!many!sustained!these!changes.!!
!
!
!
!
112!
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!
!
!
!
118!
Table!3.1.!
!
Demographic+variable+description+of+clinically+meaningful+change+groups+with+follow^
up+data+(N!=!246)!!
! ! Improvement!
n!=!76!
No!Change!
n!=!128!
Worsen!
n!=!42!
Variable! ! ! ! !
!!Race/ethnicity! ! ! !
!!!!!White!!!!!!! ! 44%! 39%! 23%!
!!!!!Black! ! 28%! 32%! 23%!
!!!!!Latino! ! 17%! 20%! 46%!
!!!!!Other! ! 11%! 9%! 8%!
!!Age! ! 73.6! 75.5! 75.9!
!!Gender! ! ! ! !
!!!!!Female! ! 63%! 73%! 75%!
!!!!!Male! ! ! ! !
!!Education! ! ! ! !
!!!!!College!degree! 23%! 13%! 8%!
!!!!!Some!college! 42%! 35%! 27%!
!!!!!High!school!diploma! 17%! 25%! 19%!
!!!!!Did!not!finish!high!school! 18%! 28%! 46%!
! ! ! ! !
!
!
!
!
!
!
119!
Table!3.2.!
!
CESO D!outcome+mean+change+relative+to+pre^test+stratified+by+clinically+significant+
change+groups++
Outcome!variable! PreO test!!
M!(SD)!
FollowO up!
M!(SD)!
Mean!
difference!
from!baseline!
p+value!
!
!
PreO test!to!6O month!FollowO up!(N!=!246)!
! ! ! ! !
Improve!(n!=+76)! 14.53!(12.46)! !7.96!(7!.99)! O 6.57! .000***!
No!Change!(n+=+128)! 11.91!(9.57)! 12.32!(8.93)! !0.41! .528!
Worsen!(n+=+42)! 16.31!(11.15)! 19.76!(9.67)! !3.45! .022
1!
! ! ! ! !
PreO test!to!12O month!FollowO up!(N!=!244)!
! ! ! ! !
Improve!(n+=+75)! 14.27!(12.01)! 10.57!(10.81)! O 3.69! .000***!
No!Change!(n+=+130)! 12.04!(9.58)! 12.78!(8.60)! !0.75! .207!
Worsen!(n!=+39)! 16.79!(11.54)! 20.90!(11.12)! !4.11! .033
1
!
! ! ! ! !
Note.+CESO D!=!Center!for!Epidemiologic!Studies!Depression!Scale.!
1!
Was!not!significant!after!employing!a!p!multiple!hypotheses!and!type!I!errors.!
!
!
!
!
!
!
120!
Table 3.3.

Chi-square test of difference between ratio of clinical change groups by pre-intervention to post-intervention status at 6-
and 12-month follow-up
6-month Follow-up
Improve
vs.
Baseline
No Change
vs.
Baseline
Worsen
vs.
Baseline
Chi-square
test
†

Pre- to Post-test Group
With 6-month Follow-up

N (% retained)

Improve (n = 76) 46 (60.5%) 27 (35.5%) 3 (4.0%)
Worsen (n = 42) 4 (9.5%) 20 (47.6%) 18 (42.9%)
50 — 21 X
2
(1, N = 71) = 11.85, p < .001
12-month Follow-up
Improve
vs.
Baseline
No Change
vs.
Baseline
Worsen
vs.
Baseline
Chi-square
test
†

Pre- to Post-test Group
With 6-month Follow-up

N (% retained)

