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Investigação-intervenção nos cuidados de saúde primários : A acessibilidade pedonal percebida e as estratégias cognitivas-comportamentais na prática de actividade física em adultos maiores de 65 anos
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Abstract(s)
Com base nos últimos desenvolvimentos na área cognitivo-comportamental e nas
contribuições do modelo ecológico de comportamentos de saúde na área da actividade física
em adultos maiores de 65 anos, o presente trabalho procurou investigar a influência da
acessibilidade pedonal percebida e a eficácia de três diferentes estratégias no incremento da
actividade física numa amostra de pessoas com idade superior a 65 anos.
Na primeira parte deste trabalho apresentamos o resultado de um estudo exploratório
onde se pretendeu contribuir para a tradução para português e validação de um instrumento que
permite avaliar a acessibilidade pedonal percebida - a percepção do espaço envolvente como
sendo seguro, atractivo, próximo de transportes públicos e de outras estruturas relevantes, e
acessível para caminhar - em maiores de 65 anos. A pertinência da existencia de um
instrumento desta natureza prende-se com a noção de que os atributos percebidos do meio
envolvente estão positivamente associados à prática de actividade física (Trost et al., 2002),
assumindo especial relevância nas pessoas com mais de 65 anos. O primeiro estudo
apresentado teve o propósito de adaptar, explorar a estrutura factorial e características
psicométricas de uma escala de percepção da acessibilidade pedonal para adultos na idade
maior (PAP+65). Participaram neste estudo 79 pessoas, 44 mulheres e 35 homens, com uma
média de idades de 72,15 anos (DP=6,23), não institucionalizados, recrutados em três
associações de apoio a adultos maiores de 65 anos, da região de Lisboa. Constituíram critérios
de exclusão de participação neste estudo, o não saber ler e escrever e o défice cognitivo,
avaliado com a versão Portuguesa do Mini Mental State Examination (Guerreiro, 1994). A
participação foi voluntária e não remunerada. As medidas foram obtidas numa entrevista semiestruturada
com a duração de aproximadamente 60 minutos. As variáveis socio-demográficas
incluiram sexo, idade e rendimento mensal líquido. A variável prática de actividade física
resultou do compósito do relato da frequência semanal e duração das sessões das 3 actividades
físicas mais frequentemente praticadas. Foram realizadas questões relativas à percepção do
número de horas dispendido sentado, a ver TV e de sono. A existência de diagnóstico de comorbilidades
foi avaliada por resposta Sim/Não. Altura, peso e perímetro da cintura (PC) foram
medidos pelo investigador e o índice de massa corporal (IMC) foi obtido pela fórmula P/A2. A
acessibilidade pedonal percebida do bairro para caminhar foi avaliada com recurso a uma
escala de 15 itens (Merom et al. 2009) com possibilidade de resposta entre 1-Discordo
totalmente e 4-Concordo Totalmente, concebida especificamente para adultos maiores de 65
anos, adaptada da versão NEWS Australiana (Cerin, Leslie, Owen & Bauman, 2008).
Apresenta-se a estrutura factorial e as características psicométricas da PAP + 65, tendo a
Análise factorial Exploratória (AFE) identificado 4 factores: Proximidade de destinos (e.g.
distância entre a habitação e estabelecimentos comerciais); Estética (e.g. espaços verdes,
estética do bairro), Segurança (e.g. grau de inclinação na rua, trânsito e criminalidade), e
Condições físicas do bairro (e.g. existência de passadeiras e sinalização para peões, transportes
públicos, iluminação durante a noite). A solução adoptada de 13 itens apresenta uma variância
total explicada de 65,64%, KMO= 0,67, e os valores de consistência interna dos quatros
factores variaram entre 0,58 (Segurança) e 0,78 (Estética). Os resultados sugerem que a PAP
+65 pode ser útil na avaliação da acessibilidade pedonal percebida em adultos maiores de 65
anos, quer em contexto de investigação, quer em intervenção na promoção da actividade física.
A análise dos resultados dos scores na PAP+65 e os indicadores de saúde revelou que a baixa
acessibilidade pedonal percebida do ambiente envolvente está associada a estar mais horas
sentado, o bairro ter um cenário esteticamente pouco aprazível está associado a passar mais
horas a ver TV; a existência de destinos acessíveis a uma curta distância a pé (por exemplo
lojas) e um cenário estético aprazível estão positivamente associados à incidência da diabetes; e
o não existirem lojas e outros destinos acessíveis a uma curta distância a pé da habitação está
associado a um índice de massa corporal e perímetro da cintura superiores.