Improve (n = 75) 35 (46.7%) 32 (42.7%) 8 (10.7%)
Worsen (n = 39) 6 (15.4%) 18 (46.2%) 15 (38.5%)
41 — 23 X
2
(1, N = 64) = 5.06, p < .05
†
Chi-square test is for the difference between ratio of Improve / Worsen at follow up (i.e., relative to baseline)
!
!
!
!
121!
Table!3.4.!
!
Description+of+Improvement!Group!participants+who+changed+from+clinically+depressed+to+non5depressed+by+time+point.!
Improvement!Group!Participants!with!Clinical!Depression!Levels!at!Pre@test!(N+=!30)!
!
N!(%!retained!from!post@test!improvement)!
! Post@test! 6@month!!
Follow@up!
12@month!!
Follow@up!
Clinically!Depressed
†
Diagnosis!Δ!
Depressed!→!Non@Depressed!
26!! 16/26!(61.5%)! 9/26!(34.6%)!
Note:!
†
Clinical!depression!is!defined!as!having!a!CES@D!score!of!16!or!above.!
! 122!
!
Table!3.5.! ! ! !
! ! ! !
Predictors*of*sustained*clinically*significant*improvement*at*66*and*126months*following*the*
intervention!
! 6!Months! ! !!!!!!!!!!!!!!!!!!12!Months!
! OR! B!(SE)! P;value! !!!!!!!!! OR! B!(SE)! !!!P;value!
Intercept! 4.85! 1.58!(.96)! .099! ! 1.68! .52!(.84)! .536!
Age!≥!75! .43! ;.84!(.49)! .086! ! .54! ;.61!(.51)! .231!
College!Education
†
! 1.36! .30!(.57)! .596! ! 1.06! .05!(.59)! .927!
White! .92! ;.08!(.51)! .871! ! 1.05! .05!(.55)! .929!
English!Language! .39! ;.95!(.90)! .291! ! .79! ;.24!(.80)! .768!
Married! .96! ;.05!(.58)! .937! ! .58! .34!(.60)! .567!
Male! 1.18! .17!(.53)! .755! ! .01! ;1.14!(.56)! !!!!!!!!!.012!
Note.!OR!=!odds!ratio;!B!=!unstandardized!logistic!regression!coefficient;!SE!=!standard!error!
†!
=!4!years!of!college!completed.!
!
!
!
!
!
!
!
!
!
!
!
123!
!
Figure 3.1. CES-D score trajectories as a function of clinically meaningful depression change
groups.
0
6
12
18
24
30
Pre$test' Post$test' 6$month'
Follow$up'
12$month'
Follow$up'
CES-D Scores
CES-D Trajectories by Change Group
Improve
No Change
Worsen
! 124!
!
CONCLUSION
This!dissertation!examined!the!sustainability!of!the!Well!Elderly!2!(WE2)!
intervention’s!positive!effects!by!using!non;experimental!data!and!focusing!on!the!
outcomes!of!depression,!life!satisfaction,!and!self;rated!mental!and!physical!health.!
This!work!elucidated!various!methodological!issues!that!arise!in!inferring!
sustainability!in!non;experimental!contexts.!!It!also!identified!both!clinically!
significant!change!and!its!beneficiaries.!!!!
The!aim!of!Chapter!1!was!to!verify!the!extent!to!which!WE2;based!positive!
treatment!effects!on!depression,!life!satisfaction,!mental!health,!and!physical!health!
were!sustained!at!the!6;!and!12;month!post;intervention!follow;ups.!!As!expected,!
there!was!significant!improvement!in!depression,!life!satisfaction,!mental!health,!
and!physical!health!at!the!end!of!the!intervention.!!Furthermore,!the!intervention!
effect!on!depressive!symptoms!was!found!to!be!significant!and!maintained!a!small!
positive!effect!at!the!6;month!follow;up.!!However,!despite!the!sustainment!of!
reduced!depression!at!the!6;month!follow;up,!post;intervention!treatment!effects!in!
life!satisfaction,!mental!health,!and!physical!health!did!not!evidence!any!statistically!
significant!lasting!effect!beyond!the!time!of!post;testing,!and!none!of!the!study!
outcomes,!including!depression,!were!sustained!at!the!12;month!follow;up.!!!
Overall,!then,!the!results!of!Chapter!1!demonstrated!that!sustainability!of!the!
major!studied!outcomes!was!present,!but!limited,!in!this!intervention.!!However,!
various!outcomes!that,!for!particular!subgroups,!had!somewhat!larger!effect!sizes!
were!associated!with!greater!sustainability.!!!
! 125!
!
The!purpose!of!Chapter!2!was!to!identify!which!older!adults!in!the!WE2!
study!had!clinically!meaningful!positive!improvement!in!depression,!life!
satisfaction,!mental!health,!or!physical!health!from!pre;!to!post;intervention.''
Results!indicated!that!for!each!of!the!three!psychosocial!outcomes!at!post;test,!
slightly!under!one;third!of!the!sample!experienced!clinically!meaningful!
improvement.!!Moreover,!the!number!of!participants!who!made!clinically!
meaningful!improvement!in!the!psychosocial!outcomes!was!nearly!twice!the!
number!who!experienced!clinical!decline.!!Only!19%!of!participants,!however,!
experienced!clinically!meaningful!positive!change!in!self;rated!physical!health,!and!
this!percentage!did!not!exceed!the!corresponding!percentage!who!worsened.!!For!
each!of!the!four!outcomes,!14!–!17%!of!participants!had!clinically!meaningful!
decline.!!Throughout!the!course!of!the!intervention,!the!overall!greatest!
improvement!occurred!in!the!area!of!psychosocial!health,!and!the!least!
improvement!took!place!in!the!area!of!physical!health.!!These!findings!are!consistent!
with!results!from!WE1!(Clark!et!al.,!1997)!and!WE2!(Clark!et!al.,!2012)!and!suggest!
that!the!psychosocial!outcomes!were!more!amenable!to!the!WE2!study!intervention,!
which!was!designed!to!target!psychosocially!relevant!lifestyle!concerns.!!Moreover,!
analyses!in!Chapter!2!also!revealed!that!within!the!improvement!group,!over!three;
fourths!of!the!roughly!one;third!of!participants!who!reported!levels!of!clinical!
depressive!symptomology!at!pre;test!no!longer!had!clinically!diagnosable!levels!at!
the!time!of!post;test.!!
!
! 126!
!
In!essence,!Chapter!2!showed!that!the!common!practice!of!reporting!only!
mean!changes!in!activity;based!intervention!studies!may!overlook!important!
clinically!relevant!information!that!can!guide!treatment!planning!and!research!
hypotheses!for!future!studies.!!Findings!from!Chapter!2!also!demonstrated!that,!in!
interventions!where!researchers!observe!only!small!mean!changes!in!depression!
and!other!quality!of!life!variables,!a!significant!portion!of!participants!may!in!fact!
still!experience!clinically!beneficial!change!in!these!outcomes.!!!
Chapter!3!strove!to!determine!if!WE2!study!participants!sustained!clinically!
meaningful!positive!change!in!depression!at!6;!and!12;months!post;intervention.!!
This!chapter!also!aimed!to!identify!potential!socio;demographic!and!personal!
characteristics!associated!with!the!sustainment!of!clinically!meaningful!change!in!
depression!over!the!follow;up!periods.!!Results!from!Chapter!3!revealed!that!
clinically!meaningful!pre;!to!post;test!change!in!depression!was!maintained!
throughout!the!6;!and!12;month!follow;up!periods!in!over!a!quarter!(26%)!of!the!
total!sample.!!These!findings!demonstrated!that!clinically!meaningful!treatment!
change!at!post;test!is!durable!in!subsets!of!participants.!!These!results!also!revealed!
that!participants!who!improve!the!most!in!a!targeted!health!outcome!at!the!
conclusion!of!an!intervention!are!those!most!likely!to!maintain!treatment!gains!over!
time.!
In!conclusion,!important!issues!must!be!taken!into!consideration!when!
determining!the!efficacy!of!interventions!designed!to!improve!aging!outcomes!in!
older!adults.!!First,!longitudinal!follow;up!assessments!beyond!post;test!are!
necessary!to!document!whether!or!not!treatment!effects!are!sustainable!in!the!long;
! 127!
!
term.!!Second,!researchers!using!non;experimental!data!to!examine!effect!
sustainability!must,!to!the!extent!possible,!incorporate!methodology!that!controls!
for!threats!to!internal!validity!in!order!to!arrive!at!valid!conclusions!about!change!at!
post;intervention!and!over!time.!!Third,!researchers!should!identify!subgroups!that!
experience!greater!clinically!meaningful!change!when!designing!interventions.!!And!
fourth,!given!the!complexity!of!many!interventions,!it!may!be!unreasonable!for!
researchers!to!expect!equal!effectiveness!across!all!groups.!!Therefore,!when!
designing!interventions,!researchers!should!identify!which!groups!have!larger!effect!
sizes,!and!can!expect!that!larger!effects!equate!to!more!sustainability.!!Through!
awareness!of!these!issues,!researchers!and!practitioners!can!(1)!improve!
interventions!so!as!to!sustain!clinically!meaningful!health!effects,!and!(2)!identify!
methodological!enhancements!while!documenting!sustainable!effects!based!on!non;
experimental!data.!!!
!
Future'Directions'
Additional!longitudinal!research!must!be!conducted!to!test!the!generality!of!
effects!across!different!lifestyle!interventions.!!Examining!both!the!rate!of!change!
during!the!treatment!period!(i.e.,!pre;!to!post;test)!and!the!rate!of!change!that!
occurs!during!extended!post;intervention!intervals!can!provide!insight!into!the!