Na segunda parte desta tese apresentamos os resultados de uma intervenção cognitivocomportamental
com a duração de 24 semanas que visou promover a prática de actividade física
com recurso à prescrição da prática de caminhada diária em pessoas maiores de 65 anos. Esta
intervenção constituiu o âmago de um Projecto I&D financiado pela Fundação para a Ciência e
Tecnologia intitulado “Promoção da actividade física em idosos nos cuidados de saúde
primários” (ref#PTDC/SAU-SAP/110799/2009). Participaram neste projecto 108 pessoas
maiores de 65 anos, 61 mulheres e 47 homens, dos quais 44 entraram no estudo com o seu
cônjuge. Os participantes eram utentes de cinco centros de saúde da região de Lisboa. A
intervenção decorreu ao longo de 24 semanas, com seis sessões de acompanhamento face-a-face
às 1ª, 4ª, 8ª, 16ª e 24ª semanas. Os participantes foram referenciados para o estudo pelos médicos
de clínica geral do Agrupamento de Centros de Saúde de Oeiras- ACES Oeiras, com base nos
seguintes critérios de inclusão: idade igual ou superior a 65 anos com necessidade de aumentar os
seus níveis de actividade física e sem comorbilidade impeditiva da realização de caminhada
diária. Foram referenciados 498 utentes de cinco centros de saúde, tendo sido admitidos no
estudo 108 participantes, que foram distribuídos aleatoriamente pelas seguintes condições
experimentais: Formulação de objectivos; Formulação de objectivos + Planos de acção e
Formulação de objectivos + Planos de acção + Planos de coping para identificar e superar
barreiras à practica da caminhada. Os participantes foram aleatorizados de acordo com o género e
condição em que entravam no estudo (individual vs casal). Todos os participantes receberam um
pedómetro e um caderno para registo diário do número de passos total do dia. A Análise
Univariada de Covariância (ANCOVA) revelou que não houve diferenças entre as três condições
experimentais, i.e, todas as estratégias foram igualmente eficientes no aumento do
comportamento de caminhada diária. No total da amostra, o número total de passos realizados
por dia aumentou 32,8% no final dos 6 meses face à baseline. Contudo a análise revelou que o
comportamento de caminhada variou em função de ser realizado individualmente ou em casal.
Para os participantes que realizaram a caminhada diária individualmente a Formulação de
objectivos + Planos de acção + estratégias de coping foi a estratégia mais eficiente. Em
contrapartida para os participantes que aderiram à intervenção enquanto casal, a estratégia mais
eficiente foi apenas a de Formulação de objectivos. A acessibilidade pedonal percebida não
revelou influência no comportamento de actividade física. Neste estudo obtivemos uma taxa de
adesão de 72,2% e 27,8% de mortalidade experimental com uma distribuição equitativa entre a
4ª, 8ª, 16ª e 24ª semana.
ABSTRACT : On the basis of recent developments of the cognitive models and ecological model of health behaviour, the present research aimed to understand the influence of the perceived neighbourhood walkability on older adults’ physical activity levels and to test the effectiveness of three different strategies in increasing physical activity in this population. In the first part of this work, we present the results of an exploratory study where it was intended to contribute to the translation into Portuguese and validation of an instrument that allows evaluating the perceived neighbourhood walkability - the perception of the surrounding space as being safe, attractive, close to public transport and other relevant structures, and accessible for walking - in over 65s. The relevance of the existence of an instrument of this nature is related to the notion that the perceived attributes of the environment are positively associated with the practice of physical activity (Trost, 2002), assuming special relevance in people over 65 years of age. The first study had the purpose of adapting, exploring the factorial structure and psychometric characteristics of a perceived neighbourhood walkability scale for older adults’ (PAP + 65). Participants in the study were 79 people, 44 women and 35 men, with a mean age of 72.15 years (SD = 6.23), non-institutionalized, recruited from three associations of elderly support in the Lisbon region. The criteria for exclusion of participation in this study were the lack of literacy and cognitive deficit, evaluated with the Portuguese version of the Mini Mental State Examination (Guerreiro, 1994). Participation was voluntary and unpaid. The measurements were obtained in a semi-structured interview with duration of approximately 60 minutes. The socio-demographic variables included sex, age and monthly net income. The variable of physical activity resulted from the