trajectory!of!change!specifically!associated!with!treatment!or!sustainment.!!
Furthermore,!because!the!goal!of!behavioral!interventions!is!to!provide!sustained!
healthful!lifestyle!change,!it!would!be!desirable!to!incorporate!more!frequent!follow;
up!assessments!to!be!better!able!to!track!and!understand!the!mechanisms!for!how!
! 128!
!
lifestyle!changes!can!be!maintained.!!Likewise,!there!is!a!need!for!studies!to!explore!
the!types!of!change!that!occur!among!participants.!!While!some!participants!make!
small,!but!reliable!improvements!in!outcomes!such!as!depression,!some!additionally!
make!clinically!meaningful!change.!!Future!analyses!that!examine!and!identify!which!
participants!are!improving!and!sustaining!that!improvement!at!clinically!significant!
levels!can!help!inform!future!researchers!of!the!mechanisms!involved!with!creating!
and!sustaining!long;lasting!healthy!lifestyle!change!thereby!leading!to!improved!
interventions.!!In!addition,!future!studies!should!continue!to!explore!the!application!
of!clinically!meaningful!change!criteria!to!differences!in!depression!or!other!
outcomes!and!other!heath;related!quality!of!life!indicators!during!interventions!to!
identify!subgroups!that!may!be!particularly!responsive!to!the!treatment.!!This!would!
also!allow!researchers!to!better!understand!factors!that!may!modify!treatment!
effects!on!depression!and!examine!potential!predictors!of!outcome!trajectories!over!
time.!
!
Summary!
Insight!gained!from!this!dissertation!provided!a!method!of!dealing!with!
threats!to!the!ability!to!infer!sustainable!effects!using!non;experimental!data.!!Next,!
this!dissertation!dealt!with!threats!to!the!ability!to!infer!sustainable!effects!using!
non;experimental!data.!!Additionally,!this!work!addressed!questions!about!the!
relative!degree!of!sustainability!of!stronger!versus!weaker!intervention!effects!(i.e.,!
smaller!vs.!larger!effect!sizes).!!Finally,!this!work!sought!to!identify!which!
participants!benefitted!the!most!from!the!WE!intervention,!and!how!often!the!
! 129!
!
obtained!changes!were!clinically!meaningful.!!The!overall!results!of!this!dissertation!
are!important!because!knowledge!of!the!studied!issues!can!assist!researchers!and!
practitioners!in!(a)!improving!interventions!so!as!to!sustain!clinically!meaningful!
health!effects,!and!(b)!identifying!methodological!enhancements!in!attempting!to!
document!sustainable!effects!based!on!non;experimental!data.!!!
!
!
! 130!
!
References'
Clark,!F.,!Azen,!S.!P.,!Zemke,!R.,!Jackson,!J.,!Carlson,!M.,!Mandel,!D.,!…!Lipson,!L.!
(1997).!Occupational!therapy!for!independent;living!older!adults:!A!
randomized!controlled!trial.!Journal*of*the*American*Medical*Association,*278,*
1321;1326.!
Clark,!F.,!Jackson,!J.,!Carlson,!M.,!Chou,!C.,!Cherry,!B.,!Jordan;Marsh,!M.,!…!Azen,!S.!P.!
(2012).!!Effectiveness!of!a!lifestyle!intervention!in!promoting!the!well;being!
of!independently!living!older!people:!Results!of!the!Well!Elderly!2!
Randomised!Controlled!Trial.!!Journal*of*Epidemiology*and*Community*
Health,*66,*782;790.!
!

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Asset Metadata

Creator Pisca, Nicholas E. (author)

Core Title Examination of the long-term psychosocial and functioning effects of a healthy living, life management behavior intervention for older adults

School Leonard Davis School of Gerontology

Degree Doctor of Philosophy

Degree Program Gerontology

Publication Date 09/16/2015

Defense Date 09/10/2015

Publisher University of Southern California (original), University of Southern California. Libraries (digital)

Tag clinically meaningful change,OAI-PMH Harvest,older adults,regression artifacts,sustainability of treatment effects

Format application/pdf (imt)

Language English

Contributor Electronically uploaded by the author (provenance)

Advisor Crimmins, Eileen (committee chair), Carlson, Michael (committee member), Clark, Florence (committee member), Hagedorn, Aaron (committee member)

Creator Email nicholas.pisca@gmail.com,pisca@usc.edu

Permanent Link (DOI) https://doi.org/10.25549/usctheses-c40-182514

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