composite of the report of the weekly frequency and duration of the sessions of the 3 most frequently physical activities practiced. There were questions regarding the perception of the number of hours spent sitting, watching TV and sleep. The existence of a diagnosis of comorbidities was evaluated by Yes / No response. Height, weight and waist circumference (WC) were measured by the investigator and the body mass index (BMI) was obtained by the formula P / A2. The perceived neighbourhood walkability was assessed using a scale of 15 items (Merom et al., 2009) with the possibility of a response between 1-Strongly Disagree and 4-Strongly Agree, designed specifically for adults over 65, adapted of the Australian NEWS version (Cerin, Leslie, Owen & Bauman, 2008). The factorial structure and the psychometric characteristics of the PAP + 65 are presented, the Factorial Exploratory Factor Analysis (EFA) identified 4 factors: Proximity of destinations (e.g., distance between the home and commercial establishments); Aesthetics (eg green spaces, aesthetics of the neighbourhood), Safety (eg degree of inclination in the street, traffic and crime), and Physical conditions of the neighbourhood (eg pedestrian crossings and signs, public transport, night lighting). The adopted solution of 13 items presents a total explained variance of 65.64%, KMO = 0.67, and the internal consistency values of the four factors ranged from 0.58 (Safety) to 0.78 (Aesthetics). The results suggest that PAP +65 may be useful in assessing perceived neighbourhood walkability in adults over 65 years of age, both in the context of research and intervention for promoting physical activity. The analysis of the results of the scores in PAP + 65 and the health indicators revealed that the low perception of the neighbourhood walkability is associated with being seated for more hours, the neighbourhood having an aesthetically unpleasant scenery is associated with spending more hours watching TV; The existence of accessible destinations within walking distance (eg shops) and a pleasant aesthetic scenario are positively associated with the incidence of Diabetes; And the there no shops and other destinations accessible within walking distance of the dwelling is associated with a higher body mass index and upper waist perimeter. In the second part of this thesis we present the results of a 24-week cognitive-behavioural intervention aimed to promote the practice of physical activity with the prescription of daily walking practice in people over 65 years. This intervention was at the heart of a I&D project financed by the Foundation for Science and Technology entitled " Increasing physical activity in older adults: Walking by prescription in a primary care setting " (ref # PTDC / SAU-SAP / 110799/2009). The project involved 108 people over 65 years of age, 61 women and 47 men, of whom 44 entered the study with their spouse. Participants were referred to the study by the general practitioners of the Oeiras-ACES Oeiras Health Centers Group, based on the following inclusion criteria: age 65 or older with a need to increase their levels of physical activity and no comorbidity preventing daily walking. A total of 498 patients from five health centers were referenced and 108 participants were admitted to the study and randomly assigned to the following experimental conditions: Goal setting; Goal setting + Action Plans and Goal setting + Action Plans + Coping Plans to identify and overcome barriers to the practice of walking. Participants were randomized according to their gender and condition (individual vs couple). All participants received a pedometer and a logbook for daily recording the total number of steps of the day. Univariate Covariance Analysis (ANCOVA) revealed that there were no differences between the three experimental conditions, i.e. all strategies were equally effective in increasing daily walking behaviour. In the total sample, the total number of steps performed per day increased by 32.8% at the end of the 6 months compared to the baseline. However, the analysis revealed that walking behaviour varied depending on whether it was performed individually or as a couple. For the participants who carried out the daily walk individually the Goal Setting + Action Plans + Coping Plans was the most efficient strategy. In contrast, for the participants who participated in the intervention as a couple, the most effective strategy was the intervention only of goal setting. Perceived neighbourhood walkability did not reveal influence on the behaviour of physical activity. In this study, we obtained a 72.2% adherence rate and 27.8% drop-out rate with equitable distribution between the 4th, 8th, 16th and 24th weeks.
ABSTRACT : On the basis of recent developments of the cognitive models and ecological model of health behaviour, the present research aimed to understand the influence of the perceived neighbourhood walkability on older adults’ physical activity levels and to test the effectiveness of three different strategies in increasing physical activity in this population. In the first part of this work, we present the results of an exploratory study where it was intended to contribute to the translation into Portuguese and validation of an instrument that allows evaluating the perceived neighbourhood walkability - the perception of the surrounding space as being safe, attractive, close to public transport and other relevant structures, and accessible for walking - in over 65s. The relevance of the existence of an instrument of this nature is related to the notion that the perceived attributes of the environment are positively associated with the practice of physical activity (Trost, 2002), assuming special relevance in people over 65 years of age. The first study had the purpose of adapting, exploring the factorial structure and psychometric characteristics of a perceived neighbourhood walkability scale for older adults’ (PAP + 65). Participants in the study were 79 people, 44 women and 35 men, with a mean age of 72.15 years (SD = 6.23), non-institutionalized, recruited from three associations of elderly support in the Lisbon region. The criteria for exclusion of participation in this study were the lack of literacy and cognitive deficit, evaluated with the Portuguese version of the Mini Mental State Examination (Guerreiro, 1994). Participation was voluntary and unpaid. The measurements were obtained in a semi-structured interview with duration of approximately 60 minutes. The socio-demographic variables included sex, age and monthly net income. The variable of physical activity resulted from the composite of the report of the weekly frequency and duration of the sessions of the 3 most frequently physical activities practiced. There were questions regarding the perception of the number of hours spent sitting, watching TV and sleep. The existence of a diagnosis of comorbidities was evaluated by Yes / No response. Height, weight and waist circumference (WC) were measured by the investigator and the body mass index (BMI) was obtained by the formula P / A2. The perceived neighbourhood walkability was assessed using a scale of 15 items (Merom et al., 2009) with the possibility of a response between 1-Strongly Disagree and 4-Strongly Agree, designed specifically for adults over 65, adapted of the Australian NEWS version (Cerin, Leslie, Owen & Bauman, 2008). The factorial structure and the psychometric characteristics of the PAP + 65 are presented, the Factorial Exploratory Factor Analysis (EFA) identified 4 factors: Proximity of destinations (e.g., distance between the home and commercial establishments); Aesthetics (eg green spaces, aesthetics of the neighbourhood), Safety (eg degree of inclination in the street, traffic and crime), and Physical conditions of the neighbourhood (eg pedestrian crossings and signs, public transport, night lighting). The adopted solution of 13 items presents a total explained variance of 65.64%, KMO = 0.67, and the internal consistency values of the four factors ranged from 0.58 (Safety) to 0.78 (Aesthetics). The results suggest that PAP +65 may be useful in assessing perceived neighbourhood walkability in adults over 65 years of age, both in the context of research and intervention for promoting physical activity. The analysis of the results of the scores in PAP + 65 and the health indicators revealed that the low perception of the neighbourhood walkability is associated with being seated for more hours, the neighbourhood having an aesthetically unpleasant scenery is associated with spending more hours watching TV; The existence of accessible destinations within walking distance (eg shops) and a pleasant aesthetic scenario are positively associated with the incidence of Diabetes; And the there no shops and other destinations accessible within walking distance of the dwelling is associated with a higher body mass index and upper waist perimeter. In the second part of this thesis we present the results of a 24-week cognitive-behavioural intervention aimed to promote the practice of physical activity with the prescription of daily walking practice in people over 65 years. This intervention was at the heart of a I&D project financed by the Foundation for Science and Technology entitled " Increasing physical activity in older adults: Walking by prescription in a primary care setting " (ref # PTDC / SAU-SAP / 110799/2009). The project involved 108 people over 65 years of age, 61 women and 47 men, of whom 44 entered the study with their spouse. Participants were referred to the study by the general practitioners of the Oeiras-ACES Oeiras Health Centers Group, based on the following inclusion criteria: age 65 or older with a need to increase their levels of physical activity and no comorbidity preventing daily walking. A total of 498 patients from five health centers were referenced and 108 participants were admitted to the study and randomly assigned to the following experimental conditions: Goal setting; Goal setting + Action Plans and Goal setting + Action Plans + Coping Plans to identify and overcome barriers to the practice of walking. Participants were randomized according to their gender and condition (individual vs couple). All participants received a pedometer and a logbook for daily recording the total number of steps of the day. Univariate Covariance Analysis (ANCOVA) revealed that there were no differences between the three experimental conditions, i.e. all strategies were equally effective in increasing daily walking behaviour. In the total sample, the total number of steps performed per day increased by 32.8% at the end of the 6 months compared to the baseline. However, the analysis revealed that walking behaviour varied depending on whether it was performed individually or as a couple. For the participants who carried out the daily walk individually the Goal Setting + Action Plans + Coping Plans was the most efficient strategy. In contrast, for the participants who participated in the intervention as a couple, the most effective strategy was the intervention only of goal setting. Perceived neighbourhood walkability did not reveal influence on the behaviour of physical activity. In this study, we obtained a 72.2% adherence rate and 27.8% drop-out rate with equitable distribution between the 4th, 8th, 16th and 24th weeks.
Description
Tese de Doutoramento em Psicologia na área de especialidade Psicologia da Saúde apresentada ao ISPA - Instituto Universitário
Keywords
Idosos Actividade física Caminhada Ambiente Percepção Recrutamento Pedómetros Implementação de intenções Coping Older adults Physical activity Walkability Environment Perception Recruitment Pedometers Implementation intentions Coping